Cancer Epidemiology, Biomarkers & Prevention

BackgroundWe previously reported that >5% of the population carries pathogenic or likely pathogenic variants (P/LPVs) in key cancer susceptibility genes. However, gene-specific cancer prevalence, spectrum, burden, lifetime risk, comorbidity, and the risk associated with autosomal recessive (AR) genes among carriers remain incompletely defined. MethodsWe analyzed 72 cancer susceptibility genes in the All of Us dataset (N=633,547), including 287,076 participants with both genomic and electronic health record data. Cancer diagnoses were identified using SNOMED codes and grouped into 35 categories. Associations between P/LPVs and overall and site-specific cancer risk were evaluated using regression models adjusted for age, sex, race, and ethnicity. ResultsAmong genes with [≥]10 unique carriers, cancer prevalence was highest for MEN1 (80%), followed by TP53 (57.7%), MLH1 (48.4%), and MSH2 (47.2%). Carriers of P/LPVs in BRCA1, BRCA2, MLH1, APC, NF1, PTEN, and PALB2 had significantly earlier cancer diagnosis compared to non-carriers. Cancer prevalence was markedly higher in BRCA1 and BRCA2 carriers who are also mono-allelic MUTYH carriers (75% and 45.5%, respectively) compared with BRCA1 and BRCA2 alone (43.2% and 36.5%). Adjusted survival analysis showed increased cancer risk for MLH1 (OR=6.08), PTEN (OR=5.80), and MSH2 (OR=5.19). Novel associations included MITF with anal/perianal and prostate cancer; BLM with ovarian and soft tissue/sarcoma; WRN with gynecologic cancer (NOS); and FH with hematologic malignancy. ConclusionsThis population-based analysis defines gene-specific cancer prevalence, spectrum, and risk, including contributions from AR variants, in the U.S. population. These findings support more precise genetic testing, screening, and risk stratification for individuals carrying inherited P/LPVs.

BackgroundLynch syndrome (LS) is a cancer susceptibility syndrome caused by germline pathogenic variants in DNA mismatch repair (MMR) genes. Due to increased risk of colorectal cancer (CRC), enhanced colonoscopic surveillance is recommended for heterozygote MMR-carriers. ObjectiveUsing a registry of English LS patients linked to digital National Health Service records, we aimed to assess adherence of MMR-carriers to national surveillance guidelines, and to determine the impact of surveillance on CRC incidence and mortality. DesignWe described the frequency of colonoscopies in 4,732 MMR-carriers and used logistic regression to determine predictors of surveillance adherence. For MMR-carriers with a record of surveillance and those without, we: estimated age-specific annual CRC incidence rates (AS-AIRs) and cumulative lifetime risks, assessed for stage-shift by comparing CRC stage distributions and stage-specific AS-AIRs, and estimated risks of death from CRC and any cause using Kaplan-Meier methods and Cox Proportional Hazards regression. ResultsSurveillance at a mean interval of [≤] 3 years (n=3028) was associated with a decrease in CRC-specific and all-cause mortality, without an associated change in total CRC incidence, even after multivariate adjustment. No strong evidence of stage-shift was observed. Colonoscopic surveillance at a mean interval of [≤] 2 years (n=1569) was associated with an increase in total CRC incidence. Incidence of early-stage cancers was also higher, with no corresponding decrease in late-stage cancers, which may reflect the short follow-up period or the impact of overdiagnosis. ConclusionThe observed reduction in all-cause mortality amongst regularly-surveilled MMR-carriers may indicate an impact of surveillance on CRC-specific mortality, though in the context of a non-randomised study likely reflects the influence of selection bias. KEY MESSAGES OF ARTICLEO_ST_ABSWhat is already known on this topicC_ST_ABSRegular surveillance colonoscopy is recommended in Lynch syndrome, though evidence to support this remains mixed. We searched PubMed for articles published from inception to 01/05/2024 using the terms "Lynch syndrome", "HNPCC", "colonoscopy", "sigmoidoscopy", "surveillance", and "screening". We found one controlled trial and several small analytical studies dating from the early 2000s which compared surveilled and non-surveilled populations and found surveillance to be associated with reduced colorectal cancer (CRC) incidence and improved survival. More recent longitudinal observational studies, most without comparator groups, found a high incidence of CRC in LS populations despite being resident in countries where surveillance was recommended. A small number of studies directly assessed time since last colonoscopy against CRC incidence and stage with mixed findings. Finally, cross-sectional comparisons between countries of CRC incidence rates and surveillance interval recommendations found no relationship between the two1,2. What this study addsHere, we conduct an observational cohort study on a large national cohort of MMR germline pathogenic variant (GPV) carriers (MMR-carriers) in England (n=4,732), comparing CRC incidence and mortality in individuals with a record of regular surveillance to those without. Through linkage of the English National Lynch Syndrome Registry to Hospital Episodes Statistics data, we are uniquely able to study a comprehensive national population of MMR-carriers and identify the dates on which colonoscopies were undertaken over time, allowing assessment of adherence to national surveillance guidelines and the impact this has on CRC outcomes. Notably, receipt of regular colonoscopy was strongly associated with deprivation as well as ethnicity. The results show that regular surveillance at an average interval of 3 years (or less) is not associated with a reduction in CRC incidence when compared to less frequent surveillance, but an apparent decrease in both CRC-specific and overall mortality is observed, even after adjustment for confounding variables. Conversely, regular surveillance at an average interval of 2 years (or less) is associated with an increase in CRC incidence when compared to less frequent surveillance, which may suggest increased diagnosis of early-stage cancers or, due to the absence of a reduction in late-stage cancers, overdiagnosis. The observed impact of surveillance on overall mortality may demonstrate the impact of surveillance on CRC-specific mortality, or, in the context of an observational (non-randomised) study, indicate that the results are subject to selection bias. How this study might affect research, practice, or policyEvidence for the benefit of surveillance colonoscopy remains mixed. Whilst polypectomy would be anticipated to prevent CRC development (thus reducing CRC incidence), several studies have observed increased frequency of CRCs in MMR-carriers undergoing frequent surveillance colonoscopy, which may reflect overdiagnosis. The selection bias inherent to observational studies of surveillance renders mortality outcomes challenging to interpret. Randomised controlled trials of colonoscopic surveillance in MMR-carriers are required for effectiveness of this intervention to be accurately assessed. Given ethical and feasibility challenges, randomised controlled trials might be complemented by quasi-experimental designs using advanced observational methods for assessing effectiveness.

