Jacob Canick, PhD on behalf of the FASTER Consortium 12 th International Conference on Prenatal Diagnosis and Therapy Budapest June 24-27, 2004 First and Second Trimester Screening Markers: Results of the FASTER Trial

The Faster Consortium Mary D’Alton overall PI Fergal Malone co-PI Nicholas Wald analysis Alicja Rudnicka analysis Allan Hackshaw analysis Jacob Canick laboratory Geralyn Messerlian lab Diana Bianchi fetal cells and fetal outcome Kimberly Dukes data mgmt Robert Ball Intermountain Utah David Nyberg Swedish Med Ctr Christine Comstock Beaumont Radek Bukowski UT-Galveston Richard Berkowitz Mount Sinai Susan Gross Albert Einstein Lorraine Dugoff Univ Colorado Sabrina Craigo Tufts NE Med Ctr Ilan Timor NYU Stephen Carr Women & Infants Honor Wolfe UNC Chapel Hill National Institute of Child Health and Human Development Grant RO1 HD 38652

FASTER Components Coordinating and educational center Columbia University, New York Enrollment centers 15 prenatal diagnostic centers in the U.S. Assays, reporting, and NT management Women & Infants Hospital, Brown Medical School Data management DMStat, Inc., Boston Data analysis Wolfson Institute for Preventive Medicine, London

Swedish Medical Center University of Colorado UTMB Galveston UNC Chapel Hill William Beaumont Hospital University of Utah Intermountain HealthCare Columbia University Mount Sinai Albert Einstein New York University Tufts University Brown University The FASTER Consortium

OBJECTIVES To define performance of first trimester combined ultrasound and serum screening. To compare performance of first trimester combined screening and second trimester quad marker screening in the same women. To describe optimal combinations of tests for population-based Down syndrome screening.

STUDY DESIGN Prospective trial: intervention only after both 1 st and 2 nd trimester screening completed. A direct comparison is the only way to compare 1 st and 2 nd trimester screening fairly. Inclusion criteria: Viable singleton pregnancy (≥ 16 yrs) 10 3 – 13 6 weeks (CRL 36 – 79 mm) Exclusion criteria: Anencephaly Septated cystic hygroma

10 3 – 13 6 weeks NT / PAPP-A / fβhCG / Age 15 0 – 18 6 weeks AFP / hCG / uE3 / Inh-A / Age First - Second - First - Second + First + Second - First + Second + Genetic Counseling Amniocentesis offered Follow-Up (pregnancy / pediatric) Karyotype (amnio / SAB / cord blood) Septated cystic hygroma

Nuchal Translucency Sonography 102 sonographers Initial uniform practical training Standard NT protocol > 50 images each to confirm technique

RESULTS These results were reported at the Society for Maternal Fetal Medicine annual meeting, held in New Orleans in February The results are from an interim analysis. Final data analysis has now been completed, and the principal findings of the FASTER Trial are being prepared for publication. The performance estimates will be slightly different in the final analysis.

42,367 Evaluated 134 Cystic Hygroma 38,033 First Trimester Screening 4,178 Ineligible* 22 Anencephaly RESULTS 38,189 Eligible 35,244 Second Trimester Screening (93%) *Ineligible due to: CRL outside range (2636); multiple (896); <16 years (357); refused (203); other (69) 2,789 No quad sample

Completeness of Ascertainment Pregnancies enrolled38,189 Outcome obtained (n)37,002 Outcome obtained (%) 97% Downs expected* 112 Downs observed 117 * Estimates based on maternal age distribution of enrolled patients, and 23% loss rate from wks

Maternal Age Distribution* Mean = 30.1 years SD = 5.8 years Range = 16 – 53 years < 35 ≥ 35 * Maternal age in years at Estimated Date of Delivery

Maternal Race Distribution Other (2%) Asian (4%) African-American (5%) Hispanic (22%) Caucasian (67%)

Down Syndrome Screening Performance Directly Observed Results 1.Combined First Trimester Screen NT / PAPP-A / fβhCG / age 2.Second Trimester Serum Screen AFP / hCG / uE3 / Inhibin-A / age 3.Integrated 1 st and 2 nd Trimester Screen I.SERUM: PAPP-A / AFP / hCG / uE3 / Inh-A / age II.FULL: NT / PAPP-A / AFP / hCG / uE3 / Inh-A / age

Observed Detection Rates and FPRs DRFPR Combined screen83%5.6% (1:300 term cut-off) Quad screen85%8.5% (1:300 term cut-off) Based on pregnancies with complete 1 st and 2 nd trimester data (87 Downs; unaffected)

Combined Versus Quad Screening Which is better? p = 0.7 Discordant pairs analysis: No significant difference.

