Long-term health-related quality of life in head and neck cancer survivors: A large multinational study

Head and neck cancer (HNC) patients suffer from a range of health-related quality of life (HRQoL) issues, but little is known about their long-term HRQoL. This study explored associations between treatment group and HRQoL at least 5 years' post-diagnosis in HNC survivors. In an international cross-sectional study, HNC survivors completed the European Organization for Research and Treatment of Cancer (EORTC) quality of life core questionnaire (EORTC-QLQ-C30) and its HNC module (EORTC-QLQ-H&N35). Meaningful HRQoL differences were examined between five treatment groups: (a) surgery, (b) radiotherapy, (c) chemo-radiotherapy, (d) radiotherapy ± chemotherapy and neck dissection and (e) any other surgery (meaning any tumour surgery that is not a neck dissection) and radiotherapy ± chemotherapy. Twenty-six sites in 11 countries enrolled 1105 survivors. They had a median time since diagnosis of 8 years, a mean age of 66 years and 71% were male. After adjusting for age, sex, tumour site and UICC stage, there was evidence for meaningful differences (10 points or more) in HRQoL between treatment groups in seven domains (Fatigue, Mouth Pain, Swallowing, Senses, Opening Mouth, Dry Mouth and Sticky Saliva). Survivors who had single-modality treatment had better or equal HRQoL in every domain compared to survivors with multimodal treatment, with the largest differences for Dry Mouth and Sticky Saliva. For Global Quality of Life, Physical and Social Functioning, Constipation, Dyspnoea and Financial Difficulties, at least some treatment groups had better outcomes compared to a general population. Our data suggest that multimodal treatment is associated with worse HRQoL in the long-term compared to single modality.

World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project: V. physical examination standards in endometriosis research

OBJECTIVE

The World Endometriosis Research Foundation (WERF) established the Endometriosis Phenome and Biobanking Harmonisation Project (EPHect) to create standardized documentation tools (with common data elements) to facilitate the comparison and combination of data across different research sites and studies. In 2014, four data research standards were published: clinician-reported surgical data, patient-reported clinical data, and fluid and tissue biospecimen collection. Our current objective is to create an EPHect standard for the clinician-reported physical examination (EPHect-PE) for research studies.

DESIGN

An international consortium involving 26 clinical and academic experts and patient partners from 11 countries representing 25 institutions and organizations. Two virtual workshops, followed by the development of the physical examination standards that underwent multiple rounds of iterations and revisions.

SUBJECTS

N/A MAIN OUTCOME MEASURE(S): N/A RESULT(S): The EPHect physical examination (EPHect-PE) tool provides standardised assessment of physical examination characteristics and pain phenotyping. Data elements involve examination of a) back and pelvic girdle; b) abdomen including allodynia and trigger points; c) vulva including provoked vestibulodynia; d) pelvic floor muscle tone and tenderness; e) tenderness on unidigital pelvic exam; f) presence of pelvic nodularity; g) uterine size and mobility; h) presence of adnexal masses; i) presence of incisional masses; j) speculum examination; k) tenderness and allodynia at an extra-pelvic site (e.g. forearm); and l) recording of anthropometrics.

CONCLUSION(S)

The EPHect physical examination standards (EPHect-PE) will facilitate the standardised documentation of the physical examination, including the assessment and documentation of examination phenotyping of endometriosis-associated pelvic pain.

Mental healthcare utilization among head and neck cancer patients: A longitudinal cohort study

OBJECTIVE

To investigate utilization of mental healthcare among head and neck cancer (HNC) patients from diagnosis to 2 years after treatment, in relation to psychological symptoms, mental disorders, need for mental healthcare, and sociodemographic, clinical and personal factors.

METHODS

Netherlands Quality of life and Biomedical Cohort study data as measured before treatment, at 3 and 6 months, and at 1 and 2 years after treatment was used (n = 610). Data on mental healthcare utilization (iMCQ), psychological symptoms (Hospital Anxiety and Depression Scale, Cancer Worry Scale), mental disorders (CIDI interview), need for mental healthcare (Supportive Care Needs Survey Short-Form 34, either as continuous outcome indicating the level of need or dichotomized into unmet need (yes/no)) and several sociodemographic, clinical and personal factors were collected. Factors associated with mental healthcare utilization were investigated using generalized estimating equations (p < 0.05).

RESULTS

Of all HNC patients, 5%-9% used mental healthcare per timepoint. This was 4%-14% in patients with mild-severe psychological symptoms, 4%-17% in patients with severe psychological symptoms, 15%-35% in patients with a mental disorder and 5%-16% in patients with an unmet need for mental healthcare. Among all patients, higher symptoms of anxiety, a higher need for mental healthcare, lower age, higher disease stage, lower self-efficacy and higher social support seeking were significantly associated with mental healthcare utilization.

CONCLUSION

Mental health care utilization among HNC patients is limited, and is related to psychological symptoms, need for mental healthcare, and sociodemographic, clinical and personal factors.

Changes in Sexuality and Sexual Dysfunction over Time in the First Two Years after Treatment of Head and Neck Cancer

The aim of this study was to investigate changes in sexuality and sexual dysfunction in head and neck cancer (HNC) patients in the first two years after treatment, in relation to the type of treatment. Data were used of 588 HNC patients participating in the prospective NETherlands Quality of life and Biomedical Cohort Study (NET-QUBIC) from diagnosis to 3, 6, 12 and 24 months after treatment. Primary outcome measures were the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI). The total scores of the IIEF and FSFI were dichotomized into sexual (dys)function. In men, type of treatment was significantly associated with change in erectile function, orgasm, satisfaction with intercourse, and overall satisfaction. In women, type of treatment was significantly associated with change in desire, arousal, and orgasm. There were significant differences between treatment groups in change in dysfunctional sexuality. A deterioration in sexuality and sexual dysfunction from baseline to 3 months after treatment was observed especially in patients treated with chemoradiation. Changes in sexuality and sexual dysfunction in HNC patients were related to treatment, with an acute negative effect of chemoradiation. This effect on the various domains of sexuality seems to differ between men and women.

The course of health-related quality of life in the first 2 years after a diagnosis of head and neck cancer: the role of personal, clinical, psychological, physical, social, lifestyle, disease-related, and biological factors

PURPOSE

The aim of this prospective cohort study was to estimate the relationship between the course of HRQOL in the first 2 years after diagnosis and treatment of head and neck cancer (HNC) and personal, clinical, psychological, physical, social, lifestyle, HNC-related, and biological factors.

METHODS

Data were used from 638 HNC patients of the NETherlands QUality of life and BIomedical Cohort study (NET-QUBIC). Linear mixed models were used to investigate factors associated with the course of HRQOL (EORTC QLQ-C30 global quality of life (QL) and summary score (SumSc)) from baseline to 3, 6, 12, and 24 months after treatment.

RESULTS

Baseline depressive symptoms, social contacts, and oral pain were significantly associated with the course of QL from baseline to 24 months. Tumor subsite and baseline social eating, stress (hyperarousal), coughing, feeling ill, and IL-10 were associated with the course of SumSc. Post-treatment social contacts and stress (avoidance) were significantly associated with the course of QL from 6 to 24 months, and social contacts and weight loss with the course of SumSc. The course of SumSc from 6 to 24 months was also significantly associated with a change in financial problems, speech problems, weight loss, and shoulder problems between baseline and 6 months.

CONCLUSION

Baseline clinical, psychological, social, lifestyle, HNC-related, and biological factors are associated with the course of HRQOL from baseline to 24 months after treatment. Post-treatment social, lifestyle, and HNC-related factors are associated with the course of HRQOL from 6 to 24 months after treatment.

Human and porcine aortic valve endothelial and interstitial cell isolation and characterization

Background

Calcific aortic valve stenosis (AVS) is defined by pathological changes in the aortic valve (AV) and their predominant cell types: valvular interstitial (VICs) and endothelial cells (VECs). Understanding the cellular and molecular mechanisms of this disease is a prerequisite to identify potential pharmacological treatment strategies. In this study, we present a unique aortic valve cell isolation technique to acquire specific human and porcine cell populations and compared VICs and VECs of these species with each other for the first time.

Methods

AV cells were isolated from tissue obtained from human patients undergoing surgical aortic valve replacement (SAVR) or from porcine hearts. Functional analysis and in vitro experiments revealed that endothelial-to-mesenchymal transition (EndMT) can be induced in hVECs, leading to a significant increase in mesenchymal markers. In vitro calcification experiments of VICs demonstrated pronounced expression of calcification markers and visible calcific deposits in Alizarin Red staining in both species after incubation with pro-calcific media.

Results

Cells isolated from patient-derived AVs showed mesenchymal and endothelial-specific gene signatures (VIC and VEC, respectively). For instance, von Willebrand factor (vWF) and platelet endothelial adhesion molecule-1 (PECAM1) were upregulated in VECs, while the myofibroblastic markers alpha-smooth muscle actin (α-SMA) and vimentin (VIM) were downregulated in VECs compared to VICs. Analysis of cell function by migration revealed that VECs are more migratory than VICs. Induction of EndMT in vitro in VECs displayed increased expression of EndMT markers and decreased expression of endothelial markers, confirming their mesenchymal transdifferentiation ability. In vitro calcification of VICs revealed upregulation of alkaline phosphatase (ALPL), a hallmark of calcification. In addition, other calcification-related genes such as osteocalcin (BGLAP) and runt-related factor 2 (RUNX2) were upregulated. Alizarin red staining of calcified cells provided a further layer of confirmation that the isolated cells were VICs with osteoblastic differentiation capacity.

Conclusion

This study aims to take a first step towards standardizing a reproducible isolation technique for specific human and porcine VEC and VIC populations. A comparison of human and porcine aortic valve cells demonstrated that porcine cells may serve as an alternative cellular model system in settings where human tissue is difficult to obtain.

Unmet supportive care needs among informal caregivers of patients with head and neck cancer in the first 2 years after diagnosis and treatment: a prospective cohort study

OBJECTIVE

Informal caregivers of head and neck cancer (HNC) patients have a high caregiver burden and often face complex practical caregiving tasks. This may result in unmet supportive care needs, which can impact their quality of life (QoL) and cause psychological distress. In this study, we identify caregivers' unmet needs during long-term follow-up and identify caregivers prone to unmet supportive care needs.

METHODS

Data were used from the multicenter prospective cohort study NETherlands QUality of life and Biomedical cohort studies In Cancer (NET-QUBIC). The unmet supportive care needs, psychological distress, caregiver burden, and QoL were measured for 234 informal caregivers and their related patients at baseline, 3, 6, 12, and 24 months after. Mixed effect models for repeated measurements were used.

RESULTS

At baseline, most caregivers (70.3%) reported at least one unmet supportive care need, with most of the identified needs in the "healthcare & illness" domain. During the follow-up period, caregivers' unmet needs decreased significantly in all domains. Nevertheless, 2 years after treatment, 28.3% were still reporting at least one unmet need. Financial problems were increasingly associated with unmet needs over time. Furthermore, caring for a patient who themselves had many unmet needs, an advanced tumor stage, or severe comorbidity was associated with significantly more unmet needs in caregivers.

CONCLUSIONS

The current study shows the strong likelihood of caregivers of HNC patients facing unmet supportive care needs and the interaction between the needs of patients and caregivers. It is important to optimally support informal caregivers by involving them from the start when counseling patients, by providing them with relevant and understandable information, and by referring vulnerable caregivers for (psychosocial) support.

