Patient Advocates and Researchers as Partners in Cancer Research: A Winning Combination

Inclusion of advocates as partners in research is now required by numerous international funding agencies. The role of advocates has expanded in recent years to include all areas of research, including basic cancer research, translational research, and clinical trial design and development. The involvement of advocates as partners in cancer research can be challenging for the advocate and for the researchers, but this collaboration is beneficial to all involved. Herein, we will define patient advocacy, explore advocate engagement, and share information on programs that train advocates and researchers to work together as partners.

Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update

PURPOSE

To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with immune checkpoint inhibitor (ICPi) therapy.

METHODS

A multidisciplinary panel of medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to update the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 through 2021.

RESULTS

A total of 175 studies met the eligibility criteria of the systematic review and were pertinent to the development of the recommendations. Because of the paucity of high-quality evidence, recommendations are based on expert consensus.

RECOMMENDATIONS

Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to the organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, except for some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert ≤ grade 1. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids. Corticosteroids should be tapered over the course of at least 4-6 weeks. Some refractory cases may require other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, except for endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines.

Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy: ASCO Guideline

PURPOSE

To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with chimeric antigen receptor (CAR) T-cell therapy.

METHODS

A multidisciplinary panel of medical oncology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to develop the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 to 2021.

RESULTS

The systematic review identified 35 eligible publications. Because of the paucity of high-quality evidence, recommendations are based on expert consensus.

RECOMMENDATIONS

The multidisciplinary team issued recommendations to aid in the recognition, workup, evaluation, and management of the most common CAR T-cell-related toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, B-cell aplasia, cytopenias, and infections. Management of short-term toxicities associated with CAR T cells begins with supportive care for most patients, but may require pharmacologic interventions for those without adequate response. Management of patients with prolonged or severe CAR T-cell-associated cytokine release syndrome includes treatment with tocilizumab with or without a corticosteroid. On the basis of the potential for rapid decline, patients with moderate to severe immune effector cell-associated neurotoxicity syndrome should be managed with corticosteroids and supportive care.Additional information is available at www.asco.org/supportive-care-guidelines.

Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline

Purpose To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events in patients treated with immune checkpoint inhibitor (ICPi) therapy. Methods A multidisciplinary, multi-organizational panel of experts in medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, urology, neurology, hematology, emergency medicine, nursing, trialist, and advocacy was convened to develop the clinical practice guideline. Guideline development involved a systematic review of the literature and an informal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, randomized controlled trials, and case series published from 2000 through 2017. Results The systematic review identified 204 eligible publications. Much of the evidence consisted of systematic reviews of observational data, consensus guidelines, case series, and case reports. Due to the paucity of high-quality evidence on management of immune-related adverse events, recommendations are based on expert consensus. Recommendations Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, with the exception of some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert to grade 1 or less. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids (prednisone 1 to 2 mg/kg/d or methylprednisolone 1 to 2 mg/kg/d). Corticosteroids should be tapered over the course of at least 4 to 6 weeks. Some refractory cases may require infliximab or other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, with the exception of endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .

Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline

Purpose To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events in patients treated with immune checkpoint inhibitor (ICPi) therapy. Methods A multidisciplinary, multi-organizational panel of experts in medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, urology, neurology, hematology, emergency medicine, nursing, trialist, and advocacy was convened to develop the clinical practice guideline. Guideline development involved a systematic review of the literature and an informal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, randomized controlled trials, and case series published from 2000 through 2017. Results The systematic review identified 204 eligible publications. Much of the evidence consisted of systematic reviews of observational data, consensus guidelines, case series, and case reports. Due to the paucity of high-quality evidence on management of immune-related adverse events, recommendations are based on expert consensus. Recommendations Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, with the exception of some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert to grade 1 or less. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids (prednisone 1 to 2 mg/kg/d or methylprednisolone 1 to 2 mg/kg/d). Corticosteroids should be tapered over the course of at least 4 to 6 weeks. Some refractory cases may require infliximab or other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, with the exception of endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .

