A novel preclinical model of the normal human breast

Improved screening and treatment have decreased breast cancer mortality, although incidence continues to rise. Women at increased risk of breast cancer can be offered risk reducing treatments, such as tamoxifen, but this has not been shown to reduce breast cancer mortality. New, more efficacious, risk-reducing agents are needed. The identification of novel candidates for prevention is hampered by a lack of good preclinical models. Current patient derived in vitro and in vivo models cannot fully recapitulate the complexities of the human tissue, lacking human extracellular matrix, stroma, and immune cells, all of which are known to influence therapy response. Here we describe a normal breast explant model utilising a tuneable hydrogel which maintains epithelial proliferation, hormone receptor expression, and residency of T cells and macrophages over 7 days. Unlike other organotypic tissue cultures which are often limited by hyper-proliferation, loss of hormone signalling, and short treatment windows (< 48h), our model shows that tissue remains viable over 7 days with none of these early changes. This offers a powerful and unique opportunity to model the normal breast and study changes in response to various risk factors, such as breast density and hormone exposure. Further validation of the model, using samples from patients undergoing preventive therapies, will hopefully confirm this to be a valuable tool, allowing us to test novel agents for breast cancer risk reduction preclinically.

Implementation and external validation of the Cambridge Multimorbidity Score in the UK Biobank cohort

BACKGROUND

Patients with multiple conditions present a growing challenge for healthcare provision. Measures of multimorbidity may support clinical management, healthcare resource allocation and accounting for the health of participants in purpose-designed cohorts. The recently developed Cambridge Multimorbidity scores (CMS) have the potential to achieve these aims using primary care records, however, they have not yet been validated outside of their development cohort.

METHODS

The CMS, developed in the Clinical Research Practice Dataset (CPRD), were validated in UK Biobank participants whose data is not available in CPRD (the cohort used for CMS development) with available primary care records (n = 111,898). This required mapping of the 37 pre-existing conditions used in the CMS to the coding frameworks used by UK Biobank data providers. We used calibration plots and measures of discrimination to validate the CMS for two of the three outcomes used in the development study (death and primary care consultation rate) and explored variation by age and sex. We also examined the predictive ability of the CMS for the outcome of cancer diagnosis. The results were compared to an unweighted count score of the 37 pre-existing conditions.

RESULTS

For all three outcomes considered, the CMS were poorly calibrated in UK Biobank. We observed a similar discriminative ability for the outcome of primary care consultation rate to that reported in the development study (C-index: 0.67 (95%CI:0.66-0.68) for both, 5-year follow-up); however, we report lower discrimination for the outcome of death than the development study (0.69 (0.68-0.70) and 0.89 (0.88-0.90) respectively). Discrimination for cancer diagnosis was adequate (0.64 (0.63-0.65)). The CMS performs favourably to the unweighted count score for death, but not for the outcomes of primary care consultation rate or cancer diagnosis.

CONCLUSIONS

In the UK Biobank, CMS discriminates reasonably for the outcomes of death, primary care consultation rate and cancer diagnosis and may be a valuable resource for clinicians, public health professionals and data scientists. However, recalibration will be required to make accurate predictions when cohort composition and risk levels differ substantially from the development cohort. The generated resources (including codelists for the conditions and code for CMS implementation in UK Biobank) are available online.

Risk-stratified screening for the early detection of kidney cancer

Earlier detection and screening for kidney cancer has been identified as a key research priority, however the low prevalence of the disease in unselected populations limits the cost-effectiveness of screening. Risk-stratified screening for kidney cancer may improve early detection by targeting high-risk individuals whilst limiting harms in low-risk individuals, potentially increasing the cost-effectiveness of screening. A number of models have been identified which estimate kidney cancer risk based on both phenotypic and genetic data, and while several of the former have been shown to identify individuals at high-risk of developing kidney cancer with reasonable accuracy, current evidence does not support including a genetic component. Combined screening for lung cancer and kidney cancer has been proposed, as the two malignancies share some common risk factors. A modelling study estimated that using lung cancer risk models (currently used for risk-stratified lung cancer screening) could capture 25% of patients with kidney cancer, which is only slightly lower than using the best performing kidney cancer-specific risk models based on phenotypic data (27%-33%). Additionally, risk-stratified screening for kidney cancer has been shown to be acceptable to the public. The following review summarises existing evidence regarding risk-stratified screening for kidney cancer, highlighting the risks and benefits, as well as exploring the management of potential harms and further research needs.

Risk Prediction Models for Oral Cancer: A Systematic Review

In the last 30 years, there has been an increasing incidence of oral cancer worldwide. Earlier detection of oral cancer has been shown to improve survival rates. However, given the relatively low prevalence of this disease, population-wide screening is likely to be inefficient. Risk prediction models could be used to target screening to those at highest risk or to select individuals for preventative interventions. This review (a) systematically identified published models that predict the development of oral cancer and are suitable for use in the general population and (b) described and compared the identified models, focusing on their development, including risk factors, performance and applicability to risk-stratified screening. A search was carried out in November 2022 in the Medline, Embase and Cochrane Library databases to identify primary research papers that report the development or validation of models predicting the risk of developing oral cancer (cancers of the oral cavity or oropharynx). The PROBAST tool was used to evaluate the risk of bias in the identified studies and the applicability of the models they describe. The search identified 11,222 articles, of which 14 studies (describing 23 models), satisfied the eligibility criteria of this review. The most commonly included risk factors were age (n = 20), alcohol consumption (n = 18) and smoking (n = 17). Six of the included models incorporated genetic information and three used biomarkers as predictors. Including information on human papillomavirus status was shown to improve model performance; however, this was only included in a small number of models. Most of the identified models (n = 13) showed good or excellent discrimination (AUROC > 0.7). Only fourteen models had been validated and only two of these validations were carried out in populations distinct from the model development population (external validation). Conclusions: Several risk prediction models have been identified that could be used to identify individuals at the highest risk of oral cancer within the context of screening programmes. However, external validation of these models in the target population is required, and, subsequently, an assessment of the feasibility of implementation with a risk-stratified screening programme for oral cancer.

Phenotypes and rates of cancer-relevant symptoms and tests in the year before cancer diagnosis in UK Biobank and CPRD Gold

Early diagnosis of cancer relies on accurate assessment of cancer risk in patients presenting with symptoms, when screening is not appropriate. But recorded symptoms in cancer patients pre-diagnosis may vary between different sources of electronic health records (EHRs), either genuinely or due to differential completeness of symptom recording. To assess possible differences, we analysed primary care EHRs in the year pre-diagnosis of cancer in UK Biobank and Clinical Practice Research Datalink (CPRD) populations linked to cancer registry data. We developed harmonised phenotypes in Read v2 and CTV3 coding systems for 21 symptoms and eight blood tests relevant to cancer diagnosis. Among 22,601 CPRD and 11,594 UK Biobank cancer patients, 54% and 36%, respectively, had at least one consultation for possible cancer symptoms recorded in the year before their diagnosis. Adjusted comparisons between datasets were made using multivariable Poisson models, comparing rates of symptoms/tests in CPRD against expected rates if cancer site-age-sex-deprivation associations were the same as in UK Biobank. UK Biobank cancer patients compared with those in CPRD had lower rates of consultation for possible cancer symptoms [RR: 0.61 (0.59-0.63)], and lower rates for any primary care consultation [RR: 0.86 (95%CI 0.85-0.87)]. Differences were larger for 'non-alarm' symptoms [RR: 0.54 (0.52-0.56)], and smaller for 'alarm' symptoms [RR: 0.80 (0.76-0.84)] and blood tests [RR: 0.93 (0.90-0.95)]. In the CPRD cohort, approximately representative of the UK population, half of cancer patients had recorded symptoms in the year before diagnosis. The frequency of non-specific presenting symptoms recorded in the year pre-diagnosis of cancer was substantially lower among UK Biobank participants. The degree to which results based on highly selected biobank cohorts are generalisable needs to be examined in disease-specific contexts.

Introducing a group-based psychoeducation intervention for older people in an inpatient mental healthcare setting

This article reports on a service evaluation of a group-based psychoeducation programme for older people in an inpatient mental healthcare setting. It sought to explore how the programme was experienced by patients and staff, as well as its acceptability and the feasibility for implementation in the longer term. Via questionnaires, views were gathered from patients and staff. A focus group interview with staff facilitating the group sessions was also undertaken, and patient attendance records for sessions were collected and compared with demographic data relating to the two wards housed in the unit where the programme took place. The programme was generally viewed as a positive addition to care delivery by staff and patient respondents in offering an adjunct to pharmacological treatment, increasing familiarity with psychology staff, encouraging patients to develop a greater degree of mastery regarding their health and fostering mutual support among the patient community. The role of the ward environment in supporting access to group-based intervention is also considered.