BackgroundThe genetic architecture of Breast Cancer (BC) in Arab populations remains largely understudied, limiting the precision of current prevention and screening programs. The Emirati Genome Program (EGP), one of the worlds first nation-wide sequencing initiatives, offers an unprecedented opportunity to delineate inherited BC risk across an entire population. MethodsWe analyzed 436,780 EGP individuals, including 229,309 women, integrating whole-genome sequencing (WGS) with electronic health records (EHRs). We quantified the prevalence and penetrance of pathogenic and likely pathogenic (P/LP) variants across 13 NCCN-recommended BC genes, evaluated the performance of established polygenic risk scores (PRS), and reconstructed >48,000 pedigrees to measure familial aggregation. ResultsP/LP variants were identified in 0.84% of women, accounting for 5.2% of BC cases (mean age of 45.9{+/-}11.1 years). Highly penetrant BRCA1 c.4065_4068del (p.Asn1355fs) and BRCA2 c.2808_2811del (p.Ala938Profs) variants showed age-specific cumulative risks of 37.6% and 31% by age 60, respectively, and allele frequencies up to tenfold higher in the Emirati population than in global reference datasets. The European-derived PRS model (PGS000004) demonstrated strong performance, advancing 10-year BC risk onset by a decade for women in the top decile. Family-based PRS discriminated affected from unaffected individuals, revealing higher polygenic risk even within sister pairs. Integration of monogenic, polygenic, and familial data defined a national framework for risk stratification, identifying disease-free women potentially eligible for targeted prevention. ConclusionsNation-scale genome sequencing reveals, for the first time, the comprehensive landscape of inherited BC susceptibility within a Middle Eastern population. The integration of monogenic, polygenic, and familial data establishes a national framework for genomic risk stratification--transforming population genomics into a foundation for precision prevention and early detection in the UAE and beyond.

