Perceptions of cancer care coordination in patient-family caregiver dyads

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Background: Family caregivers (FCGs) can play a key role in coordinating care for cancer patients. However, little is known about FCGs’ perspectives of care coordination (CC). In this cross-sectional study, we evaluated perceptions of CC in cancer patient-family caregiver dyads using the Care Coordination Instrument (CCI), a validated self-report measure with excellent psychometric properties. Methods: Patients receiving active treatment for cancer and their primary FCGs ( N = 54 dyads) completed the 29-item CCI (patient) and the CCICG (a parallel FCG version) at private oncology practices or hospital-based facilities from June to Sept. 2019. The CCI and CCICG assess overall perceptions of CC (Total) and across 3 domains: Communication, Navigation, and Operational. The CCICG includes a supplemental questionnaire that assesses the degree of caregiver CC involvement on a 4-point Likert scale. Mixed regression models were used to examine differences between patients and FCGs’ perceptions of CC and to identify predictors of dyadic differences on the CCI scores. Pearson’s correlation was used to evaluate associations between FCGs’ perceptions of CC and the degree of caregiver involvement. Results: CCICG Total scores demonstrated a bimodal distribution, representing FCGs’ perceptions of CC in distinct high and low subgroups; thus, all analyses were conducted by subgroups (highCG, lowCG). Overall, no dyadic differences were found in the highCG group on the CCI scores. However, in the lowCG group, FCGs reported poorer Total ( p < .01), Communication ( p < .01), Navigation ( p < .01), and Operational ( p < .05) scores than patients. Provider setting (private practices) and the absence of an identified patient navigator significantly predicted poorer FCG Total scores compared to patients’ perceptions ( p < .05). FCGs’ Total scores were inversely associated with the degree of caregiver involvement among FCGs in the lowCG group ( p < .05) but not among FCGs in the highCG group. Conclusions: Our findings demonstrate that a subgroup of FCGs has poorer perceptions of CC that differ significantly from patient perceptions and is most apparent for patients receiving treatment in a private practice setting and in the absence of a patient navigator. These FCGs report a high degree of caregiver involvement and may be providing additional CC support that is not recognized by cancer patients. These findings underscore the need for interventions to support FCG CC involvement as a member of the care team in order to improve the quality and value of patient-centered cancer care delivery.

Incidence of breast pain in breast cancer patients in a multi-ethnic cohort

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Background: Breast cancer is the most common cancer in women. Prevalence rates for persistent pain following breast cancer surgery are reported to be up to 60%. Younger age, radiation, more invasive surgery, and acute post-operative pain have been identified as predictors of chronic pain after surgery. Several studies have looked at factors predicting breast pain, but to our knowledge none of these studies have reported on perceived pain among ethnic groups beyond white and non-white comparisons. Methods: Participants were asked to complete an anonymous breast pain questionnaire based on the McGill pain questionnaire, either online or face-to-face in a clinical setting. Incidence and type of breast pain, common risk factors (age, type of surgery, treatment: chemotherapy, radiation and endocrine therapy), and race/ethnicity was collected and analyzed through descriptive and multivariate analysis. Results: 238 responses were collected and analyzed. About 36% of participants reported breast pain, where 82% reported these symptoms for more than a year. More than 71% identified as non-white, with the majority identifying as Asian (50%) followed by White (11%), Multi-ethnic (9%) and Native Hawaiian (8%). The majority of participants were older than 60 years of age (57%), with 30% being older than 70. Japanese, Filipino and Native Hawaiian participants reported significantly more pain compared to White participants (p < .0001). The majority of participants reported a 3/10 pain level on a pain scale and described overall breast pain as mild. The most common descriptor of mild pain was aching and represents the dullness pain characteristic. The most common descriptor of moderate pain was sharp characterizing an incisive pressure, and the most common descriptors of severe pain were heavy, tender, shooting and throbbing, representing various pain characteristics. Participants who were undergoing radiation (p < .0001) or chemotherapy (p < .05) reported statistically higher breast pain, although there were no differences in breast pain according to the type of surgery (mastectomy vs lumpectomy). Participants who completed the survey online also reported more pain (p < .0001) than participants who completed the survey face-to-face. Conclusions: Breast pain is a significant problem in our breast cancer community. This questionnaire has informed our understanding of the type of pain our multi-ethnic breast cancer patients are experiencing and in turn we are developing culturally appropriate pain management strategies to treat this challenging symptom for breast cancer survivors.

Assessing Patients' Perceptions of Cancer Care Coordination in a Community-Based Setting

PURPOSE

Effective care coordination (CC) is a hallmark of a high-quality cancer care. However, efforts to improve cancer care delivery are limited by the lack of a clinically useful tool to assess CC. In this study, we examined patients' perceptions of cancer CC using a novel tool, the Care Coordination Instrument (CCI), and evaluated the quality of the CCI.

METHODS

The CCI is a 29-item patient questionnaire that assesses CC across varied practice settings and patient populations overall and for three critical domains of CC: communication, navigation, and operational. We conducted univariable and multivariable regression analyses to identify patient clinical and practice characteristics associated with optimal versus suboptimal CC.

RESULTS

Two hundred patients with cancer completed the CCI questionnaire between October 2018 and January 2019, of whom 189 were used for the analysis. The presence of a family caregiver and a diagnosis of a blood cancer were correlated with overall positive reports of CC (P < .001 and P < .05, respectively). Poorer perceptions of CC were associated with having a head and neck cancer and the absence of family caregiver support. The effects of cancer disease stage and having access to a patient navigator on CC were not statistically significant.

CONCLUSION

Integrating a patient-centered tool to assess cancer CC can be a strategy to optimize cancer care delivery. Understanding factors associated with effective and ineffective CC can help inform efforts to improve overall quality of care and care delivery.