Prioritising cardiovascular disease risk assessment to high risk individuals based on primary care records

OBJECTIVE

To provide quantitative evidence for systematically prioritising individuals for full formal cardiovascular disease (CVD) risk assessment using primary care records with a novel tool (eHEART) with age- and sex- specific risk thresholds.

METHODS AND ANALYSIS

eHEART was derived using landmark Cox models for incident CVD with repeated measures of conventional CVD risk predictors in 1,642,498 individuals from the Clinical Practice Research Datalink. Using 119,137 individuals from UK Biobank, we modelled the implications of initiating guideline-recommended statin therapy using eHEART with age- and sex-specific prioritisation thresholds corresponding to 5% false negative rates to prioritise adults aged 40-69 years in a population in England for invitation to a formal CVD risk assessment.

RESULTS

Formal CVD risk assessment on all adults would identify 76% and 49% of future CVD events amongst men and women respectively, and 93 (95% CI: 90, 95) men and 279 (95% CI: 259, 297) women would need to be screened (NNS) to prevent one CVD event. In contrast, if eHEART was first used to prioritise individuals for formal CVD risk assessment, we would identify 73% and 47% of future events amongst men and women respectively, and a NNS of 75 (95% CI: 72, 77) men and 162 (95% CI: 150, 172) women. Replacing the age- and sex-specific prioritisation thresholds with a 10% threshold identify around 10% less events.

CONCLUSIONS

The use of prioritisation tools with age- and sex-specific thresholds could lead to more efficient CVD assessment programmes with only small reductions in effectiveness at preventing new CVD events.

Using Polygenic Risk Scores for Prioritizing Individuals at Greatest Need of a Cardiovascular Disease Risk Assessment

Background The aim of this study was to provide quantitative evidence of the use of polygenic risk scores for systematically identifying individuals for invitation for full formal cardiovascular disease (CVD) risk assessment. Methods and Results A total of 108 685 participants aged 40 to 69 years, with measured biomarkers, linked primary care records, and genetic data in UK Biobank were used for model derivation and population health modeling. Prioritization tools using age, polygenic risk scores for coronary artery disease and stroke, and conventional risk factors for CVD available within longitudinal primary care records were derived using sex-specific Cox models. We modeled the implications of initiating guideline-recommended statin therapy after prioritizing individuals for invitation to a formal CVD risk assessment. If primary care records were used to prioritize individuals for formal risk assessment using age- and sex-specific thresholds corresponding to 5% false-negative rates, then the numbers of men and women needed to be screened to prevent 1 CVD event are 149 and 280, respectively. In contrast, adding polygenic risk scores to both prioritization and formal assessments, and selecting thresholds to capture the same number of events, resulted in a number needed to screen of 116 for men and 180 for women. Conclusions Using both polygenic risk scores and primary care records to prioritize individuals at highest risk of a CVD event for a formal CVD risk assessment can efficiently prioritize those who need interventions the most than using primary care records alone. This could lead to better allocation of resources by reducing the number of risk assessments in primary care while still preventing the same number of CVD events.

Patient experience of follow-up after surgery for kidney cancer: a focus group study

OBJECTIVE

To explore patient experience of follow-up care after kidney cancer surgery and to develop recommendations for best practice.

METHODS

We conducted two focus groups, including 14 participants with experience of kidney cancer follow-up after surgery, to elicit patient views on current follow-up care. Thematic analysis was used to identify unifying themes to describe the patient experience of follow-up, and the results were then used to develop a set of recommendations for best practice.

RESULTS

We identified six themes (feelings of abandonment; uncertainty about the plan; anxiety about appointments; variation in care; a need for information; and a need for emotional support) that described current patient experience and areas in which current care could be improved. In particular, while most of the participants felt that their physical needs had been met, many had struggled with unmet emotional needs and a lack of information and resources. This was especially noted in the period immediately following surgery, when feelings of abandonment were common, and around follow-up scans and routine appointments, which were a source of anxiety. Our participants also described concerns about the lack of consistency between different hospitals and centres around the United Kingdom, with differences in the content and quality of follow-up care. Based on the results, we developed a list of recommendations to address some of the challenges described through relatively minor changes to the care pathway.

CONCLUSIONS

We identified gaps and variability in current follow-up care after kidney cancer surgery, and have developed a set of recommendations that, if implemented, would improve the follow-up care experience for these patients.

Estimating the Effectiveness of Kidney Cancer Screening Within Lung Cancer Screening Programmes: A Validation in UK Biobank

In the absence of population-based screening, addition of screening for kidney cancer to lung cancer screening could provide an efficient and low-resource means to improve early detection. In this study, we used the UK Biobank cohort (n = 442 865) to determine the performance of the Yorkshire Lung Cancer Screening Trial (YLST) eligibility criteria for selecting individuals for kidney cancer screening. We measured the performance of two models widely used to determine eligibility for lung cancer screening (PLCO[m2012] and the Liverpool-Lung-Project-v2) and the performance of the combined YLST criteria. We found that the lung cancer models have discrimination (area under the receiver operating curve) between 0.60 and 0.68 for kidney cancer. In the UK, one in four cases (25%) of kidney cancer cases is expected to occur in those eligible for lung cancer screening, and one case of kidney cancer detected for every 200 people invited to lung cancer screening. These results suggest that adding kidney cancer screening to lung cancer screening would be an effective strategy to improve early detection rates of kidney cancer. However, most kidney cancers would not be picked up by this approach. This analysis does not address other important considerations about kidney cancer screening, such as overdiagnosis. PATIENT SUMMARY: It has been proposed that adding-on kidney cancer screening to lung cancer screening (both carried out by a computed tomography scan of the chest/abdomen) would be an easy and low-cost way of detecting cases of kidney cancer earlier, when these can be treated more easily. Lung cancer screening is usually targeted at people who are at a high risk (eg, older smokers); therefore, here we look at whether the same group of people are also at a high risk of kidney cancer. Our analysis shows that one in four people later diagnosed with kidney cancer are also at a high risk of lung cancer; hence, a combined screening programme could detect up to a quarter of kidney cancers.

Observation of Directed Flow of Hypernuclei _{Λ}^{3}H and _{Λ}^{4}H in sqrt[s_{NN}]=3 GeV Au+Au Collisions at RHIC

We report here the first observation of directed flow (v_{1}) of the hypernuclei _{Λ}^{3}H and _{Λ}^{4}H in mid-central Au+Au collisions at sqrt[s_{NN}]=3  GeV at RHIC. These data are taken as part of the beam energy scan program carried out by the STAR experiment. From 165×10^{6} events in 5%-40% centrality, about 8400 _{Λ}^{3}H and 5200 _{Λ}^{4}H candidates are reconstructed through two- and three-body decay channels. We observe that these hypernuclei exhibit significant directed flow. Comparing to that of light nuclei, it is found that the midrapidity v_{1} slopes of _{Λ}^{3}H and _{Λ}^{4}H follow baryon number scaling, implying that the coalescence is the dominant mechanism for these hypernuclei production in the 3 GeV Au+Au collisions.

Exploring the benefits of nature-based interventions in socio-economically deprived communities: a narrative review of the evidence to date

AIM

Socio-economic deprivation encompasses the relative disadvantage experienced by individuals or communities in relation to financial, material or social resources. Nature-based interventions (NBIs) are a public health approach that promote sustainable, healthy communities through engagement with nature and show potential to address inequalities experienced by socio-economically deprived communities. This narrative review aims to identify and evaluate the benefits of NBIs in socio-economically deprived communities.

METHOD

A systematic literature search of six electronic publication databases (APA PsycInfo, CENTRAL, CDSR, CINAHL, Medline and Web of Science) was conducted on 5 February 2021 and repeated on 30 August 2022. In total, 3852 records were identified and 18 experimental studies (published between 2015 and 2022) were included in this review.

RESULTS

Interventions including therapeutic horticulture, care farming, green exercise and wilderness arts and craft were evaluated in the literature. Key benefits were observed for cost savings, diet diversity, food security, anthropometric outcomes, mental health outcomes, nature visits, physical activity and physical health. Age, gender, ethnicity, level of engagement and perception of environment safety influenced the effectiveness of the interventions.

CONCLUSION

Results demonstrate there are clear benefits of NBIs on economic, environmental, health and social outcomes. Further research including qualitative analyses, more stringent experimental designs and use of standardised outcome measures is recommended.

