A pre-implementation examination of barriers and facilitators of an electronic prospective surveillance model for cancer rehabilitation: a qualitative study

BACKGROUND

An electronic Prospective Surveillance Model (ePSM) uses patient-reported outcomes to monitor symptoms along the cancer pathway for timely identification and treatment. Randomized controlled trials show that ePSMs can effectively manage treatment-related adverse effects. However, an understanding of optimal approaches for implementing these systems into routine cancer care is limited. This study aimed to identify barriers and facilitators prior to the implementation of an ePSM to inform the selection of implementation strategies.

METHODS

A qualitative study using virtual focus groups and individual interviews was conducted with cancer survivors, oncology healthcare providers, and clinic leadership across four cancer centres in Canada. The Consolidated Framework for Implementation Research (CFIR) guided the interviews and analysis of barriers and facilitators based on five domains (intervention characteristics, individual characteristics, inner setting, outer setting, and process).

RESULTS

We conducted 13 focus groups and nine individual interviews with 13 patient participants and 56 clinic staff. Of the 39 CFIR constructs, 18 were identified as relevant determinants to the implementation. The adaptability, relative advantage, and complexity of an ePSM emerged as key intervention-level factors that could influence implementation. Knowledge of the system was important at the individual level. Within the inner setting, major determinants were the potential fit of an ePSM with clinical workflows (compatibility) and the resources that could be dedicated to the implementation effort (readiness for implementation). In the outer setting, meeting the needs of patients and the availability of rehabilitation supports were key determinants. Engaging various stakeholders was critical at the process level.

CONCLUSIONS

Improving the implementation of ePSMs in routine cancer care has the potential to facilitate early identification and management of treatment-related adverse effects, thereby improving quality of life. This study provides insight into important factors that may influence the implementation of an ePSM, which can be used to select appropriate implementation strategies to address these factors.

TAZ upregulates MIR-224 to inhibit oxidative stress response in multiple myeloma

BACKGROUND

Oxidative stress within the bone marrow niche of multiple myeloma contributes to disease progression and drug resistance. Recent studies have associated the Hippo pathway with miRNA biogenesis and oxidative stress in solid tumors. Oxidative stress and miRNA pathway inter-relates in several cancers. Our group recently showed that TAZ functions as a tumor suppressor in MM. However, the role of TAZ in oxidative stress in MM is unknown.

AIMS

We sought to examine the role of TAZ in myeloma cells' response to BM oxidative stress. We postulated that TAZ might be associated with an oxidative stress phenotype and distinct miRNA signature in MM.

METHODS AND RESULTS

Using human myeloma cell lines and clinical samples, we demonstrate that TAZ promotes myeloma cells' sensitivity to oxidative stress and anticancer-induced cytotoxicity by inducing miR-224 to repress the NRF2 antioxidant program in MM. We show that low expression of TAZ protein confers an oxidative stress-resistant phenotype in MM. Furthermore, we provide evidence that overexpression of miR-224 in myeloma cells expressing low amounts of TAZ protein inhibits cell growth and enhances sensitivity to anti-myeloma therapeutics.

CONCLUSION

Our findings uncover a potential role for TAZ in oxidative stress response in MM via the miR-224-NRF2 molecular pathway. This provides the scientific ground to explore miR-224 as a potential molecular target to modify TAZ expression and enhance myeloma sensitivity to treatment.

MST1 DOWNREGULATES TAZ TUMOUR SUPPRESSOR PROTEIN IN MULTIPLE MYELOMA AND IS A POTENTIAL THERAPEUTIC TARGET

We have previously reported that TAZ functions as a tumor suppressor in multiple myeloma. MST1 is a serine-threonine kinase upstream of the Hippo-signaling pathway that functions as a tumor suppressor in many non-haematological malignancies. However, its role in hematological malignancies, including MM is still poorly understood. In this paper, we provide evidence that MST1 expression is higher in MM, and negatively correlates with TAZ expression in both cell lines and patient samples. High MST1 expression was associated with poor clinical outcomes. Genetic or pharmacological inhibition of MST1 leads to increased TAZ expression and cell death. Importantly, MST1 inhibitors sensitizes myeloma cells to frontline antimyeloma agent-lenalidomide and dexamethasone. Taken together, our data reveals a key role for MST1 in MM pathogenesis and provide evidence to explore the therapeutic potential of using MST inhibitors to upregulate TAZ expression in MM to promote response to anticancer agents.

Implementation of electronic prospective surveillance models in cancer care: a scoping review

BACKGROUND

Electronic prospective surveillance models (ePSMs) for cancer rehabilitation include routine monitoring of the development of treatment toxicities and impairments via electronic patient-reported outcomes. Implementing ePSMs to address the knowledge-to-practice gap between the high incidence of impairments and low uptake of rehabilitation services is a top priority in cancer care.

METHODS

We conducted a scoping review to understand the state of the evidence concerning the implementation of ePSMs in oncology. Seven electronic databases were searched from inception to February 2021. All articles were screened and extracted by two independent reviewers. Data regarding the implementation strategies, outcomes, and determinants were extracted. The Expert Recommendations for Implementing Change taxonomy and the implementation outcomes taxonomy guided the synthesis of the implementation strategies and outcomes, respectively. The Consolidated Framework for Implementation Research guided the synthesis of determinants based on five domains (intervention characteristics, individual characteristics, inner setting, outer setting, and process).

RESULTS

Of the 5122 records identified, 46 interventions met inclusion criteria. The common implementation strategies employed were "conduct educational meetings," "distribute educational materials," "change record systems," and "intervene with patients to enhance uptake and adherence." Feasibility and acceptability were the prominent outcomes used to assess implementation. The complexity, relative advantage, design quality, and packaging were major implementation determinants at the intervention level. Knowledge was key at the individual level. At the inner setting level, major determinants were the implementation climate and readiness for implementation. At the outer setting level, meeting the needs of patients was the primary determinant. Engaging various stakeholders was key at the process level.

CONCLUSIONS

This review provides a comprehensive summary of what is known concerning the implementation of ePSMs. The results can inform future implementation and evaluation of ePSMs, including planning for key determinants, selecting implementation strategies, and considering outcomes alongside local contextual factors to guide the implementation process.

Nanoparticle surface-enhanced Raman spectroscopy as a noninvasive, label-free tool to monitor hematological malignancy

Aim: Monitoring minimal residual disease remains a challenge to the effective medical management of hematological malignancies; yet surface-enhanced Raman spectroscopy (SERS) has emerged as a potential clinical tool to do so. Materials & methods: We developed a cell-free, label-free SERS approach using gold nanoparticles (nanoSERS) to classify hematological malignancies referenced against two control cohorts: healthy and noncancer cardiovascular disease. A predictive model was built using machine-learning algorithms to incorporate disease burden scores for patients under standard treatment upon. Results: Linear- and quadratic-discriminant analysis distinguished three cohorts with 69.8 and 71.4% accuracies, respectively. A predictive nanoSERS model correlated (MSE = 1.6) with established clinical parameters. Conclusion: This study offers a proof-of-concept for the noninvasive monitoring of disease progression, highlighting the potential to incorporate nanoSERS into translational medicine.

Immunohistochemical validation study of 15-gene biomarker panel predictive of benefit from adjuvant chemotherapy in resected non-small-cell lung cancer: analysis of JBR.10

Objective

There are no validated approaches to predict benefit from adjuvant chemotherapy for resected patients with non-small-cell lung cancer (NSCLC). The aim of this study was to translate a 15-gene mRNA expression profile published by Zhu et al, shown to be prognostic and predictive of benefit, into a readily applicable immunohistochemistry (IHC) panel.

Methods

For seven of the genes in the gene expression profile (GEP) for which suitable commercial antibodies were available, we semiquantitatively assessed the IHC expression and prognostic significance for 173 patients treated at the Saint John Regional Hospital (SJRH). Cut-offs for high and low expression were defined for each marker and applied to IHC scores from 291 of the 482 patients in JBR.10, including patients on both the adjuvant chemotherapy and observation arms. The prognostic and predictive value of these markers on overall survival (OS) or recurrence-free survival (RFS) was assessed by Cox regression models.