Abstract P6-06-13: Racial/ethnic differences in tumor infiltrating lymphocytes

Background/Rationale: There have been increasing studies regarding the morphologic evaluation of tumor-infiltrating lymphocytes (TILs) and the tumor microenvironment. In breast cancer, TILs are more abundant in stroma (sTILs) compared to intratumoral (iTILs) areas and iTILs have been an unreliable marker due to difficulty in standardizing their evaluation. The International Immuno-Oncology Working Group published recommendations to guide the accurate assessment of TILs. TILs have relevance in the setting of neoadjuvant therapy (NAT), primarily in triple negative and HER2 positive breast cancers. Studies report that sTIL infiltration is predictive of response to NAT in these two breast cancer subtypes, but not in the estrogen positive breast cancer subtype. The presence of TILs is a good prognostic indicator and correlates with axillary lymph node negativity, lower histological grade and improved recurrence-free survival. Therefore, evaluating TILs prior to NAT can provide important predictive and prognostic information for clinicians. There are insufficient data exploring differences in sTILs among different racial/ethnic groups. Previous data showed Asians had more sTILs compared to White and African American patients, consistent with data from Asia that found substantial sTILs in their respective patient populations. Our diverse population has known racial/ethnic disparities, where Pacific Islanders have a higher mortality compared to Asian and White patients. Evaluating sTILs within this population may reveal tumor biology differences that could contribute to health disparities.

Research objectives:

To determine the stromal tumor infiltrating lymphocytes on core biopsy specimens and correlate them with clinical characteristics: ethnicity, age, BMI and stage

To determine differences in pathologic complete response (pCR) with ethnicity, age, BMI, neoadjuvant therapy and stage

Table 1. % Stromal tumor infiltrating lymphocytes (sTILs) compared to age, BMI, ethnicity, stage and pCR adjusted for breast cancer subtypeVariableValueNMeanSDPAge30838.615.140927.123.0.30501834.626.6.67601431.121.3.4570+826.822.8.30BMI&lt; 252825.918.825-301638.521.9.07&gt; 301337.228.0.12EthnicityAsian1636.724.2.01Pacific Islander2038.021.3.004White1818.515.9Other348.130.6.02Stage1A818.48.01B933.425.5.192A1631.923.0.172B938.620.6.113A630.823.2.313B937.225.8.10pCRno3233.019.8yes2530.825.6.72

Table 2. Pathologic complete tesponse (pCR) compared to age, BMI, neoadjuvant therapy, ethnicity and stage adjusted for breast cancer subtypeVariableValueNMeanSDPAge3080.5500.5354090.4060.527.5650180.4450.511.6360140.3030.469.2770+80.5860.518.89BMI&lt; 25280.5260.50825-30160.2730.447.11&gt; 30130.4530.519.65Neoadjuvant TherapyACT140.2680.469.88TC110.2370.505TCHP160.7480.479.02THP120.4280.515.41Letrozole40.3850.500.62EthnicityAsian160.4720.512.77Pacific Islander200.3890.503.85White180.4200.511other30.7060.577.36Stage1A80.2410.3541B90.4270.527.412A160.7240.479.022B90.0320.441.403A60.8220.516.023B90.2680.500.90

Results: We evaluated 57 neoadjuvant breast cancer cases for sTILs according to the International Immuno-Oncology Working Group recommendations and reviewed their clinical characteristics. We found significant % sTILs differences in ethnicity, specifically Asian (35%), Pacific Islander (38.5%) and Other (46%) category compared to White (19%) Table 1. There were no differences found in sTILs according to age, BMI or stage. We also found no significant pCR differences according to age, BMI or ethnicity, however for certain stages and neoadjuvant therapy, there is an increased rate of pCR, although these are a small number of cases, no conclusions can be made, Table 2. Future studies to evaluate the significance of sTILs in different ethnicities may be informative to delineate possible mechanisms contributing to known disparities they experience.

Citation Format: Jami Fukui, Alana Taniguchi, Madison Meister, Ian Pagano, Jeffrey Killeen. Racial/ethnic differences in tumor infiltrating lymphocytes [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-06-13.

Plasminogen activator inhibitor-2 (PAI-2) overexpression supports bladder cancer development in PAI-1 knockout mice in N-butyl-N- (4-hydroxybutyl)-nitrosamine- induced bladder cancer mouse model

BACKGROUND

Accumulating evidence suggests that plasminogen activator inhibitor-1 (PAI-1) plays an important role in bladder tumorigenesis by regulating cell cycle. However, it remains unclear whether and how inhibition of PAI-1 suppresses bladder tumorigenesis.

METHODS

To elucidate the therapeutic effect of PAI-1 inhibition, we tested its tumorigenicity in PAI-1 knockout (KO) mice exposed to a known bladder carcinogen.

RESULTS

PAI-1 deficiency did not inhibit carcinogen-induced bladder cancer in mice although carcinogen-exposed wild type mice significantly increased PAI-1 levels in bladder tissue, plasma and urine. We found that PAI-1 KO mice exposed to carcinogen tended to upregulate protein C inhibitor (PAI-3), urokinase-type plasminogen activator (uPA) and tissue-type PA (tPA), and significantly increased PAI-2, suggesting a potential compensatory function of these molecules when PAI-1 is abrogated. Subsequent studies employing gene expression microarray using mouse bladder tissues followed by post hoc bioinformatics analysis and validation experiments by qPCR and IHC demonstrated that SERPING1 is further downregulated in PAI-1 KO mice exposed to BBN, suggesting that SERPING1 as a potential missing factor that regulate PAI-2 overexpression (compensation pathway).