Inferring outcrossing in the homothallic fungus Sclerotinia sclerotiorum using linkage disequilibrium decay

The occurrence and frequency of outcrossing in homothallic fungal species in nature is an unresolved question. Here we report detection of frequent outcrossing in the homothallic fungus Sclerotinia sclerotiorum. In using multilocus linkage disequilibrium (LD) to infer recombination among microsatellite alleles, high mutation rates confound the estimates of recombination. To distinguish high mutation rates from recombination to infer outcrossing, 8 population samples comprising 268 S. sclerotiorum isolates from widely distributed agricultural fields were genotyped for 12 microsatellite markers, resulting in multiple polymorphic markers on three chromosomes. Each isolate was homokaryotic for the 12 loci. Pairwise LD was estimated using three methods: Fisher's exact test, index of association (IA) and Hedrick's D'. For most of the populations, pairwise LD decayed with increasing physical distance between loci in two of the three chromosomes. Therefore, the observed recombination of alleles cannot be simply attributed to mutation alone. Different recombination rates in various DNA regions (recombination hot/cold spots) and different evolutionary histories of the populations could explain the observed differences in rates of LD decay among the chromosomes and among populations. The majority of the isolates exhibited mycelial incompatibility, minimizing the possibility of heterokaryon formation and mitotic recombination. Thus, the observed high intrachromosomal recombination is due to meiotic recombination, suggesting frequent outcrossing in these populations, supporting the view that homothallism favors universal compatibility of gametes instead of traditionally believed haploid selfing in S. sclerotiorum. Frequent outcrossing facilitates emergence and spread of new traits such as fungicide resistance, increasing difficulties in managing Sclerotinia diseases.

First Report of Lentil Root Rot Caused by Aphanomyces euteiches in Idaho

In June 2008, lentil plants (Lens culinaris Medik. cv. Crimson) in a field in Kendrick, ID exhibited symptoms including stunting, leaf chlorosis, reddening of abaxial leaf surfaces, root browning, and necrosis. Roots were surface sterilized, plated on water agar, and pure cultures were obtained through hyphal tips. DNA was extracted from mycelia and amplified with PCR primers that produced a 1,332-bp fragment specific for Aphanomyces euteiches Drechs (4). DNA of A. euteiches isolated from pea (Pisum sativum L.) was used as a positive control for PCR. A PCR product of the expected size was amplified from the positive control and also from a single isolate obtained from symptomatic lentils. Mycelial mats of the isolate (No. 823) were incubated overnight in a dilute mineral salt solution (1), a process that routinely produced 350,000 zoospores/ml, which were used to screen 33 advanced lentil breeding lines and three lentil cultivars (Eston, Crimson, and Pardina). Plants were grown in greenhouse flats containing perlite. At the time of planting, all flats were inoculated with a liquid suspension of Rhizobium leguminosarum bv. viceae. One week after emergence, all seedlings were inoculated with 20,000 or 5,000 zoospores of A. euteiches isolate 823. Plants were scored 14 days after inoculation using a 1 (no discoloration of roots) to 5 (dead seedling) disease severity index (DSI) commonly used to evaluate disease reaction to A. euteiches in pea (3). For each inoculum level, six plants of each lentil genotype were scored for disease reaction and the experiments were repeated once. A pooled analysis of both replications indicated that all entries were at least moderately susceptible to A. euteiches (mean DSI ≥3) at both inoculum levels, and the majority was highly susceptible (DSI ≥4). Oospores ~20 μm in diameter were observed in lentil roots 14 days after inoculation. In addition, five plants each of 73 NPGS PI accessions and four lentil cultivars (Eston, Crimson, Pardina, and Riveland) were inoculated with 250 zoospores per plant and scored for disease reaction. These experiments were repeated twice. Significant differences in DSI were observed among entries. The grand mean DSI of all entries was 3.56. The mean DSI of entries based on a pooled analysis of three replications ranged from 2.67 (Riveland) to 4.0 (PI 472561). All plants for each replication were bulked and dried in an oven, as were five noninoculated plants for each entry, and weighed. The average percent weight of inoculated plants relative to that of noninoculated plants for all 77 entries was 32.7% and the correlation between this percentage and DSI was -0.25 (P = 0.03). The results suggest that resistance to A. euteiches is lacking in the lentil genotypes examined and that plant biomass is reduced by the pathogen. Moussart et al. (2) recently demonstrated that a French pea isolate of A. euteiches caused severe disease among a set of 28 lentil genotypes. We detected A. euteiches in a field in which peas were recently grown and this isolate likely originated from peas. Additional lentil fields in Washington and Idaho will be surveyed for the presence of A. euteiches. Preliminary lentil breeding lines and additional accessions will be screened for tolerance to A. euteiches in the greenhouse and field. References: (1) L. M. Carman et al. Phytopathology 49:535, 1959. (2) A. Moussart et al. Eur. J. Plant Pathol. 122:321, 2008. (3) A. Rao et al. Plant Dis. 79:128, 1995. (4) G. J. Vandemark et al. Phytopathology 90:1137, 2000.