Results

In the SJRH cohort, in 62 patients with resected stage II–III NSCLC, the prognostic significance of IHC assays for four proteins were concordant with Zhu’s GEP results. Low FOSL2 (OS, HR=0.15; p=0.0001; RFS, HR=0.14; p<0.0001) and high STMN2 (RFS, HR=2.501; p=0.0197) were adverse prognostic factors. Low ATP1B1 and low TRIM14 expression trended toward worse OS and RFS. Validation of these markers with JBR.10 patients failed to show prognostic significance either individually or in combined risk classifications. Additionally, the interaction between these markers and chemotherapy treatment in predicting OS (FOSL2, p=0.52; STMN2 p=0.14; ATP1B1, p=0.33; TRIM14, p=0.81) or RFS (FOSL2, p=0.63; STMN2, p=0.12; ATP1B1, p=0.66; TRIM14, p=0.57) did not reach significance, individually or in combination panels.

Conclusions

Zhu’s GEP could not be translated into an IHC panel predictive of benefit from adjuvant chemotherapy. Future predictive biomarker analysis in the adjuvant NSCLC setting may need to focus on novel therapies.

Weekly carfilzomib plus cyclophosphamide and dexamethasone in the treatment of relapsed/refractory multiple myeloma: Final results from the MCRN-003/MYX.1 single arm phase II trial

The MCRN-003/CCTGMYX.1 is a single arm phase II trial of weekly carfilzomib, cyclophosphamide and dexamethasone (wKCd), exploring a convenient immunomodulator (IMiD)-free regimen in relapsed myeloma. Weekly carfilzomib (20/70 mg/m² ), dexamethasone 40 mg and cyclophosphamide 300 mg/m² was delivered over 28-day cycles. The primary endpoint was overall response after four cycles. Secondary endpoints included toxicity, response depth, PFS and OS. Exploratory endpoints included the impact of cytogenetics, prior therapy exposure and serum free light chain (sFLC) escape; 76 patients were accrued. The ORR was 85% (68% ≥very good partial response [VGPR] and 29% ≥complete response [CR]). The median OS and PFS were 27 and 17 months respectively. High-risk cytogenetics conferred a worse ORR (75% vs. 97%, p = .013) and median OS (18 months vs. NR, p = .002) with a trend toward a worse median PFS (14 vs. 22 months, p = .06). Prior proteasome inhibitor (PI) or lenalidomide did not influence OS or PFS. The sFLC was noted in 15% of patients with a median PFS of 17 months when included as a progression event. The most common ≥ grade 3 non-hematologic adverse events were infectious (40%), vascular (17%) and cardiac (15%). The wKCD is a safe and effective regimen in relapse, especially for patients ineligible for lenalidomide-based therapies.

Real-world outcomes with bortezomib-containing regimens and lenalidomide plus dexamethasone for the treatment of transplant-ineligible multiple myeloma: a multi-institutional report from the Canadian Myeloma Research Group database

Bortezomib-containing regimens (BCRs) represented standard, first-line therapy for transplant-ineligible multiple myeloma (TIMM) in Canada until the introduction of lenalidomide and low-dose dexamethasone (Ld). However, little comparative data exist to inform the selection of regimens. We assessed the outcomes for TIMM patients treated with cyclophosphamide, bortezomib and dexamethasone or prednisone (CyBorD/P), bortezomib, melphalan and prednisone (VMP), bortezomib and dexamethasone or prednisone (VD/P) and lenalidomide and low-dose dexamethasone (Ld) using the Canadian Myeloma Research Group database. Of 1156 TIMM patients evaluated, 82% received bortezomib combinations while 18% received Ld. Median progression-free survival (PFS) was 21·0, 21·1, 13·2 and 28·5 months (P = 0·0002) and median overall survival (OS) was 52·0, 63·6, 30·8 and 65·7 months (P < 0·0001) in the CyBorD/P, VMP, VD/P and Ld groups respectively. There was no significant difference in PFS and OS between the two triplet bortezomib regimens (VMP and CyBorD/P). Ld was associated with a longer PFS but not a significantly superior OS to date. Outcomes with the bortezomib-steroid doublet were inferior (VD/P). However, multivariable analysis identified features related to disease biology as the most important prognostic factors for PFS and OS. Such factors, as well as those affecting the physician's choice of regimen, are likely to influence the results observed with different regimens. This study demonstrated real-world outcomes in TIMM similar to those reported in clinical trials.

Antimyeloma Potential of Caffeic Acid Phenethyl Ester and Its Analogues through Sp1 Mediated Downregulation of IKZF1-IRF4-MYC Axis

Caffeic acid phenethyl ester (CAPE, 2), a natural compound from propolis, is a well-documented antitumor agent with nuclear factor kappa B (NF-κB) inhibitory activity. Key transcription factors regulated by NF-κB, namely, interferon regulatory factor-4 (IRF4) and octameric binding protein-2 (OCT2), are implicated in the tumorigenesis of multiple myeloma (MM), an incurable bone marrow cancer. Adverse effects and resistance to current chemotherapeutics pose a great challenge for MM treatment. Hence, the structure-activity relationships of CAPE (2) and 21 of its analogues were evaluated for their antimyeloma potential. Preclinical evaluation revealed that CAPE (2) and the 3-phenylpropyl (4), 2,5-dihydroxycinnamic acid 3-phenylpropyl ester (17), and 3,4-dihydroxycinnamic ether (22) analogues inhibited human myeloma cell growth. Analogue 4 surpassed CAPE (2) and lenalidomide in showing strong apoptotic effects with a remarkable decrease in IRF4 levels. The analogue 17 exhibited the most potent anti-MM activity. The downregulation of specificity protein 1 (Sp1) and the IKZF1-IRF4-MYC axis by CAPE (2) analogues 4 and 17 revealed their novel mechanism of action. The analogues showed no adverse cytotoxic effects on normal human cells and exhibited appropriate in silico pharmacokinetic properties and drug-likeness. These findings suggest the promising application of CAPE (2) analogues to target Ikaros (IKZF1)/IRF4 addiction, the so-called Achilles heel of myeloma, for better treatment outcomes.

Targeting NK Cell Inhibitory Receptors for Precision Multiple Myeloma Immunotherapy

Innate immune surveillance of cancer involves multiple types of immune cells including the innate lymphoid cells (ILCs). Natural killer (NK) cells are considered the most active ILC subset for tumor elimination because of their ability to target infected and malignant cells without prior sensitization. NK cells are equipped with an array of activating and inhibitory receptors (IRs); hence NK cell activity is controlled by balanced signals between the activating and IRs. Multiple myeloma (MM) is a hematological malignancy that is known for its altered immune landscape. Despite improvements in therapeutic options for MM, this disease remains incurable. An emerging trend to improve clinical outcomes in MM involves harnessing the inherent ability of NK cells to kill malignant cells by recruiting NK cells and enhancing their cytotoxicity toward the malignant MM cells. Following the clinical success of blocking T cell IRs in multiple cancers, targeting NK cell IRs is drawing increasing attention. Relevant NK cell IRs that are attractive candidates for checkpoint blockades include KIRs, NKG2A, LAG-3, TIGIT, PD-1, and TIM-3 receptors. Investigating these NK cell IRs as pathogenic agents and therapeutic targets could lead to promising applications in MM therapy. This review describes the critical role of enhancing NK cell activity in MM and discusses the potential of blocking NK cell IRs as a future MM therapy.

Abstract 6559: Novel anti-myeloma potential of CAPE analogs: Downregulation of IKZF1-IRF4-MYC axis

Background: Multiple myeloma (MM) is the second most common hematological malignancy and an incurable bone marrow cancer so far. The hallmark of myeloma is chromosomal translocations that transform plasma cells into malignant myeloma cells. 50-75% of myeloma patients exhibit translocations at the immunoglobulin heavy chain (IgH) locus juxtaposing oncogenes from partner chromosome under the control of strong 3' IgH enhancers. Overexpression of oncogenes such as Cyclin D1, Cyclin D3, interferon regulatory factor (IRF4) etc. occurs, depending on the translocating partner locus. We have earlier reported that elevated expression of octameric binding protein-2 (OCT2), a key transcription factor in IgH translocations as a poor prognostic factor and shown its association with reduced survival in MM patients. IRF4 is another indispensable transcription factor for plasma cell differentiation, and its juxtaposition with IgH locus leads to IRF4 overexpression mediated tumorigenesis. Both OCT2 and IRF4 are regulated by the transcription factor, nuclear factor kappa B (NF-κB). Current chemotherapeutics exhibit several side effects, and face the challenge of chemoresistance, thus warranting the need for novel therapeutics for myeloma. Caffeic acid phenethyl ester (CAPE) is an active principle of propolis from honeybee hives, with potent NF-κB inhibitory activity. Hence, we synthesized and evaluated the structure-activity relationship of twenty-one CAPE analogs for their anti-myeloma potential.