Serious Long-Term Effects of Head and Neck Cancer from the Survivors' Point of View

The long-term problems of head and neck cancer survivors (HNCS) are not well known. In a cross-sectional international study aimed at exploring the long-term quality of life in this population, 1114 HNCS were asked to state their two most serious long-term effects. A clinician recorded the responses during face-to-face appointments. A list of 15 example problems was provided, but a free text field was also available. A total of 1033 survivors responded to the question. The most frequent problems were 'dry mouth' (DM) (n = 476; 46%), 'difficulty swallowing/eating' (DSE) (n = 408; 40%), 'hoarseness/difficulty speaking' (HDS) (n = 169; 16%), and 'pain in the head and neck' (PHN) (n = 142; 14%). A total of 5% reported no problems. Logistic regression adjusted for age, gender, treatment, and tumor stage and site showed increased odds of reporting DM and DSE for chemo-radiotherapy (CRT) alone compared to surgery alone (odds ratio (OR): 4.7, 95% confidence interval (CI): 2.5-9.0; OR: 2.1, CI: 1.1-3.9), but decreased odds for HDS and PHN (OR: 0.3, CI: 0.1-0.6; OR: 0.2, CI: 0.1-0.5). Survivors with UICC stage IV at diagnosis compared to stage I had increased odds of reporting HDS (OR: 1.9, CI: 1.2-3.0). Laryngeal cancer survivors had reduced odds compared to oropharynx cancer survivors of reporting DM (OR: 0.4, CI: 0.3-0.6) but increased odds of HDS (OR: 7.2, CI: 4.3-12.3). This study provides evidence of the serious long-term problems among HNCS.

The Change in Social Eating over Time in People with Head and Neck Cancer Treated with Primary (Chemo)Radiotherapy: The Role of Swallowing, Oral Function, and Nutritional Status

This study aimed at investigating the change in social eating problems from diagnosis to 24 months after primary (chemo)radiotherapy and its associations with swallowing, oral function, and nutritional status, in addition to the clinical, personal, physical, psychological, social, and lifestyle dimensions. Adult patients from the NETherlands QUality of life and BIomedical Cohort (NET-QUBIC) treated with curative intent with primary (chemo)radiotherapy for newly-diagnosed HNC and who provided baseline social eating data were included. Social eating problems were measured at baseline and at 3-, 6-, 12-, and 24-month follow-up, with hypothesized associated variables at baseline and at 6 months. Associations were analyzed through linear mixed models. Included patients were 361 (male: 281 (77.8%), age: mean = 63.3, SD = 8.6). Social eating problems increased at the 3-month follow-up and decreased up to 24 months (F = 33.134, p < 0.001). The baseline-to-24 month change in social eating problems was associated with baseline swallowing-related quality of life (F = 9.906, p < 0.001) and symptoms (F = 4.173, p = 0.002), nutritional status (F = 4.692, p = 0.001), tumor site (F = 2.724, p = 0.001), age (F = 3.627, p = 0.006), and depressive symptoms (F = 5.914, p < 0.001). The 6-24-month change in social eating problems was associated with a 6-month nutritional status (F = 6.089, p = 0.002), age (F = 5.727, p = 0.004), muscle strength (F = 5.218, p = 0.006), and hearing problems (F = 5.155, p = 0.006). Results suggest monitoring social eating problems until 12-month follow-up and basing interventions on patients' features.

Self-efficacy and coping style in relation to psychological distress and quality of life in informal caregivers of patients with head and neck cancer: a longitudinal study

OBJECTIVE

In order to understand how informal caregivers of head and neck cancer (HNC) patients deal with the consequences of the disease, we investigated their self-efficacy and coping style in relation to symptoms of anxiety and depression (distress) and quality of life (QoL) over time. In addition, factors associated with self-efficacy and coping style were investigated.

METHODS

A total of 222 informal caregivers and their related HNC patients were prospectively followed as part from the multicenter cohort NETherlands QUality of life and Biomedical cohort studies In Cancer (NET-QUBIC). Self-efficacy and coping style were measured at baseline, and distress and QoL at baseline and 3, 6, 12, and 24 months after treatment.

RESULTS

Informal caregivers had a high level of self-efficacy comparable with patients. Caregivers used "seeking social support," "passive reacting," and "expression of emotions" more often than patients. Factors associated with self-efficacy and coping were higher age and lower education. Higher self-efficacy was related with better QoL and "active tackling" was associated with less depression symptoms. "Passive reacting" and "expression of emotions" were associated with higher psychological distress and reduced QoL.

CONCLUSION

Among informal caregivers of HNC patients, higher self-efficacy and "active tackling" were associated with better functioning over time, while "passive reacting" and "expression of negative emotions" were associated with worse functioning. Awareness of the differences in self-efficacy skills and coping and their relationship with QoL and psychological distress will help clinicians to identify caregivers that may benefit from additional support that improve self-efficacy and "active tackling" and reduce negative coping styles.

Caregiver Burden, Psychological Distress and Quality of Life among Informal Caregivers of Patients with Head and Neck Cancer: A Longitudinal Study

(1) Background: The aim of this study was to investigate caregiver burden among informal caregivers of head and neck cancer patients, in relation to distress and quality of life (QoL), and the relationship between informal caregivers and patients. (2) Methods: Data of 234 dyads from the multicenter prospective cohort study Netherlands Quality of life and Biomedical Cohort studies in cancer was used. Caregiver burden, psychological distress, global QoL, physical and social functioning were measured from baseline until 24 months after treatment. (4) Conclusions: This prospective cohort study shows the high burden of caring for HNC patients, the impact of this burden and the interaction between caregiver and patient. We suggest that healthcare professionals include caregivers in counseling and support.

Reach and efficacy of the eHealth application Oncokompas, facilitating partners of incurably ill cancer patients to self-manage their caregiver needs: a randomized controlled trial

Purpose

Many partners of incurably ill cancer patients experience caregiver burden. The eHealth application “Oncokompas” supports these partners to manage their caregiver needs and to find optimal supportive care for themselves. The aim of this randomized controlled trial (RCT) was to investigate the reach of Oncokompas and its efficacy on caregiver burden, self-efficacy, and health-related quality of life (HRQOL).

Methods

The reach was estimated based on eligibility, participation rate, and an evaluation of the recruitment process. Efficacy on caregiver burden was measured using the Caregiver Strain Index + (CSI +). Secondary outcomes were self-efficacy (General Self-Efficacy Scale (GSE)) and HRQOL (EQ-5D VAS). Assessments were scheduled at baseline, 2 weeks after randomization and 3 months after baseline. Linear mixed models were used to compare longitudinal changes between the experimental and control group from baseline to the 3-month follow-up.

Results

The reach, in terms of eligibility and participation rate, was estimated at 83–91%. Partners were most likely reached via palliative care consultants, patient organizations, and palliative care networks. In the one-and-a-half-year recruitment period and via the 101 organizations involved, 58 partners were included. There were no significant effects of Oncokompas on caregiver burden, self-efficacy, or HRQOL.

Conclusion

The reach of Oncokompas among interested individuals was high, but the difficulties that were encountered to include partners suggest that the reach in real life may be lower. This study showed no effect of Oncokompas on caregiver burden, self-efficacy, or HRQOL in partners of incurably ill cancer patients.

Relevance

The results of this study may be used in the process of developing, efficacy testing, and implementing eHealth applications for caregivers of incurably ill cancer patients.

Trial registration

Netherlands Trial Register identifier: NTR7636/NL7411. Registered on November 23, 2018 (https://www.trialregister.nl/).

The course of swallowing problems in the first 2 years after diagnosis of head and neck cancer

INTRODUCTION

Head and neck cancer (HNC) and its treatment often negatively impact swallowing function. The aim was to investigate the course of patient-reported swallowing problems from diagnosis to 3, 6, 12, and 24 months after treatment, in relation to demographic, clinical, and lifestyle factors.

METHODS

Data were used of the Netherlands Quality of Life and Biomedical Cohort Study in head and neck cancer research (NET-QUBIC). The primary outcome measures were the subscales of the Swallowing Quality of Life Questionnaire (SWAL-QOL). Linear mixed-effects models (LMM) were conducted to investigate changes over time and associations with patient, clinical, and lifestyle parameters as assessed at baseline.

RESULTS

Data were available of 603 patients. There was a significant change over time on all subscales. Before treatment, 53% of patients reported swallowing problems. This number increased to 70% at M3 and decreased to 59% at M6, 50% at M12, and 48% at M24. Swallowing problems (i.e., longer eating duration) were more pronounced in the case of female, current smoking, weight loss prior to treatment, and stage III or IV tumor, and were more prevalent at 3 to 6 months after treatment. Especially patients with an oropharynx and oral cavity tumor, and patients receiving (C)RT following surgery or CRT only showed a longer eating duration after treatment, which did not return to baseline levels.

CONCLUSION

Half of the patients with HNC report swallowing problems before treatment. Eating duration was associated with sex, smoking, weight loss, tumor site and stage, and treatment modality, and was more pronounced 3 to 6 months after treatment.

Loss of ceramide synthase 5 reduces the development of aortic valve stenosis in mice with high fat diet

Background

Ceramide synthase 5 (CerS5) is essential to maintain C:16 ceramide levels in mice. Ceramides contribute to inflammation and calcification, two hallmarks of aortic valve stenosis development. It is known, that loss of CerS5 function reduces diet-induced obesity.

Purpose

The aim of this study was to investigate the effect of ceramide synthase 5 and high-fat diet on the development of aortic valve stenosis with a mouse model.

Methods

Our experiment consists of four groups of mice: Wild type (WT) and CerS5 (−/−) mice, with normal and high fat diet. We induced the aortic valve stenosis development through a wire-injury. For this model, a coronary angiography wire is introduced into the left ventricle over the right carotid artery, followed by rotation on the aortic valve level to generate a defined injury. Development of aortic valve stenosis was determined by measuring the peak velocity 14, 28 and 42 days after the wire-injury. With histological analysis of the aortic valve, we measured macrophage infiltration with CD68 immunostaining and calcification using von Kossa staining. For statistical analysis ANOVA and Turkeys multiple comparisons were performed.

Results

Histological analysis of the aortic valve revealed, that in CerS5 (−/−) mice with high fat diet (HFD) immune cell infiltration is reduced, while there is no difference between CerS5 (−/−) mice and wild type, when fed with normal diet (A). Also calcification showed a trend towards a reduction in CerS5 mice with high fat diet, but was not statistically significant (B). Echocardiography could detect a reduced peak velocity of CerS5 mice with high fat diet, in comparison to the other groups, four and six weeks after wire injury (C).

Conclusion

Our experiments indicate that loss of CerS5 function reduces the development of aortic valve stenosis in mice with high fat diet, by decreasing immune cell infiltration and calcification. Interestingly, in the groups with normal chow, loss of CerS5 function had no effect. In addition, high-fat diet alone had no negative effect in our mouse model. Based on our results it can be assumed that upon high fat diet CerS5 mediates for pro-inflammatory effects in the aortic valve, which are absent on normal diet.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Ernst & Berta Grimmke Foundation (13/19)

Characterization of the mitochondrial unfolded protein response in human coronary artery endothelial cells

Background

The unfolded protein response of the endoplasmic reticulum (UPRER) is highly activated in cardiovascular diseases and aims to restore homeostasis by improving protein folding. An analogue cytoprotective mitochondrial unfolded protein response (UPRMito) regulated by an orthologue of the activating transcription factor 5 (ATF5) was described in model organism c. elegans. However, in humans it is not clear if there is a distinct UPRMito, and if there is an activation of an UPRMito during stress induced by cardiovascular diseases. The endothelium is subjected to high levels of mitochondrial stress, e.g. in atherosclerosis.

