Background: Many Chinese patent medicines have been reported to show anti-tumor cell effects on cervical cancer. To estimate the comparative effectiveness and safety of Chinese patent medicines for cervical high-risk human papillomavirus (HR-HPV) infection.Methods: Randomized controlled trials (RCTs) of Chinese patent medicines for HR-HPV infection were searched in eight databases until 31 August 2022, and two review authors independently extracted data and assessed the risk of bias. Outcomes concerning efficacy were evaluated as odds ratio (OR) and 95% credible intervals (CrI) utilizing R 4.1.2 and Stata 16.1. The protocol was registered on the International Prospective Register of Systematic Reviews (CRD42022351120).Results: We ultimately identified 60 RCTs that involved 5,951 participants and 8 interventions. Chinese patent medicines combined with recombinant human interferon (rhIFN) have better treatment effects than rhIFN alone. The results showed that Baofukang suppository (BFK) combined with rhIFN is greater for the rate of HR-HPV clearance follow-up at 6 months (SUCRA = 78.16%). Kushen gel (KS) combined with rhIFN ranked first for the rate of HR-HPV clearance after treatment (SUCRA = 90.77%). Furthermore, KS + rhIFN is most likely to be the best intervention for improving the clinical effectiveness rate (SUCRA = 87.39%). Adverse reactions were not statistically significant in BFK + rhIFN versus BFK, BFK + rhIFN versus rhIFN, and BFK versus rhIFN.Conclusion: The combination of Chinese patent medicines with rhIFN may demonstrate a higher efficacy than rhIFN alone in clearing the virus and improving cervical symptoms. Weighing with the clinical comprehensive efficacy, BFK + rhIFN and KS + rhIFN maybe the optimal treatments for cervical HR-HPV infection. However, more high-quality randomized controlled trials are needed in the future to further confirm the efficacy and safety of proprietary Chinese medicines for cervical HR-HPV infection. Cervical cancer is the second largest malignant tumor in female malignancy after breast cancer In 2021, the International Federation of Gynecology and Obstetrics (FIGO) proposed tertiary prevention measures for cervical cancer, but mainly for uninfected people and people who have already developed cervical intraepithelial neoplasia (CIN) 2 and CIN 3 At present, local medicines with good effects at home and abroad still cannot meet the clinical needs, Chinese patent medicine combined with interferon seems to be expected to improve the long-term efficacy of HR-HPV infection. There are literatures report on systematic reviews of proprietary Chinese medicines alone or in combination with recombinant human interferon for the treatment of HR-HPV infection, such as Baofukang suppository (BFK) Supplementary S1. The protocol was registered on the International Prospective Registration of Systematic Reviews (PROSPERO) (Number CRD42022351120). There was no ethical approval or consent required for any of the analyses because they were based on previously published studies.The procedure of current NMA was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines “NMA extended version” Supplementary S2. Further eligible studies were identified by manually searching the reference lists of relevant meta-analyses and review articles.The randomized controlled trials (RCTs) of Chinese patent medicine alone or in combination with recombinant human interferon for HR-HPV infection included were recruited through PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Chinese Biomedical Databases (CBM), China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), and Wanfang data from the start of database construction until August 31, 2022. Medical Subject Heading (MeSH) and keyword search terms included were “Chinese herbal”, “Traditional Chinese Medicine”, “Chinese patent medicines”, “high-risk human papillomavirus infection”, “high-risk HPV infection”, “cervical intraepithelial neoplasia”. Besides, the searched Chinese patent medicines were all listed in the Catalogue of Drugs for Basic National Medical Insurance (The 2018 Edition). The English database search strategy was provided in We included published RCTs based on the predetermined selection rules that met the following PICOS criterion:1) Population: Women diagnosed with oncogenic HR-HPV positive but cytology negative or cytology-atypical squamous cells of undetermined significance (ASC-US), or low-grade squamous intraepithelial lesions (LISL), or CIN 1. The definition, screening of HR-HPV and cervical cytology was according to American Society for Colposcopy and Cervical Pathology (ASCCP) Intervention: The experiment group involve Chinese patent medicines combined with recombinant human interferon, Chinese patent medicines only. Both Chinese patent medicines and recombinant human interferon are transvaginal medications.3) Comparison: The control group consist of recombinant human interferon alone or Chinese patent medicines.4) Outcomes: The primary outcome was the rate of HR-HPV clearance follow-up at 6 months . The secondary outcomes were the rate of HR-HPV clearance after treatment and clinical effectiveness rate.5) Study design: We confined our study design to RCTs published with Chinese or English restriction.Studies not adhering to the inclusion criteria were excluded. Other exclusion criteria were:1) Nonrandomized controlled studies such as case-control studies, cohort studies.2) Trials not including the relevant outcomes.3) Trials that did not clearly identify HR-HPV.4) Participants with high-grade CIN 2, CIN 3.5) Data not available or cannot be extracted.6) Interventions include surgery or physiotherapy.7) The duration of treatment is more than 6 months or less than half a month.8) Sample size of the experiment group or control group is less than 10.Two investigators (BCL and MJ) screened the titles, abstracts and full text of retrieved citations independently to identify potentially eligible trials. Any disagreements were discussed between researchers until a consensus was reached. We implemented data a extraction form the collection relevant data for included trial. The following information was recorded from the included RCTs: basic publication information , characteristics of the participants , intervention, intervention duration and outcomes.Two investigators (BCL and MJ) independently conducted quality assessment. Any disagreement was resolved through discussion or judged by an expert as a third author (WSB). We assessed risk of bias of individual studies using the Cochrane Risk of Bias Tool We used GRADE  to evaluate the quality of the evidence for each outcome measure. For direct evidence, we evaluate the quality from five aspects  2, with I2 < 50% indicating no statistical heterogeneity The key assumptions of a network meta-analysis are transitivity, homogeneity and consistency. To determine whether a network meta-analysis was appropriate, the clinical setting and characteristics of trials  reporting each drug class were evaluated. To determine the degree of fit of the model, the deviance information criterion (DIC) between the fixed-effect and random-effect models was used In order to demonstrate direct and indirect comparative relationships among different interventions, we developed evidence networks Figure 1. All of the 60 RCTs were published as Chinese language articles from 2011 to 2022. All the eligible Chinese patent medicines and rhIFN were taken vaginally, and the duration of intervention was from 1 to 3 months. A reference list of the included RCTs was shown in Supplementary S3. We considered a network meta-analysis to be appropriate due to the comparability of patients involved, outcome measures, inclusion criteria, and exclusion criteria. The detailed characteristics of 60 included researches were demonstrated in Supplementary S4. More details of the Chinese patent medicines product  were presented in Supplementary S5, which is convenient for gynecologists and pharmacologists to acquire comprehensive information of the included Chinese patent medicines.We identified 1,252 records from the initial title and abstract screening and retrieved and reviewed 107 reports in full text. We retrieved relevant articles by hand-search to ensure we didn't miss eligible research by omitting the electronic database. We found one RCT Supplementary S6. All of the evidence quality was low or very low. Supplementary S7-S9 presented the GRADE assessment for three outcomes.Most trials (51.67%) described the stochastic methods in detail as random numbers or random lottery. None of those trials mentioned blinding of participants and personnel. All trials reflected a low risk of bias in incomplete outcome data and other biases with sufficient original data. The selection and reporting bias of all studies were unclear risk. Briefly, the risk of bias was moderate in most of the evaluation entries. Full details regarding risk of bias for each RCT were shown in Figure 2 presented the results of the pairwise meta-analysis and heterogeneity estimates. The results of the pairwise meta-analysis showed that four Chinese patent medicines  compared with rhIFN were better than only rhIFN for the HR-HPV clearance rate and the clinical effectiveness rate. BFK + rhIFN was better than only BFK for the HR-HPV clearance rate after treatment and the clinical effectiveness rate. SZJ was worse than rhIFN for the HR-HPV clearance rate and the clinical effectiveness rate. Adverse reactions were not statistically significant in BFK + rhIFN versus BFK, BFK + rhIFN versus rhIFN, and BFK versus rhIFN.Figure 3. Briefly, all outcomes were recombinant human interferon-centric, with the rate of HR-HPV clearance follow-up at 6 months with no closed loop, and for the other two outcomes with one closed loop. Supplementary S10 presented the DIC values and I-square of the fixed-effect model and random-effect model. The DICs of the rate of HR-HPV clearance after treatment and clinical effectiveness rate were similar, and the rate of HR-HPV clearance follow-up at 6 months was smaller in the random-effect model. Therefore, the random-effect model of the three outcomes was used for data analysis in this study. There was no statistical heterogeneity for three outcomes with I2 < 50%.The networks were presented in Figure 3. The results of the network meta-analysis indicated that BFK + rhIFN , SJZ + rhIFN , KS + rhIFN , rhIFN  were better than SJZ. There was no statistically significant difference between the other outcomes (see in Table 1). According to the ranking probabilities of Table 1 and Supplementary S11, BFK + rhIFN (SUCRA = 78.16%) was the first-rank combination in improving the HR-HPV clearance rate follow-up at 6 months, followed by SJZ + rhIFN (SUCRA = 75.40%) and KS + rhIFN (SUCRA = 73.17%).There were 6 interventions, of which rhIFN  was the most studied, followed by BFK + rhIFN . The network plot for the primary outcome of the rate of HR-HPV clearance follow-up at 6 months appeared in Figure 3). According to SUCRA probability results (Table ), KS + rhIFN was the most likely to become the best option for improving the HR-HPV clearance rate after treatment (SUCRA = 90.77%), followed by BFK + rhIFN (SUCRA = 72.15%) and SJZ + rhIFN (SUCRA = 70.04%).There were 24 RCTs reported the rate of HR-HPV clearance after treatment including 8 interventions , which was higher in KS + rhIFN , BFK + rhIFN , ZMK + rhIFN , SJZ + rhIFN  than in those using only rhIFN (see in Table 3). On the basis of SUCRA probability results (Table ), KS + rhIFN (SUCRA = 87.39%) was the optimum therapeutic measure in improving the clinical effectiveness rate, BFK + rhIFN (SUCRA = 78.61%) was number two, and ZMK + rhIFN (SUCRA = 75.78%) was the third.A total of 11 RCTs reported the clinical effectiveness rate  (p > 0.05), indicating