The Research on Medical Education Outcomes (ROMEO) Registry: Addressing Ethical and Practical Challenges of Using "Bigger," Longitudinal Educational Data

PROBLEM

Efforts to evaluate and optimize the effectiveness of medical education have been limited by the difficulty of designing medical education research. Longitudinal, epidemiological views of educational outcomes can help overcome limitations, but these approaches require "bigger data"-more learners, sources, and time points. The rich data institutions collect on students and residents can be mined, however, ethical and practical barriers to using these data must first be overcome.

APPROACH

In 2008, the authors established the Research on Medical Education Outcomes (ROMEO) Registry, an educational data registry modeled after patient registries. New York University School of Medicine students, residents, and fellows provide consent for routinely collected educational, performance, quality improvement, and clinical practice data to be compiled into a deidentified, longitudinal database. As of January 2015, this registry included 1,225 residents and fellows across 12 programs (71% consent rate) and 841 medical students (86% consent rate). Procedures ensuring voluntary informed consent are essential to ethical enrollment and data use. Substantial resources are required to provide access to and manage the data.

OUTCOMES

The registry supports educational scholarship. Seventy-two studies using registry data have been presented or published. These focus on evaluating the curriculum, quality of care, and measurement quality and on assessing needs, competencies, skills development, transfer of skills to practice, remediation patterns, and links between education and patient outcomes.

NEXT STEPS

The authors are working to integrate assessment of relevant outcomes into the curriculum, maximize both the quantity and quality of the data, and expand the registry across institutions.

Assessment of Developmental Progress Using an Objective Structured Clinical Examination-Simulation Hybrid Examination for Obstetrics and Gynecology Residents

OBJECTIVE

The Test of Integrated Professional Skills (TIPS) is an objective structured clinical examination-simulation hybrid examination that assesses resident integration of technical, cognitive, and affective skills in Obstetrics and Gynecology (OBGYN) residents. The aim of this study was to analyze performance patterns and reactions of residents to the test to understand how it may fit within a comprehensive assessment program.

DESIGN

A retrospective, mixed methods review of the design and implementation of the examination, patterns of performance of trainees at different levels of training, focus group data, and description of use of TIPS results for resident remediation and curriculum development.

SETTING

OBGYN residents at New York University Langone Medical Center, a tertiary-care, urban academic health center.

PARTICIPANTS

OBGYN residents in all years of training, postgraduate year-1 through postgraduate year, all residents completing the TIPS examination and consenting to participate in focus groups were included.

RESULTS

In all, 24 residents completed the TIPS examination. Performance on the examination varied widely among individuals at each stage of training, and did not follow developmental trends, except for technical skills. Cronbach α for both standardized patient and faculty ratings ranged from 0.69 to 0.84, suggesting internal consistency. Focus group results indicated that residents respond to the TIPS examination in complex ways, ranging from anxiety about performance to mixed feelings about how to use the data for their learning.

CONCLUSION

TIPS assesses a range of attributes, and can support both formative and summative evaluation. Lack of clear developmental differences and wide variation in performance by learners at the same level of training support the argument for individualized learning plans and competency-based education.

‘We might as well be speaking different languages’: an innovative interprofessional education tool to teach and assess communication skills critical to patient safety

Introduction

All practicing health professionals must be able to communicate effectively with their colleagues around the care of patients. Better communication between health professionals not only improves patient outcomes, but also cuts down on costly and unnecessary tests or healthcare services. At New York University (NYU), we have addressed the need for interprofessional education (IPE) by incorporating a set of interprofessional objective structured clinical examinations (OSCEs) cases into our performance-based assessment programme to expand the educational tools for interprofessional collaborative (IPC) practice, assessment and feedback.

Methods

We identified and operationalised IPC competencies to create an assessment tool for use in IPC clinical cases, delineating core domains and then identifying observable behaviours that represented the broader competencies. IPC cases (for use in OSCEs) were designed in a way that required medical students and residents to collaborate effectively with a health professional from another discipline (standardised registered nurse (RN)) in order to provide quality care to a (standardised) patient. Feedback from the standardised RN and the participants was content analysed and our own experience in implementing was described.

