Publications by authors named "Eleftheria Kalaitzaki"

25 Publications

  • Page 1 of 1

Rationale and design of the POLEM trial: avelumab plus fluoropyrimidine-based chemotherapy as adjuvant treatment for stage III mismatch repair deficient or POLE exonuclease domain mutant colon cancer: a phase III randomised study.

ESMO Open 2020 02;5(1)

Royal Surrey NHS Foundation Trust, Guildford, UK

Background: 10%-15% of early-stage colon cancers harbour either deficient mismatch repair (dMMR), microsatellite instability high (MSI-H) or exonuclease domain mutations, and are characterised by high tumour mutational burden and increased lymphocytic infiltrate. Metastatic dMMR colon cancers are highly sensitive to immune checkpoint inhibition, and recent data show -mutant tumours are similarly responsive. We are conducting a phase III randomised trial to determine if the addition of the anti-PD-L1 antibody avelumab following adjuvant chemotherapy improves disease-free survival (DFS) in patients with stage III dMMR/MSI-H or mutant colon cancer and is a cost-effective approach for the UK National Health Service (NHS).

Methods: We are recruiting patients with completely resected, stage III colon cancer confirmed to have dMMR/MSI-H, locally or exonuclease domain mutation on central testing. Eligible patients are randomised in a 1:1 ratio to standard fluoropyrimidine-based chemotherapy (capecitabine, oxaliplatin for 12 weeks or capecitabine for 24 weeks) or chemotherapy, followed by avelumab (10 mg/kg, 2 weekly for 24 weeks). Stratification is by chemotherapy received and MMR/MSI-H status. The primary endpoint is DFS. Secondary endpoints include overall survival, toxicity, quality of life and health resource use. The 3-year DFS rate in the control arm is expected to be ~75%. Avelumab is expected to improve the 3-year DFS rate by 12% (ie, 87%). Target accrual is 402 patients, which provides 80% power to detect an HR of 0.48 for DFS at a two-sided alpha of 0.05. This national, multicentre phase III trial is sponsored by the Royal Marsden NHS Foundation Trust and it is anticipated that approximately 40 centres in the UK will participate. This study opened to recruitment in August 2018.

Trial Registration Number: NCT03827044.
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http://dx.doi.org/10.1136/esmoopen-2019-000638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7046393PMC
February 2020

MRI Tumor Regression Grade and Circulating Tumor DNA as Complementary Tools to Assess Response and Guide Therapy Adaptation in Rectal Cancer.

Clin Cancer Res 2020 01 18;26(1):183-192. Epub 2019 Dec 18.

Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust, London and Surrey, United Kingdom.

Purpose: Response to preoperative chemo-radiotherapy (CRT) varies. We assessed whether circulating tumor DNA (ctDNA) might be an early indicator of tumor response or progression to guide therapy adaptation in rectal cancer.

Experimental Design: A total of 243 serial plasma samples were analyzed from 47 patients with localized rectal cancer undergoing CRT. Up to three somatic variants were tracked in plasma using droplet digital PCR. RECIST and MRI tumor regression grade (mrTRG) evaluated response. Survival analyses applied Kaplan-Meier method and Cox regression.

Results: ctDNA detection rates were: 74% ( = 35/47) pretreatment, 21% ( = 10/47) mid CRT, 21% ( = 10/47) after completing CRT, and 13% ( = 3/23) after surgery. ctDNA status after CRT was associated with primary tumor response by mrTRG ( = 0.03). With a median follow-up of 26.4 months, metastases-free survival was shorter in patients with detectable ctDNA after completing CRT [HR 7.1; 95% confidence interval (CI), 2.4-21.5; < 0.001], persistently detectable ctDNA pre and mid CRT (HR 3.8; 95% CI, 1.2-11.7; = 0.02), and pre, mid, and after CRT (HR 11.5; 95% CI, 3.3-40.4; < 0.001) compared with patients with undetectable or nonpersistent ctDNA. In patients with detectable ctDNA, a fractional abundance threshold of ≥0.07% mid CRT or ≥0.13% after completing CRT predicted for metastases with 100% sensitivity and 83.3% specificity for mid CRT and 66.7% for CRT completion. All 3 patients with detectable ctDNA post-surgery relapsed compared with none of the 20 patients with undetectable ctDNA ( = 0.001).

Conclusions: ctDNA identified patients at risk of developing metastases during the neoadjuvant period and post-surgery, and could be used to tailor treatment.
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http://dx.doi.org/10.1158/1078-0432.CCR-19-1996DOI Listing
January 2020

Outcomes of Patients with Early Onset Colorectal Cancer Treated in a UK Specialist Cancer Center.

Cancers (Basel) 2019 Oct 14;11(10). Epub 2019 Oct 14.

Department of Medicine, The Royal Marsden Foundation Trust, London and Surrey SM2 5PT, UK.

The incidence of early onset colorectal cancer (EOCRC) is rapidly increasing, but there remains paucity of outcome data for young CRC patients. We reviewed the characteristics and outcomes of 241 adults, age <50, who were diagnosed with EOCRC between January 2009 and December 2014. Median age was 42, 56% were male, and 7% had hereditary etiology. Seventy percent had left-sided primaries. At diagnosis, 11%, 50%, and 39% had stage II, III, and IV CRC. Of the patients with stage II and III CRC who underwent curative surgery, 60% and 88% had adjuvant chemotherapy, with 5-year relapse free survival of 82% and 74% respectively. Of the 123 patients with metastatic (m) EOCRC, 93%, 63%, 33%, and 12% had 1st, 2nd, 3rd, and 4th line systemic anticancer therapy (SACT) respectively. For first line SACT, 99% had doublet chemotherapy, with bevacizumab or an anti-EGFR antibody in 57%. Median overall survival (mOS) of mEOCRC patients was 20.1 months (95% C.I: 15.9-23.2). Younger age and signet cells were associated with shorter mOS, whereas more lines of SACT and curative metastasectomy with longer mOS. Metastatic EOCRC patients had poorer outcomes than expected, despite optimal multimodality treatment. This suggests an aggressive disease biology that warrants further research and therapy development.
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http://dx.doi.org/10.3390/cancers11101558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826435PMC
October 2019

Analysis of KRAS, NRAS, BRAF, PIK3CA and TP53 mutations in a large prospective series of locally advanced rectal cancer patients.

