Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in 12 world regions

Comorbidity in lung cancer patients and its association with medical service cost and treatment choice in China

Background

It is evident that comorbidity exacerbate the complexity of the management of lung cancer, however, limited research has been conducted to investigate the impact of comorbidity on health service utilization and cost, as well as the treatment choice among lung cancer patients. We examined the association of comorbidity with medical service utilization, cost and treatment choice among lung cancer patients in China.

Methods

We used claims data from China Urban Employees’ Basic Medical Insurance (UEBMI) and Urban Residents’ Basic Medical Insurance (URBMI) between 2013 to 2016 and data from Hospital Information System (HIS) Database in Beijing Cancer Hospital (BCH). Elixhauser Comorbidity Index was used to assess comorbidity. Negative binomial regression, generalized linear model (GLM) with a gamma distribution and a log link, and logistic regression was applied to assess the associations between comorbidity and medical service utilization, cost and treatment choice, respectively.

Results

Among 8655 patients with lung cancer, 31.3% of had at least one comorbid conditions. Having comorbidity was associated with increased number of annual outpatient visits (1.6, 95%CI: 1.3, 1.9) and inpatients admissions (0.8, 95%CI, 0.70, 0.90), increased outpatient (USD635.5, 95%CI: 490.3, 780.8) and inpatient expenditure (USD2 470.3, 95CI%: 1998.6, 2941.9), as well as increased possibility of choosing radio therapy (OR: 1.208, 95%CI:1.012–1.441) and chemotherapy (1.363, 1.196–1.554), and decreased possibility of choosing surgery (0.850, 0.730–0.989). The medical utilization and expenditure, the possibility of choosing radiotherapy increases, and the possibility of choosing surgery decreases with the increasing number of chronic conditions. There are variations in the association with medical service utilization and expenditure, and treatment choice among individuals with different types of comorbid conditions.

Conclusion

Comorbidity among lung cancer patients restricts the potential treatment choices and poses an extra substantial health care burden. Our findings provide implications for both the clinical management and health service planning and financing for lung cancer patients.

Hepatocellular Protein Arginine Methyltransferase 1 Suppresses Alcohol-Induced Hepatocellular Carcinoma Formation by Inhibition of Inducible Nitric Oxide Synthase

Alcohol is a well-established risk factor for hepatocellular carcinoma (HCC), but the mechanisms by which alcohol promotes liver cancer are not well understood. Studies suggest that ethanol may enhance tumor progression by increasing hepatocyte proliferation and through alcohol-induced liver inflammation. Protein arginine methyltransferase 1 (PRMT1) is the main enzyme responsible for cellular arginine methylation. Asymmetric dimethyl arginine, produced by PRMT1, is a potent inhibitor of nitric oxide synthases. PRMT1 is implicated in the development of several types of tumors and cardiovascular disease. Our previous work has shown that PRMT1 in the liver regulates hepatocyte proliferation and oxidative stress and protects from alcohol-induced liver injury. However, its role in HCC development remains controversial. In this study, we found that hepatocyte-specific PRMT1-knockout mice develop an increased number of tumors in an N-nitrosodiethylamine (DEN) alcohol model of liver tumorigenesis in mice. This effect was specific to the alcohol-related component because wild-type and knockout mice developed similar tumor numbers in the DEN model without the addition of alcohol. We found that in the presence of alcohol, the increase in tumor number was associated with increased proliferation in liver and tumor, increased WNT/β-catenin signaling, and increased inflammation. We hypothesized that increased inflammation was due to increased oxidative and nitrosative stress in knockout mice. By blocking excess nitric oxide production using an inducible nitric oxide synthase inhibitor, we reduced hepatocyte death and inflammation in the liver and prevented the increase in WNT/β-catenin signaling, proliferation, and tumor number in livers of knockout mice. Conclusion: PRMT1 is an important protection factor from alcohol-induced liver injury, inflammation, and HCC development.

Evaluation of erectile potency and radiation dose to the penile bulb using image guided radiotherapy in the CHHiP trial

BACKGROUND AND PURPOSE

The penile bulb (PB) dose may be critical in development of post prostate radiotherapy erectile dysfunction (ED). This study aimed to generate PB dose constraints based on dose-volume histograms (DVHs) in patients treated with prostate radiotherapy, and to identify clinical and dosimetric parameters that predict the risk of ED post prostate radiotherapy.

MATERIALS AND METHODS

Penile bulb DVHs were generated for 276 patients treated within the randomised IGRT substudy of the multicentre randomised trial, CHHiP. Incidence of ED in relation to dose and randomised IGRT groups were evaluated using Wilcoxon rank sum, Chi-squared test and atlases of complication incidence. Youden index was used to find dose-volume constraints that discriminated for ED. Multivariate analysis (MVA) of effect of dosimetry, clinical and patient-related variables was performed.

RESULTS

Reduced treatment margins using IGRT (IGRT-R) produced significantly reduced mean PB dose compared with standard margins (IGRT-S) (median: 25 Gy (IGRT-S) versus 11 Gy (IGRT-R); p < 0.0001). Significant difference in both mean (median: 23 Gy (ED) vs. 18 Gy (no ED); p = 0.011) and maximum (median: 59 Gy (ED) vs. 52 Gy (no ED); p = 0.018) PB doses between those with and without clinician reported ED were identified. Mean PB dose cut-point for ED was derived at around 20 Gy. On MVA, PB mean dose and age predicted for impotence.

CONCLUSION

PB dose appears predictive of post-radiotherapy ED with calculated threshold mean dose of around 20 Gy, substantially lower than published recommendations. IGRT-R enables favourable PB dosimetry and can be recommended provided prostate coverage is not compromised.

Burden of Gastric Cancer

Gastric cancer is a global health problem, with more than 1 million people newly diagnosed with gastric cancer worldwide each year. Despite its worldwide decline in incidence and mortality over the past 5 decades, gastric cancer remains the third leading cause of cancer-related death. Knowledge of global as well as regional epidemiology and risk factors for gastric cancer is essential for the practicing gastroenterologist to make personalized decisions about risk stratification, screening, and prevention. In this article, we review the epidemiology of gastric cancer as well as screening and prevention efforts to reduce global morbidity and mortality from gastric cancer. First, we discuss the descriptive epidemiology of gastric cancer, including its incidence, mortality, survival, and secular trends. We combine a synthesis of published studies with an analysis of data from the International Agency for Research on Cancer GLOBOCAN project to describe the global burden of gastric cancer and data from the US Cancer Statistics registry to discuss the change in incidence of gastric cancer in the United States. Next, we summarize current knowledge of risk factors for gastric cancer. Finally, we discuss prevention strategies and screening efforts for gastric cancer.

Outcomes after venous thromboembolism in patients with gastric cancer: Analysis of the RIETE Registry

Gastric cancer is the fifth most common malignancy worldwide. Venous thromboembolism is an independent predictor of death among patients with gastric cancer. We aimed to describe the factors associated with mortality, thrombosis recurrence, and bleeding complications in patients with gastric cancer who develop venous thromboembolism. We included 612 patients with gastric cancer and venous thromboembolism in the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry from 2001 to 2018. We used Cox proportional hazard ratios and a Fine-Gray model to define factors associated with outcomes. The overall mortality at 6 months was 44.4%. Factors associated with increased 6-month mortality included immobility (HR 1.8, 95% CI 1.3-2.4; p < 0.001), anemia (HR 1.4, 95% CI 1.1-1.8; p < 0.02), and leukocytosis (HR 1.8, 95% CI 1.4-2.3; p < 0.001). Recurrent thrombosis occurred in 6.5% of patients and major bleeding complications in 8.5% of the cohort. Male sex was the main factor associated with thrombosis recurrence (HR 2.1, 95% CI 1.1-4.0; p < 0.02) and hemoglobin below 10 g/dL (HR 1.6, 95% CI 1.05-2.50; p = 0.03) the main factor associated with bleeding. In conclusion, patients with gastric cancer who develop venous thrombosis have a very high likelihood of death. Low hemoglobin in this population is associated with poor outcomes.

Mechanistic Pathways and Molecular Targets of Plant-Derived Anticancer ent-Kaurane Diterpenes

Since the first discovery in 1961, more than 1300 ent-kaurane diterpenoids have been isolated and identified from different plant sources, mainly the genus Isodon. Chemically, they consist of a perhydrophenanthrene subunit and a cyclopentane ring. A large number of reports describe the anticancer potential and mechanism of action of ent-kaurane compounds in a series of cancer cell lines. Oridonin is one of the prime anticancer ent-kaurane diterpenoids that is currently in a phase-I clinical trial in China. In this review, we have extensively summarized the anticancer activities of ent-kaurane diterpenoids according to their plant sources, mechanistic pathways, and biological targets. Literature analysis found that anticancer effect of ent-kauranes are mainly mediated through regulation of apoptosis, cell cycle arrest, autophagy, and metastasis. Induction of apoptosis is associated with modulation of BCL-2, BAX, PARP, cytochrome c, and cleaved caspase-3, -8, and -9, while cell cycle arrest is controlled by cyclin D1, c-Myc, p21, p53, and CDK-2 and -4. The most common metastatic target proteins of ent-kauranes are MMP-2, MMP-9, VEGF, and VEGFR whereas LC-II and mTOR are key regulators to induce autophagy.

The Metabolic Syndrome Is a Risk Factor for Breast Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

The metabolic syndrome (MetS) has been associated with the pathogenesis and prognosis of various malignant tumors. In this systematic review and meta-analysis, we explored the relationship between MetS and breast cancer (BC).

