Primary Palliative Care in Urology: Quality Improvement Summit 2021-2022

INTRODUCTION

The AUA convened a 2021-2022 Quality Improvement Summit to bring together interdisciplinary providers to inform the current state and to discuss potential strategies for integrating primary palliative care into urology practice. We hypothesized that the Summit findings would inform a scalable primary palliative care model for urology.

METHODS

The 3-part summit reached a total of 160 interdisciplinary health care professionals. Webinar 1, "Building a Primary Palliative Care Model for Urology," focused on a urologist's role in palliative care. Webinar 2, "Perspectives on Increasing the Use of Palliative Care in Advanced Urologic Disease," addressed barriers to possible implementation of a primary palliative care model. The in-person Summit, "Laying the Foundation for Primary Palliative Care in Urology," focused on operationalization of primary palliative care, clinical innovations needed, and relevant metrics.

RESULTS

Participants agreed that palliative care is needed early in the disease course for patients with advanced disease, including those with benign and malignant conditions. The group agreed about the important domains that should be addressed as well as the interdisciplinary providers who are best suited to address each domain. There was consensus that a primary "quarterback" was needed, encapsulated in a conceptual model-UroPal-with a urologist at the hub of care.

CONCLUSIONS

The Summit provides the field of urology with a framework and specific steps that can be taken to move urology-palliative care integration forward. Urologists are uniquely positioned to provide primary palliative care for their many patients with serious illness, both in the surgical and chronic care contexts.

Integrin α3 negative podocytes: A gene expression study

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New cell model to investigate the impact of loss of integrin α3 in podocytes.

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In this novel model, genes of the extracellular matrix and adhesome are mostly downregulated.

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Loss of integrin α3 results in changes of cell adhesion and spreading.

Integrin α3β1 is a cell adhesion receptor widely expressed in epithelial cells. Pathogenic variants in the gene encoding the integrin α3 subunit ITGA3 lead to a syndrome including interstitial lung disease, nephrotic syndrome, and epidermolysis bullosa (ILNEB). Renal involvement mainly consists of glomerular disease caused by loss of adhesion between podocytes and the glomerular basement membrane.

The aim of this study was to characterize the impact of loss of integrin α3 on human podocytes.

ITGA3 was stably knocked-out in the human podocyte cell line AB8/13, designated as Podo^A3−, and in human proximal tubule epithelial cell line HK2 using the targeted genome editing technique CRISPR/Cas9. Cell clones were characterized by Sanger sequencing, quantitative PCR, Western Blot and immunofluorescence staining. RNASeq of integrin α3 negative cells and controls was performed to identify differential gene expression patterns.

Differentiated Podo^A3− did not substantially change morphology and adhesion under standard culture conditions, but displayed significantly reduced spreading and adhesion when seed on laminin 511 in serum free medium. Gene expression studies demonstrated a distinct dysregulation of the adhesion network with downregulation of most integrin α3 interaction partners. In agreement with this, biological processes such as “extracellular matrix organization” and “cell differentiation” as well as KEGG pathways such as “ECM-receptor interaction”, “focal adhesion” and the “PI3K-Akt signaling pathway” were significantly downregulated in human podocytes lacking the integrin α3 subunit.

Abstract 55: A genome-wide atlas of recurrent repeat expansions in human cancer genomes

Expansion of a single repetitive DNA sequence, termed a tandem repeat (TR), is known to cause more than 40 neurodegenerative diseases. However, repeat expansions have not been systematically examined in contexts beyond neurological disorders. In a specific form of cancer, termed microsatellite instability (MSI), mutations accumulate in short (<50 bp) tracts of TRs, suggesting that cancer genomes may also harbor larger repeat expansions. Here, we developed a new method to systematically identify TR alterations and applied it to the analysis of 2,622 cancer genomes spanning 29 cancer types. We identified 160 recurrent repeat expansions (rREs) in 7 cancers; most (155/160) rREs were cancer-subtype specific. Surprisingly, rREs were not correlated with MSI status, demonstrating that they arise by a distinct process. We also found that rREs are situated closer to candidate cis-regulatory elements than expected by chance, suggesting a role in gene regulation. Interestingly, an rRE in the intron of UGT2B7, detected in 34% of renal cell carcinoma samples, is associated with a decrease in gene expression. Our results demonstrate that rREs are an important and unexplored source of genetic variation in human cancer and provide a large catalog for further study.

Citation Format: Graham S. Erwin, Gamze Gursoy, Rashid Al-Abri, Christian Hoerner, Egor Dolzhenko, Michael Eberle, Alice Fan, John Leppert, Mark Gerstein, Michael P. Snyder. A genome-wide atlas of recurrent repeat expansions in human cancer genomes [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 55.