that the results were reliable.The funnel plot of the three main results shows the publication bias in The results of this Bayesian network meta-analysis included 60 RCTs to assess the effects of 8 interventions on three outcomes in people with HR-HPV infection. From the results of network meta-analysis, it can be seen that BFK + rhIFN showed the best effect on long-term HR-HPV clear and KS + rhIFN had the best clinical efficacy. In addition, BFK + rhIFN did not appear to increase adverse effects. In summary, the results of this network meta-analysis have certain enlightenment significance for the clinical application and development of traditional Chinese medicine in the prevention and treatment for HR-HPV infection.HPV is a small non-enveloped long double-stranded circular DNA virus, and the expression of viral coding genes E6 and E7 in host cells is a key factor in the occurrence of cervical cancer. Viral DNA integrates E6 and E7-based gene fragments into host cell DNA and activates E6 and E7 gene fragments that regulate virus growth, allowing them to transcribe without restriction, resulting in changes such as immortalized host cells and the evolution of malignant cells In 2021, the World Health Organization's (WHO) “WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition” specifically emphasized and recommended HPV-DNA testing as the preferred method for cervical cancer screening. In nations that have implemented cytology-based screening and treatment programs, the mortality rate associated with cervical cancer has decreased by a factor of five over the past 50 years In recent years, Chinese patent medicines have been widely used for cervical HR-HPV infection. According to studies conducted on cells and animals, Chinese medicine inhibits the expression of HPV16 E6 and E7 genes, regulating immune function For the primary outcome, BFK + rhIFN ranked first (SUCRA = 78.16%). Baofukang suppository, a Chinese medication with a long history of usage for treating gynecological illnesses, has been consistently reported in recent decades that its combination with recombinant human interferon-2b is effective for the treatment of cervical HPV infection. A meta-analysis reported that the HPV clearance rate and total effective rate of the combination of BFK and interferon were superior to those of interferon alone KS + rhIFN performed the best for improving the rate of HR-HPV clearance after treatment (SUCRA = 90.77%) and the clinical effectiveness rate (SUCRA = 87.39%). The main component of KS is matrine, which has antibacterial, anti-inflammatory, insecticidal, itching, antipyretic, analgesic, immunomodulation, antitumor, and other pharmacological effects Post-treatment HPV persistence estimates varied widely and were influenced by patient age, HPV type, detection method, treatment method, and minimum HPV post-treatment testing interval. Overall, HPV infection tended to gradually clear after CIN treatment for the different treatment modalities Of the included literatures, only BFK, rhIFN, and BFK + rhIFN mentioned the occurrence of adverse events. Most adverse reactions are related to the sensitivity of the cervical tissue caused by the patient's hormone levels, which can disappear on their own without serious reactions such as local infection and cervical injury. Due to the limitations of the literature, it is not yet possible to compare the safety of proprietary Chinese medicines, and more trials observing the safety indicators of proprietary Chinese medicines will be needed in the future to verify this.The combination of Chinese patent medicines and recombinant human interferon performs well in clinical efficiency and HR-HPV clearance rate, thereby providing guidance for the clinical treatment of HR-HPV infection. For patients with a long-term infection and weakened immunity, a combination of BFK and recombinant human interferon may be considered. If cervical symptoms are evident, KS combined with recombinant human interferon may be considered. However, these results must be interpreted cautiously.The first network meta-analysis of different Chinese patent medicines for cervical HR-HPV infection was conducted to provide evidence to support and create traditional Chinese medicine guideline recommendations. We conducted detailed literature reviews and screening, and independently extracted data to ensure that our results were comprehensive and rigorous based on the same criteria. We rigorously conducted subgroup analyses with different time nodes to explore the efficacy of proprietary Chinese medicines at different detection time nodes.However, our network meta-analysis has some limitations. First, all included trials were at high or unclear risk of bias, making the quality of evidence low or very low across all comparisons. Second, the duration of HR-HPV infection, the evaluation criteria for clinical efficacy vary greatly in different trials, and some studies did not mention more details. We recognized that there would be heterogeneity in definitions between trials. Third, there will be some limitations on the external adaptability of the findings, as all the studies were conducted in China. In view of the imperfect design scheme of the included literature, it is recommended that forthcoming randomized controlled trials provide comprehensive descriptions of randomization, allocation concealment, and blinding. Furthermore, the correlation between the duration of treatment of Chinese patent medicines, the follow-up time after treatment, and the rate of negative conversion is a clinically significant matter, and future research can increase the reports in this regard.Chinese patent medicines combined with rhIFN can be more effective than rhIFN alone in clearing the virus and improving cervical symptoms. In terms of clinical efficacy, BFK + rhIFN and KS + rhIFN may be the best treatments for cervical HR-HPV infection. However, due to the poor methodological quality of the included trials, our conclusions should be carefully interpreted. More high-quality randomized controlled trials are required in the future to confirm the efficacy and safety of proprietary Chinese medicines for cervical HR-HPV infection.Supplementary information and tables.Click here for additional data file.


Aging is a dynamic and heterogeneous process that may better be captured by trajectories of aging biomarkers. Biological age has been advocated as a better biomarker of aging than chronological age, and plant-based dietary patterns have been found to be linked to aging. However, the associations of biological age trajectories with mortality and plant-based dietary patterns remained unclear.Using group-based trajectory modeling approach, we identified distinctive aging trajectory groups among 12,784 participants based on a recently developed biological aging measure acquired at four-time points within an 8-year period. We then examined associations between aging trajectories and quintiles of plant-based dietary patterns assessed by overall plant-based diet index (PDI), healthful PDI (hPDI), and unhealthful PDI (uPDI) among 10,191 participants who had complete data on dietary intake, using multivariable multinomial logistics regression adjusting for sociodemographic and lifestyles factors. Cox proportional hazards regression models were applied to investigate the association between aging trajectories and all-cause mortality.We identified three latent classes of accelerated aging trajectories: slow aging, medium-degree, and high-degree accelerated aging trajectories. Participants who had higher PDI or hPDI had lower odds of being in medium-degree  or high-degree  accelerated aging trajectories. Participants in the highest quintile of uPDI were more likely to be in medium-degree  or high-degree  accelerated aging trajectories. With a mean follow-up time of 8.40 years and 803 (6.28%) participants died by the end of follow-up, we found that participants in medium-degree  or high-degree  accelerated aging trajectory groups had higher risks of death than those in the slow aging trajectory.We identified three distinctive aging trajectories in a large Asian cohort and found that adopting a plant-based dietary pattern, especially when rich in healthful plant foods, was associated with substantially lowered pace of aging.The online version contains supplementary material available at 10.1186/s12916-023-02974-9. The number of individuals aged 65 years and older is increasing at an unprecedented pace, and it is expected to reach 1.6 billion by 2050 . HoweverSince aging is a dynamic and heterogeneous process of complex biological system, it may better be captured by repeated measures of aging biomarkers along the years. Recently, biological age has been advocated as a more accurate indicator of aging than chronological age, which integrates multiple objective biomarkers relevant to physical functions and provides information about overall health status , and it Nutrition and diet have been advocated as major determinants of health . ParticuTherefore, in the large prospective MJ cohort, we first established aging trajectories based on a newly developed biological aging index and assessed the associations between the aging trajectories with all-cause mortality; then, we evaluated the impacts of plant-based dietary patterns on these aging trajectories.The study population was obtained from a standard medical screening program with the same models of instruments conducted by the MJ Health Management Institution. Recruitment happened at four geographically representative clinics located in the northern, northwest, central, and southern parts of Taiwan. Detailed information on the study design, methods, and rationale of the MJ prospective cohort has been reported previously –24. UponIn order to establish aging trajectories, we included 12,784 participants who were enrolled between 1996 and 2011, aged 50 years or older, and had completed data on the multi-dimensional aging measure (MDAge) at four times within an 8-year period after initial enrollment. To examine the associations between plant-based dietary patterns and aging trajectories, we further excluded 2593 (20.34%) participants who had incomplete data on food intake, leaving 10,191 participants for the analysis.Data for sociodemographic characteristics , lifestyle factors , food intake frequency, and personal and family medical history  were collected by a self-administered questionnaire at baseline, and trained staffs provided detailed information if needed. Physical examinations were conducted by trained staffs with calibrated instruments following standard protocols, and height, weight, blood pressure, and lung function were measured. A 10-mL fasting blood sample from each participant was collected for laboratory tests at every physical examination. A timeline of data collection was shown in Additional file Education , marital status , smoking status , and drinking status  were modeled as categorical variables. Body mass index (BMI) was calculated by dividing weight in kilograms by height in meters squared. Diabetes status was defined as having fasting blood glucose ≥ 126 mg/dL, having been diagnosed with diabetes by a doctor, or reported receiving anti-diabetic medication treatment. Hypertension was similarly defined as having systolic pressure ≥ 140 mm Hg, having been diagnosed with hypertension, or reported receiving anti-hypertensive medication treatment.We calculated multi-dimensional aging measure (MDAge) in accordance with the method described previously . Brieflye(B10)), calculated as 2(△BIC). This factor can be interpreted as the strength of evidence favoring the alternative model. Then, we determined the trajectory shapes that best describe the observed trajectories, and linear, quadratic, and cubic functions were