Pratylenchus neglectus, P. thornei, and Paratylenchus hamatus Nematodes Causing Yield Reduction to Dryland Peas and Lentils in Idaho

In June 2006, stunted and chlorotic plants were observed in large patches in two 40.5-ha fields of dryland peas (Pisum sativum) in Latah County, Idaho, which resulted in 90 and 75% crop loss. In the same region, a 121.4-ha field of dryland lentils (Lens culinaris) also had plants showing poor growth, wilting, and yellowing in large patches, which resulted in 40% crop loss. Two species of lesion nematodes (Pratylenchus neglectus and P. thornei) and one species of pin nematode (Paratylenchus hamatus) were extracted from rhizosphere soil and the roots of symptomatic plants from these fields. In a subsequent survey of seven dryland pea fields, under cv. Columbian, in Latah and Nez Perce counties and one dryland pea field, under cv. Small Sieve, in Latah County, plant samples had means of 551 and 2,178 mixed species of lesion nematodes per gram of dry root, respectively. Plant samples from 12 lentil fields in Latah County, six planted with cv. Red Chief and six with cv. Pardina, had means of 279 and 987 mixed species of lesion nematodes per gram of dry root, respectively. Soil samples from the same fields had a mean of 628 and 671 pin nematodes, Paratylenchus hamatus, per 250 cm³ soil for Red Chief and Pardina, respectively. Lentils cv. Pardina and peas cv. Columbian were planted separately in six pots, five seeds per pot containing 250 g of infested soil brought from the field to the greenhouse. Fumigated sandy loam soil was used as control. These assays were repeated three times. In addition, peas and lentils were planted to pots infested singly with each of the three nematode species. For this assay, nematodes were extracted from field soil, surface sterilized, and used to infest 250 g of fumigated sandy loam soil at two nematodes per gram of soil. Six plants per nematode species and an uninoculated control were used in the greenhouse assays, which were repeated three times. Nematodes in all of the assays reduced plant growth in comparison with controls; an average of 50 to 70% reduction in plant height was noted. The lesion nematode populations increased in all pots. The greenhouse assays verified the negative impact of these nematodes on growth of dryland peas cvs. Columbian and Small Sieve and lentils cvs. Red Chief and Pardina. P. neglectus, P. thornei, and Paratylenchus spp. previously have been reported from the semi-arid Pacific Northwest (1). However, to our knowledge, this is the first report attributing plant growth and yield reduction of certain cultivars of lentils and peas to these two species of lesion nematodes and pin nematodes, identified to species level as Paratylenchus hamatus. Reference: (1) R. W. Smiley et al. J. Nematol. 36:54, 2004.

Survival of Sporangia of New Clonal Lineages of Phytophthora infestans in Soil Under Semiarid Conditions

Currently, there is no information on the viability of sporangia in soil of the new metalaxyl-resistant genotypes of Phytophthora infestans in the semiarid Columbia Basin of Washington and potato-growing regions throughout the world. Sporangia of metalaxyl-resistant US-8 and US-11 clonal lineages of P. infestans survived a maximum of 23 to 30 days in a Shano silt loam and a Quincy loamy fine sand. There were no significant differences between soil types in area under the spore survival curve (AUSSC) in two trials, however, sporangia of P. infestans in the Quincy sand had a significantly greater mean maximum days of sporangia survival (MDSS) than did the Shano silt loam in one of two trials. AUSSC and MDSS were significantly greater (P < 0.05) for sporangia in wet soil than in dry soil under shaded conditions. Mean AUSSC and MDSS significantly decreased (P < 0.01) under nonshaded conditions versus shaded conditions. Three metalaxyl-resistant isolates (two US-8 and one US-11) of P. infestans did not significantly differ (P < 0.05) in AUSSC and MDSS.