CONCLUSIONS

These results indicate that serpin compensation pathway, specifically PAI-2 overexpression in this model, supports bladder cancer development when oncoprotein PAI-1 is deleted. Further investigations into PAI-1 are necessary in order to identify true potential targets for bladder cancer therapy.

Development and psychometric evaluation of a questionnaire to measure cancer patients' perception of care coordination

BACKGROUND

Although the importance of care coordination (CC) is well-recognized, cancer patients often receive poorly coordinated care across varied care settings and different oncology providers. Efforts to improve cancer care are hampered by lack of adequate measures. In this two-part, mixed-method study, we describe the development, refinement, and validation of a new care coordination instrument (CCI) designed to assess cancer patients' perception of CC.

METHODS

In Study 1, an initial CCI was developed incorporating questions based on literature review. The items were then modified following four field tests conducted in a large academic hospital with oncology nurses (n = 20) and cancer patients (n = 120). This modified instrument was used to determine whether the CCI was able to distinguish CC between two practices (30 GI and 30 myeloma patients) within the same hospital setting. In Study 2, 68 patients receiving community-based care participated in seven focus groups. Based on these discussions, the CCI items were again refined, and psychometric evaluation was conducted to assess the quality of the instrument.

RESULTS

Based on field tests, 3 domains of the CCI, Communication, Navigation, and Operational, were defined as critical components of CC. The Operational domain evaluates efficiency of care and is unique to this CCI. The field test demonstrated that GI patients reported significantly better CC Overall and for the Communication and Navigation domains (all p < .05). In Study 2, patients expressed concordance with the CCI items and their CC experiences, establishing validity of the CCI. Qualitative analysis of the focus group discussions indicated that the items with the highest frequencies of participants' comments were related to the concepts of Navigator, Team, Survey, and Communication. Quantitative analysis identified items with a limited response range or high rates of "neutral" responses; accordingly, those items were removed. The final CCI survey is a 29 item, multiple-choice questionnaire with excellent reliability, Cronbach's α = .922.

CONCLUSIONS

We developed a novel, patient-centered tool with excellent psychometric properties that can be utilized across varied practice settings to assess patients' perception of cancer care coordination.

TRIAL REGISTRATION

Not required; retrospectively registered ClinicalTrials.gov NCT03594006 20 July 2018.

Using a cultural dance program to increase sustainable physical activity for breast cancer survivors-A pilot study

BACKGROUND

Studies have shown that physical activity can reduce the risk of mortality for female breast cancer patients and improve quality of life, reduce weight, and alter circulating biomarker levels. We conducted a pilot trial to determine the feasibility of increasing physical activity through a cultural dance intervention to achieve similar benefits.

METHODS

Conducted a pilot trial implementing a cultural dance intervention to increase and sustain physical activity for breast cancer survivors, which consisted of a six-month group-based intervention of Hula Dance. Anthropometric measures, fasting blood draws, and self-reported questionnaires to assess physical activity, mood, and quality of life, were completed at baseline, at the end of the 6-month intervention (time point month-6), and at two additional post-intervention time points (month-12 and month-24) to assess sustainability.

RESULTS

A total of 11 women with a median age of 63 years were enrolled in the intervention trial. Eight of the 11 (73%) completed the trial to month-12 and demonstrated an overall significant increase in weekly moderate exercise. There were no significant changes in intra-individual body mass index (BMI). However, there was a sustained post-intervention reduction in waist circumference and significant changes in circulating biomarker levels. For the self-reported measures, there was a significant increase in vigor/activity (p < 0.001; Profile of Mood States-Short Form).

CONCLUSION

Our intervention pilot trial demonstrated that a cultural dance program could achieve a sustainable increase in physical activity for breast cancer survivors, with potential to improve quality of life, increase vigor, and decrease levels of circulating cytokines associated with obesity and inflammation.

Detailed 3-dimensional body shape features predict body composition, blood metabolites, and functional strength: the Shape Up! studies

BACKGROUND

Three-dimensional optical (3DO) body scanning has been proposed for automatic anthropometry. However, conventional measurements fail to capture detailed body shape. More sophisticated shape features could better indicate health status.

OBJECTIVES

The objectives were to predict DXA total and regional body composition, serum lipid and diabetes markers, and functional strength from 3DO body scans using statistical shape modeling.

METHODS

Healthy adults underwent whole-body 3DO and DXA scans, blood tests, and strength assessments in the Shape Up! Adults cross-sectional observational study. Principal component analysis was performed on registered 3DO scans. Stepwise linear regressions were performed to estimate body composition, serum biomarkers, and strength using 3DO principal components (PCs). 3DO model accuracy was compared with simple anthropometric models and precision was compared with DXA.

RESULTS

This analysis included 407 subjects. Eleven PCs for each sex captured 95% of body shape variance. 3DO body composition accuracy to DXA was: fat mass R2 = 0.88 male, 0.93 female; visceral fat mass R2 = 0.67 male, 0.75 female. 3DO body fat test-retest precision was: root mean squared error = 0.81 kg male, 0.66 kg female. 3DO visceral fat was as precise (%CV = 7.4 for males, 6.8 for females) as DXA (%CV = 6.8 for males, 7.4 for females). Multiple 3DO PCs were significantly correlated with serum HDL cholesterol, triglycerides, glucose, insulin, and HOMA-IR, independent of simple anthropometrics. 3DO PCs improved prediction of isometric knee strength (combined model R2 = 0.67 male, 0.59 female; anthropometrics-only model R2 = 0.34 male, 0.24 female).

CONCLUSIONS

3DO body shape PCs predict body composition with good accuracy and precision comparable to existing methods. 3DO PCs improve prediction of serum lipid and diabetes markers, and functional strength measurements. The safety and accessibility of 3DO scanning make it appropriate for monitoring individual body composition, and metabolic health and functional strength in epidemiological settings.This trial was registered at clinicaltrials.gov as NCT03637855.

