Association of Proton Pump Inhibitor Use and Severe Pneumonitis in Stage III Non-Small-Cell Lung Cancer Treated with Primary Chemoradiation and Adjuvant Durvalumab

PURPOSE/OBJECTIVE(S)

Prior studies have suggested gut microbiome changes induced by long-term acid-reducing medication use could modulate immunotherapy efficacy and toxicity. We assessed the relationship between baseline acid-reducing medication use (proton pump inhibitors [PPI] or H2 antagonists [H2A]) on treatment-related toxicity and efficacy in a large cohort of stage III non-small-cell lung cancer (NSCLC) patients treated with or without immunotherapy.

MATERIALS/METHODS

Patients with unresectable stage III NSCLC treated with primary concurrent chemoradiation with or without adjuvant durvalumab from 2015 to 2021 were identified in the Veterans Affairs (VA) system. We defined baseline acid-reducing medication use with VA and non-VA pharmacy records in the year prior to radiation start; the number of prescriptions and the cumulative duration of therapy were quantified. Using multivariable Cox models adjusting for potential baseline confounders and stratified by adjuvant durvalumab use, we estimated the association between PPI or H2A use and subsequent severe pneumonitis, progression-free survival, and overall survival. Pneumonitis was determined and graded by manual chart review.

RESULTS

We included 1994 patients with stage III NSCLC treated with primary chemoradiation, of whom 1005 (50%) received adjuvant durvalumab, 1064 (53%) received any PPI and 1030 (52%) received any H2A. In the overall sample, baseline use of any PPI was associated with increased risk of grade 3-5 pneumonitis (adjusted hazard ratio [aHR] 1.53, 95% CI 1.12-2.10, p = 0.008) and was found to be significant only in durvalumab-treated patients (aHR 1.67, 95% CI 1.10-2.54, p = 0.016), but not for patients treated without durvalumab (aHR 1.34, 95% CI 0.82-2.20, p = 0.2). Higher number of PPI prescriptions were associated with increased risk of severe pneumonitis (aHR 1.38 per 5 prescriptions, 95% CI 1.03-1.85, p = 0.03) and longer duration of PPIs trended toward significance (aHR 1.04 per 90 days, 95% CI 1.00-1.09, p = 0.066). Any PPI use was associated with worse OS in durvalumab-treated patients (aHR 1.30, 95% CI 1.05-1.61, p = 0.016) but not for patients without durvalumab use (aHR 0.99, 95% CI 0.86-1.14, p = 0.9). PPI use had no association with progression-free survival in either cohort. No significant associations between baseline H2A use and pneumonitis, PFS, or OS in either cohort were seen.

CONCLUSION

PPIs, but not H2As, are associated with increased risk of treatment-related pneumonitis and inferior OS in stage III NSCLC patients treated with chemoradiation and immunotherapy. This association was not observed among patients treated with chemoradiation alone. No association was found between PPI use and cancer progression. Further work is warranted to confirm these findings in other immunotherapy-treated cohorts.

Hormonal status effects on the electrophysiological correlates of performance monitoring in women

Fluctuations in ovarian hormones are thought to play a role in the increased prevalence of mood and anxiety disorders in women. Error-related negativity (ERN) and error positivity (Pe) are two putative electrophysiological biomarkers for these internalizing disorders. We investigated whether female hormonal status, specifically menstrual cycle phase and oral contraceptive (OC) use, impact ERN and Pe. Additionally, we examined whether the relationship between the ERN and negative affect (NA) was moderated by hormonal status and tested whether the ERN mediated the relation between ovarian hormones and NA. Participants were healthy, pre-menopausal women who were naturally cycling (NC) or using OCs. Using a counterbalanced within-subject design, all participants performed a speeded-choice reaction-time task twice while undergoing electroencephalography measurements. NC women (N = 42) performed this task during the early follicular and midluteal phase (when estrogen and progesterone are both low and both high, respectively), while OC users (N = 42) performed the task during active OC use and during their pill-free week. Estradiol and progesterone levels were assessed in saliva. Comparing the two cycle phases within NC women revealed no differences in the (Δ)ERN, (Δ)Pe or NA. We did observe a negative relation between phase-related changes in the ΔERN and changes in NA. Mediation analysis additionally showed that phase-related changes in estradiol were indirectly and negatively related to NA through a reduction of ΔERN amplitudes. When comparing active OC users with NC women, we observed increased ΔPe- but not (Δ)ERN amplitudes in the former group. No evidence was found for moderating effects of menstrual cycle phase or OC use on the relation between the ERN and NA. These findings suggest that hormonal status may impact the neural correlates of performance monitoring and error sensitivity, and that this could be a potential mechanism through which ovarian hormones influence mood.

