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      Development of cancer surveillance guidelines in ataxia telangiectasia: A Delphi‐based consensus survey of international experts

      research-article
      1 , 2 , , 3 , 4 , 2 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 9 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 15 , 16 , 27 , 23 , 28 , 11 , 29 , 5 , 30 , 31 , 7 , 32 , 33 , 1 , 34 , 35
      Cancer Medicine
      John Wiley and Sons Inc.
      ataxia telangiectasia, cancer predisposition, cancer surveillance, guidelines, international survey, life‐limiting disease

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          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background/Objectives

          Ataxia telangiectasia (A‐T) is a multiorgan disorder with increased vulnerability to cancer. Despite this increased cancer risk, there are no widely accepted guidelines for cancer surveillance in people affected by A‐T. We aimed to understand the current international practice regarding cancer surveillance in A‐T and agreed‐upon approaches to develop cancer surveillance in A‐T.

          Design/Methods

          We used a consensus development method, the e‐Delphi technique, comprising three rounds. Round 1 consisted of a Delphi questionnaire and a survey that collected the details of respondents' professional background, experience, and current practice of cancer surveillance in A‐T. Rounds 2 and 3 were designed based on previous rounds and modified according to the comments made by the panellists. The pre‐specified consensus threshold was ≥75% agreement.

          Results

          Thirty‐five expert panellists from 13 countries completed the study. The survey indicated that the current practice of cancer surveillance varies widely between experts and centres'. Consensus was reached that evidence‐based guidelines are needed for cancer surveillance in people with A‐T, with separate recommendations for adults and children. Statements relating to the tests that should be included, the age for starting and stopping cancer surveillance and the optimal surveillance interval were also agreed upon, although in some areas, the consensus was that further research is needed.

          Conclusion

          The international expert consensus statement confirms the need for evidence‐based cancer surveillance guidelines in A‐T, highlights key features that the guidelines should include, and identifies areas of uncertainty in the expert community. This elucidates current knowledge gaps and will inform the design of future clinical trials.

          Abstract

          Ataxia Telangiectasia (A‐T) is a multiorgan disorder with increased vulnerability to cancer. Despite this increased cancer risk, there are no widely accepted guidelines for cancer surveillance in people affected by A‐T. The international expert consensus statement developed in this study, confirms the need for evidence‐based cancer surveillance guidelines in A‐T, highlights key features that the guidelines should include, and identifies areas of uncertainty in the expert community.

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          Most cited references38

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          Consulting the oracle: ten lessons from using the Delphi technique in nursing research.

          The aim of this paper was to provide insight into the Delphi technique by outlining our personal experiences during its use over a 10-year period in a variety of applications. As a means of achieving consensus on an issue, the Delphi research method has become widely used in healthcare research generally and nursing research in particular. The literature on this technique is expanding, mainly addressing what it is and how it should be used. However, there is still much confusion and uncertainty surrounding it, particularly about issues such as modifications, consensus, anonymity, definition of experts, how 'experts' are selected and how non-respondents are pursued. This issues that arise when planning and carrying out a Delphi study include the definition of consensus; the issue of anonymity vs. quasi-anonymity for participants; how to estimate the time needed to collect the data, analyse each 'round', feed back results to participants, and gain their responses to this feedback; how to define and select the 'experts' who will be asked to participate; how to enhance response rates; and how many 'rounds' to conduct. Many challenges and questions are raised when using the Delphi technique, but there is no doubt that it is an important method for achieving consensus on issues where none previously existed. Researchers need to adapt the method to suit their particular study.
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            Ataxia telangiectasia: a review

