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Brouwer CG, Hartman YAW, Stelten S, Kenkhuis MF, van Lonkhuijzen LRCW, Kenter GG, Kos M, van de Ven PM, Driel WJV, Winkels RM, Bekkers RLM, Ottevanger PB, Hoedjes M, Buffart LM. Effects of a combined exercise and dietary intervention on clinical outcomes in patients with ovarian cancer: the Physical Activity and Dietary intervention in OVArian cancer (PADOVA) randomized controlled trial. Int J Gynecol Cancer 2024:ijgc-2024-005634. [PMID: 39244208 DOI: 10.1136/ijgc-2024-005634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2024] Open
Abstract
OBJECTIVE Chemotherapy treatment modifications can impact survival in patients with ovarian cancer, particularly when the relative dose intensity falls below 85%. Exercise and dietary interventions may benefit treatment tolerability. This study aimed to explore the effects of a combined exercise and dietary intervention on secondary outcomes of the Physical Activity and Dietary intervention in OVArian cancer (PADOVA) trial, specifically relative dose intensity and progression-free survival. METHODS 81 patients with ovarian cancer were randomized into a combined supervised exercise and dietary intervention during (neo)adjuvant chemotherapy or a usual care control group. Relative dose intensity was calculated as the ratio of delivered dose intensity (dose per actual time) to the standard dose for six chemotherapy cycles. The effect on relative dose intensity was analyzed using logistic regression and Bayesian posterior probability of correctly identifying the best study arm. The effect on progression-free survival was examined using Cox regression. RESULTS The proportion of patients achieving a relative dose intensity ≥85% was 74.4% in the intervention group compared with 61.5% in the control group (OR 2.04, 95% CI 0.75 to 5.84). The Bayesian posterior probability that the intervention group had a higher proportion of patients with a relative dose intensity ≥85% was 88.4%. Intervention effect on progression-free survival was not statistically significant (HR 1.63, 95% CI 0.82 to 3.23). At 18 months, the proportion of patients without disease progression was 73% in the intervention group and 51% in the control group. CONCLUSION The proportions of patients with ovarian cancer with a relative dose intensity ≥85% and an 18-month progression-free survival were numerically higher in the intervention group compared with the control group, but these differences were not statistically significant. The higher proportions and the 88.4% probability that intervention is superior to usual care for clinical outcomes support future studies on exercise and dietary interventions with a focus on clinical outcomes as primary endpoints. TRIAL REGISTRATION NUMBER Registered in the Netherlands Trial Registry (NTR6300).
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Affiliation(s)
- Calvin G Brouwer
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne A W Hartman
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephanie Stelten
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Malou-Floor Kenkhuis
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luc R C W van Lonkhuijzen
- Department of Gynecologic Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Gemma G Kenter
- Department of Gynecologic Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Gynecology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Milan Kos
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Data Science and Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Willemien J van Driel
- Gynecology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Renate M Winkels
- Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
| | - Ruud L M Bekkers
- Department of Gynecology, Catharina Hospital, Eindhoven, The Netherlands
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
- Grow School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Petronella B Ottevanger
- Department of Medical Oncology, Dutch Gynaecological Oncology Group (DGOG), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Meeke Hoedjes
- Department of Medical and Clinical Psychology, CoRPS - Center of Research on Psychological and Somatic disorders, Tilburg University, Tilburg, The Netherlands
| | - Laurien M Buffart