METHODS

Relevant studies were systematically searched on Ovid MEDLINE, Embase, Cochrane database, and PubMed up to September 16, 2019, using "breast cancer" and "metabolic syndrome" as keywords. Eligible studies with clear definition of MetS, available data, and relationships between MetS and BC were evaluated using a risk ratio (RR) and its 95% confidence interval (CI).

RESULTS

Twenty-five studies, including 13 cohort studies and 12 case-control studies, met the inclusion criteria, which assessed a total of 392,583 female participants and 19,628 BC patients. The results revealed a statistically significant increase by 52% of the risk of BC in adult females with MetS (RR = 1.49, 95% CI = 1.31-1.70, p < 0.0001). Postmenopausal MetS patients may have a twofold risk to suffer BC (RR = 2.01, 95% CI = 1.55-2.60, p < 0.001). The risk of BC increased markedly with the number of MetS components: RR = 1.00 for 1 component (p = 0.976), RR = 1.40 for 2 components (p = 0.121), and RR = 1.98 for >3 components (p < 0.001). The risk factors associated with BC were obesity, hypertension, and diabetes (RR = 1.33, 1.19, and 1.30 respectively, all p < 0.001).

CONCLUSIONS

Our study demonstrated that MetS is highly related with BC. In postmenopausal patients with ≥2 MetS components or a combination of obesity, hypertension, and diabetes, routine BC screening could help to detect BC at an early stage.

The Quality of Pap Smears from the Brazilian Cervical Cancer Screening Program According to the Human Development Index

Brazil is a country with strong socioeconomic disparities, which may explain the different rates of cervical cancer incidence and mortality and influence the quality of cervical cancer screening tests. The aim of this study was to perform a trend analysis of some quality indicators of Pap smears according to the Municipal Human Development Index (MHDI). Information about cytopathological exams (approximately 65,000,000) performed from 2006 to 2014 in women ages 25 to 64 years was obtained from the Cervical Cancer Information System (SISCOLO). The average annual percentage change (AAPC) for each indicator was calculated using the Joinpoint Regression Program, according to MHDI levels. Very low frequencies of unsatisfactory cases (<5%) were observed at different MHDI levels. Although the positivity index in the low- and medium-MHDI groups has increased, the values remained below international recommendations (3%-10%). The HSIL (high-grade squamous intraepithelial lesion) percentage remained stationary at all levels of the MHDI. In the low- and medium-MHDI groups, most quality indicators were below the recommendations by Brazilian National Cancer Institute INCA, with no improvement trend; in the high-MHDI group, the majority of the indicators also presented no improvement, although they show slightly better quality indicators. The MHDI should be considered in the definition of the policies of the screening program for cervical cancer in Brazil, and the current program may require adjustments to achieve improved efficiency.

Arsenic sulfide induces RAG1-dependent DNA damage for cell killing by inhibiting NFATc3 in gastric cancer cells

Background

Arsenic sulfide was found to have potential anti-cancer activities, especially in gastric cancer. However, the underlying mechanism need to be further explored. This study was aimed to investigate the mechanism of arsenic compounds on gastric cancer.

Methods

Gastric cancer cell lines were infected with lentiviral vector carrying shNFATc3 and/or treated with arsenic sulfide. MTT assay were performed to assess cell growth. Flow cytometer assays were used to detect cell cycle and reactive oxygen species (ROS) level of gastric cancer cells. Western blot was carried out to detect nuclear factor of activated T-cells, cytoplasmic 3 (NFATc3), cell cycle markers, DNA damage pathway protein expression as well as other protein expression in gastric cancer cell lines. The expression of recombination activating gene 1 (RAG1) in gastric cancer cell lines was determined by RNA-sequencing analyses and Real-Time qPCR. The effect of NFATc3 on RAG1 were determined by CHIP-qPCR assay. The effect of arsenic sulfide on AGS cells was evaluated in vivo.

Results

We show that arsenic sulfide as well as knockdown of NFATc3 resulted in increased double-strand DNA damage in gastric cancer cells by increasing the expression of RAG1, an endonuclease essential for immunoglobulin V(D) J recombination. Overexpression of NFATc3 blocked the expression of RAG1 expression and DNA damage induced by arsenic sulfide. Arsenic sulfide induced cellular oxidative stress to redistribute NFATc3, thereby inhibiting its transcriptional function, which can be reversed by N-acetyl-L-cysteine (NAC). We show that NFATc3 targets the promoter of RAG1 for transcriptional inhibition. We further showed that NFATc3 upregulation and RAG1 downregulation significantly associated with poor prognosis in patients with gastric cancer. Our in vivo experiments further confirmed that arsenic sulfide exerted cytotoxic activity against gastric cancer cells through inhibiting NFATc3 to activate RAG1 pathway.

Conclusion

These results demonstrate that arsenic sulfide targets NFATc3 to induce double strand DNA break (DSB) for cell killing through activating RAG1 expression. Our results link arsenic compound to the regulation of DNA damage control and RAG1 expression as a mechanism for its cytotoxic effect.

Development of a novel prediction model for recurrent stage II colon cancer

PURPOSE

Adjuvant chemotherapy is recommended for patients with high-risk stage II colon cancer. High-risk stage II is defined by clinicopathological factors in some guidelines. However, there is no unified definition. The aim of this study was to examine the risk factors and develop a novel model to predict the recurrence of stage II colon cancer.

METHODS

Three hundred fifty patients who underwent curative resection for stage II colon cancer at Osaka International Cancer Institute and Yao Municipal Hospital from 2004 to 2012 were included. Clinicopathological factors were assessed in a subgroup of 298 patients (Learning Set), and the relapse-free survival (RFS) rate was evaluated as the main outcome. A statistical analysis was performed using a proportional hazards model to determine the factors associated with RFS and a nomogram was developed to predict recurrence. A second subgroup of 52 independent patients who underwent curative resection in 2012 (Validation Set) was used to validate the nomogram.

RESULTS

The median RFS time was 4.96 years, and recurrence was observed in 35 patients. A univariate analysis revealed that a high serum CEA level, preoperative occlusion, tumor location (left-side colon), lymphatic invasion, and vascular invasion were significantly correlated with RFS. These variables were used to develop the nomogram. The C-index was 0.701 in the learning set and 0.585 in the validation set. Using nomogram points, the patients were classified into low-risk, middle-risk, and high-risk categories.

CONCLUSION

A recurrence prediction model was developed that integrated multiple risk factors in stage II colon cancer patients. High-risk patients were identified by the nomogram.

circ-FNTA accelerates proliferation and invasion of bladder cancer

Role of circ-FNTA in the progression of bladder cancer (BCa) and its underlying mechanism were investigated. circ-FNTA level in BCa tissues and cell lines was detected. The prognostic potential of circ-FNTA was assessed by Kaplan-Meier methods and the proliferative and invasive abilities of BCa influenced by circ-FNTA were explored. Through dual-luciferase reporter gene assay, miRNA-451a, the target of circ-FNTA and the target gene of miRNA-451a, S1PR3 were determined. circ-FNTA was upregulated in BCa, especially in invasive BCa. High level of circ-FNTA indicated worse prognosis in BCa patients. Silence of circ-FNTA attenuated the proliferative and invasive abilities of T24 and UM-UC-3 cells. miRNA-451a was verified to be the target of circ-FNTA, which was downregulated in BCa cells. circ-FNTA negatively regulated the expression level of miRNA-451a. Moreover, S1PR3 was the downstream gene of miRNA-451a. Overexpression of miRNA-451a downregulated S1PR3 level in BCa cells. circ-FNTA accelerates the proliferative and invasive abilities of BCa through targeting miRNA-451a/S1PR3 axis, and indicates a poor prognosis of BCa patients.

Interplay Between Socioeconomic Status and Otitis Media Disease Burden in Resource-rich and Resource-poor Nations

OBJECTIVES/HYPOTHESIS

To characterize global differences in otitis media (OM)-related disease burden between socioeconomically advantaged and disadvantaged nations.

METHODS

Using the Global Health Data Exchange, worldwide OM burden was evaluated using age-standardized disability-adjusted life years (DALYs) per 100,000 individuals in 183 countries from 1990 to 2015. Countries were organized by socioeconomic status using Human Development Index (HDI) values collected from the United Nations Development Program. Gini coefficients and concentration indices were employed to analyze disparities in OM disease burden.

RESULTS

From 1990 to 2015, the mean DALY rate across all nations decreased by 21.9%. When considering disease burden in relation to socioeconomic status, age-standardized DALYs decreased as HDI values increased (p < 0.001). For both children and adults, DALY rates were significantly different between HDI groups (p < 0.01). Gini coefficients decreased from 0.821 in 1990 to 0.810 in 2015, indicating a modest reduction in international health inequality. Global disparities in OM disease burden, as measured by the concentration index, worsened from 1990 to 2010 before showing a small trend reversal in 2015.

CONCLUSIONS

To our knowledge, this is the first analysis investigating socioeconomic-related global disparities in OM disease burden using HDI values, Gini coefficients, and concentration indices. While the overall mean decrease in DALY rate from 1990 to 2015 is encouraging, the net decrease in concentration index during this period suggests less-developed nations continue to shoulder a disproportionate burden. Greater resource allocation to resource-poor nations may be warranted, as disease burden negatively impacts these countries to a greater degree.

Compound Kushen Injection for gastric cancer: A protocol of systematic review and meta-analysis

BACKGROUND AND AIMS

In recent years, the clinical research about Compound Kushen Injection (CKI) treatment of Gastric cancer (GC) has been increased, but the conclusion is different. The aim of our study is to objective comment the efficacy and adverse effects of CKI treatment of GC.