Public Preferences for Determining Eligibility for Screening in Risk-Stratified Cancer Screening Programs: A Discrete Choice Experiment

BACKGROUND

Risk stratification has been proposed to improve the efficiency of population-level cancer screening. We aimed to describe and quantify the relative importance of different attributes of potential screening programs among the public, focusing on stratifying eligibility.

METHODS

We conducted a discrete choice experiment in which respondents selected between 2 hypothetical screening programs in a series of 9 questions. We presented the risk factors used to determine eligibility (age, sex, or lifestyle or genetic risk scores) and anticipated outcomes based on eligibility criteria with different sensitivity and specificity levels. We performed conditional logit regression models and used the results to estimate preferences for different approaches. We also analyzed free-text comments on respondents' views on the programs.

RESULTS

A total of 1,172 respondents completed the survey. Sensitivity was the most important attribute (7 and 11 times more important than specificity and risk factors, respectively). Eligibility criteria based on age and sex or genetics were preferred over age alone and lifestyle risk scores. Phenotypic and polygenic risk prediction models would be more acceptable than screening everyone aged 55 to 70 y if they had high discrimination (area under the receiver-operating characteristic curve ≥0.75 and 0.80, respectively).

LIMITATIONS

Although our sample was representative with respect to age, sex, and ethnicity, it may not be representative of the UK population regarding other important characteristics. Also, some respondents may have not understood all the information provided to inform decision making.

CONCLUSIONS

The public prioritized lives saved from cancer over reductions in numbers screened or experiencing unnecessary follow-up. Incorporating personal-level risk factors into screening eligibility criteria is acceptable to the public if it increases sensitivity; therefore, maximizing sensitivity in model development and communication could increase uptake.

HIGHLIGHTS

The public prioritized lives saved when considering changing from age-based eligibility criteria to risk-stratified cancer screening over reductions in numbers of people being screened or experiencing unnecessary follow-up.The risk stratification strategy used to do this was the least important component, although age plus sex or genetics were relatively preferable to using age alone and lifestyle risk scores.Communication strategies that emphasize improvements in the numbers of cancers detected or not missed across the population are more likely to be salient than reductions in unnecessary investigations or follow-up among some groups.Future research should focus on developing implementation strategies that maximize gains in sensitivity within the context of resource constraints and how to present attributes relating to specificity to facilitate understanding and informed decision making.

Measurement of Sequential ϒ Suppression in Au+Au Collisions at sqrt[s_{NN}]=200 GeV with the STAR Experiment

We report on measurements of sequential ϒ suppression in Au+Au collisions at sqrt[s_{NN}]=200  GeV with the STAR detector at the Relativistic Heavy Ion Collider (RHIC) through both the dielectron and dimuon decay channels. In the 0%-60% centrality class, the nuclear modification factors (R_{AA}), which quantify the level of yield suppression in heavy-ion collisions compared to p+p collisions, for ϒ(1S) and ϒ(2S) are 0.40±0.03(stat)±0.03(sys)±0.09(norm) and 0.26±0.08(stat)±0.02(sys)±0.06(norm), respectively, while the upper limit of the ϒ(3S) R_{AA} is 0.17 at a 95% confidence level. This provides experimental evidence that the ϒ(3S) is significantly more suppressed than the ϒ(1S) at RHIC. The level of suppression for ϒ(1S) is comparable to that observed at the much higher collision energy at the Large Hadron Collider. These results point to the creation of a medium at RHIC whose temperature is sufficiently high to strongly suppress excited ϒ states.

Beam Energy Dependence of Fifth- and Sixth-Order Net-Proton Number Fluctuations in Au+Au Collisions at RHIC

We report the beam energy and collision centrality dependence of fifth and sixth order cumulants (C_{5}, C_{6}) and factorial cumulants (κ_{5}, κ_{6}) of net-proton and proton number distributions, from center-of-mass energy (sqrt[s_{NN}]) 3 GeV to 200 GeV Au+Au collisions at RHIC. Cumulant ratios of net-proton (taken as proxy for net-baryon) distributions generally follow the hierarchy expected from QCD thermodynamics, except for the case of collisions at 3 GeV. The measured values of C_{6}/C_{2} for 0%-40% centrality collisions show progressively negative trend with decreasing energy, while it is positive for the lowest energy studied. These observed negative signs are consistent with QCD calculations (for baryon chemical potential, μ_{B}≤110  MeV) which contains the crossover transition range. In addition, for energies above 7.7 GeV, the measured proton κ_{n}, within uncertainties, does not support the two-component (Poisson+binomial) shape of proton number distributions that would be expected from a first-order phase transition. Taken in combination, the hyperorder proton number fluctuations suggest that the structure of QCD matter at high baryon density, μ_{B}∼750  MeV at sqrt[s_{NN}]=3  GeV is starkly different from those at vanishing μ_{B}∼24  MeV at sqrt[s_{NN}]=200  GeV and higher collision energies.

A realist approach to understanding alliancing within Local Government public health and social care service provision

BACKGROUND

Within the current context of continued austerity and post-pandemic recovery, it remains important that Local Government services address the increasing needs of residents as cost-effectively as possible. Alliancing, whereby services work collaboratively focusing on the 'whole-system', has gained popularity as a tool with the potential to support collaborative whole systems approaches. This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health, wider National Health Service (NHS) and social care-related services.

METHODS

A realist literature synthesis was undertaken in order to identify underlying generative mechanisms associated with alliancing, the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result. An iterative approach was taken, using a recent systematic review of the effectiveness of Alliancing, online database searches, and grey literature searches.

RESULTS

Three mechanistic components were identified within the data as being core to the successful implementation of alliances in public health and social care-related services within Local Government: (i) Achieving a system-level approach; (ii) placing local populations at the heart of the system; and (iii) creating a cultural shift. Programme theories were postulated within these components.

CONCLUSIONS

The alliancing approach offers an opportunity to achieve system-level change with the potential to benefit local populations. The realist synthesis approach taken within this study has provided insights into the necessary contextual and mechanistic factors of the Alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

Diagnostic Performance of Biomarkers for Bladder Cancer Detection Suitable for Community and Primary Care Settings: A Systematic Review and Meta-Analysis

Evidence on the use of biomarkers to detect bladder cancer in the general population is scarce. This study aimed to systematically review evidence on the diagnostic performance of biomarkers which might be suitable for use in community and primary care settings [PROSPERO Registration: CRD42021258754]. Database searches on MEDLINE and EMBASE from January 2000 to May 2022 resulted in 4914 unique citations, 44 of which met inclusion criteria. Included studies reported on 112 biomarkers and combinations. Heterogeneity of designs, populations and outcomes allowed for the meta-analysis of three biomarkers identified in at least five studies (NMP-22, UroVysion, uCyt+). These three biomarkers showed similar discriminative ability (adjusted AUC estimates ranging from 0.650 to 0.707), although for NMP-22 and UroVysion there was significant unexplained heterogeneity between included studies. Narrative synthesis revealed the potential of these biomarkers for use in the general population based on their reported clinical utility, including effects on clinicians, patients, and the healthcare system. Finally, we identified some promising novel biomarkers and biomarker combinations (N < 3 studies for each biomarker/combination) with negative predictive values of ≥90%. These biomarkers have potential for use as a triage tool in community and primary care settings for reducing unnecessary specialist referrals. Despite promising emerging evidence, further validation studies in the general population are required at different stages within the diagnostic pathway.

Collision-System and Beam-Energy Dependence of Anisotropic Flow Fluctuations

Elliptic flow measurements from two-, four-, and six-particle correlations are used to investigate flow fluctuations in collisions of U+U at sqrt[s_{NN}]=193  GeV, Cu+Au at sqrt[s_{NN}]=200  GeV and Au+Au spanning the range sqrt[s_{NN}]=11.5-200  GeV. The measurements show a strong dependence of the flow fluctuations on collision centrality, a modest dependence on system size, and very little if any, dependence on particle species and beam energy. The results, when compared to similar LHC measurements, viscous hydrodynamic calculations, and trento model eccentricities, indicate that initial-state-driven fluctuations predominate the flow fluctuations generated in the collisions studied.

The current state of genetic risk models for the development of kidney cancer: a review and validation

OBJECTIVE

To review the current state of genetic risk models for predicting the development of kidney cancer, by identifying and comparing the performance of published models.

METHODS

Risk models were identified from a recent systematic review and the Cancer-PRS web directory. A narrative synthesis of the models, previous validation studies and related genome-wide association studies (GWAS) was carried out. The discrimination and calibration of the identified models was then assessed and compared in the UK Biobank (UKB) cohort (cases, 452; controls, 487 925).

