The Emotional Impact of a Cancer Diagnosis: A Qualitative Study of Adolescent and Young Adult Experience.

The biographical disruption that occurs in adolescents and young adults following a cancer diagnosis can affect various important psychosocial domains including relationships with family and friends, sexual development, vocational and educational trajectories, and physical and emotional wellbeing. While there is evidence of the physical impact of cancer during this period, less is known about the impact on emotional wellbeing and especially on the barriers for young people accessing help and support. We aimed to obtain a more in-depth understanding of young people's experiences of their diagnosis, treatment, psychological impact, and range of resources they could or wanted to access for their mental health. We conducted an in-depth qualitative study using semi-structured interviews with 43 young people who had developed cancer aged 16 to 39 years and were either within 6 months of diagnosis or 3-5 years after treatment had ended. Framework analysis identified three themes: the emotional impact of cancer (expressed through anxiety, anger, and fear of recurrence); personal barriers to support through avoidance; and support to improve mental health through mental health services or adolescent and young adult treatment teams. We showed the barriers young people have to access care, particularly participant avoidance of support. Interrupting this process to better support young people and provide them with flexible, adaptable, consistent, long-term psychological support has the potential to improve their quality of life and wellbeing.

Forest carbon storage and sink estimates under different management scenarios in China from 2020 to 2100.

Forests play a crucial role in mitigating climate change through carbon storage and sequestration, though environmental change drivers and management scenarios are likely to influence these contributions across multiple spatial and temporal scales. In this study, we employed three tree growth models-the Richard, Hossfeld, and Korf models-that account for the biological characteristics of trees, alongside national forest inventory (NFI) datasets from 1994 to 2018, to evaluate the carbon sink potential of existing forests and afforested regions in China from 2020 to 2100, assuming multiple afforestation and forest management scenarios. Our results indicate that the Richard, Hossfeld, and Korf models provided a good fit for 26 types of vegetation biomass in both natural and planted Chinese forests. These models estimate that in 2020, carbon stocks in existing Chinese forests are 7.62 ± 0.05 Pg C, equivalent to an average of 44.32 ± 0.32 Mg C/ ha. Our predictions then indicate this total forest carbon stock is expected to increase to 15.51 ± 0.99 Pg C (or 72.26 ± 4.6 Mg C/ha) in 2060, and further to 19.59 ± 1.36 Pg C (or 91.31 ± 6.33 Mg C/ha) in 2100. We also show that plantation management measures, namely tree species replacement, would increase carbon sinks to 0.09 Pg C/ year (contributing 38.9 %) in 2030 and 0.06 Pg C/ year (contributing 32.4 %) in 2060. Afforestation using tree species with strong carbon sink capacity in existing plantations would further significantly increase carbon sinks from 0.02 Pg C/year (contributing 10.3 %) in 2030 to 0.06 Pg C/year (contributing 28.2 %) in 2060. Our results quantify the role plantation management plays in providing a strong increase in forest carbon sequestration at national scales, pointing to afforestation with native tree species with high carbon sequestration as key in achieving China's 2060 carbon neutrality target.

Morphogenesis: Setting the pace of embryo folding.

Tissue folding is a key process for shape generation during embryonic development. A new study reports how a fold in the Drosophila embryo forms by a propagating trigger wave.

Effectiveness and cost-effectiveness of a sustainable obesity prevention programme for preschool children delivered at scale 'HENRY' (Health, Exercise, Nutrition for the Really Young): protocol for the HENRY III cluster randomised controlled trial.

