Updated European guidelines for clinical management of familial adenomatous polyposis (FAP), MUTYH-associated polyposis (MAP), gastric adenocarcinoma, proximal polyposis of the stomach (GAPPS) and other rare adenomatous polyposis syndromes: a joint EHTG-ESCP revision

BACKGROUND

Hereditary adenomatous polyposis syndromes, including familial adenomatous polyposis and other rare adenomatous polyposis syndromes, increase the lifetime risk of colorectal and other cancers.

METHODS

A team of 38 experts convened to update the 2008 European recommendations for the clinical management of patients with adenomatous polyposis syndromes. Additionally, other rare monogenic adenomatous polyposis syndromes were reviewed and added. Eighty-nine clinically relevant questions were answered after a systematic review of the existing literature with grading of the evidence according to Grading of Recommendations, Assessment, Development, and Evaluation methodology. Two levels of consensus were identified: consensus threshold (≥67% of voting guideline committee members voting either 'Strongly agree' or 'Agree' during the Delphi rounds) and high threshold (consensus ≥ 80%).

RESULTS

One hundred and forty statements reached a high level of consensus concerning the management of hereditary adenomatous polyposis syndromes.

CONCLUSION

These updated guidelines provide current, comprehensive, and evidence-based practical recommendations for the management of surveillance and treatment of familial adenomatous polyposis patients, encompassing additionally MUTYH-associated polyposis, gastric adenocarcinoma and proximal polyposis of the stomach and other recently identified polyposis syndromes based on pathogenic variants in other genes than APC or MUTYH. Due to the rarity of these diseases, patients should be managed at specialized centres.

Mortality by age, gene and gender in carriers of pathogenic mismatch repair gene variants receiving surveillance for early cancer diagnosis and treatment: a report from the prospective Lynch syndrome database

Background

The Prospective Lynch Syndrome Database (PLSD) collates information on carriers of pathogenic or likely pathogenic MMR variants (path_MMR) who are receiving medical follow-up, including colonoscopy surveillance, which aims to the achieve early diagnosis and treatment of cancers. Here we use the most recent PLSD cohort that is larger and has wider geographical representation than previous versions, allowing us to present mortality as an outcome, and median ages at cancer diagnoses for the first time.

Methods

The PLSD is a prospective observational study without a control group that was designed in 2012 and updated up to October 2022. Data for 8500 carriers of path_MMR variants from 25 countries were included, providing 71,713 years of follow up. Cumulative cancer incidences at 65 years of age were combined with 10-year crude survival following cancer, to derive estimates of mortality up to 75 years of age by organ, gene, and gender.

Findings

Gynaecological cancers were more frequent than colorectal cancers in path_MSH2, path_MSH6 and path_PMS2 carriers [cumulative incidence: 53.3%, 49.6% and 23.3% at 75 years, respectively]. Endometrial, colon and ovarian cancer had low mortality [8%, 13% and 15%, respectively] and prostate cancers were frequent in male path_MSH2 carriers [cumulative incidence: 39.7% at 75 years]. Pancreatic, brain, biliary tract and ureter and kidney and urinary bladder cancers were associated with high mortality [83%, 66%, 58%, 27%, and 29%, respectively]. Among path_MMR carriers undergoing colonoscopy surveillance, particularly path_MSH2 carriers, more deaths followed non-colorectal Lynch syndrome cancers than colorectal cancers.

Interpretation

In path_MMR carriers undergoing colonoscopy surveillance, non-colorectal Lynch syndrome cancers were associated with more deaths than were colorectal cancers. Reducing deaths from non-colorectal cancers presents a key challenge in contemporary medical care in Lynch syndrome.

Funding

We acknowledge funding from the Norwegian Cancer Society, contract 194751-2017.

The Public Health Playbook: ideas for challenging the Corporate Playbook

Background

Many commercial actors use a range of coordinated and sophisticated strategies to protect business interests at the expense of public health, for example: attacking and undermining legitimate science, intimidating and vilifying critics, and framing and reframing discussion and debate. These strategies can be thought of as a ‘Corporate Playbook’ that spans numerous health and planet-harming industries. To counter this Corporate Playbook and advance health and wellbeing, public health actors need to develop, refine, and modernize their own Public Health Playbook.

Methods

This paper seeks to consolidate thinking around how public health can counter and proactively minimize powerful commercial influences. It draws on previous attempts to develop approaches to counter commercial influence for public health, sustainability, human rights and democracy, and develops eight thematically grouped strategies.