RESULTS

A total of 39 genetic models predicting the development of kidney cancer were identified and 31 were validated in the UKB. Several of the genetic-only models (seven of 25) and most of the mixed genetic-phenotypic models (five of six) had some discriminatory ability (area under the receiver operating characteristic curve >0.5) in this cohort. In general, models containing a larger number of genetic variants identified in GWAS performed better than models containing a small number of variants associated with known causal pathways. However, the performance of the included models was consistently poorer than genetic risk models for other cancers.

CONCLUSIONS

Although there is potential for genetic models to identify those at highest risk of developing kidney cancer, their performance is poorer than the best genetic risk models for other cancers. This may be due to the comparatively small number of genetic variants associated with kidney cancer identified in GWAS to date. The development of improved genetic risk models for kidney cancer is dependent on the identification of more variants associated with this disease. Whether these will have utility within future kidney cancer screening pathways is yet to determined.

Risk models for recurrence and survival after kidney cancer: a systematic review

OBJECTIVE

To systematically identify and compare the performance of prognostic models providing estimates of survival or recurrence of localized renal cell cancer (RCC) in patients treated with surgery with curative intent.

MATERIALS AND METHODS

We performed a systematic review (PROSPERO CRD42019162349). We searched Medline, EMBASE and the Cochrane Library from 1 January 2000 to 12 December 2019 to identify studies reporting the performance of one or more prognostic model(s) that predict recurrence-free survival (RFS), cancer-specific survival (CSS) or overall survival (OS) in patients who have undergone surgical resection for localized RCC. For each outcome we summarized the discrimination of each model using the C-statistic and performed multivariate random-effects meta-analysis of the logit transformed C-statistic to rank the models.

RESULTS

Of a total of 13 549 articles, 57 included data on the performance of 22 models in external populations. C-statistics ranged from 0.59 to 0.90. Several risk models were assessed in two or more external populations and had similarly high discriminative performance. For RFS, these were the Sorbellini, Karakiewicz, Leibovich and Kattan models, with the UCLA Integrated Staging System model also having similar performance in European/US populations. All had C-statistics ≥0.75 in at least half of the validations. For CSS, they the models with the highest discriminative performance in two or more external validation studies were the Zisman, Stage, Size, Grade and Necrosis (SSIGN), Karakiewicz, Leibovich and Sorbellini models (C-statistic ≥0.80 in at least half of the validations), and for OS they were the Leibovich, Karakiewicz, Sorbellini and SSIGN models. For all outcomes, the models based on clinical features at presentation alone (Cindolo and Yaycioglu) had consistently lower discrimination. Estimates of model calibration were only infrequently included but most underestimated survival.

CONCLUSION

Several models had good discriminative ability, with there being no single 'best' model. The choice from these models for each setting should be informed by both the comparative performance and availability of factors included in the models. All would need recalibration if used to provide absolute survival estimates.

301 BENEFITS OF ENVIRONMENTAL MUSIC THERAPY IN AN ACUTE HOSPITAL

Background

Environmental Music Therapy (EMT) uses live music played by a music therapist to enhance the surrounding environment and is increasingly used in clinical settings. Studies show that EMT may reduce anxiety, enhance wellbeing, promote better communication between patients and staff, and reduce patient perception of waiting times in hospital. We aimed to explore the benefit of EMT for older adults in a geriatric outpatient setting and on rehabilitation wards.

Methods

Harp music was played by a music therapist in the vicinity of ambulatory clinics and on rehabilitation wards for 4 hours per week (over a 2-day period) for 20 weeks. Music exposure on any given day was to an estimated 50 outpatients, as well as 50 people passing the vicinity or to about 30 patients on the rehabilitation ward. Music was selected and played in a dynamic process, responding to verbal and non-verbal reactions of patients, family, and staff. Voluntary responses were recorded and collated.

Results

There were 36 recorded responses and all reflected positively on EMT. Patients cited that the music created a welcoming space and stimulated interaction and conversation. Several patients waiting for their clinic appointment noted that it distracted from fearful expectation and was a source of comfort. Some commented that they felt more relaxed and that it reduced stress. On rehabilitation wards, patients found familiar music to be calming with nurses citing that it stimulated social interaction between patients, family and staff. Responses to EMT gave insights that resulted in patient referrals for music therapy.

Conclusion

Environmental music played by a music therapist was found to modify patient hospital experiences. In particular, it appeared to reduce self-perceived stress and stimulate positive social interaction and conversation. This supports the use of EMT to advance the integration of the arts for wellbeing in an acute hospital.

Evidence for Nonlinear Gluon Effects in QCD and Their Mass Number Dependence at STAR

The STAR Collaboration reports measurements of back-to-back azimuthal correlations of di-π^{0}s produced at forward pseudorapidities (2.6<η<4.0) in p+p, p+Al, and p+Au collisions at a center-of-mass energy of 200 GeV. We observe a clear suppression of the correlated yields of back-to-back π^{0} pairs in p+Al and p+Au collisions compared to the p+p data. The observed suppression of back-to-back pairs as a function of transverse momentum suggests nonlinear gluon dynamics arising at high parton densities. The larger suppression found in p+Au relative to p+Al collisions exhibits a dependence of the saturation scale Q_{s}^{2} on the mass number A. A linear scaling of the suppression with A^{1/3} is observed with a slope of -0.09±0.01.

A community jury study exploring the public acceptability of using risk stratification to determine eligibility for cancer screening

INTRODUCTION

Using risk stratification to determine eligibility for cancer screening is likely to improve the efficiency of screening programmes by targeting resources towards those most likely to benefit. We aimed to explore the implications of this approach from a societal perspective by understanding public views on the most acceptable stratification strategies.

METHODS

We conducted three online community juries with 9 or 10 participants in each. Participants were purposefully sampled by age (40-79 years), sex, ethnicity, social grade and English region. On the first day, participants were informed of the potential benefits and harms of cancer screening and the implications of different ways of introducing stratification using scenarios based on phenotypic and genetic risk scores. On the second day, participants deliberated to reach a verdict on the research question, 'Which approach(es) to inviting people to screening are acceptable, and under what circumstances?' Deliberations and feedback were recorded and analysed using thematic analysis.

RESULTS

Across the juries, the principle of risk stratification was generally considered to be an acceptable approach for determining eligibility for screening. Disregarding increasing capacity, the participants considered it to enable efficient resource allocation to high-risk individuals and could see how it might help to save lives. However, there were concerns regarding fair implementation, particularly how the risk assessment would be performed at scale and how people at low risk would be managed. Some favoured using the most accurate risk prediction model whereas others thought that certain risk factors should be prioritized (particularly factors considered as non-modifiable and relatively stable, such as genetics and family history). Transparently justifying the programme and public education about cancer risk emerged as important contributors to acceptability.

CONCLUSION

Using risk stratification to determine eligibility for cancer screening was acceptable to informed members of the public, particularly if it included risk factors they considered fair and when communicated transparently.

PATIENT OR PUBLIC CONTRIBUTION

Two patient and public involvement representatives were involved throughout this study. They were not involved in synthesizing the results but contributed to producing study materials, co-facilitated the community juries and commented on the interpretation of the findings and final report.

Measurements of Proton High-Order Cumulants in sqrt[s_{NN}]=3 GeV Au+Au Collisions and Implications for the QCD Critical Point

We report cumulants of the proton multiplicity distribution from dedicated fixed-target Au+Au collisions at sqrt[s_{NN}]=3.0  GeV, measured by the STAR experiment in the kinematic acceptance of rapidity (y) and transverse momentum (p_{T}) within -0.5<y<0 and 0.4<p_{T}<2.0  GeV/c. In the most central 0%-5% collisions, a proton cumulant ratio is measured to be C_{4}/C_{2}=-0.85±0.09 (stat)±0.82 (syst), which is 2σ below the Poisson baseline with respect to both the statistical and systematic uncertainties. The hadronic transport UrQMD model reproduces our C_{4}/C_{2} in the measured acceptance. Compared to higher energy results and the transport model calculations, the suppression in C_{4}/C_{2} is consistent with fluctuations driven by baryon number conservation and indicates an energy regime dominated by hadronic interactions. These data imply that the QCD critical region, if created in heavy-ion collisions, could only exist at energies higher than 3 GeV.