Oral contraceptives positively affect mood in healthy PMS-free women: A longitudinal study

OBJECTIVE

Menstrual cycle phase and oral contraceptives (OC) use influence mood and cognition and these effects may be moderated by the mineralocorticoid receptor (MR) genotype. The effect of menstrual cycle phase on mood may be increased if participants know that this is the focus of study. We assessed aspects associated with reproductive depression such as mood, interpersonal sensitivity, affect lability and depressive cognitions in MR-genotyped OC-users and naturally cycling (NC) women in a carefully masked design.

METHODS

A homogenous sample of healthy, PMS-free, pre-menopausal MR-genotyped women (n=92) completed online questionnaires eight times during two consecutive cycles.

RESULTS

The masking of the research question was successful. OC-users did not differ significantly from NC women in positive and negative affect at the time of assessment, personality characteristics (e.g. neuroticism) or mental and physical health. Both groups reported more shifts in anger in the first cycle week (p<0.001; η_p²=0.08). Compared to NC women, OC-users reported fewer mood-shifts between depression and elation in the mid-luteal phase of the menstrual cycle (p=0.002; η_p²=0.10) and had fewer ruminating thoughts at all phases (p=0.003; η_p²=0.11). Effects of MR-genotype were not significant after correction for multiple comparisons.

CONCLUSION

OC users scored more favorably on measures associated with reproductive depression. OC users also showed a decreased affect variability possibly indicating an emotional blunting effect, which is in line with previous reports on affect-stabilizing effects of OC. Limitations were loss of cases due to irregularities in the menstrual cycle length and possible confounding by the 'survivor effect', since almost all OC-users took OC for more than a year.

Mineralocorticoid receptor haplotype, estradiol, progesterone and emotional information processing

BACKGROUND

Carriers of MR-haplotype 1 and 3 (GA/CG; rs5522 and rs2070951) are more sensitive to the influence of oral contraceptives (OC) and menstrual cycle phase on emotional information processing than MR-haplotype 2 (CA) carriers. We investigated whether this effect is associated with estradiol (E2) and/or progesterone (P4) levels.

METHOD

Healthy MR-genotyped premenopausal women were tested twice in a counterbalanced design. Naturally cycling (NC) women were tested in the early-follicular and mid-luteal phase and OC-users during OC-intake and in the pill-free week. At both sessions E2 and P4 were assessed in saliva. Tests included implicit and explicit positive and negative affect, attentional blink accuracy, emotional memory, emotion recognition, and risky decision-making (gambling).

RESULTS

MR-haplotype 2 homozygotes had higher implicit happiness scores than MR-haplotype 2 heterozygotes (p=0.031) and MR-haplotype 1/3 carriers (p<0.001). MR-haplotype 2 homozygotes also had longer reaction times to happy faces in an emotion recognition test than MR-haplotype 1/3 (p=0.001). Practice effects were observed for most measures. The pattern of correlations between information processing and P4 or E2 differed between sessions, as well as the moderating effects of the MR genotype. In the first session the MR-genotype moderated the influence of P4 on implicit anxiety (sr=-0.30; p=0.005): higher P4 was associated with reduction in implicit anxiety, but only in MR-haplotype 2 homozygotes (sr=-0.61; p=0.012). In the second session the MR-genotype moderated the influence of E2 on the recognition of facial expressions of happiness (sr=-0.21; p=0.035): only in MR-haplotype 1/3 higher E2 was correlated with happiness recognition (sr=0.29; p=0.005). In the second session higher E2 and P4 were negatively correlated with accuracy in lag2 trials of the attentional blink task (p<0.001). Thus NC women, compared to OC-users, performed worse on lag 2 trials (p=0.041).

CONCLUSION

The higher implicit happiness scores of MR-haplotype 2 homozygotes are in line with previous reports. Performance in the attentional blink task may be influenced by OC-use. The MR-genotype moderates the influence of E2 and P4 on emotional information processing. This moderating effect may depend on the novelty of the situation.

Mineralocorticoid receptor haplotype moderates the effects of oral contraceptives and menstrual cycle on emotional information processing

RATIONALE

The processing of emotional information is affected by menstrual cycle phase and by the use of oral contraceptives (OCs). The stress hormone cortisol is known to affect emotional information processing via the limbic mineralocorticoid receptor (MR).

OBJECTIVES

We investigated in an exploratory study whether the MR-genotype moderates the effect of both OC-use and menstrual cycle phase on emotional cognition.

