Dopamine transporter binding in the brain is linked to irritable bowel syndrome in Parkinson's disease

BACKGROUND

Gastrointestinal symptoms are common in Parkinson's disease (PD), but their neurophysiological correlates are not well understood. We recently reported that functional gastrointestinal symptoms were not associated with asymmetry per se but might be associated with lower left striatal dopamine transporter (DAT) binding. The purpose of this study was to further investigate if specific gastrointestinal symptoms associate with monoamine transporter changes in specific striatal or extrastriatal areas.

METHODS

Ninety PD patients, who underwent DAT ¹^{2 3} I-FP-CIT SPECT imaging, were assessed using the MDS-Unified Parkinson's Disease Rating Scale part III, Rome III, and Wexner constipation score. DAT binding was calculated from striatal subregions using region-to-occipital cortex ratio. Voxel-wise analysis was used to assess the relationship between gastrointestinal symptoms and striatal DAT and extrastriatal serotonin transporter (SERT) binding.

RESULTS

Irritable bowel syndrome (IBS) criteria were fulfilled in 17 patients and were linked to higher ¹^{2 3} I-FP-CIT binding in the right posterior putamen and adjacent areas as compared to patients without IBS. No other significant associations between gastrointestinal symptoms and DAT or SERT binding were found.

CONCLUSIONS

These findings suggest that PD patients with IBS may have higher DAT binding in the right hemisphere. This finding implicates alterations of brain neurotransmitter physiology in the gastrointestinal symptoms of PD patients.

Floating door sign does not differentiate Parkinson's disease from essential tremor

Diagnostic usefulness of the floating door sign was tested in 144 PD patients, 41 essential tremor patients and 38 controls. There were no differences in the presence of floating door sign between PD and ET patients. The sign does not seem to be a reliable differential diagnostic tool.

Diagnostic value of micrographia in Parkinson's disease: a study with [123I]FP-CIT SPECT

Micrographia is a common symptom of Parkinson’s disease (PD), and it may precede other motor symptoms. Despite the high prevalence of micrographia in PD, its neurobiological mechanisms are not known. Given that levodopa may alleviate consistent micrographia and that nondopaminergic essential tremor (ET) is not associated with micrographia, micrographia could possibly be used as an ancillary diagnostic method that reflects nigrostriatal dopamine function. We evaluated the usefulness of micrographia as a simple one-sentence writing test in differentiating PD from ET. A total of 146 PD patients, 42 ET patients and 38 healthy controls provided writing samples and were scanned with brain [¹²³I]FP-CIT dopamine transporter (DAT) SPECT imaging with ROI-based and voxelwise analyses. The diagnostic accuracy of micrographia was evaluated and compared to that of DAT binding. Compared to ET and healthy controls, PD patients showed micrographia (consistent, 25.6% smaller area of handwriting sample in PD compared to ET, p = 0.002, and 27.2% smaller area of handwriting compared to healthy controls, p = 0.004). PD patients showed 133% more severe progressive micrographia compared with ET patients (median b =  − 0.14 in PD, b =  − 0.06 in ET, p = 0.021). In early unmedicated cognitively normal patients, consistent micrographia showed 71.2% specificity and 87.5% sensitivity in PD versus ET differentiation, but micrographia had no correlation with striatal or extrastriatal [¹²³I]FP-CIT binding in patients with PD. The one-sentence micrographia test shows moderately good accuracy in PD versus ET differentiation. The severity of micrographia has no relationship with DAT binding, suggesting nondopaminergic mechanism of micrographia in PD.

ClinicalTrials.gov identifier: NCT02650843 (NMDAT study).

Gastrointestinal Symptoms and Dopamine Transporter Asymmetry in Early Parkinson's Disease

Background

The neurophysiological correlates of gastrointestinal symptoms (GISs) in Parkinson's disease (PD) are not well understood. It has been proposed that in patients with a gastrointestinal origin of PD dopaminergic neurodegeneration would be more symmetric.

Objectives

The aim is to assess the associations between GISs and asymmetry of nigrostriatal dopaminergic neurodegeneration in PD.

Methods

Ninety PD patients were assessed using motor and GIS scales and ¹²³I‐FP‐CIT SPECT. We calculated the asymmetry index and the predominant side of motor symptoms and dopamine transporter (DAT) imaging defect and assessed their association with GISs.

Results

There were no significant differences in GISs between symmetric and asymmetric dopaminergic defect. Left predominant defect was related to more GIS and higher constipation scores.

Conclusions

GISs were associated with left predominant reduction in putaminal DAT binding but not asymmetry per se. It remains open whether left‐sided DAT deficit is related to more pronounced GI involvement or symptom perception in PD. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson Movement Disorder Society.

Abstract P4-09-03: Simulated outcomes of personalized versus guideline-based breast cancer screening

Introduction: Personalized screening, or screening tailored to individual breast cancer risk, is being studied as an improvement on the current practice of guideline-based screening. WISDOM (Women Informed to Screen Depending on Measures of Risk) is an ongoing randomized trial comparing personalized to annual screening. To project the efficacy, safety, and cost of personalized screening on a population level, we constructed a simulation model comparing personalized to guideline-based strategies across the outcomes of advanced (Stage IIB+) cancers, false positives, biopsies, and cost.

Methods: Our simulated cohort consisted of 100,000 women aged 40-74 with demographic and risk factor distributions based on the U.S. screening population. We modeled the WISDOM approach to personalized screening where recommendations are based on the results of panel-based mutation testing and 5-year risk estimates from a clinical risk model modified by a polygenic risk score containing 76 genetic variants (SNPs). Simulated women were randomly assigned a clinical and genetic risk profile, which were integrated to generate a 5-year risk estimate. This was then used to assign a starting and stopping age, frequency, and modality (MRI vs. mammogram) of screening. We compared the aggregate outcomes over a 1-year time window between personalized screening and 3 strategies based on U.S. professional society guidelines (Table).

