Approche qualitative des motifs à accepter ou à refuser la réalisation d’une mammographie : l’apport de la théorie du renversement

Objectif : Examiner les motifs conduisant les femmes à accepter ou à refuser la réalisation d’une mammographie et la manière dont ceux-ci s’organisent autour des états motivationnels de la théorie du renversement.

Méthode : Seize entretiens semi-directifs ont été réalisés. Des analyses lexicométriques et de contenu ont été effectuées en prenant appui sur les dix états motivationnels de la théorie du renversement.

Résultats : Consentir à réaliser une mammographie peut répondre à la volonté d’atteindre un objectif et/ou de suivre les règles communément admises à l’égard de cet examen. Refuser de réaliser une mammographie peut être influencé par la volonté d’atteindre un objectif, par un besoin de liberté, par des préoccupations personnelles et/ou par une aspiration à être au centre du soin. Ainsi, respectivement, les motifs facilitateurs les plus impliqués se rapportent aux états motivationnels télique et conformisme. Les motifs barrières les plus impliqués se rapportent aux états télique, négativiste, intra-autique (et plus modérément à l’état autocentrique).

Conclusion : Les résultats de cette étude, et plus particulièrement le rapport qu’entretiennent les femmes avec les normes établies en matière de dépistage du cancer du sein, peuvent amorcer de nouvelles réflexions dans le champ de la santé publique.

Evidence of the contribution of the X chromosome to systemic sclerosis susceptibility: association with the functional IRAK1 196Phe/532Ser haplotype

OBJECTIVE

Several autoimmune disorders, including systemic sclerosis (SSc), are characterized by a strong sex bias. To date, it is not known whether genes on the sex chromosomes influence SSc susceptibility. Recently, an IRAK1 haplotype that contains the 196Phe functional variant (rs1059702), located on Xq28, was found to confer susceptibility to systemic lupus erythematosus (SLE). This study was undertaken to test for an association between SSc and the IRAK1 SLE risk haplotype.

METHODS

We tested for an association with the IRAK1 SLE risk haplotype in a discovery set of 849 SSc patients and 625 controls. IRAK1 rs1059702 was further genotyped in a replication set, which included Caucasian women from Italy (493 SSc patients and 509 controls) and Germany (466 SSc patients and 1,083 controls).

RESULTS

An association between the IRAK1 haplotype and SSc was detected in the discovery set. In both the discovery and replication sets, the rs1059702 TT genotype was found to be associated with specific SSc subsets, highlighting a potential contribution to disease severity. A meta-analysis provided evidence of an association of both the T allele and TT genotype with the overall disease, with an odds ratio (OR) of 1.20 and 95% confidence interval (95% CI) of 1.06-1.35 for the T allele (P = 0.003) and an OR of 1.49 and 95% CI of 1.06-2.10 for the TT genotype (P = 0.023). However, the most notable associations were observed with the diffuse cutaneous, anti-topoisomerase I antibody positive, and SSc-related fibrosing alveolitis subsets (OR 2.35 [95% CI 1.51-3.66], P = 1.56 × 10(-4), OR 2.84 [95% CI 1.87-4.32], P = 1.07 × 10(-6), and OR 2.09 [95% CI 1.35-3.24], P = 9.05 × 10(-4), respectively).

CONCLUSION

Our study provides the first evidence of an association between IRAK1 and SSc, demonstrating that a sex chromosome gene directly influences SSc susceptibility and its phenotypic heterogeneity.