METHODS

We will retrieve the Randomized controlled trials from the following 6 electronic databases on their inception to April 2019: PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wangfang and Chinese Biomedical Literature Database. Study selection and data collection will be performed independently by 2 reviewers. Cochrane Risk of Bias tool will be used to assess the risk of bias of included studies. The outcomes included overall response rate, complete response rate, 3-year progression-free survival rate, 3-year overall survival rate, and different types of treatment-related adverse events. We calculated the risk ratios as well as their 95% confidence intervals of these outcomes and pooled the results using RevMan 5.2 software and Stata 14.0 software.

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSION

The results of this review will be widely disseminated through peer-reviewed publications and conference presentations. This evidence may also provide helpful evidence for clinical practice and health policy-makers for the treatment of GC.

PROSPERO REGISTRATION NUMBER

CRD42019133770.

Preparation and characterization of inorganic radioactive holmium-166 microspheres for internal radionuclide therapy

Microspheres with high specific activities of radionuclides are very interesting for internal radiotherapy treatments. This work focuses on the formulation and characterization of inorganic microspheres with a high content of holmium and therefore a high specific radioactivity of holmium-166. Two novel formulations of inorganic microspheres were obtained by dispersing solid holmium acetylacetonate microspheres (Ho₂(AcAc)₃-ms) in NaH₂PO₄ or NaOH solutions followed by 2 h incubation at room temperature. By exchange of acetylacetonate with phosphate or hydroxyl ions, holmium phosphate microspheres (HoPO₄-ms) and holmium hydroxide microspheres (Ho(OH)₃-ms) were formed respectively. The inorganic microspheres had a significantly smaller diameter (28.5 ± 4.4 μm (HoPO₄-ms) and 25.1 ± 3.5 μm (Ho(OH)₃-ms)) than those of Ho₂(AcAc)₃-ms (32.6 ± 5.2 μm). The weight percentage of holmium-165 in the microspheres increased significantly from 47% (Ho₂(AcAc)₃-ms) to 55% (HoPO₄-ms) and 73% (Ho(OH)₃-ms). After preparation of both HoPO₄-ms and Ho(OH)₃-ms, the stable holmium-165 isotope was partly converted by neutron activation into radioactive holmium-166 to yield radioactive microspheres. High specific activities were achieved ranging from 21.7 to 59.9 MBq/mg (¹⁶⁶HoPO₄-ms) and from 28.8 to 79.9 MBq/mg (¹⁶⁶Ho(OH)₃-ms) depending on the neutron activation time. The structure of both microspheres was preserved up to neutron activations of 6 h in a thermal neutron flux of 4.72 × 10¹⁶ n m^-2 s^-1. After activation, both microspheres revealed excellent stability in administration fluids (saline and phosphate buffer) having less than 0.05% of holmium released after 72 h incubation. Finally, the hemocompatibility of these inorganic microspheres was evaluated and it was shown that the microspheres did cause neither hemolysis nor depletion or inhibition of the coagulation factors of the intrinsic blood coagulation pathway meaning that the microspheres have a good hemocompatibility. Overall, this work shows that radioactive inorganic microspheres with high specific activities of holmium-166 can be prepared which potentially can be used for internal radionuclide therapy.

Gantry-Mounted Linear Accelerator-Based Stereotactic Body Radiation Therapy for Low- and Intermediate-Risk Prostate Cancer

Purpose

To establish the safety and efficacy of gantry-mounted linear accelerator-based stereotactic body radiation therapy (SBRT) for low- and intermediate-risk prostate cancer.

Methods

We pooled 921 patients enrolled on 7 single-institution prospective phase II trials of gantry-based SBRT from 2006 to 2017. The cumulative incidences of biochemical recurrence (defined by the Phoenix definition) and physician-scored genitourinary (GU) and gastrointestinal (GI) toxicities (defined per the original trials using Common Terminology Criteria for Adverse Events) were estimated using a competing risk framework. Multivariable logistic regression was used to evaluate the relationship between late toxicity and prespecified covariates: biologically effective dose, every other day versus weekly fractionation, intrafractional motion monitoring, and acute toxicity.

Results

Median follow-up was 3.1 years (range, 0.5-10.8 years). In addition, 505 (54.8%) patients had low-risk disease, 236 (25.6%) had favorable intermediate-risk disease, and 180 (19.5%) had unfavorable intermediate-risk disease. Intrafractional motion monitoring was performed in 78.0% of patients. The 3-year cumulative incidence of biochemical recurrence was 0.8% (95% confidence interval [CI], 0-1.7%), 2.2% (95% CI, 0-4.3%), and 5.1% (95% CI, 1.0-9.2%) for low-, favorable intermediate-, and unfavorable intermediate-risk disease. Acute grade ≥2 GU and GI toxicity occurred in 14.5% and 4.6% of patients, respectively. Three-year cumulative incidence estimates of late grade 2 GU and GI toxicity were 4.1% (95% CI, 2.6-5.5%) and 1.3% (95% CI, 0.5-2.1%), respectively, with late grade ≥3 GU and GI toxicity estimates of 0.7% (95% CI, 0.1-1.3%) and 0.4% (95% CI, 0-0.8%), respectively. The only identified significant predictors of late grade ≥2 toxicity were acute grade ≥2 toxicity (P < .001) and weekly fractionation (P < .01), although only 12.4% of patients were treated weekly.

Conclusions

Gantry-based SBRT for prostate cancer is associated with a favorable safety and efficacy profile, despite variable intrafractional motion management techniques. These findings suggest that multiple treatment platforms can be used to safely deliver prostate SBRT.

Availability, Price and Affordability of Anticancer Medicines: Evidence from Two Cross-Sectional Surveys in the Jiangsu Province, China

Objectives: With the increasing incidence of cancer, poor access to affordable anticancer medicines has been a serious public health problem in China. To help address this issue, we assessed the availability, price and affordability of pharmacotherapy for cancer in public hospitals in the Jiangsu Province, China. Methods: In 2012 and 2016, anticancer medicine availability and price information in the capital and five other cities was collected. A total of six cancer care hospitals, 26 tertiary general hospitals and 28 secondary general hospitals were sampled, using an adaptation of the World Health Organization/Health Action International methodology. Data was collected for the anticancer medicines in stock at the time of the surveys. Prices were expressed as inflation-adjusted median unit prices (MUPs). Medicine was affordable if the overall cost of all the prescribed anticancer medicines was less than 20% of the household’s capacity to pay. We used generalized estimating equations to estimate the significance of differences in availability from 2012 to 2016 and the Wilcoxon rank test to estimate the significance of differences in MUPs. Multivariate logistic regression was computed to measure predictors of affordability. Results: From 2012 to 2016 there was a significant decrease in the mean availability of originator brands (OBs) (from 7.79% to 5.71%, p = 0.012) and lowest-priced generics (LPGs) (36.29% to 32.67%, p = 0.009). The mean availability of anticancer medicines in secondary general hospitals was significantly lower than the cancer care, as well as in tertiary general hospitals. The MUPs of OBs (difference: −21.29%, p < 0.01) and their LPGs (−22.63%, p < 0.01) decreased significantly from 2012 to 2016. The OBs (16.67%) of all the anticancer medicines were found to be less affordable than LPGs (34.62% for urban residents and 30.77% for rural residents); their affordability varied among the different income regions. From 2012 to 2016, the proportion of LPGs with low availability and low affordability dropped from 30.77% to 19.23% in urban areas and 34.62% to 26.92% in rural areas, respectively. Generic substitution and medicine covered by basic medical insurance are factors facilitating affordability. Conclusion: There were concerning decreases in the availability of anticancer medicines in 2016 from already low availability in 2012. Anticancer medicines were more affordable for the patients in high-income regions than the patients in low-income regions. Governments should consider using their bargaining power to reduce procurement prices and abolish taxes on anticancer medicines. Policy should focus on the special health insurance plan for low-income patients with cancer. The goal of drug policy should ensure that first-line generic drugs are available for cancer patients and preferentially prescribed.

lncRNA UCA1 Predicts a Poor Prognosis and Regulates Cell Proliferation and Migration by Repressing p21 and SPRY1 Expression in GC

Dysregulated expression of long non-coding RNAs (lncRNAs) has been reported in many types of cancers, indicating that it has important regulatory roles in human cancer biology. Recently, lncRNA urothelial cancer-associated 1 (UCA1) was shown to be dysregulated in many cancer types, but the detailed mechanisms remain largely unknown. In our study, we found that upregulated UCA1 is associated with poor prognosis in gastric cancer patients. Further experiments revealed that UCA1 knockdown significantly repressed the proliferation and migration both in vitro and in vivo. Moreover, RNA sequencing (RNA-seq) analysis revealed that UCA1 knockdown preferentially affected genes that are linked to cell proliferation, cell cycle, and cell migration. Mechanistically, UCA1 promotes cell proliferation progression through repressing p21 and Sprouty RTK signaling antagonist 1 (SPRY1) expression by binding to EZH2. We found that UCA1 could mediate the trimethylation of H3K27 in promoters of p21 and SPRY1. To our knowledge, this is the first report showing the global gene profile of downstream targets of UCA1 in the progression of gastric cancer. Collectively, our data reveal the important roles of UCA1 in gastric cancer (GC) oncogenesis.