Purpose

To provide a systematic characterization of the UPRMito in human coronary artery endothelial cells (HCAEC).

Methods and results

HCAEC were treated with Nicotinamide Riboside (NR), a NAD+ precursor that activates UPRMito without inducing cellular stress. NR treatment did not induce toxicity and improved cell viability at a concentration of 100μM NR. Quantitative PCR confirmed a dose-dependent upregulation of UPRMito markers. Additionally, we measured expression of ATF4, which is discussed to regulate an integrated stress response in mammals by activating both the UPRMito and UPRER. ATF4 upregulation upon NR treatment was more pronounced than ATF5 upregulation. Analysis of GTEX-Data showed that ATF5 is almost exclusively expressed in liver tissue, while ATF4 shows ubiquitous expression. Among 54 tissues, aortic tissue and coronary arterial tissue are among the five tissues with the highest ATF4 expression.

Analysis of RNA-seq-data of human carotid atherosclerosis revealed that the two transcription factors are differentially regulated. ATF4 is downregulated in unstable plaque, while ATF5 is upregulated. Moreover, ATF4 is in both conditions highly more abundant than ATF5. Accordingly, endothelial cells incubated under atherosclerotic conditions (oxLDL + high glucose) exhibited a ATF4 down- and ATF5 upregulation. Genes previously described to be involved in the UPRMito exhibited a similar expression pattern as ATF4.

To further elucidate these findings, we will perform transcriptomic analyses of HCAEC treated with atherosclerotic stimuli (IL-1β, oxLDL), UPRER inductors (Thapsigargin, Tunicamycin) and stressors of mitochondrial proteostasis (Oligomycin, MitoBloCK-6), to analyze, if ATF5- or ATF4-related pathways are dysregulated. Specific inhibitors and UPRMito activators will be used to investigate the significance of ATF4 and ATF5 on endothelial cell function (proliferation, migration, apoptosis, monocyte adhesion).

Conclusion

The UPRMito is dysregulated during the pathogenesis of atherosclerosis in HCAEC. Further findings are required to elucidate, if the UPRMito is activated separately and specifically by ATF5 or as part of an integrated cellular stress response by ATF4. A deeper understanding of these stress responses is crucial for the identification of novel therapeutic targets in atherosclerosis.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University hospital Bonn

Serum levels of the endoplasmic-reticulum-stress chaperone GRP78 identify patients with coronary artery disease and predict mortality

Background

Endoplasmic-reticulum-stress (ER Stress) and associated chaperones like the main ER-Stress moderator GRP78 (glucose-regulated-protein, 78kDa) are involved in the pathogenesis of coronary artery disease (CAD). In addition to their intracellular localization and effects, secretion and extracellular properties of chaperones, including GRP78, were recently described. However, a diagnostic or prognostic relevance of serum ER-chaperones in patients with CAD has not been established yet.

Purpose

To investigate the significance of serum GRP78 in patients undergoing coronary angiography for suspected CAD.

Methods

Serum concentration of GRP78 was measured by ELISA in 789 patients with indication for coronary angiography (both ACS and CCS). CAD was defined as &gt;50% stenosis in any major coronary artery. Clinical endpoint was one-year all-cause mortality.

Results

Mean age was 70.8±11.9 years and 65% of patients were male. 192 (24%) patients presented with acute coronary syndrome (ACS). CAD was found in 72.4% of patients. Mean GRP78 serum concentration was 2492 ng/ml. Increased levels of GRP78 (&gt; median) were associated with diabetes (29.9% vs. 23.1%, p=0.03), a higher BMI (28.9±7.1 kg/m2 vs. 27.0±6.0 kg/m2, p&lt;0.0001) and chronic kidney disease (CKD: 23.3% vs. 17.1%, p=0.03). There was no difference regarding age or sex.

GRP78 levels were increased in patients with CAD when compared to patients without CAD (2640 ng/ml [95% CI: 2415–2864] vs. 2178 ng/ml [95% CI: 1893–2463], p=0.013, Fig A). Interestingly, GRP78 levels were lower in patients with ACS than in patients with CCS (2284 ng/ml [95% CI: 1944–2642] vs. 2822 [95% CI: 2531–3113], p=0.018, Fig B). To further elucidate these findings, we analyzed available proteomics of patients with hypertrophic cardiomyopathy undergoing septal ablation as a model for a planned myocardial infarction (PMI)1. Coronary sinus blood samples drawn 10 and 60 min after PMI showed a downregulation of GRP78 levels compared to baseline.

Finally, we assessed prognostic relevance of GRP78 in patients with CAD. Increased GRP78 levels were associated with lower one-year mortality (5.3% vs. 10.6% vs. p=0.016). Increased GRP78 levels were associated with reduced one-year mortality in both continuous (HR: 0.48 [95% CI: 0.25–0.92]) and categorial analyses stratified by median GRP78. After adjusting for age, sex, BMI, diabetes, CKD and ACS, GRP78 remained an independent predictor of one-year mortality (HR: 0.51 [0.26–0.96], p=0.039).

Conclusion

GRP78 serum levels are generally elevated in patients with CAD but downregulated during ACS. Reduced levels are associated with increased one-year mortality. These results support previous findings that GRP78 secretion is a protective mechanism in cardiovascular diseases. Further mechanistic studies are warranted to foster our understanding of the effects of extracellular GRP78 and to aid in the identification of modifying therapeutic targets.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University hospital Bonn

The endoplasmic reticulum (ER) chaperone GRP78 is secreted during ER Stress and alleviates endothelial cell inflammation

Introduction

Glucose-Regulated Protein 78kD (GRP78) is a chaperone and the main regulator of the ER-stress response. Upon ER Stress, GRP78 activates the unfolded protein response (UPR), which aims to clear unfolded proteins and restore ER homeostasis. A prolonged activation of the UPR triggers inflammation, thus contributing to the progression of cardiovascular diseases. Recently, extracellular secretion of GRP78 was described. However, the pathophysiological relevance of secreted GRP78 in atherosclerosis and endothelial cell inflammation remains to be elucidated.

Aim

Aim of this study is to investigate the role of GRP78 secretion in endothelial cells.

Methods and results

First, we sought to investigate if vascular cells secrete GRP78 during ER Stress. Human coronary artery endothelial cells (HCAEC) were treated with the ER stress inductor tunicamycin for up to 48h. After ER Stress induction, Western Blot and ELISA experiments detected an increased intracellular GRP78 expression. Intriguingly, prolonged ER Stress also promoted extracellular secretion of GRP78. Proteomic analysis confirmed that after ER-Stress induction, GRP78 is one of the most highly upregulated extracellular proteins (2.43-fold). Co-incubation with Brefeldin A, an inhibitor of ER-Golgi protein transport, abolished extracellular secretion (Fig.1). Hence, ER-Stress-induced GRP78 secretion is an actively regulated process.

Next, the effect of GRP78 containing conditioned medium (CM) on HCAEC was analyzed. Treatment with GRP78 containing CM decreased GRP78 mRNA expression in target cells (0.35-fold vs. control [+BFA], p&lt;0.0001). Furthermore, it increased viability (93.0% vs. 79.6%, p=0.017) and decreased formation of reactive oxygen species (0.78-fold). Moreover, expression of markers of vascular inflammation and ER Stress (e.g., NF-κB and CHOP) was decreased when compared to control CM with additional BFA treatment.

However, ER Stress induced by tunicamycin exhibits deleterious effects on donor cells and is therefore not feasible for in vivo usage. Thus, we utilized Bip protein inducer x (Bix), a recently described small-molecule activator of GRP78. Treatment with Bix also promoted expression of GRP78 and general UPR activation (e.g., ATF4, XBP1). Moreover, in contrast to tunicamycin, Bix treatment did not impair viability of HCAEC.

After treatment with Bix-induced CM, apoptosis (0.77-fold vs. 1.64-fold, p&lt;0.0001) and expression of markers of vascular inflammation (e.g., Il-6) were significantly decreased compared to control CM. Furthermore, presence of GRP78 was able to promote proliferation and viability.

Conclusion

Endothelial ER Stress promotes GRP78 secretion. Presence of GRP78 in conditioned medium ameliorates subsequent ER Stress and endothelial inflammation, which play a critical role in atherogenesis. Modification of GRP78 secretion by Bix might be a feasible and innovative therapeutic option for vascular inflammation and endothelial regeneration.

Funding Acknowledgement

Type of funding sources: None.

OAT3A1/NKD2 mediates increased calcification of aortic valvular interstitial cells under in vitro conditions of uremia

Background

Chronic kidney disease is closely associated with cardiovascular disease which contributes to a high mortality and morbidity in these patients. Calcific aortic valve stenosis is the most common valve disease among adults. CKD leads to a higher incidence of AS and is associated with impaired clinical outcomes after valve replacement. CKD leads to retention of uremic toxins, such as indoxyl sulfate (IS), which is known to induce inflammatory and pro-calcific processes. The influence of IS on AS pathophysiology is currently not known.

Methods and results

Human aortic valvular interstitial cells (VICs) were stimulated by 4 different conditions: Control medium (CM), CM and IS in a concentration of 50 mmol/l, pro-calcifying medium (PCM) which was produced by adding NaH2PO4 and L-ascorbic acid to CM and PCM+IS. After 7 days of incubation, VICs were fixed in formalin and calcification was evaluated through staining with alizarin red solution (B). Staining was quantified by photometric measurements at 540 nm. We observed a significantly higher degree of VIC calcification under the influence PCM+IS compared to PCM alone (C). VICs were stimulated for 7 days and next-generation RNA Sequencing (RNA Seq) was performed. Analysis of RNA Seq dataset identified naked cuticle homologue 2 (NKD2) to be strongly regulated by IS. This effect was confirmed by qPCR using VICs from a total of three different human donors and immunoblot analysis (D, E). We observed a more pronounced upregulation of NKD2 gene expression under PCM+IS vs. PCM alone (p&lt;0.0001) (D). To investigate the influence of NKD2 on VIC calcification genetic knockdown of NKD2 was performed by transfecting VICs with NKD2 siRNA compared and scrambled siRNA as negative control (nc siRNA) (F). After 21 days of stimulation and subsequent alizarin staining, we observed a significant decrease in VIC calcification under NKD2 knockdown compared to negative control under PCM+IS conditions (G, H). To identify upstream mechanisms that lead to NKD2 upregulation by IS we investigated the influence of organic anion transporters (OAT) which are responsible for cellular uptake of IS. Probenecid, known as a potent inhibitor of OATs showed a dose dependent suppression of NKD2 upregulation under PCM+IS (I). Systematic analysis of RNA Seq data regarding SLCO genes coding for OAT and OAT-peptides revealed that only SLCO3A1, coding for OAT3A1 is highly abundant in VICs (J). SLCO3A1 knockdown showed a significant decrease of NKD2 expression after stimulation with PCM+IS for 7 days compared to negative control (K).