Cystic Hygroma Outcome 134 Cases (1 : 285 Pregnancies) 50% Aneuploidy (n=67): 37% Down (n=25) 28% Turner (n=19) 20% Trisomy 18 (n=13) 15% Other (n=10) 50% Euploid (n=67): 32% Cardiac anomaly (n=21) 12% Skeletal anomaly (n=8) 10% Fetal demise (n=7) 46% “Normal” (n=31)

Observed Detection Rates and FPRs DRFPR Combined screen83%5.6% (1:300 term cut-off) Combined screen87%5.6% With hygromas (1:300 term cut-off) Quad screen85%8.5% (1:300 term cut-off) Based on pregnancies with complete 1 st and 2 nd trimester data (87 Downs; unaffected)

Developed by Nick Wald in The integration of the best tests performed at different times in pregnancy into a single test. A single risk is estimated after the two parts of the test have been completed PAPP-A quad test = SERUM INTEGRATED NT+PAPP-A quad test = FULL INTEGRATED (weeks) Integrate results into a single risk Other Combinations of Markers: The Integrated Test

Observed Detection Rates for 5% FPR 1 st TrimesterIntegrated 1 st / 2 nd Trim.2 nd Trimester All screens include maternal age ≥ 31% 0% 20% 40% 60% 80% 100% Age 35NTCombinedTripleQuadrupleSerumFull

Observed Detection Rates for 5% FPR 1 st TrimesterIntegrated 1 st / 2 nd Trim.2 nd Trimester All screens include maternal age ≥ 67% 83% 31% 0% 20% 40% 60% 80% 100% Age 35NTCombinedTripleQuadrupleSerumFull

Observed Detection Rates for 5% FPR 1 st TrimesterIntegrated 1 st / 2 nd Trim.2 nd Trimester All screens include maternal age ≥ 67% 72% 79% 83% 31% 0% 20% 40% 60% 80% 100% Age 35NTCombinedTripleQuadrupleSerumFull

Observed Detection Rates for 5% FPR 1 st TrimesterIntegrated 1 st / 2 nd Trim.2 nd Trimester All screens include maternal age ≥ 67% 72% 84% 88% 79% 83% 31% 0% 20% 40% 60% 80% 100% Age 35NTCombinedTripleQuadrupleSerumFull

1 st TrimesterIntegrated 1 st / 2 nd Trim.2 nd Trimester All screens include maternal age Observed FPR for 85% Detection Rate 7.6% 17.4% 0% 5% 10% 15% 20% NTCombinedTripleQuadrupleSerumFull

1 st TrimesterIntegrated 1 st / 2 nd Trim.2 nd Trimester All screens include maternal age Observed FPR for 85% Detection Rate 7.2% 11.5% 7.6% 17.4% 0% 5% 10% 15% 20% NTCombinedTripleQuadrupleSerumFull

1 st TrimesterIntegrated 1 st / 2 nd Trim.2 nd Trimester All screens include maternal age Observed FPR for 85% Detection Rate 2.4% 5.5% 7.2% 11.5% 7.6% 17.4% 0% 5% 10% 15% 20% NTCombinedTripleQuadrupleSerumFull

Down Syndrome Pregnancies First Trimester Median MoMs Completed week NT PAPP-A fβhCG Calculated from linear regression of individual Downs cases

Using these data and applying them to the U.S. population of pregnancies, the following results were obtained: Down Syndrome Screening Performance

Modeled Detection Rates for 5% FPR NT alone Quad 73% 66% 57% 0% 20% 40% 60% 80% 100% 11 weeks12 weeks13 weeks

Modeled Detection Rates for 5% FPR NT aloneCombined Quad 73% 66% 57% 93% 84% 72% 0% 20% 40% 60% 80% 100% 11 weeks12 weeks13 weeks