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Asakitogum DA, Nutor JJ, Pozzar R, Hammer M, Miaskowski C. Systematic Review of the Literature on Multiple Co-occurring Symptoms in Patients Receiving Treatment for Gynecologic Cancers. Semin Oncol Nurs 2024; 40:151572. [PMID: 38246840 DOI: 10.1016/j.soncn.2023.151572] [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: 09/09/2023] [Revised: 11/23/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVE Patients with gynecologic cancers experience a very high symptom burden that has a negative impact on their quality of life. This systematic review aims to identify the common co-occurring symptoms, the prevalence of common symptoms, common instruments used to measure symptoms, associated risk factors, and the symptom burden in patients with gynecologic cancers. DATA SOURCES A search of four databases (ie, PubMed, Embase, Web of Science, and CINAHL) was done from January 1, 2012, through September 5, 2022. A qualitative synthesis of the extant literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA 2020). CONCLUSION A total of 118 studies met the prespecified inclusion criteria. Ninety-six symptoms were assessed across these studies. The top six symptoms and their grand mean prevalence rates were lack of energy (64.4%), fatigue (62.1%), abdominal pain (53.3%), depression (52.6%), concentration dysfunction (52.0%), and drowsiness (51.9%). Numerous methodologic challenges were evident across studies. Future research needs to develop a disease-specific symptom assessment measure, evaluate for risk factors associated with a higher symptom burden, and determine the impact of multiple symptoms on patient outcomes. IMPLICATION FOR NURSING PRACTICE The results are relevant for oncology clinicians to assess patients with gynecologic cancers for the presence of common symptoms and risk factors for higher symptom burden in the patients and to offer effective management interventions.
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Affiliation(s)
- David Ayangba Asakitogum
- Doctoral student, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, CA.
| | - Jerry John Nutor
- Assistant Professor, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, CA
| | - Rachel Pozzar
- Nurse Scientist and Instructor, Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA
| | - Marilyn Hammer
- Nurse Scientist and Instructor, Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA; Director, Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA
| | - Christine Miaskowski
- Professor, Departments of Physiological Nursing and Anesthesia, School of Nursing and Medicine, University of California, San Francisco, CA
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Snijders RAH, Brom L, Theunissen M, van den Beuken-van Everdingen MHJ. Update on Prevalence of Pain in Patients with Cancer 2022: A Systematic Literature Review and Meta-Analysis. Cancers (Basel) 2023; 15:591. [PMID: 36765547 PMCID: PMC9913127 DOI: 10.3390/cancers15030591] [Citation(s) in RCA: 74] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
Experiencing pain and insufficient relief can be devastating and negatively affect a patient's quality of life. Developments in oncology such as new treatments and adjusted pain management guidelines may have influenced the prevalence of cancer pain and severity in patients. This review aims to provide an overview of the prevalence and severity of pain in cancer patients in the 2014-2021 literature period. A systematic literature search was performed using the databases PubMed, Embase, CINAHL, and Cochrane. Titles and abstracts were screened, and full texts were evaluated and assessed on methodological quality. A meta-analysis was performed on the pooled prevalence and severity rates. A meta-regression analysis was used to explore differences between treatment groups. We identified 10,637 studies, of which 444 studies were included. The overall prevalence of pain was 44.5%. Moderate to severe pain was experienced by 30.6% of the patients, a lower proportion compared to previous research. Pain experienced by cancer survivors was significantly lower compared to most treatment groups. Our results imply that both the prevalence of pain and pain severity declined in the past decade. Increased attention to the assessment and management of pain might have fostered the decline in the prevalence and severity of pain.
