Measuring health promotion in a sports club setting: a modified Delphi study

Background

The settings-based approach has become an increasing focus in health promotion since the World Health Organization’s 1986 Ottawa Charter. Schools and cities have implemented this approach, but development within sports clubs is limited. Thus, an internationally validated measurement of health promotion within this setting is lacking.

Methods

A modified Delphi study was completed to develop an international evaluation tool grounded in the settings-based approach. Expert panelists from academia, sports and health sectors were invited to participate in 3 online rounds. Items were generated or selected based on 3 prior Delphi-based studies and 2 nationally validated scales. Round one created a collaborative list of items, round two validated items based on relevance, importance and feasibility and the final round classified items into one of four determinants: cultural, social, environmental or economic.

Results

Panelists (69) from 13 countries participated in creating a final list of 62 items at 3 organizational levels. The sports club level included; 5 cultural, 6 social, 6 environmental and 5 economic items. The management level included; 5 cultural, 5 social, 5 environmental and 3 economic items. The coaching level included; 5 cultural, 5 social, 4 environmental and 4 economic items.

Conclusions

This study provides three important innovations; 1- it is rooted in theory through the settings-based approach, 2- the measurement tool includes three levels within sports clubs, capturing a whole club dynamic and 3- all items included in the tool have been validated by an international panel of experts.

Key messages

This 62-item measurement tool allows the comparison of perceptions from participants, coaches and management regarding how health is promoted within their sports club. This information offers insight on the capacity of sports clubs to implement and monitor policies and practices on the promotion of health beyond sports performance within their organization.

Mercury concentrations in biota in the Mediterranean Sea, a compilation of 40 years of surveys

The Mediterranean Region has a long lasting legacy of mercury mining activities and a high density of sub-marine volcanoes that has strongly contributed to its mercury budget. In the last forty years, there have been recorded increases in mercury concentrations in biota that have spurred a growing number of research activities to assess the impact of mercury pollution on human health and environment. Field investigations that quantify mercury concentrations in marine biota have led to a large amount of experimental data scattered in many peer-reviewed publications making it difficult for modelling applications and regional environmental assessments. This paper reviews existing peer-reviewed literature and datasets on mercury concentration in marine flora and fauna (Animal, Plants and Chromista Kingdoms) in the Mediterranean basin. A total of 24,465 records have been retrieved from 539 sources and included in Mercury in Mediterranean Biota (M2B). Well-defined specimens account for 24,407 observations, while a few records include generic plankton and unidentified fish species. Among all considered species, we selected Diplodus sargus, Sardina pilchardus, Thunnus thynnus and Xiphias gladius to show trends of mercury concentration against WHO and EU limits. Few notes on how M2B is intended to support the implementation of the Minamata Convention on Mercury by a user-driven Knowledge Hub are finally reported.

Measurement(s)	mercury
Technology Type(s)	digital curation
Factor Type(s)	geographic location • fishing area • species • sampling time • depth • weight • tissue
Sample Characteristic - Organism	Eukaryota
Sample Characteristic - Environment	ocean biome
Sample Characteristic - Location	Mediterranean Sea • Black Sea

Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.9886004

C-13 Sex Differences in Cognitive and Neurobiological Markers of Alzheimer's Disease

Objective

Previous work has demonstrated that intra-individual cognitive variability (IICV) has predictive power similar to traditional Alzheimer’s disease (AD) biomarkers, such as CSF or hippocampal volume (HV) loss. Genetic factors, such as sex, have been identified as predictors of cognitive decline. Analysis of sex differences in IICV and other biomarkers may elucidate additional dimensions of this metric.

Method

Baseline neurocognitive test and neuroimaging data from 335 participants with ≥2 visits enrolled in the Wisconsin Alzheimer’s Disease Research Center Clinical Core were included. Z-scores were calculated comparing individual performance to group performance by test (Rey Auditory Verbal Learning Test (Learning and Delayed Recall), Trail Making Test (A and B), and either Boston Naming Test (BNT) or Multilingual Naming Test (MINT)). MINT scores were converted to BNT scores using the NACC Crosswalk Study. The standard deviation of z-scores across tests was calculated to determine IICV. Characteristics by sex were compared using Mann-Whitney and Fisher’s Exact tests. Spearman’s Rho was calculated to compare IICV and HV (relative to intercranial volume).

