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Narasimhan P, Levy AR, Rogers SN, Schache AG, Patterson JM, Williams NH, Brooker RC, Midgley AW. A protocol for the longitudinal investigation of cancer related fatigue in head and neck cancer with an emphasis on the role of physical activity. PLoS One 2024; 19:e0308400. [PMID: 39141642 PMCID: PMC11324130 DOI: 10.1371/journal.pone.0308400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/24/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND AND AIM Cancer related fatigue significantly impairs the ability to undertake sustained physical activity across the domains of daily living, work and recreation. The purpose of this study is to monitor cancer related fatigue and the factors affected or caused by it for 12 months in head and neck cancer patients following their diagnosis. Their perceptions of how fatigue might affect their activity levels in addition to identifying avenues to improve engagement with physical activity will be also explored. METHODS A single centre longitudinal mixed-methods study will be conducted. Forty head and neck cancer patients will be recruited over 6 months following the confirmation of their treatment plan, after which fatigue and physical activity will be assessed at four time points over 12 months. Additionally, other factors which influence fatigue such as body composition, blood counts, systemic inflammation levels, haemoglobin concentration, thyroid function, sleep quality, cardiorespiratory fitness and upper and lower extremity strength will be measured to understand how the multifactorial problem of fatigue may evolve over time and influence physical activity levels. Semi-structured interviews will be conducted after treatment completion and at end of twelve months which will analyse the participants fatigue experiences, understand how their perceived fatigue may have impacted physical activity and report the factors which may improve engagement with physical activity during cancer. Quantitative data will be analysed and reported using standard descriptive statistics and post-hoc pairwise comparisons. The changes in outcome measures across time will be analysed using the MIXED procedure in SPSS software. Statistical significance will be accepted at p<0.05. Qualitative data will be analysed using the Interpretative Phenomenological Approach using the NVivo software. DISCUSSION The results from this study may help inform the planning and delivery of appropriately timed interventions for the management of cancer related fatigue.
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Affiliation(s)
- Prahalad Narasimhan
- Department of Sport and Physical Activity, Edge Hill University, Ormskirk, United Kingdom
| | - Andrew R. Levy
- Health Research Institute, Edge Hill University, Ormskirk, United Kingdom
- Department of Psychology, Edge Hill University, Ormskirk, United Kingdom
| | - Simon N. Rogers
- Wirral University Teaching Hospital, Wirral, United Kingdom
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, United Kingdom
| | - Andrew G. Schache
- Liverpool Head and Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Joanne M. Patterson
- Liverpool Head and Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Nefyn H. Williams
- Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Rachel C. Brooker
- Liverpool Head and Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - Adrian W. Midgley
- Department of Sport and Physical Activity, Edge Hill University, Ormskirk, United Kingdom
- Health Research Institute, Edge Hill University, Ormskirk, United Kingdom
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Bower JE, Ganz PA, Irwin MR, Crespi CM, Petersen L, Asher A, Hurvitz SA, Cole SW. Type I interferons, inflammation, and fatigue in a longitudinal RNA study of women with breast cancer. Brain Behav Immun 2024; 118:312-317. [PMID: 38325563 PMCID: PMC11095951 DOI: 10.1016/j.bbi.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/12/2024] [Accepted: 02/02/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Fatigue is a common side effect of cancer and its treatment and is thought to be driven in part by activation of the proinflammatory cytokine network. However, the cellular and molecular underpinnings of cancer-related fatigue (CRF) have not been determined, nor have immune pathways beyond inflammation been carefully investigated. The goal of this study was to examine the association between CRF and activation of canonical proinflammatory gene regulation pathways and Type I interferon (IFN) signaling pathways in breast cancer patients during and after treatment. METHODS Women diagnosed with early-stage breast cancer (n = 181) completed assessments before and after treatment with radiation and/or chemotherapy and at 6, 12, and 18-month post-treatment follow-ups. Assessments included self-reported fatigue (Multidimensional Fatigue Symptom Inventory - Short Form) and expression of pre-specified sets of Type I IFN and pro-inflammatory immune response genes determined from mRNA sequencing of PBMCs. Mixed effect linear models examined changes in fatigue and immune gene expression over time and tested the hypothesis that fatigue would be associated with increased expression of Type I IFN and inflammatory response genes. RESULTS There were significant changes in fatigue and immune gene expression across the assessment period; all measures increased from pre- to post-treatment but showed diverging patterns over the follow-up, with declines in fatigue and persistent elevations in Type I IFN and proinflammatory gene expression. In mixed effect linear models, expression of Type I IFN response genes was elevated in association with fatigue across the assessment period, from pre-treatment to 18-month follow-up. In contrast, pro-inflammatory gene expression was associated with fatigue only at 6, 12, and 18-month follow-ups. Analyses controlling for changes in leukocyte subsets continued to show a significant association between fatigue and Type I IFN gene expression but reduced the time-dependent association with pro-inflammatory gene expression to non-significant. CONCLUSIONS Results revealed unexpected complexity in the immune underpinnings of CRF and identify a novel role for IFN signaling as a robust contributor to this symptom before, during, and after treatment. Pro-inflammatory gene expression emerged as a predictor of fatigue later in the cancer trajectory, and that effect was primarily accounted for by a concurrent increase in monocyte prevalence.
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Affiliation(s)
- Julienne E Bower
- UCLA Department of Psychology, United States; UCLA Department of Psychiatry and Biobehavioral Sciences, United States; Cousins Center for Psychoneuroimmunology, United States; Jonsson Comprehensive Cancer Center, United States.
| | - Patricia A Ganz
- Jonsson Comprehensive Cancer Center, United States; UCLA Schools of Medicine and Public Health, United States
| | - Michael R Irwin
- UCLA Department of Psychiatry and Biobehavioral Sciences, United States; Cousins Center for Psychoneuroimmunology, United States
| | - Catherine M Crespi
- Jonsson Comprehensive Cancer Center, United States; UCLA Department of Biostatistics, United States
| | | | - Arash Asher
- Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai Medical Center, United States
| | - Sara A Hurvitz
- University of Washington Department of Medicine, United States; Fred Hutchinson Cancer Center, United States
| | - Steve W Cole
- UCLA Department of Psychiatry and Biobehavioral Sciences, United States; Cousins Center for Psychoneuroimmunology, United States; UCLA Department of Medicine, United States
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Bolnykh I, Patterson JM, Harding S, Watson LJ, Lu L, Hurley K, Thomas SJ, Sharp L. Cancer-related pain in head and neck cancer survivors: longitudinal findings from the Head and Neck 5000 clinical cohort. J Cancer Surviv 2024:10.1007/s11764-024-01554-x. [PMID: 38421499 DOI: 10.1007/s11764-024-01554-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Reports suggest pain is common in head and neck cancer (HNC). However, past studies are limited by small sample sizes and design and measurement heterogeneity. Using data from the Head and Neck 5000 longitudinal cohort, we investigated pain over a year post-diagnosis. We assessed: temporal trends; compared pain across HNC treatments, stages, sites and by HPV status; and identified subgroups of patients at increased risk of pain. METHODS Sociodemographic and clinical data and patient-reported pain (measured by EORTC QLQ-C30 and QLQ-H&N35) were collected at baseline (pre-treatment), 4- and 12- months. Using mixed effects multivariable regression, we investigated time trends and identified associations between (i) clinically-important general pain and (ii) HN-specific pain and clinical, socio-economic, and demographic variables. RESULTS 2,870 patients were included. At baseline, 40.9% had clinically-important general pain, rising to 47.6% at 4-months and declining to 35.5% at 12-months. HN-specific pain followed a similar pattern (mean score (sd): baseline 26.4 (25.10); 4-months. 28.9 (26.55); 12-months, 17.2 (19.83)). Across time, general and HN-specific pain levels were increased in: younger patients, smokers, and those with depression and comorbidities at baseline, and more advanced, oral cavity and HPV negative cancers. CONCLUSIONS There is high prevalence of general pain in people living with HNC. We identified subgroups more often reporting general and HN-specific pain towards whom interventions could be targeted. IMPLICATIONS FOR CANCER SURVIVORS Greater emphasis should be placed on identifying and treating pain in HNC. Systematic pain screening could help identify those who could benefit from an early pain management plan.
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Affiliation(s)
- Iakov Bolnykh
- Population Health Sciences Institute, Newcastle University Centre for Cancer, Newcastle, UK
| | - Joanne M Patterson
- Liverpool Head and Neck Centre, School of Health Science, University of Liverpool, Liverpool, UK
| | - Sam Harding
- Speech and Language Therapy Research Unit, Southmead Hospital North Bristol NHS Hospital Trust, Bristol, UK
| | - Laura-Jayne Watson
- Speech & Language Therapy, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Liya Lu
- Population Health Sciences Institute, Newcastle University Centre for Cancer, Newcastle, UK
- NHS Forth Valley, Stirling, Scotland, UK
| | - Katrina Hurley
- Head & Neck 5000 Study, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Steve J Thomas
- Head & Neck 5000 Study, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University Centre for Cancer, Newcastle, UK.
