Background The ovarian cancer (OC) preclinical detectable phase (PCDP), defined as the interval during which cancer is detectable prior to clinical diagnosis, remains poorly characterised. We report exploratory analyses from the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). Methods In UKCTOCS between Apr-2001 and Sep-2005, 101,314 postmenopausal women were randomised to no screening (NS) and 50,625 to annual multimodal screening (MMS) (until Dec-2011) using serum CA-125 interpreted by the Risk of Ovarian Cancer Algorithm (ROCA). All provided a baseline blood sample. Women with invasive epithelial OC diagnosed between randomisation and trial censorship (Dec-2014) in the MMS and NS arms with two or more CA-125 measurements, including one within two years of diagnosis were included. OCfree women (2:1 to cases) from the MMS arm provided information on baseline CA-125 distribution. CA-125 measurements were obtained from MMS results, secondary analysis of baseline samples, and medical records. PCDP duration and in-vivo tumour doubling time were estimated using the change-point model underlying ROCA. Early-stage (Stage I and II) PCDP was estimated from a Bayesian model for the probability of early stage given a CA-125 measurement. Findings Of 541 women (2371 CA-125 measurements) with high-grade serous cancer (HGSC), 93% (504/541) secreted CA-125 into the circulation. Median CA-125 PCDP duration for clinically-diagnosed HGSC was 15.2 (IQR 13.1-16.9, 95% IPR 9.6-21.8) months, of which 11.9 (IQR 10.5-13.1, 95% IPR 7.5-16.5) months was in early stage. The median HGSC in-vivo tumour doubling time for cancers secreting CA-125 was 2.9 (IQR 2.3-3.7, 95% IPR 1.5-7.6) months. Interpretation We report a comprehensive characterisation of the OC CA-125 PCDP. The 12-month window for early- stage detection and short tumour doubling time of HGSC provide a benchmark for researchers evaluating novel screening approaches including need to reduce diagnostic workup interval. Equally the fi ndings provide urgent impetus for clinicians to reduce intervals from presentation to treatment onset. Funding NCI Early Detection Research Network, Concord (MA) Detect Ovarian Cancer Early Fund, MRC Clinical Trials Unit at UCL Core Funding. Copyright (c) 2025 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Randomised controlled trials are challenging to deliver. There is a constant need to review and refine recruitment and implementation strategies if they are to be completed on time and within budget. We present the strategies adopted in the United Kingdom Collaborative Trial of Ovarian Cancer Screening, one of the largest individually randomised controlled trials in the world. The trial recruited over 202,000 women (2001–5) and delivered over 670,000 annual screens (2001–11) and over 3 million women-years of follow-up (2001–20). Key to the successful completion were the involvement of senior investigators in the day-to-day running of the trial, proactive trial management and willingness to innovate and use technology. Our underlying ethos was that trial participants should always be at the centre of all our processes. We ensured that they were able to contact either the site or the coordinating centre teams for clarifications about their results, for follow-up and for rescheduling of appointments. To facilitate this, we shared personal identifiers (with consent) with both teams and had dedicated reception staff at both site and coordinating centre. Key aspects were a comprehensive online trial management system which included an electronic data capture system (resulting in an almost paperless trial), biobanking, monitoring and project management modules. The automation of algorithms (to ascertain eligibility and classify results and ensuing actions) and processes (scheduling of appointments, printing of letters, etc.) ensured the protocol was closely followed and timelines were met. Significant engagement with participants ensured retention and low rates of complaints. Our solutions to the design, conduct and analyses issues we faced are highly relevant, given the renewed focus on trials for early detection of cancer. Future work There is a pressing need to increase the evidence base to support decision making about all aspects of trial methodology. Trial registration ISRCTN-22488978; ClinicalTrials.gov-NCT00058032. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 16/46/01. The long-term follow-up UKCTOCS (2015 20) was supported by National Institute for Health and Care Research (NIHR HTA grant 16/46/01), Cancer Research UK, and The Eve Appeal. UKCTOCS (2001–14) was funded by the MRC (G9901012 and G0801228), Cancer Research UK (C1479/A2884), and the UK Department of Health, with additional support from The Eve Appeal. Researchers at UCL were supported by the NIHR UCL Hospitals Biomedical Research Centre and by the MRC Clinical Trials Unit at UCL core funding (MC_UU_00004/09, MC_UU_00004/08, MC_UU_00004/07). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the UK Department of Health and Social Care.