METHODS

Healthy premenopausal volunteers (n=93) of West-European descent completed a battery of emotional cognition tests. Forty-nine participants were OC users and 44 naturally cycling, 21 of whom were tested in the early follicular (EF) and 23 in the mid-luteal (ML) phase of the menstrual cycle.

RESULTS

In MR-haplotype 1/3 carriers, ML women gambled more than EF women when their risk to lose was relatively small. In MR-haplotype 2, ML women gambled more than EF women, regardless of their odds of winning. OC-users with MR-haplotype 1/3 recognised fewer facial expressions than ML women with MR-haplotype 1/3.

CONCLUSION

MR-haplotype 1/3 carriers may be more sensitive to the influence of their female hormonal status. MR-haplotype 2 carriers showed more risky decision-making. As this may reflect optimistic expectations, this finding may support previous observations in female carriers of MR-haplotype 2 in a naturalistic cohort study.

Mineralocorticoid receptor haplotype, oral contraceptives and emotional information processing

BACKGROUND

Oral contraceptives (OCs) affect mood in some women and may have more subtle effects on emotional information processing in many more users. Female carriers of mineralocorticoid receptor (MR) haplotype 2 have been shown to be more optimistic and less vulnerable to depression.

AIM

To investigate the effects of oral contraceptives on emotional information processing and a possible moderating effect of MR haplotype.

METHODS

Cross-sectional study in 85 healthy premenopausal women of West-European descent.

RESULTS

We found significant main effects of oral contraceptives on facial expression recognition, emotional memory and decision-making. Furthermore, carriers of MR haplotype 1 or 3 were sensitive to the impact of OCs on the recognition of sad and fearful faces and on emotional memory, whereas MR haplotype 2 carriers were not.

LIMITATIONS

Different compounds of OCs were included. No hormonal measures were taken. Most naturally cycling participants were assessed in the luteal phase of their menstrual cycle.

CONCLUSIONS

Carriers of MR haplotype 2 may be less sensitive to depressogenic side-effects of OCs.

Counseling patients about sexual health when considering post-prostatectomy radiation treatment

Prostate cancer is the second most frequently diagnosed cancer in men in the United States. Many men with clinically localized prostate cancer survive for 15 years or more. Although early detection and successful definitive treatments are increasingly common, a debate regarding how aggressively to treat prostate cancer is ongoing because of the effect of aggressive treatment on the quality of life, including sexual functioning. We examined current research on the effect of post-prostatectomy radiation treatment on sexual functioning, and suggest a way in which patient desired outcomes might be taken into consideration while making decisions with regard to the timing of radiation therapy after prostatectomy.

Fusion of the HSV-1 tegument protein vp22 to cytosine deaminase confers enhanced bystander effect and increased therapeutic benefit

A major limitation in cancer gene therapy, specifically gene-dependent enzyme prodrug therapy (GDEPT), is inefficient gene delivery and expression. The suicide gene cytosine deaminase (CD) and its substrate, 5-fluorocytosine (5-FC), have been extensively explored due to the inherent 'bystander' effect achieved through diffusion of the toxic metabolite 5-fluorouracil (5-FU). In this study, we aimed to enhance this 'bystander' effect by fusing the Saccharomyces cerevisiae CD to the HSV-1 tegument protein vp22, a novel translocating protein. Two constructs were created: one with vp22 fused to CD (vp22CD) and a second wherein a truncated vp22, lacking the necessary residues for trafficking, fused to CD (delvp22CD). The generated 9L stable lines exhibited similar growth rates, enzyme expression, CD activity, and sensitivity to 5-FC and 5-FU. However, mixed population colony formation assays demonstrated greater bystander effect with the vp22CD fusion as compared to delvp22CD. This enhancement was maintained in vivo where 9L tumors expressing 20 or 50% vp22CD exhibited increased growth delay compared to the respective delvp22CD tumors. Moreover, adenoviral transduction of established wild-type 9L tumors showed increased growth delay with vp22CD (Ad-EF_vp22CD) as compared to equivalent CD (Ad-EF_CD) transduced tumors. Finally, confirming the increased efficacy, (19)F magnetic resonance spectroscopy (MRS) of vp22CD-expressing tumors demonstrated increased 5-FU levels as compared to tumors expressing the nontranslocating CD. These results together demonstrated that fusion of vp22 to CD resulted in CD translocation, which in turn amplified conversion of 5-FC to 5-FU in vivo and enhanced the therapeutic benefit of this GDEPT strategy.