Modeled Detection Rates for 5% FPR NT aloneCombinedSerum Integrated Quad 73% 66% 57% 93% 84% 72% 92% 86% 82% 0% 20% 40% 60% 80% 100% 11 weeks12 weeks13 weeks

Modeled Detection Rates for 5% FPR NT aloneCombinedSerum Integrated Quad Full Integrated 73% 66% 57% 93% 84% 72% 92% 86% 82% 98% 95% 89% 0% 20% 40% 60% 80% 100% 11 weeks12 weeks13 weeks

Modeled Detection Rates for 5% FPR NT aloneCombinedSerum Integrated Quad Full Integrated 73% 66% 57% 93% 84% 72% 92% 86% 82% 98% 95% 89% 80% 0% 20% 40% 60% 80% 100% 11 weeks12 weeks13 weeks

NT alone Quad FPR for 85% Detection Rate 24% 34% 15.4% 0% 10% 20% 30% 40% 11 weeks12 weeks13 weeks

NT aloneCombined Quad FPR for 85% Detection Rate 24% 34% 1.4% 5.9% 14% 15.4% 0% 10% 20% 30% 40% 11 weeks12 weeks13 weeks

NT aloneCombined Quad FPR for 85% Detection Rate Serum Integrated 24% 34% 1.4% 5.9% 14% 1.7% 4.7% 6.6% 15.4% 0% 10% 20% 30% 40% 11 weeks12 weeks13 weeks

NT aloneCombined Quad FPR for 85% Detection Rate Serum IntegratedFull Integrated 24% 34% 1.4% 5.9% 14% 1.7% 4.7% 6.6% 0.2% 0.8% 3% 15.4% 0% 10% 20% 30% 40% 11 weeks12 weeks13 weeks

NT aloneCombined Quad FPR for 85% Detection Rate Serum IntegratedFull Integrated 24% 34% 1.4% 5.9% 14% 1.7% 4.7% 6.6% 0.2% 0.8% 3% 15.4% 7.6% 0% 10% 20% 30% 40% 11 weeks12 weeks13 weeks

Published Studies on First Trimester Screening for Down Syndrome using NT/PAPP-A/free  -hCG Studies Downs cases Detection rate False positive rate *Including maternal ageMalone et al, Obstet Gynecol 2003;102: % 5%

*Including maternal ageMalone et al, Obstet Gynecol 2003;102:1066 Compare to FASTER: 87% DR for 5% FPR (hygromas included) Studies Downs cases Detection rate False positive rate % 5% Published Studies on First Trimester Screening for Down Syndrome using NT/PAPP-A/free  -hCG

CONCLUSIONS 1 st trimester combined and 2 nd trimester quad screening are similarly effective. The Integrated test performs better than either the 1 st or 2 nd trimester screening methods. 1 st trimester markers vary by gestational age. Algorithms should account for these gestational age effects.

ACKNOWLEDGMENTS Columbia:K. Welch, R. Denchy, K. Berentsen Univ Utah:F. Porter, L. Cannon, K. Nelson, C. Loucks, A. Yoshimura Swedish:D. Luthy, S. Coe Beaumont:D. Schmidt, J. Esler UTMB:G. Saade, G. Hankins, J. Lee Mount Sinai:K. Eddleman, Y. Kharbutli Montefiore:I. Merkatz, S. Carter U Colorado:J. Hobbins, L. Schultz Tufts U:B. Isquith, B. Berlin NYU:M. Paidas, J. Borsuk Brown U:C. Duquette UNC:R. Baughman DM-STAT:D. Emig, T. Tripp, J. Vidaver, L. Sullivan, N. Tibbetts, P. Folan NICHD:J. Hanson, D. Alexander, F. de la Cruz ….. and all 102 sonographers who participated

NT Sonography Choice of Ultrasound Probe Mean time to obtain NT: 12.2 mins Range 4 – 25 mins

NT Sonography Failure and Rejection Rates by Gestation p = NT FailureNT Rejected

NT Sonography Image Success and Rejection Rates

NT Sonography Failure and Rejection Rates by Year of Trial p = NT Failure NT Rejected

20% decrease per week Down Syndrome Pregnancies First Trimester NT values

35% decrease per week Down Syndrome Pregnancies First Trimester PAPP-A values

26% increase per week Down Syndrome Pregnancies First Trimester free  -hCG values