Int J Cancer 2020 01 5;146(1):94-102. Epub 2019 Jul 5.

Department of Medicine, The Royal Marsden NHS Foundation Trust, London, United Kingdom.

Little information is available on the clinical significance of cancer-related genes such as KRAS, NRAS, BRAF, PIK3CA and TP53 in nonmetastatic rectal cancer. We investigated mutations of these genes in a large prospective series of locally advanced rectal cancer (LARC) patients who were recruited into two phase II trials. Mutational analyses were performed with diagnostically validated methods including polymerase chain reaction, capillary electrophoresis single-strand conformational analysis, Sanger sequencing and next-generation sequencing. Associations between single or multiple gene mutations and clinicopathological characteristics and treatment outcomes were explored. Of these 269, 210 (78%) patients were assessable. Mutations of KRAS, NRAS, BRAF, PIK3CA and TP53 occurred in 43, 9, 4, 9 and 60% of patients, respectively. Concordance between paired biopsy and resection specimens was 82% for KRAS, 95% for NRAS, 99% for BRAF, 96% for PIK3CA and 63% for TP53. TP53 mutations were associated with extramural venous invasion on baseline MRI (78% vs. 65%, p = 0.04), poor pathological tumour regression (23% vs. 36%, p = 0.05) and a trend toward a worse 5-year progression-free survival (PFS; 60% vs. 74%, HR 1.59, p = 0.06). Patients with tumours harbouring mutation of TP53 and either KRAS or NRAS (32%) had a worse 5-year PFS than those with TP53/KRAS/NRAS wild-type tumours (54% vs. 72%, HR 1.75, p = 0.02). In univariate analysis, BRAF mutation predicted poor 5-year overall survival only among patients treated without cetuximab (20% vs. 73%, HR 3.29, p = 0.03). This is one of the largest biomarker studies in a prospective, largely homogeneous, LARC population. Our findings are hypothesis generating and require validation in independent series.
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http://dx.doi.org/10.1002/ijc.32507DOI Listing
January 2020

Combined Ultrasound and Cone Beam CT Improves Target Segmentation for Image Guided Radiation Therapy in Uterine Cervix Cancer.

Int J Radiat Oncol Biol Phys 2019 07 11;104(3):685-693. Epub 2019 Mar 11.

Radiotherapy Department, Royal Marsden NHS Foundation Trust, London, United Kingdom.

Purpose: Adaptive radiation therapy strategies could account for interfractional uterine motion observed in patients with cervix cancer, but the current cone beam computed tomography (CBCT)-based treatment workflow is limited by poor soft-tissue contrast. The goal of the present study was to determine if ultrasound (US) could be used to improve visualization of the uterus, either as a single modality or in combination with CBCT.

Methods And Materials: Interobserver uterine contour agreement and confidence were compared on 40 corresponding CBCT, US, and CBCT-US-fused images from 11 patients with cervix cancer. Contour agreement was measured using the Dice similarity coefficient (DSC) and mean contour-to-contour distance (MCCD). Observers rated their contour confidence on a scale from 1 to 10. Pairwise Wilcoxon signed-rank tests were used to measure differences in contour agreement and confidence.

Results: CBCT-US fused images had significantly better contour agreement and confidence than either individual modality (P < .05), with median (interquartile range [IQR]) values of 0.84 (0.11), 1.26 (0.23) mm, and 7 (2) for the DSC, MCCD, and observer confidence ratings, respectively. Contour agreement was similar between US and CBCT, with median (IQR) DSCs of 0.81 (0.17) and 0.82 (0.14) and MCCDs of 1.75 (1.15) mm and 1.62 (0.74) mm. Observers were significantly more confident in their US-based contours than in their CBCT-based contours (P < .05), with median (IQR) confidence ratings of 7 (2.75) versus 5 (4).

Conclusions: CBCT and US are complementary and improve uterine segmentation precision when combined. Observers could localize the uterus with a similar precision on independent US and CBCT images.
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http://dx.doi.org/10.1016/j.ijrobp.2019.03.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542416PMC
July 2019

Efficacy and Cardiotoxic Safety Profile of Raltitrexed in Fluoropyrimidines-Pretreated or High-Risk Cardiac Patients With GI Malignancies: Large Single-Center Experience.

Clin Colorectal Cancer 2019 03 29;18(1):64-71.e1. Epub 2018 Sep 29.

Department of Medicine, GI and Lymphoma Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, UK. Electronic address:

Background: Gastrointestinal (GI) cancer patients may not be considered for therapy with fluoropyrimidines (FPs) because of previous cardiovascular (CV) toxicity or preexisting risk factors; such patients may benefit from raltitrexed-based therapy.

Patients And Methods: Patient, tumor, and treatment characteristics, as well as clinical outcomes of all consecutively treated patients with raltitrexed at the Royal Marsden Hospital between October 1998 and July 2011 were examined. GI cancer patients who developed CV toxicity as a result of FPs and those with significant CV risk factors receiving raltitrexed were included in this analysis.

Results: A total of 247 patients (155 and 92 with CV FP-related CV toxicities and significant CV risk factors, respectively) treated with raltitrexed alone or in combination were examined after a median follow-up of 47.1 months. CV toxicity profiles of patients receiving capecitabine (n = 110) and 5-fluorouracil (n = 45) were largely similar. Of raltitrexed-treated patients, 13 (5%) experienced CV toxicities and 1 (< 0.1%) died as a result of myocardial infarction. The median progression-free survival (PFS) and overall survival (OS) were 36.0 months (95% confidence interval [CI], 26.5-48.6) and 44.3 months (95% CI, 33.1-56.8), respectively. The 5-year survival for early stage GI malignancies (n = 140) was 62.0% (95% CI, 50.1-71.9). Median PFS and OS were not reached in this group (interquartile range = 38.4 months to NR); median PFS and OS for advanced GI malignancies (n = 107) were 18.8 (95% CI, 11.9-25.7) and 23.7 months (95% CI, 17.0-26.9), respectively.

Conclusion: A raltitrexed-based regimen is well-tolerated therapy with comparable efficacy to FPs in patients with GI malignancies with significant CV toxicities or risk factors.
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http://dx.doi.org/10.1016/j.clcc.2018.09.010DOI Listing
March 2019

Survival in Advanced Esophagogastric Adenocarcinoma Improves With Use of Multiple Lines of Therapy: Results From an Analysis of More Than 500 Patients.