P5537Biomarkers in addition to clinical characteristics for prediction of peripheral artery disease in patients with recent myocardial infarction

Background

Peripheral artery disease (PAD) is associated with increased risk of cardiovascular events and mortality. PAD is underdiagnosed in patients admitted for myocardial infarction (MI).

Purpose

To evaluate whether biomarkers in addition to clinical characteristics could improve the identification of PAD in MI patients.

Methods

Two prospectively observational studies including unselected patients with recent ST-elevation or non-ST elevation MI were used for the analyses. PAD was defined as abnormal ankle brachial indexes (ABI) score (<0.9 or >1.4) on at least one side. The Proximity Extension Assay (PEA) technique was used to simultaneously analyze 92 biomarkers with association to cardiovascular disease (CVD I and III, Olink Proteomics) in samples early after the acute MI. Random forest was used to identify the biomarkers with higher association to PAD. The discriminating accuracy of adding biomarkers to clinical characteristics including age, sex, diabetes mellitus, hypertension and smoking were analyzed by the c-statistic.

Results

In the REBUS cohort (n=420) the mean age was 67 years, 22.1% were women, 26.4% were smoking, 16.2% had diabetes and 53.3% hypertension. In the VAMIS cohort (n=998) the mean age was 71 years, 33.5% were women, 19.9% were smoking, 18.1% and 49.9% had diabetes and hypertension, respectively. PAD was found in 20.0% and 22.8% of the patients in the REBUS and VAMIS cohort, respectively. Six biomarkers associated with PAD (Tnfrsf 14, tnf r2, tnf r1, GDF-15, IL-6 ra, ctsd) were identified in the REBUS cohort and validated in the VAMIS cohort.

Additional predictive value of the biomarkers compared to the performance of the model with clinical characteristics, as measured by the c-statistic Clinical characteristics (CC) CC + Tnfrsf14 CC + Tnf r2 CC + Tnf r1 CC + GDF-15 CC + IL-6 ra CC + ctsd REBUS (n=420) 0.683 (0.610,0.756) 0.702 (0.632, 0.772) 0.703 (0.633, 0.773) 0.709 (0.640, 0.779) 0.710 (0.640, 0.781) 0.682 (0.608, 0.775) 0.683 (0.610, 0.757) VaMIS (n=998) 0.729 (0.687, 0.770) 0.732 (0.691, 0.733) 0.745 (0.704, 0.785) 0.746 (0.706, 0.787) 0.752 (0.711, 0.792) 0.729 (0.688, 0.770) 0.736 (0.695, 0.777) Tnfrsf 14 = tumor necrosis factor receptor superfamily member 14; Tnf r2 = tumor necrosis factor receptor 2; Tnf r1 = tumor necrosis factor receptor 1; GDF-15 = growth differentiation factor 15; IL-6 ra = interleukin-6 receptor subunit alpha; ctsd = Cathepsin D.

Conclusion

Out of a large panel of biomarkers, tumor necrosis factor and its receptors and GDF-15 were identified associated with PAD in MI patients.

In this underdiagnosed manifestation of atherosclerosis in MI patients, clinical characteristics are strong predictors of PAD, but the cytokines may have an additional value. Further studies focusing on more widespread atherosclerosis in acute coronary syndrome might identify a patient group with benefit of treatment targeting inflammation.

Acknowledgement/Funding

None

Comparative effectiveness of non-cisplatin (cis)-based first-line (1L) regimens in patients with metastatic urothelial carcinoma (mUC): Veterans Affairs control cohorts vs. IMvigor210

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Background: For mUC patients (pts) ineligible for cis, 1L carboplatin (carbo)-based regimens and checkpoint inhibitors are recommended, but comparative data are lacking. We assessed OS in pts given 1L atezolizumab (atezo; anti–PD-L1) from Ph 2 study IMvigor210 and Veterans Affairs (VA) mUC pts treated with carbo standards. Methods: Carbo-based control cohorts were derived from the VA Health Care Network databases (diagnosed 2006-2017), with treatment (tx) defined per NCCN guidelines V2.2005. IMvigor210 eligibility criteria were used to refine non-cis VA cohorts. Prespecified OS predictors were balanced between VA and IMvigor210 pts using entropy (e)-balance weighting. OS was evaluated by Kaplan-Meier (KM) and Cox regression (weighted). Sensitivity analyses used stabilized inverse probability weighting (sIPW) and statistical adjustments. Results: Of 2056 VA pts included, 926 received carbo-based tx, of whom 380 received carbo+gemcitabine [CarboGem]; after IMvigor210 exclusion criteria, the carbo-based cohort included 282 pts, of whom 120 had CarboGem. Non-proportional hazards were seen with KM curves crossing at ≈ 5 (CarboGem) and 9 mo (carbo based). OS data are in the table. Weighted analyses showed OS benefit for atezo vs CarboGem and delayed benefit vs carbo-based tx. HRs from sensitivity analyses were consistent in direction and significance. Conclusions: We compared OS in mUC pts receiving 1L non-cis regimens in VA (carbo) and IMvigor210 (atezo) mUC cohorts. A lower risk of death was seen for atezo vs carbo, manifesting after a few months of tx. Randomized studies may validate these 1L mUC tx trends. Clinical trial information: NCT02951767. [Table: see text]