Diffusion MRI detects early events in the response of a glioma model to the yeast cytosine deaminase gene therapy strategy

Detection of a therapeutic response early in the course of cancer treatment, before tumor growth delay or regression, is not currently possible in experimental models or clinical medicine. New interim measures of therapeutic response would be particularly useful in the development of cancer chemosensitization gene therapy by facilitating optimization of gene transfer protocols and prodrug dosing schedules. Diffusion MRI is a sensitive technique producing quantitative and noninvasive images of the apparent mobility of water within a tissue. We investigated the utility of diffusion MRI for detecting early changes associated with a refined cytosine deaminase (CD)/5-fluorocytosine (5FC) chemosensitization gene therapy paradigm in orthotopic 9L gliomas stably expressing the recently cloned S. cerevisiae CD gene. Mean tumor diffusion increased 31% within 8 days of initiating 5-FC treatment, preceding tumor growth arrest and regression. Complete regression of the intracranial tumor was observed in four of five treated animals, and recurrent tumor in the remaining animal exhibited water diffusion behavior similar to primary, untreated tumors. These results demonstrate the efficacy of the yCD/5FC strategy for glioma and suggest that increased tumor water diffusion is an indicator of active therapeutic intervention.

Combined effect of tumor necrosis factor-related apoptosis-inducing ligand and ionizing radiation in breast cancer therapy

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is a potent endogenous activator of the cell death pathway and functions by activating the cell surface death receptors 4 and 5 (DR4 and DR5). TRAIL is nontoxic in vivo and preferentially kills neoplastically transformed cells over normal cells by an undefined mechanism. Radiotherapy is a common treatment for breast cancer as well as many other cancers. Here we demonstrate that ionizing radiation can sensitize breast carcinoma cells to TRAIL-induced apoptosis. This synergistic effect is p53-dependent and may be the result of radiation-induced up-regulation of the TRAIL-receptor DR5. Importantly, TRAIL and ionizing radiation have a synergistic effect in the regression of established breast cancer xenografts. Changes in tumor cellularity and extracellular space were monitored in vivo by diffusion-weighted magnetic resonance imaging (diffusion MRI), a noninvasive technique to produce quantitative images of the apparent mobility of water within a tissue. Increased water mobility was observed in combined TRAIL- and radiation-treated tumors but not in tumors treated with TRAIL or radiation alone. Histological analysis confirmed the loss of cellularity and increased numbers of apoptotic cells in TRAIL- and radiation-treated tumors. Taken together, our results provide support for combining radiation with TRAIL to improve tumor eradication and suggest that efficacy of apoptosis-inducing cancer therapies may be monitored noninvasively, using diffusion MRI.

Expression of endogenously activated secreted or cell surface carboxypeptidase A sensitizes tumor cells to methotrexate-alpha-peptide prodrugs

Methotrexate (MTX) is one of the most commonly used agents in the treatment of solid malignancies; however, the toxicities of MTX to bone marrow and gastrointestinal tract complicate this therapy. We, therefore, propose a gene-dependent enzyme prodrug therapy to limit these toxicities by localizing the production of MTX to the site of the tumor. The combination of MTX-alpha-peptide prodrugs, which cannot be internalized by the cellular reduced folate carrier, with carboxypeptidase A (CPA), which can remove the blocking peptide, has been demonstrated previously in vitro using antibody-dependent enzyme prodrug therapy. CPA is normally synthesized as a zymogen that is inactive without proteolytic removal of its propeptide by trypsin. Therefore, to adapt this system to gene-dependent enzyme prodrug therapy, a mutant form of CPA was engineered, CPA(ST3), that does not require trypsin-dependent zymogen cleavage but is instead activated by ubiquitously expressed intracellular propeptidases. Purification, peptide sequencing, and kinetic analysis indicated that mature CPA(ST3) is structurally and functionally similar to the trypsin-activated, wild-type enzyme. In addition, CPA(ST3)-expressing tumors cells were sensitized to MTX prodrugs in a dose- and time-dependent manner. To limit diffusion of CPA, a cell surface localized form was generated by constructing a fusion protein between CPA(ST3) and the phosphatidylinositol linkage domain from decay accelerating factor. SDS-PAGE and flow cytometric analysis of infected tumor cells indicated that CPA(DAF) was cell surface localized. Finally, after retroviral transduction, this enzyme/prodrug strategy exhibited a potent bystander effect, even when <10% of the cells were transduced, because extracellular production of MTX sensitized both transduced and nontransduced cells.

