Quantifying the effects of risk-stratified breast cancer screening when delivered in real time as routine practice versus usual screening: the BC-Predict non-randomised controlled study (NCT04359420)

BACKGROUND

Risk stratification as a routine part of the NHS Breast Screening Programme (NHSBSP) could provide a better balance of benefits and harms. We developed BC-Predict, to offer women when invited to the NHSBSP, which collects standard risk factor information; mammographic density; and in a sub-sample, a Polygenic Risk Score (PRS).

METHODS

Risk prediction was estimated primarily from self-reported questionnaires and mammographic density using the Tyrer-Cuzick risk model. Women eligible for NHSBSP were recruited. BC-Predict produced risk feedback letters, inviting women at high risk (≥8% 10-year) or moderate risk (≥5-<8% 10-year) to have appointments to discuss prevention and additional screening.

RESULTS

Overall uptake of BC-Predict in screening attendees was 16.9% with 2472 consenting to the study; 76.8% of those received risk feedback within the 8-week timeframe. Recruitment was 63.2% with an onsite recruiter and paper questionnaire compared to <10% with BC-Predict only (P < 0.0001). Risk appointment attendance was highest for those at high risk (40.6%); 77.5% of those opted for preventive medication.

DISCUSSION

We have shown that a real-time offer of breast cancer risk information (including both mammographic density and PRS) is feasible and can be delivered in reasonable time, although uptake requires personal contact. Preventive medication uptake in women newly identified at high risk is high and could improve the cost-effectiveness of risk stratification.

TRIAL REGISTRATION

Retrospectively registered with clinicaltrials.gov (NCT04359420).

91 Can ‘Pop-Up’ Style Simulation Teaching Improve The Care That Our Children and Young People’s Emergency Department Team Provide for Children Presenting with Fever?

We wanted to use simulation teaching to improve our multi-disciplinary team’s (MDT) management of children who presented to our Children and Young People’s ED (CYPED) with fever.

The aims of the study were: first, to use simulation teaching to train the MDT in our CYPED, to improve the care delivered to children presenting with fever, measured as an improvement in our compliance with the Royal College of Emergency Medicine’s (RCEM) standards

For cycle one of our audits, we looked at a sample of 136 children who presented to our CYPED with fever; 61 patients met the inclusion criteria and were included. To improve compliance to the RCEM standards

Staff’s self-rated knowledge of the RCEM standards

‘Pop-up’ style simulation teaching can be used to improve the care that we offer our patients, as reflected by an improvement in staff’s confidence and in the department’s compliance with RCEM standards

What are the benefits and harms of risk stratified screening as part of the NHS breast screening Programme? Study protocol for a multi-site non-randomised comparison of BC-predict versus usual screening (NCT04359420)

BACKGROUND

In principle, risk-stratification as a routine part of the NHS Breast Screening Programme (NHSBSP) should produce a better balance of benefits and harms. The main benefit is the offer of NICE-approved more frequent screening and/ or chemoprevention for women who are at increased risk, but are unaware of this. We have developed BC-Predict, to be offered to women when invited to NHSBSP which collects information on risk factors (self-reported information on family history and hormone-related factors via questionnaire; mammographic density; and in a sub-sample, Single Nucleotide Polymorphisms). BC-Predict produces risk feedback letters, inviting women at high risk (≥8% 10-year) or moderate risk (≥5 to < 8% 10-year) to have discussion of prevention and early detection options at Family History, Risk and Prevention Clinics. Despite the promise of systems such as BC-Predict, there are still too many uncertainties for a fully-powered definitive trial to be appropriate or ethical. The present research aims to identify these key uncertainties regarding the feasibility of integrating BC-Predict into the NHSBSP. Key objectives of the present research are to quantify important potential benefits and harms, and identify key drivers of the relative cost-effectiveness of embedding BC-Predict into NHSBSP.

METHODS

A non-randomised fully counterbalanced study design will be used, to include approximately equal numbers of women offered NHSBSP (n = 18,700) and BC-Predict (n = 18,700) from selected screening sites (n = 7). In the initial 8-month time period, women eligible for NHSBSP will be offered BC-Predict in four screening sites. Three screening sites will offer women usual NHSBSP. In the following 8-months the study sites offering usual NHSBSP switch to BC-Predict and vice versa. Key potential benefits including uptake of risk consultations, chemoprevention and additional screening will be obtained for both groups. Key potential harms such as increased anxiety will be obtained via self-report questionnaires, with embedded qualitative process analysis. A decision-analytic model-based cost-effectiveness analysis will identify the key uncertainties underpinning the relative cost-effectiveness of embedding BC-Predict into NHSBSP.

DISCUSSION

We will assess the feasibility of integrating BC-Predict into the NHSBSP, and identify the main uncertainties for a definitive evaluation of the clinical and cost-effectiveness of BC-Predict.