Results: There was no statistically significant difference in advanced cancers between screening strategies (Table). However, the biennial, hybrid, and personalized strategies resulted in fewer false positives and biopsies compared to annual screening, and at lower cost. Though aggregate outcomes between the hybrid and personalized strategies were similar, the average 5-year risk of women assigned to annual screening under the personalized strategy was higher than that of the hybrid strategy, 1.7% vs. 1.2%. Similarly, the average 5-year risk of women assigned to biennial screening was lower under the personalized strategy, 1.1% vs. 1.9%.

Conclusion: Our simulations show that personalized screening results in a similar incidence of advanced cancers as annual screening while reducing false positives, biopsies, and cost. Compared to other guideline-based strategies, personalized screening better allocates screening resources by identifying higher-risk women for more intensive screening, and lower-risk women for less intensive screening.

Descriptions and simulated outcomes of four screening strategiesStrategyStarting age, yearsStopping age, yearsFrequencyStage IIB+ cancers, RR1 (95% CI)2False positives, RR1 (95% CI)2Biopsies, RR1 (95% CI)2Cost, millions USD per 100,000 womenAnnual (American College of Obstetricians and Gynecologists)4074Annualrefrefref$22.1Biennial (U.S. Preventive Services Task Force)5074Biennial1.13 (0.98-1.28)0.44 (0.33-0.56)0.46 (0.35-0.58)$8.4Hybrid (American Cancer Society)45Per life expectancy45-55: Annual 55+: Biennial1.09 (0.95-1.25)0.58 (0.49-0.67)0.64 (0.56-0.73)$14.7Personalized (WISDOM)40-503Per life expectancyAnnual or Biennial41.01 (0.89-1.12)0.55 (0.46-0.65)0.56 (0.47-0.65)$14.11relative risk; 295% confidence interval; 3start when 5-year risk > 1.3%; 4annual if age 40-49 + dense breasts or top 2.5th percentile of 5-year risk

Citation Format: Shieh Y, Esserman L, Eklund M. Simulated outcomes of personalized versus guideline-based breast cancer screening [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 P4-09-03.

Abstract P4-01-26: Circulating cell-free DNA in serum as a marker for the early detection of tumor recurrence in breast cancer patients

Background: Quantitative estimation of circulating cell-free DNA (cfDNA) isolated from serum by noninvasive procedures can serve as a potential biomarker for the early detection of many cancers. However, a simple, straightforward technique is unavailable to estimate the cfDNA in clinical labs. Moreover, the prognostic value of cfDNA in patients with breast cancer (BrCa) is currently under debate. The aim of this study was to develop a simple yet effective quantitative method for measuring the cfDNA in serum and to eventually investigate the relationship between cfDNA and the occurrence of recurrence in BrCa patients.

Methods: A total of 240 patient cases (n=240) were selected and are comprised of different subtypes of breast cancer patients and control individuals. We selected 21 serum samples from patients which showed recurrence after 4-7 years of disease-free survival. For the compare studies, each of the recurrent and non-recurrent serum samples was incubated with the SYBR Green I (2 μM). A standard graph was also made with known DNA concentration to calculate the amount of cfDNA in these recurrent and non-recurrent serum samples. Additionally, a comparative study was also performed with the serum of patients with non-recurrent BrCa versus healthy patients.

Results: We develop a simple fluorescent based measuring technique which can easily estimate the cfDNA in one step. SYBR Green binds to DNA, and as a result, the fluorescence of SYBR Green increases substantially. Global Wilcoxon analyses were performed to compare the cfDNA amount between non-recurrent and recurrent patients. There is a significant difference in fluorescent intensities between recurrent patients' samples versus non-recurrent patients which are directly proportional to the cfDNA levels. The amount of cfDNA is higher in recurrent patient (ratio is 1.3 up; p= 0.03; AUC=0.76) compared to similar non-recurrent patients. While we compared the fluorescence data between normal/healthy patients versus non-recurrent is turned out as non-significant (healthy to non-recurrent ratio = 1.03; p= 0.20, AUC=0.61).

Conclusion: In this current study, we developed a straightforward one-step technique to measure the amount of cfDNA in serum, which can easily translate into a clinical diagnostic tool. To the best of our knowledge, this is the first report which demonstrates serum cfDNA as an early detection marker for recurrent breast cancer patients. The relatively high level of cfDNA in the serum of recurrent breast cancer patients compared to non-recurrent breast cancer patients indicates an uncovered circulating genetic information which triggers the cancer recurrence pathway to relapse cancer in the near future.

Citation Format: Bera A, Eidelman O, Russ E, Landa A, Karaian J, Eklund M, Hu H, Pollard HB, Shriver CD, Srivastava M. Circulating cell-free DNA in serum as a marker for the early detection of tumor recurrence in breast cancer patients [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 P4-01-26.

Abstract OT2-08-01: Personalized breast cancer screening in a population based study: Women Informed to Screen Depending On Measures of risk (WISDOM)

Background: WISDOM is a 100,000 healthy women preference-tolerant, pragmatic study comparing annual to personalized risk-based breast screening. The novelty of WISDOM personalized screening is the integration of previously validated genetic and clinical risk factors (age, family history, breast biopsy results, ethnicity, mammographic density) into a single risk assessment model that directs the starting age, timing, and frequency of screening. The goal of WISDOM is to determine if personalized screening, compared to annual screening, is as safe, less morbid, enables prevention, and is preferred by women. The study is registered on ClinicalTrials.gov, NCT02620852.

Methods: Women aged 40-74 years with no history of breast cancer or DCIS, and no previous double mastectomy can join the study online at wisdomstudy.org. Participants can elect randomization or self-select a study arm, and provide electronic consent and Release for Medical Information using DocuSign. For all participants, 5-year risk of developing breast cancer is calculated according to the Breast Cancer Screening Consortium (BCSC) model. Participants in the personalized arm undergo panel-based mutation testing, and their 5-year risk is calculated using the BCSC score combined with a Polygenic Risk Score (BCSC-PRS) that includes 75 single nucleotide polymorphisms (SNPs, increase to 229) known to increase breast cancer risk. SNPs and mutations (BRCA1, BRCA2, TP53, PTEN, STK11, CDH1, ATM, PALB2, and CHEK2) are assessed by saliva-based testing through Color Genomics. 5-year risk level thresholds are used to stratify for low-, moderate- and high risk. Risk stratification determines age to start, stop, and frequency of screening.