Results

This method demonstrates that IPC practice can effectively be incorporated into medical education training and assessment, at the undergraduate and graduate level. We found high internal consistency among items within each of the core IPC competency domains (Cronbach's α 0.80–0.85). Based on both standardised RN and faculty feedback, the cases were effective in discriminating among learners within and across undergraduate medical education (UME) and graduate medical education (GME) levels, and within learners, in identifying individual strengths and weaknesses. Learners found these cases to be realistic, challenging and stimulating.

Conclusions

OSCE-based IPC training is a feasible and useful methodology. Ultimately, IPC OSCE cases are training tools that provide learners with a safe environment to practice, receive feedback and develop the critical skills needed for our evolving healthcare system. The next steps are to expand the scope of IPE cases to include more team members, and team work to also incorporate faculty development to ensure that our teachers and role models are effective in providing feedback on IPC practice.

Panel Management to Improve Smoking and Hypertension Outcomes by VA Primary Care Teams: A Cluster-Randomized Controlled Trial

BACKGROUND

Panel Management can expand prevention and chronic illness management beyond the office visit, but there is limited evidence for its effectiveness or guidance on how best to incorporate it into practice.

OBJECTIVE

We aimed to test the effectiveness of incorporating panel management into clinical practice by incorporating Panel Management Assistants (PMAs) into primary care teams with and without panel management education.

DESIGN

We conducted an 8-month cluster-randomized controlled trial of panel management for improving hypertension and smoking cessation outcomes among veterans.

PATRICIPANTS

Twenty primary care teams from the Veterans Affairs New York Harbor were randomized to control, panel management support, or panel management support plus education groups. Teams included 69 clinical staff serving 8,153 hypertensive and/or smoking veterans.

INTERVENTIONS

Teams assigned to the intervention groups worked with non-clinical Panel Management Assistants (PMAs) who monitored care gaps and conducted proactive patient outreach, including referrals, mail reminders and motivational interviewing by telephone.

MAIN MEASURES

Measurements included mean systolic and diastolic blood pressure, proportion of patients with controlled blood pressure, self-reported quit attempts, nicotine replacement therapy (NRT) prescriptions, and referrals to disease management services.

KEY RESULTS

Change in mean blood pressure, blood pressure control, and smoking quit rates were similar across study groups. Patients on intervention teams were more likely to receive NRT (OR = 1.4; 95% CI 1.2-1.6) and enroll in the disease management services MOVE! (OR = 1.2; 95% CI 1.1-1.6) and Telehealth (OR = 1.7, 95% CI 1.4-2.1) than patients on control teams.

CONCLUSIONS

Panel Management support for primary care teams improved process, but not outcome variables among veterans with hypertension and smoking. Incorporating PMAs into teams was feasible and highly valued by the clinical staff, but clinical impact may require a longer intervention.

Assessing cultural competency skills in gastroenterology fellowship training

AIM: To assess and teach cultural competency skills at the fellowship training level through the use of objective structured clinical examinations (OSCEs).

METHODS: We revised four scenarios to infuse a specific focus on cross-cultural care, and to render them appropriate for gastroenterology fellows. Three are discussed here: (1) Poor Health Literacy; (2) Disclosing/Apologizing for a Complication to a Patient Who Mistrusts the Healthcare System; and (3) Breaking Bad News to a Fatalistic Patient. A fourth case emphasizing shared decision-making will be described elsewhere. Four stations were completed by fellows and observed live by four faculty members, and the fellows’ performance was assessed.

RESULTS: Eleven fellows from four programs participated in the four OSCE. In the “Poor Health Literacy” case, 18% (2/11) of participants recognized that the standardized patient (SP) had below-basic health literacy. None successfully evaluated the SP’s reading skills in a culturally-sensitive manner. In “Disclosing/Apologizing for a Complication”, 4/11 (36%) personally apologized for the complication. 1/11 recognized the SP’s mistrust of the medical system. With “Breaking Bad News”, 27% (3/11) explored the patient’s values to identify her fatalistic beliefs.