Methods: Human myeloma cell lines, lenalidomide, CAPE and its analogs were used for the study. Myeloma cell growth inhibition by CAPE analogs was determined by PrestoBlue cell viability assays. Effect of CAPE analogs on IRF4, OCT2, CyclinD3, caspase-3, Ikaros (IKZF1), MYC levels were evaluated by qRT-PCR and/or immunoblotting methods; apoptosis induction detected by Annexin V-PI flow cytometry assays.

Results: Cyclohexylethyl and two phenpropyl ester analogs exhibited high myeloma cell growth inhibition in comparison with CAPE and lenalidomide. IRF4 was significantly downregulated both at mRNA and protein levels by the phenpropyl ester analog that demonstrated a remarkable increase in cleaved caspase-3 levels and apoptotic cell number. For the first time, we have demonstrated the ability of CAPE analogs to decrease OCT2, IKZF1, IRF4 and MYC levels in myeloma cells. Downregulation of the IKZF1-IRF4-MYC axis by CAPE and its key analogs revealed their novel anti-myeloma mechanism of action. Furthermore, the lead analogs showed no adverse cytotoxic effect on normal human mononuclear or naïve B-cells, also exhibited appropriate in silico pharmacokinetic properties and drug-likeness.

Conclusion: Thus, our findings suggest the promising application of CAPE analogs to target Ikaros/IRF4 addiction, the so-called Achilles heel of myeloma, thereby leading to better therapeutic outcomes.

Citation Format: Alli Murugesan, Gregoire Lasalle-Claux, Lauren Hogan, Elise Vaillancourt, Ayyoub Selka, Katie Luiker, Andy Hong, MinJi Kim, Mohamed Touaibia, Tony Reiman. Novel anti-myeloma potential of CAPE analogs: Downregulation of IKZF1-IRF4-MYC axis [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6559.

A phase I study of romidepsin, gemcitabine, dexamethasone and cisplatin combination therapy in the treatment of peripheral T-cell and diffuse large B-cell lymphoma; the Canadian cancer trials group LY.15 study†

We investigated GDP (gemcitabine, 1000 mg/m² IV d1, d8; dexamethasone, 40 mg po d1-4; cisplatin, 75 mg/m² IV d1) combined with romidepsin on days 1 and 8 every 21 days to a maximum of six cycles in a standard 3 + 3, phase I dose escalation trial for patients with relapsed/refractory peripheral T-cell (PTCL) or diffuse large B-cell (DLBCL) lymphoma (NCT01846390). After treating four patients, gemcitabine and romidepsin were given on days 1 and 15 every 28 days. On the 21-day schedule at 6 mg/m² romidepsin, there were three dose-limiting toxicities (DLTs) among four patients. On the 28-day schedule, there were no DLTs at the 6, 8, or 10 mg/m² dose. At 12 mg/m², there were four observed grade 3 DLTs among six evaluable patients. Full doses of GDP can be combined with a recommended phase II romidepsin dose of 10 mg/m² if given on a day 1, 15 every 28 days schedule.

Making It Happen: Middle Managers' Roles in Innovation Implementation in Health Care

Background

Middle managers are given scant attention in the implementation literature in health care, where the focus is on senior leaders and frontline clinicians.

Aims

To empirically examine the role of middle managers relevant to innovation implementation and how middle managers experience the implementation process.

Methods

A qualitative study was conducted using the methods of grounded theory. Data were collected through semistructured interviews with middle managers (N = 15) in Nova Scotia and New Brunswick, Canada. Participants were purposively sampled, based on their involvement in implementation initiatives and to obtain variation in manager characteristics. Data were collected and analyzed concurrently, using an inductive constant comparative approach. Data collection and analysis continued until theoretical saturation was reached.

Results

Middle managers see themselves as being responsible for making implementation happen in their programs and services. As a result, they carry out five roles related to implementation: planner, coordinator, facilitator, motivator, and evaluator. However, the data also revealed two determinants of middle managers' role in implementation, which they must negotiate to fulfill their specific implementation roles and activities: (1) They perform many other roles and responsibilities within their organizations, both clinical and managerial in nature, and (2) they have limited decision‐making power with respect to implementation and must work within the parameters set by upper levels of the organization.

Linking Evidence to Action

Middle managers play an important role in translating adoption decisions into on‐the‐ground implementation. Optimizing their capacity to fulfill this role may be key to improving innovation implementation in healthcare organizations.

Factors influencing middle managers' commitment to the implementation of innovations in cancer care

OBJECTIVE

To identify and illuminate influences on middle managers' commitment to innovation implementation.

METHODS

A qualitative study was conducted, employing the methods of grounded theory. Semi-structured interviews were used to collect data from middle managers (n = 15) in Nova Scotia and New Brunswick, Canada. Data were collected and analysed concurrently, using an inductive constant comparative approach. Data collection and analysis continued until theoretical saturation was reached.

RESULTS

The data revealed middle managers contemplate two central issues in terms of their commitment to implementation, that is whether or not they fully engage in and support the implementation of a particular innovation. These issues are (1) ease of implementation and (2) potential benefit for patients. Middle managers' views and expectations related to ease of implementation are influenced by available resources, fit with setting, and stakeholder buy-in. Their views on patient benefit are influenced by external evidence of benefit and local gaps in care.

CONCLUSIONS

These findings provide further insight into the factors that influence middle managers' commitment to innovation implementation, and how middle managers consider these factors in the context of their work settings.

Salvage chemotherapy and autologous stem cell transplantation for peripheral T-cell lymphoma: a subset analysis of the Canadian Cancer Trials Group LY.12 randomized phase 3 study. Leuk Lymphoma 2017;58:2319-2327. [PMID: 28504033 DOI: 10.1080/10428194.2017.1312379]

Peripheral T-cell lymphoma (PTCL) is a rare, heterogeneous malignancy. Of the 619 patients with relapsed and refractory (R/R) aggressive lymphoma enrolled in the Canadian Cancer Trials Group LY.12 phase 3 trial, 59 (9.5%) had PTCL. Among these, 81% had advanced stage disease, 41% had an International Prognostic Score ≥3, and 41% were refractory to primary therapy. Within the PTCL cohort, the overall response rate after two cycles of salvage chemotherapy was 36%; no difference was observed between dexamethasone, cytarabine, cisplatin (10/30, 33%), and gemcitabine, cisplatin, dexamethasone (11/29, 38%) therapy. At one year, event-free survival (EFS) was 16% and overall survival (OS) was 28%. For PTCL patients, who received autologous stem cell transplant, two-year EFS and OS were 21% and 42%, respectively. Patients with PTCL had inferior OS (HR 0.49, p < .0001) and EFS (HR 0.53, p < .0001) compared to B-cell lymphoma. Outcomes for patients with R/R PTCL are poor with currently available therapies.

Clinician participation in CADTH's pan-Canadian Oncology Drug Review: contribution and impact on cancer drug funding recommendations

In any given week, media headlines publicize the benefits of a new “breakthrough” cancer drug, with patients and clinicians subsequently advocating for its use. [...]

Abstract 3791: TRPV6 calcium channel peptide antagonists as novel antimyeloma and antiresorptive agents