all tried. The best-fitting trajectory models were selected based on the log Bayes factor, appropriate average posterior probability (> 0.7), and a minimum sample size in each group that accounted for > 5.0% of the overall population. More details of the GBTM approach have been described previously [Distinct aging trajectories were then identified by group-based trajectory modeling (GBTM) approach based on MDAgeAccel at the four time points. The GBTM approach assumes that study population is comprised of a mixture of distinct groups defined by individual developmental trajectories . The proeviously –35. ThesWe evaluated the plant-based dietary patterns by constructing the plant-based diet index (PDI), healthful plant-based diet index (hPDI), and unhealthful plant-based diet index (uPDI), following an adapted approach used by Satija et al. .Self-reported information on dietary intake was collected at first examination using a standardized and validated semi-quantitative food frequency questionnaire (FFQ) , 38. ThiTo calculate PDI, we assigned scores for each food group according to the intake frequency: a score of 5 was assigned for the highest frequency and 1 for the lowest frequency regarding the intake of plant food (positive scores); a score of 1 was assigned for the highest frequency and 5 for the lowest frequency regarding the intake of animal food (reverse scores). Therefore, the higher the frequency of eating plant foods and the lower the frequency of eating animal food, the higher the PDI.However, not all plant-based foods are beneficial to aging in the long term. The healthy PDI (hPDI) and unhealthy PDI (uPDI) were created to represent healthy and unhealthy versions of a plant-based diet. Based on the most recent evidence , 36, we We calculated the follow-up time from the date of the fourth physical examination to the date of death or December 31, 2011, whichever came first. Mortality data were obtained by linking study participants to the Taiwan death file through 2011 using the unique identification numbers assigned to the residents.Data on chronic disease conditions including stroke, cancer, COPD, osteoarthritis, diabetes mellitus, hypertension, and myocardial infarction were collected by self-reported questionnaires at the first physical examination. A chronic disease count variable ranging from 0 to 7 was created with 4 categories: 0, 1, 2, and 3 or more.The baseline characteristics of participants at the first physical examination were summarized using descriptive statistics. Spearman correlation analysis was conducted for food groups and dietary indices.We applied multivariable multinomial logistics regression to estimate the associations between quintiles of PDI, hPDI, or uPDI and aging trajectories, with the lowest quintile as the reference for the exposure and slow aging as the reference category for the outcome. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. Trend tests were conducted by assigning the median value to each quintile of an index and entering as a continuous variable in the model. In addition, we treated these indexes as continuous variables (per 10-unit increment) in our analyses. We also conducted sex- and age-stratified analyses to evaluate the associations between PDI, hPDI, or uPDI and aging trajectories. We used multinomial logistics regression models adjusting for age, gender, education level, marital status, smoking status, drinking status, and disease count at baseline. ORs and 95% CIs were reported. Moreover, we investigated the associations of 14 individual food items with aging trajectories using multinomial logistics regression models adjusting for age and gender.Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% CIs for the associations between aging trajectories and all-cause mortality. For this analysis, the follow-up started at the fourth physical examination. A three-stage modeling process was adopted. Model 1 adjusted for age, gender, and MDAgeAccel (continuous) at baseline. Model 2 additionally adjusted for education level, marital status, smoking status, and drinking status. Model 3 further adjusted for disease count at baseline. We then used Kaplan–Meier survival curves and log-rank tests to estimate the incidence of mortality by aging trajectories in all participants and gender-stratified groups. We conducted complete case analyses, and participants with missing covariates data were excluded from corresponding analysis.p-value < 0.05 was considered statistically significant.All analyses were performed using SAS 9.3 , and plots were created using R 3.5.3. A two-sided Table Three latent classes of accelerated aging trajectories were identified by GBTM and were illustrated in Fig. Based on the Kaplan–Meier curve, differential risks of mortality were observed for each aging trajectory Fig. A, and thPDI score was slightly higher among the participants in the slow aging trajectory Table . Table 2The hPDI score was slightly higher while uPDI score was lower among the participants in the slow aging trajectory, and the details were shown in Table The results of the associations of hPDI and uPDI with accelerated aging trajectories were shown in Table Linear regression analysis indicated that a 10-unit increment in hPDI was associated with lower odds of being in the medium-degree accelerated trajectory  or of being in the high-degree accelerated trajectory . Whereas a 10-unit increment in uPDI was associated with 43% higher odds of being in the medium-degree accelerated trajectory  or 39% higher odds of being in the high-degree accelerated trajectory . Detailed results were listed in Table We generated reconstructed hPDI (rhPDI) and reconstructed uPDI (ruPDI) by excluding animal food scores and investigated the associations of rhPDI and ruPDI with the trajectory groups. The correlation matrix among plant-based food groups and reconstructed food indices was provided in Additional file We further conducted sex- and age-stratified analyses Table . Overall≥2 servings/day vs <0.5 servings/day = 0.70; 95% CI, 0.60, 0.82), fresh vegetables , and legumes  were potentially the main contributors to the beneficial associations of PDI and hPDI with aging; and higher intake frequency of refined grain , salt-preserved vegetable , dairy products , and pluck  were primary contributors to the detrimental association of uPDI with aging .


Background: Nasopharyngeal carcinoma (NPC) is a head and neck cancer more frequent among East Asian populations compared with Western populations. While much is known about human papillomavirus’s (HPV’s) role in oropharyngeal cancer (OPC), little is known about its prevalence and prognostic value in NPC. The aim of this study is to investigate the role of HPV in NPC treated with definitive radiotherapy at a single institution. Methods: A retrospective cohort analysis of patient’s medical records and HPV status treated for NPC in Rambam Health Care Campus (Rambam HCC). Immunohistochemical staining for p16 was used as a surrogate marker of HPV infection in the tumor cells. All specimens were stained and evaluated by pathologists at the referring center independently. Results: In total, 87 patients diagnosed with NPC were treated at Rambam HCC between 2005 and 2018. Seventy-four patients had accessible data on the disease’s clinical parameters and p16 status. In total, 10/74 (13.5%) had p16-positive staining in tumor cells; 75% were men and over 50% were smokers. The average age of diagnosis for the whole cohort was 48 years, being lower for p16-positive patients compared with p16-negative patients at 43 and 49 years old, respectively. A total of 84% of the patients had advanced disease of stage III and IV at presentation. Only 16% were diagnosed with stage I and II. Unlike the p16-negative group, the p16-positive group did not include any stage I or II disease. In univariate and multivariate analysis of overall survival rates, the age at diagnosis and the nodal spread status were the only statistically significant measures. P16 status was not found to be associated with survival. Conclusions: The HPV prevalence in NPC is nontrivial. p16-positive patients had significantly less nodal spread and tended to be younger. Both age and nodal status were significantly correlated with the survival, but P16 status was not prognostic. Further large-scale trials are needed to elucidate the role of HPV in NPC. Nasopharyngeal carcinoma (NPC) is an epithelial carcinoma of the head and neck region, arising mostly within the posterolateral pharyngeal recess. It is twice as common in men than in women, with over 130,000 new cases yearly worldwide. In the past decade, the incidence and mortality have steadily declined, perhaps due to changes in etiological factors, as well as better and earlier diagnostic and therapeutic modalities .Despite the histological similarity and anatomical proximity, it is distinctly different from other tumor subtypes originating from the head and neck mucosal lining, having different etiology, distribution, staging and treatment.Among various etiological factors reported, viral oncogenes have been strongly implicated in the pathogenesis of NPC, being most frequently associated with Epstein–Barr virus (EBV), indicated by histopathological examination and geographical distribution. It is more common in EBV endemic regions such as East and Southeast Asia, making up over 70% of the newly diagnosed cases worldwide, of which 95% are of the non-keratinizing subtype that is known to be strongly associated with EBV ,4.Recently, multiple studies have supported the diagnostic and prognostic value of anti-EBV antibodies and free viral DNA in plasma and showed correlation to tumor burden. Ling-Long Tang et al. reported a non-inferior 3-year failure-free survival for patients with low-risk NPC, defined as stage II/T3N0M0 without adverse features, including Epstein–Barr virus DNA <4000 copies/mL treated with radiotherapy alone compared with standard chemoradiation . FurtherAlmost all NPC cells demonstrate monoclonal EBV episomes in tumor cells. The proposed pathomechanism of carcinogenesis is through the expression of type II EBV latency gene products  facilitating global hyper-methylation, altering multiple cellular pathways and host microenvironments, thus promoting clonal expansion, proliferation and oncogenesis .Human papilloma virus (HPV) is a well-known causative factor for oropharyngeal carcinoma (OPC). Nowadays, it is found in over 70% and 50% of the newly diagnosed cases in the United States and the United Kingdom, respectively . RecentlHPV is a small 55 nm diameter non-enveloped, circular double-stranded deoxyribonucleic acid (DNA) oncogenic virus, best known to be a sexually transmitted disease (STD) having a strong tropism for host mucosal and cutaneous stratified squamous epithelium. It has been shown to cause genital warts, pre-cancerous lesions and cancers among different body sub-sites, mainly gynecological malignancies , anal cancer and head and neck cancers; it mostly affects sites harboring lymphoid tissue of the Waldeyer’s ring , occurring predominantly within the Oropharynx .Multiple HPV strains have been identified. They are divided into low-risk non-cancerous strains  causing indolent lesions, and high-risk aggressive strains causing cancers; 14 of these strains are the most prevalent , where 16 and 18 are responsible for over 70% of HPV-related cancers .HPV exerts its oncogenic effect mainly through the integration of the HPV genome into the host chromosome, subsequently allowing for the expression of the viral E6 and E7 genes so that their oncoproteins disrupt the tumor suppressor genes P53 and RB, respectively, resulting in dysregulated and selective growth advantage .Although HPV-positive oropharyngeal carcinoma (OPC) is strongly known to behave