Clin Colorectal Cancer 2018 09 8;17(3):223-230. Epub 2018 Jun 8.

Department of Medicine, Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom. Electronic address:

Background: Although progress has been made in the molecular stratification of esophagogastric adenocarcinoma, the outlook for advanced disease remains poor. The present evaluation of over 500 patients treated at a single European high-volume tertiary center during a 6-year period gives important information on current and developing "real-world" treatment patterns and outcomes.

Results: The overall survival for the whole cohort was 11.5 months, with a range of treatments used in first-, second-, and third-line settings. Treatment with sequential lines of therapy was associated with better outcomes, although only 39% and 14% of patients subsequently received treatment in the second- and third-line setting, respectively. Treatment within a therapeutic clinical trial was associated with significantly improved survival.

Conclusion: At present, a substantial proportion of patients with advanced esophagogastric adenocarcinoma will not proceed beyond first-line therapy, and for this group refinement of initial systemic therapies are required to improve outcomes. Although a number of established first- and second-line treatment options are now available, the therapeutic landscape of the disease continues to change, most notably in the application of immunotherapy and increasing interest in establishing evidence-based interventions in the third-line setting and beyond. A small but growing proportion of patients will benefit from sequential treatment approaches incorporating multiple lines of therapy, and improved selection of such patients will be a key challenge for clinicians moving forwards. Data such as these provide an overview of current treatment patterns and outcomes which can be used to inform planning of future research effectively within existing treatment frameworks.
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http://dx.doi.org/10.1016/j.clcc.2018.05.014DOI Listing
September 2018

KRAS and BRAF mutations in circulating tumour DNA from locally advanced rectal cancer.

Sci Rep 2018 01 23;8(1):1445. Epub 2018 Jan 23.

The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom.

There are limited data on circulating, cell-free, tumour (ct)DNA analysis in locally advanced rectal cancer (LARC). Digital droplet (dd)PCR was used to investigate KRAS/BRAF mutations in ctDNA from baseline blood samples of 97 LARC patients who were treated with CAPOX followed by chemoradiotherapy, surgery and adjuvant CAPOX ± cetuximab in a randomised phase II trial. KRAS mutation in G12D, G12V or G13D was detected in the ctDNA of 43% and 35% of patients with tumours that were mutant and wild-type for these hotspot mutations, respectively, according to standard PCR-based analyses on tissue. The detection rate in the ctDNA of 10 patients with less common mutations was 50%. In 26 cases ctDNA analysis revealed KRAS mutations that were not previously found in tissue. Twenty-two of these (84.6%) were detected following repeat tissue testing by ddPCR. Overall, the ctDNA detection rate in the KRAS mutant population was 66%. Detection of KRAS mutation in ctDNA failed to predict prognosis or refine patient selection for cetuximab. While this study confirms the feasibility of ctDNA analysis in LARC and the high sensitivity of ddPCR, larger series are needed to better address the role of ctDNA as a prognostic or predictive tool in this setting.
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http://dx.doi.org/10.1038/s41598-018-19212-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5780472PMC
January 2018

Molecular profiling of colorectal pulmonary metastases and primary tumours: implications for targeted treatment.

Oncotarget 2017 Sep 11;8(39):64999-65008. Epub 2017 Apr 11.

The Royal Marsden NHS Foundation Trust, London and Sutton, United Kingdom.

This study aimed to molecularly characterise colorectal pulmonary metastases (PM) and investigate whether their molecular profiles were concordant with those of the primary tumour. Clinical data and archival formalin fixed paraffin embedded tissue samples were retrospectively collected from patients who underwent ≥ 1 pulmonary metastasectomies for colorectal cancer between 1997-2012. Primary tumour and metastatic samples were analysed using a targeted capture sequencing panel of 46 cancer-associated genes. The 5-year progression-free and overall survival rates for the 81 patients in this study were 32% (95% CI 22-42%) and 77% (95% CI 66-85%) respectively. Fifty-four patients had samples available from ≥ 1 PM, and sequencing data were successfully obtained from 33 PM from 24 patients. The most frequently mutated genes were (71%), (58%) and (46%). Seventy-three percent of the 15 patients with matched primary and PM samples and 6 of the 7 patients (86%) with data from ≥ 2 PM had concordant molecular profiles. The concordance for and was 100%. At our institutions, patients with resectable colorectal PM had a favourable prognosis. RAS mutations were commonly detected in PM and the molecular profiles of colorectal PM were highly concordant with the primary tumour.
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http://dx.doi.org/10.18632/oncotarget.17048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5630307PMC
September 2017

Treatment and prognosis of leptomeningeal disease secondary to metastatic breast cancer: A single-centre experience.

Breast 2017 Dec 29;36:54-59. Epub 2017 Sep 29.

The Royal Marsden NHS Foundation Trust, London and Surrey, UK. Electronic address:

Purpose: Leptomeningeal disease (LMD) is an uncommon complication of advanced breast cancer. The prognosis is poor, and although radiotherapy (RT), systemic and intra-thecal (IT) chemotherapy are accepted treatment modalities, efficacy data are limited. This study was designed to evaluate potential predictors of survival in this patient group.

Methods: Breast cancer patients with LMD diagnosed by MRI in a 10-year period (2004-2014) were identified from electronic patient records. PFS and OS estimates were calculated using Kaplan-Meier method, with planned sub-group analysis by treatment modality. Cox regression was employed to identify significant prognostic variables.

Results: We identified 182 eligible patients; all female, median age at LMD diagnosis 52.5 years (range 23-80). Ninety patients (49.5%) were ER positive/HER2 negative; 48 (26.4%) were HER2 positive, and 27 (14.8%) were triple negative. HER2 status was unknown in 17 (9.3%). Initial management of LMD was most commonly whole or partial brain RT in 62 (34.1%), systemic therapy in 45 (24.7%) or supportive care alone in 37 (20.3%). Fourteen patients (7.7%) underwent IT chemotherapy, of whom two also received IT trastuzumab. From diagnosis of LMD, the median PFS was 3.9 months (95%CI 3.2-5.0) and median OS was 5.4 months (95%CI 4.2-6.6). Patients treated with systemic therapy had the longest OS (median 8.8 months, 95%CI 5.5-11.1), compared to RT; 6.1 months (95%CI 4.2-7.9 months), IT therapy; 2.9 months (95%CI 1.2-5.8) and supportive care; 1.7 months (95%CI 0.9-3.0). On multivariable analysis, triple negative histology, concomitant brain metastases, and LMD involving both the brain and spinal cord were associated with poor OS.

