Survey of disease and treatment-related symptoms in outpatients with invasive cancer of the breast, prostate, lung, or colon/rectum (E2Z02, the SOAPP study)

9619

Background: The full spectrum and impact of symptoms experienced by ambulatory patients (pts) in medical oncology clinics throughout their care trajectory is poorly understood. Methods: This large prospective study by the Eastern Cooperative Oncology Group (ECOG) enrolled pts with invasive cancer of the breast, prostate, colon/rectum or lung regardless of phase of care or stage of disease. The study was conducted between 3/06 and 5/08 at multiple academic (n=7) and community (n=32) medical oncology clinics. Pre-defined sampling algorithms were used to reduce selection bias. At baseline and again 4 weeks later, pts completed a 25-item measure of symptoms and functional interference (M.D. Anderson Symptom Inventory-ECOG). Patients’ providers simultaneously prioritized their symptoms. Results: 3124 patients were enrolled (90% from community clinics) and 3077 were analyzable with 1524 breast (50%), 715 colorectal (23%), 518 lung (17%), and 320 prostate (10%) pts. The most prevalent moderate-to-severe symptoms of the full cohort at baseline (B) and follow-up (F) were: fatigue (B34% to F32%), disturbed sleep (B27% to F21%), drowsiness (B22% to F21%), hair loss (B20% to F19%), pain (B19% to F18%), dry mouth (B19% to F15%), and numbness/tingling (B19% to F17%). At baseline, 40% of the cohort had at least 3 moderate-to-severe symptoms and 36% had this attribute at follow-up. Clinician perception of symptoms was strongly correlated with patient symptom survey results regardless of disease site, race, or ethnicity. Of the 849 pts receiving anti-cancer treatment for metastatic disease, half had 2 or more metastatic sites with 75% receiving cytotoxic chemotherapy. Clinicians judged lung cancer patients’ symptoms to be the most difficult to manage (p<0.01). Conclusions: Non-pain symptoms, particularly fatigue and sleep disturbance, are a major source of symptom distress in ambulatory medical oncology practice. Overall, symptom burden remains substantial and difficult to resolve. These data will help guide future interventional studies.

No significant financial relationships to disclose.

Post-transplant diabetes mellitus in children following renal transplantation

PTDM plays a role in chronic allograft nephropathy and decreases graft and patient survival. Considering the serious outcome of chronic hyperglycemia, the importance of early recognition and the few data in children, in this retrospective analysis we studied the characteristics and risk factors of PTDM in 45 pediatric renal transplant recipients receiving Tac or CyA-based immunosuppression. Fasting blood sampling and OGTT were performed. PTDM has been developed in six patients (13%), while seven children (16%) had IGT, with the overall incidence of a glucose metabolic disorder of 29% in pediatric renal transplants. Patients in the PTDM + IGT group were younger and had higher systolic blood pressure and serum triglyceride level than children with normal glucose tolerance. Multivariate analysis identified Tac treatment, Tac trough level, steroid pulse therapy and family history of diabetes to be associated with the onset of PTDM. In pediatric renal transplants, OGTT and frequent assessment of blood glucose levels might be essential not only in the post-transplant management, but also prior to transplantation, particularly with family history of diabetes. Careful monitoring and modified protocols help to minimize the side effects of Tac and corticosteroids.

Morphology of glomerular hematuria is reproduced in vitro by carbonyl stress

BACKGROUND

In glomerulonephritides, dysmorphic red blood cells (RBCs) with membrane blebs can be found in the urine; this is referred to as glomerular hematuria. Glomerulonephritides are characterized by increased carbonyl stress and elevated methylglyoxal (MGO) levels. MGO causes oxidative stress and intracellular calcium accumulation. In the present study, we investigated whether the effect of MGO-induced calcium accumulation in RBCs develops through increased oxidative stress. Furthermore, we studied whether MGO can lead to RBC membrane blebbing.