Conclusion

Our findings show that in vitro conditions of uremia increase calcification of aortic VICs. NKD2 expression is regulated by PCM and IS, and PCM+IS treated cells show the strongest upregulation of NKD2. Genetic knockdown of NKD2 attenuates VIC calcification suggesting a role of NKD2 in this process. Further, our findings suggest that OAT3A1 is involved in IS mediated regulation of NKD2 expression.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical faculty of the University of Bonn, German Cardiac Society (DGK), German Research Foundation (DFG), TRR259

Low blood levels of the lncRNA MRPL20-AS1 are associated with severe obstructive sleep apnea

Introduction

Obstructive sleep apnea syndrome (OSAS) is the most common sleep disorder and it is associated with arterial hypertension, heart failure, coronary artery disease as well as atrial fibrillation. The underlying pathomechanisms for this association are only incompletely understood. In recent years long non-coding RNAs (lncRNA) have been shown to be involved in various cardiovascular pathologies. The aim of this study is to identify lncRNAs which are associated with OSAS in order to provide potential therapeutic targets.

Methods and results

In order to tackle this issue, we included 23 Patients with a suspected OSAS in a pilot study and sampled blood on the evening before and on the morning after polysomnographic analysis. Citrate was used to inhibit clotting of the blood and cellular components were removed by centrifugation, before the plasma was stored at −80°C. One patient had no sign of OSAS as indicated by an Apnea/Hypopnea-Index (AHI) &lt;5 per hour and was therefore excluded. The remaining 22 patients had a mean age of 44.45 years and a mean AHI of 28.38 per hour. Three of the patients were female and nineteen were male. In four of those patients with high AHI levels, we performed a RNA sequencing analysis from the citrate plasma and found MRPL20-AS1 to be the most significantly regulated lncRNA after the night of polysomnographic analysis (A). Low coding potential of MRPL20-AS1 was confirmed in silico via the Coding-Potential Assessment Tool (http://lilab.research.bcm.edu/) resulting in a coding probability of 0.06148. Then MRPL20-AS1 levels were measured via qPCR in the remaining patients. From 19 patients, we obtained evaluable results. We found that MRPL20-AS1 blood levels had the tendency to be lower after the night of polysomnographic assessment (B). Interestingly MRPL20-AS1 levels were inversely correlated with the AHI of the OSAS patients (C). This indicates that severe OSAS was associated with low levels of MRPL20-AS1 in our cohort (D). In order to further investigate these results in vitro, we subjected human coronary artery endothelial cells (HCAECs) to hypoxia (1% and 5% O2) for 24 h. We found that hypoxia leads to a significant downregulation of MRPL20-AS1 in HCAECs (E).

Conclusion

MRPL20-AS1 blood levels are lower in patients with severe OSAS after nocturnal hypoxia. In endothelial cells MRPL20-AS1 is downregulated after hypoxia. MRPL20-AS1 can therefore be useful to identify patients suffering from severe OSAS. Further investigations are needed to elucidate the biological function of MRPL20-AS1 in the context of OSAS and to investigate MRPL20-AS1 as a potential therapeutic target to counteract cardiovascular effects of OSAS

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Unviversity of BonnUniversity of Cologne

Psychoneurological Symptoms and Biomarkers of Stress and Inflammation in Newly Diagnosed Head and Neck Cancer Patients: A Network Analysis

Psychoneurological symptoms are commonly reported by newly diagnosed head and neck cancer (HNC) patients, yet there is limited research on the associations of these symptoms with biomarkers of stress and inflammation. In this article, pre-treatment data of a multi-center cohort of HNC patients were analyzed using a network analysis to examine connections between symptoms (poor sleep quality, anxiety, depression, fatigue, and oral pain), biomarkers of stress (diurnal cortisol slope), inflammation markers (c-reactive protein [CRP], interleukin [IL]-6, IL-10, and tumor necrosis factor alpha [TNF-α]), and covariates (age and body mass index [BMI]). Three centrality indices were calculated: degree (number of connections), closeness (proximity of a variable to other variables), and betweenness (based on the number of times a variable is located on the shortest path between any pair of other variables). In a sample of 264 patients, poor sleep quality and fatigue had the highest degree index; fatigue and CRP had the highest closeness index; and IL-6 had the highest betweenness index. The model yielded two clusters: a symptoms-cortisol slope-CRP cluster and a IL-6-IL-10-TNF-α-age-BMI cluster. Both clusters were connected most prominently via IL-6. Our findings provide evidence that poor sleep quality, fatigue, CRP, and IL-6 play an important role in the interconnections between psychoneurological symptoms and biomarkers of stress and inflammation in newly diagnosed HNC patients.

Cost-Utility of the eHealth Application ‘Oncokompas’, Supporting Incurably Ill Cancer Patients to Self-Manage Their Cancer-Related Symptoms: Results of a Randomized Controlled Trial

Evidence on the cost-effectiveness of eHealth in palliative care is scarce. Oncokompas, a fully automated behavioral intervention technology, aims to support self-management in cancer patients. This study aimed to assess the cost-utility of the eHealth application Oncokompas among incurably ill cancer patients, compared to care as usual. In this randomized controlled trial, patients were randomized into the intervention group (access to Oncokompas) or the waiting-list control group (access after three months). Healthcare costs, productivity losses, and health status were measured at baseline and three months. Intervention costs were also taken into account. Non-parametric bootstrapping with 5000 replications was used to obtain 95% confidence intervals around the incremental costs and quality-adjusted life years (QALYs). A probabilistic approach was used because of the skewness of cost data. Altogether, 138 patients completed the baseline questionnaire and were randomly assigned to the intervention group (69) or the control group (69). In the base case analysis, mean total costs and mean total effects were non-significantly lower in the intervention group (−€806 and −0.01 QALYs). The probability that the intervention was more effective and less costly was 4%, whereas the probability of being less effective and less costly was 74%. Among patients with incurable cancer, Oncokompas does not impact incremental costs and seems slightly less effective in terms of QALYs, compared to care as usual. Future research on the costs of eHealth in palliative cancer care is warranted to assess the generalizability of the findings of this study.

O-283 Evidence based management of endometriosis – what has changed since 2013?

In 2005, under the auspices of ESHRE, a group of international experts evaluated the existing best evidence and published the first European guideline on the management of endometriosis. This highly successful project was the first guideline by ESHRE and was adopted by many counties as their national standard. A second, fully-updated edition was presented in 2013.

For the new ESHRE Endometriosis Guideline, published in February 2022, all available evidence for twelve chosen topics was gathered by a senior research specialist. Subgroups comprised of patient representatives and experts in healthcare, reproductive science and epidemiology evaluated the data according to GRADE criteria. Each subgroup wrote a chapter and formulated their recommendations which were then presented by a representative to the core group. There, a provisional document was generated and made available for stakeholder review. The resulting comments were taken into account and where relevant incorporated into the final guideline document for which approval was sought and gained from the ESHRE Executive Committee.

35 PICO (Patients, Interventions, Comparison, Outcome) and seven narrative questions were addressed resulting in 78 Research Recommendations were formulated. Where sufficient scientific evidence was lacking and the Guideline Development Group (GDG) was of the opinion that an important topic needed to be highlighted Good Clinical Practice Points where created based on experts’ experience.

During the process of reviewing the literature it became apparent that large knowledge gaps of the best clinical approach to endometriosis exist. As a result, 30 research recommendations were also produced.

One of the main differences to the 2013 version of the ESHRE guidelines is that laparoscopy is no longer the gold standard for endometriosis per se as there exist sufficient data to support the use of transvaginal ultrasound performed by an experienced operator or MRI can equally identify or rule out ovarian and most of deep endometriosis. However, it is recognised by the GDG that the required imaging standards are not ubiquitously available and for peritoneal disease both sensitivity and specificity using either imaging modalities are still poor. As opposed to the 2013 recommendation, the GDG does not anymore recommend an ultralong protocol for the women with rASRM stage III/IV endometriosis to improve IVF success rates. Furthermore, gonadotropin releasing hormone antagonists seem to be effective in the treatment of endometriosis-associate pain and, where available, could be considered as second-line treatment.

Other changes were specific chapters on endometriosis in adolescents and in menopausal women as the GDG strongly felt that these groups are concerningly underrepresented in clinical care and research. Finally, a chapter focussing on the association of endometriosis with certain forms of cancer namely subgroups of ovarian cancer, breast and thyroid cancer was added to give both patients and clinicians a better insight into the current evidence of this complex topic.

The GDG hope that the new ESHRE Endometriosis Guideline will improve the clinical management of a highly prevalent and heterogenous disease and that the freely-available patient-friendly version of the guideline empowers symptomatic and asymptomatic women to seek the best available advice, support and treatment.

Psychological Problems among Head and Neck Cancer Patients in Relation to Utilization of Healthcare and Informal Care and Costs in the First Two Years after Diagnosis

Background: To investigate associations between psychological problems and the use of healthcare and informal care and total costs among head and neck cancer (HNC) patients. Method: Data were used of the NETherlands QUality of Life and Biomedical Cohort study. Anxiety and depression disorder (diagnostic interview), distress, symptoms of anxiety and depression (HADS), and fear of cancer recurrence (FCR) and cancer worry scale (CWS) were measured at baseline and at 12-month follow-up. Care use and costs (questionnaire) were measured at baseline, 3-, 6-, 12-, and 24-month follow-up. Associations between psychological problems and care use/costs were investigated using logistic and multiple regression analyses. Results: Data of 558 patients were used. Distress, symptoms of anxiety or depression, FCR, and/or anxiety disorder at baseline were significantly associated with higher use of primary care, supportive care, and/or informal care (odds ratios (ORs) between 1.55 and 4.76). Symptoms of anxiety, FCR, and/or depression disorder at 12-month follow-up were significantly associated with use of primary care, supportive care, and/or informal care (ORs between 1.74 and 6.42). Distress, symptoms of anxiety, and FCR at baseline were associated with higher total costs. Discussion: HNC patients with psychological problems make more use of healthcare and informal care and have higher costs. This is not the result of worse clinical outcomes.

ESHRE guideline: endometriosis

STUDY QUESTION

How should endometriosis be diagnosed and managed based on the best available evidence from published literature?

SUMMARY ANSWER

The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer.

WHAT IS KNOWN ALREADY

Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected.

LIMITATIONS REASONS FOR CAUTION

The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).

Prospective longitudinal study on fear of cancer recurrence in patients newly diagnosed with head and neck cancer: Course, trajectories, and associated factors

Background

This study assessed the course of fear of cancer recurrence (FCR) in patients newly diagnosed with head and neck cancer (HNC), identified FCR trajectories and factors associated with FCR trajectories.

Methods

Six hundred and seventeen HNC patients from the NET‐QUBIC cohort study completed the Cancer Worry Scale‐6 at diagnosis, 3 and 6 months post‐treatment. FCR trajectories were identified using Latent Class Growth Analysis. Associations were explored between FCR trajectories and baseline demographic and medical variables, coping and self‐efficacy.

Results

Overall, FCR decreased slightly between baseline and 3 months post‐treatment and remained stable up to 6 months. Two FCR trajectories were identified: “high stable” (n = 125) and “low declining” (n = 492). Patients with high stable FCR were younger, reported more negative adjustment, passive coping, and reassuring thoughts, and less avoidance.

Conclusions

The majority of HNC patients have low declining FCR after diagnosis, but one in five patients experience persistent high FCR up to 6 months post‐treatment.