Mixed-methods research to evaluate a novel patient-centered cancer care coordination instrument

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Background: Effective care coordination (CC) is a critical component of high-quality cancer care; however, efforts to improve cancer care coordination are hampered by limited patient-centered measures. This mixed-methods research reports on patients’ feedback and the utility of a novel care coordination instrument (CCI) designed to assess cancer care coordination. Methods: 7 focus group discussions were conducted with 68 cancer patients receiving active therapy to evaluate validity of the CCI. Subsequently, the CCI was modified and administered to additional 200 cancer patients derived from community-based private and hospital clinics. The CCI is a 29-item, multiple-choice questionnaire and includes subscales that evaluate CC in 3 domains (Communication, Navigation, Operational) across 4 areas of CC (patient-physician; between providers; during inpatient-to-ambulatory care transitions; during transitions across phases of care). Results: Qualitative analysis of focus group discussions demonstrated that the CCI has good face and content validity. Content analysis identified the following themes: Survey, Education/Knowledge, Navigator, Communication, Support, Access, Providers, and Team. Questions with unclear wording or high proportions of not applicable or missing responses were refined or removed. Results of the revised survey indicated that the CCI is able to distinguish patient- and practice characteristics associated with optimal/poor CC. Specifically, cancer types (leukemia, myeloma) and having a patient navigator predicted high overall patients’ ratings of CC ( p < .05). Marginally significant differences were found for practice setting ( p = .085). A multiple regression model with all predictors entered simultaneously revealed that the presence of a family/friend caregiver significantly predicted better CC ( p < .001); however, the benefits of a patient navigator were no longer significant. Conclusions: This study demonstrates the utility of the CCI for assessing patients’ perspectives of cancer CC. Use and integration of this instrument in oncology practices/clinics can identify areas of potential interventions for CC improvement and lead to a better quality of care.

Parental Support, Parent-Adolescent Conflict, and Substance Use of Native Hawaiian and Other Pacific Islander Youth: Ethnic Differences in Stress-Buffering and Vulnerability Effects

This research study examined the overall and ethnic-specific effects of parental emotional and instrumental support, parent-adolescent interpersonal conflict, and negative life events (i.e., major life stressors, such as parental job loss or school suspension) on the substance use of Caucasian, Asian-American, Filipino, and Native Hawaiian and other Pacific Islander (NHOPI) youth in Hawai'i. Adolescents (N = 3,561) from 10 public middle/intermediate schools completed paper/pencil surveys, and multiple regression and structural equation models were developed to examine overall and ethnic-specific effects. Parental support was found to buffer against the influence of negative life events on substance use in the overall sample; however, this effect was not observed for either Caucasian or NHOPI youth in ethnic-specific analyses. The impact of parent-adolescent conflict and negative life events on substance use was more pronounced for both Filipino and NHOPI youth. While the study may have had some limitations related to regional specificity and measurement, the findings nonetheless point to the differential effects of risk and protective factors for NHOPI youth, compared with other youth ethnic groups in Hawai'i. Implications of these findings for culturally specific, family-focused prevention research and practice for NHOPI youth are discussed.

Adolescent Tobacco and Betel Nut Use in the US-Affiliated Pacific Islands: Evidence From Guam

PURPOSE

To determine the prevalence of, and the risk and protective factors associated with, tobacco product use among adolescents in Guam, a US-Affiliated Pacific Island (USAPI) territory. To examine disparities in risk and protective factors across indigenous and nonindigenous groups.

DESIGN

Quantitative; cross-sectional.

SETTING

Middle and high schools in Guam.

SAMPLE

The Global Youth Tobacco Survey sample included a representative sample of 2449 6th to 12th graders (71% response rate). Sample for the supplemental study included 670 middle school students (76% response rate across randomly selected classrooms).

MEASURES

Self-reported measures of lifetime and past 30-day tobacco and betel nut use, social competence, resistance self-efficacy, risk perceptions, friend and family tobacco product use, and ease of access to tobacco products.

ANALYSIS

Multilevel logistic regression and analysis of covariance.

RESULTS

The prevalence rates of current cigarette, smokeless tobacco, and e-cigarette use among middle school students were 8%, 8%, and 25%, respectively. Ability to resist social pressure to use tobacco/betel nut use was strongly associated with lower likelihood of tobacco (odds ratio [OR] = 0.76; 95% confidence interval [CI]: 0.68-0.84) and betel nut use (OR = 0.74; 95% CI: 0.67-0.82). Indigenous Pacific Islanders scored significantly lower on protective and higher on risk factors.

CONCLUSION

Tobacco product use rates among Guam middle school students appear to be 4 to 5 times higher than the US national average rates. There is an urgent need for developing tobacco and betel nut use prevention programs for USAPI youth that are tailored to the needs of indigenous Pacific Islanders.

Validation of an oncology-specific instrument to measure cancer patients’ perception of care coordination