Enrollment: As of July 2018, the WISDOM study is open to all eligible women in California, North Dakota, South Dakota, Minnesota and Iowa. To date, 23,329 eligible women have registered and 14,393 women have consented to participate in the trial. We analyzed 3,255 participants who have completed risk assessment in the personalized arm. The median age was 56 years. 82% were Caucasian, 1% African-American, and 6% Asian. 9% self-reported as Hispanic. We are partnering with health insurers and self-insured companies using coverage with evidence progression. To strengthen generalizability, we are expanding to other states. WISDOM enrollment will continue past 2019.

Feasibility: To evaluate the addition of PRS, we used paired statistical tests (McNemar) to compare the distributions of BCSC, and BCSC-PRS risk estimates around low-risk (<1.3%), and very-high risk (>6%) thresholds, the latter corresponding to 5-year risk of a BRCA mutation carrier. The median 5-year risk was 1.5% (IQR 1.0-2.1%) using the BCSC model, and 1.4% (IQR 0.8-2.5%) using the BCSC-PRS model. The BCSC-PRS model classified more women into the low (<1%) and very high (≥6%) risk categories compared to the BCSC model (p < 0.001).

Conclusions: Our findings demonstrate that incorporating genetic variants into a validated clinical model is feasible and impacts risk classification compared to a model without genetic risk factors. Results at 5 years will reveal if this classification improves healthcare value by reducing screen volumes and costs without jeopardizing outcomes.

Citation Format: Acerbi I, Shieh Y, Madlensky L, Tice J, Ziv E, Eklund M, Blanco A, DeRosa D, Tong B, Goodman D, Nassereddine L, Anderson N, Harvey H, Layton T, Park HL, Petruse A, Stewart S, Wernisch J, Risty L, Koenig B, Sarrafan S, Firouzian R, Kaplan C, Hiatt R, Parker BA, Wenger N, Lee V, Heditsian D, Brain S, Stover Fiscalini A, Borowsky AD, Anton-Culver H, Naeim A, Kaster A, Talley M, van 't Veer LJ, LaCroix A, Wisdom Study and Athena Breast Health Network Investigators and Advocate Partners, Esserman LJ. Personalized breast cancer screening in a population based study: Women Informed to Screen Depending On Measures of risk (WISDOM) [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 OT2-08-01.

Workforce participation and activities in Parkinson's disease patients receiving device-aided therapy

OBJECTIVES

Many countries have an aging population, and it is thus likely that Parkinson's disease (PD) will become an increasing health problem. It is important to ensure this group can use their resources in the best way possible, including remaining in the work market. This study aimed to investigate workforce participation and daily activities among patients with PD receiving device-aided therapy to provide new knowledge that may be used to inform decisions about these therapy options.

MATERIALS AND METHODS

This was a retrospective, descriptive quantitative pilot study, including 67 patients with PD from 3 centers in Sweden and Denmark. Included patients were younger than 67 years at the time of introduction of device-aided therapy. Eligible patients were identified by the Swedish national Parkinson patient registry or by the treating neurologist. Quantitative interviews were made by telephone.

RESULTS

A majority of the patients could perform the same, or more, amount of activities approximately 5 years after the introduction of device-aided therapy. A small number of patients receiving deep brain stimulation (DBS) and levodopa-carbidopa intestinal gel (LCIG) were able to increase their work capacity within 1 year of initiating device-aided therapy and a remarkably high share could still work at the end-point of this study, approximately 15 years since the diagnosis of PD.

CONCLUSIONS

Device-aided therapy may sustain or increase daily activities and workforce participation in patients with PD who have not yet reached retirement age. There is need for prospective studies, both quantitative and qualitative, to confirm these results.

Standardized ileal digestibility of amino acids in European soya bean and rapeseed products fed to growing pigs

This study was conducted to determine the chemical composition and standardized ileal digestibility coefficients (SID) of crude protein (CP) and amino acids (AA) of European soya bean and rapeseed products in pigs. Six soya bean and two rapeseed products were used as the sole dietary source of CP and AA, including raw (FFSB) and roasted full-fat soya beans (FFSBRoasted ), soya bean (SBC) and rapeseed cake (RSC), and rapeseed meal (RSM) from Bavaria (Germany), soya bean meal (SBM) from the Danube region (Austria; SBMAustria ), a commercially available standard SBM (SBMStd ) and an imported genetically modified organism-free SBM (SBMGMO-free ). Eight ileal- cannulated pigs with an initial body weight of 32 ± 2 kg were allotted to a row-column design with eight diets and six periods of seven days each. Trypsin inhibitor activity (TIA) ranged from 1.8 in SBMStd to 24.5 mg/g DM in FFSB. The SID of CP and all AA in FFSBRoasted were greater than in FFSB, but lower when compared to SBC and SBMAustria (p < .05). The SID of CP and all AA (except glutamic acid) were not different between SBC and SBMAustria , but the SID of CP and all AA (except methionine) were greater (p < .05) in SBC than in SBMGMO-free . Furthermore, the SID of CP and most AA showed a quadratic response with decreasing TIA, and there exists a quadratic response in SID of CP and all AA with increasing lysine to CP ratio and neutral detergent insoluble nitrogen (p < .05). In conclusion, variation in chemical composition and SID of CP and AA was observed in different European soya bean and rapeseed products as influenced by differences in processing conditions. European SBC and SBMAustria can be used as alternative to imported SBMGMO-free and SBMStd in diets for growing pigs.