Results

At baseline (Table 1): (1) Males had more education than females; (2) females had both higher relative HV and IICV; and (3) in females, relative HV demonstrated a weak positive correlation with baseline IICV (Figure 1).

Conclusions

IICV has previously demonstrated potential as a cost-effective non-invasive marker of preclinical AD. In females, larger relative HV and its correlation with IICV may be due to differences in metabolic brain age or concurrent progression of HV and IICV through the AD process. Analyses of other biopsychosocial factors are needed.

C-12 Race and Sex Differences in Cognitive and Neurobiological Markers of Alzheimer's Disease

Objective

Intra-Individual Cognitive Variability (IICV) previously demonstrated predictive power similar to AD biomarkers (i.e., CSF and hippocampal volume (HV) loss). Previous work suggested sex differences in relative HV and IICV. Additionally, IICV differs in whites and underrepresented racial groups (URG). Our objective was to analyze these sex differences in white and URG participants.

Method

Baseline neurocognitive test and neuroimaging data from 335 cognitively healthy participants with ≥2 visits enrolled in the Wisconsin ADRC Clinical Core were included. Z-scores were calculated comparing individual performance to group performance by test (Rey Auditory Verbal Learning Test (Learning and Delayed Recall), Trail Making Test (A and B), and either Boston Naming Test (BNT) or Multilingual Naming Test (MINT)). MINT scores were converted to BNT scores using the NACC Crosswalk Study. The standard deviation of z-scores across tests was calculated to determine IICV. Characteristics by race and sex were compared using Mann-Whitney, Fisher’s Exact, and Kruskal-Wallis tests. Spearman’s Rho was calculated to compare baseline IICV and relative HV.

Results

At baseline (Table 1), differences across racial groups in age, years of education, relative HV, and IICV were identified. Sex and racial group differences were identified (Table 2). A weak positive correlation between HV and IICV was seen in white females (Figure 1).

Conclusions

IICV has potential to become a cost-effective, non-invasive marker of preclinical AD. Again, correlation between HV and IICV was seen, but only in white females. Analyses suggest group differences between white and URG males and females. However, more data is needed to further explore these differences.

Primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in cutaneous melanoma: a clinical practice guideline

Background

For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (slnb), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck.

Methods

Using Ovid, the medline and embase electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of slnb for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017.

Results

Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection.Key updated recommendations include:■ Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth.■ slnb should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth.■ Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection.

Conclusions

Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature.

Abstract 1533: IMGC936, a first-in-class ADAM9-targeting antibody-drug conjugate, demonstrates promising anti-tumor activity

Dysregulation of ADAM9, a member of the ADAM (a disintegrin and metalloproteinase) family of proteases, has been implicated in tumor progression and metastasis, as well as pathological neovascularization. ADAM9 overexpression correlates with poor prognosis in multiple cancers. We have shown that ADAM9 is overexpressed in multiple solid tumor indications and that anti-ADAM9 antibodies are efficiently internalized and degraded by tumor cell lines making ADAM9 an attractive target for antibody-drug conjugate (ADC) development. Here, we describe IMGC936, the first ADAM9-targeting ADC to enter preclinical development. IMGC936 is comprised of a high-affinity humanized antibody site-specifically conjugated to DM21, a next-generation linker-payload that combines a maytansinoid microtubule-disrupting payload with a stable peptide linker at a drug-antibody ratio of two. To maximize the potential for IMGC936 activity, the M252Y/S254T/T256E (YTE) mutation was introduced into the CH2 domain of the antibody to increase in vivo plasma half-life and exposure. In vitro studies demonstrated targeted cytotoxicity of IMGC936 across a panel of ADAM9-positve tumor cell lines with activity at least 2 logs greater than a non-targeting conjugate. Consistent with the in vitroactivity, an anti-ADAM9-DM21 conjugate displayed compelling anti-tumor activity in multiple xenograft models representing non-small cell lung, gastric and colorectal cancers. For example, in the EBC-1 non-small cell lung cancer subcutaneous xenograft model with only moderate ADAM9 expression (H-score of 130), anti-ADAM9-DM21 not only induced tumor growth delay but produced complete and durable remissions in 6/6 mice following a single intravenous dose of 8.6 mg Ab/kg (100 ug DM21/kg). IMGC936 demonstrated a favorable pharmacokinetic profile with good conjugate stability in non-human primates. Importantly, IMGC936 was well-tolerated following repeat dosing in cynomolgus monkeys with no ADAM9 target-related toxicities identified at doses exceeding the levels required for anti-tumor activity in murine xenograft models. Based on the totality of the preclinical data, IMGC936 represents a promising therapeutic candidate to target a wide range of ADAM9-expressing tumors.