Conclusions: Breast cancer patients with triple negative LMD, concomitant brain metastases or LMD affecting both the spine and brain have the poorest prognosis. Clinical trials to identify more effective treatments for these patients are urgently needed.
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http://dx.doi.org/10.1016/j.breast.2017.07.015DOI Listing
December 2017

Functional imaging and circulating biomarkers of response to regorafenib in treatment-refractory metastatic colorectal cancer patients in a prospective phase II study.

Gut 2018 08 8;67(8):1484-1492. Epub 2017 Aug 8.

Department of Medicine, The Royal Marsden NHS Trust, London and Sutton, UK.

Objective: Regorafenib demonstrated efficacy in patients with metastatic colorectal cancer (mCRC). Lack of predictive biomarkers, potential toxicities and cost-effectiveness concerns highlight the unmet need for better patient selection.

Design: Patients with mutant mCRC with biopsiable metastases were enrolled in this phase II trial. Dynamic contrast-enhanced (DCE) MRI was acquired pretreatment and at day 15 post-treatment. Median values of volume transfer constant (K), enhancing fraction (EF) and their product KEF (summarised median values of K× EF) were generated. Circulating tumour (ct) DNA was collected monthly until progressive disease and tested for clonal mutations by digital-droplet PCR. Tumour vasculature (CD-31) was scored by immunohistochemistry on 70 sequential tissue biopsies.

Results: Twenty-seven patients with paired DCE-MRI scans were analysed. Median KEF decrease was 58.2%. Of the 23 patients with outcome data, >70% drop in KEF (6/23) was associated with higher disease control rate (p=0.048) measured by RECIST V. 1.1 at 2 months, improved progression-free survival (PFS) (HR 0.16 (95% CI 0.04 to 0.72), p=0.02), 4-month PFS (66.7% vs 23.5%) and overall survival (OS) (HR 0.08 (95% CI 0.01 to 0.63), p=0.02). KEF drop correlated with CD-31 reduction in sequential tissue biopsies (p=0.04). mutant clones decay in ctDNA after 8 weeks of treatment was associated with better PFS (HR 0.21 (95% CI 0.06 to 0.71), p=0.01) and OS (HR 0.28 (95% CI 0.07-1.04), p=0.06).

Conclusions: Combining DCE-MRI and ctDNA predicts duration of anti-angiogenic response to regorafenib and may improve patient management with potential health/economic implications.
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http://dx.doi.org/10.1136/gutjnl-2017-314178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204951PMC
August 2018

Systemic Chemotherapy as Salvage Treatment for Locally Advanced Rectal Cancer Patients Who Fail to Respond to Standard Neoadjuvant Chemoradiotherapy.

Oncologist 2017 06 5;22(6):728-736. Epub 2017 May 5.

Department of Medicine, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom.

Background: The potential of chemotherapy as salvage treatment after failure of neoadjuvant chemoradiotherapy for locally advanced rectal cancer (LARC) has never been explored. We conducted a single-center, retrospective analysis to address this question.

Patients And Methods: Patients with newly diagnosed LARC who were inoperable or candidates for extensive (i.e., beyond total mesorectal excision [TME]) surgery after long-course chemoradiotherapy and who received salvage chemotherapy were included. The primary objective was to estimate the proportion of patients who became suitable for TME after chemotherapy.

Results: Forty-five patients were eligible (39 candidates for extensive surgery and 6 unresectable). Previous radiotherapy was given concurrently with chemotherapy in 43 cases (median dose: 54.0 Gy). Oxaliplatin- and irinotecan-based salvage chemotherapy was administered in 40 (88.9%) and 5 (11.1%) cases, respectively. Eight patients (17.8%) became suitable for TME after chemotherapy, 10 (22.2%) ultimately underwent TME with clear margins, and 2 (4.4%) were managed with a watch and wait approach. Additionally, 13 patients had extensive surgery with curative intent. Three-year progression-free survival and 5-year overall survival in the entire population were 30.0% (95% confidence interval [CI]: 15.0-46.0) and 44.0% (95% CI: 26.0-61.0), respectively. For the curatively resected and "watch and wait" patients, these figures were 52.0% (95% CI: 27.0-73.0) and 67.0% (95% CI: 40.0-84.0), respectively.

Conclusion: Systemic chemotherapy may be an effective salvage strategy for LARC patients who fail to respond to chemoradiotherapy and are inoperable or candidates for beyond TME surgery. According to our study, one out of five patients may become resectable or be spared from an extensive surgery after systemic chemotherapy.

Implications For Practice: High-quality evidence to inform the optimal management of rectal cancer patients who are inoperable or candidates for beyond total mesorectal excision surgery following standard chemoradiotherapy is lacking. We show for the first time that systemic chemotherapy may be beneficial and result in one out of five poor prognosis patients becoming resectable or being spared from an extensive surgical approach. Although mores studies are needed to confirm these data, administering salvage systemic chemotherapy in this setting may have the potential to minimize morbidity associated with extensive surgical procedures and improve long-term oncological outcome.
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http://dx.doi.org/10.1634/theoncologist.2016-0396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5469584PMC
June 2017

Platinum-Fluoropyrimidine and Paclitaxel-Based Chemotherapy in the Treatment of Advanced Anal Cancer Patients.

Oncologist 2017 04 16;22(4):402-408. Epub 2017 Feb 16.

Department of Medicine, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom

Background: Although treatment of localized anal cancer (AC) is well established, very little evidence is available to inform the management of advanced tumors, and the prognosis of these patients remains poor. We have analyzed treatment pathways and outcomes of a single-institution series of advanced AC patients in order to provide insight into the management of this rare condition.

Materials And Methods: Inclusion criteria included epidermoid histology, inoperable locally recurrent or metastatic disease, and availability of full medical records. The primary objective was overall survival (OS). Prognostic factors were analyzed in univariate models.