Responsiveness of stem-like human glioma cells to all-trans retinoic acid and requirement of retinoic acid receptor isotypes α, β and γ

Retinoic acid (RA) is required for development and homeostasis of the normal mammalian brain and may play a role in the initiation and progression of malignant brain tumors, such as the glioblastoma multiforme (GBM) and the gliosarcoma (Gsarc). The subpopulation of stem-like glioma cells (SLGCs) was shown to resist standard glioma radio-/chemotherapy and to propagate tumor regrowth. We used phenotypically distinct, self-renewing SLGC lines from six human GBMs, two Gsarcs, and two subcloned SLGC derivatives in order to investigate their responsiveness to all-trans retinoic acid (atRA) and to identify the RA-receptor (RAR) isotypes involved. In general, atRA exerted a pro-proliferative and pro-survival effect on SLGCs, though the efficacy was distinct. By means of RAR isotype-selective retinoids we disclosed that these effects were mediated by RARα and RARγ, except for one SLGC line, in which the pro-proliferative signal was induced by the RARβ-selective retinoid. Only one GBM-derived cell line (T1338) and a subpopulation of another (T1389) displayed neural differentiation in response to atRA. Differentiation of T1338 was induced by RARα and RARγ isotype-selective retinoids, associated with down-regulation of Sox2, and the failure to induce orthotopic tumors in the brains of SCID mice. The differential responsiveness of the SLGC lines appeared unrelated to the expression of RARβ, as (i) atRA augmented RAR isotype mRNA expression and particularly rarβ mRNA in all SLGC lines, (ii) rarβ promoter hypomethylation in the SLGC lines was not related to differentiation and (iii) the induction of T1338 differentiation was by RARα- and RARγ-selective ligands.

Abstract 2283: Nano-scale proteomic profiles of response to targeted therapy in patients with RCC

Novel agents that inhibit targets in the hypoxia and MTOR pathways can achieve response rates of 30-60% in renal cell carcinoma (RCC); however, biomarkers have not yet been identified to measure degree of target inhibition and mechanism of biologic response in individual patients. We developed the use of a high-throughput, nanoscale immunoassay (NIA, Nanopro1000 Instrument, Protein Simple) to profile hypoxia pathways and downstream signaling in serially sampled clinical specimens from patients with RCC. NIA uses charge-based separation to distinguish multiple charged modifications of individual proteins, and measure relative ratios of individual unphosphorylated and phosphorylated isoforms. We first developed and optimized assays to measure therapeutic targets and proteins in hypoxia, proliferation and metabolic pathways (including CaIX, HIF, VEGFR, ERK, AKT, MYC, glutaminase) to analyze frozen surgical specimens, fine needle aspirates (FNA's) and blood PBMC specimens from patients with RCC. Next, we analyzed more than 200 FNA's from solid tumors, comparing RCC with paired adjacent non-tumor tissue and other epithelial malignancies. Basal MAPK signaling across the samples ranged across 3 logs for both normal and tumor tissue, demonstrating the difficulty in setting a threshold predictive of response based on a single pre-treatment measurement. To test whether analysis of serial specimens could detect changes, we prospectively collected and analyzed blood peripheral mononuclear cells from 20 RCC patients before and during treatment with standard targeted therapies including MTOR and tyrosine kinase inhibitors. We report for the first time that targeted inhibitors can preferentially inhibit or activate specific protein phospho-isoforms in patients with RCC. Our studies demonstrate that rapid and quantitative nanoproteomic profiling in very small amounts of serially sampled clinical specimen may accelerate translational studies for predictive proteomic biomarkers of response to targeted therapy.