differently from HPV-negative OPC, the clinical behavior and prognostic value of HPV in NPC has been controversial, as trials have shown contradictory results ,16,17,18Traditionally, the treatment of locally advanced NPC has been definitive radiotherapy or chemoradiotherapy with neo-adjuvant or adjuvant chemotherapy depending on the disease stage at presentation, regardless of HPV and EBV status, even though the latter has been shown to be prognostic ,20,21,22This treatment approach has largely been shaped by large-scale trials from endemic regions. Nevertheless, it has been adopted by most centers even in non-endemic areas, mainly due to the lack of deep understanding of the differences in the disease behavior and response to treatment between endemic and non-endemic NPC. For instance, despite two previous pivotal trials ,21 in enAdditionally, the histological subtypes’ distribution differs, as non-endemic countries have a higher prevalence of keratinizing squamous cells carcinoma compared with non-endemic countries where the undifferentiated subtype with a better prognosis predominates. As we are eager to allow precision medicine for all, there is an ongoing need to deepen our understanding of the various etiological and biological factors associated with the disease.The aim of this study is to retrospectively investigate the prevalence, clinical outcomes and prognostic value of HPV among patients diagnosed with non-metastatic NPC treated with definitive radiotherapy or chemoradiotherapy at our institution.Our study received an institutional research ethics board approval. All patients who were newly diagnosed with nasopharyngeal carcinoma and treated with curative intent using external beam radiotherapy between the years 2005 and 2018 in Rambm Health Care Camps (the tertiary cancer center of north Israel) were included. All patients had clinical and imaging follow-up at our institution as stated by the NCCN guidelines dated for the same period. Patients with distant metastasis were excluded from the study as well as patients for whom tissue samples were unavailable for examination of the viral status.The viral etiology was confirmed using p16 immunohistochemistry staining (≥70% strong nuclear and cytoplasmic staining), a surrogate marker of prior HPV infection in the tumor tissue. The tissue samples’ evaluations were made by head and neck pathologists from 10 different institutes across Israel, each made by pathologists at the local institutes of the initial tissue sampling.Patients’ clinical characteristics, demographics, treatments and outcome data were retrieved from the local electrical medical records database. All tumors were staged using the AJCC TNM Classification eighth edition, which were based on the initial radiology reports at diagnosis. A multidisciplinary team comprising radiation oncologists, medical oncologists and an otorhinolaryngology surgeon treated our patients. Fifteen patients were treated with 3D conformal radiotherapy and the rest of the patients were treated with intensity-modulated radiotherapy (IMRT) with or without chemotherapy. Patients who had locally advanced diseased of T category 3 or 4 or having lymph node–positive NPC received concurrent chemoradiotherapy with additional induction chemotherapy. Patients with T1N0 were treated with radiotherapy alone and patients with T2N0 were managed with concurrent chemoradiotherapy without additional induction chemotherapy.The tumor volume receiving a radiation dose of 70 Gy and the electively treated volume irradiated to 56 Gy were contoured by senior head and neck radiation oncologist based on the Radiation Therapy Oncology Group (RTOG) contouring guidelines. The delineation and treatment plans were reviewed in weekly quality-assurance staff meetings.The treatment response was assessed initially 4 weeks after radiotherapy by radiation oncologist and otorhinolaryngology surgeon. Patients were followed every 3 months for two years, every 4 months for the third year and every 6 months for 2 more years, and annually thereafter. Disease recurrences were diagnosed by radiologic findings and confirmed histologically whenever the findings were unequivocal.The patients’ demographics and clinical characteristics, as well as disease-free survival (DFS), disease-specific survival (DSS) and overall survival (OS) were compared for the HPV-positive and HPV-negative patients.The follow-up time was assessed from the date of diagnosis until November 2019.p < 0.05 was considered to indicate statistical significance. Differences between p16-positive and p16-negative cohorts were evaluated by applying Fisher’s exact test for categorical variables.Five-year overall survival (OS), disease-specific survival (DSS) and disease-free survival (DFS) were calculated using the Kaplan–Meier method, and differences in survival rates were assessed using the log-rank test. OS was measured from the date of surgery to the date of death or the last follow-up. For DSS, patients who died from causes other than NPC were censored at the time of death. All variables that had prognostic potential were subjected to both univariate and multivariate analyses using the Cox proportional hazards regression model. Analyses were performed using IBM SPSS Statistics for Windows, version 24 . All statistics were two-sided. A value of p value 0.721), smoking status  and female-to-male ratio  were similar. On the contrary, patients who were p16-positive had statistically significantly  less nodal spread compared with those who were p16-negative  slides for p16 stain, which were positive for 10 (13.5%) of these individuals . The mednegative . Althougnegative .p value 0.002) and the N category  were predictors for overall survival, older age was also a predictor for disease-specific mortality  and advanced T category was associated with disease recurrence .The oncological outcomes for all patients are illustrated in p value 0.017) and the N category  were also predictors for overall survival, but older age was not a predictor for disease-specific mortality anymore . Advanced T category was still associated with disease recurrence, having a roughly five-fold relative risk . There was an over 3-fold increase in mortality for patients over 60 compared with those who were younger. The p16 status was not associated with OS, DSS or DFS either on univariate analyses or on multivariate analyses , the patient age  of our patients’ biopsy specimens stained positive for p16.HPV is strongly associated with head and neck cancer, particularly with OPC and, to a lesser extent, with oral cavity cancer and NPC. Though its significance is still debatable, its prevalence among NPCs varies widely from below 10% to over 50%, with white people and Caucasian people showing the most prominent associations ,10,11.There are approximately 14 high-risk HPV strains. While HPV-16 is the predominant type in OPC, occurring in over 95% of these cases, over 60% of HPV-positive NPC patients harbor other high-risk HPV types .Several detection methods for HPV exist. Although in situ hybridization (ISH) and polymerase chain reaction (PCR) are the most sensitive techniques, they are complicated, expensive and lack specificity for causal etiology . On the Moreover, p16 positivity might indicate that the virus is transcriptionally active, suggesting that the virus is a driving factor rather than being merely a bystander infection. This causal relationship assumption is further enhanced by the rare existence of EBV and HPV co-infection in the same tumor cells ,26 and tWhile EBV is recognized as the primary etiologic factor in non-keratinizing NPC WHO type II and III, WHO type I keratinizing NPC lacks an association with EBV and is more linked to other etiological factors such as smoking and HPV. In a study of non-endemic NPC, all of the EBV-positive tumors were non-keratinizing type II and III NPC, while only two-thirds of the HPV+ NPC were as such, and two-thirds of the EBV/HPV-negative tumors were keratinizing type I NPC . Nearly The clinical presentation of HPV+ NPC seems to be different than HPV-negative NPC. Windon et al. have shown that in comparison to HPV + OPC and HPV − NPC, the HPV + non-OPC has uniqueness, a different presentation and perhaps a worse prognosis . Huang eIn contrast to its favorable prognostic value in OPC, HPV positivity remains controversial in non-OPC because even though several studies have suggested HPV to have a favorable impact on the prognosis of head and neck cancer despite sub-site, others have shown no survival benefit or even a detrimental effect among HPV-positive non-OPC patients ,16,17,18Unlike EBV + NPC, in which the predominant pattern of failure is distant metastasis, Stenmark et al. reported higher loco-regional recurrence rates among HPV + NPC . This obFurthermore, we found patients older than 60 years to have a three-fold relative risk of mortality. Nearly 80% of NPC cases occur in individuals aged 30–60 years. At our institution, 30% of NPC cases are in patients older than 60 years. A small amount of data has been published regarding the appropriate definition of elderly in NPC. Additionally, it is arguable whether the chronological age or the biological age has to be considered. Previous retrospective and prospective trials have chosen various age cutoffs where 60 was the lowest limit and a commonly used definition ,35. StudThe incidence of the HPV-related malignancies, particularly gynecological cancer, has declined dramatically after the introduction of the HPV vaccine, which is recommended at a young age to confer an effective prevention method against the sexually transmitted virus. Diana et al. found the vaccination to significantly lower the prevalence of oral HPV infection, with an estimated efficacy of 90%, but low vaccine coverage remains a major issue . Yet, thRecently, several novel vaccine-based therapies and cellular therapies have shown promise for the treatment of HPV-related head and neck malignancies. Some are being tested in combination with immune-checkpoint inhibitors, especially PD-1 inhibitors such as the biologic CUE-101 causing selective expansion of the HPV16 E711-20-specific population of cytotoxic CD8 + T cells . Thus, tAdditionally, the association between HPV and NPC raises concerns whether or not the nasopharynx has to be irradiated electively in HPV+ head and neck cancer of unknown primary. We believe this might be highly relevant for patients whose risk of having HPV+ NPC is non-negligible, particularly among non-endemic populations, Caucasian people, smokers and patients with nodal involvement patterns consistent with NPC, such as level V .Further large-scale studies are needed to validate whether p16 can serve as a good surrogate marker for HPV infection in NPC, or if advanced methods, such as PCR or ISH, should be performed. Equally, NPC should perhaps be categorized into viral etiological subgroups. The nature, clinical differences and molecular profiles of the EBV + HPV−, EBV − HPV−, EBV − HPV+ and the rarely-occurring EBV + HPV + NPC types should be investigated.In conclusion, HPV-positive NPC is assumed to be a distinct clinical entity different from other NPC or HPV-positive OPC. Its prognostic implication has to be studied while considering different confounding factors possibly affected by HPV status such as age, smoking status, histological type and disease stage.All of our patients were treated at a single medical facility, mostly receiving induction chemotherapy followed by chemoradiotherapy, and then followed for a relatively long follow-up period at our institution.Due to the nature of our study, there could be a bias, which applies to all retrospective studies.Additionally, our study lacked EBV status, HPV subtyping, standardized detection methods and centralized labs.