Results: Sixty-four patients (1997-2014) were included: 16 (25.0%) with inoperable locally advanced and 48 (75.0%) with metastatic tumors. Fifty-one (79.7%) received at least one line of chemotherapy; of these, 37% underwent multimodality treatment. A combination of a platinum agent plus a fluoropyrimidine was the most common first-line regimen (74.5%), with an objective response rate (ORR) of 34.4% (95% confidence interval [CI], 18.6%-53.2%). Paclitaxel-based chemotherapy was used in 15 patients as front-line or salvage treatment, and the overall ORR was 53.3% (95% CI, 26.6%-78.7%). Median progression-free survival (PFS) after first- and second-line chemotherapy was 5.8 (interquartile range [IQR], 2.8-7.6) and 3.2 (IQR, 2.5-7.1) months, respectively. Five-year OS in the overall population was 15% (95% CI, 7.0%-25.0%). Age ≤65 years and liver metastases were predictive of better PFS (hazard ratio [HR], 0.39; 95% CI, 0.16-0.97;  = .04) and worse OS (HR, 2.25; 95% CI, 1.25-4.03;  = .01), respectively.

Conclusion: A platinum agent plus a fluoropyrimidine and paclitaxel-based chemotherapy are active regimens for advanced AC. Clinical trials are needed to standardize treatment pathways, investigate the potential of novel therapeutics, and improve the poor prognosis of this rare condition. 2017;22:402-408 Because of the lack of randomized trials, the optimal management of advanced anal cancer is uncertain. Despite its retrospective analysis and relatively small sample size, this is the second largest study ever conducted in this setting, and, as such, it has the potential to serve as a valuable source of information for everyday clinical practice. These findings suggest that chemotherapy with a platinum agent plus a fluoropyrimidine or paclitaxel-containing regimens are reasonable treatment options for patients with inoperable locally recurrent or metastatic anal carcinoma.
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http://dx.doi.org/10.1634/theoncologist.2016-0241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388368PMC
April 2017

Survival Outcomes in Asymptomatic Patients With Normal Conventional Imaging but Raised Carcinoembryonic Antigen Levels in Colorectal Cancer Following Positron Emission Tomography-Computed Tomography Imaging.

Oncologist 2016 12 14;21(12):1502-1508. Epub 2016 Oct 14.

GI and Lymphoma Unit, Department of Medicine, The Royal Marsden National Health Service Foundation Trust, London, United Kingdom

Background: This study had two aims: (a) to evaluate the utility of fluorine 18-fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography (CT) in detecting occult disease recurrence with raised carcinoembryonic antigen (CEA) and (b) to establish the prognostic effects of early detection of disease recurrence in patients with colorectal cancer (CRC).

Patients And Methods: Clinico-pathological data were obtained from all consecutive patients undergoing CRC surveillance from 2004 to 2010 who had an elevated CEA level (>3 ng/mL in nonsmokers, >5 ng/mL in smokers) but normal or equivocal conventional investigations. Histopathological confirmation or a minimum of 12 months' clinical and radiological follow-up were required to ascertain disease relapse.

Results: A total of 1,200 patients were screened; of those, 88 (59% men; mean age, 66 years [SD, 9.6]) eligible patients (67 with normal and 21 with equivocal results on conventional investigations) were identified. Recurrent disease was detected in 56 of 88 patients (64%). The sensitivity of FDG PET-CT to detect recurrence was 49 of 56 (88%; 95% confidence interval [CI], 76%-95%) and specificity was 28 of 32 (88%; 95% CI, 71%-97%). Twenty-seven of 49 (55%) patients with PET-CT-detected relapsed disease were deemed eligible for further curative therapy; 19 (70%) went on to receive potentially curative therapy. The median time to progression (8.8 months [interquartile range (IQR), 4.5-19.1 months] vs. 2.2 months [IQR, 0.7-5.6]), median overall survival (39.9 months [IQR, 23.6-65.4 months] vs. 15.6 months [IQR, 7.3-25.7 months]), and 5-year survival (36.8% [95% CI, 16.5%-57.5%] vs. 6.1% [95% CI, 1.1%-17.6%]; p ≤ .001) were higher in patients who received potentially curative therapy than in those who received noncurative therapy.

Conclusion: FDG PET-CT is a highly sensitive and specific tool for the detection of occult CRC recurrence. In >50% of patients, recurrent disease may still be potentially amenable to curative therapy. Long-term survival can be achieved in such patients.

Implications For Practice: Colorectal cancer (CRC) patients who, on follow-up, have normal or equivocal results on clinical investigations but raised carcinoembryonic antigen (CEA) levels pose a significant challenge to treating physicians. This study supported the notion that the early use of fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography (CT) may have predictive and prognostic value in management of such patients. Long-term disease control and cure can be achieved in a subgroup of this patient population with low-volume disease relapse who are amenable to potentially curative treatment strategies. Reassuringly, the sensitivity and specificity for recurrence did not significantly vary as a function of the CEA level, suggesting that even with a minimal CEA rise, benefit can be attained by conducting FDG PET-CT in a timely manner.
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http://dx.doi.org/10.1634/theoncologist.2016-0222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5153343PMC
December 2016

A study of motivations and expectations of patients seen in phase 1 oncology clinics.

Cancer 2016 Nov 26;122(22):3501-3508. Epub 2016 Sep 26.

Department of Medicine, Royal Marsden NHS Foundation Trust, London, United Kingdom.

Background: To better inform clinical practice, this study was aimed at capturing patients' motivations for enrolling in phase 1 trials and at quantifying their expectations of the benefits, risks, and commitment associated with clinical trials and the impact of the initial consultation on their expectations.

Methods: This was a single-center, prospective, quantitative study of newly referred adult patients considering their first phase 1 oncology trial. Participants completed questionnaires before they were seen and an abbreviated follow-up version after their consultation.

Results: Questionnaires were completed by 396 (99%) and 301 (76%) before and after the clinic, respectively. Participants ranked the possibility of tumor shrinkage (84%) as the most important motivation for considering a phase 1 trial; this was followed by no alternative treatments (56%), their physician's recommendation (44%), and the fact that the research might benefit others (38%). When they were asked about the potential personal benefit, 43% predicted tumor shrinkage initially. After the consultation, this increased to 47%. Fourteen percent of patients expected a cure. When asked about risks, 71% of the participants expected moderate side effects. When asked about expectations of time commitments, a majority of patients did not anticipate weekly visits, although this was understood by 93% of patients after the consultation. Overall, patients were keen to consider trials and when asked before and after the consultation 72% and 84% were willing to enroll in studies, respectively.