Combined radiation and enzyme/prodrug treatment for head and neck cancer in an orthotopic animal model

In an effort to improve the therapeutic outcome for squamous cell cancer of the head and neck, we have used the enzyme cytosine deaminase (CD) and the prodrug 5-fluorocytosine (5-FC) as a means to deliver the chemotherapeutic agent 5-fluorouracil (5-FU) in a tumor-specific manner and have evaluated the use of this treatment in combination with external-beam radiation. Infection of SCCVII cells in culture with a CD-expressing retrovirus and treatment with 5-FC was cytotoxic depending on the time of treatment and dose of 5-FC. An orthotopic model of squamous cell cancer of the head and neck was used in vivo to study the CD/5-FC system both alone and with concurrent radiation due to the radiosensitizing properties that 5-FU generates in situ. Treated mice were imaged using magnetic resonance imaging (MRI), and their survival was evaluated. Neither 5-FU nor radiation either alone or combined provided a survival advantage. In contrast, 5-FC treatment prolonged survival and decreased tumor burden compared to control animals, but the tumors recurred after the treatment ceased. Finally, combined treatment with concurrent administration of 5-FC and radiation resulted in a synergistic decrease in tumor growth and enhanced survival over treatment with 5-FC or radiation alone.

Enzyme/prodrug therapy for head and neck cancer using a catalytically superior cytosine deaminase

The use of cytosine deaminase (CD) in conjunction with 5-fluorocytosine (5-FC) has been studied for cancer gene therapy as a means of achieving tumor-specific generation of the toxic metabolite 5-fluorouracil (5-FU). Since 5-FC is frequently used as an antifungal agent, and because it has little or no efficacy as an antibacterial agent, we hypothesized that yeast CD (YCD) might be more efficient at utilizing 5-FC as a substrate and hence be a better choice for a CD/5-FC gene therapy strategy than the typically utilized bacterial CD (BCD). To that end Saccharomyces cerevisiae CD was cloned from yeast genomic DNA and expressed in vitro. Functional analysis of BCD and YCD expressed in COS-1 cells indicated that BCD and YCD both utilized cytosine with equal efficacy; however, 5-FC was an extremely poor substrate for BCD, with an apparent catalytic efficiency 280-fold lower than that observed for YCD. Retroviral infection of tumor cell lines in vitro indicated that the IC50 of 5-FC was 30-fold lower in YCD-infected cultures as compared with cultures infected with BCD retrovirus. In addition, when SCCVII murine squamous cell carcinoma cells were infected in vitro at low rates of infection (< or =10%) there was no significant cytotoxicity toward BCD-expressing cells while there was potent cytotoxicity to both YCD-expressing cells and "bystander cells" even at this low level of expression. Finally, stable BCD- or YCD-expressing SCCVII clones were developed and used in an orthotopic immune-competent model of head and neck cancer. Subsequent treatment with 5-FC followed by monitoring of tumor growth by noninvasive magnetic resonance imaging (MRI) and survival of animals indicated a growth delay during the course of 5-FC treatment for BCD-expressing tumors, which quickly regrew at the end of treatment. In contrast, YCD-expressing tumors exhibited not only a growth delay, which was of longer duration, but also in some cases frank tumor regression and complete cures occurred.

Toward an enzyme/prodrug strategy for cancer gene therapy: endogenous activation of carboxypeptidase A mutants by the PACE/Furin family of propeptidases

In an effort to develop a gene-dependent enzyme/prodrug therapy (GDEPT) for tumor-specific delivery of methotrexate (MTX) we have chosen to construct mutant forms of carboxypeptidase A1 (CPA) that circumvent the requirement for trypsin-dependent activation. The basis of this strategy is that methotrexate-alpha-peptides are inefficient substrates for the reduced folate carrier (RFC) and hence cannot be internalized by cells. However, the blocking amino acid can be cleaved by CPA to liberate MTX, which is then internalized by the RFC, resulting in inhibition of dihydrofolate reductase and cytotoxicity. A battery of mutant CPAs was generated, in which the putative trypsin cleavage sites in the propeptide were mutated to the consensus recognition sequence for mammalian subtilisin-like propeptidases. These mutant forms of CPA were evaluated for expression, activation, and catalytic activity by transiently transfecting them into COS-1 cells both in the absence and in the presence of cotransfected propeptidases. CPA95 was identified as the most efficiently cleaved mutant, and further studies of this mutant indicated that the endogenously activated enzyme had kinetic parameters identical to those of the trypsin-activated wild-type protein. In addition, endogenously activated CPA95 could effectively sensitize cells to MTX-Phe in culture, decreasing the IC50 of MTX-Phe from 25- to 250-fold in squamous cell carcinoma cells expressing active CPA as compared with the parental lines.