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Kentnowski M, Cortez AJ, Mazurek AM, Mrochem-Kwarciak J, Hebda A, Kacorzyk U, Drosik-Rutowicz K, Chmielik E, Paul P, Gajda K, Łasińska I, Bobek-Billewicz B, d'Amico A, Składowski K, Śnietura M, Faden DL, Rutkowski TW. Determinants of the level of circulating-tumor HPV16 DNA in patients with HPV-associated oropharyngeal cancer at the time of diagnosis. Sci Rep 2023; 13:21226. [PMID: 38040848 PMCID: PMC10692143 DOI: 10.1038/s41598-023-48506-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023] Open
Abstract
Circulating tumor HPV DNA (ctHPV16) assessed in liquid biopsy may be used as a marker of cancer in patients with HPV-associated oropharyngeal cancer (HPV + OPC). Factors influencing the initial ctHPV16 quantity are not well recognized. In this study we aimed to establish what factors are related to the level of ctHPV16 at the time of diagnosis. 51 patients (37 men and 14 women, median age of 57 years old) with HPV + OPC prior to definitive treatment were included. ctHPV16 was measured by qPCR. Tumor and nodal staging were assessed according to AJCC8. Blood derived factors included squamous cell carcinoma antigen (SCC-Ag), serum soluble fragment of cytokeratin 19 (CYFRA 21-1), C-reactive protein (CRP), albumin level (Alb), neutrophils (Neut), thrombocytes (Plt) and lymphocyte (Lym) count, Neut/Lym ratio were assessed. The volumes of the primary tumor (TV) and involved lymph nodes (NV) were calculated using MRI, CT or PET-CT scans. Data were analysed using parametric and nonparametric methods. Variables for multivariable linear regression analysis were chosen based on the results from univariable analysis (correlation, univariable regression and difference). There were 9 (18%), 10 (19%) and 32 (63%) patients who had TV and NV assessed in MRI, CT or PET respectively. Primary tumor neither as T-stage nor TV was related to ctHPV16 level. Significant differences in the ctHPV16 between patients with high vs low pain (P = 0.038), NV (P = 0.023), TV + NV (P = 0.018), CYFRA 21-1 (P = 0.002), CRP (P = 0.019), and N1 vs N3 (P = 0.044) were observed. ctHPV16 was significantly associated with CYFRA 21-1 (P = 0.017), N stage (P = 0.005), NV (P = 0.009), TV + NV (P = 0.002), CRP (P = 0.019), and pain (P = 0.038). In univariable linear regression analysis the same variables predicted ctHPV16 level. In multivariable analyses, CYFRA 21-1 and CRP (both as categorical variables) were predictors of ctHPV16 level even above NV. ctHPV16 at presentation is driven by tumor volume measured mostly by N. CYFRA 21-1 and CRP are additional factors related to ctHPV16 prior to the treatment.
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Affiliation(s)
- Marek Kentnowski
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Alexander J Cortez
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Agnieszka M Mazurek
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Jolanta Mrochem-Kwarciak
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Anna Hebda
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Urszula Kacorzyk
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Katarzyna Drosik-Rutowicz
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Ewa Chmielik
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Piotr Paul
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Karolina Gajda
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Izabela Łasińska
- Department of Medical and Experimental Oncology, Cancer Institute, Poznań University of Medical Sciences, 16/18 Grunwaldzka Street, 60-786, Poznan, Poland
- Department of Nursing, Institute of Health Sciences, University of Zielona Góra, 2 Energetyków Street, 65-417, Zielona Góra, Poland
| | - Barbara Bobek-Billewicz
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Andrea d'Amico
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Krzysztof Składowski
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Mirosław Śnietura
- Department of Pathomorphology and Molecular Diagnostics, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Daniel L Faden
- Department of Otolaryngology-Head and Neck Surgery Harvard Medical School, Mass Eye and Ear, Mass General Hospital, Broad Institute of MIT and Harvard, Cambridge, USA
| | - Tomasz W Rutkowski
- Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeże Armii Krajowej 15, 44-101, Gliwice, Poland.
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Barandouzi ZA, Eng T, Shelton J, Khanna N, Scott I, Meador R, Bruner DW. Associations of the gut microbiome with psychoneurological symptom cluster in women with gynecologic cancers: a longitudinal study. Support Care Cancer 2023; 31:626. [PMID: 37819383 DOI: 10.1007/s00520-023-08058-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/20/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE The present study aimed to evaluate the associations between the gut microbiome and psychoneurological symptoms (PNS) cluster in women with gynecologic cancers over time. METHODS In this secondary data analysis, 19 women with cervical and endometrial cancers treated with radiotherapy were followed at pre-treatment, 6-8 weeks, and 6 months post-treatment. To measure symptoms, Functional Assessment of Cancer Therapy-General (FACT-G) and Patient Health Questionnaire-9 (PHQ-9) were used. An average Z score of at least three out of five symptoms was computed as the PNS cluster total score. Rectal swabs were also collected at the same time points and sequenced using 16S rRNA V4 regions. The Kruskal-Wallis and permutational multivariable analysis of variance tests were used to compare α- and β-diversity between patients with high and low PNS cluster. The linear discriminant analysis effect size (LEfSe) tested taxa differences between study groups. Also, the linear mixed-effect model was used to evaluate the association of the gut microbiome and the PNS cluster over cancer treatment. RESULTS The patients' mean age was 58 years, 47% Black, 52% single/divorced, and 66% had college or above education. Among the participants, 63% had endometrial cancer with stage I disease. There was a different taxonomy profile between patients with high and low PNS. Patients with high PNS had a lower α-diversity than those with low PNS (Shannon, p = 0.03, evenness, p = 0.03). The mixed effects model results showed that low α-diversity and abundance of Fusicatenibacter and Ruminococcus were associated with high PNS cluster over cancer treatment. CONCLUSION The association between the gut microbiome and PNS cluster suggest that the gut microbiota plays a role in developing the PNS cluster. Future larger studies are required to shed light on the gut microbiota role in symptom development in gynecologic cancer patients.
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Affiliation(s)
- Zahra Amirkhanzadeh Barandouzi
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, GA, 30322, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Tony Eng
- Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
- School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Joseph Shelton
- Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
- School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Namita Khanna
- Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
- School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Isabelle Scott
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Rebecca Meador
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Deborah Watkins Bruner
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, GA, 30322, USA.
- Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA.
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Sharp L, Watson LJ, Lu L, Harding S, Hurley K, Thomas SJ, Patterson JM. Cancer-Related Fatigue in Head and Neck Cancer Survivors: Longitudinal Findings from the Head and Neck 5000 Prospective Clinical Cohort. Cancers (Basel) 2023; 15:4864. [PMID: 37835558 PMCID: PMC10571913 DOI: 10.3390/cancers15194864] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 09/28/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
Cancer-related fatigue (CRF) is a common side-effect of cancer and its treatments. For head and neck cancer (HNC), CRF may exacerbate the symptom burden and poor quality-of-life. Using data from the Head and Neck 5000 prospective clinical cohort, we investigated clinically important CRF over a year post-diagnosis, assessing temporal trends, CRF by HNC site and treatment received, and subgroups at higher risk of CRF. Recruitment was undertaken in 2011-2014. Socio-demographic and clinical data, and patient-reported CRF (EORTC QLQ-C30 fatigue subscale score ≥39 of a possible 100) were collected at baseline (pre-treatment) and 4- and 12- months post-baseline. Mixed-effects logistic multivariable regression was used to investigate time trends, compare cancer sites and treatment groups, and identify associations between clinical, socio-demographic and lifestyle variables and CRF. At baseline, 27.8% of 2847 patients scored in the range for clinically important CRF. This was 44.7% at 4 months and 29.6% at 12 months. In the multivariable model, after adjusting for time-point, the odds of having CRF over 12 months were significantly increased in females and current smokers; those with stage 3/4 disease, comorbidities and multimodal treatment; and those who had depression at baseline. The high prevalence of clinically important CRF indicates the need for additional interventions and supports for affected HNC patients. These findings also identified patient subgroups towards whom such interventions could be targeted.
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Affiliation(s)
- Linda Sharp
- Population Health Sciences Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle NE1 7RU, UK;
| | - Laura-Jayne Watson
- Speech & Language Therapy, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Foundation Trust, Sunderland SR4 7TP, UK;
| | - Liya Lu
- Population Health Sciences Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle NE1 7RU, UK;
| | - Sam Harding
- Speech and Language Therapy Research Unit, Southmead Hospital North Bristol NHS Hospital Trust, Bristol BS10 5NB, UK;
| | - Katrina Hurley
- Head & Neck 5000 Study, Weston NHS Foundation Trust, University of Bristol, Bristol BS8 1TU, UK (S.J.T.)
| | - Steve J. Thomas
- Head & Neck 5000 Study, Weston NHS Foundation Trust, University of Bristol, Bristol BS8 1TU, UK (S.J.T.)
| | - Joanne M. Patterson
- Liverpool Head and Neck Centre, School of Health Science, University of Liverpool, Liverpool L69 3BG, UK;
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Huang S, Zhan Y, Jeon S, Bruner DW, Miller AH, Felger JC, Wommack EC, Saba NF, Higgins KA, Irwin ML, Gary RA, Xiao C. Longitudinal associations among physical activity, inflammatory markers, and quality of life in patients with head and neck cancer. Head Neck 2023; 45:1952-1966. [PMID: 37288586 PMCID: PMC10330673 DOI: 10.1002/hed.27420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 06/09/2023] Open
Abstract
INTRODUCTION The aim of this study was to explore the associations among physical activity (PA), inflammatory markers, and quality of life (QoL) from preradiotherapy to 1-year postradiotherapy for patients with head and neck cancer (HNC). METHODS This was an observational longitudinal study. Mixed-effect models incorporating within-subject correlation were used to examine the relationship among the three key variables. RESULTS Aerobically active patients had significantly lower levels of sTNFR2 (but not other inflammatory markers) than aerobically inactive patients. Being aerobically active and lower inflammation were independently associated with better total QoL scores after adjusting covariates. The trend was similar for patients engaged in strength exercises. CONCLUSIONS Being aerobically active was associated with lower inflammation as represented by sTNFR2 but not with other inflammatory markers. Higher PA (aerobic and strength) and lower inflammation were linked to better QoL. More research is warranted to validate the association among PA, inflammation, and QoL.