METHODS

RBC suspensions from healthy volunteers were incubated with different concentrations of MGO at 37 degrees C. We measured oxidative stress and intracellular calcium level using fluorescent indicators. We determined the frequency of dysmorphic RBCs, and also performed scanning electron microscopy.

RESULTS

MGO increased oxidative stress and caused accumulation of calcium in isolated RBCs. These effects could be prevented using antioxidants. In the presence of MGO, RBC membrane blebbing developed.

CONCLUSION

According to our findings, MGO causes calcium accumulation through oxidative stress. Carbonyl and oxidative stress may play an important role in the formation of dysmorphic RBCs in glomerular hematuria.

Cigarette smoke-induced alterations in endothelial nitric oxide synthase phosphorylation: role of protein kinase C

Endothelial nitric oxide synthase (eNOS) is regulated by phosphorylation of Ser(1177) and Thr(495), which affects NO bioavailability. Cigarette smoke disturbs the eNOS-cGMP-NO pathway and causes decreased NO production. Here the authors investigated the acute effects of cigarette smoke on eNOS phosphorylation, focusing on protein kinases (PKs). Endothelial cell culture was concentration- and time-dependently treated first with cigarette smoke buffer (CSB), then with reduced glutathione (GSH) or various PK inhibitors (H-89, LY-294002, Ro-318425, and ruboxistaurin). eNOS, phospho-Ser(1177)-eNOS, phospho-Thr(495)-eNOS, Akt(PKB), and phospho-Akt protein levels were determined by Western blot. CSB increased the phosphorylation of eNOS at Ser(1177) and more at Thr(495) in a concentration- and time-dependent manner (p < .01, p < .05 versus control, respectively) and resulted in the dissociation of the active dimeric form of eNOS (p < .05). GSH decreased the phosphorylation of eNOS at both sites (p < .05 versus CSB without GSH) and prevented the decrease of dimer eNOS level. CSB treatment also decreased the level of phospho-Ser(473)-Akt (p < .05 versus control). Inhibition of PKA by H-89 did not affect CSB-induced phosphorylation, whereas the PKB inhibitor LY-294002 enhanced it at Ser(1117). The PKC blockers Ro-318425 and ruboxistaurin augmented the CSB-induced phosphorylation at Ser(1177) but decreased phosphorylation at Thr(495) (p < .05 versus CSB). Cigarette smoke causes a disruption of the enzymatically active eNOS dimers and shifts the eNOS phosphorylation to an inhibitory state. Both effects might lead to reduced NO bioavailability. The shift of the eNOS phosphorylation pattern to an inhibitory state seems to be independent of the PKA and phosphoinositol 3-kinase (PI3-K)/Akt pathways, whereas PKC appears to play a key role.

Reduced TGF-beta1 expression and its target genes in human insulinomas

Aiming to identify signalling pathways relevant for ss-cell growth we performed an explorative micro-array analysis comparing the gene expression profiles of three human insulinomas and one normal pancreatic islet preparation. This revealed an insulinoma-associated down-regulation of the transforming growth factor beta 1 (TGF-beta1) and its target genes. Comparative quantitative real-time PCR (qRT-PCR) including an expanded sample number of both insulinomas (n=9) and pancreatic islet preparations (n=4) confirmed the decreased TGF-beta1 expression and its target molecules (TGFBI, NNMT, RPN2) in insulinomas. Similarly, TGF-beta1 immunofluorescence analysis revealed reduced expression in insulinomas when compared to pancreatic islets. In contrast, TGFBR2 (transforming growth factor beta receptor II) was found up-regulated. However, the consistent down-regulation of the TGF-beta1 targets TGFBI (transforming growth factor, beta-induced), NNMT (nicotinamide N-methyltransferase), RPN2 (ribophorin II) indicates that the parallel up-regulation of TGFBR2 does not compensate for the only marginal TGF-beta1 expression levels in insulinomas. TGFBR2 expression was confirmed at the protein level in insulinomas. SMAD2/3 protein expression was found at higher levels in human pancreatic islets when compared with insulinomas by dual colour confocal microscopy. TGF-beta1 signalling is known to be involved in cell replication and is abrogated in ductal pancreatic tumours. The down-regulation of TGF-beta1 expression and its target molecules in insulinomas is a new aspect of this cytokine. Our data underline parallels in endocrine and exocrine pancreatic tumour development, which may implicate common progenitor cells.