Abstract P4-12-03: Tailoring screening to individual risk decreases the cost and improves the value of screening

Introduction:

Health care spending rose from 5% to 17.8% of GDP between 1960 and 2015. Clinicians and researchers must engage in increasing health care value – better outcomes at less cost. Personalized screening is one such opportunity. The Patient Centered Outcomes Research Institute recently funded WISDOM (Women Informed to Screen Depending On Measures of risk), a randomized trial to tests the safety and efficacy of basing starting age, stopping age, frequency and modality of breast cancer screening on individual risk (Clinical Trials Identifier NCT02620852). The personalized arm of WISDOM integrates genetic testing into the risk algorithm. Funding for the clinical services of WISDOM (genetic test, risk assessment, high-risk counseling) are expected to be covered ( health plans, insurers). Risk determines the frequency, time to initiate screening and drives cost of downstream screening services. The cost of genetic testing is now less than $250, comparable to a mammogram. The WISDOM study model brings payers, policy makers, provider, technology, and advocate partners together to generate evidence to see if risk based screening is as safe, less morbid, preferred by women, promotes prevention, and has greater health care value. Health plans need to know the value proposition, thus we evaluated financial implications of coverage for risk-based screening.

Methods:

A model was developed to compare costs and benefits of risk-based vs. current screening practices from the perspective of a health plan. Modeled cohorts resembled a screening population with risk determining screening interval for the risk-based model, and average time between mammograms determining the interval for the model of current screening practices. Model parameters were gathered from published literature, national databases, early findings from WISDOM and health plan claims data. Sensitivity analysis was performed on all parameters, including costs of clinical services, screening rates, and health plan turnover. The clinical services specific to WISDOM use a fixed-fee schedule, and not varied in the model. All other costs were conservative, based on Medicare rates and published literature.

Results:

We estimated that over five years, risk-based screening is at worst cost neutral with potential for savings of up to $215 per participant. Based on current trial enrollment, we estimated that 30 per 1,000 health plan enrollees would join, resulting in an upfront cost of $6,000 for WISDOM-specific services, primarily the genetic test, and $600 in ongoing costs after Year 1. However, the health plan would save on mammogram and work up costs as participants would receive an average of 2-3 fewer mammograms over five years. Savings are sensitive to the age of participants, cost of mammograms, and savings increase over time. Per participant, five-year savings of $300 and $35 for those aged 40-49 and 65-74 respectively, and increased costs of $30 for those aged 50-64. Overall, an upfront investment of $6,000 per 1,000 health plan enrollees (30 participants) yields $3,800 in five-year savings.

Conclusion:

Personalized screening could provide cost savings and has the potential to increase health care value. Enrollment in the Wisdom study is ongoing and results will be reported in 5 years.

Citation Format: Wimmer K, Stover Fiscalini A, Eklund M, DiGiorgio K, Naeim A, Athena and Wisdom Investigators, Esserman L. Tailoring screening to individual risk decreases the cost and improves the value of screening [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-12-03.

Abstract PD2-14: Participation in a personalized breast cancer screening trial does not increase anxiety at baseline

Introduction: The purpose of this study is to examine whether participation in a personalized screening trial is associated with anxiety or breast cancer worry. The Patient Centered Outcomes Research Institute recently funded WISDOM (Women Informed to Screen Depending On Measures of risk), which is a randomized trial that tests the safety and efficacy of basing starting age, stopping age, frequency and modality of breast cancer screening on individual risk (Clinical Trials Identifier NCT02620852).

Methods: In WISDOM, participants can be randomized to annual screening or personalized screening arm, or self-select an arm an observational cohort. This interim analysis examined the first 1817 participants to determine if the personalized risk arm is acceptable and to explore whether baseline anxiety was associated with study arm. For acceptability our target was to have &gt;60% of participants agree to randomization. Participants completed questions about their Risk Perception, the PROMIS Anxiety short form 8a (total scores 8-40 with higher scores indicating more anxiety), and Breast Cancer Risk Worry (BCRW) survey (total scores 5-20) with higher scores indicating more worry) at baseline and before they were given information on their personal risk or study assignment. For the purposes of these analyses, we defined high anxiety to be the percentage of participants scoring =&gt;22 on the PROMIS and &gt;8 on the BCRW.

Results: The participants were recruited from three sites (UCSD, UCSF, Sanford Health). Of the 1817 initial participants, 1643 completed the baseline questionnaire. Participants has a mean age of 57 years (SD 9). 15.8% felt their chances of developing breast cancer was high, 19.5% felt their chance of developing breast cancer was greater than the average women, and 56.6% felt their lifetime risk of developing breast cancer was &gt;25. Risk perception was not significantly different between women who opted to be randomized versus the observational arm.

The majority of participants were willing to be randomly assigned to an arm (1071/1643, 65.1%). Of those who joined the observational cohort, the majority selected personalized risk arm (474/572, 82.9%). Overall, PROMIS anxiety scores were low at baseline (14.0 MEAN (SD 4.6)) as were the Breast Cancer Risk Worry scores (5.7 MEAN (SD 1.05)). Less than 8% of participants had PROMIS scores &gt;22 and that did not vary across the randomized or observational groups (P=0.2)). About 2% of participants had a BCRW scores &gt;8. Women who worried with breast cancer were more likely to select to be in the observational (3.5%) than randomized (1.7%) arm of the study (P=0.02).

Conclusions: For the women approached to participate in Wisdom, personalized screening was acceptable alternative to annual mammography. Participants in general overestimated their lifetime risk of breast cancer, had very low anxiety and low breast cancer worry. Those who were worried about breast cancer opted more often for the observational arm of the study to allow them to choose between the personalized versus annual arm. Future analyses will follow participants prospectively to determine adherence to assigned or selected arm, and whether anxiety changes after receipt of their personalized risk information.

Citation Format: Naeim A, Sepucha K, Wenger N, Eklund M, Annette S, Madlensky L, van't Veer L, Parker B, Yau C, Cink T, Anton-Culver H, Borowsky A, Petruse A, Sarrafan S, Stover-Fiscalini A, LaCroix A, Adduci K, Wisdom Advocate Partners, Laura E. Participation in a personalized breast cancer screening trial does not increase anxiety at baseline [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-14.