AbstractBackgroundOvarian cancer is the most lethal of all gynecological cancers. Cancer Antigen 125 (CA125) is the best‐performing ovarian cancer biomarker which however is still not effective as a screening test in the general population. Recent literature reports additional biomarkers with the potential to improve on CA125 for early detection when using longitudinal multimarker models.MethodsOur data comprised 180 controls and 44 cases with serum samples sourced from the multimodal arm of UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). Our models were based on Bayesian change‐point detection and recurrent neural networks.ResultsWe obtained a significantly higher performance for CA125–HE4 model using both methodologies (AUC 0.971, sensitivity 96.7% and AUC 0.987, sensitivity 96.7%) with respect to CA125 (AUC 0.949, sensitivity 90.8% and AUC 0.953, sensitivity 92.1%) for Bayesian change‐point model (BCP) and recurrent neural networks (RNN) approaches, respectively. One year before diagnosis, the CA125–HE4 model also ranked as the best, whereas at 2 years before diagnosis no multimarker model outperformed CA125.ConclusionsOur study identified and tested different combination of biomarkers using longitudinal multivariable models that outperformed CA125 alone. We showed the potential of multivariable models and candidate biomarkers to increase the detection rate of ovarian cancer.

Detection of thrombospondin 1 (TSP-1) by MRM in resectable PDAC cases versus advanced PDAC cases

Objective. UKCTOCS provides an opportunity to explore symptoms in preclinical invasive epithelial ovarian cancer (iEOC). We report on symptoms in women with pre-clinical (screen-detected) cancers (PC) compared to clinically diagnosed (CD) cancers. Methods. In UKCTOCS, 202638 postmenopausal women, aged 50-74 were randomly allocated (April 17, 2001-September 29, 2005) 2:1:1 to no screening or annual screening till Dec 31,2011, using a multimodal or ultrasound strategy. Follow-up was through national registries. An outcomes committee adjudicated on OC diagnosis, histotype, stage. Eligible women were those diagnosed with iEOC at primary censorship (Dec 31, 2014). Symptom details were extracted from trial clinical-assessment forms and medical records. Descriptive statistics were used to compare symptoms in PC versus CD women with early (I/II) and advanced (III/IV/unable to stage) stage high-grade-serous (HGSC) cancer. ISRCTN-22488978; ClinicalTrials.gov-NCT00058032. Results. 1133 (286PC; 847CD) women developed iEOC. Median age (years) at diagnosis was earlier in PC compared to CD (66.8PC, 68.7CD, p = 0.0001) group. In the PC group, 48% (112/234; 90%, 660/730CD) reported symptoms when questioned. Half PC (50%, 13/26PC; 36%, 29/80CD; p = 0.213) women with symptomatic HGSC had >1symptom, with abdominal symptoms most common, both in early (62%, 16/26, PC; 53% 42/80, CD; p = 0.421) and advanced (57%, 49/86, PC; 74%, 431/580, CD; p = 0.001) stages. In symptomatic early stage HGSC, compared to CD, PC women reported more gastrointestinal (change in bowel habits and dyspepsia) (35%, 9/26PC; 9%, 7/80CD; p = 0.001) and systemic (mostly lethargy/tiredness) (27%, 7/26PC; 9%, 7/80CD; p = 0.017) symptoms. Conclusions. Our findings, add to the growing evidence, that we should reconsider what constitutes alert symptoms for early tubo-ovarian cancer. We need a more nuanced complex of key symptoms which is then evaluated and refined in a prospective trial.(c) 2023 The Authors. Published by Elsevier Inc.

Background Earlier detection of pancreatic ductal adenocarcinoma (PDAC) is key to improving patient outcomes, as it is mostly detected at advanced stages which are associated with poor survival. Developing non-invasive blood tests for early detection would be an important breakthrough. Methods The primary objective of the work presented here is to use a dataset that is prospectively collected, to quantify a set of cancer-associated proteins and construct multi-marker models with the capacity to predict PDAC years before diagnosis. The data used is part of a nested case-control study within the UK Collaborative Trial of Ovarian Cancer Screening and is comprised of 218 samples, collected from a total of 143 post-menopausal women who were diagnosed with pancreatic cancer within 70 months after sample collection, and 249 matched non-cancer controls. We develop a stacked ensemble modelling technique to achieve robustness in predictions and, therefore, improve performance in newly collected datasets. Results Here we show that with ensemble learning we can predict PDAC status with an AUC of 0.91 (95% CI 0.75–1.0), sensitivity of 92% (95% CI 0.54–1.0) at 90% specificity, up to 1 year prior to diagnosis, and at an AUC of 0.85 (95% CI 0.74–0.93) up to 2 years prior to diagnosis (sensitivity of 61%, 95% CI 0.17–0.83, at 90% specificity). Conclusions The ensemble modelling strategy explored here outperforms considerably biomarker combinations cited in the literature. Further developments in the selection of classifiers balancing performance and heterogeneity should further enhance the predictive capacity of the method.