We sought to predict clinically meaningful changes in physical, sexual, and psychosocial well-being for women undergoing cancer-related mastectomy and breast reconstruction 2 years after surgery using machine learning (ML) algorithms trained on clinical and patient-reported outcomes data.We used data from women undergoing mastectomy and reconstruction at 11 study sites in North America to develop three distinct ML models. We used data of ten sites to predict clinically meaningful improvement or worsening by comparing pre-surgical scores with 2 year follow-up data measured by validated Breast-Q domains. We employed ten-fold cross-validation to train and test the algorithms, and then externally validated them using the 11th site’s data. We considered area-under-the-receiver-operating-characteristics-curve (AUC) as the primary metric to evaluate performance.Overall, between 1454 and 1538 patients completed 2 year follow-up with data for physical, sexual, and psychosocial well-being. In the hold-out validation set, our ML algorithms were able to predict clinically significant changes in physical well-being (chest and upper body) , sexual well-being , and psychosocial well-being . Baseline patient-reported outcome (PRO) variables showed the largest influence on model predictions.Machine learning can predict long-term individual PROs of patients undergoing postmastectomy breast reconstruction with acceptable accuracy. This may better help patients and clinicians make informed decisions regarding expected long-term effect of treatment, facilitate patient-centered care, and ultimately improve postoperative health-related quality of life.The online version contains supplementary material available at 10.1245/s10434-023-13971-w. Tailoring individual care to match each patient’s expected QOL after reconstruction is necessary and warrants further investigation. Fortunately, the emergence of cutting-edge computational techniques—machine learning (ML)—accompanied by the usage of individual patient-reported outcome (PRO) data provides the potential to address this knowledge gap and to help patients and clinicians make informed decisions before the initiation of breast reconstruction procedures to facilitate patient-centered care.Clinical studies have been conducted to compare different options and evaluate the outcome of PMBR, to provide insights into treatment options, and to inform patients’ decision-making.8 By learning patterns from data, ML has the unique capability to predict future outcomes at the individual level. This ability to provide personalized predictions and recommendations tailored to individual patients has the potential to greatly enhance patient care, leading to growing enthusiasm for the application of ML techniques in addressing clinical problems. Trained ML models using supervised learning techniques have consistently demonstrated exceptional performance across a range of challenging prediction tasks in the medical field. These tasks include, but are not limited to, prediction of mortality in cancer patients,9 natural language processing,10 prediction of financial toxicity caused by cancer treatment,11 and classification of benign or malignant tumor.12 The success of ML in these predictive tasks can be attributed to its strong capability to identify subtle nonlinear interactions between events and outcomes within multidimensional data.13 This ability allows ML models to uncover complex relationships that may not be discernible through traditional methods, resulting in more accurate predictions and improved decision-making across various healthcare domains.As a branch of artificial intelligence, ML involves training algorithms to identify intricate patterns within data and make precise predictions.15 In this comprehensive study, we aimed to develop and validate ML algorithms to accurately predict clinically meaningful, long-term changes in physical, sexual, and psychosocial well-being for women undergoing PMBR at 2 year follow-up to enhance decision-making in this area, shifting a focus from satisfaction to the critical areas of health-related QOL, using the same study population as those prior two studies, and affording unique insights into the PRO on the health-related QOL prediction for women with breast cancer.Machine learning algorithms have previously achieved excellent performance in predicting breast satisfaction, one of the key outcomes for women undergoing PMBR, both at 1 and 2 year follow-up.14This study cohort was a subgroup of the international Mastectomy Reconstruction Outcomes Consortium  study that was conducted at 11 study sites in both Canada and the USA between 2012 and 2017. A total of 3058 women undergoing PMBR were recruited as described in detail elsewhere.Inclusion criteria were women aged 18 years or older, undergoing first time bilateral or unilateral, immediate or delayed PMBR for risk reducing or therapeutic purposes. These patients could have undergone implant-based and/or autologous reconstruction, based on the surgeon’s recommendation or their preferences. Exclusion criteria were patients with previous failed breast reconstruction. For the present analysis, patients with unreported PROs at baseline or 2 year follow-up were also excluded.All included study sites received ethical approval from the respective institutional review board.16 Cronbach’s alpha coefficients are reportedly greater than 0.8 and the score of each scale ranges from 0 (worst well-being) to 100 (best well-being).17Patient-reported physical, sexual, and psychosocial well-being were evaluated before the initiation of the reconstruction procedure and at 2 year follow up by the validated and reliable BREAST-Q.18 We defined three types of outcomes for each domain when comparing baseline PROs with those at 2 year follow-up: outcomes of health-related QOL were (1) worsened if the 2-year follow-up score was reduced at least by the respective MCIDs compared to baseline, (2) improved if the 2-year follow-up score was increased at least by the respective MCIDs compared with baseline, or (3) otherwise stable.Minimal clinically important difference (MCID) estimates have previously been reported: MCID in physical well-being (chest and upper body) is a score difference of at least 3, and a score difference of at least 4 in both sexual and psychosocial well-being.To facilitate the construction of ML predictive models, we recoded the outcome into binary .19 and reported findings following relevant guidelines (TRIPOD).20We trained three ML algorithms with varying levels of complexity for each domain given their demonstrated promising performance in published similar medical studies conducted by our team,14Logistic regression (LR) with elastic net penalty.13The LR with penalized magnitudes of coefficients is known for its easy-to-interpret prediction process, ability to avoid overfitting, and enhanced generalizability on new datasets.Extreme gradient boosting (XGBoost) tree.21The XGboost tree, as an ensemble-learning algorithm of several built models, is suitable for complex classification tasks due to its enhanced capability in identifying complex relationships among predictors.Neural network.A neural network has a unique network structure consisting of connected units that is inspired by the structure of the human cortex. This enables identification of complex patterns within the dataset and capturing nonlinear relations among the input and output variables.We briefly describe each algorithm below. A detailed description can be found in online supplemental documents of our previously published study.14 We included four patients, five preoperative PRO, and seven clinical variables as predictive factors (Table 1 in Supplement 1).We split the 11-site data into a development set of 10 sites and a validation set of 1 site. The validation site with initials of “BW” was chosen based on the number of events, as reported in our previous research on breast satisfaction prediction.K = 5), removed zero variance variables, centered and scaled all numerical variables, and dummied all categorical variables with one hot encoding. Variables having an absolute correlation with other variables over a threshold of 0.9 were removed, to address the multicollinearity issues.For data preparation, we imputed missing values using the K-nearest neighbors algorithm , precision, and recall, to assess model performance in each fold. We embraced the “Kappa” metric to evaluate final model performance in the test fold because of the possible class-imbalance effect. We chose the simplest model that was within a 3% tolerance of the empirically optimal model as the final model to reduce overfitting and improve generalizability to new datasets.23 We compared model performance among each racial group to evaluate the fairness of ML algorithms.24Based on our previous research, we excluded five socioeconomic and racial variables to avoid racial bias.25 and local interpretable model-agnostic explanations (LIME) for the neural network.26 For comparison, traditional binary logistic regression models are provided as well. To assess the fairness of model performance, we compared the predictive performance of the models across all racial groups in the validation set. To assess algorithm calibration in the validation set, we plot calibration plots with predicted versus observed rates of outcome.27 We conducted the Spiegelhalter Z test for calibration accuracy assessment,28 with a p-value greater than 0.05 indicating the model was well calibrated. We calculated the scaled Brier score with a range between 0 (perfect predictive performance) and 1 (poor predictive performance).29The predictive performance of the ML algorithms were measured via accuracy and AUC. Point estimates along with a 95% confidence interval (CI) are reported. To provide insights into model predictions and improve transparency and interpretability, we reported regularized coefficients for the LR with elastic net penalty, Shapley Additive explanations (SHAP) values for XGBoost tree,Lastly, we conduct receiver operating characteristic curve comparisons among ML model performance in both development and validation sets for each scale to assess their statistical significance. We plotted AUC of models to predict improved and worsened health-related QOL outcomes together to get the full picture of the performance of the trained ML model at each scale.We carried out all analyses within the “R” programming environment with version 4.2.1. and developed ML models using the “caret” package.The analysis set comprised 1538 participants for physical well-being , 1454 for sexual well-being , and 1538 for