Study retention and attrition in a longitudinal cohort study including patient-reported outcomes, fieldwork and biobank samples: results of the Netherlands quality of life and Biomedical cohort study (NET-QUBIC) among 739 head and neck cancer patients and 262 informal caregivers

Background

Longitudinal observational cohort studies in cancer patients are important to move research and clinical practice forward. Continued study participation (study retention) is of importance to maintain the statistical power of research and facilitate representativeness of study findings. This study aimed to investigate study retention and attrition (drop-out) and its associated sociodemographic and clinical factors among head and neck cancer (HNC) patients and informal caregivers included in the Netherlands Quality of Life and Biomedical Cohort Study (NET-QUBIC).

Methods

NET-QUBIC is a longitudinal cohort study among 739 HNC patients and 262 informal caregivers with collection of patient-reported outcome measures (PROMs), fieldwork data (interview, objective tests and medical examination) and biobank materials. Study retention and attrition was described from baseline (before treatment) up to 2-years follow-up (after treatment). Sociodemographic and clinical characteristics associated with retention in NET-QUBIC components at baseline (PROMs, fieldwork and biobank samples) and retention in general (participation in at least one component) were investigated using Chi-square, Fisher exact or independent t-tests (p< 0.05).

Results

Study retention at 2-years follow-up was 80% among patients alive (66% among all patients) and 70% among caregivers of patients who were alive and participating (52% among all caregivers). Attrition was most often caused by mortality, and logistic, physical, or psychological-related reasons. Tumor stage I/II, better physical performance and better (lower) comorbidity score were associated with participation in the PROMs component among patients. No factors associated with participation in the fieldwork component (patients), overall sample collection (patients and caregivers) or PROMs component (caregivers) were identified. A better performance and comorbidity score (among patients) and higher age (among caregivers) were associated with study retention at 2-years follow-up.

Conclusions

Retention rates were high at two years follow-up (i.e. 80% among HNC patients alive and 70% among informal caregivers with an active patient). Nevertheless, some selection was shown in terms of tumor stage, physical performance, comorbidity and age, which might limit representativeness of NET-QUBIC data and samples. To facilitate representativeness of study findings future cohort studies might benefit from oversampling specific subgroups, such as patients with poor clinical outcomes or higher comorbidity and younger caregivers.

Prevalence of neurocognitive and perceived speech deficits in patients with head and neck cancer before treatment: Associations with demographic, behavioral, and disease-related factors

Background

Neurocognition and speech, relevant domains in head and neck cancer (HNC), may be affected pretreatment. However, the prevalence of pretreatment deficits and their possible concurrent predictors are poorly understood.

Methods

Using an HNC prospective cohort (Netherlands Quality of Life and Biomedical Cohort Study, N ≥ 444) with a cross‐sectional design, we investigated the estimated prevalence of pretreatment deficits and their relationship with selected demographic, behavioral, and disease‐related factors.

Results

Using objective assessments, rates of moderate‐to‐severe neurocognitive deficit ranged between 4% and 8%. From patient‐reported outcomes, 6.5% of patients reported high levels of cognitive failures and 46.1% reported speech deficits. Patient‐reported speech functioning was worse in larynx compared to other subsites. Other nonspeech outcomes were unrelated to any variable. Patient‐reported neurocognitive and speech functioning were modestly correlated, especially in the larynx group.

Conclusions

These findings indicate that a subgroup of patients with HNC shows pretreatment deficits, possibly accentuated in the case of larynx tumors.

Circulating microRNA-122-5p correlates with improvement in left-ventricular function after transcatheter aortic valve replacement and regulates viability of cardiomyocytes via extracellular vesicles

 

Transcatheter aortic valve replacement (TAVR) is a well-established treatment option for high- and intermediate-risk patients with severe symptomatic aortic valve stenosis (AVS). However, a specific role for circulating microRNAs (miRNAs) in the improvement of cardiac function for patients after TAVR has not yet been investigated. Herein, we generally explored the differential expression of miRNAs in circulating extracellular vesicles (EV-miRNAs) in patients after TAVR and, in particular, the novel role of circulating miR-122-5p in cardiomyocytes.

Circulating EV-associated miRNAs were investigated by using an unbiased Taqman-based human miR array. Several EV-miRNAs (miR-122-5p, miR-26a, miR-192, miR-483-5p, miR-720, miR-885-5p, and miR-1274) were significantly deregulated in aortic stenosis patients at day seven after TAVR in comparison to the pre-procedural levels in patients without LVEF-improvement. The higher levels of miR-122 were negatively correlated with LVEF improvement at both day seven (r=−0.264 and p=0.015) and at six months (r=−0.328 and p=0.0018) after TAVR. At the three-year follow-up, patients with a higher level of miR-122-5p displayed significantly increased cardiovascular mortality (p=0.03). By utilization of patient-derived samples and a murine aortic-stenosis model, we observed that the expression of miR-122-5p correlates negatively with cardiac function, which is associated with LVEF. Graded wire-injury-induced aortic-valve-stenotic mice demonstrated a higher level of miR-122-5p, which was related to cardiomyocyte dysfunction. Murine ex vivo experiments revealed that miR-122-5p is highly enriched in endothelial cells in comparison to cardiomyocytes. Co-culture experiments with endothelial cells and cardiomyocytes, copy-number analysis, fluorescence microscopy with Cy3-labeled miR-122-5p demonstrated that miR-122-5p can be shuttled via large extracellular vesicles from endothelial cells into cardiomyocytes. Gain- and loss-of-function experiments suggested that EV-mediated shuttling of miR-122-5p increases the level of miR-122-5p in recipient cardiomyocytes and regulates viability of the cardiomyocytes. In silico prediction and mass spectrometry were used to search for binding partners of miR-122-5p. Mechanistically, miR pulldown, electrophoretic mobility shift assay, and RNA immunoprecipitation confirmed that miR-122-5p interacts with an RNA-binding protein, hnRNPU, in a sequence-specific manner to encapsulate miR-122-5p into large EVs. Upon shuttling into recipient cells, miR-122-5p negatively regulates the expression of the anti-apoptotic gene BCL2, by binding to its 3' untranslated region to regulate its translation, and thereby decreasing the viability of target cardiomyocytes.

Increased levels of circulating pro-apoptotic EV-incorporated miR-122-5p is associated with reduced LVEF after TAVR. Extracellular vesicular shuttling of miR-122-5p regulates the viability and apoptosis of cardiomyocytes in a Bcl2-dependent manner.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Research Foundation (DFG); German Society of Cardiology (DGK)

Coronary artery disease ameliorates extracellular vesicle lncRNA PUNISHER regulates angiogenic response andendothelial cells function via NFkB-dependent mechanism

 

Augmenting evidence indicates that long noncoding RNAs (lncRNAs) are playing a crucial role in diverse cellular/pathological processes. Intercellular transfer of extracellular vesicles (EVs) transmitted lncRNA regulates vascular health and diseases. However, whether lncRNA expression in EVs is regulated in patients with coronary artery disease, is unknown.

A PCR-based lncRNA array analysis revealed that EV-PUNISHER was significantly upregulated in patients with CAD (n=221) compared to healthy subjects. Our data showed that PUNISHER is the most upregulated lncRNA in CAD in accordance with other highly expressed lncRNAs. To examine the specific role of PUNISHER in EC phenotypic regulation, siRNA-mediated silencing in ECs revealed that depletion of PUNISHER suppresses the migration and proliferation of ECs. Moreover, depletion of PUNISHER decreases cell survival by reducing cell viability and proliferation through increased apoptosis and cytotoxicity. In order to investigate EC function in PUNISHER depleted cells, in vitro sprouting and tube formation assay revealed that PUNISHER is an important mediator EC functions, which acts as an anti-angiogenic factor. In vitro atherosclerotic stimuli increased PUNISHER expression in EV/EC in a dose-dependent way. Microarray analysis identified a series of pro- and anti-angiogenic genes as well genes directly involved in cell viability that are differentially regulated.

We confirmed that PUNISHER is incorporated into endothelial microvesicles (EMVs) and transferred to recipient cells by using different experiments. By using lncRNA-FISH and vesicle degradation assays, we showed that PUNISHER is incorporated into EMVs, augmented recipient EC function in vitro upon transfer via EMVs. To examine whether EMV-PUNISHER promotes the EC function, different in vitro functional experiments with ECs confirmed that PUNISHER is an important regulator. Mass spectrometry analysis has revealed EMV contains numerous proteins, including RNA binding proteins such as hnRNPU. By using RNA-pulldown and RNA-IP, we confirmed that PUNISHER interacts with hnRNPU, which facilitates packaging into EMV prior to transfer to recipient EC. The interaction acts as an important positive regulator of cell viability and survival of recipient cells, identified using functional assay. Transcription factor array has shown that PUNISHER regulates NFkB to control cellular viability and apoptosis. A murine re-endothelialization model after injection of 1×107 EVs or bulk ncRNAs revealed that EV-PUNISHER promotes reendothelialization. Ex vivo internalization/uptake of PKH-67-labeled EVs revealed that EVs are detectable in the cross-section of EV-perfused carotid artery.

Our study unveiled for the first time that EV-PUNISHER exerts its function in endothelial cells which might be beneficial in cardiovascular pathologies where the endothelial function is dysregulated. Our data indicate that PUNISHER can be targeted to develop targeted therapeutics.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): German Research Foundation (DFG); German Society of Cardiology (DGK)

Adjustment disorder in cancer patients after treatment: prevalence and acceptance of psychological treatment

Purpose

To investigate the prevalence of adjustment disorder (AD) among cancer patients and the acceptance of psychological treatment, in relation to sociodemographic, clinical, and psychological factors.

Methods

Breast, prostate, and head and neck cancer patients of all stages and treatment modalities (N = 200) participated in this observational study. Patients completed the Hospital Anxiety and Depression Scale, Checklist Individual Strength, Distress Thermometer and problem list. Patients with increased risk on AD based on these questionnaires were scheduled for a diagnostic interview. Patients diagnosed with AD were invited to participate in a randomized controlled trial on the cost-effectiveness of psychological treatment. Participation in this trial was used as a proxy of acceptance of psychological treatment. Logistic regression analyses were used to investigate associated factors.

Results

The overall prevalence of AD was estimated at 13.1%. Sensitivity analyses showed prevalence rates of AD of 11.5%, 15.0%, and 23.5%. Acceptance of psychological treatment was estimated at 65%. AD was associated both with being employed (OR = 3.3, CI = 1.3–8.4) and having a shorter time since diagnosis (OR = 0.3, CI = 0.1–0.8).

Conclusion

Taking sensitivity analysis into account, the prevalence of AD among cancer patients is estimated at 13 to 15%, and is related to being employed and having a shorter time since diagnosis. The majority of cancer patients with AD accept psychological treatment.

Associations between testosterone and patient reported sexual outcomes among male and female head and neck cancer patients before and six months after treatment: A pilot study

OBJECTIVES

To investigate associations between testosterone and patient reported sexual problems and need for sexual care in head and neck cancer patients at time of diagnosis and 6 months after treatment.

PATIENTS AND METHODS

Data and samples were used of 40 patients (20 men, 20 women) before and 6 months after treatment. Outcome measures were total testosterone level (TT) and free testosterone index (FTI), testosterone insufficiency (TI), the EORTC QLQ-HN35 Sexuality subscale, the subscales of the International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI), and the Sexuality subscale of the Short-Form Supportive Care Needs Survey (SCNS-SF34).