Background: Multiple myeloma and its associated bone disease are generally incurable. Hence, better therapies are needed, ideally targeting biomolecules implicated in the aberrant biology of the disease. Overexpression of transient receptor potential cation channel TRPV6, a highly selective calcium channel has been observed in breast, colon, thyroid, ovary and prostate cancer tissues, and in several tumour cell lines. TRPV6 expression has also been seen in osteoclasts, however its role in bone metabolism remains unclear. The reciprocal interaction between osteoclasts and myeloma cells is pivotal to the generation of bone lesions that characterize myeloma. While myeloma cells secrete factors promoting osteoclast activity, osteoclasts in turn are known to induce myeloma cell growth and survival. The TRPV6 peptide antagonist SOR-C13 is currently in phase I clinical trials as an anti-cancer therapy for advanced cancers. We investigated the expression and potential therapeutic significance of TRPV6 in human osteoclasts and myeloma cells using shrew venom derived peptide antagonists. Methods: High affinity TRPV6 peptide antagonists SOR-C13 and SOR-C27 derived from the C-terminus of venom from the short-tailed shrew, Blarina brevicauda were used. Human primary osteoclasts were generated in vitro from human bone marrow (BM) aspirates; characterized by Hoechst-phalloidin staining, Tartrate resistant acid phosphatase (TRAP) staining, TRAP enzyme activity and Cathepsin K expression. CD138 positive myeloma cells were isolated from patient bone marrow specimens by EasySep immunomagnetic separation, or examined in tissue microarrays of patient BM core biopsies. TRPV6 expression in primary human osteoclasts, myeloma cell lines and myeloma patient BM microarray was checked by qPCR, immunohistochemistry or immunoblotting. Anti-resorptive potential of SOR peptides using human osteoclasts was evaluated in Osteoassay plates that mimic bone, and myeloma cell growth inhibition was determined by prestoblue cell viability assays. Results: We found strong expression of TRPV6 protein in human myeloma cells and osteoclasts by immunohistochemical staining on myeloma patient bone marrow sections. Human osteoclasts generated in vitro and CD138 positive myeloma patient bone marrow plasma cells were found to express TRPV6. We saw dose-dependent inhibition of osteoclast activity in vitro by SOR-C13 and SOR-C27, including markedly reduced osteoclast formation, decreased TRAP activity and reduced osteoassay surface resorption. TRPV6 peptide antagonists were also found to inhibit the growth of human myeloma cell lines U266 and KMM-1. Conclusion: Anti-myeloma and anti-osteoclast activity of human TRPV6 antagonist peptides was seen in the current study. Taken together, our findings suggest a novel therapeutic approach for multiple myeloma involving TRPV6 inhibition to target both myeloma cells and osteoclasts.

Citation Format: Alli Murugesan, Philippe Tremblay, Ming Han, Bithika Ray, Tyler Lutes, Tony Reiman. TRPV6 calcium channel peptide antagonists as novel antimyeloma and antiresorptive agents. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3791.

A simple prognostic model for overall survival in metastatic renal cell carcinoma

INTRODUCTION

The primary purpose of this study was to develop a simpler prognostic model to predict overall survival for patients treated for metastatic renal cell carcinoma (mRCC) by examining variables shown in the literature to be associated with survival.

METHODS

We conducted a retrospective analysis of patients treated for mRCC at two Canadian centres. All patients who started first-line treatment were included in the analysis. A multivariate Cox proportional hazards regression model was constructed using a stepwise procedure. Patients were assigned to risk groups depending on how many of the three risk factors from the final multivariate model they had.

RESULTS

There were three risk factors in the final multivariate model: hemoglobin, prior nephrectomy, and time from diagnosis to treatment. Patients in the high-risk group (two or three risk factors) had a median survival of 5.9 months, while those in the intermediate-risk group (one risk factor) had a median survival of 16.2 months, and those in the low-risk group (no risk factors) had a median survival of 50.6 months.

CONCLUSIONS

In multivariate analysis, shorter survival times were associated with hemoglobin below the lower limit of normal, absence of prior nephrectomy, and initiation of treatment within one year of diagnosis.

Effects of supervised exercise on progression-free survival in lymphoma patients: an exploratory follow-up of the HELP Trial

PURPOSE

Few randomized controlled trials in exercise oncology have examined survival outcomes. Here, we report an exploratory follow-up of progression-free survival (PFS) from the Healthy Exercise for Lymphoma Patients (HELP) Trial.

METHODS

The HELP Trial randomized 122 lymphoma patients between 2005 and 2008 to either control (n = 62) or 12 weeks of supervised aerobic exercise (n = 60). PFS events were abstracted from medical records in 2013. In addition to the randomized comparison, we explored the effects of exercise adherence (<80 % vs. ≥80 %) and control group crossover (no vs. yes).

RESULTS

After a median follow-up of 61 months (interquartile range 36-67), the adjusted 5-year PFS was 64.8 % for the exercise group compared with 65.0 % for the control group (Hazard ratio [HR] 1.01, 95 % CI 0.51-2.01, p = 0.98). In the secondary analysis, the adjusted 5-year PFS was 59.0 % in the control group without crossover compared with 69.2 % for the control group with crossover (HR 0.68, 95 % CI 0.22-2.06, p = 0.49), 67.7 % for the exercise group with <80 % adherence (HR 0.72, 95 % CI 0.28-1.85, p = 0.50), and 68.4 % for the exercise group with ≥80 % adherence (HR 0.70, 95 % CI 0.32-1.56, p = 0.39). In a post hoc analysis combining the three groups that received supervised exercise, the adjusted 5-year PFS for the supervised exercise groups was 68.5 % compared with 59.0 % for the group that received no supervised exercise (HR 0.70, 95 % CI 0.35-1.39, p = 0.31).

CONCLUSIONS

This exploratory follow-up of the HELP Trial suggests that supervised aerobic exercise may be associated with improved PFS in lymphoma patients. Larger trials designed to answer this question are needed.

Systematic review of the risk of adverse outcomes associated with vascular endothelial growth factor inhibitors for the treatment of cancer

BACKGROUND

Anti-angiogenic therapy targeted at vascular endothelial growth factor (VEGF) is now used to treat several types of cancer. We did a systematic review of randomized controlled trials (RCTs) to summarize the adverse effects of vascular endothelial growth factor inhibitors (VEGFi), focusing on those with vascular pathogenesis.

METHODS AND FINDINGS

We searched MEDLINE, EMBASE and Cochrane Library until April 19, 2012 to identify parallel RCTs comparing a VEGFi with a control among adults with any cancer. We pooled the risk of mortality, vascular events (myocardial infarction, stroke, heart failure, and thromboembolism), hypertension and new proteinuria using random-effects models and calculated unadjusted relative risk (RR). We also did meta-regression and assessed publication bias. We retrieved 83 comparisons from 72 studies (n = 38,078) on 11 different VEGFi from 7901 identified citations. The risk of mortality was significantly lower among VEGFi recipients than controls (pooled RR 0.96, 95% confidence interval [CI] 0.94 to 0.98, I2 = 0%, tau2 = 0; risk difference 2%). Compared to controls, VEGFi recipients had significantly higher risk of myocardial infarction (MI) (RR 3.54, 95% CI 1.61 to 7.80, I2 = 0%, tau2 = 0), arterial thrombotic events (RR 1.80, 95% CI 1.24 to 2.59, I2 = 0%, tau2 = 0); hypertension (RR 3.46, 95% CI 2.89 to 4.15, I2 = 58%, tau2 = 0.16), and new proteinuria (RR 2.51, 95% CI 1.60 to 3.94, I2 = 87%, tau2 = 0.65). The absolute risk difference was 0.8% for MI, 1% for arterial thrombotic events, 15% for hypertension and 12% for new proteinuria. Meta-regression did not suggest any statistically significant modifiers of the association between VEGFi treatment and any of the vascular events. Limitations include heterogeneity across the trials.

CONCLUSIONS

VEGFi increases the risk of MI, hypertension, arterial thromboembolism and proteinuria. The absolute magnitude of the excess risk appears clinically relevant, as the number needed to harm ranges from 7 to 125. These adverse events must be weighed against the lower mortality associated with VEGFi treatment.

Dietary patterns of patients with advanced lung or colorectal cancer

The purpose of this study was to identify dietary patterns among patients with advanced cancer. Differences between cancer groups are described, and food groups contributing higher proportions to overall caloric intake are identified. Patients with advanced cancer (n=51) were recruited from a regional cancer centre and completed a three-day dietary record. Food items were categorized according to macronutrient content. After adjustment for body weight, substantial variation in energy intake was observed (range: 13.7 to 55.4 kcal/kg/day). For 49% of patients, protein intake was below recommendations. Overall, patients consumed the largest proportion of their calories from meat (16%), other foods (11%), dessert (9%), fruit (9%), white bread (7%), and milk (7%). Only 5% of patients consumed meal replacement supplements. The results of this descriptive study provide important insights into the dietary habits of patients with advanced cancer. These insights could be translated into the development of effective recommendations for maintaining or improving health and quality of life.

Patient satisfaction with participation in a randomized exercise trial: effects of randomization and a usual care posttrial exercise program

BACKGROUND

Participation in an exercise trial is a major commitment for cancer survivors, but few exercise trials have evaluated patient satisfaction with trial participation.

PURPOSE

To examine patient satisfaction with participation in the Healthy Exercise for Lymphoma Patients (HELP) Trial and to explore possible determinants.

METHODS

The HELP Trial randomized 122 lymphoma patients to 12 weeks of supervised aerobic exercise training (AET; n = 60) or to usual care (UC; n = 62), with the option of participating in a 4-week posttrial exercise program. At the 6-month follow-up assessment, participants evaluated their overall trial satisfaction.