Abstract P3-09-02: Risk stratification using clinical risk factors and genetic variants in a personalized screening trial

Introduction: Tailoring breast cancer screening according to individual risk may represent an improvement over the current practice of age-based screening. WISDOM (Women Informed to Screen Depending on Measures of Risk) is an ongoing randomized trial comparing the safety, efficacy, cost, and patient acceptability of personalized versus annual screening. Women in the personalized arm receive screening recommendations based on sequencing of 9 genes associated with hereditary breast cancer and a 5-year risk estimate from the Breast Cancer Surveillance Consortium (BCSC) risk model modified by a polygenic risk score (PRS) comprised of 75 single nucleotide polymorphisms. WISDOM represents the first-ever use of a PRS to prospectively modify risk estimates and allows comparison of risk model performance in a population-based setting. Thus, we evaluated the risk estimates generated by: 1) the Breast Cancer Risk Assessment Tool (BCRAT) based on the Gail model, 2) the BCSC model, and 3) the BCSC model modified by the PRS (BCSC-PRS).

Methods: We analyzed participants in the personalized screening arm of the WISDOM Study (NCT02620852). The trial opened in October 2016 and is enrolling participants aged 40-74 years. Participants' self-reported demographic and risk factor information were collected through an online portal. Genotyping of participants in the personalized arm was done using a custom panel from Color Genomics. 5-year risk estimates were generated using the BCRAT (2011 version), BCSC, and BCSC-PRS models. In the latter, the PRS was used as a Bayesian likelihood ratio to modify the BCSC 5-year risk estimate. We compared the distributions of BCRAT, BCSC, and BCSC-PRS risk estimates around a low-risk (&lt;1%) and moderately high-risk (≥3%) threshold using a paired statistical test (McNemar).

Results: To date, WISDOM has enrolled 2,065 participants, of whom 1,157 are in the personalized arm and 830 have completed risk assessment. The median age was 57 years (interquartile range, IQR 49-64). 83% were Caucasian, 2% African-American, and 7% Asian. 8% self-reported as Hispanic. The median 5-year risk was 1.7% (IQR 1.1-2.3%) using the BCRAT, 1.6% (IQR 1.1-2.3%) using the BCSC model, and 1.5% (IQR 0.9-2.7%) using the BCSC-PRS model. The BCSC-PRS model classified more women into the low (&lt;1%) and moderately high (≥3%) risk categories compared with the BCRAT (p &lt; 0.001) and BCSC model (p &lt; 0.001), Table.

5-year risk classification according to the BCRAT, BCSC and BCSC-PRS models &lt;1%1-3%≥3% n (%)n (%)n (%)Gail161 (19)556 (67)113 (14)BCSC159 (19)568 (68)103 (12)BCSC-PRS275 (33)379 (46)176 (21)

Discussion: Adding a PRS to the BCSC model categorized significantly more women below the low-risk threshold and above the moderately high-risk threshold compared with the BCSC model and BCRAT. Furthermore, the BCSC and BCRAT generated similar distributions of risk estimates. Follow-up with incident breast cancer data is needed to determine whether the reclassification provided by the PRS improves risk stratification and clinical outcomes. However, our preliminary findings suggest that incorporating genetic variants into a validated clinical model is feasible and could enhance risk prediction.

Citation Format: Shieh Y, Ziv E, Eklund M, Sabacan L, Firouzian R, Madlensky L, Anton-Culver H, Borowsky A, LaCroix A, Naeim A, Parker B, van't Veer L, Esserman L, Tice J, WISDOM Study and Athena Network Investigators WS. Risk stratification using clinical risk factors and genetic variants in a personalized screening trial [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-09-02.

Ileal starch digestibility of different cereal grains fed to growing pigs

The objective of the present study was to determine, in growing pigs, the ileal starch digestibility and ileal digestible starch content of 8 different genotypes of barley, rye, triticale, and wheat each. Therefore, 4 experiments were conducted with 34 ileally cannulated growing pigs (initial BW of 24 to 32 kg) in total. The experimental diets were formulated to contain 1 of the 8 genotypes of each cereal grain at an inclusion level of 95%. Cereal grains were ground through a 2-mm sieve and were the sole dietary source of starch. All diets were supplemented with plant oil, minerals and vitamins, and titanium dioxide as an indigestible marker. The experiments were arranged either as a row-column design with 8 periods of 6 d each and 9 pigs (for barley and wheat) or according to an 8 × 8 Latin square design with 8 periods of 6 (rye) or 7 d (triticale) and 8 pigs. Experimental periods comprised 4 (barley, rye, and wheat) or 5 d (triticale) for adaptation followed by 2 d for ileal digesta collection. The daily feed intake amounted to 4% of pigs' average BW, corresponding to about 3 times the animals' energy requirement for maintenance (106 kcal of ME [as-fed basis]/kg of metabolic BW). Ileal starch digestibility was different ( < 0.05) within barley and triticale genotypes, with values ranging between 90.1 and 95.0% for barley and between 96.5 and 98.1% for triticale and tended to differ within rye genotypes ( < 0.1). Ileal digestible starch content was different ( < 0.05) within all cereal grains. On average, ileal starch digestibility amounted to 92.7, 95.0, 97.3, and 92.2% for barley, rye, triticale, and wheat, respectively, and was different among cereal grains ( < 0.001). Average ileal digestible starch content was greatest ( < 0.001) in triticale (68.3%, DM basis) followed by wheat (66.1%, DM basis), rye (61.1%, DM basis), and barley (57.6%, DM basis). Differences in ileal starch digestibility and ileal digestible starch content within and among grain genotypes may reflect variations in contents of several fiber fractions such as NDF, ADF, and nonstarch polysaccharides (NSP). For most cereal grains, ileal starch digestibility and ileal digestible starch content decreased ( < 0.05) with increasing contents of soluble, insoluble, and total NSP. In conclusion, in the present study, triticale is superior when compared with the other cereal grains due to its relatively low fiber and high starch content and its high ileal starch digestibility values.