Measurements of _{Λ}^{3}H and _{Λ}^{4}H Lifetimes and Yields in Au+Au Collisions in the High Baryon Density Region

We report precision measurements of hypernuclei _{Λ}^{3}H and _{Λ}^{4}H lifetimes obtained from Au+Au collisions at sqrt[s_{NN}]=3.0  GeV and 7.2 GeV collected by the STAR experiment at the Relativistic Heavy Ion Collider, and the first measurement of _{Λ}^{3}H and _{Λ}^{4}H midrapidity yields in Au+Au collisions at sqrt[s_{NN}]=3.0  GeV. _{Λ}^{3}H and _{Λ}^{4}H, being the two simplest bound states composed of hyperons and nucleons, are cornerstones in the field of hypernuclear physics. Their lifetimes are measured to be 221±15(stat)±19(syst)  ps for _{Λ}^{3}H and 218±6(stat)±13(syst)  ps for _{Λ}^{4}H. The p_{T}-integrated yields of _{Λ}^{3}H and _{Λ}^{4}H are presented in different centrality and rapidity intervals. It is observed that the shape of the rapidity distribution of _{Λ}^{4}H is different for 0%-10% and 10%-50% centrality collisions. Thermal model calculations, using the canonical ensemble for strangeness, describes the _{Λ}^{3}H yield well, while underestimating the _{Λ}^{4}H yield. Transport models, combining baryonic mean-field and coalescence (jam) or utilizing dynamical cluster formation via baryonic interactions (phqmd) for light nuclei and hypernuclei production, approximately describe the measured _{Λ}^{3}H and _{Λ}^{4}H yields. Our measurements provide means to precisely assess our understanding of the fundamental baryonic interactions with strange quarks, which can impact our understanding of more complicated systems involving hyperons, such as the interior of neutron stars or exotic hypernuclei.

Validation and public health modelling of risk prediction models for kidney cancer using the UK Biobank

OBJECTIVES

To externally validate risk models for the detection of kidney cancer, as early detection of kidney cancer improves survival and stratifying the population using risk models could enable an individually tailored screening programme.

METHODS

We validated the performance of 30 existing phenotypic models predicting the risk of kidney cancer in the UK Biobank cohort (n = 450 687). We compared the discrimination and calibration of models for men, women, and a mixed-sex cohort. Population level data were used to estimate model performance in a screening scenario for a range of risk thresholds (6-year risk: 0.1-1.0%).

RESULTS

In all, 10 models had reasonable discrimination (area under the receiver-operating characteristic curve >0.60), although some had poor calibration. Modelling demonstrated similar performance of the best models over a range of thresholds. The models showed an improvement in ability to identify cases compared to age- and sex-based screening. All the models performed less well in women than men.

CONCLUSIONS

The present study is the first comprehensive external validation of risk models for kidney cancer. The best-performing models are better at identifying individuals at high risk of kidney cancer than age and sex alone; however, the benefits are relatively small. Feasibility studies are required to determine applicability to a screening programme.

Probing the Gluonic Structure of the Deuteron with J/ψ Photoproduction in d+Au Ultraperipheral Collisions

Understanding gluon density distributions and how they are modified in nuclei are among the most important goals in nuclear physics. In recent years, diffractive vector meson production measured in ultraperipheral collisions (UPCs) at heavy-ion colliders has provided a new tool for probing the gluon density. In this Letter, we report the first measurement of J/ψ photoproduction off the deuteron in UPCs at the center-of-mass energy sqrt[s_{NN}]=200  GeV in d+Au collisions. The differential cross section as a function of momentum transfer -t is measured. In addition, data with a neutron tagged in the deuteron-going zero-degree calorimeter is investigated for the first time, which is found to be consistent with the expectation of incoherent diffractive scattering at low momentum transfer. Theoretical predictions based on the color glass condensate saturation model and the leading twist approximation nuclear shadowing model are compared with the data quantitatively. A better agreement with the saturation model has been observed. With the current measurement, the results are found to be directly sensitive to the gluon density distribution of the deuteron and the deuteron breakup process, which provides insights into the nuclear gluonic structure.

Search for the Chiral Magnetic Effect via Charge-Dependent Azimuthal Correlations Relative to Spectator and Participant Planes in Au+Au Collisions at sqrt[s_{NN}]=200 GeV

The chiral magnetic effect (CME) refers to charge separation along a strong magnetic field due to imbalanced chirality of quarks in local parity and charge-parity violating domains in quantum chromodynamics. The experimental measurement of the charge separation is made difficult by the presence of a major background from elliptic azimuthal anisotropy. This background and the CME signal have different sensitivities to the spectator and participant planes, and could thus be determined by measurements with respect to these planes. We report such measurements in Au+Au collisions at a nucleon-nucleon center-of-mass energy of 200 GeV at the Relativistic Heavy-Ion Collider. It is found that the charge separation, with the flow background removed, is consistent with zero in peripheral (large impact parameter) collisions. Some indication of finite CME signals is seen in midcentral (intermediate impact parameter) collisions. Significant residual background effects may, however, still be present.

Risk prediction models for symptomatic patients with bladder and kidney cancer: a systematic review

BACKGROUND

Timely diagnosis of bladder and kidney cancer is key to improving clinical outcomes. Given the challenges of early diagnosis, models incorporating clinical symptoms and signs may be helpful to primary care clinicians when triaging at-risk patients.

AIM

To identify and compare published models that use clinical signs and symptoms to predict the risk of undiagnosed prevalent bladder or kidney cancer.

DESIGN AND SETTING

Systematic review.

METHOD

A search identified primary research reporting or validating models predicting the risk of bladder or kidney cancer in MEDLINE and EMBASE. After screening identified studies for inclusion, data were extracted onto a standardised form. The risk models were classified using TRIPOD guidelines and evaluated using the PROBAST assessment tool.

RESULTS

The search identified 20 661 articles. Twenty studies (29 models) were identified through screening. All the models included haematuria (visible, non-visible, or unspecified), and seven included additional signs and symptoms (such as abdominal pain). The models combined clinical features with other factors (including demographic factors and urinary biomarkers) to predict the risk of undiagnosed prevalent cancer. Several models (n = 13) with good discrimination (area under the receiver operating curve >0.8) were identified; however, only eight had been externally validated. All of the studies had either high or unclear risk of bias.

CONCLUSION

Models were identified that could be used in primary care to guide referrals, with potential to identify lower-risk patients with visible haematuria and to stratify individuals who present with non-visible haematuria. However, before application in general practice, external validations in appropriate populations are required.

Measurement of the Sixth-Order Cumulant of Net-Proton Multiplicity Distributions in Au+Au Collisions at sqrt[s_{NN}]=27, 54.4, and 200 GeV at RHIC

According to first-principle lattice QCD calculations, the transition from quark-gluon plasma to hadronic matter is a smooth crossover in the region μ_{B}≤T_{c}. In this range the ratio, C_{6}/C_{2}, of net-baryon distributions are predicted to be negative. In this Letter, we report the first measurement of the midrapidity net-proton C_{6}/C_{2} from 27, 54.4, and 200 GeV Au+Au collisions at the Relativistic Heavy Ion Collider (RHIC). The dependence on collision centrality and kinematic acceptance in (p_{T}, y) are analyzed. While for 27 and 54.4 GeV collisions the C_{6}/C_{2} values are close to zero within uncertainties, it is observed that for 200 GeV collisions, the C_{6}/C_{2} ratio becomes progressively negative from peripheral to central collisions. Transport model calculations without critical dynamics predict mostly positive values except for the most central collisions within uncertainties. These observations seem to favor a smooth crossover in the high-energy nuclear collisions at top RHIC energy.

Risk Prediction Models for Kidney Cancer: A Systematic Review

CONTEXT

Early detection of kidney cancer improves survival; however, low prevalence means that population-wide screening may be inefficient. Stratification of the population into risk categories could allow for the introduction of a screening programme tailored to individuals.

OBJECTIVE

This review will identify and compare published models that predict the risk of developing kidney cancer in the general population.

EVIDENCE ACQUISITION

A search identified primary research reporting or validating models predicting the risk of kidney cancer in Medline and EMBASE. After screening identified studies for inclusion, we extracted data onto a standardised form. The risk models were classified using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) guidelines and evaluated using the PROBAST assessment tool.

EVIDENCE SYNTHESIS

The search identified 15 281 articles. Sixty-two satisfied the inclusion criteria; performance measures were provided for 11 models. Some models predicted the risk of prevalent undiagnosed disease and others future incident disease. Six of the models had been validated, two using external populations. The most commonly included risk factors were age, smoking status, and body mass index. Most of the models had acceptable-to-good discrimination (area under the receiver-operating curve >0.7) in development and validation. Many models also had high specificity; however, several had low sensitivity. The highest performance was seen for the models using only biomarkers to detect kidney cancer; however, these were developed and validated in small case-control studies.

CONCLUSIONS

We identified a small number of risk models that could be used to stratify the population according to the risk of kidney cancer. Most exhibit reasonable discrimination, but a few have been validated externally in population-based studies.

PATIENT SUMMARY

In this review, we looked at mathematical models predicting the likelihood of an individual developing kidney cancer. We found several suitable models, using a range of risk factors (such as age and smoking) to predict the risk for individuals. Most of the models identified require further testing in the general population to confirm their usefulness.