Summary statistics fine-mapping methods offer advantages over classical methods, including avoiding data-sharing constraints and improved modelling of correlated variables and sparse effects. However, its performance has not been comprehensively evaluated in breast cancer using real-world data. Previous multinomial stepwise regression (MNR) fine-mapping analyses for breast cancer identified 196 credible sets. Here, we apply summary statistics fine-mapping, compare methods, and assess parameters influencing performance. Using summary statistics from the Breast Cancer Association Consortium, we compared finiMOM, SuSiE, and FINEMAP to published MNR results across 129 regions. Performance was assessed by recall using in-sample and out-of-sample LD. Discordant credible sets were examined for technical factors, and target genes were defined using the INQUISIT pipeline. SuSiE showed the closest agreement with MNR. Results varied across regions depending on the assumed number of causal variants (L), with higher values reducing recall and no single L maximising performance. At optimal L per region, SuSiE identified 8,192 CCVs in 244 credible sets, with recall of 88%, 86%, and 72% for overall, ER-positive, and ER-negative breast cancer. Thirty MNR sets were missed. Discordance was partially explained by allele flips, imputation quality, and array heterogeneity. Fifty-two MNR-identified genes, including BRCA2, WNT7B and CREBBP were not recovered, while additional candidate genes were identified. Using out-of-sample LD reduced recall by 3% but identified novel variants. Fine-mapping results vary across methods, and no single approach is sufficient. The choice of L strongly influences results, and combining analytical approaches with functional validation can improve causal variant identification.

BackgroundIdentifying metabolites associated with prostate cancer (PC) aggressiveness may elucidate mechanisms underlying disease severity. Doing so for plasma and formalin-fixed, paraffin-embedded (FFPE) tissue could accelerate discovery. In this cross-sectional pilot study, we generated hypotheses for further exploration by assessing associations between plasma metabolites and Gleason score in individuals with PC and evaluating correlations between plasma and FFPE metabolite levels. MethodsWe examined plasma and FFPE samples from 10 individuals with Gleason score 7 (six 3+4, four 4+3) and nine individuals with Gleason score 9 (six 4+5, three 5+4) tumors from a convenience sample of 19 men with PC. We measured the relative abundance of polar metabolites at the time of radical prostatectomy. We used linear models of log2 fold changes to examine plasma metabolite levels relative to pathologic tumor grade. Relationships among metabolite levels measured in plasma and FFPE tumor tissue within individuals across metabolites were examined using Pearson correlations. ResultsAmong 18 plasma metabolites selected a priori because of prior associations with PC aggressiveness, serine (p=0.0051) and ornithine (p=0.036) levels were higher in individuals with Gleason 9 than Gleason 7 PC. After multiple testing correction, however, no associations were statistically significant. The median correlation between levels in plasma and FFPE tumor tissue was 0.45 (range: 0.40-0.53) for the 94 metabolites measured in both biospecimens. ConclusionsPlasma serine and ornithine demonstrated the largest differences between individuals with Gleason 7 and Gleason 9 PC. Metabolite levels in FFPE prostate tissue samples were moderately correlated with plasma levels. Future studies in larger samples are needed to further explore the hypotheses generated by this study.

IntroductionSporadic colorectal cancer (CRC) remains a significant driver of worldwide morbidity and mortality. Environmental factors associated with CRC are increasingly well-described and now include generalized colonic dysbiosis and individual enteric bacteria. Clostridioides difficile is one such species, with recent mouse model work suggesting prolonged exposure to C. difficile toxin B is conducive to colonic tumorigenesis. However, there is a dearth of real-world human evidence linking C. difficile infection and CRC. MethodsHerein, we analyzed a multicenter, longitudinal, Electronic Health Record (EHR)-based dataset to test the association between C. difficile test positivity and the risk for incident CRC utilizing unadjusted and multivariable (controlled for clinical conditions independently associated with CRC development) Cox proportional hazard modeling to compare C. difficile exposed and non-exposed cohorts ResultsWe found that individuals who tested recurrently positive for C. difficile had a significantly increased risk for incident CRC (aHR 2.05 [95% CI 1.27-3.29]) compared with those who tested positive only once (aHR 0.70 [0.45-1.10]) or never. Furthermore, we found potential trends that the effect of C. difficile test positivity on the risk for incident CRC was stronger amongst females compared with males. ImportanceThese findings help translate emerging mouse model work on C. difficile-influenced colorectal tumorigenesis and lay groundwork for more substantial human investigations into this connection. These findings also may begin to help guide the personalized deployment of novel fecal microbiota-based therapies designed to interrupt the life cycle of C. difficile within the gut of human hosts and, potentially, prevent long-term health sequelae of chronic C. difficile infection.