RESULTS

Personal satisfaction with trial participation was strongly influenced by group assignment with participants randomized to AET reporting participation to be more rewarding (p < 0.001) and personally useful (p < 0.001) than participants randomized to UC. UC participants who completed the optional 4-week posttrial exercise program reported participation to be more rewarding (p = 0.008) and personally useful (p < 0.001) than UC participants who declined the program.

LIMITATIONS

The study is limited by the lack of a validated measure of participant satisfaction, and the fact that the offer of participation in the posttrial exercise program to the UC group was not randomized.

CONCLUSIONS

Lymphoma patients randomized to UC viewed it as less rewarding and personally useful despite being offered a 4-week posttrial exercise program. UC participants who completed the 4-week program reported personal satisfaction levels similar to the AET group; however, the causal direction of this association is unknown. Researchers should continue to evaluate participant satisfaction in exercise trials.

International Myeloma Working Group recommendations for the treatment of multiple myeloma-related bone disease

PURPOSE

The aim of the International Myeloma Working Group was to develop practice recommendations for the management of multiple myeloma (MM) -related bone disease.

METHODOLOGY

An interdisciplinary panel of clinical experts on MM and myeloma bone disease developed recommendations based on published data through August 2012. Expert consensus was used to propose additional recommendations in situations where there were insufficient published data. Levels of evidence and grades of recommendations were assigned and approved by panel members.

RECOMMENDATIONS

Bisphosphonates (BPs) should be considered in all patients with MM receiving first-line antimyeloma therapy, regardless of presence of osteolytic bone lesions on conventional radiography. However, it is unknown if BPs offer any advantage in patients with no bone disease assessed by magnetic resonance imaging or positron emission tomography/computed tomography. Intravenous (IV) zoledronic acid (ZOL) or pamidronate (PAM) is recommended for preventing skeletal-related events in patients with MM. ZOL is preferred over oral clodronate in newly diagnosed patients with MM because of its potential antimyeloma effects and survival benefits. BPs should be administered every 3 to 4 weeks IV during initial therapy. ZOL or PAM should be continued in patients with active disease and should be resumed after disease relapse, if discontinued in patients achieving complete or very good partial response. BPs are well tolerated, but preventive strategies must be instituted to avoid renal toxicity or osteonecrosis of the jaw. Kyphoplasty should be considered for symptomatic vertebral compression fractures. Low-dose radiation therapy can be used for palliation of uncontrolled pain, impending pathologic fracture, or spinal cord compression. Orthopedic consultation should be sought for long-bone fractures, spinal cord compression, and vertebral column instability.

Cancer Cachexia in the Age of Obesity: Skeletal Muscle Depletion Is a Powerful Prognostic Factor, Independent of Body Mass Index

Purpose

Emerging evidence suggests muscle depletion predicts survival of patients with cancer.

Patients and Methods

At a cancer center in Alberta, Canada, consecutive patients with cancer (lung or GI; N = 1,473) were assessed at presentation for weight loss history, lumbar skeletal muscle index, and mean muscle attenuation (Hounsfield units) by computed tomography (CT). Univariate and multivariate analyses were conducted. Concordance (c) statistics were used to test predictive accuracy of survival models.

Results

Body mass index (BMI) distribution was 17% obese, 35% overweight, 36% normal weight, and 12% underweight. Patients in all BMI categories varied widely in weight loss, muscle index, and muscle attenuation. Thresholds defining associations between these three variables and survival were determined using optimal stratification. High weight loss, low muscle index, and low muscle attenuation were independently prognostic of survival. A survival model containing conventional covariates (cancer diagnosis, stage, age, performance status) gave a c statistic of 0.73 (95% CI, 0.67 to 0.79), whereas a model ignoring conventional variables and including only BMI, weight loss, muscle index, and muscle attenuation gave a c statistic of 0.92 (95% CI, 0.88 to 0.95; P < .001). Patients who possessed all three of these poor prognostic variables survived 8.4 months (95% CI, 6.5 to 10.3), regardless of whether they presented as obese, overweight, normal weight, or underweight, in contrast to patients who had none of these features, who survived 28.4 months (95% CI, 24.2 to 32.6; P < .001).

Conclusion

CT images reveal otherwise occult muscle depletion. Patients with cancer who are cachexic by the conventional criterion (involuntary weight loss) and by two additional criteria (muscle depletion and low muscle attenuation) share a poor prognosis, regardless of overall body weight.

Lenalidomide plus melphalan without prednisone for previously untreated older patients with multiple myeloma: a phase II trial

BACKGROUND

We conducted a phase II trial that evaluated the tolerability and efficacy of combining lenalidomide with melphalan in previously untreated patients with multiple myeloma who were not candidates for autologous stem cell transplantation.

METHODS

After a run-in phase of 6 patients, we planned to conduct a randomized phase II selection-design trial that assessed 2 dose levels of lenalidomide, given days 1 to 21, combined with melphalan, given days 1 to 4, and every 28 days. Planned doses of melphalan were 9 mg/m(2)/d and respective doses of lenalidomide were 10 and 20 mg/d (M9L10 and M9L20). Coprimary endpoints were the frequency of dose-limiting Planned doses of melphalan were 9 mg/m(2)/d and respective doses of lenalidomide were 10 and 20 mg/d (M9L10 and M9L20). toxicities (DLT) and complete response (CR).

RESULTS

Four patients received M9L10; all experienced DLTs, which resulted in closure of this cohort. When using the same schedule, we then sequentially tested M6L10 (melphalan 6 mg/m(2) on days 1 to 4 and lenalidomide 10 mg/d on days 1 to 21 every 28 days) (6 patients), M4L15 (melphalan 4 mg/m(2) on days 1 to 4 and lenalidomide 15 mg/d on days 1 to 21 every 28 days) (6 patients), and M5L10 (melphalan 5 mg/m(2) days 1 to 4 and lenalidomide 10 mg/d days 1 to 21 every 28 days) (34 patients). In each cohort, the DLT endpoint was reached because of severe and prolonged hematologic toxicity. At the final dose level, M5L10, 20 of 27 patients experienced DLTs within their first 3 cycles; among 10 patients who received at least 6 cycles, none achieved a CR.

CONCLUSIONS

Combining lenalidomide plus melphalan without prednisone is associated with substantial hematologic toxicity that precludes cyclical administration of adequate drug doses.

An open-label single-arm pilot phase II study (PX-171-003-A0) of low-dose, single-agent carfilzomib in patients with relapsed and refractory multiple myeloma

An open-label single-arm multicenter pilot phase II study of the next-generation selective proteasome inhibitor carfilzomib was conducted in 46 patients with relapsed and refractory multiple myeloma (MM) after ≥ 2 previous therapies. The best overall response rate (ORR) was 16.7%, with a median duration of response of 7.2 months. This pilot study was the first phase II single-agent trial conducted with carfilzomib.

BACKGROUND

Carfilzomib is a next-generation selective proteasome inhibitor that irreversibly binds its target and has demonstrated single-agent activity in patients with bortezomib-resistant multiple myeloma (MM). PX-171-003-A0, an open-label single-arm multicenter pilot phase II study, enrolled 46 patients with relapsed MM after ≥ 2 previous therapies including bortezomib and an immunomodulator (thalidomide or lenalidomide) and disease refractory to the last treatment regimen preceding study entry.

METHODS

Patients received carfilzomib 20 mg/m(2) intravenously on days 1, 2, 8, 9, 15, and 16 every 28 days for up to 12 cycles. Responses in 42 evaluable patients were assessed per International Myeloma Working Group Uniform Response Criteria, with minimal response assessed per European Group for Blood and Marrow Transplantation (EBMT) criteria.

RESULTS

The primary endpoint of best ORR was 16.7%, including 7 partial responses. Median duration of response was 7.2 months. Clinical benefit response (CBR) rate was 23.8% with a median duration of response of 13.8 months. The most common treatment-emergent adverse events (AEs) of any grade were anemia (73.9%), fatigue (69.6%), and thrombocytopenia (50.0%). Notably, peripheral neuropathy and neuropathy-related AEs were generally mild and infrequent.

CONCLUSION

This pilot study was the first phase II single-agent trial conducted with carfilzomib. Based on these findings, the study was amended to test a higher carfilzomib dose in an additional 250 patients (PX-171-003-A1).