Conclusions: This study reports that more than 80% of patients enroll in early-phase clinical oncology trials motivated by the potential of a clinical benefit, with approximately half expecting tumor shrinkage and approximately a tenth anticipating a cure. The typical phase 1 response rate is 4% to 20%, and this discrepancy exemplifies the challenges faced by patients and healthcare professionals during their interactions for phase 1 studies. Cancer 2016;122:3501-3508. © 2016 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5111585PMC
November 2016

Socio-demographic variation in chest pain incidence and subsequent coronary heart disease in primary care in the United Kingdom.

Eur J Prev Cardiol 2014 May 22;21(5):566-75. Epub 2012 May 22.

Department of Primary Care and Population Health, University College London, UK.

Background: We know little about socio-demographic differences in chest pain presenting to primary care and subsequent coronary heart disease (CHD) diagnosis.

Methods: We conducted a cohort study with 198,209 patients aged 30 years and over with a first episode of chest pain, using data from 339 general practices in The Health Improvement Network (THIN) primary care database during 1997-2007. We calculated incidence of chest pain and subsequent CHD by age, gender and quintiles of Townsend area deprivation score.

Results: Chest pain incidence was 19.6/1000 person years at risk (PYAR, 95% CI 19.5-19.7). Incidence rose with age and increasing deprivation, with minimal gender differences. The incidence of CHD in the year following chest pain in primary care was 96.6/1000 PYAR (95% CI 95.1-98.0). There were significant interactions with age/deprivation and gender/deprivation on subsequent CHD diagnosis. The effect of deprivation was less for those over 60 years, and greater for younger women. Women in their 30s with chest pain in deprived areas had 8.77 times (95% CI 3.34-23.06) the CHD incidence compared to those in the most affluent areas. The absolute risk difference was small (8/1000 PYAR, 95% CI 4.5-11.5/1000 PYAR).

Conclusions: There was a modestly greater incidence of chest pain in primary care in more deprived areas compared to the least deprived areas. There were interactions between age, gender and deprivation on subsequent CHD diagnosis, with the greatest effect of deprivation on CHD diagnosis seen in younger women. This observation suggests the need for targeting health promotion and CHD prevention among younger women in deprived areas.
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http://dx.doi.org/10.1177/2047487312449415DOI Listing
May 2014

Group art therapy as an adjunctive treatment for people with schizophrenia: multicentre pragmatic randomised trial.

BMJ 2012 Feb 28;344:e846. Epub 2012 Feb 28.

Centre for Mental Health, Department of Medicine, Imperial College London, Claybrook Centre, London W6 8LN, UK.

Objectives: To evaluate the clinical effectiveness of group art therapy for people with schizophrenia and to test whether any benefits exceed those of an active control treatment.

Design: Three arm, rater blinded, pragmatic, randomised controlled trial.

Setting: Secondary care services across 15 sites in the United Kingdom.

Participants: 417 people aged 18 or over, who had a diagnosis of schizophrenia and provided written informed consent to take part in the study.

Interventions: Participants, stratified by site, were randomised to 12 months of weekly group art therapy plus standard care, 12 months of weekly activity groups plus standard care, or standard care alone. Art therapy and activity groups had up to eight members and lasted for 90 minutes. In art therapy, members were given access to a range of art materials and encouraged to use these to express themselves freely. Members of activity groups were offered various activities that did not involve use of art or craft materials and were encouraged to collectively select those they wanted to pursue.

Main Outcome Measures: The primary outcomes were global functioning, measured using the global assessment of functioning scale, and mental health symptoms, measured using the positive and negative syndrome scale, 24 months after randomisation. Main secondary outcomes were levels of group attendance, social functioning, and satisfaction with care at 12 and 24 months.

Results: 417 participants were assigned to either art therapy (n=140), activity groups (n=140), or standard care alone (n=137). Primary outcomes between the three study arms did not differ. The adjusted mean difference between art therapy and standard care at 24 months on the global assessment of functioning scale was -0.9 (95% confidence interval -3.8 to 2.1), and on the positive and negative syndrome scale was 0.7 (-3.1 to 4.6). Secondary outcomes did not differ between those referred to art therapy or those referred to standard care at 12 or 24 months.

Conclusions: Referring people with established schizophrenia to group art therapy as delivered in this trial did not improve global functioning, mental health, or other health related outcomes.

Trial Registration: Current Controlled Trials ISRCTN46150447.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289714PMC
http://dx.doi.org/10.1136/bmj.e846DOI Listing
February 2012

Impact of length or relevance of questionnaires on attrition in online trials: randomized controlled trial.

J Med Internet Res 2011 Nov 18;13(4):e96. Epub 2011 Nov 18.

Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom.

Background: There has been limited study of factors influencing response rates and attrition in online research. Online experiments were nested within the pilot (study 1, n = 3780) and main trial (study 2, n = 2667) phases of an evaluation of a Web-based intervention for hazardous drinkers: the Down Your Drink randomized controlled trial (DYD-RCT).

Objectives: The objective was to determine whether differences in the length and relevance of questionnaires can impact upon loss to follow-up in online trials.

Methods: A randomized controlled trial design was used. All participants who consented to enter DYD-RCT and completed the primary outcome questionnaires were randomized to complete one of four secondary outcome questionnaires at baseline and at follow-up. These questionnaires varied in length (additional 23 or 34 versus 10 items) and relevance (alcohol problems versus mental health). The outcome measure was the proportion of participants who completed follow-up at each of two follow-up intervals: study 1 after 1 and 3 months and study 2 after 3 and 12 months.

Results: At all four follow-up intervals there were no significant effects of additional questionnaire length on follow-up. Randomization to the less relevant questionnaire resulted in significantly lower rates of follow-up in two of the four assessments made (absolute difference of 4%, 95% confidence interval [CI] 0%-8%, in both study 1 after 1 month and in study 2 after 12 months). A post hoc pooled analysis across all four follow-up intervals found this effect of marginal statistical significance (unadjusted difference, 3%, range 1%-5%, P = .01; difference adjusted for prespecified covariates, 3%, range 0%-5%, P = .05).