CONCLUSION: OSCEs can be used to assess deficiencies in culturally-competent care at the fellowship level. OSCEs also afford fellowships the opportunity to inform future training curricula.

Quality of life after total and subtotal gastrectomy for gastric carcinoma

BACKGROUND

There remains debate as to whether quality of life (QoL) is better for patients following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar survival rates provided an R0 resection is performed and in many series the morbidity and mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in patients after TG and SG for cancer.

METHOD

All surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the gastric module (QLQ-STO22).

RESULTS

From a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group.

CONCLUSION

This study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG.

Self-assessment and goal-setting is associated with an improvement in interviewing skills

PURPOSE

Describe the relationship between medical students' self-assessment and goal-setting (SAGS) skills and development of interviewing skills during the first-year doctoring course.

METHOD

157 first-year medical students completed three two-case standardized patient (SP) interviews. After each of the first two, students viewed videotapes of their interview, completed a SAGS worksheet, and reviewed a selected tape segment in a seminar. SAGS was categorized into good and poor quality and interviewing skills were rated by trained raters.

RESULTS

SAGS improved over time (37% good week 1 vs. 61% good week 10). Baseline SAGS and interviewing skills were not associated. Initial SAGS quality was associated with change in interviewing skills - those with poor-quality SAGS demonstrated a decrease and those with good-quality SAGS demonstrated an increase in scores by 17 weeks (ANOVA F=4.16, p=0.024). For students whose SAGS skills were good at both week 1 and 10, interviewing skills declined in weeks 1-10 and then increased significantly at week 17. For those whose SAGS remained 'poor' in weeks 1-10, interviewing skills declined in weeks 10-17.

CONCLUSIONS

In general, the quality of students' SAGS improved over time. Poor baseline SAGS skills and failure to improve were associated with a decrease in interviewing skills at 17 weeks. For students with better SAGS, interviewing skills increased at week 17. Improvement in SAGS skills was not associated with improved interviewing skills. Understanding structured self-assessment skills helps identify student characteristics that influence progressive mastery of communication skills and therefore may inform curriculum and remediation tailoring.

Using standardized patients to train telephone counselors for a clinical trial

Background

Standardized Patients (SPs) are actors trained to portray health care patients during the training and assessment of health care providers. This paper describes the methods and costs associated with using SPs to evaluate the skills of telephone counselors working on a clinical trial that evaluated a telephone smoking cessation program tailored for smokers using Department of Veterans Affairs mental health clinics.

Findings

Conducting the SP exercises required five main steps: (1) Write a SP case description detailing patient demographics, demeanor, clinical symptoms and history, and instructions on how to respond to counseling, (2) Identify, select and train actors to portray the SP cases; (3) Conduct audio-taped counseling encounters between the SPs and counselors, (4) Rate the counselors on their core counseling competencies, (5) Provide feedback to counselors. The SPs and study supervisors reported that the checklist was easy to use when rating the counselors. Counselors reported that the SP encounters were realistic and helpful for practicing their clinical work and for building self-efficacy for working with real patients. The labor costs of developing two SP cases and training two SP actors was approximately $1,475. The per-session labor cost of conducting a 1-hour counseling session between one SP and one counselor was approximately $314.

Conclusions

Using SPs to train telephone counselors working on a clinical trial was feasible and offered training benefits beyond those provided by didactic instruction and role plays. Our research group is now routinely using SPs for the training of incoming telephone counselors.

Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system

BACKGROUND

While unannounced standardized patients (USPs) have been used to assess physicians' clinical skills in the ambulatory setting, they can also provide valuable information on patients' experience of the health care setting beyond the physician encounter. This paper explores the use of USPs as a methodology for evaluating patient-centered care in the health care system.