Reasons for intending to accept or decline kidney cancer screening: thematic analysis of free text from an online survey

OBJECTIVES

Kidney cancer has been identified as a disease for which screening might provide significant benefit for patients. The aim of this study was to understand in detail the facilitators and barriers towards uptake of a future kidney cancer screening programme, and to compare these across four proposed screening modalities.

DESIGN

An online survey including free-text responses.

SETTING

UK PARTICIPANTS: 668 adults PRIMARY AND SECONDARY OUTCOME MEASURES: The survey assessed participants' self-reported intention to take-up kidney cancer screening with four different test methods (urine test, blood test, ultrasound scan and low-dose CT). We conducted thematic analysis of 2559 free-text comments made within the survey using an inductive approach.

RESULTS

We identified five overarching themes that influenced screening intention: 'personal health beliefs', 'practicalities', 'opinions of the test', 'attitudes towards screening' and 'cancer apprehension'. Overall, participants considered the tests presented as simple to complete and the benefits of early detection to outweigh any drawbacks to screening. Dominant facilitators and barriers varied with patterns of intention to take up screening across the four tests. Most intended to take up screening by all four tests, and for these participants, screening was seen as a positive health behaviour. A significant minority were driven by practicalities and the risks of the tests offered. A smaller proportion intended to reject all forms of screening offered, often due to fear or worry about results and unnecessary medical intervention or a general negative view of screening.

CONCLUSIONS

Most individuals would accept kidney cancer screening by any of the four test options presented because of strong positive attitudes towards screening in general and the perceived simplicity of the tests. Providing information about the rationale for screening in general and the potential benefits of early detection will be important to optimise uptake among uncertain individuals.

Acceptability and potential impact on uptake of using different risk stratification approaches to determine eligibility for screening: A population-based survey

BACKGROUND

Using risk stratification approaches to determine eligibility has the potential to improve efficiency of screening.

OBJECTIVES

To compare the public acceptability and potential impact on uptake of using different approaches to determine eligibility for screening.

DESIGN

An online population-based survey of 668 adults in the UK aged 45-79 including a series of scenarios in the context of a potential kidney cancer screening programme in which eligibility was determined by age, sex, age and sex combined, a simple risk score (age, sex, body mass index, smoking status), a complex risk score additionally incorporating family history and lifestyle, or a genetic risk score.

OUTCOME MEASURES

We used multi-level ordinal logistic regression to compare acceptability and potential uptake within individuals and multivariable ordinal logistic regression differences between individuals.

RESULTS

Using sex, age and sex, or the simple risk score were less acceptable than age (P < .0001). All approaches were less acceptable to women than men. Over 70% were comfortable waiting until they were older if the complex risk score or genetics indicated a low risk. If told they were high risk, 85% would be more likely to take up screening. Being told they were low risk had no overall influence on uptake.

CONCLUSIONS

Varying the starting age of screening based on estimated risk from models incorporating phenotypic or genetic risk factors would be acceptable to most individuals and may increase uptake.

PATIENT OR PUBLIC CONTRIBUTION

Two members of the public contributed to the development of the survey and have commented on this paper.

Public attitudes towards screening for kidney cancer: an online survey

BACKGROUND

Kidney cancer is often asymptomatic, leading to proposals for a screening programme. The views of the public towards introducing a new screening programme for kidney cancer are unknown. The aim of this study was to explore attitudes towards kidney cancer screening and factors influencing intention to attend a future screening programme.

METHODS

We conducted an online population-based survey of 1021 adults aged 45-77 years. The main outcome measure was intention to attend four possible screening tests (urine, blood, ultrasound scan, low-dose CT) as well as extended low-dose CT scans within lung cancer screening programmes. We used multivariable regression to examine the association between intention and each screening test.

RESULTS

Most participants stated that they would be 'very likely' or 'likely' to undergo each of the screening tests [urine test: n = 961 (94.1%); blood test: n = 922 (90.3%); ultrasound: n = 914 (89.5%); low-dose CT: n = 804 (78.8%); lung CT: n = 962 (95.2%)]. Greater intention to attend was associated with higher general cancer worry and less perceived burden/inconvenience about the screening tests. Less worry about the screening test was also associated with higher intention to attend, but only in those with low general cancer worry (cancer worry scale ≤ 5). Compared with intention to take up screening with a urine test, participants were half as likely to report that they intended to undergo blood [OR 0.56 (0.43-0.73)] or ultrasound [OR 0.50 (0.38-0.67)] testing, and half as likely again to report that they intended to take part in a screening programme featuring a low dose CT scan for kidney cancer screening alone [OR 0.19 (0.14-0.27)].

CONCLUSION

Participants in this study expressed high levels of intention to accept an invitation to screening for kidney cancer, both within a kidney cancer specific screening programme and in conjunction with lung cancer screening. The choice of screening test is likely to influence uptake. Together these findings support on-going research into kidney cancer screening tests and the potential for combining kidney cancer screening with existing or new screening programmes.

Patterns of use of secondary mental health services before and during COVID-19 lockdown: observational study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on both the physical and mental well-being of the global population. Relatively few studies have measured the impact of lockdown on utilisation of secondary mental health services in England.

AIMS

To describe secondary mental health service utilisation pre-lockdown and during lockdown within Leicestershire, UK, and the numbers of serious incidents during this time frame.

METHOD

Data pertaining to mental health referral and hospital admissions to adult mental health, child and adolescent mental health, intellectual disability and mental health services for older people were collated retrospectively from electronic records for both 8 weeks pre-lockdown and the first 8 weeks of lockdown in England. Serious incidents during this time frame were also analysed.

RESULTS

Significantly (P < 0.05) reduced referrals to a diverse range of mental health services were observed during lockdown, including child and adolescent, adult, older people and intellectual disability services. Although admissions remained relatively stable before and during lockdown for several services, admissions to both acute adult and mental health services for older people were significantly (P < 0.05) reduced during lockdown. Numbers of serious incidents in the pre-lockdown and lockdown periods were similar, with 23 incidents pre-lockdown, compared with 20 incidents in lockdown.

CONCLUSIONS

To the best of our knowledge, this is the first UK-based study reporting patterns of use of mental health services immediately prior to and during COVID-19 lockdown. Overall numbers of referrals and admissions reduced following commencement of COVID-19 lockdown. Potential reasons for these observations are discussed.

The mevalonate precursor enzyme HMGCS1 is a novel marker and key mediator of cancer stem cell enrichment in luminal and basal models of breast cancer

The definitive characterization of common cancer stem cell (CSCs) subpopulations in breast cancer subtypes with distinct genotypic and phenotypic features remains an ongoing challenge. In this study, we have used a non-biased genome wide screening approach to identify transcriptional networks that may be specific to the CSC subpopulations in both luminal and basal breast cancer subtypes. In depth studies of three CSC-enriched breast cancer cell lines representing various subtypes of breast cancer revealed a striking hyperactivation of the mevalonate metabolic pathway in comparison to control cells. The upregulation of metabolic networks is a key feature of tumour cells securing growth and proliferative capabilities and dysregulated mevalonate metabolism has been associated with tumour malignancy and cellular transformation in breast cancer. Furthermore, accumulating evidence suggests that Simvastatin therapy, a mevalonate pathway inhibitor, could affect breast cancer progression and reduce breast cancer recurrence. When detailing the mevalonate pathway in breast cancer using a single-cell qPCR, we identified the mevalonate precursor enzyme, HMGCS1, as a specific marker of CSC-enriched subpopulations within both luminal and basal tumour subtypes. Down-regulation of HMGCS1 also decreased the CSC fraction and function in various model systems, suggesting that HMGCS1 is essential for CSC-activities in breast cancer in general. These data was supported by strong associations between HMGCS1 expression and aggressive features, such as high tumour grade, p53 mutations as well as ER-negativity in lymph node positive breast cancer. Importantly, loss of HMGCS1 also had a much more pronounced effect on CSC-activities compared to treatment with standard doses of Simvastatin. Taken together, this study highlights HMGCS1 as a potential gatekeeper for dysregulated mevalonate metabolism important for CSC-features in both luminal and basal breast cancer subtypes. Pharmacological inhibition of HMGCS1 could therefore be a superior novel treatment approach for breast cancer patients via additional CSC blocking functions.