Citation Format: Alice C. Fan, John Leppert, Joanna E. Liliental, Liwen Xu, Thomas J. Metzner, Emelyn Shroff, Alia Yaghi, Christine Yost, James D. Brooks, Lauren C. Harshman, Chiara Sabatti, Sandhya Srinivas, Dean W. Felsher. Nano-scale proteomic profiles of response to targeted therapy in patients with RCC. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2283. doi:10.1158/1538-7445.AM2013-2283

Nanoscale proteomic profiling to define diagnostic signatures and biomarkers of therapeutic activity in patients with RCC

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Background: Novel agents that inhibit kinases in the hypoxia and MTOR pathways can achieve response rates of 30-60% in renal cell carcinoma (RCC); however, protein biomarkers to diagnose RCC and guide treatment have not been identified. Methods: We developed the use of two high-throughput, nanoscale immunoassays to profile hypoxia and downstream signaling in clinical specimens from patients with RCC. These automated technologies minimize errors due to manual variability, and make 96 independent measurements per overnight experiment. We used size-based protein separation (Sally Instrument, Protein Simple) to quantify proteins using antibody-specific detection, normalized to loading control. Next, we used a nano-immunoassay with charge-based separation (NIA, Nanopro1000 Instrument, Protein Simple) to distinguish multiple charged modifications of individual proteins, and measure relative ratios of individual unphosphorylated and phosphorylated isoforms. Results: We first optimized assays for proteins in MAPK, PI3K and STAT pathways, and loading controls, to analyze frozen surgical specimens and ex-vivo fine needle aspirates (FNA’s) performed immediately following nephrectomy. We analyzed more than 200 FNA’s from solid tumors, comparing RCC with paired adjacent non-tumor tissue, and other epithelial malignancies. Basal MAPK signaling of tumors varied across 3 logs of expression. Unique to NIA, we analyzed percent phosphorylation and resolved differences in single phosphorylations. Subtle differences in basal MAPK signaling between tumor calls and adjacent non-tumor tissue can distinguish RCC from other malignancies. Lastly, we prospectively collected and analyzed blood peripheral mononuclear cells from 20 RCC patients before and during treatment with standard targeted therapies. Kinase inhibitors can preferentially inhibit or activate specific protein phospho-isoforms. Conclusions: Our studies demonstrate that rapid and quantitative nanoproteomic profiling in very small amounts of clinical specimen may accelerate translational studies for novel diagnostic and predictive biomarkers.

Use of nano-immuno assay to generate rapid, quantitative nanoscale proteomic profiling of the hypoxia pathway in renal cell carcinoma clinical specimens

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Background: Novel agents that inhibit kinases in the hypoxia pathway [VEGF, PDGF] can achieve response rates of 30-57% in renal cell carcinoma (RCC); however, threshold levels of targets and downstream signaling proteins in patient cells have not been identified as biomarkers to guide treatment. Rapid and quantitative measurements of overall levels and % phosphorylation of proteins in the hypoxia pathway from patient specimens might better enable the development of proteomic biomarkers. Methods: We have developed the use of an automated nanoscale immuno assay (NIA) to profile hypoxia proteins in solid tumors, and now present NIA assays to measure EGFR, VEGF-R, AKT2, GSK3β, CA-9, MEK1 and ERK1/2 proteins in RCC clinical specimens. Furthermore, to decrease the amount of tissue and the invasiveness of the procedure required to obtain specimens for analysis, we have optimized assays to profile RCC specimens acquired by fine needle aspiration (FNA). Results: Unique to NIA technology, we have analyzed percent phosphorylation for phosphorylated proteins and can distinguish differences in even a single phosphorylation in the FNA specimens, allowing us to group tumors based upon different patterns of phosphorylation. In addition, we compared 10-parameter hypoxia profiles in a panel of RCC paired with adjacent non-tumor tissue and will present the proteins that can distinguish tumor from non-tumor tissue. Importantly, we have determined that we can present protein profiles to the clinical team within 8 hours of receiving the specimen (1 hour preparation time, 6 hours of unattended automated instrument time, 1 hour of analysis). Conclusions: NIA is an extremely efficient, quantitative and high-throughput platform that has the potential to be used to rapidly generate proteomic profiles for clinical specimens for the development of novel diagnostic and predictive biomarkers.

Maltreatment, MAOA, and delinquency: sex differences in gene-environment interaction in a large population-based cohort of adolescents

The present study investigated a possible interaction between a functional polymorphism in the MAOA gene promoter (MAOA-VNTR) and childhood maltreatment in the prediction of adolescent male and female delinquency. A cohort of 1,825 high school students, 17-18 years old, completed an anonymous questionnaire during class hours which included questions on childhood maltreatment, sexual abuse, and delinquency. Saliva samples were collected for DNA isolation, and analyzed for the MAOA-VNTR polymorphism. Self-reported maltreatment was a strong risk factor for adolescent delinquent behavior. The MAOA genotype also showed a significant main effect when controlled for maltreatment. Boys with a short variant and girls with one or two long variants of the polymorphism showed a higher risk for delinquency when exposed to maltreatment. Our results confirm previous findings of an interaction between the MAOA-VNTR polymorphism and self-reported maltreatment. Results for boys and girls differ according to MAOA-VNTR genotype and direction of phenotypic expression.