A refined molecular taxonomy of breast cancer

The current histoclinical breast cancer classification is simple but imprecise. Several molecular classifications of breast cancers based on expression profiling have been proposed as alternatives. However, their reliability and clinical utility have been repeatedly questioned, notably because most of them were derived from relatively small initial patient populations. We analyzed the transcriptomes of 537 breast tumors using three unsupervised classification methods. A core subset of 355 tumors was assigned to six clusters by all three methods. These six subgroups overlapped with previously defined molecular classes of breast cancer, but also showed important differences, notably the absence of an ERBB2 subgroup and the division of the large luminal ER+ group into four subgroups, two of them being highly proliferative. Of the six subgroups, four were ER+/PR+/AR+, one was ER−/PR−/AR+ and one was triple negative (AR−/ER−/PR−). ERBB2-amplified tumors were split between the ER−/PR−/AR+ subgroup and the highly proliferative ER+ LumC subgroup. Importantly, each of these six molecular subgroups showed specific copy-number alterations. Gene expression changes were correlated to specific signaling pathways. Each of these six subgroups showed very significant differences in tumor grade, metastatic sites, relapse-free survival or response to chemotherapy. All these findings were validated on large external datasets including more than 3000 tumors. Our data thus indicate that these six molecular subgroups represent well-defined clinico-biological entities of breast cancer. Their identification should facilitate the detection of novel prognostic factors or therapeutical targets in breast cancer.

NLRP1 influences the systemic sclerosis phenotype: a new clue for the contribution of innate immunity in systemic sclerosis-related fibrosing alveolitis pathogenesis

BACKGROUND

Recent evidence has highlighted a potential role of interleukin 1β (IL-1β) in systemic sclerosis (SSc). NLRP1 provides a scaffold for the assembly of the inflammasome that promotes the processing and maturation of pro-IL-1β. In addition, NLRP1 variants were found to confer susceptibility to autoimmune disorders.

OBJECTIVE

/st> To study a possible association of the NLRP1 rs6502867, rs2670660 and rs8182352, rs12150220 and rs4790797 with SSc in the European Caucasian population.

METHODS

NLRP1 single nucleotide polymorphisms were genotyped in 3227 individuals comprising a discovery set (870 SSc patients and 962 controls) and a replication set including individuals from Germany (532 SSc patients and 324 controls) and Italy (527 SSc patients and 301 controls), all individuals being of European Caucasian origin.

RESULTS

Conditional analyses revealed a significant association for the NLRP1 rs8182352 variant with both anti-topoisomerase-positive and SSc-related fibrosing alveolitis (FA) subsets under an additive model: p=0.0042, OR 1.23 (95% CI 1.07 to 1.41) and p=0.0065 OR 1.19 (95% CI 1.05 to 1.36), respectively. Logistic regression analysis showed an additive effect of IRF5 rs2004640, STAT4 rs7574865 and NLRP1 rs8182352 risk alleles on SSc-related FA.

CONCLUSIONS

Our results establish NLRP1 as a new genetic susceptibility factor for SSc-related pulmonary fibrosis and anti-topoisomerase-positive SSc phenotypes. This provides new insights into the pathogenesis of SSc, underlining the potential role of innate immunity in particular in the FA-positive SSc subphenotype, which represents a severe subset of the disease.

Association of the TNFAIP3 rs5029939 variant with systemic sclerosis in the European Caucasian population

BACKGROUND

TNFAIP3 encodes the ubiquitin-modifying enzyme, a key regulator of inflammatory signalling pathways. Convincing associations between TNFAIP3 variants and autoimmune diseases have been reported.

OBJECTIVE

To investigate the association of TNFAIP3 polymorphisms with systemic sclerosis (SSc).

METHODS

Three single nucleotide polymorphisms (SNPs) in a set of 1018 patients with SSc and 1012 controls of French Caucasian origin were genotyped. Two intergenic SNPs, rs10499194 and rs6920220, and one located in TNFAIP3 intron 2, rs5029939, were selected. The TNFAIP3 rs5029939 found to be associated with SSc in this first set was then genotyped in a second set of 465 patients with SSc and 182 controls from Germany and 184 patients with SSc and 124 controls from Italy. Pooled odd ratios were calculated by Mantel-Haenszel meta-analysis.

