Emma Turner | University of Bristol (original) (raw)

Papers by Emma Turner

British Journal of General Practice

PharmacoEconomics, 2021

We are grateful to Dr. O’Mahony [10] for his comments on our paper [11]. We think he makes some i... more We are grateful to Dr. O’Mahony [10] for his comments on our paper [11]. We think he makes some important points regarding the selection of appropriate comparators and the aims of cost-effectiveness analyses (CEAs). There are several specific points to which we would like to respond. Dr. O’Mahony’s first point is that by asking experts only what screening strategies should be provided, comparator strategies may have been missed, and therefore the analysis will not include the strategies appropriate for incremental analysis. He suggests including longer screening intervals and alternative screening age ranges, combinations of tests and risk thresholds to those suggested by the participants. We appreciate this point and acknowledge it to a degree in the discussion where we suggest that future cost-effectiveness models could explore different combinations of screening age ranges and intervals within the limits suggested by the participants, rather than the exact ranges and intervals sp...

Pharmacoeconomics, 2021

Challenges can exist when framing the decision question in a cost-effectiveness analysis, particu... more Challenges can exist when framing the decision question in a cost-effectiveness analysis, particularly when there is disagreement among experts on relevant comparators. Using prostate cancer screening and recent developments in risk stratification, early-detection biomarkers, and diagnostic technologies as a case study, we report a modified Delphi approach to handle decision-question uncertainty. The study involved two rounds of anonymous online questionnaires to identify the prostate cancer screening strategies that international researchers, clinicians and decision makers felt important to consider in a cost-effectiveness model. Both purposive and snowball sampling were used to recruit experts. The questionnaire was based on a review of the literature and was piloted for language, comprehension and ease of use prior to dissemination. In Round 1, respondents indicated their preferred screening strategy (including no screening) through a series of multiple-choice questions. The resp...

BMJ Open

ObjectivesActive surveillance (AS) enables men with low risk, localised prostate cancer (PCa) to ... more ObjectivesActive surveillance (AS) enables men with low risk, localised prostate cancer (PCa) to avoid radical treatment unless progression occurs; lack of reliable AS protocols to determine progression leaves uncertainties for men and clinicians. This study investigated men’s strategies for coping with the uncertainties of active monitoring (AM, a surveillance strategy within the Prostate testing for cancer and Treatment, ProtecT trial) over the longer term and implications for optimising supportive care.DesignLongitudinal serial in-depth qualitative interviews every 2–3 years for a median 7 (range 6–14) years following diagnosis.SettingFour centres within the UK Protect trial.ParticipantsPurposive sample of 20 men with localised PCa: median age at diagnosis 64 years (range 52–68); 15 (75%) had low-risk PCa; 12 randomly allocated to, 8 choosing AM. Eleven men continued with AM throughout the study period (median 7 years). Nine received radical treatment after a median 4 years (rang...

Background: Polygenic hazard scores (PHS) can identify individuals with increased risk of prostat... more Background: Polygenic hazard scores (PHS) can identify individuals with increased risk of prostate cancer. We estimated the benefit of additional SNPs on performance of a previously validated PHS (PHS46). Materials and Method: 180 SNPs, shown to be previously associated with prostate cancer, were used to develop a PHS model in men with European ancestry. A machine-learning approach, LASSO-regularized Cox regression, was used to select SNPs and to estimate their coefficients in the training set (75,596 men). Performance of the resulting model was evaluated in the testing/validation set (6,411 men) with two metrics: (1) hazard ratios (HRs) and (2) positive predictive value (PPV) of prostate-specific antigen (PSA) testing. HRs were estimated between individuals with PHS in the top 5% to those in the middle 40% (HR95/50), top 20% to bottom 20% (HR80/20), and bottom 20% to middle 40% (HR20/50). PPV was calculated for the top 20% (PPV80) and top 5% (PPV95) of PHS as the fraction of indivi...

Journal of Clinical Oncology

5042Background: Limited data exist regarding disease-related complications (DRCs), such as bone f... more 5042Background: Limited data exist regarding disease-related complications (DRCs), such as bone fractures and urinary obstruction (UO), near end of life of men who die with prostate cancer. We aime...

JAMA, Mar 6, 2018

Prostate cancer screening remains controversial because potential mortality or quality-of-life be... more Prostate cancer screening remains controversial because potential mortality or quality-of-life benefits may be outweighed by harms from overdetection and overtreatment. To evaluate the effect of a single prostate-specific antigen (PSA) screening intervention and standardized diagnostic pathway on prostate cancer-specific mortality. The Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP) included 419 582 men aged 50 to 69 years and was conducted at 573 primary care practices across the United Kingdom. Randomization and recruitment of the practices occurred between 2001 and 2009; patient follow-up ended on March 31, 2016. An invitation to attend a PSA testing clinic and receive a single PSA test vs standard (unscreened) practice. Primary outcome: prostate cancer-specific mortality at a median follow-up of 10 years. Prespecified secondary outcomes: diagnostic cancer stage and Gleason grade (range, 2-10; higher scores indicate a poorer prognosis) of prostate cancers identi...