Citation Format: Stuart Hicks, Deryk Loo, Kerstin Sinkevicius, Juniper Scribner, Bhaswati Barat, Nicholas Yoder, Christopher Espelin, Marian Themeles, Francine Chen, Jacquelynn Lucas, Jennifer Brown, Bahar Matin, Megan Fuller, Jenny Lee, Paulin Salomon, Juliet Costoplus, Sadiqa Yancey, Gundo Diedrich, Sergey Gorlatov, Thomas Son, Michael Chiechi, Pam Li, Michael Spliedt, Valentina Ciccarone, Jeff Hooley, Nadia Gantt, James Tamura, Kerry Donahue, Paul Moore, Syd Johnson, Thomas Chittenden, Richard Gregory, Ezio Bonvini. IMGC936, a first-in-class ADAM9-targeting antibody-drug conjugate, demonstrates promising anti-tumor activity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1533.

Abstract 554: Tumor-antigen 5T4-dependent activation of the CD137 costimulatory pathway by bispecific 5T4 x CD137 x CD137 TRIDENT™ molecules

Introduction: Trophoblast glycoprotein 5T4 is expressed on the cell surface of multiple cancers yet sparingly on normal adult tissues. CD137 (4-1BB) is a co-stimulatory molecule expressed by activated T and NK cells that support cell activation, proliferation and survival. Previously we described bispecific tumor associated antigen x CD137 DART® molecules limiting CD137 mediated immunostimulation to the tumor microenvironment (AACR2017) as an approach to reduce the unwanted systemic CD137 effects associated with agonistic anti-CD137 mAbs. We subsequently identified a bispecific TRIDENT format bearing bivalent CD137 and monovalent tumor antigen engagement that provides maximal CD137 activation in a tumor antigen anchored manner. Here we apply that format to generate a 5T4 x CD137 x CD137 TRIDENT molecule that promotes CD137 activation in proximity to 5T4-expressing tumor cells leading to enhanced T-cell co-stimulation, proliferation and tumor cell killing activity when combined with CD3-engaging tumor-targeting bispecific DART molecules.

Methods: TRIDENT molecules were constructed comprising bivalent CD137 binding and monovalent 5T4 binding. Binding properties were evaluated by surface plasmon resonance (SPR) and flow cytometry. Signaling was assessed using a NF-κB luciferase reporter cell line expressing CD137. Co-stimulatory activity was characterized with primary human or cynomolgus monkey T cells. T cells were incubated with or without antigen-expressing cells and submaximal concentrations of either anti-CD3 bead or CD3-engaging tumor-targeting bispecific DART molecules.