Comparison of TSP-1 tissue expression in PDAC patients with clinicopathological parameters.

Peptides and their fragment ions used in MRM assays for TSP-1.

Background In UKCTOCS, there was a decrease in the diagnosis of advanced stage tubo-ovarian cancer but no reduction in deaths in the multimodal screening group compared with the no screening group. Therefore, we did exploratory analyses of patients with high-grade serous ovarian cancer to understand the reason for the discrepancy.Methods UKCTOCS was a 13-centre randomised controlled trial of screening postmenopausal women from the general population, aged 50-74 years, with intact ovaries. The trial management system randomly allocated (2:1:1) eligible participants (recruited from April 17, 2001, to Sept 29, 2005) in blocks of 32 using computer generated random numbers to no screening or annual screening (multimodal screening or ultrasound screening) until Dec 31, 2011. Follow-up was through national registries until June 30, 2020. An outcome review committee, masked to randomisation group, adjudicated on ovarian cancer diagnosis, histotype, stage, and cause of death. In this study, analyses were intention-to -screen comparisons of women with high-grade serous cancer at censorship (Dec 31, 2014) in multimodal screening versus no screening, using descriptive statistics for stage and treatment endpoints, and the Versatile test for survival from randomisation. This trial is registered with the ISRCTN Registry, 22488978, and ClinicalTrials.gov, NCT00058032.Findings 202 562 eligible women were recruited (50 625 multimodal screening; 50 623 ultrasound screening; 101 314 no screening). 259 (0 center dot 5%) of 50 625 participants in the multimodal screening group and 520 (0 center dot 5%) of 101 314 in the no screening group were diagnosed with high-grade serous cancer. In the multimodal screening group compared with the no screening group, fewer were diagnosed with advanced stage disease (195 [75%] of 259 vs 446 [86%] of 520; p=0 center dot 0003), more had primary surgery (158 [61%] vs 219 [42%]; p<0 center dot 0001), more had zero residual disease following debulking surgery (119 [46%] vs 157 [30%]; p<0 center dot 0001), and more received treatment including both surgery and chemotherapy (192 [74%] vs 331 [64%]; p=0 center dot 0032). There was no difference in the first-line combination chemotherapy rate (142 [55%] vs 293 [56%]; p=0 center dot 69). Median follow-up from randomisation of 779 women with high-grade serous cancer in the multimodal and no screening groups was 9 center dot 51 years (IQR 6 center dot 04-13 center dot 00). At censorship (June 30, 2020), survival from randomisation was longer in women with high-grade serous cancer in the multimodal screening group than in the no screening group with absolute difference in survival of 6 center dot 9% (95% CI 0 center dot 4-13 center dot 0; p=0 center dot 042) at 18 years (21% [95% CI 15 center dot 6-26 center dot 2] vs 14% [95% CI 10 center dot 5-17 center dot 4]).Interpretation To our knowledge, this is the first evidence that screening can detect high-grade serous cancer earlier and lead to improved short-term treatment outcomes compared with no screening. The potential survival benefit for women with high-grade serous cancer was small, most likely due to only modest gains in early detection and treatment improvement, and tumour biology. The cumulative results of the trial suggest that surrogate endpoints for disease-specific mortality should not currently be used in screening trials for ovarian cancer.Funding National Institute for Health Research, Medical Research Council, Cancer Research UK, The Eve Appeal.Copyright (c) 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Related Articles from The Sine Qua Non of Discovering Novel Biomarkers for Early Detection of Ovarian Cancer: Carefully Selected Preclinical Samples

PDF file - 206K, Table S1 Numbers of test positive cases and controls using CA19-9 37 U/mL and CA125 30 U/mL cut-offs Figure S1 Scatter plots showing distribution of CA19-9, CA125, CEACAM1 and REG3A levels against time to diagnosis for discovery set. Zero represents the point of clinical diagnosis. Figure S2 Examples of CA19-9 and CA125 levels in individual cases with serial/longitudinal samples. Figure S3 Box and whisker plots showing serum levels of CA19-9 and CA125 for case control validation samples grouped into different time to diagnosis groups. Whisker limits represent the 5th and 95th percentiles, the box limits represent interquartile range, the horizontal line the median and the cross the mean. Case and control groups were compared using the Mann-Whitney test; significant P values (<0.05) are shown above the plots.