Calcium-binding protein secretagogin-expressing neurones in the human hippocampus are largely resistant to neurodegeneration in Alzheimer's disease

The pathological findings in Alzheimer's disease (AD) are partly attributed to alterations in calcium-binding protein (CBP) functions. We showed previously that immunoreactivity of secretagogin, a recently cloned CBP, in the human hippocampus is restricted to pyramidal neurones and that the amount of immunoreactive neurones does not differ between AD cases and controls. In this study we investigate the influence of hippocampal tau pathology on secretagogin expression in more details. The study group consisted of 26 cases with different degrees of neuropathologically confirmed AD pathology. Sections were incubated separately with secretagogin- and tau-specific antibodies, respectively. The amount of immunoreactive neurones and integral optical densities were assessed. In addition, double immunofluorescence for both secretagogin and tau was performed. No difference with respect to secretagogin immunoreactivity was observed in different stages of AD pathology, and similarly no significant associations were seen between the amount of secretagogin and tau immunoreactivity in the different hippocampal subfields. Double immunofluorescence revealed that both proteins rarely colocalize because only 5.3% of tau and 2.9% of secretagogin immunoreactive neurones, respectively, showed colocalization. Because there are no differences in the amount of hippocampal secretagogin expression between AD cases and controls (as we have shown previously), the lack of an association between the amount of secretagogin expression and tau burden together with the low frequency of colocalization of tau and secretagogin in the human hippocampus, suggest that secretagogin-expressing neurones are largely resistant to neurodegeneration in AD.

New functional aspects of the neuroendocrine marker secretagogin based on the characterization of its rat homolog

Secretagogin is a recently cloned human beta-cell-expressed EF-hand Ca(2+)-binding protein. Converging evidence indicates that it exerts Ca(2+) sensor activity and is involved in regulation of insulin synthesis and secretion. To obtain a potent tool for the extension of its functional analysis in rat in vitro systems, we cloned the rat homolog of human secretagogin. Using comparative sequence analysis, immunostaining, and immunoblotting, we demonstrated a high degree of sequence homology and similar tissue expression patterns of human and rat secretagogin. Highest rat secretagogin expression levels were found in pancreatic beta-cells. On the basis of newly generated anti-rat secretagogin antibodies, we established a rat secretagogin-specific sandwich capture ELISA and demonstrated release of secretagogin from viable Rin-5F cells. Dexamethasone treatment of Rin-5F cells resulted in an increased secretagogin release rate, which was inversely correlated with insulin secretion. In contrast, the secretagogin transcription rate was markedly reduced. This resulted in a decreased intracellular secretagogin content under the influence of dexamethasone. Sucrose gradient cell fractionation analysis of Rin-5F cells confirmed the predominant cytosolic localization of secretagogin, with only limited association of secretagogin with insulin granules. The loss of intracellular secretagogin after dexamethasone treatment affected predominantly the insulin granule-associated secretagogin fractions. The sequence homology and the comparable tissue expression patterns of human and rat secretagogin indicate conserved intracellular functions. The effects of dexamethasone on the total secretagogin content in Rin-5F cells and on its intracellular distribution might result in an impaired Ca(2+) sensitivity of dexamethasone-treated insulin-secreting cells.