Conclusions: Apparently minor differences in study design decisions may have a measurable impact on attrition in trials. Further investigation is warranted of the impact of the relevance of outcome measures on follow-up rates and, more broadly, of the consequences of what we ask participants to do when we invite them to take part in research studies.

Trial Registration: ISRCTN Register 31070347; http://www.controlled-trials.com/ISRCTN31070347/31070347 Archived by WebCite at (http://www.webcitation.org/62cpeyYaY).
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http://dx.doi.org/10.2196/jmir.1733DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3236666PMC
November 2011

Allowing for missing outcome data and incomplete uptake of randomised interventions, with application to an Internet-based alcohol trial.

Stat Med 2011 Nov 21;30(27):3192-207. Epub 2011 Sep 21.

Medical Research Council Biostatistics Unit, Cambridge, UK.

Missing outcome data and incomplete uptake of randomised interventions are common problems, which complicate the analysis and interpretation of randomised controlled trials, and are rarely addressed well in practice. To promote the implementation of recent methodological developments, we describe sequences of randomisation-based analyses that can be used to explore both issues. We illustrate these in an Internet-based trial evaluating the use of a new interactive website for those seeking help to reduce their alcohol consumption, in which the primary outcome was available for less than half of the participants and uptake of the intervention was limited. For missing outcome data, we first employ data on intermediate outcomes and intervention use to make a missing at random assumption more plausible, with analyses based on general estimating equations, mixed models and multiple imputation. We then use data on the ease of obtaining outcome data and sensitivity analyses to explore departures from the missing at random assumption. For incomplete uptake of randomised interventions, we estimate structural mean models by using instrumental variable methods. In the alcohol trial, there is no evidence of benefit unless rather extreme assumptions are made about the missing data nor an important benefit in more extensive users of the intervention. These findings considerably aid the interpretation of the trial's results. More generally, the analyses proposed are applicable to many trials with missing outcome data or incomplete intervention uptake. To facilitate use by others, Stata code is provided for all methods.
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http://dx.doi.org/10.1002/sim.4360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279649PMC
November 2011

On-line randomized controlled trial of an internet based psychologically enhanced intervention for people with hazardous alcohol consumption.

PLoS One 2011 Mar 9;6(3):e14740. Epub 2011 Mar 9.

E-health Unit, Research Department of Primary Care and Population Health, University College London, London, United Kingdom.

Background: Interventions delivered via the Internet have the potential to address the problem of hazardous alcohol consumption at minimal incremental cost, with potentially major public health implications. It was hypothesised that providing access to a psychologically enhanced website would result in greater reductions in drinking and related problems than giving access to a typical alcohol website simply providing information on potential harms of alcohol. DYD-RCT Trial registration: ISRCTN 31070347.

Methodology/principal Findings: A two-arm randomised controlled trial was conducted entirely on-line through the Down Your Drink (DYD) website. A total of 7935 individuals who screened positive for hazardous alcohol consumption were recruited and randomized. At entry to the trial, the geometric mean reported past week alcohol consumption was 46.0 (SD 31.2) units. Consumption levels reduced substantially in both groups at the principal 3 month assessment point to an average of 26.0 (SD 22.3) units. Similar changes were reported at 1 month and 12 months. There were no significant differences between the groups for either alcohol consumption at 3 months (intervention: control ratio of geometric means 1.03, 95% CI 0.97 to 1.10) or for this outcome and the main secondary outcomes at any of the assessments. The results were not materially changed following imputation of missing values, nor was there any evidence that the impact of the intervention varied with baseline measures or level of exposure to the intervention.

Conclusions/significance: Findings did not provide support for the hypothesis that access to a psychologically enhanced website confers additional benefit over standard practice and indicate the need for further research to optimise the effectiveness of Internet-based behavioural interventions. The trial demonstrates a widespread and potentially sustainable demand for Internet based interventions for people with hazardous alcohol consumption, which could be delivered internationally.

Trial Registration: Controlled-Trials.com ISRCTN31070347.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0014740PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052303PMC
March 2011

Impact and costs of incentives to reduce attrition in online trials: two randomized controlled trials.

J Med Internet Res 2011 Mar 2;13(1):e26. Epub 2011 Mar 2.

E-health Unit, Research Department of Primary Care and Population Health, University College London, London, United Kingdom.

Background: Attrition from follow-up is a major methodological challenge in randomized trials. Incentives are known to improve response rates in cross-sectional postal and online surveys, yet few studies have investigated whether they can reduce attrition from follow-up in online trials, which are particularly vulnerable to low follow-up rates.

Objectives: Our objective was to determine the impact of incentives on follow-up rates in an online trial.

Methods: Two randomized controlled trials were embedded in a large online trial of a Web-based intervention to reduce alcohol consumption (the Down Your Drink randomized controlled trial, DYD-RCT). Participants were those in the DYD pilot trial eligible for 3-month follow-up (study 1) and those eligible for 12-month follow-up in the DYD main trial (study 2). Participants in both studies were randomly allocated to receive an offer of an incentive or to receive no offer of an incentive. In study 1, participants in the incentive arm were randomly offered a £5 Amazon.co.uk gift voucher, a £5 charity donation to Cancer Research UK, or entry in a prize draw for £250. In study 2, participants in the incentive arm were offered a £10 Amazon.co.uk gift voucher. The primary outcome was the proportion of participants who completed follow-up questionnaires in the incentive arm(s) compared with the no incentive arm.

Results: In study 1 (n = 1226), there was no significant difference in response rates between those participants offered an incentive (175/615, 29%) and those with no offer (162/611, 27%) (difference = 2%, 95% confidence interval [CI] -3% to 7%). There was no significant difference in response rates among the three different incentives offered. In study 2 (n = 2591), response rates were 9% higher in the group offered an incentive (476/1296, 37%) than in the group not offered an incentive (364/1295, 28%) (difference = 9%, 95% CI 5% to 12%, P < .001). The incremental cost per extra successful follow-up in the incentive arm was £110 in study 1 and £52 in study 2.

Conclusion: Whereas an offer of a £10 Amazon.co.uk gift voucher can increase follow-up rates in online trials, an offer of a lower incentive may not. The marginal costs involved require careful consideration.