Results: SPR and flow cytometry analyses demonstrate that 5T4 x CD137 x CD137 TRIDENT molecule binds human and monkey target antigens. The 5T4 x CD137 x CD137 TRIDENT molecule induces CD137 signaling in a reporter cell line and promotes cytokine release in primary human & cynomolgus monkey T-cell assays in the presence of 5T4+ tumor cells. In the absence of 5T4+ tumor cells, the TRIDENT molecule lacks agonistic activity. Furthermore, 5T4 x CD137 x CD137 TRIDENT molecule enhances T-cell proliferation and tumor cell cytolysis induced by CD3-targeted DART molecules. Consistent with preferential induction of CD137 by CD8 T-cells, 5T4 x CD137 x CD137 TRIDENT increases the fraction of CD8+ central memory and effector memory T cells in the presence 5T4+ tumor cells.

Conclusions: 5T4 x CD137 x CD137 TRIDENT molecule promotes T-cell co-stimulation in a tumor antigen-dependent manner offering an opportunity to target CD137 immunostimulation, while potentially limiting non-specific systemic T-cell activation and related side effects.

Citation Format: Liqin Liu, Ling Huang, Vatana Long, Yinhua Yang, Robert Burns, Jonathan Li, Jennifer DiChiara, Qihong Xu, Arin Whiddon, Chia-Ying K Lam, Jim Tamura, Valentina Ciccarone, Syd Johnson, Ezio Bonvini, Paul Moore. Tumor-antigen 5T4-dependent activation of the CD137 costimulatory pathway by bispecific 5T4 x CD137 x CD137 TRIDENT™ molecules [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 554.

Abstract 1560: Selection of a bispecific trivalent HER2 x CD137 TRIDENT format providing optimal tumor-anchored immune co-stimulation

Introduction: CD137 (4-1BB) signaling provides co-stimulation of CD8 or NK cells following antigen or FcγR engagement, respectively. Efforts to leverage CD137 co-stimulation via agonistic monoclonal antibodies (mAbs) have been thwarted by limited clinical efficacy or unacceptable toxicity. Bispecific targeting strategies linking CD137 activation to a tumor-targeting moiety provides an approach to localize CD137 activation to the tumor microenvironment. Here we evaluate a panel of Fc-bearing HER2 x CD137 bispecific molecules incorporating different valency and geometry to define the format providing optimal CD137 co-stimulation in a tumor-cell anchor-dependent manner.

Methods: An anti-HER2 mAb specificity that does not cross compete with margetuximab, trastuzumab or pertuzumab and a proprietary anti-CD137 mAb were utilized to assemble a set of HER2 x CD137 bispecific molecules in bivalent and tetravalent DART® or trivalent TRIDENTTM configurations. The resulting molecules were compared in binding, signaling and co-stimulation assays in the presence or absence of tumor cells expressing HER2. Combination studies were performed in vitro and in immune deficient mice reconstituted with human PBMCs.

Results: TRIDENT molecules bearing bivalent CD137 and monovalent HER2 binding achieve optimal HER2-dependent tumor-cell anchored CD137 immune cell co-stimulation. CD137 co-stimulation increases proportionally with the level of HER2 expression as observed with HER2 1+ (MCF7 breast), HER2 2+ (JIMT1 breast) and 3+ (N87 gastric) tumor cells and was paralleled with increased HER2+/CD137+ cell association. No CD137 activation is observed in the absence of HER2-expressing tumor cells. HER2 x CD137 bispecifics enhance NK-cell proliferation and IFN-γ release induced by margetuximab, an Fc-optimized anti-HER2 mAb that up-regulates CD137 expression on NK-cells concomitant with enhanced ADCC against HER2-positive cells. Similarly, HER2 x CD137 bispecific molecules enhanced the in vitro activity of orlotamab, a B7-H3 x CD3 bispecific DART molecule that up-regulates CD137 during T-cell redirected killing. Finally, in vivo mouse studies demonstrate the ability of HER2 x CD137 molecules to expand tumor-associated CD8 cells when co-administered with a tumor targeted CD3 bispecific molecule and support enhance anti-tumor activity.