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Affiliation(s)
- Shuyuan Huang
- NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Yan Zhan
- Yale School of Nursing, Orange, Connecticut, USA
| | | | | | | | | | | | - Nabil F Saba
- Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Melinda L Irwin
- Yale University School of Public Health, New Haven, Connecticut, USA
| | - Rebecca A Gary
- Emory University School of Nursing, Atlanta, Georgia, USA
| | - Canhua Xiao
- Emory University School of Nursing, Atlanta, Georgia, USA
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Amirkhanzadeh Barandouzi Z, Bruner DW, Miller AH, Paul S, Felger JC, Wommack EC, Higgins KA, Shin DM, Saba NF, Xiao C. Associations of inflammation with neuropsychological symptom cluster in patients with Head and neck cancer: A longitudinal study. Brain Behav Immun Health 2023; 30:100649. [PMID: 37396338 PMCID: PMC10308212 DOI: 10.1016/j.bbih.2023.100649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/17/2023] [Accepted: 06/03/2023] [Indexed: 07/04/2023] Open
Abstract
Purpose Head and neck cancer (HNC) patients may experience multiple co-occurring neuropsychological symptoms (NPS) cluster, including fatigue, depression, pain, sleep disturbance, and cognitive impairment. While inflammation has been attributed as a key mechanism for some of these symptoms, its association with the NPS as a cluster of symptoms is unknown. Thus, the aim of this study was to examine the association between peripheral inflammation and NPS cluster among HNC patients over cancer treatment (radiotherapy with or without chemotherapy). Methods HNC patients were recruited and followed at pre-treatment, end of treatment, three months and one-year post-treatment. Plasma inflammatory markers, including C-reactive protein (CRP), tumor necrosis factor-alpha (TNFA), soluble tumor necrosis factor receptor-2 (sTNFR2), interleukin-1 beta (IL1-β), interleukin-6 (IL-6), interleukin-10 (IL-10), monocyte chemotactic protein-1 (MCP-1), and interleukin-1 receptor antagonist (IL-1RA) and patient-reported NPS cluster were collected at the 4 time points. Associations between inflammatory markers and the NPS cluster were analyzed using linear mixed-effects models and generalized estimating equations (GEE) models controlling covariates. Results 147 HNC patients were eligible for analysis. 56% of the patients received chemoradiotherapy as treatment. The highest NPS cluster score was reported at the end of treatment, which gradually decreased over time. An increase in inflammatory markers including CRP, sTNFR2, IL-6 and IL-1RA was associated with higher continuous NPS cluster scores (p<0.001, p = 0.003, p<0.001, p<0.001; respectively). GEE further confirmed that patients with at least two moderate symptoms had elevated sTNFR2, IL-6, and IL-1RA (p = 0.017, p = 0.038, p = 0.008; respectively). Notably, this positive association between NPS cluster and inflammatory markers was still significant at one-year post-treatment for CRP (p = 0.001), sTNFR2 (p = 0.006), and IL-1RA (p = 0.043). Conclusions Most HNC patients experienced NPS clusters over time, especially immediately after the end of treatment. Elevated inflammation, as represented by inflammatory markers, was strongly associated with worse NPS cluster over time; this trend was also notable at one-year post-treatment. Our findings suggest that peripheral inflammation plays a pivotal role in the NPS cluster over cancer treatment, including long-term follow-ups. Interventions on reducing peripheral inflammation may contribute to alleviating the NPS cluster in cancer patients.
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Affiliation(s)
| | - Deborah W. Bruner
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Andrew H. Miller
- School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Sudeshna Paul
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Jennifer C. Felger
- School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Evanthia C. Wommack
- School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Kristin A. Higgins
- School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Dong M. Shin
- School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Nabil F. Saba
- School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Canhua Xiao
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, GA, 30322, USA
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Silver JA, Schwartz R, Roy CF, Sadeghi N, Henry M. Patient-Reported Outcome Measures of Psychosocial Quality of Life in Oropharyngeal Cancer Patients: A Scoping Review. J Clin Med 2023; 12:jcm12062122. [PMID: 36983125 PMCID: PMC10057395 DOI: 10.3390/jcm12062122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 03/30/2023] Open
Abstract
Background: Oropharyngeal squamous cell carcinoma (OPSCC) patients are burdened by the effect of the disease process and treatment toxicities on organs important in everyday activities, such as breathing, speaking, eating, and drinking. There is a rise in OPSCC due to human papilloma virus (HPV)-associated OPSCC, affecting younger and healthier patients and with a better overall prognosis. Emphasis must be shared between oncologic outcomes and the effects on quality of life. While there have been efforts to study global and physical quality of life, the impact on psychosocial quality of life has not yet been specifically reviewed. Methods: A scoping review methodology was employed to explore the emotional, social, and mental quality of life in OPSCC patients and determine the impact of HPV status or treatment modalities. Results: Eighty-seven full-text articles were evaluated for eligibility. Fifteen articles met final inclusion criteria. The majority of the studies were conducted in the United States (n = 10) and study methodology was divided between cross-sectional (n = 6), prospective (n = 5), and retrospective studies (n = 4). Four psychosocial quality of life themes were explored: the impact on mental health and emotional wellbeing, social wellbeing and function, stress, and relationship and sexual behavior. Eighteen different patient-reported outcome measures were used, including both general head and neck oncology questionnaires and symptom-specific surveys. Conclusion: There is a paucity of research regarding the effect of OPSCC on patients' psychosocial quality of life. Learning more about this component of quality of life can guide outreach programs and multidisciplinary involvement in improving patient care.
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Affiliation(s)
- Jennifer A Silver
- Department of Otolaryngology-Head and Neck Surgery, McGill University, 3755 Côte St. Catherine Road, Pavilion E Room E-903, Montreal, QC H3T 1E2, Canada
| | - Russell Schwartz
- Department of Otolaryngology-Head and Neck Surgery, McGill University, 3755 Côte St. Catherine Road, Pavilion E Room E-903, Montreal, QC H3T 1E2, Canada
| | - Catherine F Roy
- Department of Otolaryngology-Head and Neck Surgery, McGill University, 3755 Côte St. Catherine Road, Pavilion E Room E-903, Montreal, QC H3T 1E2, Canada
| | - Nader Sadeghi
- Department of Otolaryngology-Head and Neck Surgery, McGill University, 3755 Côte St. Catherine Road, Pavilion E Room E-903, Montreal, QC H3T 1E2, Canada
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
- Gerald Bronfman Department of Oncology, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | - Melissa Henry
- Department of Otolaryngology-Head and Neck Surgery, McGill University, 3755 Côte St. Catherine Road, Pavilion E Room E-903, Montreal, QC H3T 1E2, Canada
- Gerald Bronfman Department of Oncology, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
- Lady-Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Segal Cancer Centre, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
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10
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Edwards A, Brown T, Hughes BGM, Bauer J. The changing face of head and neck cancer: are patients with human papillomavirus-positive disease at greater nutritional risk? A systematic review. Support Care Cancer 2022; 30:7191-7204. [PMID: 35477809 PMCID: PMC9385807 DOI: 10.1007/s00520-022-07056-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/11/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Human papillomavirus (HPV) is now the primary cause of oropharyngeal head and neck cancer (OPC) worldwide; yet limited research has examined the effect of HPV-positive status (OPC+) on nutrition outcomes. This study aims to determine the impact of HPV status on nutritional outcomes for adult patients with OPC undergoing any treatment modality. METHODS A systematic literature review was conducted up to and including July 2021 of PubMed, Embase, CENTRAL, CINAHL, and Web of Science to identify studies conducted in adults (>18 years) with known OPC reporting on any outcome(s) related to nutrition, according to HPV status (OPC+ versus OPC-). Bias was assessed using QUIPS tool, with certainty of evidence assessed using GRADE system. RESULTS Six studies (total n = 635) all at moderate-high risk of bias were included. Three studies reported on weight change (n = 255), three feeding tube dependency (n = 380), three feeding tube timing of placement (prophylactic or reactive) and/or utilisation (n = 255), two nutritional (energy and/or protein) intake (n = 230), and one nutritional status (n = 83). Patients with OPC+ may experience greater weight loss, may have higher utilisation of reactive feeding tubes (both GRADE low certainty, downgraded due to serious bias and imprecision), and may have lower feeding tube dependency rates (GRADE low certainty, downgraded due to serious bias and inconsistency) versus OPC- . It is uncertain whether nutritional intake and nutritional status differed between populations (GRADE very low certainty, downgraded due to serious bias and very serious imprecision). CONCLUSION Further, high-quality research is needed to understand optimal nutritional care practices for patients with OPC + to achieve positive health outcomes into survivorship.
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Affiliation(s)
- Anna Edwards
- School of Human Movements and Nutrition Sciences, University of Queensland, Brisbane, QLD, Australia.
- Nutrition & Dietetics, Toowoomba Hospital, Darling Downs Health, Toowoomba, QLD, Australia.