            Definition of the disease Ataxia telangiectasia (A-T) is an autosomal recessive disorder primarily characterized by cerebellar degeneration, telangiectasia, immunodeficiency, cancer susceptibility and radiation sensitivity. A-T is often referred to as a genome instability or DNA damage response syndrome. Epidemiology The world-wide prevalence of A-T is estimated to be between 1 in 40,000 and 1 in 100,000 live births. Clinical description A-T is a complex disorder with substantial variability in the severity of features between affected individuals, and at different ages. Neurological symptoms most often first appear in early childhood when children begin to sit or walk. They have immunological abnormalities including immunoglobulin and antibody deficiencies and lymphopenia. People with A-T have an increased predisposition for cancers, particularly of lymphoid origin. Pulmonary disease and problems with feeding, swallowing and nutrition are common, and there also may be dermatological and endocrine manifestations. Etiology A-T is caused by mutations in the ATM (Ataxia Telangiectasia, Mutated) gene which encodes a protein of the same name. The primary role of the ATM protein is coordination of cellular signaling pathways in response to DNA double strand breaks, oxidative stress and other genotoxic stress. Diagnosis The diagnosis of A-T is usually suspected by the combination of neurologic clinical features (ataxia, abnormal control of eye movement, and postural instability) with one or more of the following which may vary in their appearance: telangiectasia, frequent sinopulmonary infections and specific laboratory abnormalities (e.g. IgA deficiency, lymphopenia especially affecting T lymphocytes and increased alpha-fetoprotein levels). Because certain neurological features may arise later, a diagnosis of A-T should be carefully considered for any ataxic child with an otherwise elusive diagnosis. A diagnosis of A-T can be confirmed by the finding of an absence or deficiency of the ATM protein or its kinase activity in cultured cell lines, and/or identification of the pathological mutations in the ATM gene. Differential diagnosis There are several other neurologic and rare disorders that physicians must consider when diagnosing A-T and that can be confused with A-T. Differentiation of these various disorders is often possible with clinical features and selected laboratory tests, including gene sequencing. Antenatal diagnosis Antenatal diagnosis can be performed if the pathological ATM mutations in that family have been identified in an affected child. In the absence of identifying mutations, antenatal diagnosis can be made by haplotype analysis if an unambiguous diagnosis of the affected child has been made through clinical and laboratory findings and/or ATM protein analysis. Genetic counseling Genetic counseling can help family members of a patient with A-T understand when genetic testing for A-T is feasible, and how the test results should be interpreted. Management and prognosis Treatment of the neurologic problems associated with A-T is symptomatic and supportive, as there are no treatments known to slow or stop the neurodegeneration. However, other manifestations of A-T, e.g. immunodeficiency, pulmonary disease, failure to thrive and diabetes can be treated effectively.
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              Cancer Screening Recommendations for Individuals with Li-Fraumeni Syndrome

              Li-Fraumeni syndrome (LFS) is an autosomal dominantly inherited condition caused by germline mutations of the TP53 tumor suppressor gene encoding p53, a transcription factor triggered as a protective cellular mechanism against different stressors. Loss of p53 function renders affected individuals highly susceptible to a broad range of solid and hematologic cancers. It has recently become evident that children and adults with LFS benefit from intensive surveillance aimed at early tumor detection. In October 2016, the American Association for Cancer Research held a meeting of international LFS experts to evaluate the current knowledge on LFS and propose consensus surveillance recommendations. Herein, we briefly summarize clinical and genetic aspects of this aggressive cancer predisposition syndrome. In addition, the expert panel concludes that there are sufficient existing data to recommend that all patients with LFS be offered cancer surveillance as soon as the clinical or molecular LFS diagnosis is established. Specifically, the panel recommends adoption of a modified version of the "Toronto protocol" that includes a combination of physical exams, blood tests, and imaging. The panel also recommends that further research be promoted to explore the feasibility and effectiveness of these risk-adapted surveillance and cancer prevention strategies while addressing the psychosocial needs of individuals and families with LFS. Clin Cancer Res; 23(11); e38-e45. ©2017 AACRSee all articles in the online-only CCR Pediatric Oncology Series.
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                Author and article information