RESULTS

In men, higher FTI before treatment was significantly associated with better IIEF Orgasm (p = 0.020) and at 6 months follow-up with IIEF Desire (p = 0.019). Before treatment, insufficient testosterone was present in 5 males (25%) and in 3 at follow-up (15%) (2 patients who had TI before treatment plus one). In women, higher TT at follow-up was significantly associated with better EORTC Sexuality (p = 0.031) and FSFI Satisfaction (p = 0.020); FTI at follow-up was associated with FSFI Satisfaction (p = 0.012). Before treatment, TI was present in 2 women (10%) and in 3 (15%) at follow-up (the same 2 patients plus one).

CONCLUSION

This pilot study showed that testosterone seems to be associated with patient reported sexual outcomes among male and female head and neck cancer patients. It is estimated that 10-25% of HNC patients may have testosterone insufficiency before treatment and/or at 6 months after treatment.

Supportive care needs and utilization of bladder cancer patients undergoing radical cystectomy: A longitudinal study

OBJECTIVES

Investigating supportive care (SC) needs and utilization/willingness to use SC services from diagnosis to one year after radical cystectomy in bladder cancer (BC) patients. MATERIALS & METHODS: A longitudinal cohort study was conducted in 90 BC patients at Ghent/Leuven University Hospitals between April 2017 and December 2020. The Supportive Care Needs Survey-short form (SCNS-SF34) was used before radical cystectomy, one, three, six and 12 months after radical cystectomy. Additional questions assessed utilization/willingness to use SC services. Linear mixed models were performed.

RESULTS

The majority of BC patients report at least one moderate or high SC need at diagnosis (82%), month 1 (84%), month 3 (86%), month 6 (64%), and month 12 (60%). Significant decreases over time were seen for all domains (p < 0.001), except for sexuality (p = 0.275). From baseline to month 1, physical needs first significantly increased (p = 0.001) after which they decreased. Psychological (e.g. fears about the future) and informational (e.g. information on how to get better) needs were most common at baseline whereas physical (e.g. lack of energy) and informational needs were more common in the early postoperative phases. The majority of patients (ranging from 81% (month 1) to 91% (month 12)) did not make use of SC services and the majority of the patients (ranging from 81% (month 1) to 88% (month 12)) did not wish to talk about their problems to someone. Those willing to talk to someone preferred their physician.

CONCLUSIONS

A clear gap exists between the large proportion of SC needs experienced by BC patients undergoing radical cystectomy and the low use of SC services.

Reasons for not reaching or using web-based self-management applications, and the use and evaluation of Oncokompas among cancer survivors, in the context of a randomised controlled trial

INTRODUCTION

The web-based self-management application Oncokompas was developed to support cancer survivors to monitor health-related quality of life and symptoms (Measure) and to provide tailored information (Learn) and supportive care options (Act). In a previously reported randomised controlled trial (RCT), 68% of 655 recruited survivors were eligible, and of those 45% participated in the RCT. Among participants of the RCT that were randomised to the intervention group, 52% used Oncokompas as intended. The aim of this study was to explore reasons for not participating in the RCT, and reasons for not using Oncokompas among non-users, and the use and evaluation of Oncokompas among users.

METHODS

Reasons for not participating were assessed with a study-specific questionnaire among 243 survivors who declined participation. Usage was investigated among 320 participants randomised to the intervention group of the RCT via system data and a study-specific questionnaire that was assessed during the 1 week follow-up (T1) assessment.

RESULTS

Main reasons for not participating were not interested in participation in scientific research (40%) and not interested in scientific research and Oncokompas (28%). Main reasons for not being interested in Oncokompas were wanting to leave the period of being ill behind (29%), no symptom burden (23%), or lacking internet skills (18%). Out of the 320 participants in the intervention group 167 (52%) used Oncokompas as intended. Among 72 non-users, main reasons for not using Oncokompas were no symptom burden (32%) or lack of time (26%). Among 248 survivors that activated their account, satisfaction and user-friendliness were rated with a 7 (scale 0-10). Within 3 (IQR 1-4) sessions, users selected 32 (IQR 6-37) topics. Main reasons for not using healthcare options in Act were that the information in Learn was already sufficient (44%) or no supportive care needs (32%).

DISCUSSION

Main reasons for not reaching or using Oncokompas were no symptom burden, no supportive care needs, or lack of time. Users selected many cancer-generic and tumour-specific topics to address, indicating added value of the wide range of available topics.

Mastication, swallowing, and salivary flow in patients with head and neck cancer: objective tests versus patient-reported outcomes

Purpose

Before and after treatment for head and neck cancer (HNC), many patients have problems with mastication, swallowing, and salivary flow. The aim of this study was to investigate the association between objective test outcomes of mastication, swallowing, and salivary flow versus patient-reported outcomes (PROs) measuring mastication-, swallowing-, and salivary flow–related quality of life.

Methods

Data of the prospective cohort “Netherlands Quality of Life and Biomedical Cohort Study” was used as collected before treatment, and 3 and 6 months after treatment. Spearman’s rho was used to test the association between objective test outcomes of the mixing ability test (MAT) for masticatory performance, the water-swallowing test (WST) for swallowing performance, and the salivary flow test versus PROs (subscales of the EORTC QLQ-H&N35, Swallow Quality of Life questionnaire (SWAL-QoL-NL) and Groningen Radiation-Induced Xerostomia (GRIX)).

Results

Data of 142 patients were used, and in total, 285 measurements were performed. No significant correlations were found between the MAT or WST and subscales of the EORTC QLQ-H&N35. Significant but weak correlations were found between the MAT or WST and 4 subscales of the SWAL-QoL-NL. Weak to moderate correlations were found between the salivary flow test and GRIX at 3 and 6 months after treatment, with the highest correlation between salivary flow and xerostomia during the day (Spearman’s rho =  − 0.441, p = 0.001).

Conclusion

The association between objective test outcomes and PROs is weak, indicating that these outcome measures provide different information about masticatory performance, swallowing, and salivary flow in patients with HNC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06368-6.

Psychological problems among cancer patients in relation to healthcare and societal costs: A systematic review

OBJECTIVE

This study systematically reviewed the association of psychological problems among cancer patients with healthcare and societal resource use and costs.

METHODS

PubMed, PsycINFO, and Embase were searched (until 31 January 2021) for studies on psychological symptoms (anxiety, depression, distress, fear of recurrence) or psychiatric disorders (anxiety, depression, adjustment) and healthcare use (e.g., mental, inpatient healthcare), economic losses by patients and family, economic losses in other sectors (e.g., absence from work), and costs. The search, data extraction, and quality assessment were performed by two authors.

RESULTS

Of the 4157 identified records, 49 articles were included (psychological symptoms (n = 34), psychiatric disorders (n = 14), both (n = 1)) which focused on healthcare use (n = 36), economic losses by patients and family (n = 5), economic losses in other sectors (n = 8) and/or costs (n = 13). In total, for 12 of the 94 associations strong evidence was found. Psychological symptoms and psychiatric disorders were positively associated with increased healthcare use (mental, primary, inpatient, outpatient healthcare), losses in other sectors (absence from work), and costs (inpatient, outpatient, total healthcare costs). Moderate evidence was found for a positive association between (any) psychiatric disorder and depression disorder with inpatient healthcare and medication use, respectively.

CONCLUSIONS

Psychological problems in cancer patients are associated with increased healthcare use, healthcare costs and economic losses. Further research is needed on psychological problems in relation to understudied healthcare use or costs categories, productivity losses, and informal care costs.

Smartphone app-guided secondary prevention in patients with coronary heart disease

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Deutsche Forschungsgemeinschaft

Background 

Coronary artery disease (CAD) is the leading cause of death worldwide. Lifestyle change is a crucial part of secondary prevention. Only 30% of CAD patients follow the corresponding guideline recommendations. The widespread adoption of smartphones offers the opportunity to integrate secondary prevention into the daily routine of CAD patients.

Purpose 

The purpose of this study was to show that smartphone-guided secondary prevention (SGSP) could achieve lifestyle changes and a gain of disease specific knowledge among CAD patients. 

Methods 

We developed an app to integrate secondary prevention into CAD patients’ everyday life. The app provided a daily 15-minute program that included video-guided exercises, video sessions with background information about CAD, and a tool to record blood pressure and heart rate once a day.

The SGSP app was tested with the primary outcome of 28-day adherence. The secondary outcome was a composite of self-reported behavioural changes, gain of knowledge about cardiovascular risk factors and an increase in quality of life.

Results 

Of the 66 patients screened, 43 (65%) were included into the study and, of those, 17 (40%) used the app continuously for 28 days. From this group, 14 (82%) were physically more active and ten (59%) improved their dietary habits. Usage of the SGSP app was also associated with a gain of knowledge about cardiovascular risk factors (70% physical activity, 59% healthy diet).

Conclusion 

The regular use of a SGSP app appears to support lifestyle changes in patients with CAD.

Primary and secondary endpoints Results Overall(n = 17) P-Value Adherence (28 days) 17 (39.5) 0.34 Behavioural change Significantly increased physical activity no. (%) 14 (82.4) 0.08 Implemented a healthier diet no. (%) 10 (58.8) 0.64 Relevant gain of knowledge about CVRF Physical activity no. (%) 12 (70.6) 0.13 Unhealthy diet no. (%) 10 (58.8) 1.00 Smoking no. (%) 1 (5.9) 0.47 Stress no. (%) 7 (41.2) 0.13 Potential for long-term use Willingness to use the App over a long time period (&gt;28 days), no. (%) 15 (88.2) 1.00

Abstract Figure.

Cost-utility and cost-effectiveness of a guided self-help head and neck exercise program for patients treated with total laryngectomy: Results of a multi-center randomized controlled trial

OBJECTIVES

The guided self-help exercise program called In Tune without Cords (ITwC) is effective in improving swallowing problems and communication among patients treated with a total laryngectomy (TL). This study investigated the cost-utility and cost-effectiveness of ITwC.

MATERIALS AND METHODS

Patients within 5 years after TL were included in this randomized controlled trial. Patients in the intervention group (n = 46) received access to the self-help exercise program with flexibility, range-of-motion and lymphedema exercises, and a self-care education program. Patients in the control group (n = 46) received access to the self-care education program only. Healthcare utilization (iMCQ), productivity losses (iPCQ), health status (EQ-5D-3L, EORTC QLU-C10D) and swallowing problems (SwalQol) were measured at baseline, 3- and 6-months follow-up. Hospital costs were extracted from medical files. Mean total costs and effects (quality-adjusted life-years (QALYs) or SwalQol score) were compared with regression analyses using bias-corrected accelerated bootstrapping.

RESULTS

Mean total costs were non-significantly lower (-€685) and QALYs were significantly higher (+0.06) in the intervention compared to the control group. The probability that the intervention is less costly and more effective was 73%. Sensitivity analyses with adjustment for baseline costs and EQ-5D scores showed non-significantly higher costs (+€119 to +€364) and QALYs (+0.02 to +0.03). A sensitivity analysis using the QLU-C10D to calculate QALYs showed higher costs (+€741) and lower QALYs (-0.01) and an analysis that used the SwalQol showed higher costs (+€232) and higher effects (improvement of 6 points on a 0-100 scale).

CONCLUSION

ITwC is likely to be effective, but possibly at higher expenses.

TRIAL REGISTRATION

NTR5255.

The eHealth self-management application 'Oncokompas' that supports cancer survivors to improve health-related quality of life and reduce symptoms: which groups benefit most?