- Nutrition & Dietetics, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia.
| | - Teresa Brown
- School of Human Movements and Nutrition Sciences, University of Queensland, Brisbane, QLD, Australia
- Nutrition & Dietetics, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - Brett G M Hughes
- Cancer Care Services, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Judy Bauer
- School of Human Movements and Nutrition Sciences, University of Queensland, Brisbane, QLD, Australia
- Nutrition, Dietetics & Food, School of Clinical Sciences, Monash Health, Monash University, Victoria, Australia
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11
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Takahashi H, Yoshimatsu G, Faustman DL. The Roles of TNFR2 Signaling in Cancer Cells and the Tumor Microenvironment and the Potency of TNFR2 Targeted Therapy. Cells 2022; 11:1952. [PMID: 35741080 DOI: 10.3390/cells11121952pubmedhttps:/www.ncbi.nlm.nih.gov/pubmed/35741080pubmed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 08/02/2024] Open
Abstract
The appreciation that cancer growth is promoted by a dynamic tumor microenvironment (TME) has spawned novel approaches to cancer treatment. New therapies include agents that activate quiescent T effector cells and agents that interfere with abnormal neovascularity. Although promising, many experimental therapies targeted at the TME have systemic toxicity. Another approach is to target the TME with greater specificity by taking aim at the tumor necrosis factor receptor 2 (TNFR2) signaling pathway. TNFR2 is an attractive molecular target because it is rarely expressed in normal tissues (thus, has low potential for systemic toxicity) and because it is overexpressed on many types of cancer cells as well as on associated TME components, such as T regulatory cells (Tregs), tumor-associated macrophages, and other cells that facilitate tumor progression and spread. Novel therapies that block TNFR2 signaling show promise in cell culture studies, animal models, and human studies. Novel antibodies have been developed that expressly kill only rapidly proliferating cells expressing newly synthesized TNFR2 protein. This review traces the origins of our understanding of TNFR2's multifaceted roles in the TME and discusses the therapeutic potential of agents designed to block TNFR2 as the cornerstone of a TME-specific strategy.
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Affiliation(s)
- Hiroyuki Takahashi
- Department of Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka 814-0180, Japan
- Immunobiology Department, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Gumpei Yoshimatsu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka 814-0180, Japan
| | - Denise Louise Faustman
- Immunobiology Department, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
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12
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Takahashi H, Yoshimatsu G, Faustman DL. The Roles of TNFR2 Signaling in Cancer Cells and the Tumor Microenvironment and the Potency of TNFR2 Targeted Therapy. Cells 2022; 11:cells11121952. [PMID: 35741080 PMCID: PMC9222015 DOI: 10.3390/cells11121952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 11/16/2022] Open
Abstract
The appreciation that cancer growth is promoted by a dynamic tumor microenvironment (TME) has spawned novel approaches to cancer treatment. New therapies include agents that activate quiescent T effector cells and agents that interfere with abnormal neovascularity. Although promising, many experimental therapies targeted at the TME have systemic toxicity. Another approach is to target the TME with greater specificity by taking aim at the tumor necrosis factor receptor 2 (TNFR2) signaling pathway. TNFR2 is an attractive molecular target because it is rarely expressed in normal tissues (thus, has low potential for systemic toxicity) and because it is overexpressed on many types of cancer cells as well as on associated TME components, such as T regulatory cells (Tregs), tumor-associated macrophages, and other cells that facilitate tumor progression and spread. Novel therapies that block TNFR2 signaling show promise in cell culture studies, animal models, and human studies. Novel antibodies have been developed that expressly kill only rapidly proliferating cells expressing newly synthesized TNFR2 protein. This review traces the origins of our understanding of TNFR2’s multifaceted roles in the TME and discusses the therapeutic potential of agents designed to block TNFR2 as the cornerstone of a TME-specific strategy.
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Affiliation(s)
- Hiroyuki Takahashi
- Department of Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka 814-0180, Japan; (H.T.); (G.Y.)
- Immunobiology Department, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
| | - Gumpei Yoshimatsu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka 814-0180, Japan; (H.T.); (G.Y.)
| | - Denise Louise Faustman
- Immunobiology Department, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA
- Correspondence: ; Tel.: +1-617-726-4084; Fax: +1-617-726-4095
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13
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Aggarwal P, Hutcheson KA, Goepfert RP, Garden AS, Garg N, Mott FE, Fuller CD, Lai SY, Gunn GB, Chambers MS, Hanna EY, Sturgis EM, Shete S. Risk factors associated with patient-reported fatigue among long-term oropharyngeal carcinoma survivors. Head Neck 2022; 44:952-963. [PMID: 35084077 PMCID: PMC8981739 DOI: 10.1002/hed.26991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 12/28/2021] [Accepted: 01/14/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The study objective is to identify risk factors associated with fatigue among long-term OPC survivors. METHODS This cross-sectional study included disease-free OPC survivors treated curatively between 2000 and 2013 who were surveyed from September 2015 to July 2016. The outcome variable was patient-reported fatigue. Multivariable logistic regression was used to identify factors associated with moderate to severe fatigue. RESULTS Among 863 OPC survivors, 17.4% reported moderate to severe fatigue. Self-reported thyroid problems (OR: 2.01; p = 0.003), current cigarette smoking at time of survey (OR: 3.85; p = 0.001), late lower cranial neuropathy (OR: 3.44; p = 0.002), and female sex (OR: 1.91; p = 0.010) were concurrent risk factors of reporting moderate to severe fatigue. Ipsilateral intensity-modulated radiotherapy (OR: 0.18; p = 0.014) was associated with lower risk of reporting moderate to severe fatigue. CONCLUSIONS Our study identified thyroid problems, smoking, and late lower cranial neuropathy as associated with moderate to severe fatigue. These findings should be further validated in prospective studies to address fatigue among OPC survivors.
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Affiliation(s)
- Puja Aggarwal
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ryan P Goepfert
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naveen Garg
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Frank E Mott
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gary Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark S Chambers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Erich M Sturgis
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sanjay Shete
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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14
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Mathew A, Tirkey AJ, Li H, Steffen A, Lockwood MB, Patil CL, Doorenbos AZ. Symptom Clusters in Head and Neck Cancer: A Systematic Review and Conceptual Model. Semin Oncol Nurs 2021; 37:151215. [PMID: 34483015 PMCID: PMC8492544 DOI: 10.1016/j.soncn.2021.151215] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The two approaches to symptom-cluster research include grouping symptoms and grouping patients. The objective of this systematic review was to examine the conceptual approaches and methodologies used in symptom-cluster research in patients with head and neck cancer. DATA SOURCES Articles were retrieved from electronic databases (CINAHL, MEDLINE via Ovid, APA PsycINFO, Scopus, Embase, and Cochrane Central Register of Controlled Trials-CENTRAL), five grey literature portals, and Google Scholar. Seventeen studies met the eligibility criteria. Eight studies grouped symptoms to identify symptom clusters, of which two used qualitative methods. The number of symptom clusters ranged from two to five, and the number of symptoms in a cluster ranged from 2 to 11. Nine studies grouped patients based on their experiences with multiple symptoms. Cluster analysis and factor analysis were most commonly used. Despite variable names and composition of symptom clusters, synthesis revealed three prominent symptom clusters: general, head and neck cancer-specific, and gastrointestinal. Being female and quality of life were significantly associated with high symptom group or cluster severity. Biological mechanisms were sparsely examined. CONCLUSION Symptom cluster research in head and neck cancer is emerging. Consensus on nomenclature of a symptom cluster will facilitate deduction of core clinically relevant symptom clusters in head and neck cancer. Further research is required on understanding patients' subjective experiences, identifying predictors and outcomes, and underlying mechanisms for symptom clusters. IMPLICATIONS FOR NURSING PRACTICE Identification of clinically relevant symptom clusters would enable targeted symptom assessment and management strategies, thus improving treatment efficiencies and patient outcomes.
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Affiliation(s)
- Asha Mathew
- College of Nursing, University of Illinois, Chicago; Christian Medical College, Vellore, India.
| | | | - Hongjin Li
- College of Nursing, University of Illinois, Chicago; Christian Medical College, Vellore, India
| | | | | | | | - Ardith Z Doorenbos
- College of Nursing, University of Illinois, Chicago; University of Illinois Cancer Center, Chicago
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15
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Xiao C, Miller AH, Peng G, Levine ME, Conneely KN, Zhao H, Eldridge RC, Wommack EC, Jeon S, Higgins KA, Shin DM, Saba NF, Smith AK, Burtness B, Park HS, Irwin ML, Ferrucci LM, Ulrich B, Qian DC, Beitler JJ, Bruner DW. Association of Epigenetic Age Acceleration With Risk Factors, Survival, and Quality of Life in Patients With Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2021; 111:157-167. [PMID: 33882281 PMCID: PMC8802868 DOI: 10.1016/j.ijrobp.2021.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/29/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE Epigenetic age acceleration (EAA) is robustly linked with mortality and morbidity. This study examined risk factors of EAA and its association with overall survival (OS), progression-free survival (PFS), and quality of life (QOL) in patients with head and neck cancer (HNC) receiving radiation therapy. METHODS AND MATERIALS Patients without distant metastasis were enrolled and followed before and at the end of radiation therapy and at 6 and 12 months after radiation therapy. EAA was calculated with DNAmPhenoAge at all 4 time points. Risk factors included demographic characteristics, lifestyle, clinical characteristics, treatment-related symptoms, and blood biomarkers. Survival data were collected until August 2020, and QOL was measured using Functional Assessment of Cancer Therapy-HNC. RESULTS Increased comorbidity, symptoms unrelated to human papilloma virus, and more severe treatment-related symptoms were associated with higher EAA (P = .03 to P < .001). A nonlinear association (quadratic) between body mass index (BMI) and EAA was observed: decreased BMI (<35 kg/m2; P = .04) and increased BMI (≥35 kg/m2; P = .01) were linked to higher EAA. Increased EAA (per year) was associated with worse OS (hazard ratio [HR], 1.11 [95% confidence interval {CI}, 1.03-1.18; P = .004]; HR, 1.10 [95% CI, 1.01-1.19; P = .02] for EAA at 6 and 12 months after treatment, respectively) and PFS (HR, 1.10 [95% CI, 1.02-1.19; P = .02]; HR, 1.14 [95% CI, 1.06-1.23; P < .001]; and HR, 1.08 [95% CI, 1.02-1.14; P = .01]) for EAA before, immediately after, and 6 months after radiation therapy, respectively) and QOL over time (β = -0.61; P = .001). An average of 3.25 to 3.33 years of age acceleration across time, which was responsible for 33% to 44% higher HRs of OS and PFS, was observed in those who died or developed recurrence compared with those who did not (all P < .001). CONCLUSIONS Compared with demographic and lifestyle factors, clinical characteristics were more likely to contribute to faster biological aging in patients with HNC. Acceleration in epigenetic age resulted in more aggressive adverse events, including OS and PFS. EAA could be considered as a marker for cancer outcomes, and decelerating aging could improve survival and QOL.