Variations in the chemical composition and standardized ileal digestibility of amino acids in eight genotypes of triticale fed to growing pigs

The study was conducted to determine the chemical composition, physical characteristics, and standardized ileal digestibility (SID) of CP and AA of 8 currently available genotypes of triticale fed to growing pigs. The genotypes included Grenado, Cando, Agostino, Massimo, Tarzan, HYT Prime, SW Talentro, and Cultivo. Eight barrows with an initial BW of 31 ± 2 kg were fitted with simple T-cannulas at the distal ileum and allotted to an 8 × 8 Latin square design with 8 periods of 7 d each and 8 assay diets. The N-free method was used to determine basal ileal endogenous CP and AA losses. The 8 assay diets contained 1 of 8 triticale genotypes as the sole source of CP and AA. The triticale genotypes were grown under identical environmental conditions on the same site. Among the 8 genotypes, contents of CP ranged from 104.7 to 118.1 g/kg (as-fed basis). The content of total nonstarch polysaccharides and NDF ranged, on an as-fed basis, from 84.6 to 99.5 g/kg and from 88.4 to 149.0 g/kg, respectively. Among the 8 genotypes, SID of CP ranged from 81% in Grenado to 85% in Massimo and Tarzan. The SID of CP and AA did not differ among triticale genotypes except for SID of Arg, Glu, and Gly ( < 0.05). The mean SID of CP, Lys, Met, and Trp was 4, 4, 4, and 1 percantage units less and SID of Trp was 5 percantage units greater compared with values in current feed tables. Among the 8 triticale genotypes, standardized ileal digestible content (cSID) of CP followed total CP content and ranged from 84.8 to 98.7 g/kg (as-fed basis), with the lowest ( < 0.001) values for Grenado and the greatest ( < 0.001) values for SW Talentro and Cultivo. For CP and most AA, cSID linearly decreased as the content of total, soluble, and insoluble β-glucans increased ( < 0.05) in the 8 genotypes of triticale. There was a positive correlation between thousand seed weight and cSID of CP and most AA ( < 0.01). These variables may help to predict cSID in triticale batches, whereas other nutrients are not suitable due to their low variation among the 8 genotypes. The present study provides data on chemical composition, physical characteristics, and SID of CP and AA of 8 triticale genotypes grown under similar conditions. However, as most of the present SID values are less than those in feed tables, future research is warranted to elaborate whether these differences are caused by experimental conditions or reflect a consistent decrease that needs to be accounted for in feed tables.

Prostate cancer screening in men aged 50 to 69 years (STHLM3): A prospective population-based diagnostic study. Grönberg H, Adolfsson J, Aly M, Nordström T, Wiklund P, Brandberg Y, Thompson J, Wiklund F, Lindberg J, Clements M, Egevad L, Eklund M.Lancet Oncol. 2015 Dec;16(16):1667-76. [Epub 2015 Nov 10]. doi: 10.1016/S1470-2045(15)00361-7

BACKGROUND

The prostate-specific antigen (PSA) test is used to screen for prostate cancer but has a high false-positive rate that translates into unnecessary prostate biopsies and overdiagnosis of low-risk prostate cancers. We aimed to develop and validate a model to identify high-risk prostate cancer (with a Gleason score of at least 7) with better test characteristics than that provided by PSA screening alone.

METHODS

The Stockholm 3 (STHLM3) study is a prospective, population-based, paired, screen-positive, diagnostic study of men without prostate cancer aged 50 to 69 years randomly invited by date of birth from the Swedish Population Register kept by the Swedish Tax Agency. Men with prostate cancer at enrolment were excluded from the study. The predefined STHLM3 model (a combination of plasma protein biomarkers [PSA, free PSA, intact PSA, hK2, MSMB, MIC1], genetic polymorphisms [232 SNPs], and clinical variables [age, family, history, previous prostate biopsy, prostate exam]), and PSA concentration were both tested in all participants enrolled. The primary aim was to increase the specificity compared with PSA without decreasing the sensitivity to diagnose high-risk prostate cancer. The primary outcomes were number of detected high-risk cancers (sensitivity) and the number of performed prostate biopsies (specificity). The STHLM3 training cohort was used to train the STHLM3 model, which was prospectively tested in the STHLM3 validation cohort. Logistic regression was used to test for associations between biomarkers and clinical variables and prostate cancer with a Gleason score of at least 7. This study is registered with ISCRTN.com, number ISRCTN84445406.

FINDINGS

The STHLM3 model performed significantly better than PSA alone for detection of cancers with a Gleason score of at least 7 (P<0.0001), the area under the curve was 0·56 (95% CI: 0·55-0·60) with PSA alone and 0·74 (95% CI: 0·72-0·75) with the STHLM3 model. All variables used in the STHLM3 model were significantly associated with prostate cancers with a Gleason score of at least 7 (P<0·05) in a multiple logistic regression model. At the same level of sensitivity as the PSA test using a cutoff of≥3ng/ml to diagnose high-risk prostate cancer, use of the STHLM3 model could reduce the number of biopsies by 32% (95% CI: 24-39) and could avoid 44% (35-54) of benign biopsies.

INTERPRETATION

The STHLM3 model could reduce unnecessary biopsies without compromising the ability to diagnose prostate cancer with a Gleason score of at least 7, and could be a step towards personalised risk-based prostate cancer diagnostic programmes.

FUNDING

Stockholm County Council (Stockholms Läns Landsting).

Influence of wet heating and autoclaving on chemical composition and standardized ileal crude protein and amino acid digestibility in full-fat soybeans for pigs