Conclusion: An optimal HER2 x CD137 bispecific format providing maximal CD137 activation in a HER2- dependent manner was identified as a trivalent TRIDENT molecule bearing bivalent CD137 and monovalent HER2 binding. Combinatorial activity with HER2 x CD137 bispecifics was observed with both a HER2-directed therapeutic mAb and a CD3-engaging tumor-targeted bispecific molecule. HER2 x CD137 TRIDENT molecules have therapeutic potential and provide a structural template for incorporating alternate tumor- and/or co-stimulatory-targeting arms.

Citation Format: Liqin Liu, Chia-Ying K. Lam, Ralph Alderson, Vatana Long, Yinhua Yang, Robert Burns, Lusiana Widjaja, Jonathan Li, Christina Wolf, Valentina Ciccarone, James Tamura, Gundo Diedrich, Ezio Bonvini, Syd Johnson, Paul A. Moore. Selection of a bispecific trivalent HER2 x CD137 TRIDENT format providing optimal tumor-anchored immune co-stimulation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1560.

You did not turn up… I did not realise I was invited…: understanding male attitudes towards engagement in fertility and reproductive health discussions

STUDY QUESTION

What are the underlying reasons for low male engagement in fertility and reproductive health discussions and decision-making?

SUMMARY ANSWER

The perception of women's primacy in fertility and reproductive health limits the extent to which men believe their engagement is important.

WHAT IS KNOWN ALREADY

Active participation of men in the process of informed decision-making regarding childbearing is beneficial for mother, father, and child. However, in research studies in these areas, little attention has been given to men. Additionally, there is poor engagement by men, as well as a dearth of information from, and on, the male perspective.

STUDY DESIGN SIZE DURATION

In total, 35 semi-structured telephone and face-to-face interviews were conducted in an office setting with three groups: 13 lay women, 13 lay men, and 9 (2 male and 7 female) healthcare professionals. Interviews took place between October 2016 and February 2017.

PARTICIPANTS/MATERIALS SETTING METHODS

Participants were men and women of reproductive age from the general population and healthcare professionals who had completed an online fertility awareness survey and agreed to follow-up interviews. Interviews were audio recorded and lasted ~1 hour, during which participants were asked to provide their views on childbearing decision-making, and male and female representation in fertility and reproductive health. Data was transcribed verbatim and analysed qualitatively via framework analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Both men and women saw fertility as a woman's issue, but from different viewpoints. Women saw it from the perspective of societal stereotypes regarding male and female roles, whereas men tended to defer to the woman's primacy in reproductive decisions. Men generally wanted to be involved in childbearing discussions and improve their fertility knowledge. However, they felt they did not have a voice on the topic because discussions have traditionally focused on women. The notion that men are not expected to be interested and engaged thus becomes a self-fulfilling prophecy. Healthcare professionals agreed that fertility was perceived as the woman's domain, but also highlighted that poor male involvement is typically observed across healthcare needs and is not necessarily unique to fertility and reproductive health.

LIMITATIONS REASONS FOR CAUTION

Due to the online recruitment method, there is a potential bias towards respondents of higher, rather than lower, socioeconomic status within the general population.

WIDER IMPLICATIONS OF THE FINDINGS

Fertility tends to be seen as a private topic. Additional concerted effort by reproductive health researchers, charity organisations, educators, healthcare service providers, and policy makers is needed to proactively encourage male involvement in reproductive decision-making. This can be achieved through normalising and breaking taboos around the topic, male-friendly research study design approaches, male-inclusive reproductive healthcare services, implementation of health policies that recognise the needs of men, encouraging male research staff representation, and age-appropriate educational programmes on sexual and reproductive health, which include boys and adolescents from a young age.

STUDY FUNDING/COMPETING INTERESTS

Research funding was received from SPD Development Co. Ltd. B.G. and S.J. are employed by SPD Development Co. Ltd. None of the other authors have any conflict of interest related to the discussed topic.