Results

We propose an initial eight strategies: 1) Expand the public health workforce and coalitions; 2) Increase public sector resources; 3) Link with and learn from social movements to foster collective solidarity; 4) Protect public health advocates from industry threats; 5) Develop and implement rigorous conflict of interest safeguards; 6) Monitor and expose corporate activities; 7) Debunk corporate arguments; and 8) Leverage diverse commercial interests.

Conclusions

This set of strategies seeks to amplify inherent assets of the public health community and create opportunities to explicitly counter the Corporate Playbook. These strategies are not exhaustive, and our aim is to provoke further discussion and exploration on this topic. Moving forward, there is a need for further work to develop a rigorously researched and tested Public Health Playbook.

Food industry shaping of the principles of scientific integrity

Background

There is evidence that food industry actors try to shape science on nutrition and physical activity. But they are also involved in the influence of scientific integrity principles. Our research objective was to study the extent of that involvement, with a case study of ILSI as a key actor in that space.

Methods

We conducted a qualitative document analysis, triangulating data from an existing scoping review, publicly available information, internal industry documents, and existing freedom of information requests.

Results

Food companies have joined forces through ILSI to shape the development of scientific integrity principles. These activities started in 2007, in direct response to the growing criticism of the food industry's funding of research. ILSI first built a niche literature on conflicts of interest (COI) in food science and nutrition at the individual and study levels. Because the literature was scarce on that topic, these publications were used and cited in ILSI's and others' further work on COI, scientific integrity, and PPP, beyond the fields of nutrition and food science. In the past few years, ILSI started to shape the very principles of scientific integrity then and to propose that government agencies, professional associations, non-for-profits, and others, adopt these principles. In the process, ILSI built a reputation in the scientific integrity space. ILSI's work on scientific integrity ignores the risks of accepting corporate funding and fails to provide guidelines to protect from these risks.

Conclusions

The activities developed by ILSI on scientific integrity principles are part of a broader set of political practices of corporations to influence public health policy, research, and practice. It is important to learn about and counter these practices as they risk shaping scientific standards to suit corporate interests rather than public health ones.

Key messages

ILSI, a group funded by corporations, shaped the very principles of scientific integrity. ILSI built a reputation in the scientific integrity space.

BGCS uterine cancer guidelines: Recommendations for practice

The British Gynaecological Cancer Society has issued the first Endometrial (Uterine) Cancer guidelines as recommendation for practice for the UK.

Dimethylamine as a major alkyl amine species in particles and cloud water: Observations in semi-arid and coastal regions

Aerosol and cloud water measurements of dimethylamine (DMA), the most abundant amine in this study, were conducted in semi-arid (Tucson, Arizona) and marine (Nucleation in California Experiment, NiCE; central coast of California) areas. In both regions, DMA exhibits a unimodal aerosol mass size distribution with a dominant peak between 0.18 and 0.56 μm. Particulate DMA concentrations increase as a function of marine biogenic emissions, sulfate, BVOC emissions, and aerosol-phase water. Such data supports biogenic sources of DMA, aminium salt formation, and partitioning of DMA to condensed phases. DMA concentrations exhibit positive correlations with various trace elements and most especially vanadium, which warrants additional investigation. Cloud water DMA levels are enhanced significantly during wildfire periods unlike particulate DMA levels, including in droplet residual particles, due to effective dissolution of DMA into cloud water and probably DMA volatilization after drop evaporation. DMA:NH⁺₄ molar ratios peak between 0.18 and 1.0 μm depending on the site and time of year, suggesting that DMA competes better with NH₃ in those sizes in terms of reactive uptake by particles.

A presurgical window-of-opportunity study of metformin in obesity-driven endometrial cancer

BACKGROUND

Metformin use is associated with reduced cancer risk in several observational studies of patients with type 2 diabetes. Results from preclinical studies in endometrial cancer show that metformin reduces cellular proliferation by inhibition of the PI3K-AKT-mTOR pathway. We tested the hypothesis that metformin would reduce cellular proliferation in vivo in atypical endometrial hyperplasia and endometrial endometrioid adenocarcinoma.

METHODS

We recruited women attending gynaecological oncology clinics in Manchester, UK, with atypical endometrial hyperplasia or endometrial endometrioid adenocarcinoma. Women received metformin (850 mg twice daily) or no drug (control) during the 1-4 week presurgical window between cancer diagnosis and hysterectomy according to patient preference. Paired blood and tumour samples were obtained at recruitment and hysterectomy. Cellular proliferation was assessed by Ki-67 proliferation index. Automated scoring on two separate occasions provided consistent replicate scores (SD <10%). This study is registered with the ISRCTN register, number ISRCTN81570194.