RESULTS

The rs5029939 G allele was found to be significantly associated with SSc susceptibility (pooled OR=2.08 (95% CI 1.59 to 2.72); p=1.16×10⁻⁷), whereas the rs10499194 and rs6920220 variants displayed no association. Only one of the predicted haplotypes investigated in the French sample was significantly associated with SSc (p=8.91×10⁻⁸), and this haplotype was discriminating only in the presence of the rs5029939 risk allele, suggesting that this SNP tags the association signal. The strongest associations of rs5029939 with subphenotypes, having large magnitudes for complex genetic disorders, were observed for diffuse cutaneous SSc (pooled OR=2.71 (1.94 to 3.79), p=5.2×10⁻⁹), fibrosing alveolitis (pooled OR=2.26 (1.61 to 3.17), p=2.5×10⁻⁶) and pulmonary arterial hypertension (pooled OR=3.11 (1.86 to 5.17), p=1.3×10⁻⁵).

CONCLUSION

These results suggest that TNFAIP3 is a genetic susceptibility factor for SSc.

Selected Abstracts Submitted to the Third International Symposium on Hereditary Breast and Ovarian Cancer

Background: Germline mutation screening of BRCA1 and BRCA2 genes is performed in suspected familial breast cancer cases, but a causative mutation is found in only 30% of patients. The development of additional methods to identify good candidates for BRCA1 and BRCA2 analysis would therefore increase the efficacy of diagnostic mutation screening. With this in mind, we developed a study to determine molecular signatures of BRCA1—or BRCA2—mutated breast cancers. Materials and Methods: Array-cgh (comparative genomic hybridization) and transcriptomic analysis were performed on a series of 103 familial breast cancers. The series included 7 breast cancers with a BRCA1 mutation and 5 breast cancers with a BRCA2 mutation. The remaining 91 cases were obtained from 73 families selected on the basis of at least 3 affected first-degree relatives or at least 2 affected first-degree relatives with breast cancer at an average age of 45 years. Array-cgh analyses were performed on a 4407 BAC-array (CIT-V8) manufactured by IntegraGen. Transcriptomic analyses were performed using an Affymetrix Human Genome U133 Plus 2.0 chip. Results: Using supervised clustering analyses we identified two transcriptomic signatures: one for BRCA1-mutated breast cancers consisting of 600 probe sets and another for BRCA2-mutated breast cancers also consisting of 600 probes sets. We also defined cgh-array signatures, based on the presence of specific genomic rearrangements, one for BRCA1-mutated breast cancers and one for BRCA2-mutated breast cancers. Conclusions: This study identified molecular signatures of breast cancers with BRCA1 or BRCA2 germline mutations. Genes present in these signatures could be exploited to find new markers for such breast cancers. We also identified specific genomic rearrangements in these breast cancers, which could be screened for in a diagnostic setting using fluorescence in situ hybridization, thus improving patient selection for BRCA1 and BRCA2 molecular genetic analysis.

Association between the IRF5 rs2004640 functional polymorphism and systemic sclerosis: a new perspective for pulmonary fibrosis

OBJECTIVE

There is now growing evidence that connective tissue diseases, including systemic sclerosis (SSc), share a common genetic background. Microarray studies support a pivotal role of type I interferon (IFN) in the pathophysiology of connective tissue diseases. Interferon regulatory factors coordinate the expression of type I IFNs, and the IRF5 gene has been identified as a susceptibility gene of systemic lupus and Sjögren's syndrome. The aim of this study was to determine whether the IRF5 rs2004640 single-nucleotide polymorphism is associated with SSc.

METHODS

The IRF5 rs2004640 (GT) functional polymorphism was genotyped in 1,641 subjects of French European Caucasian origin: a discovery set comprising 427 patients with SSc and 380 control subjects and a replication set comprising 454 patients with SSc and 380 control subjects.