psychosocial well-being  to train and validate ML models as shown in Fig. p < 0.05).When comparing development and validation datasets, we observed significant differences in body mass index (BMI), baseline physical well-being, baseline physical well-being abdomen, superficial inferior epigastric artery (SIEA) flap, axillary lymph node dissection (ALND), sentinel lymph node biopsy (SLNB), high school degree, masters/doctoral degree, retired working status, part-time employed working status, $25,000–49,999 household income per year, and greater than $100,000 household income per year , followed by PRO scores at baseline (r = 0.63). The lowest level of correlation was observed between baseline physical well-being and 2 year sexual well-being (r = 0.14) (Table 2 in Supplement 1).The correlation between 2 year psychosocial well-being and 2 year sexual well-being was highest , 0.81 , and 0.81 , respectively. In predicting improved sexual well-being, the AUC was 0.76, , 0.76 , and 0.74 , respectively. For improved psychosocial well-being, AUCs were 0.66 , 0.66 , and 0.66 .p > 0.05) except for the models predicting improved compared with worsened physical well-being (p < 0.05).Figure p = 0.01) and improved psychosocial well-being (p = 0.02), LR with elastic net penalty in predicting worsened sexual well-being (p = 0.003), and XGBoost tree in predicting worsened psychosocial well-being (p = 0.01) and improved psychosocial well-being (p = 0.0001).An array of AUC curves of the models for each scale are displayed in Fig. βregularized, −1.08) was most strongly negatively correlated with improved physical well-being at 2 year follow-up.The results Table  indicateβregularized, − 0.78), tissue expander (TE) reconstruction , and radiation after reconstruction , were most strongly negatively correlated with improved changes, whereas latissimus dorsi (LD) flap reconstruction  was positively correlated.In predicting sexual well-being change at 2 year follow-up, baseline sexual well-being , mixed implants and autologous reconstruction , GAP flap , other types of mastectomy , and latissimus dorsi (LD) flap reconstruction  were most strongly negatively correlated with worsened psychosocial well-being at 2 year follow-up, whereas baseline psychosocial well-being  and mixed flaps reconstruction  were positively correlated with worsened outcomes. Similar variable importance, as well as its contribution to prediction, were also observed from XGBoost SHAP values and neural network LIME plots , respectively.Additionally, superficial inferior epigastric artery (SIEA) flap reconstruction. When comparing the logistic regression with the coefficients of the ML models, generally the same direction and magnitude of associations could be observed with few exceptions. This gives credibility into the outcome predictions made by the ML model.p < 0.05, higher scores for Asian subgroup). Neural networks performed statistically different between groups of Caucasian versus African American , and African American versus Asian in predicting worsened sexual well-being . All trained ML models showed statistically better performance for the African American group compared with the Caucasian group in both improved and worsened psychosocial well-being prediction  (Tables 6 and 7 in Supplement 1).The performance of all ML models in predicting both improved and worsened physical well-being statistically differed between the Caucasian and Asian groups  unpredictable complications, such as infection, implant-related issues, or poor wound healing, which can arise during the postoperative period and result in suboptimal physical outcomes.Compared with the sexual and psychosocial well-being of patients at 2 year follow-up, our findings show physical health improved in some patients but worsened in many more patients. This confirms previous findings that the physical well-being of the chest and upper body will not be fully restored, regardless of whether patients undergo implant-based or autologous reconstruction.30 Specifically, autologous reconstruction outperforms implants in tolerance of radiotherapy and improving QOL.31 Integrating radiotherapy with breast reconstruction results in a complex impact across multiple dimensions of a patients’ life.31 Patients with nipple-sparing mastectomy have significantly higher psychosocial and sexual well-being compared with patients with total mastectomy.32 However, inferences drawn from these group-level studies cannot infer specific treatment outcomes for individuals,33 as the relationships between variables of interest and outcomes are usually estimated after controlling for relevant co-variables, which does not reflect the real situation of each patient. Machine learning may overcome this limitation and help tailoring outcome predictions to the individual patient.13Previous studies using traditional statistical methods asserted that patients with autologous reconstruction tended to have a higher health-related QOL compared to those with implant-based reconstruction.Our results also indicate that patients with higher baseline physical, sexual, and psychosocial well-being were more likely to have worsened PROs in these three domains after breast reconstruction. Whether implant-based or autologous procedures were associated with improved or worsened QOL depended on the specific type of reconstruction, which was also seen in the binary logistic regression: taking direct-to-implant (DTI) reconstruction as a reference, TE reconstruction was associated with worsened sexual well-being and deep inferior epigastric perforator (DIEP) flap reconstruction was associated with a decreased risk of worsened physical well-being (chest and upper body). These individual-level outcomes predicted by ML models aim to better guide and optimize patient decision-making process to achieve expected postoperative outcomes when determining preferences for the exact reconstruction procedure. Nevertheless, a comparison of the performance of traditional statistical models with ML algorithms in this field appears highly warranted to help more clearly distinguish and highlight advantages of these developed intelligent decision-making tools.14 AUC of the same three ML models to predict changes in satisfaction with reconstructed breasts study  was higher compared with the performance in predicting changes in physical, sexual, and psychosocial well-being in the present analysis. Insights into predictors also underscored the importance of baseline PRO variables over clinical variables, similar to what we observed in the present analysis. Moreover, age was associated with worsened breast satisfaction  and physical well-being  but improved sexual well-being  and psychosocial well-being . This observation is underpinned by previous studies concluding that not all women necessarily experience worsening sexual function with higher age34 and that some older women have higher levels of sexual satisfaction,35 where psychosocial factors appear to play a crucial role.36Our team has previously published the development and validation of accurate ML algorithms to predict clinically meaningful changes in breast satisfaction with reconstructed breasts at 2 year follow-up in this cohort.37 However, none of the 11 study sites in this study met this requirement for all three scales simultaneously. Future, prospective validation with larger sample sizes seems warranted. Second, due to small samples or no samples in some racial groups , the ML performance assessment in these racial groups was not feasible. Some ML algorithms performed statistically significantly better in certain racial groups. We acknowledge that achieving equal performance across races becomes more challenging when sample sizes are limited, which aligns with findings of previous studies in this regard.14 Future studies may validate our findings and mitigate potential racial bias in a more diverse setting, not just academic institutions included here only. Third, although we achieved similar completion rates to similar PRO studies in literature,1 one cannot ignore that around half of the initially enrolled patients were lost to follow-up after 2 years. The results (Table 1 in Supplement 4) indicate that participants who were lost to follow-up were more likely to be younger, single, have a higher BMI, undergo TE reconstruction technique, and less likely to be married or have undergone DIEP reconstruction techniques. Future studies may consider using advanced PRO assessment approaches such as computer adaptive testing to reduce patients’ assessment burden and improve their engagement.39 Fourth, this study may establish a benchmark for interested researchers studying ML models on classification tasks for breast cancer patients. However, before implementing these algorithms in clinical practice to predict individual outcomes, necessary steps such as prospective clinical trials are needed to confirm their validity and reliability in real clinical settings.33 Fifth, the ML approach used in this study required dichotomization of outcomes. We chose this approach due to the recent upcoming concept of “clinically-important differences” in PROM research.41 However, some clinicians and patients might be more concerned about the degree or magnitude of change in their well-being due to the reconstruction procedure. This issue might be addressed in future research via modeling techniques that allow for continuous outcomes . Sixth, clinical implementation of digital health tools has proved to be a challenging task with many barriers including, for example, lack of transdisciplinary knowledge.42 Future research seems warranted to investigate the development and clinical feasibility of a digital tool that assists patients and clinicians in clinical decision-making process.This study comes with several limitations. First, general guidelines for multivariate models recommend having at least 100 events for validation.In this study, we developed and validated ML algorithms to predict clinically meaningful, long-term changes in physical, sexual, and psychosocial well-being for women undergoing cancer-related mastectomy and breast reconstruction at 2 year follow-up with acceptable accuracy. These algorithms may function as a data-driven decision-making tool to assist in making informed treatment decisions for women undergoing breast reconstruction, and further facilitate patient-centered care by tailoring individualized treatment in clinical practice.Supplementary file1 (DOCX 43 KB)Supplementary file2 (DOCX 53 KB)Supplementary file3 (DOCX 2235 KB)Supplementary file4 (DOCX 48 KB)Below is the link to the electronic supplementary material.