One batch each of eight full-fat soybeans (FFSB) was used to determine the effect of different heat treatments including wet heating (WH) and autoclaving (AC) on chemical composition and standardized ileal digestibility (SID) of CP and AA in growing pigs. The raw FFSB (K0) were either treated by WH at 80°C for 1 min (K1), at 100°C for 6 min (K2), or at 100°C for 16 min (K3). Thereafter, these batches were expanded at 125°C for 15 s. A further heat treatment included AC at 110°C for 15 (Z1), 30 (Z2), 45 (Z3), or 60 (Z4) min of FFSB that were subjected to the same WH treatment as K3. Diets were formulated to contain the respective FFSB as the sole source of CP and AA. A N-free diet was used to measure basal endogenous losses of CP and AA in an additional period at the end of the experiment. Eight ileally cannulated pigs (28 ± 1 kg) were allocated to a row-column design with 8 diets and 6 periods of 7 d each. An increase in the duration of WH had no effect on contents of AA (% of CP) and NDF, but NDIN contents linearly increased ( < 0.05) with increasing time for WH. Autoclaving resulted in a linear decrease ( < 0.05) of trypsin inhibitor activity (TIA), contents of Arg, Leu, Ala, Asp, Cys, and Gly as well as Lys to CP ratio (Lys:CP), reactive Lys to CP ratio (rLys:CP), and in an increase ( < 0.05) in contents of NDF and NDIN. There was a quadratic response ( < 0.05) of SID of CP and AA as time for WH at 100°C increased from 0 (K0) to 6 (K2) up to 16 (K3) min. Moreover, a quadratic response ( < 0.05) to increasing time of AC was observed for SID of Arg, Phe, and Pro. The SID of CP and all indispensable AA showed a quadratic response ( < 0.05) to decreasing TIA, urease activity, protein solubility in 0.2% potassium hydroxide, protein dispersibility index, Lys:CP, (lightness), and to increasing NDIN and (redness). In addition, there was a linear increase ( < 0.05) in SID values with decreasing rLys:CP and increasing NDF contents. In conclusion, WH proved to be suitable for increasing SID values. Further improvement of SID of most AA could be achieved on additional AC treatment from Z1 to Z3, however, it needs to be considered, if the observed increase due to AC is cost effective in view of the additional production costs. Several chemical and physical parameters can be used in the feed industry for quality control purposes to predict the extent of heat damage on SID of CP and indispensable AA in FFSB.

Standardized ileal digestibility of amino acids in eight genotypes of soft winter wheat fed to growing pigs

A study with growing pigs was conducted to determine the chemical composition and standardized ileal digestibility (SID) of CP and AA of 8 wheat genotypes that have recently been added to the German Descriptive Variety List. These genotypes included Tabasco, KWS Erasmus, Tobak, Skalmeje, Mulan, Event, Tommi, and Adler. The 8 genotypes were grown under identical environmental conditions on the same site, and they were harvested and processed under the same conditions. Nine barrows with an initial BW of 32 ± 2 kg were surgically fitted with simple ileal T-cannulas and allotted to a row-column design with 9 pigs and 8 periods of 6 d each. Wheat was the sole dietary source of CP and AA. Among the 8 wheat genotypes, contents of CP ranged from 10.9 to 13.3% (as-fed basis), whereas contents of total nonstarch polysaccharides ranged from 8.0 to 9.4% (as-fed basis). The SID of CP in the 8 genotypes ranged from 83 to 87%, with greatest ( = 0.01) values for Event and lowest ( = 0.01) for all other wheat genotypes. Intermediate SID of CP values were obtained for Adler and KWS Erasmus. For Lys, greater ( < 0.05) SID was observed in Adler (73%) and KWS Erasmus (74%) in comparison to Tommi, Tobak, and Mulan (69%). Adler had greater SID of Met (88%; = 0.01) when compared to Tabasco (86%); Tobak, Skalmeje, and Mulan (85%); and Tommi (84%). Among the 8 wheat genotypes, standardized ileal digestible content (cSID) of CP followed total CP content and ranged from 9.1 to 11.3% (as-fed basis). Standardized ileal digestible content of both CP and AA were greater ( < 0.001) in Adler compared to all other genotypes. For most AA, Tabasco had the lowest ( < 0.001; except for His, Trp, Asp, and Cys) cSID values of all wheat genotypes. The cSID of CP decreased ( < 0.001) as the starch content in the 8 wheat genotypes increased, but cSID of CP increased ( < 0.001) as the CP content in the 8 genotypes increased. Because SID and cSID of CP and most AA increased ( < 0.05) with lower test weight and falling number, these variables may aid to predict SID and cSID in wheat batches, whereas other nutrients such as fiber fractions are not suitable due to low variation among the 8 genotypes. The present study provides a comprehensive database on nutritional composition and SID of CP and AA of 8 wheat genotypes grown under identical conditions. Because the SID values in these genotypes are lower when compared to literature data, digestibility values in actual feed tables for wheat may overestimate their protein values and need to be updated.

Effect of processing of rapeseed under defined conditions in a pilot plant on chemical composition and standardized ileal amino acid digestibility in rapeseed meal for pigs

Five rapeseed meals (RSM) were produced from a single batch of rapeseed in a large-scale pilot plant under standardized conditions. The objective was to evaluate the effect of residence time in the desolventizer/toaster (DT) on chemical composition and standardized ileal digestibility (SID) of AA in RSM. Four RSM, with 48, 64, 76, and 93 min residence time and using unsaturated steam in the DT, referred to as RSM48, RSM64, RSM76, and RSM93, respectively, and 1 low-glucosinolate RSM, which was subjected to sequential treatment with unsaturated steam, saturated steam, and dry heat in the DT, referred to as low-GSL RSM, were assayed. Six barrows (average initial BW = 22 ± 1 kg) were surgically fitted with a T-cannula at the distal ileum. Pigs were allotted to a 5 × 6 row × column design with 5 diets and 5 periods. The 5 RSM were included in a cornstarch-casein-based basal diet. In addition, basal ileal endogenous losses and SID of AA originating from casein were determined at the conclusion of the experiment in 2 additional periods by means of the regression method and using 3 graded levels of casein. The SID of AA in the 5 RSM was determined in difference to SID of AA originating from casein. The glucosinolates (GSL) were efficiently reduced, whereas NDF, ADF, ADL, and NDIN contents increased and reactive Lys (rLys) and Lys:CP ratio decreased as the residence time in the DT was increased from 48 to 93 min. The SID of most AA in RSM linearly decreased (P < 0.05) as the residence time in the DT increased from 48 to 93 min. Moreover, there was a linear decrease (P < 0.05) in SID of AA with increasing NDF, ADF, ADL, and NDIN contents in these RSM, whereas SID of AA linearly decreased (P < 0.05) with decreasing levels of GSL and rLys and a decreasing Lys:CP ratio. The decrease (P < 0.05) in SID of AA amounted from 3 up to 6 (percentage units) for most AA, except for SID of Cys and Lys, which decreased by 10 and 11%-units (P < 0.05), respectively, as the residence time in the DT was increased from 48 to 93 min. The SID in low-GSL RSM was for CP and most AA similar to RSM93 but lower ( < 0.05) compared to RSM48. It can be concluded that time and energy-intensive heat treatment results in lower contents of SID AA in RSM together with a reduction in GSL levels. The feed industry would most likely benefit from a rapid and accurate prediction of SID of AA, for example, based on content of NDIN, GSL, rLys or on Lys:CP ratio, in different batches of RSM used for feed manufacturing.