METHODS

USPs were trained to complete a behaviorally-anchored assessment of core dimensions of patient-centered care delivered within the clinical microsystem, including: 1) Medical assistants' safe practices, quality of care, and responsiveness to patients; 2) ease of clinic navigation; and 3) the patient-centeredness of care provided by the physician. Descriptive data is provided on these three levels of patient-centeredness within the targeted clinical microsystem. Chi-square analyses were used to signal whether variations by teams within the clinical microsystem were likely to be due to chance or might reflect true differences in patient-centeredness of specific teams.

RESULTS

Sixty USP visits to 11 Primary Care teams were performed over an eight-month period (mean 5 visits/team; range 2-8). No medical assistants reported detecting an USP during the study period. USPs found the clinic easy to navigate and that teams were functioning well in 60% of visits. In 30% to 47% of visits, the physicians could have been more patient-centered. Medical assistants' patient safety measures were poor: patient identity was confirmed in only 5% of visits and no USPs observed medical assistants wash their hands. Quality of care was relatively high for vital signs (e.g. blood pressure, weight and height), but low for depression screening, occurring in only 15% of visits. In most visits, medical assistants greeted the patient in a timely fashion but took time to fully explain matters in less than half of the visits and rarely introduced themselves. Physicians tried to help patients navigate the system in 62% of visits.

CONCLUSIONS

USP assessment captured actionable, critical, behaviorally-specific information on team and system performance in an urban community clinic. This methodology provides unique insight into the patient-centeredness and quality of care in medical settings.

Test of integrated professional skills: objective structured clinical examination/simulation hybrid assessment of obstetrics-gynecology residents' skill integration

BACKGROUND

Assessment of obstetrics-gynecology residents' ability to integrate clinical judgment, interpersonal skills, and technical ability in a uniform fashion is required to document achievement of benchmarks of competency. An observed structured clinical examination that incorporates simulation and bench models uses direct observation of performance to generate formative feedback and standardized evaluation.

METHODS

The Test of Integrated Professional Skills (TIPS) is a 5-station performance-based assessment that uses standardized patients and complex scenarios involving ultrasonography, procedural skills, and evidence-based medicine. Standardized patients and faculty rated residents by using behaviorally anchored checklists. Mean scores reflecting performance in TIPS were compared across competency domains and by developmental level (using analysis of variance) and then compared to standard faculty clinical evaluations (using Spearman ρ). Participating faculty and residents were also asked to evaluate the usefulness of the TIPS.

RESULTS

Twenty-four residents participated in the TIPS. Checklist items used to assess competency were sufficiently reliable, with Cronbach α estimates from 0.69 to 0.82. Performance improved with level of training, with wide variation in performance. Standard faculty evaluations did not correlate with TIPS performance. Several residents who were rated as average or above average by faculty performed poorly on the TIPS (> 1 SD below the mean). Both faculty and residents found the TIPS format useful, providing meaningful evaluation and opportunity for feedback.

CONCLUSIONS

A simulation-based observed structured clinical examination facilitates observation of a range of skills, including competencies that are difficult to observe and measure in a standardized way. Debriefing with faculty provides an important interface for identification of performance gaps and individualization of learning plans.

Presenting quality data to vulnerable groups: charts, summaries or behavioral economic nudges?

Objectives

Despite the increased focus on health care consumers’ active choice, not enough is known about how to best facilitate the choice process. We sought to assess methods of improving this process for vulnerable consumers in the United States by testing alternatives that emphasize insights from behavioral economics, or ‘nudges’.

Methods

We performed a hypothetical choice experiment where subjects were randomized to one of five experimental conditions and asked to choose a health center (location where they would receive all their care). The conditions presented the same information about health centers in different ways, including graphically as a chart, via written summary and using behavioral economics, ‘nudging’ consumers toward particular choices. We hypothesized that these ‘nudges’ might help simplify the choice process. Our primary outcomes focused on the health center chosen and whether consumers were willing to accept ‘nudges’.

Results

We found that consumer choice was influenced by the method of presentation and the majority of consumers accepted the health center they were ‘nudged’ towards.