Journal of clinical epidemiology, Jan 26, 2017

Randomized controlled trials (RCTs) deliver robust internally valid evidence but generalizability... more Randomized controlled trials (RCTs) deliver robust internally valid evidence but generalizability is often neglected. Design features built into the ProtecT RCT of treatments for localized prostate cancer (PCa) provided insights into its generalizability. Population-based cluster-randomization created a prospective study of PSA-testing and a comprehensive-cohort study including groups choosing treatment or excluded from the RCT, as well as those randomized. Baseline information assessed selection and response during RCT conduct. The prospective study (82,430 men PSA-tested) represented healthy men likely to respond to a screening invitation. The extended comprehensive-cohort comprised 1,643 randomized, 997 choosing treatment, and 557 excluded with advanced cancer/comorbidities. Men choosing treatment were very similar to randomized men except for having more professional/managerial occupations. Excluded men were similar to the randomized socio-demographically but different clinicall...

BMJ open, Jan 14, 2017

To compare the completeness and agreement of prostate cancer data recorded by the National Cancer... more To compare the completeness and agreement of prostate cancer data recorded by the National Cancer Registration and Analysis Service (NCRAS) with research-level data specifically abstracted from medical records from the Cluster randomised triAl of prostate specific antigen (PSA) testing for Prostate cancer (CAP) trial. Cross-sectional comparison study. We included 1356 men from the CAP trial cohort who were linked to the NCRAS registry. Completeness of prostate cancer data in NCRAS and CAP and agreement for tumour, node, metastases (TNM) stage (T1/T2; T3; T4/N1/M1) and Gleason grade (4-6; 7; 8-10), measured by differences in proportions and Cohen's kappa statistic. Data were also stratified by year and pre-2010 versus post-2010, when NCRAS reporting standards changed. Compared with CAP, completeness was lower in NCRAS for Gleason grade (41.2% vs 76.7%, difference 35.5, 95% CI 32.1 to 39.0) and TNM stage (29.9% vs 67.6%, difference 37.6, 95% CI 34.1 to 41.1). NCRAS completeness fo...

BMJ open, Jan 30, 2017

Cross-sectional studies suggest that around 6% of men undergo prostate-specific antigen (PSA) tes... more Cross-sectional studies suggest that around 6% of men undergo prostate-specific antigen (PSA) testing each year in UK general practice (GP). This longitudinal study aims to determine the cumulative testing pattern of men over a 10-year period and whether this testing can be considered equivalent to screening for prostate cancer (PCa). Patient-level data on PSA tests, biopsies and PCa diagnoses were obtained from the UK Clinical Practice Research Datalink (CPRD) for the years 2002 to 2011. The cumulative risks of PSA testing and of being diagnosed with PCa were estimated for the 10-year study period. Associations of a man's age, region and index of multiple deprivation with the cumulative risk of PSA testing and PCa diagnosis were investigated. Rates of biopsy and diagnosis, following a high test result, were compared with those from the programme of PSA testing in the Prostate Testing for Cancer and Treatment (ProtecT) study. The 10-year risk of exposure to at least one PSA test...

Cancer causes & control : CCC, 2016

Previous studies indicate a possible inverse relationship between prostate-specific antigen (PSA)... more Previous studies indicate a possible inverse relationship between prostate-specific antigen (PSA) and body mass index (BMI), and a positive relationship between PSA and age. We investigated the associations between age, BMI, PSA, and screen-detected prostate cancer to determine whether an age-BMI-adjusted PSA model would be clinically useful for detecting prostate cancer. Cross-sectional analysis nested within the UK ProtecT trial of treatments for localized cancer. Of 18,238 men aged 50-69 years, 9,457 men without screen-detected prostate cancer (controls) and 1,836 men with prostate cancer (cases) met inclusion criteria: no history of prostate cancer or diabetes; PSA < 10 ng/ml; BMI between 15 and 50 kg/m(2). Multivariable linear regression models were used to investigate the relationship between log-PSA, age, and BMI in all men, controlling for prostate cancer status. In the 11,293 included men, the median PSA was 1.2 ng/ml (IQR: 0.7-2.6); mean age 61.7 years (SD 4.9); and mea...