On hepatocellular carcinoma in South America and early-age onset of the disease

Hepatocellular carcinoma (HCC) is one of the most predominant tumor types worldwide, being particularly prevalent in sub-Saharan Africa and East Asia. However, HCC is inexplicably underreported in South America, despite unsettling clinical epidemiological trends of the disease on this continent. Here, we review the current knowledge on HCC presentation in Peru. We emphasize the well-documented occurrence of an early-age nosological form of the disease in Andean descent populations. We further discuss the reasons for such HCC clinical presentation, as well as the implications for liver cancer screening, management, and prevention.

A multidisciplinary review of the policy, intellectual property rights, and international trade environment for access and affordability to essential cancer medications

In 2015, the World Health Organization (WHO) Expert Committee approved the addition of 16 cancer medicines to the WHO Model List of Essential Medicines (EML), bringing the total number of cancer medicines on the list to 46. This change represented the first major revision to the EML oncology section in recent history and reinforces international recognition of the need to ensure access and affordability for cancer treatments. Importantly, many low and middle-income countries rely on the EML, as well as the children’s EML, as a guide to establish national formularies, and moreover use these lists as tools to negotiate medicine pricing. However, EML inclusion is only one component that impacts cancer treatment access. More specifically, factors such as intellectual property rights and international trade agreements can interact with EML inclusion, drug pricing, and accessibility. To better understand this dynamic, we conducted an interdisciplinary review of the patent status of EML cancer medicines compared to other EML noncommunicable disease medicines using the 17th, 18th, 19th, 20th, and 21st editions of the list. We also explored the interaction of intellectual property rights with the international trade regime and how trade agreements can and do impact cancer treatment access and affordability. Based on this analysis, we conclude that patent status is simply one factor in the complex international environment of health systems, IPR policies, and trade regimes and that aligning these oftentimes disparate interests will require shared global governance across the cancer care continuum.

1 H NMR-based metabolomics reveal overlapping discriminatory metabolites and metabolic pathway disturbances between colorectal tumor tissues and fecal samples

Previous studies have compared fecal metabolites from healthy and colorectal cancer (CRC) patients to predict the pro-CRC signatures. However, the systemic mechanistic link between feces and colonic tissues of CRC patients is still limited. The current study was a paralleled investigation of colonic tumor tissues and their normal adjacent tissues alongside patient-matched feces by using ¹ H nuclear magnetic resonance spectroscopy combined with pattern recognition to investigate how fecal metabolic phenotypes are linked to the changes in colorectal tumor profiles. A set of overlapping discriminatory metabolites across feces and tumor tissues of CRC were identified, including elevated levels of lactate, glutamate, alanine, succinate and reduced amounts of butyrate. These changes could indicate the networks for metabolic pathway perturbations in CRC potentially involved in the disruptions of glucose and glycolytic metabolism, TCA cycle, glutaminolysis, and short chain fatty acids metabolism. Furthermore, changes in fecal acetate were positively correlated with alterations of glucose and myo-inositol in colorectal tumor tissues, implying enhanced energy production for rapid cell proliferation. Compared to other fecal metabolites, acetate demonstrated the highest diagnostic performance for diagnosing CRC, with an AUC of 0.843 in the training set, and a good predictive ability in the validation set. Overall, these associations provide evidence of distinct metabolic signatures and metabolic pathway disturbances between the colonic tissues and feces within the same individual, and changes of fecal metabolic signature could reflect the CRC tissue microenvironment, highlighting the significance of the distinct fecal metabolic profiles as potential novel and noninvasive relevant indicators for CRC detection.

Urgent Surgery for Gastric Adenocarcinoma: A Study of the National Cancer Database

BACKGROUND

Gastric adenocarcinoma is a leading cause of cancer death worldwide and, in the United States, can present emergently with upper GI hemorrhage, obstruction, or perforation. No large studies have examined how urgent surgery affects patient outcomes. This study examines the outcomes of urgent versus elective surgery for gastric cancer.

MATERIALS AND METHODS

Patients with gastric adenocarcinoma from the National Cancer Database from 2004 to 2015 were examined retrospectively. Patients with metastatic disease or incomplete data were excluded. Urgent surgery was defined as definitive surgery within 3 d of diagnosis. Univariate and multivariate analysis of patient factors, surgical outcomes, and oncologic data was performed. P-values <0.05 were statistically significant.

RESULTS

Of 26,116 total patients, 2964 had urgent surgery and 23,468 had elective surgery. Urgent surgery patients were significantly older, were female, were nonwhite, had higher pathologic stage, and were treated at a low-volume center. Urgent surgery was associated with decreased quality lymph node harvest (odds ratio [OR] 0.68 95% confidence interval {CI} [0.62, 0.74]), increased positive surgical margin (OR 1.48, 95% CI [1.32, 1.65]), increased 30-d mortality (OR 1.38, 95% CI [1.16, 1.65]), increased 90-d mortality (OR 1.30, 95% CI [1.14, 1.49]), and decreased overall survival (hazard ratio 1.21, 95% CI [1.15, 1.27]).

CONCLUSIONS

Urgent surgery for gastric cancer is associated with significantly worse outcomes than elective surgery. Stable patients requiring urgent surgical resection for gastric cancer may benefit from referral to a high-volume center for resection by an experienced surgeon. Patients undergoing urgent resection for gastric cancer should be referred to surgical and medical oncologists to ensure they receive appropriate adjuvant therapy and surveillance.

The prediction incidence of the three most common cancers among Iranian military community during 2007-2019: a time series analysis

OBJECTIVE

Cancers are one of the most important public health problems in Iran. Because of the importance of cancers, the purpose of the current study was to the prediction of the future incidence of the most common cancers among Iranian military community (MC) by using the time series analysis during 2007 to 2019.

METHODS

In the current cross-sectional study, all registered cancers among Iranian MC entered the study. To select the best model of prediction, various methods including autocorrelation function (ACF), partial autocorrelation function (PACF), and Akaike information criterion (AIC) statistics were used. All analysis was performed by using ITSM, stata14, and Excel2010 software.

RESULTS

The most prevalent cancers among Iranian MC were breast, prostate, and colon cancers respectively. The time series analysis was shown that the trend of all mentioned cancers in Iranian MC will increase in the coming years.

CONCLUSIONS

The trend of most prevalent cancers among Iranian MC was increasing but the different factors like the growth of population size and improving the registration system should be regarded.

Diagnosis and Risk Factors of Advantage Cancers in Ethiopia

BACKGROUND

Cancer is one of the leading causes of morbidity and mortality worldwide. Yet, limited is known about patterns of cancer and risk factors for advanced stage cancers in Ethiopia.

METHODS

A cross-sectional study was conducted on 919 patients with biopsy-confirmed cancers at Tikur Anbessa Hospital in Ethiopia, 2010 to 2014. Pearson chi-square test, t-test, analysis of variance and multivariate logistic regression analyses were performed.

RESULTS

The majority of the patients were females (72.4%). The commonest malignancies among males were bone and soft tissue (16.5%), colorectal (12.2%), and esophageal (9.1%). Among females, the most common cancers were cervical (39.7%), breast (18.3%), and ovarian (7.1%); of these, 41.7%, 59.0%, and 42.6% were diagnosed at advanced stages, respectively. Females had more advanced stage cancers at diagnosis than males (37.6% vs. 24.8%, P < 0.01). Among males, 46.7% of prostate and 29.0% of colorectal cancers were in advanced stages at the time of diagnosis. Delay in presentation from onset of symptoms was associated with advanced cancer among females (OR = 3.21; 95% CI = 1.69-6.10). Prostate cancer among males (OR = 5.22; 95% CI = 1.26-21.60) and breast cancer among females (OR = 1.93; 95% CI = 1.23-3.03) were more likely to be diagnosed at advanced stages.

CONCLUSIONS

Cancers with effective screening tests are common in Ethiopia and significant proportions of these were diagnosed at advanced stages, typically several months after onset of symptoms. Timely access to preventive care along with effective educational and screening strategies is needed in Ethiopia for early detection and treatment of common malignancies, such as cervical, breast and colorectal cancers.

ILK predicts the efficacy of chemoradiotherapy and the prognosis of patients with esophageal squamous cell carcinoma

Isobaric tags for relative and absolute quantitation (iTRAQ) technology was adopted to screen differentially-expressed proteins in the serum that predict the effects of chemoradiotherapy on esophageal squamous cell carcinoma (ESCC). Thus, significantly related proteins can be functionally identified at the cellular level. A total of 60 patients diagnosed with locally advanced and advanced ESCC were recruited and treated with chemoradiotherapy. The iTRAQ technique was used to screen serum differentially expressed proteins associated with chemoradiotherapeutic efficacy. Functional identification of significantly related proteins was performed at the cellular level. Cell proliferation was detected using MTT, clonogenic and fluorescence assays, and apoptosis was assessed using flow cytometry. Transwell and wound-healing assays were used to detect the invasion and migration properties of cancer cells. Proteomics results revealed that prior to chemoradiotherapy, the expression level of integrin-linked kinase (ILK) was significantly upregulated in patients with ESCC, compared with that of the control group [ratio (r)=4.386; P<0.05], and significantly downregulated in the chemoradiotherapy-sensitive group, compared with the chemoradiotherapy-resistant group (r=0.587; P<0.05). At the cellular level, the proliferation rate of cells in the experimental group was significantly inhibited (P<0.05), and the number of cell colonies was decreased (P<0.01), while the number of apoptotic cells was significantly increased (P<0.01). The invasive ability of TE-1 cells in the shILK group was significantly inhibited (P<0.01), and the migration rate was significantly retarded at 8 and 24 h (P<0.01). The present study highlighted the potential value of ILK in predicting the efficacy of chemoradiotherapeutic treatment in patients with ESCC, and that ILK gene-silencing inhibits the progression of ESCC.