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Affiliation(s)
- Rolf A. H. Snijders
- Netherlands Comprehensive Cancer Organisation (IKNL), Department of Research & Development, 3511 DT Utrecht, The Netherlands
- Netherlands Association for Palliative Care (PZNL), 3511 DT Utrecht, The Netherlands
| | - Linda Brom
- Netherlands Comprehensive Cancer Organisation (IKNL), Department of Research & Development, 3511 DT Utrecht, The Netherlands
- Netherlands Association for Palliative Care (PZNL), 3511 DT Utrecht, The Netherlands
| | - Maurice Theunissen
- Centre of Expertise for Palliative Care, Maastricht University Medical Centre+ (MUMC+), 6229 HX Maastricht, The Netherlands
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Centre+ (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Marieke H. J. van den Beuken-van Everdingen
- Centre of Expertise for Palliative Care, Maastricht University Medical Centre+ (MUMC+), 6229 HX Maastricht, The Netherlands
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Centre+ (MUMC+), 6229 HX Maastricht, The Netherlands
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Suskin JA, Paul S, Stuckey AR, Conley YP, Hammer MJ, Miaskowski C, Dunn LB. Anxiety trajectories: An observational study of women undergoing chemotherapy for breast or gynecological cancer. Eur J Oncol Nurs 2022; 61:102227. [DOI: 10.1016/j.ejon.2022.102227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/09/2022] [Indexed: 11/17/2022]
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Haryani, Hsu YY, Wang ST. Symptom clusters change over time among patients with gynecological cancer receiving chemotherapy. Eur J Oncol Nurs 2022; 60:102193. [PMID: 36030751 DOI: 10.1016/j.ejon.2022.102193] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 08/04/2022] [Accepted: 08/10/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE This study aimed to explore symptom clusters at different time points among patients with gynecological cancer undergoing chemotherapy. METHODS A longitudinal design was used to explore the patterns of symptom clusters four times: during prechemotherapy (T0), first (T1), second (T2), and third (T3) cycles of chemotherapy. The Memorial Symptom Assessment Scale was used to assess the dimension of symptoms. The study was conducted in Indonesia. Exploratory factor analysis was used to analyze the structures of symptom clusters across time. RESULTS A total of 120 subjects provided baseline data, and 82 were retained at T3. Before chemotherapy, the most prevalent symptoms were pain and difficulty in sleeping. However, after starting chemotherapy, the patients suffered from chemotherapy-related side effects, including nausea, change in taste, lack of appetite, hair loss, fatigue, and feeling of "I don't look like myself." Six symptom clusters were identified in patients with gynecological cancer across four time points during chemotherapy: pain-related, nutritional, emotional, hormonal-related, fatigue-related, and body-image symptom clusters. Nutrition and emotion symptom clusters occurred consistently from T0 to T3, fatigue-related clusters appeared after chemotherapy at T1 and T2, and body-image symptom clusters emerged at late T2 and T3. CONCLUSION The structures of symptom clusters in this study were dynamic and various. The nutrition and emotional-related symptoms constituted a cluster during chemotherapy. Oncology nurses should provide physical and psychosocial interventions to relieve these symptoms in patients with gynecological cancer undergoing chemotherapy.
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Affiliation(s)
- Haryani
- Department of Medical Surgical Nursing, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Indonesia
| | - Yu-Yun Hsu
- Department of Nursing, College of Medicine, National Cheng Kung University, Taiwan.
| | - Shan-Tair Wang
- Professor & Deputy Superintendent Ditmanson Medical Foundation, Chiayi Christian Hospital
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Wu HJ, Chuang CM, Chien CH, Wang TJ, Liang SY. Changes in Depression and Sleep Quality and Associated Factors in Women Receiving Chemotherapy for Ovarian Cancer: An Observational Study. Cancer Nurs 2022; 45:271-279. [PMID: 34310385 DOI: 10.1097/ncc.0000000000000986] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although women with ovarian cancer experience depression and poor sleep quality, little is known about how various factors, particularly self-efficacy, might be associated with these conditions. OBJECTIVES The aim of this study was to examine the prevalence of and changes in depression and sleep quality and the factors associated with these conditions in a cohort of women with ovarian cancer before, during, and after chemotherapy. METHODS A prospective repeated-measures design was adopted in this study. Participants were women with ovarian cancer who were expected to receive 4 to 6 cycles of chemotherapy and were recruited at a medical center in Taiwan. The participants were asked to complete a questionnaire that included the Symptom Distress Scale, Center for Epidemiologic Studies Depression Scale, General Self-efficacy Scale, and Pittsburgh Sleep Quality Index. The data were collected before, during, and after the course of chemotherapy. RESULTS Overall, 24.6% to 36.9% of women were at risk for depression; 75.4% to 80.0% of women had poor sleep quality. There were no significant changes in depressive symptoms and sleep quality throughout the course of chemotherapy. More severe depressive symptoms were associated with higher levels of symptom distress and lower self-efficacy. Poorer sleep quality was associated with higher levels of symptom distress. CONCLUSIONS Among participants, more depressive symptoms and poorer sleep quality were associated with higher levels of symptom distress or lower self-efficacy. IMPLICATIONS FOR PRACTICE Healthcare providers should continuously assess depression and sleep quality in women with ovarian cancer. These symptoms may be improved by strengthening self-efficacy and relieving symptom distress.