BACKGROUND

Oncokompas is a web-based self-management application that supports cancer survivors to monitor their health-related quality of life (HRQOL) and symptoms, and to obtain personalised feedback and tailored options for supportive care. In a large randomised controlled trial among survivors of head and neck cancer, colorectal cancer, and breast cancer and (non-)Hodgkin lymphoma, Oncokompas proved to improve HRQOL, and to reduce several tumour-specific symptoms. Effect sizes were however small, and no effect was observed on the primary outcome patient activation. Therefore, this study aims to explore which subgroups of cancer survivors may especially benefit from Oncokompas.

MATERIALS AND METHODS

Cancer survivors (n = 625) were randomly assigned to the intervention group (access to Oncokompas, n = 320) or control group (6 months waiting list, n = 305). Outcome measures were HRQOL, tumour-specific symptoms, and patient activation. Potential moderators included socio-demographic (sex, age, marital status, education, employment), clinical (tumour type, stage, time since diagnosis, treatment modality, comorbidities), and personal factors (self-efficacy, personal control, health literacy, Internet use), and patient activation, mental adjustment to cancer, HRQOL, symptoms, and need for supportive care, measured at baseline. Linear mixed models were performed to investigate potential moderators.

RESULTS

The intervention effect on HRQOL was the largest among cancer survivors with low to moderate self-efficacy, and among those with high personal control and those with high health literacy scores. Cancer survivors with higher baseline symptom scores benefitted more on head and neck (pain in the mouth, social eating, swallowing, coughing, trismus), and colorectal cancer (weight) specific symptoms.

DISCUSSION

Oncokompas seems most effective in reducing symptoms in head and neck cancer and colorectal cancer survivors who report a higher burden of tumour-specific symptoms. Oncokompas seems most effective in improving HRQOL in cancer survivors with lower self-efficacy, and in cancer survivors with higher personal control, and higher health literacy.

A structured expressive writing activity targeting body image-related distress among head and neck cancer survivors: who do we reach and what are the effects?

Purpose

The aim of this pretest–posttest study was to investigate the reach and effects of My Changed Body (MyCB), an expressive writing activity based on self-compassion, among head and neck cancer (HNC) survivors.

Methods

This pilot study had a pretest–posttest design. HNC survivors received an invitation to complete a baseline survey on body image-related distress. At the end of the survey, HNC survivors were asked if they were interested in the intervention study. This entailed the writing activity and a survey 1 week and 1 month post-intervention. The reach was calculated by dividing the number of participants in the intervention study, by the number of (1) eligible HNC survivors and (2) those who filled in the baseline survey. Linear mixed models were used to analyze the effect on body image-related distress. Logistic regression analysis was used to investigate factors associated with the reach and reduced body image-related distress. MyCB was evaluated using study-specific questions.

Results

The reach of MyCB was 15–33% (depending on reference group) and was associated with lower education level, more social eating problems, and fewer wound healing problems. Among the 87 participants, 9 (10%) showed a clinically relevant improvement in body image-related distress. No significant effect on body image-related distress was found. Self-compassion improved significantly during follow-up until 1 month post-intervention (p=0.003). Users rated satisfaction with MyCB as 7.2/10.

Conclusion

MyCB does not significantly improve body image-related distress, but is likely to increase self-compassion, which sustains for at least 1 month.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06114-y.

Sleep quality trajectories from head and neck cancer diagnosis to six months after treatment

OBJECTIVES

Patients with head and neck cancer (HNC) often report disturbances in their sleep quality, impairing their quality of life. This study aims to examine the trajectories of sleep quality from diagnosis up to 6-month after treatment, as well as the pre-treatment risk factors for poor sleep trajectories.

MATERIALS AND METHODS

Sleep quality (Pittsburgh sleep quality index) was measured shortly after diagnosis (pre-treatment), and at 3 and 6 months after finishing treatment. Patients were categorized into 5 trajectory groups. We examined the association of sleep quality trajectories with sociodemographic and clinical characteristics, coping style, HNC symptoms, and psychological distress.

RESULTS

Among 412 included patients, about a half either had a persistent good sleep (37.6%) or an improving (16.5%) trajectory. About a third had a persistent poor sleep (21.8%) or worsening (10.9%) sleep trajectory. The remaining patients (13.1%), alternated between good and poor sleep. Using persistent good sleep as a reference outcome, persistent poor sleepers were more likely to be woman (odds ratio [OR] = 1.98, 95% confidence interval [CI] 1.01-3.90), use painkillers prior to treatment (OR = 2.52, 95% CI 1.33-4.77), and have more pre-treatment anxiety symptoms (OR = 1.26, 95% CI 1.15-1.38).

CONCLUSION

Unfavorable sleep quality trajectories are prevalent among HNC patients from pre-treatment to 6-month after treatment. A periodic sleep evaluation starting shortly after HNC diagnosis is necessary to identify persistent sleep problems, especially among high-risk group.

Poor sleep quality among newly diagnosed head and neck cancer patients: prevalence and associated factors

BACKGROUND

Head and neck cancer (HNC) patients often suffer from distress attributed to their cancer diagnosis which may disturb their sleep. However, there is lack of research about poor sleep quality among newly diagnosed HNC patients. Therefore, our aim was to investigate the prevalence and the associated factors of poor sleep quality among HNC patients before starting treatment.

MATERIALS AND METHODS

A cross-sectional study was conducted using the baseline data from NET-QUBIC study, an ongoing multi-center cohort of HNC patients in the Netherlands. Poor sleep quality was defined as a Pittsburgh Sleep Quality Index (PSQI) total score of > 5. Risk factors examined were sociodemographic factors (age, sex, education level, living situation), clinical characteristics (HNC subsite, tumor stage, comorbidity, performance status), lifestyle factors, coping styles, and HNC symptoms.

RESULTS

Among 560 HNC patients, 246 (44%) had poor sleep quality before start of treatment. Several factors were found to be significantly associated with poor sleep: younger age (odds ratio [OR] for each additional year 0.98, 95% CI 0.96-1.00), being female (OR 2.6, 95% CI 1.7-4.1), higher passive coping style (OR 1.18, 95% CI 1.09-1.28), more oral pain (OR 1.10, 95% CI 1.01-1.19), and less sexual interest and enjoyment (OR 1.13, 95% CI 1.06-1.20).

CONCLUSION

Poor sleep quality is highly prevalent among HNC patients before start of treatment. Early evaluation and tailored intervention to improve sleep quality are necessary to prepare these patients for HNC treatment and its consequences.

The course of health-related quality of life from diagnosis to two years follow-up in patients with oropharyngeal cancer: does HPV status matter?

Purpose

To investigate the course of health-related quality of life (HRQOL) from diagnosis to 2 years follow-up among patients with oropharyngeal cancer (OPSCC), in relation to human papilloma virus (HPV) status.

Methods

This study included 270 OPSCC patients. Age, sex, tumor sublocation, tumor stage, HPV status, treatment modality, comorbidity, smoking, and alcohol use were retrieved from medical records. HPV status was positive when p16 and HPV DNA tests were both positive. HRQOL was assessed using the EORTC QLQ-C30/QLQ-H&N35 pretreatment and at 6 weeks, 6, 12, 18, and 24 months after treatment. To compare the course of HRQOL between patients with an HPV-positive versus HPV-negative tumor, linear and logistic mixed models were used.

Results

Patients with an HPV-positive tumor (29%) were more often male, diagnosed with a tumor of the tonsil or base of the tongue, treated with single treatment, had fewer comorbidities, were less often current smokers and had lower alcohol consumption. Adjusted for confounders, the course of global quality of life, physical, role, and social functioning, fatigue, pain, insomnia, and appetite loss was significantly different: patients with an HPV-positive tumor scored better before treatment, worsened during treatment, and recovered better and faster at follow-up, compared to patients with an HPV-negative tumor. The course of emotional functioning and oral pain was also significantly different between the two groups, but with other trajectories.

Conclusion

The course of HRQOL is different in patients with an HPV-positive tumor versus an HPV-negative tumor, adjusted for sociodemographic, clinical, and lifestyle confounders.

Effect of Stepped Care on Sexual Interest and Enjoyment in Distressed Patients with Head and Neck Cancer: A Randomized Controlled Trial

Introduction

A recent randomized controlled trial (RCT) in patients with head and neck cancer (HNC) with psychological distress showed that a stepped care (SC) program targeting psychological distress compared with care as usual (CAU), is (cost)effective in reducing psychological distress.

Aim

The aim of the present study was to investigate whether SC can coalleviate problems with sexual interest and enjoyment. A secondary aim was to investigate whether the presence of an unmet sexual health need and having a psychiatric disorder (depression or anxiety) at baseline moderated any effect of SC on these sexual variables until 1-year follow-up.

Methods

HNC survivors (N = 134), randomized to SC or CAU, were assessed regarding their sexual interest and enjoyment before and after the intervention and at 3, 6, 9, and 12 months follow-up. Linear mixed models were used to evaluate differences in the course of sexual interest and enjoyment between SC and CAU.

Main Outcome Measure

The “sexuality” symptom subscale, part of the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire, Head and Neck Cancer–specific module.

Results

Of all patients, 76.1% had an unmet sexual need at baseline, 24.6% had a psychiatric disorder (anxiety or depression). SC did not reduce problems with sexual interest and enjoyment at any of the follow-up measurements compared with CAU (P = .85). This was neither moderated by an unmet sexual health need at baseline (P = .64) nor by the presence of a psychiatric disorder at baseline (P = .59).

Conclusion

A substantial number of patients with HNC have unmet sexual health needs. SC targeting psychological distress does not reduce problems with sexuality in these patients. Interventions specifically targeting sexuality are recommended.

Schutte LER, Melissant HC, Jansen F, et al. Effect of Stepped Care on Sexual Interest and Enjoyment in Distressed Patients with Head and Neck Cancer: A Randomized Controlled Trial. Sex Med 2021;9:100304.

HnRNPU regulates intra- and intercellular microRNA trafficking in a sequence specific manner

Introduction

The transfer of microRNAs (miRs) through extracellular vesicles (EVs) is a well-established mechanism of vascular intercellular communication. In a previous study, we have identified the heterogeneous nuclear ribonucleoprotein U (hnRNPU) as a potent regulator of the vesicular export of a specific set of miRs in endothelial cells (ECs). Downregulation of hnRNPU caused an increased export of miRs into large EVs and lead to a reduction of the migratory capacity in EV up-taking ECs. The underlying mechanism, how hnRNPU recognizes only certain miRs and regulates their export, however, remained unclear.