Rehabilitation for Cancer Survivors: How We Can Reduce the Healthcare Service Inequality in Low- and Middle-Income Countries

Cancer diagnosis often substantially affects patient's physical, psychological, and emotional status. Most patients with cancer experience declining of energy, activity levels, social-cultural participation, and relationships. In addition, cancer progression and adverse effects of aggressive cancer treatment often cause debilitating pain, fatigue, weakness, joint stiffness, depression, emotional instability, limited mobility, poor nutritional status, skin breakdown, bowel dysfunction, swallowing difficulty, and lymphedema leading into functional impairment and disability that can be addressed through rehabilitation care. Comprehensive care models by involving cancer rehabilitation have resulted in significant improvement of patient's quality of life. Although cancer rehabilitation has been implemented in many high-income countries, it is either not yet or suboptimally delivered in most low- and middle-income countries. In this review, we discussed gaps regarding cancer rehabilitation services and identified opportunities to improve quality of cancer care in developing countries. Future collaborations among international organizations and stakeholders of health care delivery systems are required to initiate and improve high-quality cancer rehabilitation in the developing countries.

Label-free cervicovaginal fluid proteome profiling reflects the cervix neoplastic transformation

Cervicovaginal fluid (CVF) is a valuable source of clinical information about the female reproductive tract in both nonpregnant and pregnant women. The aim of this study is to specify the CVF proteome at different stages of cervix neoplastic transformation by label-free quantitation approach based on liquid chromatography tandem mass spectrometry (LC-MS/MS) method. The proteome composition of CVF from 40 women of reproductive age with human papillomavirus (HPV)-associated cervix neoplastic transformation (low-grade squamous intraepithelial lesion [LSIL], high-grade squamous intraepithelial lesion [HSIL], and CANCER) was investigated. Hierarchical clustering and principal component analysis (PCA) of the proteomic data obtained by a label-free quantitation approach show the distribution of the sample set between four major clusters (no intraepithelial lesion or malignancy [NILM], LSIL, HSIL and CANCER) depending on the form of cervical lesion. Multisample ANOVA with subsequent Welch's t test resulted in 117 that changed significantly across the four clinical stages, including 27 proteins significantly changed in cervical cancer. Some of them were indicated as promising biomarkers previously (ACTN4, VTN, ANXA1, CAP1, ANXA2, and MUC5B). CVF proteomic data from the discovery stage were analyzed by the partial least squares-discriminant analysis (PLS-DA) method to build a statistical model, allowing to differentiate severe dysplasia (HSIL and CANCER) from the mild/normal stage (NILM and LSIL), and receiver operating characteristic (ROC) area under the curve (AUC) were obtained on an independent set of 33 samples. The sensitivity of the model was 77%, and the specificity was 94%; AUC was equal to 0.87. CVF proteome proved to be reflect the stage of cervical epithelium neoplastic process.

DNA Methylation Markers for Breast Cancer Detection in the Developing World

PURPOSE

An unmet need in low-resource countries is an automated breast cancer detection assay to prioritize women who should undergo core breast biopsy and pathologic review. Therefore, we sought to identify and validate a panel of methylated DNA markers to discriminate between cancer and benign breast lesions using cells obtained by fine-needle aspiration (FNA).Experimental Design: Two case-control studies were conducted comparing cancer and benign breast tissue identified from clinical repositories in the United States, China, and South Africa for marker selection/training (N = 226) and testing (N = 246). Twenty-five methylated markers were assayed by Quantitative Multiplex-Methylation-Specific PCR (QM-MSP) to select and test a cancer-specific panel. Next, a pilot study was conducted on archival FNAs (49 benign, 24 invasive) from women with mammographically suspicious lesions using a newly developed, 5-hour, quantitative, automated cartridge system. We calculated sensitivity, specificity, and area under the receiver-operating characteristic curve (AUC) compared with histopathology for the marker panel.

RESULTS

In the discovery cohort, 10 of 25 markers were selected that were highly methylated in breast cancer compared with benign tissues by QM-MSP. In the independent test cohort, this panel yielded an AUC of 0.937 (95% CI = 0.900-0.970). In the FNA pilot, we achieved an AUC of 0.960 (95% CI = 0.883-1.0) using the automated cartridge system.

CONCLUSIONS

We developed and piloted a fast and accurate methylation marker-based automated cartridge system to detect breast cancer in FNA samples. This quick ancillary test has the potential to prioritize cancer over benign tissues for expedited pathologic evaluation in poorly resourced countries.

Association between Body Mass Index and Gastric Cancer Risk According to Effect Modification by Helicobacter pylori Infection

PURPOSE

Few studies investigated roles of body mass index (BMI) on gastric cancer (GC) risk according to Helicobacter pylori infection status. This study was conducted to evaluate associations between BMI and GC risk with consideration of H. pylori infection information.

MATERIALS AND METHODS

We performed a case-cohort study (n=2,458) that consists of a subcohort, (n=2,193 including 67 GC incident cases) randomly selected from the Korean Multicenter Cancer Cohort (KMCC) and 265 incident GC cases outside of the subcohort. H. pylori infection was assessed using an immunoblot assay. GC risk according to BMI was evaluated by calculating hazard ratios (HRs) and their 95% confidence intervals (95% CIs) using weighted Cox hazard regression model.

RESULTS

Increased GC risk in lower BMI group (< 23 kg/m2) with marginal significance, (HR, 1.32; 95% CI, 0.98 to 1.77) compared to the reference group (BMI of 23-24.9 kg/m2) was observed. In the H. pylori non-infection, both lower (< 23 kg/m2) and higher BMI (≥ 25 kg/m2) showed non-significantly increased GC risk (HR, 10.82; 95% CI, 1.25 to 93.60 and HR, 11.33; 95% CI, 1.13 to 113.66, respectively). However, these U-shaped associations between BMI and GC risk were not observed in the group who had ever been infected by H. pylori.

CONCLUSION

This study suggests the U-shaped associations between BMI and GC risk, especially in subjects who had never been infected by H. pylori.

HTRA1 promotes transdifferentiation of normal fibroblasts to cancer-associated fibroblasts through activation of the NF-κB/bFGF signaling pathway in gastric cancer

Cancer-associated fibroblasts comprise the major stromal cell populations in gastric cancer, which is a significant contributor to cancer-related death worldwide. As a member of the serine protease family, HTRA1 is reportedly involved in malignant transformation of various tumor types. In the present study, we observed that HTRA1 is positively correlated with α-SMA expression in gastric cancer tissues, which was also confirmed by correlation analysis and Gene Set Enrichment Analysis (GSEA) using the GEO database. Upregulation of HTRA1 in gastric cancer cell lines induces expression of α-SMA in normal fibroblasts. To explore how HTRA1 activates normal fibroblasts, an ELISA assay was performed. Secretion of bFGF/FGF2 from gastric cancer cells was significantly increased in response to HTRA1 overexpression. However, upreguation of α-SMA in normal fibroblasts induced by HTRA1 was restored by inhibiting the expression of bFGF. Furthermore, HTRA1 promotes bFGF/FGF2 expression through activation of NF-κB signaling in gastric cancer cells. Inhibition of the NF-κB signaling pathway partially restored baseline expression levels of α-SMA induced by HTRA1. In conclusion, HTRA1 promotes transdifferentiation of normal fibroblasts to cancer-associated fibroblasts by increasing bFGF/FGF2 expression, which is dependent upon activation of NF-κB signaling in gastric cancer.

Downregulation of DACT-2 by Promoter Methylation and its Clinicopathological Significance in Prostate Cancer

Backgrounds: Dapper homolog (DACT) 2, a member of DACT gene family, is frequently down-regulated in various malignancies and linked to tumor progression. However, the regulatory mechanism of DACT-2 expression and its biological role in human prostate cancer (PCa) remains elusive. Here, we investigated the expression and an epigenetic change of DACT-2 in prostate cancer, and determined if these findings were correlated with clinicopathologic characteristics of PCa.

Methods: The expression profile of DACT-2 of was detected by qRT-PCR, Western blotting, and immunohistochemistry in four prostate cell lines (RWPE-1, LNCaP, PC-3 and DU145), 56 cases of frozen prostate tissues (forty-seven primary prostate carcinomas, nine paired noncancerous and cancerous prostate tissues) and a tissue microarray sets including 100 paraffin-embedded prostate samples (3 normal tissues, 2 cases of adjacent tissues and 95 cases of cancer). Subsequently, the regulatory mechanism of DACT-2 down-regulation was investigated through methylation-specific PCR (MSP) and bisulfite sequencing (BSP). The role of DACT-2 in prostate cancer cell migration and invasion was respectively examined by wound healing and transwell assay. After 5-aza-2'-deoxycytidine treatment of prostate cancer cells, qRT-PCR was used to detect whether the expression of DACT-2 gene mRNA in the cells recovered.

Results: Immunohistochemical results shown that the DACT-2 protein was strongly (3+) expressed in the cytoplasm of all 5 noncancerous tissues and 12.7% (12/95) prostate cancer (PCa) tissues. Whereas 68.4% (65/95) PCa samples and 18.9% (18/95) PCa tissues respectively displayed weakly (1+) expressed and moderately (2+) expressed. In addition, DACT-2 expression was negatively associated with Gleason score in tumor specimens (p=0.029). What's more, down-regulation and promoter methylation of DACT-2 were observed in 68.1% (32/47) frozen PCa tissues and all three prostate cancer cell lines. And, the expression of DACT-2 mRNA was restored by the treatment of demethylated drug 5-aza-2'-deoxycytidine in all prostate cancer lines. Prostate cancer cells invasion and migration were significantly suppressed by ectopic expression of DACT-2 in vitro.