Effects of supervised exercise on motivational outcomes and longer-term behavior

INTRODUCTION

Supervised exercise may have positive effects on motivation and continued exercise in cancer survivors, but few randomized controlled trials have examined this issue. Here, we report the motivational outcomes and longer-term exercise behavior from the Healthy Exercise for Lymphoma Patients trial.

METHODS

Lymphoma patients were randomly assigned to 12 wk of supervised aerobic exercise (SUP, n = 60) or usual care (UC, n = 62). Motivational outcomes from the theory of planned behavior were assessed at baseline, after intervention, and at 6-month follow-up using standardized measures. Exercise behavior was self-reported at baseline and 6-month follow-up using the Godin Leisure Time Exercise Questionnaire.

RESULTS

Data were available from 95% of participants after intervention and 90% at 6-month follow-up. SUP attended a median of 92% of the supervised exercise sessions. After intervention, SUP was superior to UC for intention (+0.41 (+0.09 to +0.72), P = 0.012) and perceived behavioral control (+0.36 (+0.01 to +0.72), P = 0.047) and borderline superior for self-efficacy (+0.35 (-0.02 to +0.72), P = 0.060). At 6-month follow-up, SUP reported significantly more exercise minutes compared with UC (+133 (+38 to +227), P = 0.006), and a higher percentage of SUP participants were meeting public health exercise guidelines (+25.6% (+8.2% to +43.0%), P = 0.004). Path analysis showed that perceived behavioral control partially mediated the effects of supervised exercise (group assignment) on exercise behavior at 6-month follow-up (meeting exercise guidelines).

CONCLUSIONS

Supervised exercise has motivational effects in lymphoma patients and improves longer-term exercise behavior. Strategies to further enhance the motivational value of supervised exercise are warranted.

A randomized trial of aerobic exercise and sleep quality in lymphoma patients receiving chemotherapy or no treatments

BACKGROUND

Patients with lymphoma experience sleep problems that may be managed with aerobic exercise but no previous study has examined this issue.

METHODS

We randomized 122 patients with lymphoma to usual care (n = 62) or 12 weeks of supervised aerobic exercise training (AET; n = 60). Our primary sleep endpoint was global sleep quality assessed by the Pittsburgh Sleep Quality Index (PSQI). Secondary endpoints were the PSQI component scores. Planned subgroup analyses were also conducted.

RESULTS

Intention-to-treat analyses indicated that AET resulted in a nonsignificant (P = 0.16) improvement in global sleep quality compared with usual care [mean group difference = -0.64; 95% confidence interval (CI), -1.56 to +0.27]. In planned subgroup analyses, statistically significant or borderline significant interactions were identified for type of lymphoma (P(interaction) = 0.006), current treatment status (P(interaction) = 0.036), time since diagnosis (P(interaction) = 0.010), body mass index (P(interaction) = 0.075), and baseline sleep quality (P(interaction) = 0.041). Specifically, AET improved global sleep quality in patients with lymphoma who had indolent non-Hodgkin lymphoma (P = 0.001), were receiving chemotherapy (P = 0.013), were <2 years post-diagnosis (P = 0.005), were obese (P = 0.025), and were poor sleepers at baseline (P = 0.007).

CONCLUSIONS

AET did not significantly improve sleep quality in this heterogeneous sample of patients with lymphoma; however, clinically identifiable subgroups appeared to benefit. Future exercise trials targeting these responsive subgroups are needed to confirm these findings.

IMPACT

If replicated in larger and more focused trials, aerobic exercise may be an attractive option to manage sleep dysfunction in patients with cancer because of its favorable safety profile and other documented health benefits.

Cross-validation study of class III beta-tubulin as a predictive marker for benefit from adjuvant chemotherapy in resected non-small-cell lung cancer: analysis of four randomized trials

BACKGROUND

The IALT, JBR.10, ANITA and Cancer and Leukemia Group B 9633 trials compared adjuvant chemotherapy with observation for patients with resected non-small-cell lung cancer (R-NSCLC). Data from the metastatic setting suggest high tumor class III beta-tubulin (TUBB3) expression is a determinant of insensitivity to tubulin-targeting agents (e.g. vinorelbine, paclitaxel). In 265 patients from JBR.10 (vinorelbine-cisplatin versus observation), high TUBB3 was an adverse prognostic factor and was associated (nonsignificantly) with 'greater' survival benefit from chemotherapy. We explored this further in additional patients from JBR.10 and the other three trials.

PATIENTS AND METHODS

TUBB3 immunohistochemical staining was scored for 1149 patients on the four trials. The original JBR.10 cut-off scores were used to classify tumors as TUBB3 high or low. The prognostic and predictive value of TUBB3 on disease-free survival (DFS) and overall survival (OS) was assessed by Cox models stratified by trial and adjusted for clinical factors.

RESULTS

High TUBB3 expression was prognostic for OS [hazard ratio (HR)=1.27 (1.07-1.51), P=0.008) and DFS [HR=1.30 (1.11-1.53), P=0.001). TUBB3 was not predictive of a differential treatment effect [interaction P=0.20 (OS), P=0.23 (DFS)]. Subset analysis (n=420) on vinorelbine-cisplatin gave similar results.

CONCLUSIONS

The prognostic effect of high TUBB3 expression in patients with R-NSCLC has been validated. We were unable to confirm a predictive effect for TUBB3.

Expression, adverse prognostic significance and therapeutic small molecule inhibition of Polo-like kinase 1 in multiple myeloma

The amplified myeloma centrosome has been identified as a therapeutic target. The present study explored the expression and prognostic significance of the centrosome-associated protein PLK1 in myeloma and the effect of BI 2536, a potent and selective inhibitor of PLK1, on myeloma cells. High plasma cell expression of PLK1 protein in myeloma patient bone marrow biopsies is an independent adverse prognostic factor (HR=2.3, p=0.003 unadjusted; HR=1.9, p=0.03 in multivariable model). BI 2536 inhibits myeloma cell lines at nanomolar concentrations, and is therapeutic for xenografts in NOD/SCID mice. PLK1 inhibition is a potential new strategy for the treatment of multiple myeloma.

Predictors of follow-up exercise behavior 6 months after a randomized trial of supervised exercise training in lymphoma patients

OBJECTIVES

Supervised exercise is beneficial for lymphoma patients, but it needs to be maintained to optimize long-term benefits. Here, we report the predictors of follow-up exercise behavior 6 months after a randomized controlled trial in lymphoma patients.

METHODS

Lymphoma patients were randomly assigned to 12 weeks of supervised aerobic exercise (n = 60) or usual care (n = 62). At baseline and post-intervention, data were collected on demographic, medical, health-related fitness, quality of life, and motivational variables. At 6-month follow-up, participants were mailed a questionnaire that assessed exercise behavior and were categorized as meeting or not meeting public health exercise guidelines.

RESULTS

At 6-month follow-up, 110 participants (90.2%) responded, of which 61 (55.5%) were meeting public health exercise guidelines. In univariate analyses, 16 variables predicted 6-month follow-up exercise behavior. In a stepwise regression analysis, five variables entered the model and explained 38% (p < 0.001) of the variance including the following: accepting a post-intervention exercise prescription (β = 0.33; p < 0.001), achieving a higher peak power output at post-intervention (β = 0.28; p = 0.001), experiencing a larger positive change in perceived behavioral control (β = 0.18; p = 0.028), having Hodgkin lymphoma (β = 0.19; p = 0.025), and having a stronger post-intervention intention (β = 0.18; p = 0.034).

CONCLUSION

Exercise behavior in lymphoma patients 6 months after a randomized trial was predicted by a wide range of demographic, medical, health-related fitness, quality of life, and motivational variables. These findings may help facilitate the uptake of self-directed exercise after short-term supervised exercise in lymphoma patients.