FINDINGS

Samples from 40 women have been analysed (28 metformin-treated [median age 64 years, IQR 58-69]; 12 control [70, 64-70]). 24 of the patients (60%) were obese. 22 patients (55%) had either undiagnosed diabetes (fasting glucose >7·0 mmol/L, n=4) or insulin resistance (homoeostatic model assessment of insulin resistance >2·8, n=18). Metformin was taken for a median of 20 days (IQR 17-24), and mild gastrointestinal side-effects were reported by 22 metformin-treated patients. In the metformin-treated group, Ki-67 was 12·9% lower at hysterectomy than at recruitment (95% CI 3·7-22·1, p=0·008) after adjustment for baseline Ki-67, Ki-67 change in controls, age, and body-mass index. No significant changes in phosphorylation of AKT or markers of insulin resistance after adjustment for treatment arm were seen.

INTERPRETATION

Undiagnosed insulin resistance or diabetes were common in our study population. Short-term presurgical metformin was associated with a reduction in Ki-67 proliferation index. We are now exploring the hypothesis that metformin reduces Ki-67 expression by inducing phosphorylation of AMP-activated kinase and subsequent mTOR proproliferative inhibition, independent of insulin and insulin-like growth factor receptor activation.

FUNDING

Wellbeing of Women, Wellcome Trust.

On the competition among aerosol number, size and composition in predicting CCN variability: a multi-annual field study in an urbanized desert

A 2-year data set of measured CCN (cloud condensation nuclei) concentrations at 0.2 % supersaturation is combined with aerosol size distribution and aerosol composition data to probe the effects of aerosol number concentrations, size distribution and composition on CCN patterns. Data were collected over a period of 2 years (2012-2014) in central Tucson, Arizona: a significant urban area surrounded by a sparsely populated desert. Average CCN concentrations are typically lowest in spring (233 cm^-3), highest in winter (430 cm^-3) and have a secondary peak during the North American monsoon season (July to September; 372 cm^-3). There is significant variability outside of seasonal patterns, with extreme concentrations (1 and 99 % levels) ranging from 56 to 1945 cm^-3 as measured during the winter, the season with highest variability. Modeled CCN concentrations based on fixed chemical composition achieve better closure in winter, with size and number alone able to predict 82% of the variance in CCN concentration. Changes in aerosol chemical composition are typically aligned with changes in size and aerosol number, such that hygroscopicity can be parameterized even though it is still variable. In summer, models based on fixed chemical composition explain at best only 41% (pre-monsoon) and 36% (monsoon) of the variance. This is attributed to the effects of secondary organic aerosol (SOA) production, the competition between new particle formation and condensational growth, the complex interaction of meteorology, regional and local emissions and multi-phase chemistry during the North American monsoon. Chemical composition is found to be an important factor for improving predictability in spring and on longer timescales in winter. Parameterized models typically exhibit improved predictive skill when there are strong relationships between CCN concentrations and the prevailing meteorology and dominant aerosol physicochemical processes, suggesting that similar findings could be possible in other locations with comparable climates and geography.

An overview of regional and local characteristics of aerosols in South Africa using satellite, ground, and modeling data

We present a comprehensive overview of particulate air quality across the five major metropolitan areas of South Africa (Cape Town, Bloemfontein, Johannesburg and Tshwane (Gauteng Province), the Industrial Highveld Air Quality Priority Area (HVAPA), and Durban), based on a decadal (1 January 2000 to 31 December 2009) aerosol climatology from multiple satellite platforms and detailed analysis of ground-based data from 19 sites throughout Gauteng Province. Satellite analysis was based on aerosol optical depth (AOD) from MODIS Aqua and Terra (550 nm) and MISR (555 nm) platforms, Ångström Exponent (α) from MODIS Aqua (550/865 nm) and Terra (470/660 nm), ultraviolet aerosol index (UVAI) from TOMS, and results from the Goddard Ozone Chemistry Aerosol Radiation and Transport (GOCART) model. At continentally influenced sites, AOD, α, and UVAI reach maxima (0.12-0.20, 1.0-1.8, and 1.0-1.2, respectively) during austral spring (September-October), coinciding with a period of enhanced dust generation and the maximum integrated intensity of close-proximity and subtropical fires identified by MODIS Fire Information for Resource Management System (FIRMS). Minima in AOD, α, and UVAI occur during winter. Results from ground monitoring indicate that low-income township sites experience by far the worst particulate air quality in South Africa, with seasonally averaged PM₁₀ concentrations as much as 136 % higher in townships that in industrial areas. We report poor agreement between satellite and ground aerosol measurements, with maximum surface aerosol concentrations coinciding with minima in AOD, α, and UVAI. This result suggests that remotely sensed data are not an appropriate surrogate for ground air quality in metropolitan South Africa.