Patient Characteristics of iTRAQ sample pools.

Supplementary figures, tables and materials & methods Supplementary Figure 1. Schematic presentation of steps in immunoassay development, validation and studies for screening TP53 autoantibody in human serum samples. Supplementary Figure 2. Identifying a common cut-off value for TP53 autoantibody immunoassay. Supplementary Table 1. Characteristics of patients with invasive epithelial ovarian/tubal/peritoneal cancer in MDACC-NROSS set Supplementary Table 2. Characteristics of patients with invasive epithelial ovarian/tubal/peritoneal cancer in AOCS set Supplementary Table 3. Characteristics of patients with invasive epithelial ovarian/tubal/peritoneal cancer by stage and primary site in the UKCTOCS study Supplementary Figure 3. Examples of longitudinal analysis of CA125 and TP53 autoantibody titers in pre-diagnostic serial serum samples from ovarian cancer patients in the UKCTOCS Study. Supplementary Figure 4. ROC curve analysis for TP53 autoantibody and CA125 biomarkers in UKCTOCS trial. Supplementary Figure 5. Comparison of TP53 autoantibody titers between cancer cases with TP53 wild-type and mutant genes in the AOCS biobanking study. Supplementary Figure 6. The list of TP53 mutant protein candidates for preliminary screening of autoantibody against specific TP53 mutant proteins. Supplementary Table 4. Summary of specific TP53 mutant autoantibody titers of individual cancer patients with corresponding TP53 protein mutations in the AOCS biobanking study Supplementary Table 5. Summary of multiplex immunoassay results for screening TP53 mutant-specific autoantibody using samples from the AOCS biobanking study.

Supplementary Tables 1-4 from Tagging Single Nucleotide Polymorphisms in Cell Cycle Control Genes and Susceptibility to Invasive Epithelial Ovarian Cancer

Supplementary Table 3 from Single Nucleotide Polymorphisms in the TP53 Region and Susceptibility to Invasive Epithelial Ovarian Cancer