Multi-cancer early detection (MCED) tests can detect several cancer types and stages. We previously developed a methylation and protein (MP V1) MCED classifier. In this study, we present a refined MP V2 classifier, developed by evaluating model architectures that improved performance in prospectively enrolled case-control cohorts under standard testing conditions. The newly developed MP V2 classifier was trained to be more generalizable and achieve increased early-stage sensitivity at a target specificity of [≥]97.0%. MP V1 and MP V2 classifier performances were compared using a previously described test set, and MP V2 performance was also evaluated in a new independent clinical validation set. Compared to MP V1, the MP V2 classifier demonstrated a 7.3% increase in overall sensitivity, with sensitivity increases of 7.6%, 9.2%, and 8.3% for stages I, II, and stages I/II, respectively, in the intended use (breast and prostate cancers excluded) test set. In an independent validation intended use set, the MP V2 classifier showed an overall sensitivity of 55.6%, with sensitivities of 26.8%, 42.9%, and 34.8% for stages I, II, and stages I/II, respectively. In a case-control setting, the MP V2 classifier offered improved sensitivity for early-stage cancers at a lower specificity target.

Few studies with pre-diagnostic samples have estimated associations between circulating metabolites and risk of advanced prostate cancer. We performed untargeted metabolomic profiling of pre-diagnostic blood samples from 212 advanced prostate cancer cases (stage [&ge;]T3b or lethal during follow-up) and 212 matched controls from the Health Professionals Follow-up Study. 243 metabolites were assayed using liquid chromatography-tandem mass spectrometry (Broad Institute) and met quality control standards. We used multivariable conditional logistic regression to generate odds ratios (OR) and 95% confidence intervals (95%CI) for associations between individual metabolites and risk of advanced prostate cancer, and conducted metabolite set enrichment tests to identify metabolite classes enriched in advanced prostate cancer. Subgroup analyses were conducted by body mass index (BMI) and time between blood draw and diagnosis. Levels of 16 lipid species were nominally associated with advanced prostate cancer at p<0.05, though none were statistically significant after multiple testing correction. The strongest signals were for C56:1 triacylglycerol (TAG; OR: 1.34, 95%CI: 1.07-1.67) and C38:4 diacylglycerol (DAG; OR: 1.27, 95%CI: 1.04-1.55). Enrichment analyses revealed six metabolite classes associated with advanced prostate cancer after multiple testing adjustment, the top four of which were DAGs and TAGs: DAGs overall (P=3.4E-07), unsaturated DAGs (P=5.9E-07), unsaturated TAGs (P=2.3E-06), and TAGs overall (P=2.4E-06). 43 metabolites were nominally associated with advanced prostate cancer among individuals with BMI <25 kg/m2; only three demonstrated nominal associations in individuals with BMI [&ge;]25 kg/m2. These findings suggest associations between circulating pre-diagnostic lipid levels and aggressive prostate cancer risk, particularly in lean individuals.

Pancreatic cancer disproportionately affects Black individuals in the United States, but they have limited representation in genetic studies of pancreatic ductal adenocarcinoma (PDAC). To address this gap, we performed admixture mapping and genome-wide association analysis (GWAS) in genetically inferred African ancestry individuals (1,030 cases and 889 controls). Admixture mapping identified three regions with a significantly higher proportion of African ancestry in cases compared to controls (5q33.3, 10p1, 22q12.3). GWAS identified a genome-wide significant association at 5p15.33 (CLPTM1L, rs383009:T>C, T Allele Frequency=0.51, OR:1.45, P value=1.24x10-8), a locus previously associated with PDAC. Known loci at 5p15.33, 7q32.3, 8q24.21 and 7q25.1 also replicated (P value <0.01). Multi-ancestral fine-mapping identified two potential causal SNPs (rs3830069 and rs2735940) at 5p15.33. Collectively these findings identified novel PDAC risk loci and expanded our understanding of this deadly cancer in underrepresented populations, emphasizing the multifactorial nature of PDAC risk including inherited genetic and non-genetic factors. Statement of SignificanceTo understand how genetic variation contributes to PDAC risk in Black people in North American, we studied individuals of genetically-inferred African ancestry. We identified novel risk loci and differences in the contribution of known loci. This demonstrates that ancestry-informed genetic analyses improve our understanding of PDAC risk and enhances discovery.