Conclusions

Consumers were accepting of choices grounded in insights from behavioral economics and further consideration should be given to their role in patient choice.

Developing a toolkit for panel management: improving hypertension and smoking cessation outcomes in primary care at the VA

BACKGROUND

As primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension.

METHODS

We created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team.

RESULTS

Literature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas - continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs.

CONCLUSIONS

Although panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01677533.

Telephone care coordination for smokers in VA mental health clinics: protocol for a hybrid type-2 effectiveness-implementation trial

BACKGROUND

This paper describes an innovative protocol for a type-II hybrid effectiveness-implementation trial that is evaluating a smoking cessation telephone care coordination program for Veterans Health Administration (VA) mental-health clinic patients. As a hybrid trial, the protocol combines implementation science and clinical trial methods and outcomes that can inform future cessation studies and the implementation of tobacco cessation programs into routine care. The primary objectives of the trial are (1) to evaluate the process of adapting, implementing, and sustaining a smoking cessation telephone care coordination program in VA mental health clinics, (2) to determine the effectiveness of the program in promoting long-term abstinence from smoking among mental health patients, and (3) to compare the effectiveness of telephone counseling delivered by VA staff with that delivered by state quitlines.

METHODS/DESIGN

The care coordination program is being implemented at six VA facilities. VA mental health providers refer patients to the program via an electronic medical record consult. Program staff call referred patients to offer enrollment. All patients who enroll receive a self-help booklet, mailed smoking cessation medications, and proactive multi-call telephone counseling. Participants are randomized to receive this counseling from VA staff or their state's quitline. Four primary implementation strategies are being used to optimize program implementation and sustainability: blended facilitation, provider training, informatics support, and provider feedback. A three-phase formative evaluation is being conducted to identify barriers to, and facilitators for, program implementation and sustainability. A mixed-methods approach is being used to collect quantitative clinical effectiveness data (e.g., self-reported abstinence at six months) and both quantitative and qualitative implementation data (e.g., provider referral rates, coded interviews with providers). Summative data will be analyzed using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework.

DISCUSSION

This paper describes the rationale and methods of a trial designed to simultaneously study the clinical effectiveness and implementation of a telephone smoking cessation program for smokers using VA mental health clinics. Such hybrid designs are an important methodological design that can shorten the time between the development of an intervention and its translation into routine clinical care.

How medical students' behaviors and attitudes affect the impact of a brief curriculum on nutrition counseling

OBJECTIVE

To evaluate a nutrition curriculum and explore the influence of medical students' own nutrition practices on its impact.

METHODS

An anonymous survey was given to first-year medical students attending a required course immediately prior to and 2 weeks after a 2-hour interactive nutrition curriculum intervention in a large private urban medical school in New York, New York. Main outcomes included self-reported nutrition counseling confidence, ability to assess diet, and nutrition knowledge measured using 4-point Likert scales.

RESULTS

One hundred eleven students completed surveys pre-curriculum (69%) and 121 completed them post-curriculum (75%). The authors found overall pre-post differences in dietary assessment ability (2.65 vs 3.05, P < .001) and counseling confidence (1.86 vs 2.22, P < .001). In addition to the curricular impact, students' nutrition-related behaviors and attitudes were positively associated with outcomes.

CONCLUSIONS AND IMPLICATIONS

A nutrition curriculum for medical students improves students' nutrition counseling-related confidence, knowledge, and skills even when controlling for personal nutrition-related behaviors.

Engaging health professional students in substance abuse research: development and early evaluation of the SARET program

OBJECTIVE

There is a need to build the ranks of health care professionals engaged in substance abuse (SA)-focused clinical research. The authors simultaneously developed and evaluated SARET, the Substance Abuse Research Education and Training program. The fundamental goal of this interprofessional program is to stimulate medical, dental, and nursing student interest and experience in SA research. Evaluation aims to understand program feasibility and acceptability and to assess short-term impact.