Methods and results

Increasingly exported microRNAs into EVs after siRNA-mediated downregulation of hnRNPU were identified in a miR array and used to perform a sequence analysis with the Multiple Em for Motif Elicitation tool (MEME). The software identified the motif AAMRUGCU to be significantly enriched within the regulated miRs. Binding of hnRNPU to miR-30c-5p, which was one of the most significantly increased miRs in EVs upon downregulation of hnRNPU, was confirmed in an immunoprecipitation and an RNA-pulldown experiment. In order to investigate, if the in silico motif AARUGCU was the binding site of miR-30c-5p and hnRNPU an electrophoretic mobility shift assay (EMSA) was conducted with native miR-30c-5p, mutated miR-30c-5p as well as miR-125a-3p as a negative control. The EMSA showed that a partial mutation, which conserves the purine / pyrimidine structure in the motif of miR-30c-5p does not affect binding, while a complete disruption of the motif structure abolishes binding of hnRNPU and miR-30c-5p. Furthermore, we found that hnRNPU protects miR-30c-5p from rapid degradation after transcriptional blockage by Actinomycin D. Binding of miR-30c-5p to the predominantly nuclearly expressed hnRNPU retains miR-30c-5p in the nucleus. HnRNPU knockdown leads to a redistribution of miR-30c-5p from the nucleus to the cytoplasm. The regulating effect of hnRNPU expression on vesicular miR export was confirmed by overexpression of hnRNPU through plasmid transfection. In contrast to siRNA-mediated downregulation, overexpression of hnRNPU lead to a decrease of vesicular miR-30c-5p levels. In order to extent our findings to other cell types with high vascular relevance, siRNA mediated downregulation of hnRNPU was performed in human cardiac fibroblasts (HCF). Similar to our findings in ECs, downregulation of hnRNPU in HCFs lead to an increase in vesicular miR-30c-5p levels.

Conclusion

In conclusion, we show that hnRNPU binds miRs, which contain the motif AAMRUGCU. This leads to nuclear retainment, stabilization and inhibits vesicular export, which can be further decreased by overexpression of hnRNPU and enhanced by downregulation of hnRNPU. The effect is not restricted to ECs but applies also to HCFs. hnRNPU may therefore be an important target to influence intra- and intercellular trafficking of a specific set of miRs including miR-30c-5p.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Medical faculty of the University of Bonn, German Cardiac Society

TAC induced cardiac hypertrophy leads to increased levels of circulating microvesicles

Introduction

Cardiac hypertrophy and heart failure are wide spread diseases of elderly patients in the industrialised world and drive a majority of healthcare costs in these countries. Therefore, there is a high urgency to understand the development and progress of heart failure to find new therapeutic strategies especially in early stages. Microvesicles are involved in the development and propagation of almost all cardiac diseases and increased levels of circulating microvesicles can be found in blood of patients with chronic heart failure. To point out the underlying mechanisms and to provide a new animal model based approach, we investigated microvesicle (MV)-release in mice that underwent Transverse Aortic Constriction (TAC). TAC is a common method to induce cardiac hypertrophy and heart failure in mice by inducing pressure overload. We hypothesized that TAC leads to upregulation of total MV and MV of specific origin.

Methods and results

Wildtype C57BL/6 mice underwent TAC to induce cardiac hypertrophy and heart failure. After TAC, mice developed cardiac hypertrophy as determined by altered heart weight/ bodyweight ratio, end-diastolic and end-systolic diameter and decreased fractional shortening. Total numbers of circulating microvesicles were detected 1, 4 and 12 weeks after TAC. We found that total numbers of circulating macrovesicles raised in a time dependent manner. Similar observations could be done with samples stained for annexin V, although results were not significant. Moreover, microvesicles were stained with specific surface markers for lymphocyte (CD3), monocyte (CD14), endothelial cells (CD31), thrombocytes (CD41), B-cells (CD45) and neutrophils (Lys6). One week after TAC increased numbers of specific microvesicles could be detected which in the course declined rapidly. Only microvesicles subgroup of lymphocyte origin showed significant increase one week after TAC-OP.

Conclusion

In this study, we show that total number of circulating microvesicles raise after TAC over an observation period of 12 weeks. Furthermore, we found that increased numbers of circulating microvesicles of specific origin like lymphocytes, monocytes, endothelial cells, thrombocytes, B-cells and neutrophils showed a trend towards increased levels one week after TAC with a rapid decline in subsequent detection. To our knowledge this is the first time that the impact of TAC on number of circulating microvesicles in mice was investigated. Future studies should characterize the content and effects of these MV on recipient cells to elucidate possible contributions to heart failure progression or protective effects. Detecting new harmful or protective effects of heart failure triggered by circulating microvesicles could offer new highly needed approaches to suppress heart failure development or deliver the possibility to develop new drugs for heart failure treatment.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Else Kröner-Fresenius

Levels of platelet derived extracellular vesicles in the left atrial appendage are higher in patients with permanent atrial fibrillation

Introduction

Atrial fibrillation (AF) is a frequent arrhythmic disease and one of the most important causes of thrombembolic disease due to intracardiac thrombus formation. The left atrial appendage has been identified as the structure, where thrombus formation typically takes place in AF patients. Previous studies have shown thrombus formation is more frequent in permanent, than in paroxysmal or persistent AF. Underlying causes for this finding, however, remain unclear. Recently, it has been shown, that large extracellular vesicles (Microvesicles, MVs) are mediators of platelet activation. The aim of this study is therefore to investigate if the AF subtype correlates with the regional abundance of platelet derived MVs in the left atrial appendage.

Methods and results

In order to address this question blood samples from 59 consecutive patients undergoing left and right atrial catheterization were collected from the right atrium (RA), the left atrium (LA) and the left atrial appendage (LAA). 49% of the patients had permanent AF, 34% had non-permanent AF and 17% had no history of AF. MVs were isolated from 150 μL citrate plasma by a four-step differential centrifugation protocol (20000g x 40 min as main pelleting step). The MVs were characterized by immunoblotting and nanoparticle tracking analysis. The size of the MVs ranged between 50 and 600 nm and the MVs were shown to carry typical markers such as Annexin V. For flowcytometric analysis and quantification, Calcein AM was used to identify vesicles and CD31-PE, CD41-APC, CD235a-PE-Cy7 were applied to differentiate between platelet-derived MVs (PMVs, CD41+ CD31+), endothelial cell-derived MVs (EMVs, CD41- CD31+) and Red blood cell-derived MVs (RMVs, CD235a+). Fluorescence minus one controls, a concentration row and detergent mediated degradation were used to confirm specific staining of MVs. Total MV numbers (Calcein + events) did not differ significantly between the three cardiac localizations. In the left atrial appendage, the proportion of PMV was significantly higher in permanent AF patients compared to non-permanent AF. EMV numbers only differed in the right atrium, where permanent AF patients exhibited significantly lower numbers of EMVs compared to no AF controls. No differences between the groups were detected for RMV.

Conclusion

In the present study, we found that PMV levels in the left atrial appendage correlate with the type of atrial fibrillation (permanent vs non-permanent). PMVs have been connected to platelet activation and thrombus formation. These results may help to better understand how different types of atrial fibrillation cause different rates of thrombus formation in the LAA.

PMV and EMV numbers by AF subtype

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical Faculty University Bonn

The role of noncoding RNAs during aortic valve stenosis

Background

Aortic valve stenosis (AVS) is the most common valve disease worldwide. Thought to be a purely degenerative disease, it is now clear that shear stress/endothelial dysfunction, lipid deposition and inflammation lead to calcification and stenosis of the valve. There is evidence, that extracellular vesicles (EVs) are actively involved in calcification processes. Practically all cells, including endothelial cells, can generate EVs, which can be shed into the blood stream and into the interstitial space. EVs contain lipids, proteins and nucleic acids, including noncoding RNAs (ncRNAs). EVs can be taken up by acceptor cells and their cargo, especially the ncRNA content, can change the phenotype of these cells. NcRNAs have been shown to have protective and damaging properties in AVS, which can lead to disease progression. EVs are actively involved in atherosclerosis and vascular calcification, but their role during AVS formation remains largely unknown.

Purpose

We hypothesize, that EV-derived ncRNAs play a crucial role during calcification of the aortic valve through regulation of endothelial to mesenchymal transition (EndMT) and calcification of valvular interstitial cells.

Methods and results

In initial screening experiments, we investigated ncRNA (micro RNA, miRNA and long noncoding RNA, lncRNA) content in aortic valve tissue from explanted human aortic valves from patients undergoing surgical aortic valve replacement. There is a differential expression of miRNAs and lncRNAs in aortic valve tissue from patients with AVS and patients without AVS. We could also show a differential packaging of ncRNAs into EVs generated from patient aortic valve tissues. Furthermore, ncRNA expression in aortic valve tissue is altered in a “wire-injury” mouse model of AVS. We can demonstrate in vitro that EVs and their content can be transferred from valvular endothelial cells (VECs) to valvular interstitial cells (VICs) and vice versa. Additionally, we have established an isolation method of VECs and VICs from human samples. To identify ncRNAs involved in EndMT, we are investigating the effect of laminar and pulsatile flow on the expression of ncRNAs in vitro. We can demonstrate that different flow patterns lead to a vast change in ncRNA expression in primary VECs. Downstream effects of identified ncRNAs are currently under investigation in our in vitro calcification and EndMT models. Transfection of VICs with miRNA mimics and inhibitors and lentiviral transduction of our identified targets lead to an altered calcification potential of valve cells.

Conclusion

The analysis of the cell type specific expression of ncRNAs and the intercellular communication via EVs will greatly help our understanding of the pathomechanisms leading to valvular calcification. Pathway analysis will generate new targets that could be used to develop therapeutics to ameliorate disease progression. EV-based miRNA mimics and inhibitors could be used to treat valvular calcification.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft, TRR259; Else-Kröner-Fresenius

Toll-like-receptor-3 function is critical for aortic valve stenosis development in mice

Background

Aortic valve stenosis (AS) is the most common valve diseases in the western world. After having been considered a passive degenerative process, which develops as an inevitable consequence of age-related valvular degeneration, basic research of the last two decades has led to a paradigm shift. It is now believed that AS pathophysiology is driven by distinct molecular and cellular mechanisms which include inflammatory pathways. In recent years, Toll-like-receptor-3 (TLR3) has emerged as a major regulator of vascular inflammation. TLR3 is a lysosomal pattern recognition receptor that recognizes single and double stranded RNA. Its activation leads to expression of pro-inflammatory cytokines via NFkb activation. The role of TLR3 in the development of AS has never been investigated.

Methods

Severe AS was induced in Wildtype-, ApoE- and TLR3/ApoE−/− mice. For this, a coronary springwire was used to induce an endothelial injury under echocardiographic guidance. Stenosis development was confirmed via ultrasound examinations. To inhibit TLR-3 activation, TLR3/RNA- Complex inhibitor C4a was injected every 48h after wire injury in WT mice. Valves were explanted and stained with hematoxylin/eosin (valve thickening) or anti-68 (macrophage infiltration). Valves from patients who received aortic valve replacement due to AS or aortic regurgitation (AR) were collected and mRNA levels of TLR3 and MyD88 were measured with use of quantitative-PCR.

Results

To evaluate weather TLR3 effects AS development in mice, we subjected TLR3/ApoE double- and ApoE knockout mice to our model of wire-induced AS. Surprisingly, TLR3 deficient mice failed to develop AS after wire injury. Peak velocity measurements showed no increase and histological analysis showed lower aortic valve area and macrophage infiltration compared to control mice. In order to pharmacological inhibit TLR3, WT mice were treated with C4a after wire injury. Compared to PBS control, C4a mice also did not develop AS upon wire injury. Trans-aortic valve peak velocity levels were significantly lower in C4a mice. Histological analysis underlined these results and showed thinner aortic valves and decreased macrophage infiltration in C4a mice comparted to control animals. To confirm our hypothesis, the expression of TLR3 and its downstream effector MyD88 were measured in human aortic valve specimens. qPCR analysis revealed decreased TLR3 and MyD88 expression in patients with AS compared to patients with AR.

Conclusion

In the presented study, we present first data that theTLR3 has a crucial role in the development of AS in mice. The exact downstream effects after TLR3 activation in AS need to be further investigated.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)