IntroductionBRCA1/2 alterations are increasingly recognized as biologically and clinically relevant features in prostate cancer, yet the prognostic and therapeutic significance of zygosity status remains uncertain. Understanding differences between monoallelic and biallelic inactivation may refine risk stratification and guide therapeutic decision-making. Materials and MethodsA retrospective, desk-based observational analysis was performed using publicly accessible datasets from TCGA-PRAD (primary disease) and SU2C/PCF (metastatic disease). BRCA1/2 status was categorized as wild-type, monoallelic, or biallelic based on mutation, copy-number, and loss-of-heterozygosity profiles. Overall survival was evaluated using Kaplan-Meier estimates and Cox models. Systemic therapy outcomes were assessed by treatment class, incorporating exploratory interaction tests. ResultsIn TCGA-PRAD (n=300), OS did not significantly differ by zygosity (global log-rank p=0.45), with median OS of 80.0 months (wild-type), 78.0 months (monoallelic), and 55.0 months (biallelic). In SU2C/PCF (n=200), zygosity stratified outcomes significantly (global log-rank p=0.04): median OS was 22.0 months (wild-type), 14.0 months (monoallelic), and 16.0 months (biallelic). Treatment analyses showed ARSI exposure improved OS in wild-type disease (HR 0.60; 95% CI 0.38-0.95), while interaction testing suggested potential heterogeneity without statistical confirmation (interaction p=0.092). PARP inhibitor exposure showed directionally favorable HRs in wild-type and monoallelic groups but no significant interaction (interaction p=0.757). No therapy class demonstrated consistent effect modification by zygosity. ConclusionBRCA1/2 zygosity shows prognostic relevance in metastatic prostate cancer but not clearly in primary disease. While zygosity did not consistently modify systemic therapy associations in this dataset, findings support zygosity-aware reporting as a practical tool for molecular stratification and future research design.

PurposeGermline deletions affecting the Y-chromosomal gr/gr region were reported in 2005 as associated with susceptibility to testicular germ cell tumor (TGCT), a highly heritable tumor type that is the most common cancer type affecting adult men under the age of 45. Attempts to replicate this association have been equivocal, primarily due to limited power. MethodsHere, we compare and validate two computational approaches to gr/gr deletion calling in high-, low- and ultra-low-coverage whole genome sequencing data, applying these to two datasets from UK Biobank and the TECAC consortium. We generate dataset-specific effect size estimates for the gr/gr deletion-TGCT association using Firths bias-reduced logistic regression across a total of 198,306 men of European-like ancestry (2231 with and 196,075 without TGCT). ResultsUpon random-effects meta-analysis of estimated effect sizes in the two datasets, we found no significant association between gr/gr deletion status and TGCT risk (combined odds ratio=1.24, 95% CI=0.74-2.07, p=0.42), nor upon stratification of seminoma and non-seminoma/mixed histological subtypes. ConclusionOur analysis suggests gr/gr deletion status alone is likely not predictive of TGCT risk in population-scale analyses of European-like individuals; however, the importance of other proposed determinants of gr/gr deletion impact, including Y-haplogroups and semen phenotype, remains unexplored at scale.

BackgroundHelicobacter pylori infection accounts for 98% of gastric cancer (GC) cases in Japan. Since 2013, the nationwide expansion of H. pylori eradication therapy to chronic gastritis patients has created a unique opportunity to evaluate its population-level impact on GC primary prevention. However, short-term reductions in GC deaths are difficult to interpret given the long natural history of gastric carcinogenesis. This study aimed to assess the early impact of population-level eradication on GC deaths. MethodsWe applied a two-layer analytic framework consisting of a counterfactual analysis comparing observed GC deaths during 2013-2021 with expected GC deaths had eradication uptake remained at pre-2013 levels. This was combined with a structured, time-dependent, multilayer state-transition model to estimate GC deaths prevented by eradication using GC incidence integrated with age-dependent H. pylori prevalence. ResultsObserved GC deaths declined from 48,632 in 2013 to 41,624 in 2021, whereas counterfactual GC deaths declined more modestly, from 49,794 to 45,654. The divergence between observed and counterfactual GC deaths widened steadily from 1,162 in 2013 to 4,030 in 2021. Model-based estimates indicated that eradication prevented 1,427 GC deaths during 2013-2021, with annual GC deaths prevented increasing from 17 in 2015 to 417 in 2021, particularly among adults aged 50-79. ConclusionsThis study demonstrates that H. pylori eradication has already contributed to a 10.4% reduction in GC deaths in Japan by 2021, with annual expansion of primary prevention effects. This framework supports evidence-based evaluation of short-term reductions in GC deaths attributable to H. pylori eradication in high-prevalence settings.

Recurrence scores based on a 21-gene assay are clinically useful for predicting prognosis and chemotherapy benefit in postmenopausal node-positive breast cancer patients, but its performance in premenopausal patients is inconsistent. Here, we evaluated Ataraxis Breast RISK (ATX), an AI test that predicts recurrence risk, and compared it with the genomic assay. ATX identified high risk patients misclassified as low risk by the genomic assay and therefore may refine selection of patients for adjuvant chemotherapy.