Effects of Soil-Applied Late Blight Foliar Fungicides on Infection of Potato Tubers by Phytophthora infestans

Potato tuber infection was assessed under greenhouse and outdoor conditions when late blight foliar fungicides were applied to soil 24 h prior to soil infestation with a suspension of zoospores and sporangia of Phytophthora infestans. Spore viability of P. infestans in soil treated with various fungicides was determined using buried healthy whole tubers and by assaying infested soil applied to freshly cut tuber disks. Protection of tubers and tuber disks from infection was more effective when soil was treated with mancozeb, metiram, and cyazofamid than with other fungicides. Whole tuber infections were significantly less in soils treated with mancozeb, metiram, fluazinam, and fenamidone than when treated with distilled water. Infection of buried tubers and tuber disks was prevented for 3 to 5 days following a single soil application of mancozeb or metiram under outdoor conditions. The tuber disk method was more sensitive in determining the efficacy of a fungicide in inhibiting infection and spore viability than using whole buried tubers. However, both methods of determining viability may determine different modes of action of some fungicides that inhibit infection since whole tubers were not infected when protected by some fungicides but tuber disks were infected.

Effects of Tuber Depth and Soil Moisture on Infection of Potato Tubers in Soil by Phytophthora infestans

The effects of tuber depth, soil type, and soil moisture on potato tuber infection due to Phytophthora infestans were assessed under greenhouse conditions in soil contained in large pots. Healthy tubers were used to assess infection and were either hand buried in soil at specific depths or naturally formed from potato plants growing in the soil. A spore suspension of P. infestans was chilled to induce zoospore formation and a suspension of resulting zoospores and sporangia were applied to the soil. Soil depth at which tubers became infected was used to determine the extent of spore movement in the soils. Tuber infection significantly decreased with increasing soil depth. Most infected tubers were found at the surface of soil; infection was rare on tubers at 5 cm or deeper in the soil. Amount of tuber infection varied among soil types. Significantly less tuber infection occurred in a Shano silt loam than in medium and fine sands. Only tubers on the soil surface were infected in the Shano silt loam. Depth in soil at which tubers became infected did not differ significantly among Quincy fine sand, Quincy loamy fine sand, and Quincy medium sand. Increased soil moisture did not significantly increase the soil depth at which tuber infection occurred, regardless of the soil type.

Identification and Characterization of Resistance to Phytophthora infestans in Leaves, Stems, Flowers, and Tubers of Potato Clones in the Pacific Northwest

Resistance to Phytophthora infestans in leaves, stems, flowers, and tubers of eight cultivars grown commercially in the Columbia Basin and 29 advanced clones from the Tri-State Potato Variety Development Program was quantified. Foliage of all eight cultivars was susceptible in field and greenhouse tests. Six advanced clones had high levels of resistance in stems and leaves in the field at Mount Vernon, WA, but only two of these six clones had high levels of resistance in leaves and stems in greenhouse tests. Flowers of most plants with high to moderate levels of foliar resistance were susceptible to infection in both the field and greenhouse. Tubers of Umatilla Russet, Russet Legend, Gem Russet, and nine advanced clones, including A90586-11, had high levels of resistance in most laboratory tests. Level of foliar resistance against US-8 and US-11 clonal lineages of P. infestans was variable among clones, but tuber resistance by pathogen clonal lineage varied little among clones. Clones with high resistance expressed quantitative differences compared with susceptible cultivars and likely possess a high level of partial resistance.