INTRODUCTION: One-fifth of children start school already overweight or living with obesity, with rates disproportionately impacting those living in the most deprived areas. Social, environmental and biological factors contribute to excess weight gain and programmes delivered in early years settings aim to support families to navigate these in order to prevent obesity. One of these programmes (Health, Exercise and Nutrition for the Really Young, HENRY) has been delivered in UK community venues (hereon named 'centres') in high deprivation areas since 2008 and aims to help families to provide a healthy start for their preschool children. We aim to establish the effectiveness and cost-effectiveness of HENRY, including its potential role from a wider systems perspective. METHODS AND ANALYSIS: This is a multicentre, open-labelled, two-group, prospective, cluster randomised controlled trial, with cost-effectiveness analysis, systems-based process evaluation and internal pilot. Primary analysis will compare body mass index (BMI) z-score at 12 months in children (n=984) whose parents have attended HENRY to those who have not attended. Secondary outcomes include parent and staff BMI and waist circumference, parenting efficacy, feeding, eating habits, quality of life, resource use and medium term (3 years) BMI z-scores (child and siblings). 82 centres in ~14 local authority areas will be randomised (1:1) to receive HENRY or continue with standard practice. Intention-to-treat analysis will compare outcomes using mixed effects linear regression. Economic evaluation will estimate a within-trial calculation of cost-per unit change in BMI z-score and longer-term trajectories to determine lifelong cost savings (long-term outcomes). A systems process evaluation will explore whether (and how) implementation of HENRY impacts (and is impacted by) the early years obesity system. An established parent advisory group will support delivery and dissemination. ETHICS AND DISSEMINATION: Ethical approval has been granted by the University of York, Health Sciences' Research Governance Committee (HSRGC/2022/537/E). Dissemination includes policy reports, community resources, social media and academic outputs. TRIAL REGISTRATION NUMBER: ISRCTN16529380.

Drosophila Fog/Cta and T48 pathways have overlapping and distinct contributions to mesoderm invagination.

The regulation of the cytoskeleton by multiple signaling pathways, sometimes in parallel, is a common principle of morphogenesis. A classic example of regulation by parallel pathways is Drosophila gastrulation, where the inputs from the Folded gastrulation (Fog)/Concertina (Cta) and the T48 pathways induce apical constriction and mesoderm invagination. Whether there are distinct roles for these separate pathways in regulating the complex spatial and temporal patterns of cytoskeletal activity that accompany early embryo development is still poorly understood. We investigated the roles of the Fog/Cta and T48 pathways and found that, by themselves, the Cta and T48 pathways both promote timely mesoderm invagination and apical myosin II accumulation, with Cta being required for timely cell shape change ahead of mitotic cell division. We also identified distinct functions of T48 and Cta in regulating cellularization and the uniformity of the apical myosin II network, respectively. Our results demonstrate that both redundant and distinct functions for the Fog/Cta and T48 pathways exist.

Carbon fractions in wood for estimating embodied carbon in the built environment.

Determining wood carbon (C) fractions (CFs)-or the concentration of elemental C in wood on a per unit mass basis-in harvested wood products (HWP) is vital for accurately accounting embodied C in the built environment. Most estimates of embodied C assume that all wood-based building material is comprised of 50 % C on a per mass basis: an erroneous assumption that emerges from the literature on tree- and forest-scale C estimation, which has been shown to lead to substantial errors in C accounting. Here, we use published wood CF data from live trees, alongside laboratory analyses of sawn lumber, to quantify generalizable wood CFs for HWPs. Wood CFs in lumber average 51.7 %, deviating significantly from a 50 % default wood CF, as well as from CFs in live wood globally (which average 47.6 % across all species, and 47.1 % in tree species not typically employed in construction). Additionally, the volatile CF in lumber-i.e., the quantity of C lost upon heating of wood samples, but often overlooked in C accounting-is lower than the volatile CF in live wood, but significantly >0 % suggesting that industrial lumber drying processes remove some, but not all, of volatile C-based compounds. Our results demonstrate that empirically-supported wood CFs for construction material can correct meaningful systematic biases when estimating C storage in the built environment.

Researchers' experiences of the design and conduct challenges associated with parallel-group cluster-randomised trials and views on a novel open-cohort design.