Background and ObjectivePatients with upper urinary tract urothelial carcinoma (UTUC) undergoing radical surgery are at high risk of developing intravesical recurrences (IVR). The biology of IVR after surgery for UTUC is poorly understood, and urine markers to replace cystoscopic surveillance of the bladder are lacking. Here, we characterized the genomic landscape of UTUC and paired IVR to discover therapeutic targets and identify diagnostic markers for IVR. MethodsWe performed targeted next-generation DNA-sequencing of 571 genes in a cohort of 276 retrospectively and 138 prospectively enrolled UTUC patients who received radical surgery. Clonality and evolution were assessed in 79 paired UTUC-IVR cases. Key Findings and LimitationsMutations in TERT (72%) and FGFR3 (50%) were highly prevalent in UTUC, while mutations in KMT2C were associated with reduced risk of IVR. The mutually exclusive mutational profile of UTUC revealed five genomic subtypes with distinct clinicopathological and molecular characteristics, but none were associated with elevated IVR risk. Clonal evolution of paired UTUC-IVR occurred in 92% of cases via four evolutionary paths, with FGFR3 as a key driver in the largest path (36%). Additionally, hotspot mutations in the TERT promoter, and FGFR3 and HRAS genes were identified as potential markers for noninvasive surveillance by urine testing. Limitations include cohort heterogeneity and the selected gene-targeted sequencing approach. Conclusions and Clinical ImplicationsThe high FGFR3 mutation rate in UTUC and its association with IVR development support anti-FGFR targeted therapy to reduce IVR risk. The clonal relationship between UTUC and IVR underscores the potential for patient-friendly noninvasive urine tests for surveillance after radical surgery. SummaryUpper urinary tract urothelial carcinoma (UTUC) is a rare cancer with a high recurrence rate after surgery. We found that the FGFR3 gene is a potential therapeutic target to reduce the risk of recurrence, while recurrent mutations in TERT, FGFR3 and HRAS could serve as potential markers for noninvasive surveillance by urine testing after surgery for UTUC.

BackgroundCirculating tumor DNA (ctDNA) detection after curative-intent surgery is being used to identify minimal residual disease (MRD) in colorectal cancer (CRC). However, MRD classification is dependent on analytical sensitivity, and the impact of detection threshold on observed post-operative positivity remains incompletely characterized. We evaluated MRD positivity in stage I-III CRC using a CRISPR-based plasma sequencing assay, MUTE-Seq. MethodsPatients were prospectively enrolled and analyzed using customized tumor-informed panels applied to baseline and post-operative plasma samples collected at 4-week and 3-month. We report preliminary results from 39 plasma samples obtained from the first 14 patients. MRD positivity was assessed across multiple hypothetical detection thresholds (1-100 ppm). ResultsAll 14 patients (100%) had detectable mutations at baseline. Mutation-positive call number significantly decreased after surgery (baseline vs 4-week, p = 0.006; baseline vs 3-month, p = 0.004), and ctDNA concentration likewise declined (baseline vs 4-week, p = 0.002; baseline vs 3-month, p = 0.003). Among stage II-III patients, MRD positivity at 4-week was 20% at a 100-ppm threshold but increased to 70% at 10 ppm and 100% at 1 ppm. At 3-month, MRD positivity was 11% at a 100-ppm threshold and 78% at 1 ppm. At both time points, approximately 80% of MRD-positive stage II-III patients harbored ctDNA levels below 100 ppm, and half of these cases were below 15 ppm. Two patients (one stage I and one stage II) developed recurrence; both were MRD-positive at 4-week and demonstrated increasing mutation-positive calls at 3-month, with a median radiologic lead time of 4 months. ConclusionsPost-operative MRD classification in CRC is strongly influenced by analytical sensitivity. A substantial proportion of residual disease signals reside below the conventional ctDNA detection threshold of 100 ppm, supporting the clinical relevance of ultrasensitive ctDNA detection.