A role for CBFβ in maintaining the metastatic phenotype of breast cancer cells

Epithelial to mesenchymal transition (EMT) is a dynamic process that drives cancer cell plasticity and is thought to play a major role in metastasis. Here we show, using MDA-MB-231 cells as a model, that the plasticity of at least some metastatic breast cancer cells is dependent on the transcriptional co-regulator CBFβ. We demonstrate that CBFβ is essential to maintain the mesenchymal phenotype of triple-negative breast cancer cells and that CBFβ-depleted cells undergo a mesenchymal to epithelial transition (MET) and re-organise into acini-like structures, reminiscent of those formed by epithelial breast cells. We subsequently show, using an inducible CBFβ system, that the MET can be reversed, thus demonstrating the plasticity of CBFβ-mediated EMT. Moreover, the MET can be reversed by expression of the EMT transcription factor Slug whose expression is dependent on CBFβ. Finally, we demonstrate that loss of CBFβ inhibits the ability of metastatic breast cancer cells to invade bone cell cultures and suppresses their ability to form bone metastases in vivo. Together our findings demonstrate that CBFβ can determine the plasticity of the metastatic cancer cell phenotype, suggesting that its regulation in different micro-environments may play a key role in the establishment of metastatic tumours.

Software tools to support title and abstract screening for systematic reviews in healthcare: an evaluation

BACKGROUND

Systematic reviews are vital to the pursuit of evidence-based medicine within healthcare. Screening titles and abstracts (T&Ab) for inclusion in a systematic review is an intensive, and often collaborative, step. The use of appropriate tools is therefore important. In this study, we identified and evaluated the usability of software tools that support T&Ab screening for systematic reviews within healthcare research.

METHODS

We identified software tools using three search methods: a web-based search; a search of the online "systematic review toolbox"; and screening of references in existing literature. We included tools that were accessible and available for testing at the time of the study (December 2018), do not require specific computing infrastructure and provide basic screening functionality for systematic reviews. Key properties of each software tool were identified using a feature analysis adapted for this purpose. This analysis included a weighting developed by a group of medical researchers, therefore prioritising the most relevant features. The highest scoring tools from the feature analysis were then included in a user survey, in which we further investigated the suitability of the tools for supporting T&Ab screening amongst systematic reviewers working in medical research.

RESULTS

Fifteen tools met our inclusion criteria. They vary significantly in relation to cost, scope and intended user community. Six of the identified tools (Abstrackr, Colandr, Covidence, DRAGON, EPPI-Reviewer and Rayyan) scored higher than 75% in the feature analysis and were included in the user survey. Of these, Covidence and Rayyan were the most popular with the survey respondents. Their usability scored highly across a range of metrics, with all surveyed researchers (n = 6) stating that they would be likely (or very likely) to use these tools in the future.

CONCLUSIONS

Based on this study, we would recommend Covidence and Rayyan to systematic reviewers looking for suitable and easy to use tools to support T&Ab screening within healthcare research. These two tools consistently demonstrated good alignment with user requirements. We acknowledge, however, the role of some of the other tools we considered in providing more specialist features that may be of great importance to many researchers.

Hypoxia-induced secretion stimulates breast cancer stem cell regulatory signalling pathways

It is well known that tumour cells are dependent on communication with the tumour microenvironment. Previously, it has been shown that hypoxia (HX) induces pronounced, diverse and direct effects on cancer stem cell (CSC) qualities in different breast cancer subtypes. Here, we describe the mechanism by which HX-induced secretion influences the spreading of CSCs. Conditioned media (CM) from estrogen receptor (ER)-α-positive hypoxic breast cancer cell cultures increased the fraction of CSCs compared to normal growth conditions, as determined using sets of CSC assays and model systems. In contrast, media from ERα-negative hypoxic cell cultures instead decreased this key subpopulation of cancer cells. Further, there was a striking overrepresentation of JAK-STAT-associated cytokines in both the ERα-positive and ERα-negative linked hypoxic responses as determined by a protein screen of the CM. JAK-STAT inhibitors and knockdown experiments further supported the hypothesis that this pathway is critical for the CSC-activating and CSC-inactivating effects induced by hypoxic secretion. We also observed that the interleukin-6-JAK2-STAT3 axis was specifically central for the ERα-negative hypoxic behaviour. Our results underline the importance of considering breast cancer subtypes in treatments targeting JAK-STAT or HX-associated processes and indicate that HX is not only a confined tumour biological event, but also influences key tumour properties in widespread normoxic microenvironments.

Abstract P2-06-11: Sortilin targeted therapy in breast cancer with elevated progranulin expression

Background: A major challenge concerning breast cancer therapy is the occasional lack of effects using drugs that target cancer cells unspecifically. One possible explanation for this treatment failure is the existence of the small subpopulation of breast cancer stem cells that are believed to be more resistant towards conventional therapy and possesses the ability to drive tumor formation and disease progression. Cytokines secreted by nearby cells and other factors in the surrounding tumor microenvironment further stimulate the cancer cells, contributing to a heterogeneous and potentially more treatment resistant tumor. Thus, a more specific treatment approach targeting the breast cancer stem cell niche is crucial in preventing disease recurrences. In a cytokine screen, we identified progranulin as one of the main compounds secreted from cells exposed to hypoxia, leading to cancer stem cell propagation. Progranulin is involved in biological processes such as wound healing, inflammation and cancer progression. Progranulin and its receptor sortilin are known to be highly expressed in subgroups of breast cancer and are further associated with a clinically aggressive phenotype.

Methods/Results: By carrying out a number of in vitro and in vivo like screening assays, we demonstrate that progranulin influences the stem cell population in breast cancer and is responsible for spreading a cancer stem cell promoting signal to normoxic tumor areas. In breast cancer, progranulin induces a dedifferentiation process in the receiving cancer cells and expression of cancer stem cell markers together with an EMT-associated gene expression profile, leading to cancer stem cell expansion. By using siRNA and pharmacological inhibition of sortilin, we show that sortilin is a functional receptor of progranulin and is responsible for driving progranulin induced breast cancer stem cell propagation. Supporting the role of progranulin in cancer progression, administration of progranulin in immunocompromised mice induce lung metastasis in our breast cancer xenograft models. The use of different approaches for blocking sortilin, such as sortilin inhibitors, down-modulators or sortilin-targeted antibodies can prevent this dedifferentiation process, both in vitro and in vivo, making the tumor cells less aggressive and metastatic.

Conclusion: Targeting progranulin through its associated receptors is a potential therapeutic strategy for the treatment of patients with breast tumors having elevated progranulin or sortilin expression. By inhibiting the secretion based breast cancer progression, we could possibly block the formation of metastasis and cancer cell infiltration.

Citation Format: Berger K, Rhost S, Hughes E, Harrison H, Rafnsdottir S, Jacobsson H, Gregersson P, Magnusson Y, Fitzpatrick P, Andersson D, Ståhlberg A, Landberg G. Sortilin targeted therapy in breast cancer with elevated progranulin expression [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 P2-06-11.

The RUNX Transcriptional Coregulator, CBFβ, Suppresses Migration of ER+ Breast Cancer Cells by Repressing ERα-Mediated Expression of the Migratory Factor TFF1

Core binding factor β (CBFβ), the essential coregulator of RUNX transcription factors, is one of the most frequently mutated genes in estrogen receptor-positive (ER⁺) breast cancer. Many of these mutations are nonsense mutations and are predicted to result in loss of function, suggesting a tumor suppressor role for CBFβ. However, the impact of missense mutations and the loss of CBFβ in ER⁺ breast cancer cells have not been determined. Here we demonstrate that missense mutations in CBFβ accumulate near the Runt domain-binding region. These mutations inhibit the ability of CBFβ to form CBFβ-Runx-DNA complexes. We further show that deletion of CBFβ, using CRISPR-Cas9, in ER⁺ MCF7 cells results in an increase in cell migration. This increase in migration is dependent on the presence of ERα. Analysis of the potential mechanism revealed that the increase in migration is driven by the coregulation of Trefoil factor 1 (TFF1) by CBFβ and ERα. RUNX1-CBFβ acts to repress ERα-activated expression of TFF1. TFF1 is a motogen that stimulates migration and we show that knockdown of TFF1 in CBFβ^-/- cells inhibits the migratory phenotype. Our findings reveal a new mechanism by which RUNX1-CBFβ and ERα combine to regulate gene expression and a new role for RUNX1-CBFβ in the prevention of cell migration by suppressing the expression of the motogen TFF1. IMPLICATIONS: Mutations in CBFβ contribute to the development of breast cancer by inducing a metastatic phenotype that is dependent on ER.