Development of a functional assessment of side-effects to therapy (FAST) questionnaire to assess dermatology-related quality of life in patients treated with EGFR inhibitors (EGFRI): The FAST-EGFRI

19532

Background: Despite their beneficial antitumor effects, 75–87% patients who undergo EGFRI therapy develop dermatological toxicities (derm tox), including rash, paronychia, hair alterations, and pruritus. The purpose of this study was to develop a patient (pts) self-report questionnaire based on pts and expert (exp) input and to identify the most significant skin tox health-related quality of life (HRQL) factors. Methods: To generate the questionnaire, 20 pts with derm tox to EGFRIs and 12 expert clinicians (>50 treated pts) were asked interview questions and rated 62 items to assess the most bothersome aspects of derm tox and the impact on pts’ skin-specific HRQL. The questionnaire included items from the Skindex-29, a validated skin disease-specific HRQL questionnaire. Items were rated from 0 (not at all important) to 3 (extremely important) (range = 0–3) based on the items’ significance to patients’ HRQL. Both groups were also asked to circle 20 of the most concerning HRQL factors. Results: Eighteen pts and 11 exp completed the questionnaire. Symptoms reported frequently by both pts and exp that affected patients’ HRQL included painful (mean score 2.29 (pts), 2.70, (exp), burning (2.41 (pts), 2.70 (exp)), itchy (2.00 (pts), 2.20 (exp) skin, pain in fingers/toes (2.00 (pts), 2.40 (exp)) increased facial hair (1.93(pts), 1.70 (exp)). Both pts and exp also frequently reported that the patient’s skin condition makes them feel depressed (1.88 (pts), 2.60 (exp)) and makes work or hobbies difficult (2.00 (pts), 2.20 (exp)). The top three most concerning HRQL factors for pts were skin pain, burning and stinging, and irritation, while exp reported depression, skin pain, and derm tox affecting pts’ social life. Conclusions: These results document the trajectory of symptom burden and derm tox HRQL in EGFRI treated pts. These findings underscore that in addition to the psychosocial discomfort, physical symptoms impact HRQL. Further studies to validate the FAST-EGFRI, so that effects on HRQL of interventions against derm tox and differences between agents can be assessed are underway.

No significant financial relationships to disclose.

Single dose of acetylsalicylic acid in patients with Type 2 diabetes mellitus and/or chronic renal failure ameliorates anaemia by decreasing the rate of neocytolysis

BACKGROUND

Anaemia in diabetes mellitus (DM) and/or chronic renal failure (CRF) may be caused by a decreased production of erythropoietin (EPO), EPO resistance, and by the lysis of the young circulating red blood cells (neocytolysis) induced by subclinical inflammation and low EPO level. Aims of this study were to detect EPO resistance in patients with DM and/or CRF and to prove, that acetylsalicylic acid (ASA) is able to improve the haemopoietic status by decreasing neocytolysis.

METHODS

In a cross-sectional study, three groups of selected patients (patients with DM; patients with DM+CRF; patients with CRF without DM, n=15 each) and a group of controls (non-diabetic, nonazotemic subjects, n = 10) were compared. In the intervention part of the study, the effect of a single dose of 1 gram ASA on neocytolysis was investigated in a subgroup of these patients.

RESULTS

Despite the similar EPO level (p = 1.000), all three patient groups had lower haemoglobin and haematocrit than control persons (p < 0.05 in all cases). Patients with DM+CRF had lower haemoglobin than patients with DM or CRF alone (p < 0.05). Single dose of ASA induced a fast increase in serum EPO level, a concomitant rise of the Rtc number and rate, red blood cell count, haematocrit and haemoglobin p < 0.01 for each). These changes were accompanied by a marked decrease in serum lactate dehydrogenase activity (p < 0.01).

CONCLUSIONS

DM and CRF may induce erythropoietin resistance. In these patients, ASA treatment increases serum EPO level. The higher EPO level and the anti-inflammatory effect of ASA may decrease neocytolysis.