Sense of coherence and psychological well-being: improvement with age

BACKGROUND

Psychological well-being is important for individuals, communities and health services throughout the world because of the costs associated with psychological ill-health and the loss of quality of life for those affected and their relatives. Following a salutogenic approach, there is a link between health-promoting resources, such as generalised resistance resources and a positive state of health. Generalised resistance resources have been proposed to relate to an individual's sense of coherence (SOC). The objectives of the present study were (i) to investigate SOC in relation to age and sex, (ii) to investigate psychological well-being in relation to age and sex, and (iii) to investigate the relationship between generalised resistance resources and psychological well-being.

METHODS

A random sample of 43 598 respondents (54% female) aged 18-85 years participated in the present study via a postal survey questionnaire. SOC was measured by the SOC-13 and well-being by the General Health Questionnaire-12 questionnaire.

RESULTS

Males had both stronger SOC and well-being compared to females. There was a relationship between SOC and age, with stronger SOC in the older age groups. There was a larger proportion of individuals who experienced well-being as a function of age. In addition, an increase in SOC was related to a decrease in psychological well-being, that is, a stronger SOC corresponded to higher well-being.

CONCLUSION

Males showed a stronger SOC and more well-being than females. Moreover, SOC and well-being increased with age in both sexes. Our findings suggest that SOC may develop over a entire lifetime.

Quality of life and maintenance of improvements after early multimodal rehabilitation: A 5-year follow-up

PURPOSE

There is a paucity of long-term evaluations on rehabilitation of musculoskeletal disorders, e.g., neck, shoulder or back pain. The aim of this study was to assess quality of life and the effect of early multimodal rehabilitation on 91 patients with musculoskeletal pain and disability at a 5-year follow-up.

METHOD

The follow-up assessment, which included questions on pain, function, quality of life, perceived health, sick leave and psychosomatic symptoms, was performed 5 years after the assessment of baseline status.

RESULTS

Improvements in pain, perceived health and psychosomatic symptoms were maintained at the 5-year follow-up. In addition, improvements in function, quality of life, and level of acceptable pain were significant in comparison to baseline. At the time of the baseline assessment all patients were on sick leave (13% were on partial sick leave). At the 5-year follow-up, 58% of the patients were at work part or full time. The results show that those working differed significantly from those not working at the 5-year follow-up on almost all variables, indicating that those working enjoy better health. The most salient prognostic factors for return to work were perceived health and educational level at the time of the baseline evaluation.

CONCLUSIONS

These results show that treatment improved quality of life and the effects were basically maintained at 5 years. Work capacity as reflected in return to work increased greatly (81%) at a 1-year follow-up and was substantial (58%) at the 5-year follow-up. Moreover, perceived health and educational levels were important prognostic factors. Finally, the fact that patients working reported better health underscores the probable importance of return to work. Our results imply that it may be feasible to obtain long-term benefits from such a primary care-based intervention.

The effect of the calcium-entry blocker nifedipine on cold-induced digital vasospasm. A double-blind crossover study versus placebo

The effects of the calcium-entry blocker nifedipine 20 mg, two 10 mg capsules, t.i.d. in patients with cold-induced digital vasospastic disease of idiopathic or traumatic origin was tested in 28 patients, using double-blind crossover technique on both symptoms and test results. The effect of treatment on digital blood pressure during local cooling was assessed using the Nielsen-Lassen method. Symptomatic improvement was reported by 5 patients during placebo treatment and 17 during nifedipine treatment (p less than 0.01). The symptomatic improvement was significant in the total group of patients and in the group of patients with idiopathic vasospastic disease. The digital blood pressure during local cooling improved significantly with nifedipine at 5, 10, 15 (p less than 0.001) and 20 degrees C (p less than 0.05) for the total study population and for the two subgroups except for the change at 20 degrees C in the IDIOP group. At a digital temperature of 10 degrees C, 2 patients reached normal digital blood pressure during placebo treatment compared to 16 during nifedipine treatment (p less than 0.001). The number of side-effects increased significantly (p less than 0.05) during nifedipine treatment. We consider the use of nifedipine in patients with cold-induced digital vasospastic disease to be of great value, especially in patients with digital vasospastic disease of idiopathic origin.