Ecto-ATPase mRNA is regulated by FSH in Sertoli cells

A putative messenger RNA (mRNA) sequence, designated C8, that was up-regulated in Sertoli cells prepared from hypophysectomized rats treated with testosterone, was isolated from a Sertoli cell complementary DNA (cDNA) library. The coding region of C8 exhibited 99% identity with rat brain ecto-ATPase and expressed a 60-kilodalton protein following in vitro transcription/translation. Transfection of COS7 cells with C8 cDNA resulted in a marked increase in Ca2+- and Mg2+-dependent ATPase activity in both whole cells and cell homogenates, which is consistent with localization of this enzyme in the plasma membrane. C8 ecto-ATPase steady state mRNA levels were increased within 6 hours and for 3 day, by follicle-stimulating hormone (FSH) in Sertoli cells but not in peritubular cells. In contrast, dibutyryl-cyclic adenosine monophosphate (cAMP) increased ecto-ATPase in both Sertoli and peritubular cells. Testosterone had no significant effect under these conditions. These data indicate that ecto-ATPase mRNA is positively regulated by FSH in Sertoli cells and by cAMP in both Sertoli and peritubular cells. This enzyme may play a role in the control of extracellular signaling by ATP, adenosine, or both in the cells of the seminiferous epithelium.

Regulation of androgen receptor mRNA in rat Sertoli and peritubular cells

Regulation of 9.5-kb androgen receptor mRNA concentrations in Sertoli and peritubular cells from 20-day-old rats was studied by Northern blot analysis. Treatment of cells in vitro for 1-7 days with 300 ng/ml FSH increased androgen receptor mRNA up to 4-fold in Sertoli cells but not in peritubular cells. Testosterone (100 ng/ml) had no effect or slightly decreased androgen receptor mRNA in Sertoli and peritubular cells. Androgen receptor mRNA concentrations in Sertoli and peritubular cells from rats killed 15 days after hypophysectomy were elevated 4-5-fold over those in cells from intact rats. The androgen receptor mRNA concentration was decreased in both Sertoli and peritubular cells isolated from hypophysectomized animals treated with 500 micrograms/day testosterone propionate in vivo and subsequently with 100 ng/ml testosterone in vitro. FSH treatment (100 micrograms/day in vivo, followed by 300 ng/ml in vitro) did not increase androgen receptor mRNA over that in cells from hypophysectomized controls but rather decreased its concentration to varying degrees in Sertoli and peritubular cells. The rise in androgen receptor mRNA in both Sertoli and peritubular cells isolated from hypophysectomized animals is attributable, at least in part, to the absence of the inhibitory influence of testosterone. Other data in the literature suggest positive regulation of Sertoli cell androgen receptor protein by FSH and androgens. Consequently, complex mechanisms involving transcriptional, translational, and post-translational regulation probably control androgen receptor concentrations in the cells of the rat seminiferous tubule.

Electrophysiologic evaluation of the facial nerve in Bell's palsy. A review

Facial nerve paralysis is the most common mononeuropathy and idiopathic facial paralysis (Bell's palsy) the most common seventh nerve disease electromyographers may be asked to evaluate. The electrophysiologic method of choice to assess the facial nerve is side-to-side evoked amplitude comparison with the affected side expressed as a percentage of the nonaffected side. This examination should be performed on days 3, 5, 7, 9, 11 and 13 after onset of paralysis. If the percentage of surviving axons falls below 10% within the first 14 days, an incomplete recovery is suggested. Electromyography may assist in prognosticating a functional return, determining neural conduction across the site of injury and following reinervation in the recovery period. The persistence or early return of an absent R1 component of the blink reflex may qualitatively suggest a satisfactory functional outcome in facial paralysis. Supramaximally exciting the facial nerve at the stylomastoid foramen and comparing the clinical response on the affected and nonaffected side, maximum stimulation test, can also predict eventual seventh nerve return. Observing a minimal twitch, utilizing the nerve excitability test or measuring the facial nerve latency have yielded poor correlations with functional return and are of limited usefulness in the prognostication of acute facial palsies. Trigeminal somatosensory evoked potentials can be employed to evaluate the status of the trigeminal nerve as approximately 50% of patients with Bell's palsy also have lesions involving the fifth nerve. Side-to-side amplitude comparison and electromyography are the two most valuable electrophysiologic methods of assessing facial nerve functioning.