Conclusions: Our study provides evidence that DACT-2 may be a useful biomarker for distinguishing prostate tumor tissues from non-cancerous samples and a potential target for epigenetic silencing in primary prostate Cancer.

Correlation between the rs7101 and rs1063169 polymorphisms in the FOS noncoding region and susceptibility to and prognosis of colorectal cancer

BACKGROUND

The FOS gene is located on human chromosome 14q21-31 and encodes the nuclear oncoprotein c-Fos. This study analyzed the correlation between the FOS noncoding region rs7101 and rs1063169 polymorphisms and colorectal cancer susceptibility and prognosis.

METHODS

We analyzed the FOS genotypes in 432 colorectal cancer patients and 315 healthy subjects by PCR/Sanger sequencing. Survival was analyzed by Kaplan-Meier and Cox regression analysis. Western blot was used to detect the expression of c-Fos protein in cancer tissues and adjacent tissues in colorectal cancer patients with different genotypes.

RESULTS

The presence of a T allele at rs7101 and a T allele at rs1063169 in FOS carried a higher risk of colorectal cancer [adjusted odds ratio (OR) = 1.237, 95% confidence interval (95% CI) = 1.131-1.346, P ≤ .001 and adjusted OR = 1.218, 95% CI = 1.111-1.327, P ≤ .001, respectively]. c-Fos protein levels were significantly higher in variant cancer tissues than in normal mucosa tissues (P < .05), and c-Fos proteins levels were also higher in homozygous variant cancer tissues than in heterozygous variant cancer tissues. The 3-year survival rate of patients with wild-type FOS was higher than that of patients with variant FOS (P < .05).

CONCLUSION

The rs7101 and rs1063169 polymorphisms in the noncoding region of FOS are associated with the risk of developing colorectal cancer and the progression of colorectal cancer, which may be because the mutation enhances the expression of c-Fos protein to promote the incidence and development of colorectal cancer.

Multicenter phase II study of biweekly CAPIRI plus bevacizumab as second-line therapy in patients with metastatic colorectal cancer (JSWOG-C3 study)

Background

Triweekly capecitabine plus irinotecan (CAPIRI) was not a replacement for fluorouracil, leucovorin, and irinotecan (FOLFIRI) in the treatment of metastatic colorectal cancer (mCRC) because of the potential for greater toxicity. Recently, it has reported that mCAPIRI is well tolerated and non-inferior to FOLFIRI. In this study, we conducted a multicenter phase II trial to assess the efficacy and safety of biweekly CAPIRI plus bevacizumab as second-line chemotherapy for mCRC with reduced toxicity and preserved efficacy.

Methods

Patients with mCRC who had received prior chemotherapy, including oxaliplatin-based regimens, were eligible for this study. The treatment protocol administered capecitabine at 1000 mg/m² twice daily from the evening of day 1 to the morning of day 8, intravenous irinotecan at 150 mg/m² on day 1, and bevacizumab at 10 mg/kg on day 1 every 2 weeks. Primary endpoints for this study were progression-free survival (PFS) and safety. Secondary endpoints were overall survival (OS), time to treatment failure, response rate (RR), and disease control rate (DCR).

Results

Fifty-one patients were enrolled in this study. Median PFS was 5.5 months [95% confidence interval (CI) 4.23–7.40 months], and median OS was 13.5 months (95% CI 11.57–20.23 months). The RR was 14.6% (95% CI 6.5–28.4%), and the DCR was 66.7% (95% CI 51.5–79.2%). Hypertension was the most common Grade 3 adverse event (27.5%), followed by neutropenia (17.6%). Only two patients suffered from grade 3 hand–foot syndrome.

Conclusions

In mCRC patients, biweekly CAPIRI + bevacizumab appears effective and feasible as a second-line chemotherapy with relatively low toxicities, and has potential as a useful substitute for FOLFIRI + bevacizumab.

Influence of race and geographic setting on the management of gastric adenocarcinoma

BACKGROUND AND OBJECTIVES

Conflicting evidence indicates that both race and geographic setting may influence the management of malignancies such as gastric adenocarcinoma (GAC).

METHODS

We designed a retrospective cohort study utilizing data from the Surveillance, Epidemiology, and End Results program to identify patients with resectable GAC (N = 15 991). Exposures of interest were race and geographic region of diagnosis (West [WE], Midwest [MW], South [SO], or Northeast [NE]). Endpoints included: (1) recommendation against surgery and (2) gastric adenocarcinoma-specific survival (GACSS). Multivariable logistic and Cox regression models were used to identify pertinent associations.

RESULTS

A total of 15 991 patients were included (2007-2015). In adjusted analysis, African American individuals more frequently received a recommendation against surgical resection than White (adjusted odds ratio [aOR] = 0.86; 95% confidence interval [CI], 0.76-0.98), Asian American (aOR = 0.55; 95% CI, 0.46-0.65), and American Indian (aOR = 0.50; 95% CI, 0.31-0.82) individuals. In addition to race-based discrepancies, there was a significant association between geography and management: individuals diagnosed with GAC in the SO were more likely to receive a recommendation against surgery (odds ratio = 1.35; 95% CI, 1.23-1.49) and exhibited poorer GACSS as compared with those in the WE, MW, or NE regions.

CONCLUSIONS

Race and geographic region of diagnosis affect treatment recommendations and GACSS among individuals with resectable tumors. African Americans with resectable cancers are more likely to receive a recommendation against surgery than individuals of other racial groups.

Evaluation of Osteopontin and Pokémon genes expression in hepatitis C virus-associated hepatocellular carcinoma

Osteopontin and Pokémon genes may have an important role in the pathogenesis of different malignancies. Osteopontin is a glycoprotein of the extracellular matrix, and Pokémon is a regulator of transcription. Both have been hypothesized to be useful as therapeutic targets or diagnostic markers. We aim to assess the role of both in hepatocellular carcinoma and liver fibrosis due to hepatitis C virus (HCV) infection. We conducted our study on 50 patients and classified them into three groups-Group I: Patients with HCV-related hepatocellular carcinoma (HCC) (n = 30); Group II: Patients with hepatitis C cirrhosis (n = 10); and Group III: Patients with hepatitis C fibrosis (n = 10). We found high levels of Osteopontin and Pokémon gene expression in group I. Osteopontin levels were higher also in patients with liver fibrosis was correlated to high levels of parameters such as alpha fetoprotein and caspase. We conclude that HCC is associated with overexpression of both Osteopontin and Pokémon and that Osteopontin plays a significant role in liver fibrosis due to hepatitis C infection.

Tumor blood supply may predict neoadjuvant chemotherapy response and survival in patients with gastric cancer

Objectives

We investigated the prognostic value of tumor blood supply in patients with advanced gastric cancer (GC) receiving neoadjuvant chemotherapy.

Methods

We retrospectively reviewed 53 patients with advanced GC treated with FLEEOX chemotherapy. The tumor computed tomography (CT) enhancement value was measured before chemotherapy (CT1; arterial phase CT–plain phase CT). The liver parenchyma CT enhancement value (CT2) was also measured using the same method, to eliminate individual differences. Tumor blood supply was defined as good or poor based on the median CT1/CT2 values. We evaluated the relationships between tumor blood supply and response to chemotherapy, clinicopathologic characteristics, and overall survival (OS).

Results

A good blood supply (GBS) was associated with significantly better clinical and pathological responses to chemotherapy than a poor blood supply (PBS). The 3-year OS was 65.8% for the entire cohort. Patients with a GBS had a significantly higher OS (78.57%) than those with a PBS (54.44%). Additionally, patients with Bormann type III GC had a better blood supply than those with type II GC.

Conclusion

Patients with advanced GC and a GBS are more likely to benefit from neoadjuvant chemotherapy than those with a PBS. Blood supply may thus be a predictor for chemotherapy response.

Epidemiological variations and trends in health burden of glaucoma worldwide

PURPOSE

To evaluate the trends and variations in global health burden of glaucoma by year, age and sex, region and socio-economic status, using disability-adjusted life years (DALYs).

METHOD

The DALY numbers, crude DALY rate and age-standardized DALY rate globally and in each country were obtained the GBD 2015 study database. The corresponding human development index (HDI) and gross domestic product (GDP) per capita were obtained from the United Nations and World Bank. Environmental data were obtained from the WHO Global Health Observatory data repository.

RESULTS

From 1990 to 2015, the DALY number and age-standardized DALY rate due to glaucoma increased by 122% and 15%, respectively. Both male and female showed similar increasing trend with ageing, with the peak at 60 years old and increasing again since 75 years old. Sex disparities in DALY number were noted, with higher burden among female than male in each age group (all p < 0.001). The health burden of glaucoma was substantial unequal, with Gini coefficient of 0.865 for DALY number, 0.235 for crude DALY rate and 0.254 for age-standardized DALY rate, respectively. The age-standardized DALY was significantly associated with HDI, accounting for 22.2% variance across countries (R²  = 0.222, p < 0.001). Similarly, the GDP per capita was inversely associated with age-standardized DALY rate but can explain only 10.6% variations in age-standardized DALY rate (R²  = 0.106, p < 0.001). The age-standardized DALY rate due to glaucoma was positively associated with national levels of ultraviolet radiation and PM_2.5 .

CONCLUSION

The health burden of glaucoma continuously increased in the past 25 years and distributed unequally. Lower socio-economic level, older age, female, higher ambient ultraviolet radiation and higher level of air pollution were significantly associated with higher burden of glaucoma.