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Background: According to the IOM, effective coordination of care (CC) is a critical component of high-quality cancer care; however, lack of a reliable and validated measure limits our current understanding of cancer care coordination. We examined psychometric properties and utility of a Care Coordination Instrument (CCI), a survey developed to assess cancer patients’ perceptions of care coordination. Methods: The 29-item CCI was administered to 200 patients receiving active treatment for cancer at private oncology practices and hospital-based facilities from Oct. 2018 to Jan. 2019. The CCI includes subscales that evaluate CC in 3 domains (Communication, Navigation, Operational) across 4 areas of CC (patient-physician; between health providers; during inpatient-to-ambulatory care transitions; during transitions across different phases of care). All items were rated on a 4-point Likert scale. Results: Psychometric analyses of the CCI demonstrated that it has good internal consistency reliability (α = .917) and the three-factor solution was an acceptable fit (CFI = .853, SRMR = .065). Overall, cancer types (leukemia, myeloma) and having an identified patient navigator significantly predicted higher patients’ ratings of CC ( p < .05). Similar trends were found for Communication and Operation subscale scores ( p < .05). Having an identified navigator predicted higher Navigation scores ( p < .05). Marginally significant differences were found for practice setting, with patients receiving care in hospital-based facilities reporting better CC ( p = .085). Item-level analyses revealed significant differences in specific aspects of CC (e.g., physician-patient communication) across cancer type, presence/absence of a patient navigator, and practice setting. Conclusions: The results demonstrate that the CCI is a reliable and valid instrument for measuring cancer patients’ perceptions of care coordination. Perception of CC correlated with the presence of a navigator, underlying cancer type and (trending) practice setting. Use of this instrument may reveal important information about cancer care coordination and may identify areas of targets for improvement in patient-centered cancer care delivery.

Effectiveness of two different dose administration regimens of an IL-15 superagonist complex (ALT-803) in an orthotopic bladder cancer mouse model

BACKGROUND

We set out to determine if the administration of subcutaneous (SQ) ALT-803 was non-inferior to standard intravesical BCG treatment in a carcinogen induced mouse (C57BL/6J) bladder cancer model.

METHODS

Using this well-established carcinogen induced mouse model, we studied the effects of various dosing schemas of ALT-803 (SQ alone, SQ with intravesical BCG, intravesical alone, intravesical with intravesical BCG) compared to intravesical BCG alone (positive control) and PBS (negative control). The non-inferiority margin for the difference in bladder weight, as a surrogate for tumor mass, was defined as 7%.

RESULTS

All treatment groups (i.e., ALT-803 SQ alone, ALT-803 SQ with intravesical BCG, ALT-803 intravesical alone, ALT-803 intravesical with intravesical BCG and intravesical BCG alone) demonstrated a significant reduction in tumor burden as evident by bladder weights and H&E stain (p < 0.005). Non-inferiority tests between the intravesical BCG alone group and the additional treatment groups showed that SQ ALT-803 alone (p = 0.04) and BCG plus SQ ALT-803 (p = 0.009) were non-inferior to intravesical BCG alone. In this model, we did not see an appreciable infiltration of CD4⁺ T, CD8⁺ T or CD161/KLRB1⁺ natural killer (NK) cells in the bladder/tumor. When assessing peripheral blood mononuclear cells, SQ ALT-803 alone resulted in a robust induction of CD8⁺ T cells (p < 0.01), NKG2D⁺ NK cells (p < 0.005) and CD3⁺/NKG2D⁺ NKT cells (p < 0.005) compared to other groups, while in splenic tissue, SQ ALT-803 alone resulted in a robust induction of CD3⁺/NKG2D⁺ NKT cells (p < 0.005) compared to other groups.

CONCLUSION

Subcutaneous ALT-803 treatment alone or in combination with intravesical BCG was well tolerated and was not inferior to intravesical BCG alone. CD8⁺ T, NKG2D⁺ NK and CD3⁺/NKG2D⁺ NKT cell induction along with induction of key cytokines remain steadfast mechanisms behind ALT-803. The enhanced therapeutic index seen with BCG and ALT-803, administered SQ or intravesically, provides a powerful justification for the further development of these regimens.

E-cigarette use and respiratory disorder in an adult sample

OBJECTIVES

Little evidence is available on the association of e-cigarettes with health indices. We investigated the association of e-cigarette use with diagnosed respiratory disorder among adults in data from the Behavioral Risk Factor Surveillance Survey (BRFSS).

METHODS

The 2016 Hawaii BRFSS, a cross-sectional random-dial telephone survey, had 8087 participants; mean age was 55 years. Items asked about e-cigarette use, cigarette smoking, and being diagnosed by a health professional with (a) asthma or (b) chronic obstructive pulmonary disease. Multivariable analyses tested associations of e-cigarette use with the respiratory variables controlling for smoking and for demographic, physical, and psychosocial variables.

RESULTS

Controlling for the covariates and smoking there was a significant association of e-cigarette use with chronic pulmonary disorder in the total sample (AOR = 2.58, CI 1.36-4.89, p < 0.01) and a significant association with asthma among nonsmokers (AOR = 1.33, CI 1.00-1.77, p <  0.05). The associations were stronger among nonsmokers than among smokers. Results were similar for analyses based on relative risk and absolute risk. There was also a greater likelihood of respiratory disorder for smokers, females, and persons with overweight, financial stress, and secondhand smoke exposure.

CONCLUSIONS

This is the first study to show a significant independent association of e-cigarette use with chronic respiratory disorder. Several aspects of the data are inconsistent with the possibility that e-cigarettes were being used for smoking cessation by persons with existing respiratory disorder. Theoretical mechanisms that might link e-cigarettes use and respiratory symptoms are discussed.

A Subset of Mesotheliomas With Improved Survival Occurring in Carriers of BAP1 and Other Germline Mutations

PURPOSE

We hypothesized that four criteria could help identify malignant mesotheliomas (MMs) most likely linked to germline mutations of BAP1 or of other genes: family history of MM, BAP1-associated cancers, or multiple malignancies; or age younger than 50 years.

PATIENTS AND METHODS

Over the course of 7 years, 79 patients with MM met the four criteria; 22 of the 79 (28%) reported possible asbestos exposure. They were screened for germline BAP1 mutations by Sanger sequencing and by targeted next-generation sequencing (tNGS) for germline mutations in 55 additional cancer-linked genes. Deleterious mutations detected by tNGS were validated by Sanger sequencing.