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Affiliation(s)
- Canhua Xiao
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
| | | | - Gang Peng
- Yale University School of Medicine, New Haven, Connecticut
| | | | | | - Hongyu Zhao
- Yale University School of Medicine, New Haven, Connecticut
| | - Ronald C Eldridge
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | | | | | | | - Dong M Shin
- Emory University School of Medicine, Atlanta, Georgia
| | - Nabil F Saba
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Henry S Park
- Yale University School of Medicine, New Haven, Connecticut
| | - Melinda L Irwin
- Yale University School of Public Health and Yale Cancer Center, New Haven, Connecticut
| | - Leah M Ferrucci
- Yale University School of Public Health and Yale Cancer Center, New Haven, Connecticut
| | - Bryan Ulrich
- Emory University School of Medicine, Atlanta, Georgia
| | - David C Qian
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Deborah W Bruner
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
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16
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Scheff NN, Saloman JL. Neuroimmunology of cancer and associated symptomology. Immunol Cell Biol 2021; 99:949-961. [PMID: 34355434 DOI: 10.1111/imcb.12496] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 11/27/2022]
Abstract
Evolutionarily the nervous system and immune cells have evolved to communicate with each other to control inflammation and host responses against injury. Recent findings in neuroimmune communication demonstrate that these mechanisms extend to cancer initiation and progression. Lymphoid structures and tumors, which are often associated with inflammatory infiltrate, are highly innervated by multiple nerve types (e.g. sympathetic, parasympathetic, sensory). Recent preclinical and clinical studies demonstrate that targeting the nervous system could be a therapeutic strategy to promote anti-tumor immunity while simultaneously reducing cancer-associated neurological symptoms, such as chronic pain, fatigue, and cognitive impairment. Sympathetic nerve activity is associated with physiological or psychological stress, which can be induced by tumor development and cancer diagnosis. Targeting the stress response through suppression of sympathetic activity or activation of parasympathetic activity has been shown to drive activation of effector T cells and inhibition of myeloid derived suppressor cells within the tumor. Additionally, there is emerging evidence that sensory nerves may regulate tumor growth and metastasis by promoting or inhibiting immunosuppression in a tumor-type specific manner. Since neural effects are often tumor-type specific, further study is required to optimize clinical therapeutic strategies. This review examines the emerging evidence that neuroimmune communication can regulate anti-tumor immunity as well as contribute to development of cancer-related neurological symptoms.
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Affiliation(s)
- Nicole N Scheff
- Biobehavioral Cancer Control Program UPMC Hillman Cancer Center, Center for Neuroscience, and Pittsburgh Center for Pain Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jami L Saloman
- Biobehavioral Cancer Control Program UPMC Hillman Cancer Center, Center for Neuroscience, and Pittsburgh Center for Pain Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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17
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Aggarwal N, Yadav J, Chhakara S, Janjua D, Tripathi T, Chaudhary A, Chhokar A, Thakur K, Singh T, Bharti AC. Phytochemicals as Potential Chemopreventive and Chemotherapeutic Agents for Emerging Human Papillomavirus-Driven Head and Neck Cancer: Current Evidence and Future Prospects. Front Pharmacol 2021; 12:699044. [PMID: 34354591 PMCID: PMC8329252 DOI: 10.3389/fphar.2021.699044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/17/2021] [Indexed: 12/20/2022] Open
Abstract
Head and neck cancer (HNC) usually arises from squamous cells of the upper aerodigestive tract that line the mucosal surface in the head and neck region. In India, HNC is common in males, and it is the sixth most common cancer globally. Conventionally, HNC attributes to the use of alcohol or chewing tobacco. Over the past four decades, portions of human papillomavirus (HPV)-positive HNC are increasing at an alarming rate. Identification based on the etiological factors and molecular signatures demonstrates that these neoplastic lesions belong to a distinct category that differs in pathological characteristics and therapeutic response. Slow development in HNC therapeutics has resulted in a low 5-year survival rate in the last two decades. Interestingly, HPV-positive HNC has shown better outcomes following conservative treatments and immunotherapies. This raises demand to have a pre-therapy assessment of HPV status to decide the treatment strategy. Moreover, there is no HPV-specific treatment for HPV-positive HNC patients. Accumulating evidence suggests that phytochemicals are promising leads against HNC and show potential as adjuvants to chemoradiotherapy in HNC. However, only a few of these phytochemicals target HPV. The aim of the present article was to collate data on various leading phytochemicals that have shown promising results in the prevention and treatment of HNC in general and HPV-driven HNC. The review explores the possibility of using these leads against HPV-positive tumors as some of the signaling pathways are common. The review also addresses various challenges in the field that prevent their use in clinical settings.
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Affiliation(s)
- Nikita Aggarwal
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
| | - Joni Yadav
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
| | - Suhail Chhakara
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
| | - Divya Janjua
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
| | - Tanya Tripathi
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
| | - Apoorva Chaudhary
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
| | - Arun Chhokar
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
| | - Kulbhushan Thakur
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
| | - Tejveer Singh
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
| | - Alok Chandra Bharti
- Molecular Oncology Laboratory, Department of Zoology, Faculty of Science, University of Delhi, Delhi, India
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18
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Xiao C, Beitler JJ, Peng G, Levine ME, Conneely KN, Zhao H, Felger JC, Wommack EC, Chico CE, Jeon S, Higgins KA, Shin DM, Saba NF, Burtness BA, Bruner DW, Miller AH. Epigenetic age acceleration, fatigue, and inflammation in patients undergoing radiation therapy for head and neck cancer: A longitudinal study. Cancer 2021; 127:3361-3371. [PMID: 34027995 DOI: 10.1002/cncr.33641] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/12/2021] [Accepted: 03/22/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The authors measured epigenetic age acceleration (EAA) during and after cancer treatment and its association with inflammation and fatigue, which is a debilitating symptom in patients with cancer. METHODS Patients who had head and neck cancer without distant metastases were assessed before, immediately after, and at 6 months and 12 months postradiotherapy. Blood DNA methylation was assessed using a proprietary bead chip (the Illumina MethylationEPIC BeadChip). EAA was calculated using the Levine epigenetic clock (DNAmPhenoAge), adjusted for chronological age. Fatigue was assessed using the Multidimensional Fatigue Inventory-20. Inflammatory markers were measured using standard techniques. RESULTS Most patients (N = 133) were men, White, had advanced disease, and received concurrent chemoradiation. EAA changes over time were significant, with the largest increase (4.9 years) observed immediately after radiotherapy (P < .001). Increased EAA was associated with elevated fatigue (P = .003) over time, and patients who had severe fatigue experienced 3.1 years higher EAA than those who had low fatigue (P < .001), which was more prominent (5.6 years; P = .018) for patients who had human papillomavirus-unrelated disease at 12 months posttreatment. EAA was also positively associated with inflammatory markers, including C-reactive protein (CRP) and interleukin-6 (IL-6), over time (P < .001), and patients who had high CRP and IL-6 levels exhibited increases of 4.6 and 5.9 years, respectively, in EAA compared with those who had low CRP and IL-6 levels (P < .001). CRP and IL-6 mediated the association between EAA and fatigue (CRP: 95% CI, 0.060-0.279; IL-6: 95% CI, 0.024-0.220). CONCLUSIONS Patients with head and neck cancer experienced increased EAA, especially immediately after treatment completion. EAA was associated with greater fatigue and inflammation, including 1 year after treatment. Inflammation may be a target to reduce the impact of age acceleration on poor functional outcomes.
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Affiliation(s)
- Canhua Xiao
- Emory University School of Nursing, Atlanta, Georgia
| | | | - Gang Peng
- Yale University School of Medicine, New Haven, Connecticut
| | | | | | - Hongyu Zhao
- Yale School of Public Health, New Haven, Connecticut
| | | | | | | | - Sangchoon Jeon
- Yale University School of Nursing, New Haven, Connecticut
| | | | - Dong M Shin
- Emory University School of Medicine, Atlanta, Georgia
| | - Nabil F Saba
- Emory University School of Medicine, Atlanta, Georgia
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Korsten LHA, Jansen F, Lissenberg-Witte BI, Vergeer M, Brakenhoff RH, Leemans CR, Verdonck-de Leeuw IM. The course of health-related quality of life from diagnosis to two years follow-up in patients with oropharyngeal cancer: does HPV status matter? Support Care Cancer 2021; 29:4473-4483. [PMID: 33454834 PMCID: PMC8236449 DOI: 10.1007/s00520-020-05932-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/03/2020] [Indexed: 12/31/2022]
Abstract
Purpose To investigate the course of health-related quality of life (HRQOL) from diagnosis to 2 years follow-up among patients with oropharyngeal cancer (OPSCC), in relation to human papilloma virus (HPV) status. Methods This study included 270 OPSCC patients. Age, sex, tumor sublocation, tumor stage, HPV status, treatment modality, comorbidity, smoking, and alcohol use were retrieved from medical records. HPV status was positive when p16 and HPV DNA tests were both positive. HRQOL was assessed using the EORTC QLQ-C30/QLQ-H&N35 pretreatment and at 6 weeks, 6, 12, 18, and 24 months after treatment. To compare the course of HRQOL between patients with an HPV-positive versus HPV-negative tumor, linear and logistic mixed models were used. Results Patients with an HPV-positive tumor (29%) were more often male, diagnosed with a tumor of the tonsil or base of the tongue, treated with single treatment, had fewer comorbidities, were less often current smokers and had lower alcohol consumption. Adjusted for confounders, the course of global quality of life, physical, role, and social functioning, fatigue, pain, insomnia, and appetite loss was significantly different: patients with an HPV-positive tumor scored better before treatment, worsened during treatment, and recovered better and faster at follow-up, compared to patients with an HPV-negative tumor. The course of emotional functioning and oral pain was also significantly different between the two groups, but with other trajectories. Conclusion The course of HRQOL is different in patients with an HPV-positive tumor versus an HPV-negative tumor, adjusted for sociodemographic, clinical, and lifestyle confounders.