BACKGROUND: Two accepted designs exist for parallel-group cluster-randomised trials (CRTs). Closed-cohort designs follow the same individuals over time with a single recruitment period before randomisation, but face challenges in settings with high attrition. (Repeated) cross-sectional designs recruit at one or more timepoints before and/or after randomisation, collecting data from different individuals present in the cluster at these timepoints, but are unsuitable for assessment of individual change over time. An 'open-cohort' design allows individual follow-up with recruitment before and after cluster-randomisation, but little literature exists on acceptability to inform their use in CRTs. AIM: To document the views and experiences of expert trialists to identify: a) Design and conduct challenges with established parallel-group CRT designs,b) Perceptions of potential benefits and barriers to implementation of open-cohort CRTs,c) Methods for minimising, and investigating the impact of, bias in open-cohort CRTs. METHODS: Qualitative consultation via two expert workshops including triallists (n = 24) who had worked on CRTs over a range of settings. Workshop transcripts were analysed using Descriptive Thematic Analysis utilising inductive and deductive coding. RESULTS: Two central organising concepts were developed. Design and conduct challenges with established CRT designs confirmed that current CRT designs are unable to deal with many of the complex research and intervention circumstances found in some trial settings (e.g. care homes). Perceptions of potential benefits and barriers of open cohort designs included themes on: approaches to recruitment; data collection; analysis; minimising/investigating the impact of bias; and how open-cohort designs might address or present CRT design challenges. Open-cohort designs were felt to provide a solution for some of the challenges current CRT designs present in some settings. CONCLUSIONS: Open-cohort CRT designs hold promise for addressing the challenges associated with standard CRT designs. Research is needed to provide clarity around definition and guidance on application.

COVID-19 and EQ-5D-5L health state valuation.

BACKGROUND: We investigate whether and how general population health state values were influenced by the initial stages of the COVID-19 pandemic. Changes could have important implications, as general population values are used in health resource allocation. DATA: In Spring 2020, participants in a UK general population survey rated 2 EQ-5D-5L states, 11111 and 55555, as well as dead, using a visual analogue scale (VAS) from 100 = best imaginable health to 0 = worst imaginable health. Participants answered questions about their pandemic experiences, including COVID-19's effect on their health and quality of life, and their subjective risk/worry about infection. ANALYSIS: VAS ratings for 55555 were transformed to the full health = 1, dead = 0 scale. Tobit models were used to analyse VAS responses, as well as multinomial propensity score matching (MNPS) to create samples balanced according to participant characteristics. RESULTS: Of 3021 respondents, 2599 were used for analysis. There were statistically significant, but complex associations between experiences of COVID-19 and VAS ratings. For example, in the MNPS analysis, greater subjective risk of infection implied higher VAS ratings for dead, yet worry about infection implied lower ratings. In the Tobit analysis, people whose health was affected by COVID-19 rated 55555 higher, whether the effect on health was positive or negative. CONCLUSION: The results complement previous findings that the onset of the COVID-19 pandemic may have impacted EQ-5D-5L health state valuation, and different aspects of the pandemic had different effects.

The dynamics and biophysics of shape formation: Common themes in plant and animal morphogenesis.

The emergence of tissue form in multicellular organisms results from the complex interplay between genetics and physics. In both plants and animals, cells must act in concert to pattern their behaviors. Our understanding of the factors sculpting multicellular form has increased dramatically in the past few decades. From this work, common themes have emerged that connect plant and animal morphogenesis-an exciting connection that solidifies our understanding of the developmental basis of multicellular life. In this review, we will discuss the themes and the underlying principles that connect plant and animal morphogenesis, including the coordination of gene expression, signaling, growth, contraction, and mechanical and geometric feedback.

Change in RhoGAP and RhoGEF availability drives transitions in cortical patterning and excitability in Drosophila.

Actin cortex patterning and dynamics are critical for cell shape changes. These dynamics undergo transitions during development, often accompanying changes in collective cell behavior. While mechanisms have been established for individual cells' dynamic behaviors, mechanisms and specific molecules that result in developmental transitions in vivo are still poorly understood. Here, we took advantage of two developmental systems in Drosophila melanogaster to identify conditions that altered cortical patterning and dynamics. We identified a RhoGEF and RhoGAP pair whose relocalization from nucleus to cortex results in actomyosin waves in egg chambers. Furthermore, we found that overexpression of a different RhoGEF and RhoGAP pair resulted in actomyosin waves in the early embryo, during which RhoA activation precedes actomyosin assembly and RhoGAP recruitment by ~4 seconds. Overall, we showed a mechanism involved in inducing actomyosin waves that is essential for oocyte development and is general to other cell types.

Topological packing statistics of living and nonliving matter.