                Contributors
                renata.neves1@nottingham.ac.uk
                Journal
                Cancer Med
                Cancer Med
                10.1002/(ISSN)2045-7634
                CAM4
                Cancer Medicine
                John Wiley and Sons Inc. (Hoboken )
                2045-7634
                02 June 2023
                July 2023
                : 12
                : 13 ( doiID: 10.1002/cam4.v12.13 )
                : 14663-14673
                Affiliations
                [ 1 ] Radiological Sciences, School of Medicine University of Nottingham Nottingham UK
                [ 2 ] Department of Radiology Nottingham University Hospitals NHS Trust Nottingham UK
                [ 3 ] Centre for Rehabilitation and Ageing Research, School of Medicine University of Nottingham Nottingham UK
                [ 4 ] Medical Physics & Clinical Engineering Nottingham University Hospitals NHS Trust Nottingham UK
                [ 5 ] Department of Paediatric Oncology Nottingham University Hospitals NHS Trust Nottingham UK
                [ 6 ] Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust Nottingham UK
                [ 7 ] UK National Paediatric Ataxia Telangiectasia Clinic Nottingham University Hospitals NHS Trust Nottingham UK
                [ 8 ] Department of Human Neuroscience Sapienza University Rome Italy
                [ 9 ] Department of Translational Medical Sciences Federico II University Naples Italy
                [ 10 ] Metabolic Medicine Queensland Children's Hospital Brisbane Queensland Australia
                [ 11 ] School of Medicine University of Queensland, Brisbane Queensland Australia
                [ 12 ] Childrens Hospital Helios Klinikum Krefeld Krefeld Germany
                [ 13 ] Division of Neurology Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
                [ 14 ] Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio USA
                [ 15 ] Division of Child & Adolescent Neurology, Department of Pediatrics The University of Texas McGovern Medical School Houston Texas USA
                [ 16 ] Center for the Treatment of Pediatric Neurodegenerative Disease The University of Texas McGovern Medical School Houston Texas USA
                [ 17 ] Department of Pediatrics, Neuropediatric Unit Cairo University Children Hospital Cairo Egypt
                [ 18 ] Clinical Immunology and Allergy Department Nottingham University Hospital NHS Trust Nottingham UK
                [ 19 ] Neurologia Infantil Hospital Italiano de Buenos Aires Argentina
                [ 20 ] Department of Neurology University of California Los Angeles California USA
                [ 21 ] Pediatric Immunology and Rheumatology Department National Children's Hospital “Dr. Carlos Sáenz Herrera” San José Costa Rica
                [ 22 ] Hospital Provincial de Rosario Santa Fe Argentina
                [ 23 ] East Anglian Medical Genetics Service Cambridge University Hospitals NHS Foundation Trust Cambridge UK
                [ 24 ] Pediatric Infectious Diseases and Immunodeficiencies Unit Hospital Universitari Vall d'Hebron Barcelona Spain
                [ 25 ] Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies Barcelona Spain
                [ 26 ] Universitat Autonoma de Barcelona Barcelona Spain
                [ 27 ] Department of Pediatrics and Developmental Biology Tokyo Medical and Dental University Tokyo Japan
                [ 28 ] Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre University of Cambridge Cambridge UK
                [ 29 ] Department of Respiratory and Sleep Medicine Queensland Children's Hospital Brisbane Australia
                [ 30 ] Children's Brain Tumour Research Centre University of Nottingham Nottingham UK
                [ 31 ] Institute of Mental Health University of Nottingham Nottingham UK
                [ 32 ] Nottingham Clinical Genetics Service Nottingham University Hospitals NHS Trust Nottingham UK
                [ 33 ] Child Health, School of Medicine University of Nottingham Nottingham UK
                [ 34 ] NIHR Nottingham Biomedical Research Centre Nottingham UK
                [ 35 ] Sir Peter Mansfield Imaging Centre University of Nottingham Nottingham UK
                Author notes
                [*] [* ] Correspondence

                Renata Neves, Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK.

                Email: renata.neves1@ 123456nottingham.ac.uk

                Author information
                https://orcid.org/0000-0001-8835-2366
                https://orcid.org/0000-0002-9245-6878
                https://orcid.org/0000-0002-7580-9184
                Article
                CAM46075 CAM4-2022-11-4987.R1
                10.1002/cam4.6075
                10358231
                37264737
                358ee5b0-842b-4a97-bff3-16503e300c18
                © 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                : 17 April 2023
                : 11 November 2022
                : 03 May 2023
                Page count
                Figures: 3, Tables: 3, Pages: 11, Words: 6009
                Funding
                Funded by: Action for A‐T
                Award ID: 20NOT05
                Funded by: College of Radiographers
                Award ID: DF021
                Categories
                Research Article
                RESEARCH ARTICLES
                Cancer Prevention
                Custom metadata
                2.0
                July 2023
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.3.2 mode:remove_FC converted:20.07.2023

                Oncology & Radiotherapy
                ataxia telangiectasia,cancer predisposition,cancer surveillance,guidelines,international survey,life‐limiting disease

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