RESULTS

Of the 79 patients, 43 (16 probands and 27 relatives) had deleterious germline BAP1 mutations. The median age at diagnosis was 54 years and median survival was 5 years. Among the remaining 36 patients with no BAP1 mutation, median age at diagnosis was 45 years, median survival was 9 years, and 12 had deleterious mutations of additional genes linked to cancer. When compared with patients with MMs in the SEER cohort, median age at diagnosis (72 years), median survival for all MM stages (8 months), and stage I (11 months) were significantly different from the 79 patients with MM in the current study ( P < .0001).

CONCLUSION

We provide criteria that help identify a subset of patients with MM who had significantly improved survival. Most of these patients were not aware of asbestos exposure and carried either pathogenic germline mutations of BAP1 or of additional genes linked to cancer, some of which may have targeted-therapy options. These patients and their relatives are susceptible to development of additional cancers; therefore, genetic counseling and cancer screening should be considered.

Genetic deletion of sphingosine kinase 1 suppresses mouse breast tumor development in an HER2 transgenic model

Aberrant sphingolipid metabolism has been reported to promote breast cancer progression. Sphingosine kinase 1 (SphK1) is a key metabolic enzyme for the formation of pro-survival S1P from pro-apoptotic ceramide. The role of SphK1 in breast cancer has been well studied in estrogen receptor (ER)-positive breast cancer; however, its role in human epidermal growth factor 2 (HER2)-positive breast cancer remains unclear. Here, we show that genetic deletion of SphK1 significantly reduced mammary tumor development with reduced tumor incidence and multiplicity in the MMTV-neu transgenic mouse model. Gene expression analysis revealed significant reduction of claudin-2 (CLDN2) expression in tumors from SphK1 deficient mice, suggesting that CLDN2 may mediate SphK1's function. It is remarkable that SphK1 deficiency in HER2-positive breast cancer model inhibited tumor formation by the different mechanism from ER-positive breast cancer. In vitro experiments demonstrated that overexpression of SphK1 in ER-/PR-/HER2+ human breast cancer cells enhanced cell proliferation, colony formation, migration and invasion. Furthermore, immunostaining of SphK1 and CLDN2 in HER2-positive human breast tumors revealed a correlation in high-grade disease. Taken together, these findings suggest that SphK1 may play a pivotal role in HER2-positive breast carcinogenesis. Targeting SphK1 may represent a novel approach for HER2-positive breast cancer chemoprevention and/or treatment.

Sugar and Aldehyde Content in Flavored Electronic Cigarette Liquids

Introduction

Sugars are major constituents and additives in traditional tobacco products, but little is known about their content or related toxins (formaldehyde, acetaldehyde, and acrolein) in electronic cigarette (e-cigarette) liquids. This study quantified levels of sugars and aldehydes in e-cigarette liquids across brands, flavors, and nicotine concentrations (n = 66).

Methods

Unheated e-cigarette liquids were analyzed using liquid chromatography mass spectrometry and enzymatic test kits. Generalized linear models, Fisher's exact test, and Pearson's correlation coefficient assessed sugar, aldehyde, and nicotine concentration associations.

Results

Glucose, fructose and sucrose levels exceeded the limits of quantification in 22%, 53% and 53% of the samples. Sucrose levels were significantly higher than glucose [χ2(1) = 85.9, p < .0001] and fructose [χ2(1) = 10.6, p = .001] levels. Formaldehyde, acetaldehyde, and acrolein levels exceeded the limits of quantification in 72%, 84%, and 75% of the samples. Acetaldehyde levels were significantly higher than formaldehyde [χ2(1) = 11.7, p = .0006] and acrolein [χ2(1) = 119.5, p < .0001] levels. Differences between nicotine-based and zero-nicotine labeled e-cigarette liquids were not statistically significant for sugars or aldehydes. We found significant correlations between formaldehyde and fructose (-0.22, p = .004) and sucrose (-0.25, p = .002) and acrolein and fructose (-0.26, p = .0006) and sucrose (-0.21, p = .0006). There were no significant correlations between acetaldehyde and any of the sugars or any of the aldehydes and glucose.

Conclusions

Sugars and related aldehydes were identified in unheated e-cigarette liquids and their composition may influence experimentation in naïve users and their potential toxicity.

Implications

The data can inform the regulation of specific flavor constituents in tobacco products as a strategy to protect young people from using e-cigarettes, while balancing FDA's interest in how these emerging products could potentially benefit adult smokers who are seeking to safely quit cigarette smoking. The data can also be used to educate consumers about ingredients in products that may contain nicotine and inform future FDA regulatory policies related to product standards and accurate and comprehensible labeling of e-cigarette liquids.

Young adult e-cigarette use outcome expectancies: Validity of a revised scale and a short scale

The revised youth e-cigarette outcome expectancies measure adds new items informed by recent qualitative research with young adult e-cigarette users, especially in the domain of positive "smoking" experience. Positive "smoking" experience represents beliefs that use of e-cigarettes provides outcomes associated with a better "smoking" alternative: for example, an alternative that is more socially approved, more suitable for indoor use, and that provides a safer means of enjoying nicotine. In addition, we tested a short, 8-item version of the measure which may be more easily incorporated into surveys. We tested the validity of the revised measure, both long and short versions, in terms of factor structure and associations of the expectancy factors with current e-cigarette use, e-cigarette use susceptibility, and e-cigarette use dependence. Participants were young adults (N=470; 65% women; mean age=20.9, SD=2.1). Results replicated the findings of the previous study as well as highlighted the importance of the added domain of positive "smoking" experience and the validity of the short scale. Furthermore, results showed that positive outcome expectancies are strongly associated with e-cigarette use dependence. The long and short versions of the revised youth e-cigarette outcome expectancies scale appear to be valid and useful for application not only among cigarette smokers and e-cigarette users but also among never smokers and never e-cigarette users.