Complex disordered matter is of central importance to a wide range of disciplines, from bacterial colonies and embryonic tissues in biology to foams and granular media in materials science to stellar configurations in astrophysics. Because of the vast differences in composition and scale, comparing structural features across such disparate systems remains challenging. Here, by using the statistical properties of Delaunay tessellations, we introduce a mathematical framework for measuring topological distances between general three-dimensional point clouds. The resulting system-agnostic metric reveals subtle structural differences between bacterial biofilms as well as between zebrafish brain regions, and it recovers temporal ordering of embryonic development. We apply the metric to construct a universal topological atlas encompassing bacterial biofilms, snowflake yeast, plant shoots, zebrafish brain matter, organoids, and embryonic tissues as well as foams, colloidal packings, glassy materials, and stellar configurations. Living systems localize within a bounded island-like region of the atlas, reflecting that biological growth mechanisms result in characteristic topological properties.

Pilot study investigating estrus length and estrus behavior in Norwegian Red cattle on a commercial dairy farm.

Introduction: Norwegian Red has been shown to have high levels of estrus behavior under experimental conditions. However, the estrus behaviors of Norwegian Red cows have not been studied under commercial conditions. Methods: A herd of 89 Norwegian Red cows housed in free stalls on concrete, slatted floors, were continuously video monitored for 21 days. Ovarian cyclicity was confirmed in a final study sample group (n = 18) using milk progesterone concentrations. All mounting and standing activities were recorded, and the duration of mount estrus, standing estrus and the differences between these; prestand and poststand, were determined. The cycle stages metestrus, diestrus and proestrus were estimated based on the starting time and ending time of mount estrus. Results: All cows in the final study sample group exhibited the primary estrus sign, 'standing to be mounted' during estrus. Two (11%), eleven (61%) and six (33%) cows exhibited the behavior 'standing to be mounted' during metestrus, diestrus and proestrus, respectively. The number of mounts initiated by individual cows was higher during mount and stand estrus than during the rest of the estrous cycle. This study reports a median duration of mount estrus and stand estrus of 21.0 h (interquartile range (IQR) 15.0 to 27.3) and 14.3 h (IQR 12.0 to 18.8), respectively. The median counts per hour of all mount behaviors were 8.6 (IQR 5.6 to 11.3), 1.51 (IQR 0.3 to 3.8) and 1.7 (IQR 0.8 to 6.0) for standing estrus, prestand and poststand, respectively. Discussion: This study shows that under commercial conditions the Norwegian Red cow displays a high level of mount and stand activity associated with estrus.

Treatment and survival of Norwegian cattle after uterine prolapse.

BACKGROUND: Bovine uterine prolapse is a sporadic but life-threatening postpartum condition. The aims of this study were; (i) to determine which clinical findings determined the likelihood of treatment vs. culling, (ii) to identify the treatment methods currently employed by Norwegian veterinary surgeons and evaluate their effect on survival, (iii) to determine if clinical findings at the time of treatment could be used to determine prognosis. Practicing veterinary surgeons in Norway were contacted and asked to fill out a questionnaire on cases of bovine uterine prolapse they attended between February and October 2012. The questionnaires gathered data on signalment, clinical presentation, treatment, and outcome. These data were supplemented with culling data from the Norwegian Dairy and Beef Herd Recording Systems. The chi-squared test and logistic regression modelling was performed to identify likelihood of treatment and cox proportional hazard modelling was performed to identify the hazard of death after treatment. RESULTS: Data from 126 cases of bovine uterine prolapse were collected (78 beef and 48 dairy cows). Twenty-six cows (21%) were emergency slaughtered, or underwent euthanasia, without treatment. Of the remaining 100 cases amputation of the uterus was performed once and repositioning was performed in 99 cases. Survival data were missing from 2 of the cases that had undergone treatment leaving a study sample of 97 cases (64 beef and 33 dairy cows). Multivariable logistic regression analysis of the explanatory variables showed that beef cows were more likely to be treated than dairy cows (OR = 0.32, 95% CI 0.13 to 0.81, P = 0.017) and that cows with a significantly oedematous or traumatised uterus were less likely to be treated (OR = 0.26, 95% CI 0.10 to 0.67, P = 0.006). Treatment methods amongst Norwegian practitioners were broadly similar. In a multivariable model cows general clinical state at time of treatment was positively correlated with survival (HR = 0.29, 95% CI 0.29 to 0.73, P = 0.008) and a history of a vaginal prolapse prepartum increased the hazard of death (HR = 2.31, 95% CI 1.08 to 4.95, P = 0.031) in the first 30 days after treatment of a uterine prolapse. In the first 180 days after treatment only veterinary assessment of a cows' general clinical state was correlated with hazard of death (HR = 0.432, 95% CI 0.20 to 0.91, P = 0.046). CONCLUSIONS: This study shows that the production system and extent of uterine damage affect the likelihood of treatment, and that practitioners use similar treatment methods. A cows' general clinical state at time of treatment was positively correlated with survival, and a history of a vaginal prolapse prepartum increased the hazard of death in the first 30 days after treatment of a uterine prolapse.