RESULTS

In both the discovery set and the replication set, the TT genotype was significantly more common in patients with SSc than in control subjects, with an odds ratio (OR) for the combined populations of 1.58 (95% confidence interval [95% CI] 1.18-2.11 [P for trend 0.002]). Analyses of the whole SSc population showed a significant association between homozygosity for the T allele and the presence of antinuclear antibodies (corrected P [Pcorr]=0.04, OR 1.59, 95% CI 1.16-2.17) and fibrosing alveolitis (Pcorr=0.001, OR 2.07, 95% CI 1.38-3.11). In a multivariate analysis model including the diffuse cutaneous subtype of SSc and positivity for anti-topoisomerase I antibodies, the IRF5 rs2004640 TT genotype remained associated with fibrosing alveolitis (P=0.029, OR 1.92, 95% CI 1.07-3.44).

CONCLUSION

The IRF5 rs2004640 GT substitution is associated with susceptibility to SSc. These data provide new insight into the pathogenesis of SSc, including clues to the mechanisms leading to fibrosing alveolitis.

Genomic score predictive of metastatic evolution in breast cancer

Abstract #5069

Background: Despite of the existence of clinical and pathological prognostic factors, the metastatic evolution in breast cancer remains uncertain in a substantial proportion of cases. Previous studies have suggested that genome profiling could address this question. In this context we developed a genomic score to evaluate the total level of copy number aberrations in a given tumor, based on data from array-CGH analysis.
 Material and Methods:We performed array-CGH analysis in a series of 135 sporadic, operable breast cancers treated at our institution between 1989 and 1992 (more than 10 years follow-up). These cases included 45 invasive ductal carcinomas with metastatic evolution (M+) and 90 cases that did not relapse at 11 years (M- ). Cases were paired on patients age and initial axillary lymph node status (pN +/pN0), and were equally distributed between the two groups of evolution: 25 pN0/M+, 20 pN+/M+, 50 pN0/M- and 40 pN+/M-. Tumoral DNA was co-hybridized with pooled normal germline DNA from 20 individuals on a 4407 BAC-array (CIT-V6) provided by the CIT program and manufactured by Integragen. Gain, normal and loss status (GNL) were generated from the CapWeb pipeline developped by the bioinformatics plateforme from Institut Curie (Paris). Clinical, pathological and genomic data were retrieved through Annotator, the CIT cancer database and the analysis has been driven by using the R statistical software along with the CIT R packages.
 Results:The proposed score of genomic instability is based on two items: (i) the proportion of alteration and (ii) the number of altered genomic regions. By applying a set of appropriate thresholds on these two items we were able to define three highly different prognostic subgroups, 95 % (18/19), 74 % (65/88) and 25 % (7/28) 11 years metastatic-free survival respectively (p-value = 4.04e−10) while univariate analysis of histological parameters such as tumor size and SBR grade showed weaker associations (p-values of 0.006 and 0.065 respectively). The predictive properties of the genomic score have been assessed by cross-validation but also on other independent large data sets. A signature of genome instability inferred from genomic and gene expression profiles will also be proposed.
 Conclusion: Genomic profiling in breast carcinoma is a strong tool for prognostication in breast cancer. We developed a computational method to characterize genome instability of that predict clinical outcome in breast cancer and could be useful for more accurate therapeutic choice but also for identifying new therapeutical targets.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5069.

Computing power in case-control association studies through the use of quadratic approximations: application to meta-statistics

In the framework of case-control studies many different test statistics are available to measure the association of a marker with a given disease. Nevertheless, choosing one particular statistic can lead to very different conclusions. In the absence of a consensus for this choice, a tempting option is to evaluate the power of these different statistics prior to make any decision. We review the available methods dedicated to power computation and assess their respective reliability in treating a wide range of tests on a wide range of alternative models. Considering Monte-Carlo, non-central chi-square and Delta-Method estimates, we evaluate empirical, asymptotic and numerical approaches. Additionally we introduce the use of the Delta-Method, extended to order 2, intended to provide better results than the traditional order-1 Delta-Method. Supplementary data can be found at: http://stat.genopole.cnrs.fr/software/dm2.