E-cigarette use and asthma in a multiethnic sample of adolescents

There is minimal evidence from epidemiological studies on how e-cigarette use is related to health indices in adolescence. We hypothesized that e-cigarette use would be associated with asthma, controlling for demographics and cigarette smoking. The hypothesis was tested with cross-sectional data from a statewide sample of school students. Surveys were administered in classrooms in 2015 to adolescents in 33 high schools throughout the State of Hawaii. The sample (N=6089) was 50% female and mean age was 15.8years. Data were obtained on demographics; ever use and current (past 30days) use of e-cigarettes, combustible cigarettes, and marijuana; ever being diagnosed with asthma; and currently having asthma. Multinomial regression examined the association between e-cigarette use and asthma controlling for cigarette smoking, marijuana use, and six demographic covariates. Current e-cigarette use was associated with currently having (vs. never having) asthma (adjusted odds ratio [aOR]=1.48, CI 1.26-1.74) and with previously having (vs. never having) asthma (aOR=1.22, CI 1.07-1.40). This was independent of cigarette smoking, marijuana use, and other covariates. Smoking and marijuana were nonsignificant in the multivariate analysis. Blacks, Native Hawaiians, other Pacific Islanders, and Filipinos had higher rates of asthma compared with Asian Americans and Caucasians. We conclude that e-cigarette use by adolescents is independently associated with asthma. This finding is consistent with recent laboratory research on pulmonary effects from e-cigarette vapor. Implications for public health should be considered.

HMGB1 targeting by ethyl pyruvate suppresses malignant phenotype of human mesothelioma

Human malignant mesothelioma (MM) is an aggressive cancer linked to asbestos and erionite exposure. We previously reported that High-Mobility Group Box-1 protein (HMGB1), a prototypic damage-associated molecular pattern, drives MM development and sustains MM progression. Moreover, we demonstrated that targeting HMGB1 inhibited MM cell growth and motility in vitro, reduced tumor growth in vivo, and prolonged survival of MM-bearing mice. Ethyl pyruvate (EP), the ethyl ester of pyruvic acid, has been shown to be an effective HMGB1 inhibitor in inflammation-related diseases and several cancers. Here, we studied the effect of EP on the malignant phenotype of MM cells in tissue culture and on tumor growth in vivo using an orthotopic MM xenograft model. We found that EP impairs HMGB1 secretion by MM cells leading to reduced RAGE expression and NF-κB activation. As a consequence, EP impaired cell motility, cell proliferation, and anchorage-independent growth of MM cells. Moreover, EP reduced HMGB1 serum levels in mice and inhibited the growth of MM xenografts.

Our results indicate that EP effectively hampers the malignant phenotype of MM, offering a novel potential therapeutic approach to patients afflicted with this dismal disease.

Association of MMP-2, RB and PAI-1 with decreased recurrence-free survival and overall survival in bladder cancer patients

Background

We previously reported an accurate urine-based bladder cancer (BCa)-associated diagnostic signature that can be used to non-invasively detect BCa. In this study, we investigated whether a component of this signature could risk stratify patients with BCa.

Methods

Utilizing immunohistochemistry, we investigated angiogenin, MMP-2, p53, RB and PAI-1 expression from 939 patients with BCa. The expression levels were scored by assigning a proportion score and an intensity score to yield a total staining score for each protein. The expressions of each protein individually and as an aggregate were then correlated with progression-free survival (PFS), cancer-specific survival (CSS) and overall survival (OS).

Results

Differential expressions of these markers were noted in BCa. With multivariate analysis in non-muscle invasive bladder cancer (NMIBC) age, tumor grade portended a worse PFS, while age, tumor grade, nodal status, MMP2, RB and PAI-1 expression portended a worse OS. As for multivariate analysis in muscle invasive bladder cancer (MIBC), age MMP-2 and RB were associated with a worse PFS, while age, nodal status, MMP-2, RB and PAI-1 were associated with a worse OS. Using Kaplan-Meier survival analysis, we noted a significant reduction in OS as more of the five biomarkers were expressed in a tumor. Thus, overall, high expressions of MMP-2, RB and/or PAI-1 in bladder tumors were markers of poor prognosis.

Conclusion

Individually, MMP-2, RB and PAI-1, as well as in aggregate correlated with poor survival in patients with BCa. Thus, patients whose bladder tumors express these biomarkers may benefit from early radical treatment and/or neoadjuvant or adjuvant therapies.

Abstract A05: Does Dual Use of Cigarettes and Little Cigars/Cigarillos Increase the Risk for Nicotine Dependence Among Young Adults?

Purpose: Tobacco use continues to be the leading cause of cancer deaths in the U.S. In 2016, the Food and Drug Administration (FDA) announced that it would regulate little cigars and cigarillos (LCCs) and expressed concerns about the risks of dual use of combustible tobacco products. Little cigars and cigarillos (LCCs) are growing in popularity among young people and racial/ethnic groups who experience disproportionately higher rates of tobacco-caused cancers. To better understand the relationships between dual use patterns and nicotine dependence, this study investigated the association between dual use of cigarettes with LCCs and time to first cigarette within 5 minutes of waking in the morning. We hypothesized that dual users of cigarettes and LCCs (either with tobacco or marijuana in the LCC casing) would show increased dependence on nicotine.