TRIAL REGISTRATION NUMBER

Not applicable.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Simultaneous visualization of wall motion, beam propagation, and implosion symmetry on the National Ignition Facility (invited)

Achieving a symmetric implosion in National Ignition Facility indirect drive targets requires understanding and control of dynamic changes to the laser power transport in the hohlraum. We developed a new experimental platform to simultaneously visualize wall-plasma motion and dynamic laser power transport in the hohlraum and are using it to investigate correlations of these measurements with the imploded capsule symmetry. In a series of experiments where we made one single parameter variation, we show the value of this new platform in developing an understanding of laser transport and implosion symmetry. This platform also provides a new way to evaluate dynamic performance of advanced hohlraum designs.

Defining, Measuring and Preventing the Diagnosis of Cancer as an Emergency: A Critical Review of Current Evidence

Background: Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumor, patient and health-care factors, often in combination. Methods: We searched the literature to identify all population-based studies that examined emergency presentation as a diagnosis or independent variable. Results: Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. Conclusion: In this review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this underresearched aspect of cancer diagnosis.

Variation in 'Fast-Track' Referrals for Suspected Cancer by Patient Characteristic and Cancer Diagnosis: Evidence From 670,000 Patients With Cancers of 35 Different Sites

Background: In England, 'fast-track' (also known as 'two-week wait') general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups. Methods:  We examined data from 669,220 patients with 35 cancers diagnosed 2006-2010 following either fast-track or nonfast track primary-to-secondary care referrals using a bespoke English dataset, the 'Routes to Diagnosis' data. We estimated the proportion of fast-track referrals by sociodemographic characteristics and cancer diagnosis and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer. Results:  There were large variations in the odds of fast-track referral by cancer ( P < 0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35 respectively, using rectal cancer as reference); while patients with brain cancer and leukemias least likely (adjusted odds ratios 0.05 and 0.09 respectively for brain cancer and acute myeloid leukemia). There were sex, age and deprivation differences in the odds of fast-track referral ( P < 0.013), which varied in their size and direction for patients with different cancers ( P < 0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer. Conclusion: Fast-track referrals are less likely for cancers characterized by nonspecific presenting symptoms and patients belonging to low incidence demographic strata. Interventions beyond clinical guidelines for “alarm” symptoms are needed to improve diagnostic timeliness.

CT versus MR Imaging in Estimating Cochlear Radiation Dose during Gamma Knife Surgery for Vestibular Schwannomas

BACKGROUND AND PURPOSE

Leksell stereotactic radiosurgery is an effective option for patients with vestibular schwannomas. Some centers use a combination of stereotactic CT fused with stereotactic MR imaging to achieve an optimal target definition as well as minimize the radiation dose delivered to adjacent structures that correlate with hearing outcomes. The present prospective study was designed to determine whether there is cochlear dose variability between MR imaging and CT.

MATERIALS AND METHODS

Fifty consecutive patients underwent stereotactic radiosurgery for vestibular schwannomas. Dose-planning was performed using high-definition fused stereotactic MR imaging and stereotactic CT images. The 3D cochlear volume was determined by delineating the cochlea on both CT and T2-weighted MR imaging. The mean radiation dose, maximum dose, and 3- and 4.20-Gy cochlear volumes were identified using standard Leksell Gamma Knife software.

RESULTS

The median mean radiation dose delivered to the cochlea was 3.50 Gy (range, 1.20-6.80 Gy) on CT and 3.40 Gy (range, 1-6.70 Gy) on MR imaging (concordance correlation coefficient = 0.86, r ² = 0.9, P ≤ .001). The median maximum dose delivered to the cochlea was 6.7 Gy on CT and 6.6 Gy on MR imaging (concordance correlation coefficient = 0.89, r ² = 0.90, P ≤ .001). Dose-volume histograms generated from CT and MR imaging demonstrated a strong level of correlation in estimating the 3- and 4.20-Gy volumes (concordance correlation coefficient = 0.81, r ² = 0.82, P ≤ .001 and concordance correlation coefficient = 0.87, r ² = 0.89, P ≤ .001).

CONCLUSIONS

Both MR imaging and CT provide similar cochlear dose parameters. Despite the reported superiority of CT in identifying bony structures, high-definition MR imaging alone is sufficient to identify the radiation doses delivered to the cochlea.