Background and aimsHypertensive emergencies are caused by acutely occurring massive elevations in blood pressure with features suggestive of acute end-organ damage and are a common complication of hypertension. About 1-2% of all patients with hypertension develop this complication in their lifetime. This study was undertaken to assess short-term outcomes associated with hypertensive emergencies in a tertiary care center.MethodsWe conducted a prospective cohort study and recruited 66 consenting adults with a hypertensive emergency. Sociodemographic details, clinical characteristics, blood pressure readings at different intervals, in-hospital course, and diagnosis of end-organ damage were recorded. The in-hospital outcome was noted as dead or alive. After four weeks, patients were followed up through telephonic interviews and the patient’s status was then reviewed and recorded. Multiple logistic regression determined the predictors of death. Data were analyzed in SPSS version 26.0 .ResultsA total of 66 patients were enrolled, with a mean age of 54.57 (±38.18) years and a male predominance of 44 (66.35%) patients. The majority of patients were known hypertensives . Of the known hypertensives, 41 (74.54%) patients had discontinued their anti-hypertensive medications prior to admission. The median duration of hospitalization was 10 (7-14) days. The most common presenting complaints were dyspnea , pedal edema  and headache . Forty-one (62.12%) patients required ICU care, and 39 (59.09%) required ventilator support. The most common end-organ damage was acute-on-chronic kidney disease . The short-term mortality documented at the end of one month was 24 (36.36%). Of these, seven (10.6%) patients died in the hospital, and 17 (25.75) patients died within one month of getting discharged from the hospital. The factors that were associated with high mortality were newly-diagnosed hypertension and in-hospital hypotension.ConclusionWe found high mortality associated with hypertensive emergencies. At one month follow-up, we found that more than one-third of the patients had died. Post-hospitalisation mortality was higher than in-hospital mortality. Most patients had discontinued their anti-hypertensive medication before admission. The most frequently encountered end-organ damage was acute-on-chronic kidney disease. The factors associated with high mortality were newly-diagnosed hypertension and in-hospital hypotension. Hypertension is a significant modifiable risk factor leading to cardiovascular diseases. In 2019, the prevalence of hypertension in India was approximately 30.7% [Hypertensive emergencies are a heterogeneous group of disorders defined as acute elevations in systolic blood pressure (SBP) > 180 mmHg and/or diastolic blood pressure (DBP) >120 mmHg, with features suggestive of progressive or impending acute end-organ damage. This has often been attributed to inadequate treatment or discontinuation of anti-hypertensive medications . PatientLiterature has repeatedly highlighted the significant morbidity and mortality associated with such acute elevations in blood pressure. A study conducted among patients with a hypertensive crisis in Vishakhapatnam demonstrated an in-hospital mortality of 14%, i.e., seven out of 50 patients succumbed . Vlcek eThe physiological and lifestyle characteristics of the Indian population predispose them to develop hypertension and its complications thereof. While adequate data is available pertaining to the management of chronic hypertension, there is a paucity of data regarding the management and outcomes of hypertensive emergencies in the Indian sub-continent. Therefore, this study was undertaken with the objective of assessing the in-hospital course and estimating the short-term mortality of patients with hypertensive emergencies in a tertiary care center.A prospective observational cohort study of 66 patients was conducted for one year starting from June 2021 for all consenting adults with a hypertensive emergency . Pregnant women were excluded from the study since they form a different heterogenous group with different management measures and outcomes.Ethical clearanceThis study was granted approval by the Institutional Ethics Committee (IEC), St. John's Medical College Hospital (study reference number: 354/2019).Sample sizeThe sample size was calculated based on a study done by Euro-STAT, a multicenter European study, which estimated outcomes of hypertensive emergencies in 794 patients [Data collection instrumentA patient information sheet containing the study rationale, noting strict voluntary participation, was provided. Informed consent was obtained from the patients or legally acceptable representative (LAR) for critically ill patients. Data were collected as per the structured proforma. Various sections of the form were:Socio-Demographic CharacteristicsIt mentioned age, gender, socio-economic status, and residence.Clinical CharacteristicsIt mentioned a brief history indicating symptoms and duration of hypertension.ComorbiditiesIt mentioned diabetes mellitus, ischemic heart disease, chronic kidney disease, chronic liver disease, bronchial asthma and other comorbidities, in addition to hypertension.Treatment DetailsAnti-hypertensive medications that patients were taking and compliance with them.Blood Pressure RecordingsBlood pressure readings at admission, at one hour, at two-six hours, at 24 hours and at the time of discharge were recorded.In-hospital CourseThe procedures done in the hospital and drugs administered for high BP readings were noted.Investigations for End-organ DamageInvestigations to detect end-organ damage were carried out: ECG to detect hypertensive or ischemic changes, echocardiography to detect right wall motion abnormalities (RWMA), left ventricular hypertrophy (LVH) and ischemic changes; neuroimaging of the brain to detect infarct/bleeding; ultrasonography (USG) abdomen was also done.Criteria for specific end-organ damage were as follows:-Acute kidney injury was defined as an increase in serum creatinine by 0.3 mg/dL or more within 48 hours or an increase in serum creatinine to 1.5 times baseline or more within the last seven days or urine output less than 0.5 mL/kg/h for six hours .-Acute coronary syndrome was defined by electrocardiograph (ECG) changes and elevations in specific serum cardiac markers.-In-hospital hypotension was defined as either an episode of hypotension requiring discontinuation of the antihypertensive drug and/or the administration of vasopressors or fluids .Medical or Surgical Management MeasuresThe need for intravenous anti-hypertensive drugs was noted, and the duration of the same. Any medical/surgical intervention done to improve the status of the patient and the requirement of facilities needed to continue the management of the patient were noted.In-hospital OutcomeThe in-hospital outcome was recorded as alive or dead. Patients who were discharged against medical advice (DAMA) or those who opted for no resuscitation (DNR) were also recorded.Outcome at One MonthAfter four weeks, patients were followed up through telephonic interviews. The patient’s status was then reviewed and recorded.Study toolsProforma-Operational definitions - The patients were classified based on the European Society of Cardiology classification and on the presence of acute hypertension-mediated end-organ damage to the heart, retina, kidney, large arteries and brain .Statistical analysisThe data collected were entered in Microsoft Excel  and analyzed using Statistical Package for the Social Sciences (SPSS) version 26.0 . The socio-demographic variables and clinical variables of the study population were presented using descriptive statistics like mean, standard deviation (SD), median and interquartile range (IQR). The outcome variable in our study was all deaths at four weeks after discharge. Chi-square test of association, Fischer exact test and T-test were used as applicable. All the variables that show significant association for death in bivariate analysis were included in the multiple logistic regression model, with death as the dependent variable and the predictors from clinical and socio-demographic variables as covariates. Multiple logistic regression determined the predictors of death. The results were expressed as odds ratio with confidence interval and adjusted odds ratio for multivariate analysis. A p-value of <0.05 was considered significant for all analyses.We found that, out of 66 patients hospitalized with a hypertensive emergency, 24 (36.36%) patients died within one month of hospitalization. Of these, seven (10.6%) patients died in the hospital, and 17 (25.75%) patients died within one month of getting discharged from the hospital.The socio-demographic and clinical characteristics of the patients are depicted in Table Table Table Table To the best of our knowledge, this is the first study conducted in South India to assess the short-term mortality associated with hypertensive emergencies. We found high short-term mortality  among patients admitted with a hypertensive emergency. The in-hospital mortality was seven (10.60%). This is at par with existing literature . HoweverOur study found that the mean age of patients affected by hypertensive emergency was 54.57 ±38.18) years and demonstrated a male predilection, with 44 66.66%) male patients. These findings are consistent with a study from Vishakhapatnam 6.66% mal. The com.18 yearsThe common end-organ damage encountered was acute on acute kidney injury, intracranial hemorrhage, and acute pulmonary edema. This finding is in accordance with a cohort study wherein renal and neurovascular emergencies were the most prevalent and prominent predictors of short-term mortality . IntraveThe predictors of mortality were newly-diagnosed hypertension and in-hospital hypotension. Patients who were newly diagnosed to have hypertension were found to have greater mortality compared to known hypertensives. Literature had attributed this to the relative protection conferred by chronic hypertension-induced arteriolar hypertrophy to end organs in the setting of chronic blood pressure elevation . In newlIn-hospital hypotension, in the setting of a hypertensive emergency, has been documented by other studies too . There iLimitationsWe have not been able to assess adherence quantitatively as the patients were critically ill. Also, we have not been able to accurately diagnose and differentiate between primary and secondary hypertension, as it was an unfunded study. Multivariate analysis could not be performed due to limitations in sample size.Future studiesFuture studies are required with greater sample sizes to identify the factors associated with death for each subgroup of end-organ damage and to develop guidelines for the strategic reduction of blood pressure for respective subgroups. This will help reduce mortality associated with this medical emergency.ImplicationOur study has exhaustive implications for the short-term outcomes of hypertensive emergencies. There is a dire need for stringent policymaking on awareness regarding hypertension and its acute complications. Clinicians need to take on the pivotal role of early detection and robust management of hypertension, with a particular emphasis on health education about medication adherence. The patients and their caregivers, too, must be motivated to take responsibility for medication adherence. Post-hospitalisation course needs frequent monitoring and appropriate management through regularly scheduled visits or teleconsultation. This collective initiative will help create a supportive ecosystem for the patient, where such medical emergencies can be foreseen and prevented.We found high short-term mortality associated with hypertensive emergencies. At one month follow-up, we found that more than one-third of the patients had died. Post-hospitalisation mortality was higher than in-hospital mortality. Most of the patients had discontinued their anti-hypertensive medication prior to admission. The most frequently encountered end-organ damage was acute-on-chronic kidney disease. The majority of patients required critical care and invasive ventilation. The factors associated with high mortality were newly-diagnosed hypertension and in-hospital hypotension.