Skeletal muscle depletion is associated with reduced plasma (n-3) fatty acids in non-small cell lung cancer patients

Upwards of 50% of newly diagnosed advanced lung cancer patients have severe muscle wasting (sarcopenia). Supplementation with eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in advanced cancer has been shown to attenuate lean tissue wasting. However, the relationship between muscle mass and plasma (n-3) fatty acids in the absence of supplementation is unclear. We aimed to determine how plasma phospholipid (n-3) fatty acids relate to sarcopenia and change in muscle mass in non-small cell lung cancer patients receiving chemotherapy. Computed tomography images were used to measure muscle mass. Patients were classified as sarcopenic or nonsarcopenic based on sex-specific cutpoints. Change in muscle mass during chemotherapy (2.5 mo) was calculated and patients were divided into quartiles based on the rate of muscle loss or gain. Patients with sarcopenia had lower plasma EPA (16.7 +/- 2.1 micromol/L vs. 31.6 +/- 4.4 micromol/L; P = 0.001), DHA (36.6 +/- 4.0 micromol/L vs. 55.3 +/- 4.0 micromol/L; P = 0.003), and Sigma(n-3) fatty acids (63.6 +/- 5.6 micromol/L vs. 95.0 +/- 7.7 micromol/L; P = 0.002) than nonsarcopenic patients. Patients with maximal muscle loss (mean - 3.5 kg) had lower plasma EPA (12.2 +/- 3.3 micromol/L vs. 35.0 +/- 7.1 micromol/L; P = 0.03), DHA (26.9 +/- 8.7 micromol/L vs. 59.6 +/- 5.3 micromol/L; P = 0.01), and Sigma(n-3) fatty acids (57.8 +/- 13.5 micromol/L vs. 104.6 +/- 11.1 micromol/L; P = 0.005) compared with patients who were gaining muscle (mean +1 kg). Plasma (n-3) fatty acids are depleted in cancer patients with sarcopenia, which may contribute to accelerated rates of muscle loss.

Economic evaluation of erythropoiesis-stimulating agents for anemia related to cancer

BACKGROUND

Erythropoiesis-stimulating agents (ESA) administered to cancer patients with anemia reduce the need for blood transfusions and improve quality-of-life (QOL). Concerns about toxicity have led to more restrictive recommendations for ESA use; however, the incremental costs and benefits of such a strategy are unknown.

METHODS

The authors created a decision model to examine the costs and consequences of ESA use in patients with anemia and cancer from the perspective of the Canadian public healthcare system. Model inputs were informed by a recent systematic review. Extensive sensitivity analyses and scenario analysis rigorously assessed QOL benefits and more conservative ESA administration practices (initial hemoglobin [Hb] <10 g/dL, target Hb < or =12 g/dL, and chemotherapy induced anemia only).

RESULTS

Compared with supportive transfusions only, conventional ESA treatment was associated with an incremental cost per quality-adjusted life year (QALY) gained of $267,000 during a 15-week time frame. During a 1.3-year time horizon, ESA was associated with higher costs and worse clinical outcomes. In scenarios where multiple assumptions regarding QOL all favored ESA, the lowest incremental cost per QALY gained was $126,000. Analyses simulating the use of ESA in accordance with recently issued guidelines resulted in incremental cost per QALY gained of > $100,000 or ESA being dominated (greater costs with lower benefit) in the majority of the scenarios, although greater variability in the cost-utility ratio was present.

CONCLUSIONS

Use of ESA for anemia related to cancer is associated with incremental cost-effectiveness ratios that are not economically attractive, even when used in a conservative fashion recommended by current guidelines.

Body composition in patients with non-small cell lung cancer: a contemporary view of cancer cachexia with the use of computed tomography image analysis

BACKGROUND

The prominent clinical feature of cachexia has traditionally been understood to be weight loss; however, in recognition of the potential for divergent behavior of muscle and adipose tissue, cachexia was recently defined as loss of muscle with or without loss of fat mass. Detailed assessments are required to verify body composition in patients with cancer cachexia.

DESIGN

We adopted a population-based approach to study body composition in patients with cancer, with the use of diagnostic computed tomography images acquired for cancer diagnosis and follow-up. A prospective cohort of 441 patients with non-small cell lung cancer, who were referred consecutively to a regional medical oncology service in Alberta, Canada, was evaluated.

RESULTS

At referral (median time to death: 265 d), mean body mass index (BMI; in kg/m(2)) was 24.9, with 47.4% of patients being overweight or obese. Only 7.5% overall were underweight as conventionally understood (BMI < 18.5). Analysis of computed tomography images showed extremely high heterogeneity of muscle mass within all strata of BMI. The overall prevalence of severe muscle depletion (sarcopenia) was 46.8% and was present in patients in all BMI categories. A much higher proportion of men (61%) than women (31%) met the criteria for sarcopenia.

CONCLUSIONS

Wasting of skeletal muscle is a prominent feature of patients with lung cancer, despite normal or heavy body weights. The significance of muscle wasting in normal-weight, overweight, and obese patients as a nutritional risk factor, as a prognostic factor, and as a predictor of cancer treatment toxicity is discussed in this article.

Moderator effects in a randomized controlled trial of exercise training in lymphoma patients

BACKGROUND

The Healthy Exercise for Lymphoma Patients trial showed that aerobic exercise training improved important health outcomes in lymphoma patients. Here, we examine potential moderators of the exercise training response.

METHODS

Lymphoma patients were stratified by major disease type and current treatment status and randomly assigned to usual care (n = 62) or aerobic exercise training (n = 60) for 12 weeks. Endpoints were quality of life, cardiovascular fitness, and body composition. Moderators were patient preference for group assignment, age, sex, marital status, disease stage, body mass index, and general health.

RESULTS

Patient preference did not statistically moderate the effects of exercise training on quality of life (P for interaction = 0.36), but the interaction effect of 7.8 points favoring patients with no preference was clinically meaningful. Marital status (P for interaction = 0.083), general health (P for interaction = 0.012), and body mass index (P for interaction = 0.010) moderated the effects of aerobic exercise training on quality of life with better outcomes for unmarried versus married patients, patients in poor/fair health versus good-to-excellent health, and normal weight/obese versus overweight patients. Disease stage (P for interaction = 0.056) and general health (P for interaction = 0.012) moderated the effects of aerobic exercise training on body composition with better outcomes for patients with advanced disease versus early disease/no disease and patients in good health versus very good-to-excellent health. No variables moderated intervention effects on cardiovascular fitness. Findings were not explained by differences in adherence.

CONCLUSIONS

Clinically available variables predicted quality of life and body composition responses to aerobic exercise training in lymphoma patients. If replicated, these results may inform future randomized trials and clinical practice.

Genetic polymorphisms associated with outcome in multiple myeloma patients receiving high-dose melphalan

High-dose melphalan (HDM) is an essential component in the treatment of patients with multiple myeloma (MM). Few data are available regarding genetic polymorphisms associated with patient outcome or toxicity in this setting. To identify such polymorphisms, we performed a retrospective analysis, genotyping single nucleotide polymorphisms (SNPs) with the arrayed primer extension (APEX) technology in 169 patients having received HDM for MM. We analyzed 209 SNPs in 95 genes involved in drug metabolism, DNA repair, cell cycle and apoptosis. SNPs in ABCB1, CYP3A4 and TP53BP2 were associated with response to VAD induction therapy (P<0.01). SNPs in ALDH2, GSTT2 and BRCA1 were associated with response to HDM (P<0.01). Polymorphisms in CYP1A1, RAD51 and PARP were associated with disease progression whereas polymorphisms in ALDH2 and CYP1A1 were correlated with OS. Polymorphisms in BRCA1, CDKN1A and XRCC1 were associated with the occurrence of severe mucositis after HDM. These results suggest that SNPs of genes involved in drug metabolism or DNA repair could be used to distinguish MM patient subgroups with different toxicity/efficacy profiles.

The role of betaIII tubulin in predicting chemoresistance in non-small cell lung cancer

Lung cancer is a leading cause of death among adults. Non-small cell lung cancer (NSCLC) accounts for approximately 85% of all lung cancer cases. For more than half of all patients diagnosis does not occur until the disease has metastasised. At this advanced stage, the 5-year survival rate is just 15%. Platinum-based chemotherapy forms the backbone of treatment for patients with advanced NSCLC and forms an important component of the therapeutic regimen for many patients with earlier stage disease. However, although a number of agents are available to partner the platinum-based compounds, treatment selection is largely empiric, and chemoresistance is a considerable barrier to improving outcomes. The identification of biologic and other markers to guide treatment selection, thus ensuring patients receive the most effective regimen for their individual tumour and avoid exposure to toxic agents from which they are unlikely to benefit, will be critical to improve outcomes for patients with NSCLC. The development of alternative agents for those patients who express predictors of a negative clinical response is of vital importance. A variety of biomarkers are emerging, including expression of DNA repair enzymes, ribonucleotide subunits and betaIII tubulin. Treatment algorithms based on elucidation of such markers to guide treatment selection can already be envisaged. For example, those patients with high betaIII tubulin expression should be considered for epothilone therapy as an alternative to taxane-based regimens. The epothilones may be preferred option as the evidence suggests that these agents retain activity versus taxane-resistant cancers. This paper reviews the evidence base for betaIII tubulin expression as a prognostic and predictive biomarker in NSCLC and briefly explores the implications for clinical decision making of this and other emerging biomarkers.