Impact of Androgen Deprivation Therapy on Physical and Cognitive Function, as Well as Quality of Life of Patients With Nonmetastatic Prostate Cancer

PURPOSE

Many patients with prostate cancer receive androgen deprivation therapy for long periods. We compared physical and cognitive function, and quality of life in a cross-sectional study of 57 patients receiving androgen deprivation therapy for nonmetastatic prostate cancer and 51 healthy age matched controls.

MATERIALS AND METHODS

Physical and daily function were measured by the 6-minute walk test, grip strength, the timed up and go test, and activities of daily living measures. Cognitive function was evaluated by the High Sensitivity Cognitive Screen and by a self-report prototype Functional Assessment of Cancer Therapy cognitive function subscale. Quality of life was assessed by the Functional Assessment of Cancer Therapy-General with the subscale for fatigue and by the Patient-Oriented Prostate Utility Scale.

RESULTS

Androgen deprivation therapy was given for a median of 1.8 years (range 0.4 to 7.4). Patients had lower median hemoglobin than controls (134 vs 148 gm/l, p <0.0001). Performance on physical tests was similar in the 2 groups. Moderate or severe cognitive impairment by the High Sensitivity Cognitive Screen was similar for patients (23%) and controls (35%, p = 0.2). Self-reported cognitive dysfunction was also similar. Scores for the Functional Assessment of Cancer Therapy-General were similar but the Patient Oriented Prostate Utility Scale summary score was worse for patients (median 71 vs 86, p <0.001). More patients reported severe fatigue (Functional Assessment of Cancer Therapy-Fatigue score less than 35, p = 0.03). Low energy, poor bladder control and loss of sexual function were reported in 36%, 47% and 95% of patients, and in 16%, 34% and 33% of controls, respectively.

CONCLUSIONS

Patients treated with androgen deprivation therapy experience more symptoms and have worse fatigue than controls, but this study did not detect any effect on physical or cognitive function.

Cytokine levels in patients (pts) with localized colorectal cancer (CRC) after surgery and their relationship to fatigue and cognitive function

3623

Background: Cytokines have been associated with fatigue and cognitive dysfunction. Here we evaluate cytokine levels in pts with CRC as part of a longitudinal study evaluating these symptoms. Methods: Serum levels of 12 cytokines were measured using a LiquiChip assay on pts with localized CRC at baseline (mean 7 weeks post-surgery or before neoadjuvant therapy), 6 and 12 months. Group A (Stage III/high risk II) received chemotherapy (CT) and group B (Stage I/II) received no CT. Pts completed concurrent questionnaires for fatigue & QOL (FACT-F), anxiety/depression (GHQ), and perception of cognitive function (FACT-COG); they had neuropsychological (NP) assessment with traditional tests and CANTAB, a computerized NP battery. Associations between cytokine levels, test results, demographic and disease-related factors were sought. Results: Baseline data are available for 82 pts: 65 group A and 17 group B, with follow-up at 6 and 12 months for 32 and 15 pts. Mean age was 58 years and 68% were male. Cytokine levels were elevated in all groups with larger ranges after surgery (selected data in table ); in healthy people they are generally undetectable. There was cognitive impairment at baseline in 28% on traditional NP tests. At 6 months CT pts had more fatigue (median FACT-F 43 vs 47), perceived more cognitive impairment (median FACT-COG 127 vs 138), and had more cognitive impairment on CANTAB (42% vs 17%), but not on traditional NP tests (32% vs 33%). At 6 months, elevated cytokines (IL-1,-6,-8,-12, TNF, IFN) were associated with greater deficit on CANTAB (p<0.06); there was no association of cytokines with time from surgery, traditional NP test score, FACT-COG, fatigue, QOL or anxiety & depression. Conclusions: Cytokine levels were elevated in most pts. Cognitive impairment is present in some pts prior to chemotherapy and CT pts have worse impairment on computerized NP tests than non-CT pts. Elevated cytokines may be associated with worse cognitive function.

[Table: see text]

No significant financial relationships to disclose.