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Affiliation(s)
- Laura H A Korsten
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, MB, Amsterdam, the Netherlands
- Cancer Center Amsterdam (CCA), Amsterdam, Netherlands
| | - Femke Jansen
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, MB, Amsterdam, the Netherlands
- Cancer Center Amsterdam (CCA), Amsterdam, Netherlands
- Amsterdam Public Health research institute, Amsterdam, Netherlands
- Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Birgit I Lissenberg-Witte
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Marije Vergeer
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruud H Brakenhoff
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, MB, Amsterdam, the Netherlands
- Cancer Center Amsterdam (CCA), Amsterdam, Netherlands
| | - C René Leemans
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, MB, Amsterdam, the Netherlands
- Cancer Center Amsterdam (CCA), Amsterdam, Netherlands
| | - Irma M Verdonck-de Leeuw
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, MB, Amsterdam, the Netherlands.
- Cancer Center Amsterdam (CCA), Amsterdam, Netherlands.
- Amsterdam Public Health research institute, Amsterdam, Netherlands.
- Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
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20
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Rogers SN, Semple CJ, Humphris GM, Lowe D, Kanatas A. Using the Patient Concerns Inventory in the identification of fatigue following treatment for head and neck cancer. Int J Oral Maxillofac Surg 2020; 50:865-872. [PMID: 33250271 DOI: 10.1016/j.ijom.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/10/2020] [Accepted: 11/02/2020] [Indexed: 11/27/2022]
Abstract
Fatigue has a profound impact on health-related quality of life (HRQOL). The aim of this study was to describe the clinical characteristics and HRQOL of head and neck cancer patients who raised the issue of fatigue on the Patient Concerns Inventory (PCI) at their review consultation. Eight consultants were randomized to use the PCI as part of a cluster-controlled trial. Patients also completed the University of Washington Quality of Life version 4 (UWQOL), EQ-5D-5L (EuroQol Group), and Distress Thermometer questionnaires. The study included 140 patients who attended clinics at a median of 108 (interquartile range 70-165) days after the end of treatment. The PCI item 'fatigue' was the sixth most commonly selected, by 29% (n=40). Those with advanced tumours were more likely to have selected the item (30/84, 36% vs 10/56, 18%; P=0.02), as were those treated with radiotherapy±chemotherapy (34/87, 39% vs 6/53, 11%; P<0.001). The PCI fatigue group reported significantly worse overall quality of life, social-emotional and physical function composite scores (UWQOL), Distress Thermometer, and EQ-5D-5L. PCI fatigue was common in those with sleeping, nausea, mood, depression, mobility, breathing, and energy level concerns. In conclusion, given the problems associated with fatigue, it is appropriate to screen and seek interventions that might help patients address this.
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Affiliation(s)
- S N Rogers
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK; Liverpool Head and Neck Centre, Liverpool University Hospital Aintree, Liverpool, UK.
| | - C J Semple
- Institute of Nursing and Health Research, Ulster University, Newtownabbey, Co. Antrim, UK; South Eastern Health and Social Care, Upper Newtownards Road, Belfast, UK.
| | - G M Humphris
- School of Medicine, Medical and Biological Sciences, University of St Andrews, St Andrews, UK.
| | - D Lowe
- Astraglobe Ltd, Congleton, Cheshire, UK.
| | - A Kanatas
- Leeds Teaching Hospitals and St James Institute of Oncology, Leeds Dental Institute and Leeds General Infirmary, Leeds, UK.
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21
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Bai J, Bruner DW, Fedirko V, Beitler JJ, Zhou C, Gu J, Zhao H, Lin IH, Chico CE, Higgins KA, Shin DM, Saba NF, Miller AH, Xiao C. Gut Microbiome Associated with the Psychoneurological Symptom Cluster in Patients with Head and Neck Cancers. Cancers (Basel) 2020; 12:cancers12092531. [PMID: 32899975 PMCID: PMC7563252 DOI: 10.3390/cancers12092531] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/24/2020] [Accepted: 09/04/2020] [Indexed: 01/04/2023] Open
Abstract
Cancer patients experience a cluster of co-occurring psychoneurological symptoms (PNS) related to cancer treatments. The gut microbiome may affect severity of the PNS via neural, immune, and endocrine signaling pathways. However, the link between the gut microbiome and PNS has not been well investigated in cancer patients, including those with head and neck cancers (HNCs). This pilot study enrolled 13 patients with HNCs, who reported PNS using the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (CTCAEs). Stool specimens were collected to analyze patients' gut microbiome. All data were collected pre- and post-radiation therapy (RT). Associations between the bacterial abundances and the PNS clusters were analyzed using the linear discriminant analysis effect size; functional pathway analyses of 16S rRNA V3-V4 bacterial communities were conducted using Tax4fun. The high PNS cluster had a greater decrease in microbial evenness than the low PNS cluster from pre- to post-RT. The high and low PNS clusters showed significant differences using weighted UniFrac distance. Those individuals with the high PNS cluster were more likely to have higher abundances in phylum Bacteroidetes, order Bacteroidales, class Bacteroidia, and four genera (Ruminiclostridium9, Tyzzerella, Eubacterium_fissicatena, and DTU089), while the low PNS cluster had higher abundances in family Acidaminococcaceae and three genera (Lactococcus, Phascolarctobacterium, and Desulfovibrio). Both glycan metabolism (Lipopolysaccharide biosynthesis) and vitamin metabolism (folate biosynthesis and lipoic acid metabolism) were significantly different between the high and low PNS clusters pre- and post-RT. Our preliminary data suggest that the diversity and abundance of the gut microbiome play a potential role in developing PNS among cancer patients.
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Affiliation(s)
- Jinbing Bai
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, USA;
- Correspondence: ; Tel.: +1-404-727-2466
| | | | - Veronika Fedirko
- Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA;
| | - Jonathan J. Beitler
- Department of Radiation Oncology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (J.J.B.); (K.A.H.)
| | - Chao Zhou
- Department Biostatistics, Yale School of Public Health, Yale University, New Haven, CT 06520, USA; (C.Z.); (J.G.); (H.Z.)
| | - Jianlei Gu
- Department Biostatistics, Yale School of Public Health, Yale University, New Haven, CT 06520, USA; (C.Z.); (J.G.); (H.Z.)
| | - Hongyu Zhao
- Department Biostatistics, Yale School of Public Health, Yale University, New Haven, CT 06520, USA; (C.Z.); (J.G.); (H.Z.)
| | - I-Hsin Lin
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY 10017, USA;
| | - Cynthia E. Chico
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA; (C.E.C.); (A.H.M.)
| | - Kristin A. Higgins
- Department of Radiation Oncology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (J.J.B.); (K.A.H.)
| | - Dong M. Shin
- Department of Hematology and Medical Oncology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (D.M.S.); (N.F.S.)
| | - Nabil F. Saba
- Department of Hematology and Medical Oncology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (D.M.S.); (N.F.S.)
| | - Andrew H. Miller
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA; (C.E.C.); (A.H.M.)
| | - Canhua Xiao
- School of Nursing, Yale University, New Haven, CT 06477, USA;
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Xiao C, Beitler JJ, Higgins KA, Chico CE, Withycombe JS, Zhu Y, Zhao H, Lin IH, Li F, Jeon S, Irwin M, Bruner DW, Miller AH, Gary R. Pilot study of combined aerobic and resistance exercise on fatigue for patients with head and neck cancer: Inflammatory and epigenetic changes. Brain Behav Immun 2020; 88:184-192. [PMID: 32330594 PMCID: PMC7415514 DOI: 10.1016/j.bbi.2020.04.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 04/17/2020] [Accepted: 04/17/2020] [Indexed: 12/29/2022] Open
Abstract
This pilot study examined whether a combined aerobic resistance exercise program reduced fatigue and the potential inflammatory and epigenetic mechanisms in patients with head and neck cancer (HNC) receiving intensity-modulated radiotherapy. The exercise group (N = 12) received a 3-month supervised aerobic resistance exercise intervention that was initiated before a 6-week radiotherapy regimen; the control group (N = 14) received standard care. Fatigue was measured using Multidimensional Fatigue Inventory-20; physical function measures included a 6-minute walk distance (6MWD), chair stands, bicep curls, and hand grip strength. Inflammatory markers and DNA methylation data were acquired using standardized protocol. Patients were mostly white (93%) and male (81%) with a mean age of 57 years. At the end of the intervention, the exercise group had a marginal decrease in fatigue compared with the control (-5.0 vs. 4.9; P = 0.10). The exercise group had a significantly greater improvement in 6MWD (29.8 vs. -55.5 m; P = 0.04), and a marginally smaller decline in hand grip (-0.3 vs. -5.8 lbs; P = 0.05) at the end of the intervention than the control. No significant difference in inflammatory markers was observed between groups. Lower plasma interleukin (IL) 6, IL1 receptor antagonist, tumor necrosis factor α (TNFα), soluble TNF receptor II and C-reactive protein were significantly associated with increased 6MWD, chair stand, and bicep curl at the end of the intervention (p < 0.05). Among the 1152 differentially methylated sites (DMS) after intervention (p < 0.001), 163 DMS were located in gene promoter regions. Enrichment analysis suggested that the top 10 upstream regulators were associated with tumor (HNF4A, RPP38, HOXA9, SAHM1, CDK7, NDN, RPS15) and inflammation (IRF7, CRKL, ONECUT1). The top 5 diseases or functions annotations of the 62 hypermethylated DMS indicated anti-tumor and anti-inflammatory effects that might be linked to exercise. These findings suggest that exercise may improve physical performance and reduce fatigue, which could be further linked to decreased inflammation, during active radiotherapy for HNC patients. Larger studies are warranted.