Abstract P6-02-08: Breast cancer screening in the precision medicine era

We are entering the era of precision medicine in which cancer screening, prevention and treatment will be tailored to each individual. The progress made in this field is due, in part, to advances in our understanding of cancer risk and tumor biology. The challenge before us is to harness this knowledge and apply it in the clinical setting. Breast cancer screening provides an excellent opportunity to test the value of precision medicine in the real world. In this report we describe the process of designing a model of personalized breast cancer screening.

Methods

Risk factors were selected that have the greatest impact, have been validated and can be measured across a population. A risk model was selected that is highly calibrated, has been validated in a large screening cohort and is easy to apply in a large population of women. An expert committee was convened that set risk thresholds for stratifying women into groups that will be recommended to undergo biennial, annual or every six month screening. Risk thresholds and screening schedules are in accordance with the United States Preventive Services Task Force breast cancer screening recommendations.

Results

Risk factors: Age, race/ethnicity, personal history of breast biopsies and benign breast disease, family history, breast density and breast cancer-associated genetic mutations and single nucleotide polymorphisms (SNPs) were chosen as the risk factors that will be used to determine breast cancer risk. Risk model: The Breast Cancer Surveillance Consortium risk model will be used to calculate a woman's 5-year risk and will be modified by a polygenic risk score based on 81 SNPs. Risk thresholds: Women will be recommended to undergo biennial screening mammography when they reach the age of 50 or have the risk of an average 50 year-old woman (1.3% 5-year risk). Women will be advised to undergo annual screening if they are at increased risk of developing an interval cancer (women in their forties with extremely dense breasts and women at increased risk of developing estrogen receptor negative breast cancer based on their SNPs). Women will be recommended to undergo annual mammography and annual MRI if they are found to be gene mutation positive, have the risk of a BRCA1 mutation carrier (6% 5-year risk) or have a history of mantle radiation.

Discussion

Selecting the appropriate risk factors and risk model and determining risk thresholds are key components of designing a personalized breast cancer screening model. Personalized screening may be the way forward, but this can only be determined within the setting of a randomized controlled trial. We will conduct such a trial to determine if personalized screening is as safe as, less morbid than, more preferred by women than and enables prevention when compared to annual screening. The WISDOM (Women Informed to Screen Depending on Measures of risk) study will compare risk-based screening to annual screening within the Athena Breast Health Network with support from the Patient-Centered Outcomes Research Institute. Our intent is that this trial will provide us with the data that we need to determine the safest and most effective way to screen women for breast cancer in the era of precision medicine.

Citation Format: Thompson CK, Fiscalini AS, Donnellan P, Kaplan CP, Madlensky L, Eklund M, Ziv E, van't Veer LJ, Tice JA, Esserman LJ. Breast cancer screening in the precision medicine era. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-02-08.

Nutritive value of wheat concentrated distillers solubles in diets for growing pigs

Two experiments (Exp.) were conducted to determine the nutritive value of wheat-derived wet concentrated distillers solubles (CDS) for growing pigs. In Exp. 1, standardised ileal digestibility (SID) of amino acids (AA) was determined by the difference method, using six ileally cannulated barrows (initial bodyweight (BW) of 31 ± 2.9 kg). The pigs were fed a casein-corn starch-based diet supplemented with wheat CDS so that about half of the crude protein (CP) originated from either wheat CDS or from casein. In Exp. 2, 12 barrows with an initial BW of 17 ± 0.9 kg were used to determine digestible energy (DE) content, and to calculate metabolisable energy (ME) and net energy (NE) content of wheat CDS. Animals were fed either a casein-corn starch-based basal diet or a CDS diet containing 470 g/kg of the basal diet and 530 g/kg wheat CDS on a dry matter (DM) basis. Values of SID of CP and AA in Exp. 1 amounted to 85, 74, 83 and 70% for CP, lysine, methionine and threonine, respectively. The DE, ME and NE contents of wheat CDS were 16.8, 15.8 and 11.1 MJ/kg DM, respectively. It can be concluded that SID of CP and AA and also the energy content in wheat CDS are substantially higher than corresponding values reported in international tables with information on nutritional value of dried co-products of bioethanol production.

Effect of feeding level on ileal and total tract digestibility of nutrients and energy from soybean meal-based diets for piglets

A total of 36 piglets with an initial body weight (BW) of 5.6 ± 0.7 kg, fitted with simple T-cannulas at the distal ileum, were used to evaluate the effect of three graded feeding levels (50, 75 or 100 g/kg BW(0.75) day) on apparent ileal digestibility (AID) and total tract digestibility (ATTD) of dry matter (DM), nitrogen (N) and energy, and on ATTD of organic matter (OM), ether extracts (EE), neutral detergent fibre (NDF), acid detergent fibre (ADF) and digestible (DE), metabolisable (ME) and net energy (NE) content in soybean meal (SBM)-casein-cornstarch-based diets. The AID of DM, N and energy and ATTD of NDF, ADF and EE in the diets were not affected (p > 0.05) by the feed intake (FI) level. There was a small decrease in ATTD of DM, N (CP), OM, ash and energy, and in DE, ME and NE content in the diets (p < 0.05) with increasing FI level. The net disappearance in the large intestine (in % of ileal recovery) decreased for DM, N and energy (p < 0.05) with increasing FI level. The design of the study allowed for estimating ileal endogenous loss of N and total tract endogenous loss of ash, N and EE, for estimating corresponding true ileal and total tract digestibility values, and for estimating urinary endogenous N loss. High variability in estimates of ileal endogenous N loss and total tract endogenous losses of N, EE and ash reflects great variation in individual endogenous losses between animals. Estimation of true total tract digestibility of N, EE and ash by regression analysis was affected by their decrease in ATTD with increasing FI level, as estimates for true digestibility were lower compared to their apparent values. The present results suggest that FI level can affect both apparent and true total tract nutrient digestibility in piglets.