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Affiliation(s)
- Hui-Ju Wu
- Author Affiliations: Department of Obstetrics and Gynecology, Taipei Veterans General Hospital (Ms Wu and Dr Chuang); Faculty of Medicine, School of Medicine, National Yang-Ming University (Dr Chuang); and College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan (Ms Wu, Dr Chuang, Dr Chien, Dr Wang, and Dr Liang)
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Abstract
BACKGROUND Multiple symptoms occur in children receiving cancer therapy. Decreased steps per day may be associated with burdensome symptoms. OBJECTIVE To evaluate associations between self-reported symptoms (pain interference, anxiety, depressive symptoms, psychological stress, and fatigue) and function (physical function-mobility and physical activity) and cumulative symptom count with steps per day. METHODS Five sites enrolled English-speaking children, 8 to 17 years, receiving treatment for a first cancer diagnosis. Patient-reported outcome (PRO) surveys were administered before (T1) and after (T2) a course of chemotherapy. Garmin VivoFit 3 (Garmin International, Olathe, KS) accelerometers were worn 7 days prior to each data point. Univariate changes in scores over time were evaluated with dependent-sample t tests. Pearson correlations examined associations between PRO domains and step count. Multivariable mixed-effect models examined associations between steps and PROs. RESULTS Participants' (n = 65) steps per day decreased during treatment (4099 [T1] and 3135 [T2]; P < .01), with larger reductions observed during hospitalization and in younger children compared with adolescents. Steps significantly correlated with PROMIS (Patient-Reported Outcome Measurement Information System) Pediatric physical activity and physical function-mobility. Decreased steps per day were associated with increased fatigue and cumulative symptom count. CONCLUSIONS In children and adolescents with cancer, steps per day can serve as an indicator of fatigue, cumulative symptom count, physical activity, and physical functioning-mobility. IMPLICATIONS FOR PRACTICE Child self-reports of physical activity and physical function are valid during cancer therapy and should be captured. In the absence of self-report, decreasing step count may prompt additional assessments related to fatigue or cumulative symptom count and trigger early interventions to support physical activity and physical function-mobility.
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Christiansen MG, Pappot H, Pedersen C, Jarden M, Mirza MR, Piil K. Patient perspectives and experiences of the rapid implementation of digital consultations during COVID-19 - a qualitative study among women with gynecological cancer. Support Care Cancer 2021; 30:2545-2554. [PMID: 34796401 PMCID: PMC8601371 DOI: 10.1007/s00520-021-06651-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/24/2021] [Indexed: 11/25/2022]
Abstract
Purpose Due to the first COVID-19 outbreak and subsequent restrictions, standard practice for gynecological cancer quickly evolved to include additional digital consultations. Women with gynecological cancer have a high need for information and experience a high symptom burden. We aimed to explore the experiences and perspectives of the rapid implementation of digital consultations during COVID-19. Methods We conducted individual telephone interviews with patients with gynecological cancer 1–4 days after a telephone or video consultation during the COVID-19 outbreak in April and May 2020. We applied Braun and Clarke’s thematic analysis to analyze the qualitative data. Results Thirty-two patients with ovarian (50%), cervical (35%), vulvar (12%), and vaginal cancer (3%) participated in the study. The patients experienced that, combined, cancer and COVID-19 restrictions made their situation twice as challenging. In general, the patients valued face-to-face consultations, recommending that they were ideal for the initial appointment to build trust. Overall, there was a willingness to participate in digital consultations because of the restrictions, but the results also showed varying degrees of openness and that individual solutions were favored. Conclusion The findings of this study show that digital consultations were an accepted alternative during COVID-19. Even though this temporary solution was deemed to be beneficial for practical reasons, patients also experienced digital consultations to be impersonal. A key message is that face–to–face encounters create the foundation to establish a trusting relationship from where a valuable dialogue arises. Digital consultations should therefore be implemented with caution since no one-size-fits-all model is recommended. Among patients with gynecological cancer, however, digital technologies represent a promising and flexible method depending on the purpose of consultations, patient preferences, and needs.