Sortilin inhibition limits secretion-induced progranulin-dependent breast cancer progression and cancer stem cell expansion

Background

Cancer progression is influenced by genetic aberrations in the cancer cell population as well as by other factors including the microenvironment present within a tumour. Direct interactions between various cell types as well as cellular signalling via secreted cytokines can drive key tumourigenic properties associated with disease progression and treatment resistance. Also, cancer stem cell functions are influenced by the microenvironment. This challenging subset of cells has been linked to malignant properties. Within a screen, using in vivo like growth conditions, we identified progranulin as a highly secreted cytokine affecting cancer stem cells in breast cancer. This cytokine is known to play a role in numerous biological and tumour-related processes including therapy resistance in a range of cancer types.

Methods

Different in vitro and in vivo relevant conditions were used to validate breast cancer stem cell expansion mediated by progranulin and its receptor sortilin. Small interfering ribonucleic acid (siRNA) and pharmacological inhibition of sortilin were used to elucidate the role of sortilin as a functional receptor during progranulin-induced breast cancer stem cell propagation, both in vitro and in vivo, using breast cancer xenograft models. In addition, single-cell gene expression profiling as well as a Sox2 reporter breast cancer cell line were used to validate the role of dedifferentiation mediated by progranulin.

Results

In various in vivo-like screening assays, progranulin was identified as a potent cancer stem cell activator, highly secreted in ERα-negative breast cancer as well as in ERα-positive breast cancer under hypoxic adaptation. Progranulin exposure caused dedifferentiation as well as increased proliferation of the cancer stem cell pool, a process that was shown to be dependent on its receptor sortilin. Subcutaneous injections of progranulin or its active domain (GRN A) induced lung metastases in breast cancer xenograft models, supporting a major role for progranulin in cancer progression. Importantly, an orally bioavailable small molecule (AF38469) targeting sortilin, blocked GRN A-induced lung metastases and prevented cancer cell infiltration of the skin.

Conclusion

The collective results suggest that sortilin targeting represents a potential novel breast cancer therapy approach inhibiting tumour progression driven by secretion and microenvironmental influences.

Electronic supplementary material

The online version of this article (10.1186/s13058-018-1060-5) contains supplementary material, which is available to authorized users.

HIF1-alpha expressing cells induce a hypoxic-like response in neighbouring cancer cells

Background

Hypoxia stimulates metastasis in cancer and is linked to poor patient prognosis. In tumours, oxygen levels vary and hypoxic regions exist within a generally well-oxygenated tumour. However, whilst the heterogeneous environment is known to contribute to metastatic progression, little is known about the mechanism by which heterogeneic hypoxia contributes to cancer progression. This is largely because existing experimental models do not recapitulate the heterogeneous nature of hypoxia.

The primary effector of the hypoxic response is the transcription factor Hypoxia inducible factor 1-alpha (HIF1-alpha). HIF1-alpha is stabilised in response to low oxygen levels in the cellular environment and its expression is seen in hypoxic regions throughout the tumour.

Methods

We have developed a model system in which HIF1-alpha can be induced within a sub-population of cancer cells, thus enabling us to mimic the effects of heterogeneic HIF1-alpha expression.

Results

We show that induction of HIF1-alpha not only recapitulates elements of the hypoxic response in the induced cells but also results in significant changes in proliferation, gene expression and mammosphere formation within the HIF1-alpha negative population.

Conclusions

These findings suggest that the HIF1-alpha expressing cells found within hypoxic regions are likely to contribute to the subsequent progression of a tumour by modifying the behaviour of cells in the non-hypoxic regions of the local micro-environment.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4577-1) contains supplementary material, which is available to authorized users.

Tissue Factor promotes breast cancer stem cell activity in vitro

Cancer stem cells (CSCs) are a subpopulation of cells that can self-renew and initiate tumours. The clotting-initiating protein Tissue Factor (TF) promotes metastasis and may be overexpressed in cancer cells with increased CSC activity. We sought to determine whether TF promotes breast CSC activity in vitro using human breast cancer cell lines. TF expression was compared in anoikis-resistant (CSC-enriched) and unselected cells. In cells sorted into of TF-expressing and TF-negative (FACS), and in cells transfected to knockdown TF (siRNA) and overexpress TF (cDNA), CSC activity was compared by (i) mammosphere forming efficiency (MFE) (ii) holoclone colony formation (Hc) and (iii) ALDH1 activity. TF expression was increased in anoikis-resistant and high ALDH1-activity T47D cells compared to unselected cells. FACS sorted TF-expressing T47Ds and TF-overexpressing MCF7s had increased CSC activity compared to TF-low cells. TF siRNA cells (MDAMB231, T47D) had reduced CSC activity compared to control cells. FVIIa increased MFE and ALDH1 in a dose-dependent manner (MDAMB231, T47D). The effects of FVIIa on MFE were abrogated by TF siRNA (T47D). Breast CSCs (in vitro) demonstrate increased activity when selected for high TF expression, when induced to overexpress TF, and when stimulated (with FVIIa). Targeting the TF pathway in vivo may abrogate CSC activity.

A Fabry-Pérot interferometer with wire-grid polarizers as beamsplitters at terahertz frequencies

The design of a compact Fabry-Pérot interferometer (FPi) and results of the experimental studies carried out using the device are presented. Our FPi uses freestanding wire-grid polarizers (WGPs) as beamsplitters and is suitable for use at terahertz (THz) frequencies. The FPi was studied at the LUCX facility, KEK, Japan, and an 8 MeV linear electron accelerator was used to generate coherent Smith-Purcell radiation. The FPi was designed to be easy to align and reposition for experiments at linear accelerator facilities. All of the components used were required to have a flat or well understood frequency response in the THz range. The performance of the FPi with WGPs was compared to that of a Michelson interferometer and the FPi is seen to perform well. The effectiveness of the beamsplitters used in the FPi is also investigated. Measurements made with the FPi using WGPs, the preferred beamsplitters, are compared to measurements made with the FPi using silicon wafers as alternative beamsplitters. The FPi performs well with both types of beamsplitter in the frequency range used (0.3-0.5 THz). The successful measurements taken with the FPi demonstrate a compact and adaptable interferometer that is capable of analyzing THz radiation over a broad frequency range. The scheme is particularly well suited for polarization studies of THz radiation produced in an accelerator environment.

Robotic Mammosphere Assay for High-Throughput Screening in Triple-Negative Breast Cancer

In order to identify novel treatment principles specifically affecting cancer stem cells in triple-negative breast cancer, we have developed a high-throughput screening method based on the mammosphere and anoikis resistance assays allowing us to screen compounds using a functional readout. The assay was validated against manual protocols and through the use of positive controls, such as the response to hypoxia and treatment with the known cancer stem cell-targeting compound salinomycin. Manual and robotic procedures were compared and produced similar results in cell handling, cell cultures, and counting techniques, with no statistically significant difference produced from either method. The variance between samples processed manually versus robotically was no greater than 0.012, while Levene's test of significance was 0.2, indicating no significant difference between mammosphere data produced manually or robotically. Through the screening of 989 FDA-approved drugs and a follow-up screen assessing the antineoplastic subgroup, we have identified three therapeutic compounds with the ability to modulate the breast cancer stem cell fraction in the triple-negative breast cancer cell line MDA-MB-231, highlighting their potential usage as stem cell-specific adjuvant treatments.

Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting

BACKGROUND

Patients with chronic noncancer pain treated with higher doses of opioids or concurrent substance use are at increased risk of adverse events. Although several national guidelines recommend maximum dosing thresholds and urine drug testing, adherence to these guidelines is inconsistent.

METHODS

To identify predictors of higher-risk opioid prescriptions in 2 academic primary care clinics, the authors developed a retrospective cohort of 842 patients who were prescribed ≥5 opioid prescriptions for noncancer pain between March 2012 and March 2013. The authors evaluated odds of higher-dose opioid prescriptions and urine drug testing using multivariate logistic models.

RESULTS

Among study subjects, 47% received prescriptions for the equivalent of ≥50 mg morphine per day. After adjustment for confounders, patients with a resident primary care provider were less likely to receive higher-dose prescriptions compared with faculty providers (odds ratio = 0.66, 95% confidence interval [CI]: 0.46-0.94), whereas patients with a nonlocal home address were more likely to be prescribed higher doses (odds ratio = 2.1, 95% CI: 1.5-2.9). Hispanic, Asian, and older patients were also less likely to be prescribed higher doses. Urine drug testing was not regularly completed (35% over 2 years), but odds of testing were higher for patients who self-identified as black, had resident primary care providers, lived locally, or were prescribed higher opioid doses.

CONCLUSIONS

In this academic clinical setting, patients with a resident primary care provider are less likely to receive higher-risk opioid prescriptions, as are Hispanic, Asian, and older patients. Black patients complete urine drug tests more frequently independent of other patient and provider characteristics. Additional studies are needed to assess why patients who travel larger distances to their primary care clinic are prescribed higher doses of opioids for chronic noncancer pain.