TRIAL REGISTRATION

Retrospectively registered with clinicaltrials.gov (NCT04359420).

Abstract B10: Development of a cancer risk prediction tool for use in the Risk Estimation For Lifestyle Enhancement Combined Trial (REFLECT)

This abstract is being presented as a short talk in the scientific program. A full abstract is printed in the Proffered Abstracts section (PR14) of the Conference Proceedings.

Citation Format: Artitaya Lophatananon, Kawthar Alajmi, Emma Thorpe, John Hughes, Joanna Blodgett, Bernadette Fisher, Simon Rogers, Erika K. Waters, Kenneth R. Muir. Development of a cancer risk prediction tool for use in the Risk Estimation For Lifestyle Enhancement Combined Trial (REFLECT). [abstract]. In: Proceedings of the AACR Special Conference: Improving Cancer Risk Prediction for Prevention and Early Detection; Nov 16-19, 2016; Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(5 Suppl):Abstract nr B10.

Abstract PR14: Development of a cancer risk prediction tool for use in the Risk Estimation For Lifestyle Enhancement Combined Trial (REFLECT)

Exposure to modifiable lifestyle and environmental risk factors accounts for approximately 40% of all cancers in the UK. Therefore, primary prevention is of growing importance and an effective and engaging strategy that encourages long-term adoption of healthy lifestyle behaviours is required.

Several multivariable risk prediction models have been developed to assess an individual's risk of developing specific cancers. Such models can be used in a variety of settings for prevention, screening, and guiding investigation and treatment. Models aimed at predicting future disease risk that contains modifiable factors may be of particular use for targeting health promotion activities at an individual level. We have therefore developed a UK version of the well-established U.S. derived “YourDiseaseRisk” model which allow users to quantify their individual risk of developing individual cancers relative to the population average risk.

The UK-Manchester version of “YourDiseaseRisk” computes 10 year cancer risk for 11 cancer types utilising UK figures for prevalence of risk factors and cancer incidence. The model can be used to estimate cancer risk for use in community settings.

Using a variety of qualitative and quantitative methods we have assessed the impact of the REFLECT risk model on public understanding of cancer risk factors and UK NHS Cancer Screening programs. We have also explored public opinion and perceptions regarding the provision of information on of genetic susceptibility to aid in further personalising cancer risk information.

This abstract is also being presented as Poster B10.

Citation Format: Artitaya Lophatananon, Kawthar Alajmi, Emma Thorpe, John Hughes, Joanna Blodgett, Bernadette Fisher, Simon Rogers, Erika K. Waters, Kenneth R. Muir. Development of a cancer risk prediction tool for use in the Risk Estimation For Lifestyle Enhancement Combined Trial (REFLECT). [abstract]. In: Proceedings of the AACR Special Conference: Improving Cancer Risk Prediction for Prevention and Early Detection; Nov 16-19, 2016; Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(5 Suppl):Abstract nr PR14.

Uncertainty quantification in modeling HIV viral mechanics

We consider an in-host model for HIV-1 infection dynamics developed and validated with patient data in earlier work [7]. We revisit the earlier model in light of progress over the last several years in understanding HIV-1 progression in humans. We then consider statistical models to describe the data and use these with residual plots in generalized least squares problems to develop accurate descriptions of the proper weights for the data. We use recent parameter subset selection techniques [5,6] to investigate the impact of estimated parameters on the corresponding selection scores. Bootstrapping and asymptotic theory are compared in the context of confidence intervals for the resulting parameter estimates.

Survey of the prevalence, diagnosis and treatment of dermatological conditions in small animals in general practice

A survey was made of the prevalence, diagnosis and treatment of dermatological conditions in small animals in general practice in the UK. Out of 3707 small animal consultations in general practice that were observed and recorded, 795 (21.4 per cent) involved animals that had a dermatological problem. In dogs and exotic species, pruritus was the most common presenting sign, accounting for 30 to 40 per cent of the dermatological consultations. In cats, cutaneous swellings were the most common presentation (36 per cent). A diagnosis or recommendation for treatment was made on the basis of the presenting clinical signs and physical examination alone in 576 (72 per cent) of the cases, and various diagnostic tests were performed in the other cases. In dogs, parasitic infestations, bacterial infections and neoplasia accounted for the majority of the diagnoses. In cats, parasites and bacterial infections were the most common. In exotic species, parasites accounted for over 80 per cent of the dermatological diagnoses. In dogs, the most common final diagnoses were otitis, pyoderma, anal sac impaction, flea infestation and atopic dermatitis. In cats, abscesses, flea infestation, and otitis were the most common diagnoses. In exotic species, the most common diagnosis was an unspecified mite infestation. Systemic antibiotics were prescribed in 196 cases (25 per cent), systemic glucocorticoids were prescribed in 162 cases (20 per cent) and treatment with an ectoparasiticide was prescribed in 167 cases (21 per cent).