Procedures: An online cross-sectional survey administered in 2015 by the GfK Group (formerly Knowledge Networks) was used to collect data on LCC use behaviors among a national probability sample of African American, Hispanic, and White cigarette smokers, 18-44 years of age (n=1018). GfK conducted the survey by recruiting samples from the KnowledgePanel® and opt-in panel sources. The primary independent variable was tobacco use subtype (cigarette-only = reference; cigarette and other tobacco use excluding LCCs; LCCs with tobacco retained in the casing; LCCs with marijuana in the casing (LCC-blunt); or LCC poly use (LLC-tobacco and LCC-blunt). Associations of tobacco use subtype with the primary outcome, time to first cigarette within 5 minutes of waking were tested in multivariable regression models, which adjusted for demographics (e.g., age, gender, race/ethnicity) and other covariates, including the use of menthol cigarettes, smoking frequency, smoking intensity, self-efficacy to quit, other tobacco use, use of marijuana other than blunts, and alcohol use.

Results. In the sample of cigarette smokers, 48.6% were cigarette-only smokers, 13.9% used cigarettes and other form of tobacco not including LCCs, 15.4% used LCC-tobacco, 11.5% used LCC-blunts, and 10.6% were poly users (LCC-tobacco and LCC-blunt users). The majority of African American (57.6%), Hispanic (64.0%), and male (55.2%) cigarette smokers were dual users. In the weighted adjusted regression models, results showed that young adult cigarette smokers who were poly-users were nearly twice as likely to smoke a cigarette within the first 5 minutes of waking compared to cigarette-only users (AOR=1.97, 95% CI=1.03-3.75). Male poly users were more than twice as likely as cigarette-only users to smoke a cigarette within the first 5 minutes of waking (AOR=2.32, 95% CI= 1.04-5.17). Female blunt users were 3 times as likely as cigarette-only users to smoke a cigarette within the first 5 minutes of waking (AOR=3.19, CI=1.45-7.00). African Americans who used LCC-tobacco were less likely than cigarette-only users to smoke a cigarette within the first 5 minutes of waking (AOR=0.17, 95% CI=0.04-0.63). Hispanics who used LCC-tobacco or LCC-blunt were nearly 4 times as likely to smoke a cigarette within the first 5 minutes of waking (AOR=3.99 CI=1.39-11.43; AOR=3.88, CI=1.37-11.01). Among White cigarette smokers, there were no significant differences in time to first cigarette among tobacco use subtypes.

Conclusions. Results showed that dual use behavior is common and that there is differential risk of nicotine dependence by tobacco use subgroup type and by racial/ethnic and gender groups. Marijuana in LCCs may increase addiction to cigarettes for males, females, and Hispanics, but not for African Americans. These data are complex, but point to the need to develop tailored health messages for cigarette-only users and dual users.

Citation Format: Pebbles Fagan, Pallav Pokhrel, Thaddeus Herzog, Mignonne Guy, Ian Pagano, Kymberle Sterling. Does Dual Use of Cigarettes and Little Cigars/Cigarillos Increase the Risk for Nicotine Dependence Among Young Adults? [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A05.

Association between menthol-flavoured cigarette smoking and flavoured little cigar and cigarillo use among African-American, Hispanic, and white young and middle-aged adult smokers

OBJECTIVES

Flavour additives in cigarettes and little cigars and cigarillos (LCCs), which influence smokers' risk perceptions, may reinforce dual flavoured tobacco use. We examined the association among mentholated cigarette use, risk perceptions for flavour additives in LCCs and flavoured LCC smoking behaviour.

METHODS

Data from a national probability sample of 964 young and middle-aged adult current cigarette smokers were analysed. Multinomial logistic regression models examined the relationship among mentholated cigarette smoking, risk perceptions and current flavoured LCC use for the analytic sample and gender and race/ethnicity.

RESULTS

Daily menthol cigarette smokers, compared to occasional, non-menthol smokers, had increased odds of flavoured LCC smoking (OR=1.75, 95% CI 1.02 to 2.98). This relationship was found for males, blacks/African-Americans and Hispanics/Latinos (p<0.05). Positive perceptions of menthol-flavoured additives in LCCs was associated with increased odds of flavoured LCC use among the analytic sample, males and blacks/African-Americans (p<0.05). Positive perceptions for clove-flavoured, spice-flavoured and alcohol-flavoured additives were also associated with flavoured LCC use among the analytic sample (p<0.05).

CONCLUSIONS

Use of menthol-flavoured cigarettes and positive perceptions about menthol-flavoured and other flavour additives in LCCs may contribute to dual use with flavoured LCCs among adult cigarette smokers, specifically those from vulnerable populations.

E-cigarette use is differentially related to smoking onset among lower risk adolescents

OBJECTIVE

E-cigarette use has been linked to onset of cigarette smoking among adolescents, but some commentators have suggested that this simply reflects high-risk adolescents being more likely to use e-cigarettes and to smoke. We tested whether the effect of e-cigarette use for smoking onset differs for youth who are lower versus higher on propensity to smoke.

METHODS

School-based survey with a longitudinal sample of 1136 students (9th-11th graders, mean age 14.7 years) in Hawaii, initially surveyed in 2013 (T1) and followed up 1 year later (T2). We assessed e-cigarette use, propensity to smoke based on 3 psychosocial factors known to predict smoking (rebelliousness, parental support and willingness to smoke), and cigarette smoking status. Analyses based on T1 never-smokers tested the relation of T1 e-cigarette use to T2 smoking status for participants lower versus higher on T1 propensity to smoke.

RESULTS

The relation between T1 e-cigarette use and T2 smoking onset was stronger among participants with lower levels of rebelliousness and willingness and higher levels of parental support. A multiple logistic regression analysis with T2 smoking as the criterion tested the cross-product of T1 e-cigarette use and T1 smoking propensity score; the interaction (OR=0.88, p=0.01) indicated a significantly larger effect for smoking onset among lower risk youth.

CONCLUSIONS

The results indicate e-cigarette use is a risk factor for smoking onset, not just a marker of high risk for smoking. This study provides evidence that e-cigarettes are recruiting lower risk adolescents to smoking, which has public health implications.