International Myeloma Working Group molecular classification of multiple myeloma: spotlight review

Myeloma is a malignant proliferation of monoclonal plasma cells. Although morphologically similar, several subtypes of the disease have been identified at the genetic and molecular level. These genetic subtypes are associated with unique clinicopathological features and dissimilar outcome. At the top hierarchical level, myeloma can be divided into hyperdiploid and non-hyperdiploid subtypes. The latter is mainly composed of cases harboring IgH translocations, generally associated with more aggressive clinical features and shorter survival. The three main IgH translocations in myeloma are the t(11;14)(q13;q32), t(4;14)(p16;q32) and t(14;16)(q32;q23). Trisomies and a more indolent form of the disease characterize hyperdiploid myeloma. A number of genetic progression factors have been identified including deletions of chromosomes 13 and 17 and abnormalities of chromosome 1 (1p deletion and 1q amplification). Other key drivers of cell survival and proliferation have also been identified such as nuclear factor- B-activating mutations and other deregulation factors for the cyclin-dependent pathways regulators. Further understanding of the biological subtypes of the disease has come from the application of novel techniques such as gene expression profiling and array-based comparative genomic hybridization. The combination of data arising from these studies and that previously elucidated through other mechanisms allows for most myeloma cases to be classified under one of several genetic subtypes. This paper proposes a framework for the classification of myeloma subtypes and provides recommendations for genetic testing. This group proposes that genetic testing needs to be incorporated into daily clinical practice and also as an essential component of all ongoing and future clinical trials.

Randomized controlled trial of the effects of aerobic exercise on physical functioning and quality of life in lymphoma patients

PURPOSE

Lymphoma patients commonly experience declines in physical functioning and quality of life (QoL) that may be reversed with exercise training.

PATIENTS AND METHODS

We conducted a randomized controlled trial in Edmonton, Alberta, Canada, between 2005 and 2008 that stratified 122 lymphoma patients by major disease type and current treatment status and randomly assigned them to usual care (UC; n = 62) or 12 weeks of supervised aerobic exercise training (AET; n = 60). Our primary end point was patient-rated physical functioning assessed by the Trial Outcome Index-Anemia. Secondary end points were overall QoL, psychosocial functioning, cardiovascular fitness, and body composition.

RESULTS

Follow-up assessment for our primary end point was 96% (117 of 122) at postintervention and 90% (110 of 122) at 6-month follow-up. Median adherence to the supervised exercise program was 92%. At postintervention, AET was superior to UC for patient-rated physical functioning (mean group difference, +9.0; 95% CI, 2.0 to 16.0; P = .012), overall QoL (P = .021), fatigue (P = .013), happiness (P = .004), depression (P = .005), general health (P < .001), cardiovascular fitness (P < .001), and lean body mass (P = .008). Change in peak cardiovascular fitness mediated the change in patient-rated physical functioning. AET did not interfere with chemotherapy completion rate or treatment response. At 6-month follow-up, AET was still borderline or significantly superior to UC for overall QoL (P = .054), happiness (P = .034), and depression (P = .009) without an increased risk of disease recurrence/progression.

CONCLUSION

AET significantly improved important patient-rated outcomes and objective physical functioning in lymphoma patients without interfering with medical treatments or response. Exercise training to improve cardiovascular fitness should be considered in the management of lymphoma patients.

Correlates of adherence to supervised exercise in patients awaiting surgical removal of malignant lung lesions: results of a pilot study

PURPOSE/OBJECTIVES

To examine the demographic, medical, and social-cognitive correlates of adherence to a presurgical exercise training intervention in patients awaiting surgery for suspected malignant lung lesions.

DESIGN

Pilot study, single-group, prospective design with convenience sampling.

SETTING

Exercise training was performed at a university research fitness center in western Canada.

SAMPLE

19 patients awaiting surgical resection of suspected malignant lung lesions.

METHODS

At baseline, participants completed a questionnaire including the Theory of Planned Behavior variables of perceived behavioral control, attitude, and subjective norm, as well as medical and demographic information. Participants were asked to attend five supervised exercise sessions per week during surgical wait time (X = 8 +/- 2.4 weeks).

MAIN RESEARCH VARIABLES

Theory of Planned Behavior variables and exercise adherence.

FINDINGS

Adherence to the exercise intervention was 73% (range = 0%-100%). Correlates of adherence were perceived behavioral control (r = 0.63; p = 0.004) and subjective norm (r = 0.51; p = 0.014). Participants with greater than 80% adherence reported significantly higher behavioral control than participants with less than 80% adherence (X difference = 1.1; 95% confidence interval = 0.1-2.2; p = 0.035). Men had better adherence than women (X difference = 24.9%; 95% confidence interval = 0.4-49.4; p = 0.047).

CONCLUSIONS

Perceived behavioral control and subjective norm were the strongest correlates of exercise adherence. Women could be at risk for poor exercise adherence prior to lung surgery.

IMPLICATIONS FOR NURSING

This information could be useful for clinicians in their attempts to improve adherence to exercise interventions in patients awaiting surgery for malignant lung lesions.

Effects of presurgical exercise training on systemic inflammatory markers among patients with malignant lung lesions

Systemic inflammation plays an important role in the initiation, promotion, and progression of lung carcinogenesis. The effects of interventions to lower inflammation have not been explored. Accordingly, we conducted a pilot study to explore the effects of exercise training on changes in biomarkers of systemic inflammation among patients with malignant lung lesions. Using a single-group design, 12 patients with suspected operable lung cancer were provided with structured exercise training until surgical resection. Participants underwent cardiopulmonary exercise testing, 6 min walk testing, pulmonary function testing, and blood collection at baseline and immediately prior to surgical resection. Systemic inflammatory markers included intracellular adhesion molecule (ICAM)-1, macrophage inflammatory protein-1alpha, interleukin (IL)-6, IL-8, monocyte chemotactic protein-1, C-reactive protein, and tumor necrosis factor-alpha. The overall exercise adherence rate was 78%, with patients completing a mean of 30 +/- 25 sessions. Mean peak oxygen consumption increased 2.9 mL.kg-1.min-1 from baseline to presurgery (p = 0.016). Results indicate that exercise training resulted in a significant reduction in ICAM-1 (p = 0.041). Changes in other inflammatory markers did not reach statistical significance. Change in cardiorespiratory fitness was not associated with change in systemic inflammatory markers. This exploratory study provides an initial step for future studies to elucidate the potential role of exercise, as well as identify the underlying mechanisms of action, as a means of modulating the relationship between inflammation and cancer pathogenesis.

Benefits and harms of erythropoiesis-stimulating agents for anemia related to cancer: a meta-analysis

BACKGROUND

Erythropoiesis-stimulating agents are used to treat anemia in patients with cancer. However, their safety and effectiveness is controversial. We did a systematic review of the clinical efficacy and harms of these agents in adults with anemia related to cancer or chemotherapy.

METHODS

We conducted a systematic review of published and unpublished randomized controlled trials (RCTs) using accepted methods for literature searches, article selection, data extraction and quality assessment. We included RCTs involving anemic adults with cancer. We compared the use of erythropoiesis-stimulating agents with nonuse and assessed clinical outcomes (all-cause mortality, cardiovascular events and hypertension, health-related quality of life, blood transfusions and tumour response) and harms (serious adverse events) between groups.

RESULTS

We identified 52 trials (n = 12 006) that met our selection criteria. The pooled all-cause mortality during treatment was significantly higher in the group receiving erythropoiesis-stimulating therapy than in the control group (relative risk [RR] 1.15, 95% confidence interval [CI] 1.03 to 1.29). Compared with no treatment, use of erythropoiesis-stimulating agents led to clinically detectable improvements in disease-specific measures of quality of life. It also reduced the use of blood transfusions (RR 0.64, 95% CI 0.56 to 0.73). However, it led to an increased risk of thrombotic events (RR 1.69, 95% CI 1.27 to 2.24) and serious adverse events (RR 1.16, 95% CI 1.08 to 1.25).

INTERPRETATION

Use of erythropoiesis-stimulating agents in patients with cancer-related anemia improved some disease-specific measures of quality of life and decreased the use of blood transfusions. However, it increased the risk of death and serious adverse events. Our findings suggest that such therapy not be used routinely as an alternative to blood transfusion in patients with anemia related to cancer.