Multilevel Assessment of Stent-Induced Inflammation in the Adjacent Vascular Tissue.

A recent U.S. Food and Drug Administration report presented the currently available scientific information related to biological response to metal implants. In this work, a multilevel approach was employed to assess the implant-induced and biocorrosion-related inflammation in the adjacent vascular tissue using a mouse stent implantation model. The implications of biocorrosion on peri-implant tissue were assessed at the macroscopic level via in vivo imaging and histomorphology. Elevated matrix metalloproteinase activity, colocalized with the site of implantation, and histological staining indicated that stent surface condition and implantation time affect the inflammatory response and subsequent formation and extent of neointima. Hematological measurements also demonstrated that accumulated metal particle contamination in blood samples from corroded-stetted mice causes a stronger immune response. At the cellular level, the stent-induced alterations in the nanostructure, cytoskeleton, and mechanical properties of circulating lymphocytes were investigated. It was found that cells from corroded-stented samples exhibited higher stiffness, in terms of Young's modulus values, compared to noncorroded and sham-stented samples. Nanomechanical modifications were also accompanied by cellular remodeling, through alterations in cell morphology and stress (F-actin) fiber characteristics. Our analysis indicates that surface wear and elevated metal particle contamination, prompted by corroded stents, may contribute to the inflammatory response and the multifactorial process of in-stent restenosis. The results also suggest that circulating lymphocytes could be a novel nanomechanical biomarker for peri-implant tissue inflammation and possibly the early stage of in-stent restenosis. Large-scale studies are warranted to further investigate these findings.

Time of insemination in relation to pregnancy rates in beef cattle after oestrus detection with automated activity monitoring system.

BACKGROUND: The timing of artificial insemination is critical to achieve acceptable results in cattle production systems. Over the past 60 years the length and expression of oestrus in dairy cattle has altered. Recent studies have indicated the optimal timing for insemination after the commencement of oestrus may now be earlier than traditional recommendations in beef cattle, as is the case in dairy cattle. The aim of the current study was to evaluate the effect of time from onset of oestrus [as determined by an automated activity monitoring system (AAMS)] to artificial insemination (AI) on pregnancy outcome in Norwegian beef cattle. Five commercial beef suckler herds participated in a cohort study by providing data on the time of AAMS alarm and time of AI. Blood sampling on the day of AI was performed and serum progesterone concentration measured. Pregnancy detection was performed by transrectal ultrasonography and aging of the fetus performed when necessary. A mixed logistic regression model was fitted to study the effect of time from AAMS alarm to AI on pregnancy outcome. Time categories used in the model were < 12 h, 12-24 h, and > 24 h. RESULTS: AI periods (n = 229) with serum progesterone concentration < 1 ng/mL were available for analysis. Overall pregnancy risk per AI for the whole study period was 65.5%, with an inter-herd variation from 10 to 91%. Median time elapsed from AAMS alarm to AI was 17.75 h. Herd affected pregnancy outcome (P = 0.001), while breed and parity status (heifer/cow) did not. The time category closer to AAMS alarm 0-12 h showed a numerically lower pregnancy risk as compared to the baseline group which had AI 12-24 h after onset of oestrus. CONCLUSION: This study found no evidence to support a change in the recommended timing of AI in beef suckler cows.

Bitesize bundles F-actin and influences actin remodeling in syncytial Drosophila embryo development.

Actin networks undergo rearrangements that influence cell and tissue shape. Actin network assembly and organization is regulated in space and time by a host of actin binding proteins. The Drosophila Synaptotagmin-like protein, Bitesize (Btsz), is known to organize actin at epithelial cell apical junctions in a manner that depends on its interaction with the actin-binding protein, Moesin. Here, we showed that Btsz functions in actin reorganization at earlier, syncytial stages of Drosophila embryo development. Btsz was required for the formation of stable metaphase pseudocleavage furrows that prevented spindle collisions and nuclear fallout prior to cellularization. While previous studies focused on Btsz isoforms containing the Moesin Binding Domain (MBD), we found that isoforms lacking the MBD also function in actin remodeling. Consistent with this, we found that the C-terminal half of BtszB cooperatively binds to and bundles F-actin, suggesting a direct mechanism for Synaptotagmin-like proteins regulating actin organization during animal development.