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Affiliation(s)
| | - Helle Pappot
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Pedersen
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mary Jarden
- Department of Haematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mansoor Raza Mirza
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karin Piil
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Public Health, Faculty of Health, University of Aarhus, Aarhus, Denmark
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Zhao H, Yu H, Zheng J, Ning N, Tang F, Yang Y, Wang Y. Lowly-expressed lncRNA GAS5 facilitates progression of ovarian cancer through targeting miR-196-5p and thereby regulating HOXA5. Gynecol Oncol 2018; 151:345-355. [PMID: 30201235 DOI: 10.1016/j.ygyno.2018.08.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE This investigation was aimed at extrapolating whether and how lncRNA GAS5, miR-196a-5p and HOXA5 altered progression of ovarian cancer (OA). METHOD Totally 195 pairs of OA tissues and adjacent normal tissues were collected. Also si-GAS5, pcDNA-GAS5, miR-196a-5p mimic, miR-196a-5p inhibitor and negative control (NC) were, respectively, transfected into OA cells. Besides, dual-luciferase reporter gene assay was performed to validate the targeted relationships between GAS5 and miR-196a-5p, as well as between miR-196a-5p and HOXA5. The impacts of GAS5, miR-196a-5p and HOXA5 on viability, proliferation and apoptosis of OA cells were appraised via conduction of colony formation assay, MTT assay and flow cytometry assay. RESULT Lower GAS5 expression and higher miR-196a-5p expression were associated with larger tumor size (≥5 cm) and more advanced FIGO stage (III-IV) of OA patients (P < 0.05). Transfection of si-GAS5, miR-196a-5p mimic or si-HOXA5 conferred OA cells with stronger viability, faster proliferation and smaller percentage of apoptosis (P < 0.05). After injecting mice models with si-GAS5, miR-196a-5p mimic or si-HOXA5, a larger tumor size was also observed within the rats (P < 0.05). GAS5 was indicated to directly target miR-196a-5p and modify its expression, and the targeted relationship also seemed to exist between miR-196a-5p and HOXA5 (P < 0.05). The HOXA5 was found to reverse the effects imposed by miR-196a-5p on viability, proliferation and apoptosis of OA cells (P < 0.05). CONCLUSION LncRNA GAS5 depressed OA development by targeting miR-196a-5p and thereby down-regulating HOXA5 expression, providing substance for developing lncRNA-based strategies to treat OA.
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Affiliation(s)
- Hongmin Zhao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin City, Heilongjiang Province 150001, China
| | - Hongli Yu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin City, Heilongjiang Province 150001, China
| | - Jianhua Zheng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin City, Heilongjiang Province 150001, China
| | - Ning Ning
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin City, Heilongjiang Province 150001, China
| | - Fanglan Tang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin City, Heilongjiang Province 150001, China
| | - Yang Yang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin City, Heilongjiang Province 150001, China
| | - Yan Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin City, Heilongjiang Province 150001, China.
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