Trial Registration: ISRCTN31070347; http://www.controlled-trials.com/ISRCTN31070347 (Archived by WebCite at http://www.webcitation.org/5wgr5pl3s).
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http://dx.doi.org/10.2196/jmir.1523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221348PMC
March 2011

The MATISSE study: a randomised trial of group art therapy for people with schizophrenia.

BMC Psychiatry 2010 Aug 27;10:65. Epub 2010 Aug 27.

Centre for Mental Health, Imperial College, Claybrook Road London, W6 8LN, UK.

Background: Art Therapy has been promoted as a means of helping people who may find it difficult to express themselves verbally engage in psychological treatment. Group Art Therapy has been widely used as an adjunctive treatment for people with schizophrenia but there have been few attempts to examine its effects and cost effectiveness has not been examined. The MATISSE study aims to evaluate the clinical and cost effectiveness of group Art Therapy for people with schizophrenia.

Method/design: The MATISSE study is a three-arm, parallel group, pragmatic, randomised, controlled trial of referral to group Art Therapy plus standard care, referral to an attention control 'activity' group plus standard care, or standard care alone. Study participants were recruited from inpatient and community-based mental health and social care services at four centres in England and Northern Ireland. Participants were aged over 18 years with a clinical diagnosis of schizophrenia, confirmed by an examination of case notes using operationalised criteria. Participants were then randomised via an independent and remote telephone randomisation service using permuted stacked blocks, stratified by site. Art Therapy and activity groups were made available to participants once a week for up to 12 months. Outcome measures were assessed by researchers masked to allocation status at 12 and 24 months after randomisation. Participants and care givers were aware which arm of the trial participants were allocated to. The primary outcomes for the study are global functioning (measured using the Global Assessment of Functioning scale) and mental health symptoms (measured using the Positive and Negative Syndrome Scale) assessed at 24 months. Secondary outcomes were assessed at 12 and 24 months and comprise levels of group attendance, social function, satisfaction with care, mental wellbeing, and costs.

Discussion: We believe that this is the first large scale pragmatic trial of Art Therapy for people with schizophrenia.

Trial Registration: Current Controlled Trials ISRCTN46150447.
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http://dx.doi.org/10.1186/1471-244X-10-65DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2940860PMC
August 2010

Angina in primary care in Goa, India: sex differences and associated risk factors.

Heart Asia 2010 11;2(1):28-35. Epub 2010 Jul 11.

Research Department of Mental Health Sciences, University College London Medical School, London, UK.

Background: Little is known about the prevalence of angina in people seen in Indian general practices. The authors assessed the prevalence of angina and its associated risk factors in Goan general practices.

Methods: Cross-sectional study on consecutive attendees in nine private general practices in Goa, India. All participants completed the Rose Angina Questionnaire, to ascertain the presence of angina. Other demographic, clinical and biochemical data were also collected.

Results: 1556 (626 men and 930 women) consecutive attendees aged 30 to 75 years. Angina was detected in 37 (5.9%, 95% CI 2.4 to 9.4%) men and 99 (10.6%, 95% CI=7.4 to 11.2%) women. The prevalence of angina increased with age in both sexes but was greater in women between aged 46-60 (OR=4.3 (95% CI 2.0 to 9.2)) when compared with men. When compared with men, the odds of angina in women of all ages was 2.03 (95% CI 1.10 to 3.75) after controlling for confounders. Angina was associated with depressive and/or anxiety symptoms in both sexes (men OR=5.65, 95% CI=2.25 to 14.16; women OR=2.18, 95% CI=1.01 to 4.69) and with hypertension in men (OR=3.82, 95% CI=1.57 to 9.30) and family history of coronary heart disease (OR=1.53, 95% CI 1.05 to 2.24) in women. Borderline/high total cholesterol levels (OR=0.5, 95% CI 0.28 to 0.89) in women were associated with a reduced risk of angina.

Conclusion: Women attending general practices in Goa, India are at greater risk of angina than men. Depression/anxiety is strongly associated with angina. Greater awareness of the general practitioners to the disparity in angina between the sexes and its association with psychological distress is required.
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http://dx.doi.org/10.1136/ha.2009.001255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898508PMC
June 2016

Methodological challenges in online trials.

J Med Internet Res 2009 Apr 3;11(2):e9. Epub 2009 Apr 3.

University College London, Director, E-health Unit, Archway Campus, Highgate Hill, London N19 5LW, UK.

Health care and health care services are increasingly being delivered over the Internet. There is a strong argument that interventions delivered online should also be evaluated online to maximize the trial's external validity. Conducting a trial online can help reduce research costs and improve some aspects of internal validity. To date, there are relatively few trials of health interventions that have been conducted entirely online. In this paper we describe the major methodological issues that arise in trials (recruitment, randomization, fidelity of the intervention, retention, and data quality), consider how the online context affects these issues, and use our experience of one online trial evaluating an intervention to help hazardous drinkers drink less (DownYourDrink) to illustrate potential solutions. Further work is needed to develop online trial methodology.
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http://dx.doi.org/10.2196/jmir.1052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762798PMC
April 2009

Test-retest reliability of an online measure of past week alcohol consumption (the TOT-AL), and comparison with face-to-face interview.

Addict Behav 2009 Apr 24;34(4):337-42. Epub 2008 Nov 24.

E-health Unit, Research Department of Primary Care and Population Health, University College London, Highgate Hill, London N19 5LW, United Kingdom.

Objective: This paper reports on the development of a new online measure of beverage-specific past week alcohol consumption (the TOT-AL), its test-retest reliability, and comparability with the face-to-face approach of ascertaining alcohol intake.

Methods: University students participating in the reliability study completed the TOT-AL twice on the same day with at least 3 h apart. Students in the comparability study attended a face-to-face interview and completed the TOT-AL on the same day, in a randomised order, at least 3 h apart.

Results: There was a strong correlation between the repeated measurements of the TOT-AL (r=0.99; 95% CI: 0.98, 0.99) and between the units calculated by the TOT-AL and the face-to face interview (r=0.97; 95% CI: 0.95, 0.99). A high level of agreement between measurements was also observed in a Bland-Altman analysis.

Conclusions: The TOT-AL is a reliable, time efficient means of ascertaining alcohol intake, equivalent to that obtained face-to-face. These findings support the use of this approach to online alcohol assessment in populations with access to the Internet.
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http://dx.doi.org/10.1016/j.addbeh.2008.11.010DOI Listing
April 2009
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