ObjectiveBladder cancer (BC) is the most common malignancy of the urinary system and among the most frequently diagnosed cancers worldwide. This systematic review and meta-analysis aimed to evaluate the diagnostic accuracy of commercially available urinary biomarkers tests (UBTs) for detecting BC recurrence, focusing on pooled sensitivity and specificity estimates across different tests. MethodsA systematic search was performed on PubMed and EMBASE up to May 2025 to identify studies assessing recurrence of BC in previously diagnosed patients using non-FDA approved UBTs, including Xpert Bladder Cancer, Bladder Epicheck, ADXbladder and Uromonitor. Eligible studies were synthesized using the bivariate Generalized Linear Mixed Model (GLMM) model. ResultsOut of 307 initially screened citations, 33 studies met the eligibility criteria, encompassing a total of 10,478 patients. Xpert Bladder Cancer was evaluated on 13 studies and Bladder Epicheck was assessed on 10 studies. ADXbladder and Uromonitor were assessed in four and six studies, respectively. Meta-analyses included 13 studies for Xpert Bladder Cancer and 10 studies for Bladder Epicheck, yielding pooled sensitivity (95% CI) and specificity (95% CI) estimates of 0.71 (0.61-0.79) and 0.78 (0.74-0.82) for Xpert Bladder Cancer, and 0.75 (0.61-0.86) and 0.90 (0.84-0.94) for Bladder Epicheck. For ADXbladder and Uromonitor, meta-analyses incorporated four and six studies, respectively, resulting in pooled sensitivity and specificity values of 0.55 (0.40-0.69) and 0.60 (0.44-0.75) for ADXbladder, and 0.77 (0.61-0.88) and 0.96 (0.91-0.98) for Uromonitor. ConclusionsThis meta-analysis reveals that commercially UBTs for BC recurrence have varying diagnostic accuracy. Among the evaluated tests, Uromonitor demonstrated the highest pooled sensitivity and specificity, while Xpert Bladder Cancer and Bladder Epicheck showed reliable diagnostic performance. Further research is needed particularly for less extensively studied assays to establish their diagnostic performance.

BackgroundMulticancer early detection tests could be used for cancer screening, but may lead to harms, including false positive results and overdiagnosis of indolent tumours that would not have become clinically evident during that persons lifetime. We assessed the potential for these screening harms in the context of future population-based screening with a multicancer early detection test. MethodsWe used a microsimulation model to assess potential population-level impacts of screening at ages 50-75 years with a multicancer early detection test in Canada. We assumed high test specificity (97-99.1%) and test sensitivity increasing with cancer stage. The model includes latent indolent cancers that would not be diagnosed within that persons lifetime but can be overdiagnosed through screen-detection. We calculated the yearly and cumulative lifetime probabilities of screening overdiagnosis and false positive test results, assuming a range of preclinical screen-detectable periods (2-5 years). ResultsAn estimated 2.1-6.0% of all yearly screen-detected cancers with a multicancer screening test were predicted to be overdiagnoses across scenarios. The proportion of overdiagnosis varied by site, and strongly increased with age, going from 1% at age 50 to over 10% of screen-detected cancers by age 75. The test positive predictive value ranged from 15.9%-77.6%, meaning that there could be 0.3-5.3 false positives with no underlying cancer for every true cancer case detected by the test. ConclusionPopulation-level multicancer screening with a multicancer early detection test would likely not lead to substantial screen-related overdiagnosis. Healthcare systems should consider how screening false positives may increase their diagnostic service caseload.

BackgroundPancreatic cancer is a leading cause of cancer mortality, and early recognition is challenging. To achieve early diagnosis using symptoms alone, we examined patterns across different stages using network analysis to derive clinically useful insights. MethodsSymptom variables from a de-identified dataset of 50,000 pancreatic cancer patients were analyzed. Stratification by stage was done, followed by bootstrap resampling to address imbalances across strata. Symptom networks were then constructed with nodes representing symptoms and edges representing conditional dependencies estimated via an Ising-style neighborhood selection approach implemented through L1-regularized logistic regression. Strength, betweenness, and closeness centrality indices were then calculated, and their stability was analyzed using the case-dropping bootstrap. Network comparison tests were done, and difference networks were analyzed. Spring-layout algorithm was used for visualization, with node size being the predictability (pseudo-R{superscript 2}), and the edge weight being the mean partial correlation magnitude. ResultsOn average, symptoms were present in about one out of four patients (M = 0.26). Weight loss and abdominal discomfort were the most prevalent of the symptoms, followed by jaundice and back pain. Network structures became sparser across stages with a decreasing number of edges and centrality indices. Jaundice emerged as the dominant hub in Stage I, but shared dominance with Weight Loss in Stage II. Node predictability (pseudo-R2) was effectively zero across all disease stages. ConclusionOur network analysis of pancreatic cancer symptomatology across stages revealed distinct patterns that may improve understanding of its clinical presentation and support earlier recognition.