Combination antimicrobial therapy in the treatment of acute pelvic inflammatory disease

We compared the clinical and microbiologic efficacy of two broad-spectrum combination antimicrobial regimens in the treatment of 148 patients with acute pelvic inflammatory disease. Patients were randomized to inpatient treatment with either cefoxitin and doxycycline (n = 75) or clindamycin and tobramycin (n = 73). These antibiotics were administered intravenously for at least 4 days, and up to 48 hours beyond defervescence. Patients were discharged on a regimen of oral doxycycline or clindamycin in accordance with the intravenous regimen to complete a total duration of therapy of 2 weeks. Neisseria gonorrhoeae (53%) and Chlamydia trachomatis (31%) were the microorganisms that were isolated most frequently from the genital tract of enrolled patients. At follow-up, N. gonorrhoeae was isolated in two patients, and C. trachomatis was isolated in none. The overall initial favorable response rate to combination antimicrobial therapy was 98.5% (130/132) in patients with uncomplicated pelvic inflammatory disease and 81% (13/16) in patients with pelvic inflammatory disease that was complicated by tuboovarian abscess. A greater than 70% decrease in abdominal tenderness score occurred in 89% of 111 patients within 6 weeks of hospital discharge. There were no significant differences between antibiotic treatment groups in any response categories or in toxicity. During the initial hospitalization, five patients (three with tuboovarian abscess; one with a pyosalpinx, and one with intractable acute and chronic pelvic inflammatory disease) required surgical intervention. These results support the recommendation to use broad-spectrum combination antimicrobial therapy for the treatment of acute pelvic inflammatory disease.

Dichlorvos -- a 2-year inhalation carcinogenesis study in rats

To determine the effects of dichlorvos vapour on the tumour incidence in rats, 5 week old Carworth Farm E strain rats weighing between 94 and 150 g were exposed to 0, 0.05, 0.5 and 5.0 mg/m3 in a 2-year inhalation study. The growth rate of all treated rats was depressed, particularly in the males. There was increased survival of the rats exposed to 5 mg/m3. There were no consistent differences in food intakes, organ weights, haematological or blood chemistry estimations, except in cholinesterase activites, amongst the various groups of rats. No compound-related differences were seen in acetylcholine and choline estimations carried out on a small number of female rats' brain tissues after two years' exposure. There were no gross or microscopical compound-related changes in the rats' tissues. Ultrastructural examination of the respiratory tissues of the rats from the control and 5 mg/m3 group showed no changes attributable to dichlorvos. The results of a relative risk analysis of the tumour data showed that no dose-related increase in tumour risk was established for rats of either sex. These data confirm the results of earlier st.udies supporting the safety of insecticidal uses of dichlorvos.

The interaction of cold environment and carbon tetrachloride hepatotoxicity in mice

A single oral dose of carbon tetrachloride (CCl₄) of 1 ml./kg. was given to mice maintained at 10° and 20-22°. Cold exposure alone produced fatty changes and depletion of glycogen in the centrilobular zone and modified the liver damage induced by CCl₄ between 5-24 hr after dosing, by increasing lipid accumulation, markedly depleting glycogen, by narrowing the lumina of the sinusoids in the necrotic areas and by producing a large number of ballooned cells in the mid lobular zone.

Liver regeneration was rapid in mice kept at room temperature and was complete by 8 days. Depletion of glycogen and fatty infiltration in the centrilobular zone persisted in the liver of mice exposed to cold.

The enzymes studied by histochemical techniques were non-specific alkaline phosphatase, adenosine triphosphatase, succinic tetrazolium reductase and glutamate dehydrogenase. Exposure to cold stimulated the sinusoidal alkaline phosphatase activity and depressed the activity of succinic and glutamate dehydrogenases.

The early stages of carbon tetrachloride intoxication were accompanied by loss of activities of the latter 2 enzymes. This was more marked on exposure to cold whilst the depressed activity of canalicular adenosine triphosphatase in mice kept at room temperature was absent in those exposed to cold.

Necrosis was followed by increased sinusoidal alkaline phosphatase activity and scattered cell reaction in mice kept at both temperatures. There was intense cellular and sinusoidal adenosine triphosphatase activity in mice kept at room temperature and a wider and less intense reaction in these sites in mice exposed to cold. Activities of succinic and glutamate dehydrogenases were diminished in necrotic areas which showed non-specific deposits due to adsorption of enzymes to lipid in mice in both environments.

Liver regeneration stimulated the activities of all enzymes although those of succinic and glutamate dehydrogenases remained relatively low in mice exposed to cold environment.