Background: To address the disparity in UKCTOCS between decrease in advanced stage disease and lack of mortality reduction in tubo-ovarian cancer (OC) in the multimodal screening (MMS) compared to no screening (C) group, we undertook exploratory analyses by histotype. Methods: In UKCTOCS, 202562(50625 MMS;50623 USS;101314C) eligible women were randomised (2001-5) and followed up till 30June2020. Screening group participants underwent annual screening till 31Dec2011. An outcomes committee adjudicated on OC diagnosis, histotype, stage and cause of death. Treatment details were extracted from hospital records. In women diagnosed with cancer (high-grade serous, HGSC; non-high-grade serous, non-HGSC) at censorship (31Dec2014), we compared descriptive statistics(p-values) and survival from randomisation (Versatile test) in MMS and USS group separately to the C group.Findings: In both the MMS(259/50625) and C(520/101314) groups, 0.51% developed HGSC. In HGSC, on an intention-to-screen analysis, there was a reduction in advanced(III/IV/unable to stage) stage disease(MMS75%195/259; C86%,446/520;p=0·0003), higher rates of primary surgery(MMS61%,158/259; C42%,219/520;p<0·0001), zero residual disease(MMS 46%,119/259; C30%,157/520;p<0·0001) and treatment including surgery and chemotherapy(MMS74%,192/259; C64%,331/520;p=0·003) in the MMS compared to C group. There was no difference in those receiving first line combination chemotherapy(MMS55%, 142/259; C56%, 293/520;p=0·687). There was evidence of improvement in survival from randomisation in HGSC in MMS(MMS21%,54/259; C14%,74/520;p=0·042) in the case only analysis. No differences were observed in the comparisons in USS or non-HGSC in the MMS versus C group.Interpretation: Our findings provide robust evidence for the first time that screening can detect HGSC earlier and result in improved treatment outcomes. The lack of overall mortality benefit is likely related to the magnitude of early detection and treatment improvement as well as tumour biology. The findings do not support use of surrogate end points in place of disease-specific mortality.Funding National Institute for Health Research, MRC, Cancer Research UK, The Eve Appeal.Trial Registration: This trial is registered with ISRCTN number 22488978; ClinicalTrials.gov number NCT00058032.Funding: The Long Term Follow Up (LFTU) UKCTOCS is supported by National Institute for Health Research (NIHR HTA grant 16/46/01), Cancer Research UK (CRUK) and The Eve Appeal. UKCTOCS was funded by Medical Research Council (G9901012 and G0801228), CRUK (C1479/A2884), and the Department of Health, with additional support from The Eve Appeal. Researchers at UCL are supported by the NIHR University College London Hospitals (UCLH) Biomedical Research Centre and MRC CTU at UCL core funding (MR_UU_12023).Declaration of Interest: UM has stock ownership awarded by University College London (UCL) in Abcodia, which holds the licence for ROCA (between 1 April 2011 and 30 October 2021). She has received grants from the Medical Research Council (MRC), Cancer Research UK, the National Institute for Health Research (NIHR), and The Eve Appeal. She holds patent number EP10178345.4 for Breast Cancer Diagnostics. MP has received grants and AG-M, MB, and AR, have been funded by grants from MRC, CRUK, NIHR, and The Eve Appeal. UM, SA and AG-M received research funding from iLOF (intelligent Lab on Fiber), Micronoma, Imperial College London, QIMR Berghofer Medical Research Institute, Innovate UK, Mercy Bioanalytics, University of Innsbruck, NHMRC and MRC Proximity to Discovery Industrial Connectivity Award. UM has received an honorarium from NY Obstetrical Society and reimbursements for invited talks from NY Obstetrical Society (USA), National Cancer Policy Forum (USA), and Robinson College, Cambridge. She is a member of ACED (International Alliance for Cancer Early Detection) Gynaecological Cancers Working Group, and a member of Advisory Boards or Committees for Tina’s Wish, Mixed COVID Vaccines study, India, Yorkshire Cancer Research, GEM3, NOVEL, and PROTECTOR. UM and SA received research funding from RNA Guardian and Dana Faber. MP was a member of the EME funding committee while the project was active. MB reports funding from NIHR UCL Hospitals Biomedical Research Centre. SA received funding from Abcodia. AG-M is a member of ACED (International Alliance for Cancer Early Detection) Gynaecological Cancers Working Group, and Co-Director Research Domain Trials for ACED. RM has received grants from The Eve Appeal, Rosetrees Charity, and Barts Charity, Yorkshire Cancer Research, Ovacure, BGCS, GSK, personal fees from AstraZeneca and consulting fees from Everything Genetics Limited. AMcG was a member of NIHR HTA and EME Editorial Board from 1 April 2012 to 31 March 2022. LJF received a grant form MRC for the psycho-social arm of the UKCTOCS study 2001-2013. SJS holds the (expired) patent for ROCA, patented and owned by Massachusetts General Hospital and Queen Mary University of London, licenced to Abcodia. He reports personal fees from Abcodia, Guardant Health, and Freenome, outside the submitted work, funding from NIHR, NCI and Mercy Bioanalytics and consulting fees from Guardant Health. He participates on Board of SISCAPA Assay Technologies and has stock ownership for this. IJJ reports grants from Eve Appeal Charity, Medical Research Council, Cancer Research UK, and NIHR during the conduct of the study. He co-invented the ROCA in 1995, it was patented by Massachusetts General Hospital and Queen Mary University of London and is owned by these universities. Massachusetts General Hospital and Queen Mary University of London granted a licence to ROCA to Abcodia in 2014. IJJ is a board member, shareholder, and consultant to Abcodia and has rights to royalties from sales of the ROCA. He founded (1985), was a trustee of (2012–14), and is now an Emeritus trustee (2015–present) of The Eve Appeal, one of the funding agencies for UKCTOCS. NS received an honorarium from Astra-Zeneca-MSD and GlaxoSmithKline for participation in Advisory board. All other authors declare no competing interests.Ethical Approval: Approved by the UK North West MREC (00/8/34) on June 23, 2000.

Representative data from the T5600 iTRAQ serum 8-plex experiment. iTRAQ labels were used as follows: 113: 0-6m cases, 114: 0-6m controls, 115: 6-12m cases, 116: 6-12m controls, 117: PDAC non obstructed, 118: PDAC obstructed, 119: CP, 121: HC (PBRU) (all samples relative to 121 - HC).

Detection of CA1-9 by ELISA in (A) individual time to diagnosis groups and (B) diagnosed samples and controls.

MMT / PEB values in training and validation of the algorithms based on the primary analysis

(A) Peptides unique to TSP-1 (in red) were used to quantify the protein using multiple reaction monitoring (MRM). (B) Detection of TSP-1 by western analysis in UKCTOCS and PBRU samples. Human Foreskin Fibroblast (HFF) cells treated with TSP-1-targeting and control siRNAs were used to validate the antibody.