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Affiliation(s)
- Canhua Xiao
- School of Nursing, Yale University, 400 West Campus Drive, Orange 06477, United States.
| | - Jonathan J Beitler
- Department of Radiation, School of Medicine, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States
| | - Kristin A Higgins
- Department of Radiation, School of Medicine, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States
| | - Cynthia E Chico
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, 1365-B Clifton Road, Atlanta, GA 30322, United States
| | - Janice S Withycombe
- School of Nursing, Clemson University, 508 Edward's, Clemson, SC 29634, United States
| | - Ying Zhu
- State Key Laboratory of Medical Neurobiology and MOE Frontier Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai 200433, China
| | - Hongyu Zhao
- Department of Epidemiology and Public Health, School of Medicine, Yale University, 300 George Street, New Haven, CT 06510, United States
| | - I-Hsin Lin
- Yale Center for Analytical Sciences, School of Public Health, Yale University, 300 George Street, New Haven, CT 06510, United States
| | - Fangyong Li
- School of Public Health, Yale University, 60 College St, New Haven, CT 06510, United States
| | - Sangchoon Jeon
- School of Nursing, Yale University, 400 West Campus Drive, Orange 06477, United States
| | - Melinda Irwin
- School of Public Health, Yale University, 60 College St, New Haven, CT 06510, United States
| | - Deborah W Bruner
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States
| | - Andrew H Miller
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, 1365-B Clifton Road, Atlanta, GA 30322, United States
| | - Rebecca Gary
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States
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23
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Xiao C, Eldridge RC, Beitler JJ, Higgins KA, Chico CE, Felger JC, Wommack EC, Knobf T, Saba NF, Shin DM, Bruner DW, Miller AH. Association Among Glucocorticoid Receptor Sensitivity, Fatigue, and Inflammation in Patients With Head and Neck Cancer. Psychosom Med 2020; 82:508-516. [PMID: 32515926 PMCID: PMC7905992 DOI: 10.1097/psy.0000000000000816] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Fatigued cancer patients often have high peripheral inflammation; however, the biological mechanisms of this association remain unclear. We examined whether decreased sensitivity of immune cells to the anti-inflammatory effects of glucocorticoids may contribute to inflammation and fatigue in head and neck cancer (HNC) patients during treatment. METHODS HNC patients without distant metastasis and with curative intent (n = 77) were studied 1 week before intensity-modulated radiotherapy (IMRT) and 1 month after IMRT. At each time point, fatigue was measured by the Multidimensional Fatigue Inventory-20 along with plasma inflammation markers and glucocorticoid receptor (GR) sensitivity as determined by in vitro dexamethasone suppression of lipopolysaccharide-induced interleukin 6. Linear regression models were used. RESULTS In contrast to our hypothesis, GR sensitivity increased during treatment; however, increased fatigue was associated with a lesser increase in GR sensitivity from baseline to 1 month after IMRT (unstandardized estimate = 4.07, p = .02). This effect was more prominent in human papillomavirus-unrelated HNCs (unstandardized estimate = 8.22, p = .002). Lower increases in GR sensitivity were also associated with increased inflammation at 1 month after IMRT as represented by C-reactive protein, interleukin 6, and tumor necrosis factor α. Addition of inflammation markers to models of GR sensitivity predicting fatigue indicated that these inflammation markers were stronger predictors of fatigue than GR sensitivity. CONCLUSIONS Lower increases in GR sensitivity during HNC treatment were significantly predictive of increased fatigue and inflammation markers. Inflammation markers in turn predicted fatigue above and beyond levels of GR sensitivity. Our findings indicate that HNC patients with cancer-related fatigue may exhibit a decreased capacity for glucocorticoids to regulate inflammatory processes, as evidenced by a lower increase in GR sensitivity. Larger studies are necessary to verify the findings.
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Affiliation(s)
- Canhua Xiao
- From the School of Nursing (Xiao, Knobf), Yale University, Orange, Connecticut; and School of Nursing (Eldridge, Chico, Bruner), School of Medicine (Beitler, Higgins, Saba, Shin), and Department of Psychiatry and Behavioral Sciences, School of Medicine (Felger, Wommack, Miller), Emory University, Atlanta, Gerogia
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24
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González-Mercado VJ, Pérez-Santiago J, Lyon D, Dilán-Pantojas I, Henderson W, McMillan S, Groer M, Kane B, Marrero S, Pedro E, Saligan LN. The Role of Gut Microbiome Perturbation in Fatigue Induced by Repeated Stress from Chemoradiotherapy: A Proof of Concept Study. Adv Med 2020; 2020:6375876. [PMID: 32090133 PMCID: PMC7029262 DOI: 10.1155/2020/6375876] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/20/2019] [Accepted: 10/10/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES The objectives of this proof of concept study were to (a) examine the temporal changes in fatigue and diversity of the gut microbiome over the course of chemoradiotherapy (CRT) in adults with rectal cancers; (b) investigate whether there are differences in diversity of the gut microbiome between fatigued and nonfatigued participants at the middle and at the end of CRT; and (c) investigate whether there are differences in the relative abundance of fecal microbiota at the phylum and genus levels between fatigued and nonfatigued participants at the middle and at the end of CRT. METHODS Stool samples and symptom ratings were collected prior to the inception of CRT, at the middle (after 12-16 treatments) and at the end (after 24-28 treatments) of the CRT. Descriptive statistics and Mann-Whitney U test were computed for fatigue. Gut microbiome data were analyzed using the QIIME2 software. RESULTS Participants (N = 29) ranged in age from 37 to 80 years. The median fatigue score significantly changed at the end of CRT (median = 23.0) compared with the median score before the initiation of CRT for the total sample (median = 17.0; p ≤ 0.05). At the middle of CRT, the alpha diversity (abundance of Operational Taxonomic Units) was lower for fatigued participants (149.30 ± 53.1) than for nonfatigued participants (189.15 ± 44.18, t(23) = 2.08, p ≤ 0.05). At the middle of CRT, the alpha diversity (abundance of Operational Taxonomic Units) was lower for fatigued participants (149.30 ± 53.1) than for nonfatigued participants (189.15 ± 44.18, Proteobacteria, Firmicutes, and Bacteroidetes were the dominant phyla for fatigued participants, and Escherichia, Bacteroides, Faecalibacterium, and Oscillospira were the most abundant genera for fatigued participants. CONCLUSION CRT-associated perturbation of the gut microbiome composition may contribute to fatigue.
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Affiliation(s)
| | - Josué Pérez-Santiago
- Puerto Rico Omics Center, Comprehensive Cancer Center, University of Puerto Rico, San Juan, PR, USA
| | - Debra Lyon
- College of Nursing, University of Florida, Gainesville, FL, USA
| | - Israel Dilán-Pantojas
- Puerto Rico Omics Center, Comprehensive Cancer Center, University of Puerto Rico, San Juan, PR, USA
| | - Wendy Henderson
- Intramural Program, National Institute of Nursing Research/National Institute of Health, Bethesda, MD, USA
| | - Susan McMillan
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Maureen Groer
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Brad Kane
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Sara Marrero
- College of Arts and Sciences, University of South Florida, Tampa, FL, USA
| | - Elsa Pedro
- School of Pharmacy, Medical Science Campus, University of Puerto Rico, San Juan, PR, USA
| | - Leorey N. Saligan
- Intramural Program, National Institute of Nursing Research/National Institute of Health, Bethesda, MD, USA
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Murphy BA, Wulff-Burchfield E, Ghiam M, Bond SM, Deng J. Chronic Systemic Symptoms in Head and Neck Cancer Patients. J Natl Cancer Inst Monogr 2019; 2019:5551355. [DOI: 10.1093/jncimonographs/lgz004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/22/2019] [Accepted: 04/01/2019] [Indexed: 12/18/2022] Open
Abstract
AbstractThe systemic effects and manifestations of disease and treatment have been of interest for millennium. Until recently, basic and clinical research is just now reaching a watershed. Systemic symptoms usually do not occur in isolation but rather in clusters; however, much of the cutting-edge research pertaining to the etiology, mechanism, manifestations, and moderators of systemic symptoms in humans has been directed at individual symptoms, thus creating silos of knowledge. Breaching these silos and bridging the knowledge from disparate arenas of investigation to build a comprehensive depiction of acute and chronic systemic symptoms has been a challenge. In addition, much of the recent work in systemic symptoms has been conducted in the setting of nonmalignant disease. The degree to which the findings from other chronic disease processes can be translated into the oncologic realm is unknown. This article will explore inflammation as a major contributing factor to systemic symptoms and sickness behavior, discuss the most common manifestations in cancer survivors, and, where available, discuss specific data pertaining to head and neck cancer survivors.