METHODS

SARET comprises 2 main components: stipend-supported research mentorships and a Web-based module series, consisting of 6, interactive, multimedia modules addressing core SA research topics, delivered via course curricula and in the research mentorships. Authors assessed program feasibility and impact on student interest in conducting SA research by tracking participation and conducting participant focus groups and online surveys.

RESULTS

Thirty early health care professional students completed mentorships (25 summer, 5 yearlong) and 1324 completed at least 1 Web-module. SARET was considered attractive for the opportunity to conduct clinically oriented research and to work with health care professionals across disciplines. Mentorship students reported positive impact on their vision of SA-related clinical care, more positive attitudes about research, and, in some cases, change in career plans. Web-based modules were associated with enhanced interest in SA (35% increase, P = 0.005, in those somewhat/very interested for neurobiology module) and SA research (+38%, P < 0.001 for activation, +45%, P < 0.001 for personal impact, +7%, P = 0.089 for neurobiology).

CONCLUSIONS

The SARET program stimulates SA clinical and research interest among students of nursing, medicine, and dentistry and may lend itself to dissemination.

P3-01-10: DMBA-Breast Cancer in Diet Induced Obesity (DIO) and Lean Mice Is Related to Leptin Signaling

Introduction: Leptin, the major adipokine released by adipose tissue, is strongly linked to obesity related-cancers. We have shown previously that inhibition of leptin signaling with pegylated leptin peptide receptor antagonist 2 (PEG-LPrA2) negatively impacted human xenograft and syngeneic mouse breast cancer growth as well as VEGF/VEGFR2 levels [1,2].

Objective: We hypothesize that leptin signaling is essential for 7,12-dimethylbenz[A]anthracene (DMBA)-mammary tumor (MT) particularly in obese mice.

Methods: The study investigated the potential of PEG-LPrA2 to prevent MT in lean and diet-induced-obesity (DIO)-C57BL/6J female mice treated with 1 mg/dose/weekly for 6 weeks of DMBA. Obesity was induced by feeding DIO-mice (95% obese mice after 5 weeks) with high fat diet (PDI-1; 45% Kcal from fat). Lean mice were fed a normal diet (PDI-1; 5% Kcal from fat). PEG-LPrA2 was administered intravenously. Lean and DIO-mice received either one or two PEG-LPrA2 dose/week (50 ml/0.1 mM) two weeks prior to DMBA to test its preventative potential through the end point (32 weeks). Control mice received saline injections.

Results: Obesity was positively correlated to the development of DMBA-MT in mice. MTs were found in 17% of lean control and 69% of DIO-control mice. Notably, PEG-LPrA2 prevented the onset of DMBA-MT in lean (one and two doses: 0% tumor-bearing mice) and DIO-mice (one-dose, 29% and two-dose 0% MT). PEG-LPrA2 treatment did not alter body weight nor food intake in lean or DIO-mice. VEGF levels were significant higher (32 fold) in control DIO-mice. PEG-LPrA2 inhibition of leptin signaling decreased tumor levels of Notch ligands (Jagged-1 & DLL-4), receptors (Notch 1–4) and target genes (Survivin and Hey2) and reduced OB-R, IL-1R tI, VEGF/VEGFR2, bcl-2, HIF-1a and NFκB (p50 and p105).

Conclusions: Present data strongly suggest that leptin signaling is essential for DMBA-induced MT in the context of obesity. Overall, the effective chemoprevention of DMBA-MT by PEG-LPrA2 treatment in DIO and lean mice reinforces the potential use of leptin signaling inhibition for breast cancer prevention. These observations are most significant for obese populations showing higher levels of leptin and incidence of breast cancer. [This work was supported in part by NIH/NCI1SC1CA138658-02; NIH/ARRA/3SC1CA138658-02S1 and the Georgia Cancer Coalition Distinguished Cancer Scholar Award (to RRGP); CREDO (MSCR) 2R25RR017694-06A1 to L.S.C; the Morehouse School of Medicine (MSM) MBRS RISE Program (NIH/NIGMS 506 GM08248) to T.Z.M; and facilities and support services at Morehouse School of Medicine (NIH RR03034 and 1C06 RR18386)].