Integrated miRNA and mRNA expression analysis uncovers drug targets in laryngeal squamous cell carcinoma patients

OBJECTIVES

The current treatment of laryngeal squamous cell carcinoma (LSCC) is based on radical surgery and radiotherapy resulting in high morbidity. Chemoradiotherapy has been used as alternative to organ sparing; however, several advanced cases presented resistance to treatment, which contributes to a high risk of recurrence and mortality. Coding RNAs and miRNAs have potential to be used as biomarkers or targets for cancer therapy.

MATERIALS AND METHODS

In this study, 36 LSCC and 5 non-neoplastic control samples were investigated using miRNA and mRNA large-scale expression analysis and a cross-validation was performed using the TCGA database (116 LSCC and 12 surrounding normal tissues).

RESULTS

The large-scale profiling revealed the involvement of 28 miRNAs and 817 genes differentially expressed in LSCC. An integrative analysis comprising predicted and experimentally validated miRNA/mRNA interactions (negatively correlated), resulted in 28 miRNAs and 543 mRNAs. Decreased expression of miR-199b was significantly associated with shorter disease-free survival in LSCC (internal and TCGA datasets). The expression levels of selected miRNAs (miR-199b-5p, miR-29c-3p, miR-204-5p, miR-125b-5p and miR-92a-3p) and genes (COL3A1, COL10A1, ERBB4, HMGA2, HLF, TOP2A, MMP3, MMP13, MMP10 and PPP1R3) were confirmed as altered in LSCC by RT-qPCR. Additionally, a drug target prediction analysis revealed drug combinations based on miRNA and mRNA expression, pointing out novel alternatives to optimize the LSCC treatment.

CONCLUSION

Collectively, these findings provide new insights in the LSCC transcriptional deregulation and potential drug targets.

PRMT1-Dependent Macrophage IL-6 Production Is Required for Alcohol-Induced HCC Progression

Alcohol is a well-established risk factor for hepatocellular carcinoma, but the mechanisms are not well understood. Several studies suggested that alcohol promotes tumor growth by altering immune cell phenotypes in the liver. Arginine methylation is a common posttranslational modification generated mostly by a single protein, PRMT1. In myeloid cells PRMT1 is a key regulator of immune response. Myeloid-specific PRMT1 knockout mice are hyperresponsive to LPS and deficient in PPARγ-dependent macrophage M2 polarization. We aimed to define the role of myeloid PRMT1 in alcohol-associated liver tumor progression using a mouse model of DEN injection followed by Lieber-DeCarli alcohol liquid diet feeding. We found that PRMT1 knockout mice showed significantly lower expression of IL-10 and IL-6 cytokines in the liver and downstream STAT3 activation, which correlated with reduced number of surface tumors, reduced proliferation, and reduced number of M2 macrophages in the liver as well as within proliferating nodules. We found that blocking IL-6 signaling in alcohol-fed mice reduced the number of tumors and liver proliferation in wild-type mice but not in knockout mice suggesting that reduced IL-6 in PRMT1 knockout mice contributes to the protection from alcohol. Additionally, PRMT1 knockout did not show any protection in tumor formation in the absence of alcohol. Finally, we confirmed that this mechanism is relevant in humans. We found that PRMT1 expression in tumor-associated macrophages correlated with STAT3 activation in human HCC specimens. Taken together, these data suggest that the PRMT1-IL-6-STAT3 axis is an important mechanism of alcohol-associated tumor progression.

Dynamic Contrast-Enhanced Ultrasound of Gastric Cancer: Correlation with Perfusion CT and Histopathology

Objective

To assess the relationship between contrast-enhanced ultrasound (CEUS) parameters and perfusion CT (PCT) parameters of gastric cancers and their correlation with histologic features.

Materials and Methods

This prospective study was approved by our Institutional Review Board. We included 43 patients with pathologically-proven gastric cancers undergoing CEUS using SonoVue® (Bracco) and PCT on the same day. Correlation between the CEUS parameters (peak intensity [PI], area under the curve [AUC], rise time [RT] from 10% to 90% of PI, time to peak [TTP_US], and mean transit time [MTT_US]) and PCT parameters (blood flow, blood volume, TTP_CT, MTT_CT, and permeability surface product) of gastric cancers were analyzed using Spearman's rank correlation test. In cases of surgical resection, the CEUS and PCT parameters were compared according to histologic features using Mann-Whitney test.

Results

CEUS studies were of diagnostic quality in 88.4% (38/43) of patients. Among the CEUS parameters of gastric cancers, RT and TTP_US showed significant positive correlations with TTP_CT (rho = 0.327 and 0.374, p = 0.045 and 0.021, respectively); PI and AUC were significantly higher in well-differentiated or moderately-differentiated tumors (n = 4) than poorly-differentiated tumors (n = 18) (p = 0.026 and 0.033, respectively), whereas MTT_CT showed significant differences according to histologic types (poorly cohesive carcinoma [PCC] vs. non-PCC), T-staging (≤ T2 vs. ≥ T3), N-staging (N0 vs. N-positive), and epidermal growth factor receptor expression (≤ faint vs. ≥ moderate staining) (p values < 0.05).

Conclusion

In patients with gastric cancers, CEUS is technically feasible for the quantification of tumor perfusion and may provide correlative and complementary information to that of PCT, which may allow prediction of histologic features.

Biological characteristics of gene expression features in pancreatic cancer cells induced by proton and X-ray irradiation

BACKGROUND

Radiation therapy is an important alternative treatment for advanced cancer. The aim of the current study was to disclose distinct alterations of the biological characteristics of gene expression features in pancreatic cancer cells, MIAPaCa-2, following proton and X-ray irradiation.

MATERIALS AND METHODS

Using cDNA microarray, we examined the gene expression alterations of MIAPaCa-2 cells following proton or X-ray irradiation. We also isolated the surviving MIAPaCa-2 cells after irradiation and analyzed their gene expression profiles.

RESULTS

Although the cytocidal effects of both types of irradiation were similar at sufficient doses in vitro and in vivo, the affected gene expression profile alterations of MIAPaCa-2 cells irradiated with protons were distinct from those irradiated with X-ray. Interestingly, clustering analysis of gene expression of the surviving MIAPaCa-2 cells was also completely discernible between the two types of irradiation. However, a similar cytocidal effect was still observed in the proton- and X-ray-irradiated surviving cells after re-irradiation, commonly showing biological effects related to apoptosis and cell cycle processes.

CONCLUSIONS

Proton irradiation treatment for pancreatic cancer provides the distinct biological effect of steady gene expression alterations compared to X-ray irradiation; however, surviving cells from both types of irradiation were still susceptible to the cytocidal effects induced by proton re-irradiation treatment.

Prediction of Treatment Outcome of Chemotherapy Using Perfusion Computed Tomography in Patients with Unresectable Advanced Gastric Cancer

Objective

To evaluate whether data acquired from perfusion computed tomography (PCT) parameters can aid in the prediction of treatment outcome after palliative chemotherapy in patients with unresectable advanced gastric cancer (AGC).

Materials and Methods

Twenty-one patients with unresectable AGCs, who underwent both PCT and palliative chemotherapy, were prospectively included. Treatment response was assessed according to Response Evaluation Criteria in Solid Tumors version 1.1 (i.e., patients who achieved complete or partial response were classified as responders). The relationship between tumor response and PCT parameters was evaluated using the Mann-Whitney test and receiver operating characteristic analysis. One-year survival was estimated using the Kaplan-Meier method.

Results

After chemotherapy, six patients exhibited partial response and were allocated to the responder group while the remaining 15 patients were allocated to the non-responder group. Permeability surface (PS) value was shown to be significantly different between the responder and non-responder groups (51.0 mL/100 g/min vs. 23.4 mL/100 g/min, respectively; p = 0.002), whereas other PCT parameters did not demonstrate a significant difference. The area under the curve for prediction in responders was 0.911 (p = 0.004) for PS value, with a sensitivity of 100% (6/6) and specificity of 80% (12/15) at a cut-off value of 29.7 mL/100 g/min. One-year survival in nine patients with PS value > 29.7 mL/100 g/min was 66.7%, which was significantly higher than that in the 12 patients (33.3%) with PS value ≤ 29.7 mL/100 g/min (p = 0.019).

Conclusion

Perfusion parameter data acquired from PCT demonstrated predictive value for treatment outcome after palliative chemotherapy, reflected by the significantly higher PS value in the responder group compared with the non-responder group.

Solitary cerebellum metastasis from gastric adenocarcinoma. A rare case report

INTRODUCTION

The present study reports a case of signet-ring gastric adenocarcinoma with isolated cerebellum metastasis 2 years after gastrectomy.

PRESENTATION OF A CASE

Brain metastases originating from gastric cancer are rare accounting for 2.1-3.3% of all brain tumors registered in Japan. There are no established therapeutic strategies for brain metastases, which accordingly have a poor prognosis. We present here a 69 year old female patient who was diagnosed with solitary cerebellum metastasis 2 years after treatment for gastric adenocarcinoma. The primary gastric cancer was treated by laparotomy with distal gastrectomy and D2 lymphadenectomy. It was diagnosed as a signet ring gastric adenocarcinoma on histopathological examination of the surgical specimen. Two years postoperatively the patient reported back to our clinic complaining of vomiting, persistent headache and instability. MRI of the head showed an enhanced tumor in the left hemisphere of cerebellum and surrounding edematous changes on T1-enhanced imaging. Given the medical history brain metastasis was the first thought in differential diagnosis. Surgical resection was chosen as treatment.