Trials, Oct 13, 2016

Sociodemographic characteristics are associated with participating in cancer screening and trials... more Sociodemographic characteristics are associated with participating in cancer screening and trials. We compared the characteristics of those responding with those not responding to a single invitation for prostate-specific antigen (PSA) testing for prostate cancer as part of the Cluster randomised triAl of PSA testing for Prostate cancer (CAP). Age, rurality and deprivation among 197,763 men from 271 cluster-randomised primary care centres in the UK were compared between those responding (n = 90,300) and those not responding (n = 100,953) to a prostate cancer testing invitation. There was little difference in age between responders and nonresponders. Responders were slightly more likely to come from urban rather than rural areas and were slightly less deprived than those who did not respond. These data indicate similarities in age and only minor differences in deprivation and urban location between responders and nonresponders. These differences were smaller, but in the same directio...

The New England journal of medicine, Oct 14, 2016

Background The comparative effectiveness of treatments for prostate cancer that is detected by pr... more Background The comparative effectiveness of treatments for prostate cancer that is detected by prostate-specific antigen (PSA) testing remains uncertain. Methods We compared active monitoring, radical prostatectomy, and external-beam radiotherapy for the treatment of clinically localized prostate cancer. Between 1999 and 2009, a total of 82,429 men 50 to 69 years of age received a PSA test; 2664 received a diagnosis of localized prostate cancer, and 1643 agreed to undergo randomization to active monitoring (545 men), surgery (553), or radiotherapy (545). The primary outcome was prostate-cancer mortality at a median of 10 years of follow-up. Secondary outcomes included the rates of disease progression, metastases, and all-cause deaths. Results There were 17 prostate-cancer-specific deaths overall: 8 in the active-monitoring group (1.5 deaths per 1000 person-years; 95% confidence interval [CI], 0.7 to 3.0), 5 in the surgery group (0.9 per 1000 person-years; 95% CI, 0.4 to 2.2), and 4 ...

British journal of cancer, Jan 2, 2016

Accurate cause of death assignment is crucial for prostate cancer epidemiology and trials reporti... more Accurate cause of death assignment is crucial for prostate cancer epidemiology and trials reporting prostate cancer-specific mortality outcomes. We compared death certificate information with independent cause of death evaluation by an expert committee within a prostate cancer trial (2002-2015). Of 1236 deaths assessed, expert committee evaluation attributed 523 (42%) to prostate cancer, agreeing with death certificate cause of death in 1134 cases (92%, 95% CI: 90%, 93%). The sensitivity of death certificates in identifying prostate cancer deaths as classified by the committee was 91% (95% CI: 89%, 94%); specificity was 92% (95% CI: 90%, 94%). Sensitivity and specificity were lower where death occurred within 1 year of diagnosis, and where there was another primary cancer diagnosis. UK death certificates accurately identify cause of death in men with prostate cancer, supporting their use in routine statistics. Possible differential misattribution by trial arm supports independent ev...

BMJ Open, 2016

The CAP Trial Group (2016). Validating the use of hospital episode statistics data and comparison... more The CAP Trial Group (2016). Validating the use of hospital episode statistics data and comparison of costing methodologies for economic evaluation: An end-of-life case study from the cluster randomised triAl of PSA testing for prostate cancer (CAP). BMJ Open, 6(4), [e011063].

European Urology Supplements, 2013

Value in Health, 2014

Objectives The Hospital Episode Statistics (HES) dataset is a source of administrative 'big data'... more Objectives The Hospital Episode Statistics (HES) dataset is a source of administrative 'big data' with potential for costing purposes in economic evaluations alongside clinical trials. This study assesses the validity of coverage in the HES outpatient dataset. Methods Men who died of, or with, prostate cancer were selected from a prostate-cancer screening trial (CAP, Cluster randomised triAl of PSA testing for Prostate cancer). Details of visits that took place after 1/4/2003 to hospital outpatient departments for conditions related to prostate cancer were extracted from medical records (MR); these appointments were sought in the HES outpatient dataset based on date. The matching procedure was repeated for periods before and after 1/4/2008, when the HES outpatient dataset was accredited as a national statistic. Results 4922 outpatient appointments were extracted from MR for 370 men. 4088 appointments recorded in MR were identified in the HES outpatient dataset (83.1 %; 95 % confidence interval [CI] 82.0-84.1). For appointments occurring prior to 1/4/2008, 2195/2755 (79.7 %; 95 % CI 78.2-81.2) matches were observed, while 1893/2167 (87.4 %; 95 % CI 86.0-88.9) appointments occurring after 1/4/2008 were identified (p for difference\0.001). 215/370 men (58.1 %) had at least one appointment in the MR review that was unmatched in HES, 155 men (41.9 %) had all their appointments identified, and 20 men (5.4 %) had no appointments identified in HES. Conclusions The HES outpatient dataset appears reasonably valid for research, particularly following accreditation. The dataset may be a suitable alternative to collecting MR data from hospital notes within a trial, although caution should be exercised with data collected prior to accreditation.