In the United States, medically underserved women carry a heavier burden of cancer incidence and mortality, yet are largely underrepresented in cancer prevention studies. My Body, My Test is a n observational cohort, multi-phase cervical cancer prevention study in North Carolina that recruited low-income women, aged 30–65 years and who had not undergone Pap testing in ≥ 4 years. Participants were offered home-based self-collection of cervico-vaginal samples for primary HPV testing. Here, we aimed to describe the recruitment strategies utilized by study staff, and the resulting recruitment and self-collection kit return rates for each specific recruitment strategy. Participants were recruited through different approaches: either direct  or indirect (passive on the part of study staff). Of a total of 1,475 individuals screened for eligibility, 695 were eligible (47.1%) and 487 (70% of eligible) participants returned their self-collection kit. Small media recruitment resulted in the highest number of individuals found to be study eligible, with a relatively high self-collection kit return of 70%. In-clinic in-reach resulted in a lower number of study-eligible women, yet had the highest kit return rate (90%) among those sent kits. In contrast, 211 recruitment which resulted in the lowest kit return of 54%. Small media, word of mouth, and face-to-face outreach resulted in self-collection kit return rates ranging from 72 to 79%. The recruitment strategies undertaken by study staff support the continued study of reaching under-screened populations into cervical cancer prevention studies. In the United States, overall cancer mortality rates have steadily declined since the 1990s . Blacks To develop appropriate interventions for cervical cancer control, it is critical that recruitment and participation in cancer research ensure the proper representation of racial and ethnic minorities . In a 20Researchers have been increasingly quantitatively documenting their experiences with the recruitment and retention of medically underserved populations into clinical research and cancer prevention studies –15. HoweHere, we aimed to describe the recruitment strategies utilized by study staff, and the resulting recruitment and self-collection kit return rates for each specific recruitment strategy. Results are presented on the methods used in recruiting medically underserved women into the My Body, My Test cervical cancer prevention studies. Two phases of the My Body, My Test study (MBMT-1 and -2) investigated a home-based, self-collection screening approach to test for high-risk (oncogenic) human papillomavirus (HPV) infection—the virus that is the primary cause of cervical cancer. We describe here the recruitment strategies undertaken to reach recruit a diverse population of medically-underserved individuals, as well as the recruitment numbers and self-collection kit return rates yielded with each recruitment strategy.My Body My Test is an observational cohort, multi-phase study investigating the use of home-based self-collection of samples for high-risk HPV testing among women who are under-screened for cervical cancer. Phase one (MBMT-1) assessed the feasibility of home-based self-collection in a low-income, under-screened population as previously reported , 18. PhaIn brief, MBMT1 participants were recruited from 10 North Carolina counties identified as having relatively high rates of cervical cancer: Wake, Durham, Harnett, Guilford, Wayne, Cumberland, Robeson, Richmond, Hoke, and Scotland counties . RecruitFrom February 2012 to October 2014, MBMT-2 participants were recruited from five North Carolina counties: Alamance, Buncombe, Chatham, Durham, and Orange. Female residents of these counties were eligible if they were aged 30–64 years, not pregnant, without Pap test in the preceding 4 years, without history of hysterectomy, earning below 250% of the poverty level (determined by household income and size), and uninsured, underinsured, or insured through Medicaid.If a woman was found eligible for MBMT-1 and -2, she was mailed an at-home self-collection kit containing the Viba self-collection brush (Rovers), illustrated instructions, and a stamped return envelope . When thThis study was approved by the University of North Carolina at Chapel Hill Institutional Review Board (IRB). All participants provided written informed consent before study enrollment.MBMT-1 and MBMT-2 utilized both direct and indirect participant recruitment strategies . Most participating women were recruited directly by completing study eligibility screening with a hotline staff member. Women enrolled through clinic in-reach had their full information collected in person, and thus did not need to call the hotline to finish enrolling.At the beginning of eligibility screening, all callers to the study hotline were asked, “how did you first hear about this study?” When participants were recruited directly, study personnel recorded this recruitment source. In the MBMT-1 study, variables of age and time since last Pap were collected to determine study eligibility during initial contact with the participant, and insurance status, race, educational level, and ethnicity were collected during a second call with participants after they were deemed eligible and sent a self-collected sample kit. In MBMT-2, demographic variables were collected during the initial eligibility screening on the phone with ASHA call center after they were deemed study-eligible. All eligibility data were entered and stored in a centralized, secure study database.We calculated the demographics of the population recruited, including categories for age, education, health insurance status, race, and ethnicity. Participant self-collection return rates were calculated, comparing kit return rates across recruitment sources, comparing the recruitment methods individually and grouped as indirect versus direct approaches, using a Pearson chi-square test. Statistical tests were considered significant at p = <0.05. Analyses were conducted using SAS 9.4 .Recruitment efforts resulted in a total of 1,475 individuals screened for study eligibility, 47.1% of whom were deemed eligible (n = 695) . All eliOf those recruited and eligible, approximately half (54.4%) were under 45 years of age . Most elOf the specific recruitment methods used, small media accounted for 41.1% of individuals screened and deemed study-eligible , followeMBMT-1 and -2 resulted in relatively high self-collection kit return rates, with 70% of eligible participants returning their kits overall. Small media recruitment resulted in the highest number of individuals found to be study eligible, with a relatively high self-collection kit return of 70%. In-clinic in-reach resulted in a lower number of study-eligible women, yet had the highest kit return rate (90%) among those sent kits. In contrast, 211 recruitment which resulted in the lowest kit return of 54%. Small media, word of mouth, and face-to-face outreach resulted in self-collection kit return rates ranging from 72 to 79%.Of the 695 under-screened women who were mailed HPV self-collection kits for cervical cancer screening, kit return was relatively high when compared to similar studies involving mailed HPV self-collection kits which resulted in lower kit return rates (15%-38%) –24. The It is important to note that most chosen recruitment methods resulted in more than 70% of those recruited returning their self-collection kits. Small media recruitment resulted in the highest number of individuals found to be study eligible, with a relatively high self-collection kit return of 70%. Clinic in-reach resulted in the highest rate of patients returning their self-collection kit at 90% of eligible patients recruited via this method. This may be because these individuals were recruited while seeking healthcare services at the partner FQHC, and thus may have been more likely to complete cervical cancer screening. On the other hand, 211 referral had the lowest kit return rate, with just over half of eligible participants recruited via this method returning their self-collection kit. Because 211 referral was a collaboration with a social assistance hotline aiding low-income women, individuals may not have been able to complete the study due to other competing obstacles. Future studies should consider the balance of recruitment success by both self-collection kit return rates of participants and the representation of underserved populations in their surveyed study populations.Difficulties in the recruitment of individuals who do not have regular or easy access to healthcare, or come from underserved populations has been well documented , 10, 11.To our knowledge, there are limited data on the recruitment and participation of individuals in research on cervical cancer screening for underserved populations. A 1999 study aimed at describing recruitment strategies for a single-visit cervical cancer prevention study in a low-income, predominantly Latina population in California found that recruitment was higher and loss-to-follow-up lower in women recruited via media recruitment versus from a clinic registry . Our resRecruitment and retention challenges were identified in a 2011 small, randomized bio-behavioral clinical trial of 50 cervical cancer survivors in California, although study participants needed have regular access to a phone to be eligible for the study . In our In terms of study limitations, comparisons among the strategies about recruitment success should be interpreted with caution given that the recruitment intensity, time duration, resources and efforts of study staff for each strategy were not systematically measured. Another study limitation is that it was not possible to determine what percentage of women who received information about the study were actually study eligible. For MBMT-1 and 2 recruitment, we used several population-based recruitment approaches to identify potential participants who were relatively difficult to reach. Posters on a bus line or flyers in a church can reach many individuals, but did not allow us to assess how many individuals saw recruitment materials. As such, we were not able determine our denominator- those who encountered the recruitment materials. If a woman called into the 211 referral line, there are call records of them having been referred to the study in call records. In future studies, it would be beneficial to determine what percentage of informed women actually applied to and were successfully enrolled into the study. Another limitation was the missing socio-demographic data among participants recruited during Phase 1. In Phase 1, most demographic information was collected via a questionnaire with participants after they had been mailed the self-collection kit. Demographic information is available only for individuals who were not lost to follow up before that point. This issue was addressed in Phase 2 of the study, as this demographic information was collected earlier in the process, during the initial eligibility screening call.Both Phases 1 and 2 of the My Body My Test study resulted in relatively high self-collection kit return rates compared to other studies of a similar nature. Study staff implemented five different recruitment strategies to recruit a population of consistently underrepresented individuals. Implementation science researchers should continue to compare different recruitment strategies and to report on their success at recruiting underserved populations to ensure a diverse study population. Effectively recruiting a diverse study population is crucial in the effort to lower cervical cancer incidence and mortality in the populations that carry the highest burden.