A continent-wide detailed geological map dataset of Antarctica.

A dataset to describe exposed bedrock and surficial geology of Antarctica has been constructed by the GeoMAP Action Group of the Scientific Committee on Antarctic Research (SCAR) and GNS Science. Our group captured existing geological map data into a geographic information system (GIS), refined its spatial reliability, harmonised classification, and improved representation of glacial sequences and geomorphology, thereby creating a comprehensive and coherent representation of Antarctic geology. A total of 99,080 polygons were unified for depicting geology at 1:250,000 scale, but locally there are some areas with higher spatial resolution. Geological unit definition is based on a mixed chronostratigraphic- and lithostratigraphic-based classification. Description of rock and moraine polygons employs the international Geoscience Markup Language (GeoSciML) data protocols to provide attribute-rich and queryable information, including bibliographic links to 589 source maps and scientific literature. GeoMAP is the first detailed geological map dataset covering all of Antarctica. It depicts 'known geology' of rock exposures rather than 'interpreted' sub-ice features and is suitable for continent-wide perspectives and cross-discipline interrogation.

Global beta-diversity of angiosperm trees is shaped by Quaternary climate change.

As Earth's climate has varied strongly through geological time, studying the impacts of past climate change on biodiversity helps to understand the risks from future climate change. However, it remains unclear how paleoclimate shapes spatial variation in biodiversity. Here, we assessed the influence of Quaternary climate change on spatial dissimilarity in taxonomic, phylogenetic, and functional composition among neighboring 200-kilometer cells (beta-diversity) for angiosperm trees worldwide. We found that larger glacial-interglacial temperature change was strongly associated with lower spatial turnover (species replacements) and higher nestedness (richness changes) components of beta-diversity across all three biodiversity facets. Moreover, phylogenetic and functional turnover was lower and nestedness higher than random expectations based on taxonomic beta-diversity in regions that experienced large temperature change, reflecting phylogenetically and functionally selective processes in species replacement, extinction, and colonization during glacial-interglacial oscillations. Our results suggest that future human-driven climate change could cause local homogenization and reduction in taxonomic, phylogenetic, and functional diversity of angiosperm trees worldwide.

Leaf functional traits and pathogens: Linking coffee leaf rust with intraspecific trait variation in diversified agroecosystems.

Research has demonstrated that intraspecific functional trait variation underpins plant responses to environmental variability. However, few studies have evaluated how trait variation shifts in response to plant pathogens, even though pathogens are a major driver of plant demography and diversity, and despite evidence of plants expressing distinct strategies in response to pathogen pressures. Understanding trait-pathogen relationships can provide a more realistic understanding of global patterns of functional trait variation. We examined leaf intraspecific trait variability (ITV) in response to foliar disease severity, using Coffea arabica cv. Caturra as a model species. We quantified coffee leaf rust (CLR) severity-a fungal disease prominent in coffee systems-and measured key coffee leaf functional traits under contrasting, but widespread, management conditions in an agroforestry system. We found that coffee plants express significant ITV, which is largely related to shade tree treatment and leaf position within coffee canopy strata. Yet within a single plant canopy stratum, CLR severity increased with increasing resource conserving trait values. However, coffee leaves with visible signs of disease expressed overall greater resource acquiring trait values, as compared to plants without visible signs of disease. We provide among the first evidence that leaf traits are correlated with foliar disease severity in coffee, and that functional trait relationships and syndromes shift in response to increased disease prevalence in this plant-pathogen system. In doing so, we address a vital gap in our understanding of global patterns of functional trait variation and highlight the need to further explore the potential role of pathogens within established global trait relationships and spectra.

Temporary treatment cessation versus continuation of first-line tyrosine kinase inhibitor in patients with advanced clear cell renal cell carcinoma (STAR): an open-label, non-inferiority, randomised, controlled, phase 2/3 trial.