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Affiliation(s)
- Barbara A Murphy
- Department of Medicine and Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Elizabeth Wulff-Burchfield
- Department of Medicine and Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Michael Ghiam
- Vanderbilt University School of Medicine, Nashville, TN
| | - Stewart M Bond
- William F. Connell School of Nursing, Boston College, Boston, MA
| | - Jie Deng
- School of Nursing, University of Pennsylvania, Philadelphia PA
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Wulff-Burchfield E, Dietrich MS, Ridner S, Murphy BA. Late systemic symptoms in head and neck cancer survivors. Support Care Cancer 2019; 27:2893-2902. [PMID: 30554277 PMCID: PMC6597600 DOI: 10.1007/s00520-018-4577-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 11/27/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE Neuroinflammation and central sensitization from cancer and its therapy may result in chronic systemic symptoms (CSS) such as fatigue, sleep disturbance, chronic widespread pain, mood disorders, neuropsychiatric symptoms, and temperature dysregulation. We undertook a cross-sectional study of CSS in head and neck cancer (HNC) survivors to determine their frequency, severity, and impact. METHODS HNC patients without evidence of recurrence who were at least 12 months post-treatment completed a one-time battery of self-report measures including the Vanderbilt Head and Neck Symptom survey plus the General Symptom Subscale, the Body Image Quality of Life Inventory, Neurotoxicity Rating Scale, the Profile of Mood States, and a five-item quality of life measure. RESULTS One hundred five patients completed the surveys. Forty-eight point four percent of patients experienced one or more moderate-to-severe systemic symptom. The frequency of individual symptoms was between 20% and 56% with almost half of patients rating symptoms as moderate-to-severe in intensity. Low and high systemic symptom burden populations were identified. Previously undescribed chronic neuropsychiatric symptoms were also found to be frequent and severe. The vigor score on the POMS was low. Body image was not adversely impacted. At least 40% of HNC survivors have diminished quality of life, and up to 15% have a poor quality of life. CONCLUSIONS CSS are common among HNC survivors and are frequently moderate to severe in intensity. Of note, previously underrecognized neuropsychiatric symptoms were endorsed by a significant cohort of patients warranting further study. Quality of life was diminished in a significant cohort.
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Affiliation(s)
- Elizabeth Wulff-Burchfield
- Department of Medicine, Divisions of Medical Oncology and Palliative Medicine, University of Kansas Medical Center, 2330 Shawnee Mission Pkwy, MS 5003, Westwood, KS, 66205, USA.
| | - Mary S Dietrich
- Center for Quantitative Sciences, Vanderbilt University School of Medicine, 2220 Pierce Ave, 571 Preston Research Building, Nashville, TN, 37232, USA
- School of Nursing, Vanderbilt University Medical Center, 461 21st Ave South, Nashville, TN, 37240, USA
| | - Sheila Ridner
- School of Nursing, Vanderbilt University Medical Center, 461 21st Ave South, Nashville, TN, 37240, USA
| | - Barbara A Murphy
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, 777 Preston Research Building, Nashville, TN, 37232, USA
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Bower JE. The role of neuro-immune interactions in cancer-related fatigue: Biobehavioral risk factors and mechanisms. Cancer 2019; 125:353-364. [PMID: 30602059 DOI: 10.1002/cncr.31790] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 12/12/2022]
Abstract
Fatigue is a common and distressing symptom in both patients with cancer and cancer survivors. There is substantial variation in the severity and persistence of cancer-related fatigue that may be driven by individual differences in host factors, including characteristics that predate the cancer experience as well as responses to cancer and its treatment. This review examines biobehavioral risk factors linked to fatigue and the mechanisms through which they influence fatigue across the cancer continuum, with a focus on neuro-immune processes. Among psychosocial risk factors, childhood adversity is a strong and consistent predictor of cancer-related fatigue; other risk factors include history of depression, catastrophizing, lack of physical activity, and sleep disturbance, with compelling preliminary evidence for loneliness and trait anxiety. Among biologic systems, initial work suggests that alterations in immune, neuroendocrine, and neural processes are associated with fatigue. The identification of key risk factors and underlying mechanisms is critical for the development and deployment of targeted interventions to reduce the burden of fatigue in the growing population of cancer survivors. Given the multidimensional nature of fatigue, interventions that influence multiple systems may be most effective.
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Affiliation(s)
- Julienne E Bower
- Department of Psychology, Department of Psychiatry and Biobehavioral Sciences, Cousins Center for Psychoneuroimmunology, and Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California
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28
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Xu S, Zhang G, Xia C, Tan YH. Associations Between Poor Oral Health and Risk of Squamous Cell Carcinoma of the Head and Neck: A Meta-Analysis of Observational Studies. J Oral Maxillofac Surg 2018; 77:2128-2142. [PMID: 30448433 DOI: 10.1016/j.joms.2018.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/11/2018] [Accepted: 10/13/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE Many epidemiologic studies have reported an association of poor oral health, especially periodontal disease (PD) and tooth loss, with the risk of squamous cell carcinoma of the head and neck (SCCHN). However, these studies have yielded inconsistent results. Therefore, the present study investigated whether poor oral health is an independent predictor of SCCHN through a meta-analysis of observational studies. MATERIALS AND METHODS The PubMed, EMBASE, and Cochrane Library databases were systematically searched for relevant observational studies of the association between oral health and risk of SCCHN conducted up to October 2017. The meta-analysis was conducted using STATA 12.0 (StataCorp, College Station, TX). A fixed- or random-effects model was applied to evaluate pooled risk estimates, and sensitivity and subgroup analyses were performed to identify sources of heterogeneity and pooled estimation. Publication bias was assessed using the Begg test, the Egger test, and funnel plots. RESULTS Twenty-seven relevant observational studies were identified, consisting of 24 case-and-control studies, 2 prospective studies, and 1 cross-sectional study, with 26,750 participants. Notably, oral health correlated meaningfully with SCCHN (odds ratio [OR] = 2.24; 95% confidence interval [CI], 1.77-2.82). In subgroup analyses, participants with PD (OR = 2.52; 95% CI, 1.43-4.44) had a higher risk of developing SCCHN than those with tooth loss (OR = 2.13; 95% CI, 1.63-2.78). The risk estimates exhibited substantial heterogeneity. Evidence of publication bias was limited. CONCLUSIONS The results of this meta-analysis suggest that patients with tooth loss or PD might face a substantial and independent risk of SCCHN, even after adjusting for smoking and alcohol consumption. However, the pooled estimates from observational studies could not establish a causative relation among PD, tooth loss, and SCCHN. Additional investigations of this correlation are warranted.
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Affiliation(s)
- Shuai Xu
- Resident, Department of Stomatology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Gang Zhang
- Associate Professor, Department of Stomatology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Chao Xia
- Resident, Department of Stomatology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Ying-Hui Tan
- Professor, Department of Stomatology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
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Xiao C, Beitler JJ, Higgins KA, Wommack EC, Saba NF, Shin DM, Bruner DW, Miller AH, Cole S. Differential regulation of NF-kB and IRF target genes as they relate to fatigue in patients with head and neck cancer. Brain Behav Immun 2018; 74:291-295. [PMID: 30217537 PMCID: PMC6289813 DOI: 10.1016/j.bbi.2018.09.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/30/2018] [Accepted: 09/10/2018] [Indexed: 01/01/2023] Open
Abstract
Previous studies have linked plasma inflammatory markers to elevated fatigue in patients with head and neck cancer (HNC). To identify the molecular mechanisms underlying this association, we conducted promoter-based bioinformatics analyses to determine the relationship between fatigue and specific gene expression profiles associated with inflammation in human papillomavirus (HPV)-related and -unrelated HNC patients undergoing treatment. Patients with newly diagnosed HNC without distant metastasis were assessed at baseline (pre-radiotherapy) and one-month post-radiotherapy. Fatigue was measured by the Multidimensional Fatigue Inventory. Genome-wide gene expression profiles were collected from peripheral blood mononuclear cells (PBMC). Promoter-based bioinformatics analyses were employed to identify transcription control pathways underlying transcriptomic correlates of fatigue in the sample as a whole and in HPV-related and HPV-unrelated HNC patients separately. In transcriptome profiling analyses of PBMC from 44 patients, TELiS bioinformatics analyses linked fatigue to increased nuclear factor-kappa B (NF-kB) transcriptional activity and decreased interferon regulatory factor family (IRF) transcription factor activity. Patients with HPV-related HNC showed lower levels of fatigue-related gene expression profile compared to HPV-unrelated HNC. Fatigue in HNC patients undergoing treatment is associated with gene expression profiles consistent with the conserved transcriptional response to adversity (CTRA) characterized by increased proinflammatory and decreased anti-antiviral transcriptional activity. Interestingly, this CTRA response was mitigated in patients with HPV-related HNC and may explain the lower level of fatigue they experience relative to HPV-unrelated HNC.
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Affiliation(s)
- Canhua Xiao
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States.
| | - Jonathan J Beitler
- Department of Radiation, School of Medicine, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States
| | - Kristin A Higgins
- Department of Radiation, School of Medicine, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States
| | - Evanthia C Wommack
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, 1365-B Clifton Road, Atlanta, GA 30322, United States
| | - Nabil F Saba
- Department of Hematology and Medical Oncology, School of Medicine, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States
| | - Dong M Shin
- Department of Hematology and Medical Oncology, School of Medicine, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States
| | - Deborah W Bruner
- School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States
| | - Andrew H Miller
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, 1365-B Clifton Road, Atlanta, GA 30322, United States
| | - Steve Cole
- Division of Hematology-Oncology, UCLA AIDS Institute, Molecular Biology Institute, Jonsson Comprehensive Cancer Center, and Norman Cousins Center, UCLA School of Medicine, Los Angeles, CA 90095, United States
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