A fast, unbiased and exact allelic test for case-control association studies

Association studies are traditionally performed in the case-control framework. As a first step in the analysis process, comparing allele frequencies using the Pearson's chi-square statistic is often invoked. However such an approach assumes the independence of alleles under the hypothesis of no association, which may not always be the case. Consequently this method introduces a bias that deviates the expected type I error-rate. In this article we first propose an unbiased and exact test as an alternative to the biased allelic test. Available data require to perform thousands of such tests so we focused on its fast execution. Since the biased allelic test is still widely used in the community, we illustrate its pitfalls in the context of genome-wide association studies and particularly in the case of low-level tests. Finally, we compare the unbiased and exact test with the Cochran-Armitage test for trend and show it perfoms similarly in terms of power. The fast, unbiased and exact allelic test code is available in R, C++ and Perl at: http://stat.genopole.cnrs.fr/software/fueatest.

Do French lay people and health professionals find it acceptable to breach confidentiality to protect a patient's wife from a sexually transmitted disease?

OBJECTIVE

To determine under what conditions lay people and health professionals find it acceptable for a physician to breach confidentiality to protect the wife of a patient with a sexually transmitted disease (STD).

METHODS

In a study in France, breaching confidentiality in 48 scenarios were accepted by 144 lay people, 10 psychologists and 7 physicians. The scenarios were all possible combinations of five factors: severity of the disease (severe, lethal); time taken to discuss this with (little time, much time); intent to inform the spouse about the disease (none, one of these days, immediately); intent to adopt protective behaviours (no intent, intent); and decision to consult an expert in STDs (yes, no), 2 x 2 x 3 x 2 x 2. The importance and interactions of each factor were determined, at the group level, by performing analyses of variance and constructing graphs.

RESULTS

The concept of breaching confidentiality to protect a wife from her husband's STD was favoured much more by lay people and psychologists than by physicians (mean ratings 11.76, 9.28 and 2.90, respectively, on a scale of 0-22). The patient's stated intentions to protect his wife and to inform her of the disease had the greatest impact on acceptability. A cluster analysis showed groups of lay participants who found breaching confidentiality "always acceptable" (n = 14), "depending on the many circumstances" (n = 87), requiring "consultation with an expert" (n = 30) and "never acceptable (n = 13)".

CONCLUSIONS

Most people in France are influenced by situational factors when deciding if a physician should breach confidentiality to protect the spouse of a patient infected with STD.

The acceptability of ending a patient's life

OBJECTIVES

To clarify how lay people and health professionals judge the acceptability of ending the life of a terminally ill patient.

DESIGN

Participants judged this acceptability in a set of 16 scenarios that combined four factors: the identity of the actor (patient or physician), the patient's statement or not of a desire to have his life ended, the nature of the action as relatively active (injecting a toxin) or passive (disconnecting life support), and the type of suffering (intractable physical pain, complete dependence, or severe psychiatric illness).

PARTICIPANTS

115 lay people and 72 health professionals (22 nurse's aides, 44 nurses, six physicians) in Toulouse, France.

MAIN MEASUREMENTS

Mean acceptability ratings for each scenario for each group.

RESULTS

Life ending interventions are more acceptable to lay people than to the health professionals. For both, acceptability is highest for intractable physical suffering; is higher when patients end their own lives than when physicians do so; and, when physicians are the actors, is higher when patients have expressed a desire to die (voluntary euthanasia) than when they have not (involuntary euthanasia). In contrast, when patients perform the action, acceptability for the lay people and nurse's aides does not depend on whether the patient has expressed a desire to die, while for the nurses and physicians unassisted suicide is more acceptable than physician assisted suicide.

CONCLUSIONS

Lay participants judge the acceptability of life ending actions in largely the same way as do healthcare professionals.