BACKGROUND: Temporary drug treatment cessation might alleviate toxicity without substantially compromising efficacy in patients with cancer. We aimed to determine if a tyrosine kinase inhibitor drug-free interval strategy was non-inferior to a conventional continuation strategy for first-line treatment of advanced clear cell renal cell carcinoma. METHODS: This open-label, non-inferiority, randomised, controlled, phase 2/3 trial was done at 60 hospital sites in the UK. Eligible patients (aged ≥18 years) had histologically confirmed clear cell renal cell carcinoma, inoperable loco-regional or metastatic disease, no previous systemic therapy for advanced disease, uni-dimensionally assessed Response Evaluation Criteria in Solid Tumours-defined measurable disease, and an Eastern Cooperative Oncology Group performance status of 0-1. Patients were randomly assigned (1:1) at baseline to a conventional continuation strategy or drug-free interval strategy using a central computer-generated minimisation programme incorporating a random element. Stratification factors were Memorial Sloan Kettering Cancer Center prognostic group risk factor, sex, trial site, age, disease status, tyrosine kinase inhibitor, and previous nephrectomy. All patients received standard dosing schedules of oral sunitinib (50 mg per day) or oral pazopanib (800 mg per day) for 24 weeks before moving into their randomly allocated group. Patients allocated to the drug-free interval strategy group then had a treatment break until disease progression, when treatment was re-instated. Patients in the conventional continuation strategy group continued treatment. Patients, treating clinicians, and the study team were aware of treatment allocation. The co-primary endpoints were overall survival and quality-adjusted life-years (QALYs); non-inferiority was shown if the lower limit of the two-sided 95% CI for the overall survival hazard ratio (HR) was 0·812 or higher and if the lower limit of the two-sided 95% CI of the marginal difference in mean QALYs was -0·156 or higher. The co-primary endpoints were assessed in the intention-to-treat (ITT) population, which included all randomly assigned patients, and the per-protocol population, which excluded patients in the ITT population with major protocol violations and who did not begin their randomisation allocation as per the protocol. Non-inferiority was to be concluded if it was met for both endpoints in both analysis populations. Safety was assessed in all participants who received a tyrosine kinase inhibitor. The trial was registered with ISRCTN, 06473203, and EudraCT, 2011-001098-16. FINDINGS: Between Jan 13, 2012, and Sept 12, 2017, 2197 patients were screened for eligibility, of whom 920 were randomly assigned to the conventional continuation strategy (n=461) or the drug-free interval strategy (n=459; 668 [73%] male and 251 [27%] female; 885 [96%] White and 23 [3%] non-White). The median follow-up time was 58 months (IQR 46-73 months) in the ITT population and 58 months (46-72) in the per-protocol population. 488 patients continued on the trial after week 24. For overall survival, non-inferiority was demonstrated in the ITT population only (adjusted HR 0·97 [95% CI 0·83 to 1·12] in the ITT population; 0·94 [0·80 to 1·09] in the per-protocol population). Non-inferiority was demonstrated for QALYs in the ITT population (n=919) and per-protocol (n=871) population (marginal effect difference 0·06 [95% CI -0·11 to 0·23] for the ITT population; 0·04 [-0·14 to 0·21] for the per-protocol population). The most common grade 3 or worse adverse events were hypertension (124 [26%] of 485 patients in the conventional continuation strategy group vs 127 [29%] of 431 patients in the drug-free interval strategy group); hepatotoxicity (55 [11%] vs 48 [11%]); and fatigue (39 [8%] vs 63 [15%]). 192 (21%) of 920 participants had a serious adverse reaction. 12 treatment-related deaths were reported (three patients in the conventional continuation strategy group; nine patients in the drug-free interval strategy group) due to vascular (n=3), cardiac (n=3), hepatobiliary (n=3), gastrointestinal (n=1), or nervous system (n=1) disorders, and from infections and infestations (n=1). INTERPRETATION: Overall, non-inferiority between groups could not be concluded. However, there seemed to be no clinically meaningful reduction in life expectancy between the drug-free interval strategy and conventional continuation strategy groups and treatment breaks might be a feasible and cost-effective option with lifestyle benefits for patients during tyrosine kinase inhibitor therapy in patients with renal cell carcinoma. FUNDING: UK National Institute for Health and Care Research.