DISCUSSION

Until recently there are only two large studies that refer to metastatic brain tumors from primary gastric cancer. Besides that, official treatment guidelines for these cases do not exist. Treatment options include surgical resection (SR), whole brain radiotherapy (WBRT), steroids, chemotherapy or a combination.

CONCLUSION

A solitary cerebellum metastasis from primary gastric adenocarcinoma is a very rare presentation. Early detection of metastatic lesion and successful treatment is challenging.

Next-generation sequencing-based genomic profiling analysis reveals novel mutations for clinical diagnosis in Chinese primary epithelial ovarian cancer patients

BACKGROUND

Ovarian cancer (OC) is one of the most malignant gynecological tumors, associated with excess death rate (50-60%) in ovarian cancer patients. Particularly, among newly occurred ovarian cancer patients, 70% of clinical cases are diagnosed at the advanced stage, which definitely delay the timely treatment and lead to high mortality rate within 5 years post diagnosis. Therefore, identification of sensitive gene markers, as well as development of reliable genetic diagnosis, are important for the early detection and precise therapy for OC patients. This study aims to identify novel genetic mutations and develop a feasible clinical approach for early OC diagnosis.

METHODS

The OC tissue-derived DNA sample was acquired from 31 OC patients, and the somatic gene mutations will be identified after comparison with normal samples, using Genome-wide analysis and next-generation sequencing.

RESULTS

A total of 463 somatic mutations, which were considered as potential pathogenic sites, were assigned to 473 genes. Among them, 15 genes (TP53, TTN, MUC16, OR4N2, BRCA1, CAD, CCDC129, INSR, NAV3, NELL2, NRAS, OBSCN, PGLYRP4, RBM15B and TRPC7) were mutated on at least two sites. These genes were mapped to RNA sequencing (RNAseq) data, and a total of 117 genes had an absolute fold- change ≥ 2 and p ≤ 0.01. Five genes were mutated in at least two OC patients. Gene ontology (GO) classification indicated that a majority of genes participated in biological processes. Kyoto Enrichment of Genes and Genomes (KEGG) enrichment pathway analysis revealed that the genes were mainly involved in the regulation of metabolic signaling pathways.

CONCLUSIONS

Taken together, this study identified several novel genetic alterations pathway for early clinical diagnosis and provided abundant information for understanding molecular mechanisms of the OC occurrence and development.

Genome-wide profiling of human papillomavirus DNA integration in liquid-based cytology specimens from a Gabonese female population using HPV capture technology

Human papillomavirus (HPV) is recognised as the cause of precancerous and cancerous cervical lesions. Furthermore, in high-grade lesions, HPV is frequently integrated in the host cell genome and associated with the partial or complete loss of the E1 and E2 genes, which regulate the activity of viral oncoproteins E6 and E7. In this study, using a double-capture system followed by high-throughput sequencing, we determined the HPV integration status present in liquid-based cervical smears in an urban Gabonese population. The main inclusion criteria were based on cytological grade and the detection of the HPV16 genotype using molecular assays. The rate of HPV integration in the host genome varied with cytological grade: 85.7% (6/7), 71.4% (5/7), 66.7% (2/3) 60% (3/5) and 30.8% (4/13) for carcinomas, HSIL, ASCH, LSIL and ASCUS, respectively. For high cytological grades (carcinomas and HSIL), genotypes HPV16 and 18 represented 92.9% of the samples (13/14). The integrated form of HPV16 genotype was mainly found in high-grade lesions in 71.4% of samples regardless of cytological grade. Minority genotypes (HPV33, 51, 58 and 59) were found in LSIL samples, except HPV59, which was identified in one HSIL sample. Among all the HPV genotypes identified after double capture, 10 genotypes (HPV30, 35, 39, 44, 45, 53, 56, 59, 74 and 82) were detected only in episomal form. Our study revealed that the degree of HPV integration varies with cervical cytological grade. The integration event might be a potential clinical prognostic biomarker for the prediction of the progression of neoplastic lesions.

Long-term Outcomes of Stereotactic Body Radiotherapy for Low-Risk and Intermediate-Risk Prostate Cancer

Importance

Stereotactic body radiotherapy harnesses improvements in technology to allow the completion of a course of external beam radiotherapy treatment for prostate cancer in the span of 4 to 5 treatment sessions. Although mounting short-term data support this approach, long-term outcomes have been sparsely reported.

Objective

To assess long-term outcomes after stereotactic body radiotherapy for low-risk and intermediate-risk prostate cancer.

Design, Setting, and Participants

This cohort study analyzed individual patient data from 2142 men enrolled in 10 single-institution phase 2 trials and 2 multi-institutional phase 2 trials of stereotactic body radiotherapy for low-risk and intermediate-risk prostate cancer between January 1, 2000, and December 31, 2012. Statistical analysis was performed based on follow-up from January 1, 2013, to May 1, 2018.

Main Outcomes and Measures

The cumulative incidence of biochemical recurrence was estimated using a competing risk framework. Physician-scored genitourinary and gastrointestinal toxic event outcomes were defined per each individual study, generally by Radiation Therapy Oncology Group or Common Terminology Criteria for Adverse Events scoring systems. After central review, cumulative incidences of late grade 3 or higher toxic events were estimated using a Kaplan-Meier method.

Results

A total of 2142 men (mean [SD] age, 67.9 [9.5] years) were eligible for analysis, of whom 1185 (55.3%) had low-risk disease, 692 (32.3%) had favorable intermediate-risk disease, and 265 (12.4%) had unfavorable intermediate-risk disease. The median follow-up period was 6.9 years (interquartile range, 4.9-8.1 years). Seven-year cumulative rates of biochemical recurrence were 4.5% (95% CI, 3.2%-5.8%) for low-risk disease, 8.6% (95% CI, 6.2%-11.0%) for favorable intermediate-risk disease, 14.9% (95% CI, 9.5%-20.2%) for unfavorable intermediate-risk disease, and 10.2% (95% CI, 8.0%-12.5%) for all intermediate-risk disease. The crude incidence of acute grade 3 or higher genitourinary toxic events was 0.60% (n = 13) and of gastrointestinal toxic events was 0.09% (n = 2), and the 7-year cumulative incidence of late grade 3 or higher genitourinary toxic events was 2.4% (95% CI, 1.8%-3.2%) and of late grade 3 or higher gastrointestinal toxic events was 0.4% (95% CI, 0.2%-0.8%).

Conclusions and Relevance

In this study, stereotactic body radiotherapy for low-risk and intermediate-risk disease was associated with low rates of severe toxic events and high rates of biochemical control. These data suggest that stereotactic body radiotherapy is an appropriate definitive treatment modality for low-risk and intermediate-risk prostate cancer.

Global Patterns and Trends in Pancreatic Cancer Incidence: Age, Period, and Birth Cohort Analysis

OBJECTIVES

We aim to provide a global geographical picture of pancreatic cancer incidence and temporal trends from 1973 to 2015 for 41 countries.

METHODS

Joinpoint regression and age-period-cohort model was used.

RESULTS

In 2012, the highest age-adjusted rate was in Central and Eastern Europe for males and North America for females. Most regions showed sex disparities. During the recent 10 years, increasing trends were observed in North America, Western Europe, and Oceania. The greatest increase occurred in France. For recent birth cohorts, cohort-specific increases in risk were pronounced in Australia, Austria, Brazil, Canada, Costa Rica, Denmark, Estonia, France, Israel, Latvia, Norway, Philippines, Republic of Korea, Singapore, Spain, Sweden, the Netherlands, United States, and US white male populations and in Australia, Austria, Brazil, Bulgaria, Canada, China, Czech Republic, Finland, France, Italy, Japan, Lithuania, Norway, Republic of Korea, Singapore, Spain, The Netherlands, United Kingdom, United States, and US white female populations.

CONCLUSIONS

In contrast to the favorable effect of the decrease in smoking prevalence, other factors, including the increased prevalence of obesity and diabetes and increased physical inactivity, increased intake of red or processed meat and inadequate intake of fruits and vegetables are likely to have an unfavorable role in pancreatic cancer incidence worldwide.

Cancer risk in socially marginalised women: An exploratory study

BACKGROUND

Cancer is a leading cause of premature death in women worldwide, and is associated with socio-economic disadvantage. Yet many interventions designed to reduce risk and improve health fail to reach the most marginalised with the greatest needs. Our study focused on socially marginalised women at two women's centres that provide support and training to women in the judicial system or who have experienced domestic abuse.

METHODS

This qualitative study was framed within a sociological rather than behavioural perspective involving thirty participants in individual interviews and focus groups. It sought to understand perceptions of, and vulnerability to, cancer; decision making (including screening); cancer symptom awareness; and views on health promoting activities within the context of the women's social circumstances.

FINDINGS

Women's experiences of social adversity profoundly shaped their practices, aspirations and attitudes towards risk, health and healthcare. We found that behaviours such as unhealthy eating and smoking need to be understood in the context of inherently risky lives. They were a coping mechanism whilst living in extreme adverse circumstances, navigating complex everyday lives and structural failings. Long term experiences of neglect, harm and violence, often by people they should be able to trust, led to low self-esteem and influenced their perceptions of risk and self-care. This was reinforced by negative experiences of navigating state services and a lack of control and agency over their own lives.

CONCLUSION

Women in this study were at high risk of cancer, but it would be better to understand these risk factors as markers of distress and duress. Without appreciating the wider determinants of health and systemic disadvantage of marginalised groups, and addressing these with a structural rather than an individual response, we risk increasing cancer inequities by failing those who are in the greatest need.