References:

[1] Gonzalez RR, Chefils S, Escobar M, et al. Leptin signaling promotes the growth of mammary tumors and increases the expression of vascular endothelial growth factor (VEGF) and its receptor type two (VEGF-R2). J Biol Chem 2006, 281(36): 26320–26328.

[2] Gonzalez RR, Watters A, Xu, Y, et al. Leptin-signaling inhibition results in efficient anti-tumor activity in estrogen receptor positive or negative breast cancer. Breast Cancer Res 2009, 11:R36.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-01-10.

P5-06-10: Leptin Signaling Impacts Notch and Wnt Crosstalk in Breast Cancer

Background: Triple negative breast cancer (TNBC: ER-, PR- and Her2/neu-) is an aggressive form of the disease that disproportionately affects women of color, has an early onset, and is associated with poor survival and a resistance to common therapeutic treatments. We have previously demonstrated an association between the adipocytokine leptin and Notch signaling pathways in breast cancer. Notch participates in a crosstalk relationship with many signaling pathways involved in carcinogenesis, including Wnt and leptin, which could in turn increase tumor burden and cell survival of MMTV-Wnt1 obese mice. We hypothesize that leptin signaling crosstalk with Notch and Wnt is instrumental in the development of drug-resistant features (increased survival and proliferation) of TNBC.

Objective: The aim of this study was to determine whether leptin mediated crosstalk of the Notch and Wnt pathways has a differential impact on TNBC compared to ER+ cells.

Materials & Methods: ER+ MCF-7 and TNBC-MDA MB-231 cells (96-well plate; 1×104 cells/well) were serum deprived for 24 hours and treated with varying doses of Doxorubicin and Cisplastin for 24h in conjunction with pharmacological doses of leptin, leptin peptide antagonist (LPrA2), Wnt agonist (Wnt-1) and antagonist (Wif-1). Cell proliferation was measured via WST assay. The effect of the various treatments on the activation of Wnt (total/pβ-catenin), Notch (Notch 1–4 and JAG1/Dll-4 and targets survivin/Hey2), and leptin (STAT3 and targets VEGF/VEGFR-2) signaling pathways were measured using western blot and ELISA. β-Catenin levels were also investigated by IHC in DMBA-breast cancer samples from lean and DIO (diet-induced obese mice) mice treated with LPrA2. Apoptosis was also measured.

Results: Leptin increased the levels of beta-catenin mainly in TNBC cells. This leptin-induced effect was also detected in breast tumors from DIO-mice. Interestingly, leptin increased survival (bcl-2 and Caspase-3 activation)/proliferation (cell number and Cyclin D1), expression of Notch and attenuated the detrimental effects of Doxorubicin and Cisplastin on breast cancer cells. Wnt-1 had similar but less pronounced effects compared to leptin. We also observed differences in Notch expression. Moreover, MDA MB-231 cells showed decreased response to Wnt1 in the presence of leptin.

Conclusions: Our findings suggest that leptin could play a negative role in TNBC by increasing drug-resistance through its crosstalk with Wnt and Notch signaling pathways. This may imply that obesity, characterized by elevated leptin levels, could negatively affect the outcome of TBNC treatment. Taken together, this data supports the theory that inhibition of leptin signaling could be a novel way to prevent and treat TBNC, particularly in the context of obesity and abnormal Wnt and Notch signaling. [This work was supported in part by NIH/NCI1SC1CA138658-02; NIH/ARRA/3SC1CA138658-02S1 and the Georgia Cancer Coalition Distinguished Cancer Scholar Award (to RRGP); CREDO (MSCR) 2R25RR017694-06A1 (to L.S.C); NIGMS506GM08248 and NCRR 5P20RR11104 (to T.Z.M); and facilities and support services at MSM (NIH RR03034 and 1C06 RR18386)].

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-06-10.