BackgroundInvasive lobular breast cancer (ILC) is the most commonly diagnosed special histological subtype of breast cancer (BC). Metastatic ILC (mILC) is less sensitive to FDG-PET imaging and often metastasizes to unusual sites --peritoneum, gastrointestinal (GI) tract, ovaries, urinary tract, and orbit--which may go unrecognized after a long disease-free interval. Some metastatic sites cause nonspecific symptoms, like abdominal/epigastric pain, with numerous published case reports of mILC misdiagnosed as gastric cancer. These atypical BC metastatic sites may lead to late and/or misdiagnosis, thereby delaying effective treatments. ObjectiveWe developed a patient survey to investigate the patient-reported prevalence of delayed diagnosis or misdiagnosis of mILC and their potential impact upon treatment outcomes. MethodsA 45-question survey was developed and piloted with breast cancer researchers, clinical oncologists, and patient advocates. This IRB-approved survey was then distributed to patients with ILC. Analyses including data QC and visualization were conducted in R using descriptive statistics. Incomplete or inconsistent responses were excluded, and summary statistics were stratified by four common mILC sites to highlight subgroup differences. Results525 patient surveys were completed, with 450 patients diagnosed with ILC, and of those 321 diagnosed with mILC. For those with mILC, 33.3% (n=107) were diagnosed with de novo mILC at initial presentation. Of the patients diagnosed with mILC, 32.1% (n=103) presented with other medical conditions at diagnosis. Misdiagnosis was reported by 26.2% (n=84) of patients with mILC, and of these cases, 31% (n=26) had [&ge;]2 misdiagnoses. The top 5 misdiagnoses were bone-related condition (24.7%), benign breast condition (23.4%), another type of BC (7.8%), diagnostic delay (7.8%), and menopause related (5.2%). 44.5% of patients waited [&ge;]1 year for an accurate diagnosis. 49 patients were treated for their misdiagnosis, and 6 received incorrect cancer treatments. The most frequently reported contributors to delayed or misdiagnosis were inconclusive imaging, providers lack of ILC knowledge, and initial misdiagnosis. Of the 321 patients with mILC, 138 (42.9%) reported symptoms before diagnosis; the most common were back pain (16.5%), fatigue/malaise (14.9%), GI symptoms (11.8%), bloating (8.4%), and weight loss (8.1%). Although 40% of patients reported having a mammogram at the time of their initial misdiagnosis, ILC was detected in only 20.5% (24/116) of these cases, and mammography detected only 5 (25%) of the 20 de novo mILC cases. Patients reported additional diagnostic testing within 1-3 months of their initial mammogram, includingbiopsy, ultrasound (US), and MRI. 47.9% of patients were in active BC surveillance after curative intent therapy at the time of their mILC diagnosis; however, no statistical difference was seen in time to diagnosis versus those patients not under surveillance. ConclusionOur survey results underscore the urgent need to improve diagnostic strategies for mILC. Addressing delays and diagnostic errors in mILC is critical to optimizing treatment strategies and improving patient outcomes.

PURPOSE To evaluate cancer risk, age-specific penetrance, and mortality associated with heterozygous pathogenic or likely pathogenic (P/LP) germline PALB2 variants identified through genomic ascertainment and to assess modification by family history of cancer. PATIENTS AND METHODS We conducted a case-control study in two large population-based adult cohorts: the UK Biobank (n=469,580) and Geisinger MyCode (n=167,050). Individuals with heterozygous PALB2 P/LP variants were identified via exome sequencing and compared with non-carriers. Cancer diagnoses and vital status were obtained from linked registry and electronic health record data. We used multivariable logistic regression to estimate odds ratios (ORs) for cancer outcomes and Cox proportional hazards models to estimate hazard ratios (HRs) for all-cause mortality. Age-specific cumulative incidence (penetrance) was estimated using Kaplan-Meier methods. Models were adjusted for birth year, sex (when applicable), smoking status, and body mass index; stratified analyses assessed modification by family history of cancer. RESULTS PALB2 P/LP variant prevalence was 1:571 in UK Biobank and 1:940 in MyCode, with the higher prevalence in the UK cohort driven by the PALB2 p.Trp1038Ter founder variant. Compared with non-carriers, heterozygotes had significantly increased odds of any cancer, female breast cancer, pancreatic cancer, and cancers of ill-defined or secondary sites in both cohorts (P < 0.01). Adjusted hazard ratios for any cancer and female breast cancer ranged from 1.7 to 3.6. All-cause mortality was increased among PALB2-heterozygotes (HR 1.61-1.67), and survival after cancer diagnosis was reduced. Family history further modified cancer risk. CONCLUSION Genomic ascertainment of PALB2-heterozygotes identifies elevated risk for multiple cancers and increased mortality, although risks were lower than estimates from familial ascertainment. These findings inform risk management for individuals identified through genomic screening.