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Sah D, Shoffel-Havakuk H, Tsur N, Uhelski ML, Gottumukkala V, Cata JP. Opioids and Cancer: Current Understanding and Clinical Considerations. Curr Oncol 2024; 31:3086-3098. [PMID: 38920719 DOI: 10.3390/curroncol31060235] [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: 05/03/2024] [Revised: 05/23/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024] Open
Abstract
Pain is one of the most common symptoms in patients with cancer. Pain not only negatively affects the quality of life of patients with cancer, but it has also been associated with reduced survival. Pain management is therefore a critical component of cancer care. Prescription opioids remain the first-line approach for the management of moderate-to-severe pain associated with cancer. However, there has been increasing interest in understanding whether these analgesics could impact cancer progression. Furthermore, epidemiological data link a possible association between prescription opioid usage and cancer development. Until more robust evidence is available, patients with cancer with moderate-to-severe pain may receive opioids to decrease suffering. However, future studies should be conducted to evaluate the role of opioids and opioid receptors in specific cancers.
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Affiliation(s)
- Dhananjay Sah
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Anesthesiology and Surgical Oncology Research Group (ASORG), Houston, TX 77030, USA
| | - Hagit Shoffel-Havakuk
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petach Tiqva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Nir Tsur
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petach Tiqva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Megan L Uhelski
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Anesthesiology and Surgical Oncology Research Group (ASORG), Houston, TX 77030, USA
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Zhuang X, Li M, Xu D, Lin S, Yang Z, Xu T, Yin J. Comprehensive analysis of pain genes in prognosis of kidney renal clear cell carcinoma and tumor immunotherapy: A comprehensive bioinformatic study. Health Sci Rep 2024; 7:e1884. [PMID: 38352696 PMCID: PMC10862147 DOI: 10.1002/hsr2.1884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 12/09/2023] [Accepted: 01/23/2024] [Indexed: 02/16/2024] Open
Abstract
Background The effect of pain genes (NAV1, EHMT2, SP1, SLC6A4, COMT, OPRM1, OPRD1, CYP2D6, and CYP3A4) have not been reported previously in kidney renal clear cell carcinoma (KIRC) patients and thus we made a comprehensive analysis of pain genes in the prognosis of KIRC and tumor immunotherapy. Methods In this study, TCGA, Kaplan-Meier plotter, Metascape, STRING, Human Protein Atlas, Single Cell Expression Atlas database, LinkedOmics, cBioPortal, MethSurv, CancerSEA, COSMIC database and R package (ggplot2, version 3.3.3) were used for comprehensive analysis of pain genes in KIRC. Pearson and Spearman correlation coefficients were for co-expression analysis. Immunotherapy and TISIDB database were used for tumor Immunotherapy. Results Representative pain genes (SP1, SLC6A4, COMT, OPRD1, CYP2D6, and CYP3A4) were statistically significant (p < 0.0001) in the prognosis of KIRC. Immunotherapy (anti-PD-1 therapy, anti-PD-L1 therapy, and anti-CTLA4 therapy) and immunomodulator (immunoinhibitor, immunostimulator, and MHC molecule) in KIRC were significant associated with pain genes (SP1, SLC6A4, COMT, OPRD1, CYP2D6, and CYP3A4), which were the important addition to clinical decision making for patients. Conclusions Our study uncovered a mechanism for the effect of pain genes on KIRC outcome via the modulation of associated co-expression gene networks, gene variation, and tumor Immunotherapy.
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Affiliation(s)
- Xiao‐Yu Zhuang
- Department of AnesthesiologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Ming Li
- Department of UrologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Da‐Ming Xu
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for CancerSun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- Department of UrologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
| | - Shu‐Bin Lin
- Department of UrologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Zheng‐Liang Yang
- Department of UrologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Teng‐Yu Xu
- Department of UrologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Jun Yin
- Department of Clinical Laboratory MedicineSecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
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Chen SY, Lin TA, Sun CK, Chang R. Is there really no association between postoperative opioid use and long-term surgical outcomes in patients diagnosed with liver cancer? Pain 2023; 164:2622. [PMID: 37831938 DOI: 10.1097/j.pain.0000000000003047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Affiliation(s)
- Ssu-Yu Chen
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Ting-An Lin
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Cheuk-Kwan Sun
- Division of Medical Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Renin Chang
- Department of Emergency Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
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Tarazi D, Maynes JT. Impact of Opioids on Cellular Metabolism: Implications for Metabolic Pathways Involved in Cancer. Pharmaceutics 2023; 15:2225. [PMID: 37765194 PMCID: PMC10534826 DOI: 10.3390/pharmaceutics15092225] [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: 08/01/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Opioid utilization for pain management is prevalent among cancer patients. There is significant evidence describing the many effects of opioids on cancer development. Despite the pivotal role of metabolic reprogramming in facilitating cancer growth and metastasis, the specific impact of opioids on crucial oncogenic metabolic pathways remains inadequately investigated. This review provides an understanding of the current research on opioid-mediated changes to cellular metabolic pathways crucial for oncogenesis, including glycolysis, the tricarboxylic acid cycle, glutaminolysis, and oxidative phosphorylation (OXPHOS). The existing literature suggests that opioids affect energy production pathways via increasing intracellular glucose levels, increasing the production of lactic acid, and reducing ATP levels through impediment of OXPHOS. Opioids modulate pathways involved in redox balance which may allow cancer cells to overcome ROS-mediated apoptotic signaling. The majority of studies have been conducted in healthy tissue with a predominant focus on neuronal cells. To comprehensively understand the impact of opioids on metabolic pathways critical to cancer progression, research must extend beyond healthy tissue and encompass patient-derived cancer tissue, allowing for a better understanding in the context of the metabolic reprogramming already undergone by cancer cells. The current literature is limited by a lack of direct experimentation exploring opioid-induced changes to cancer metabolism as they relate to tumor growth and patient outcome.
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Affiliation(s)
- Doorsa Tarazi
- Department of Biochemistry, University of Toronto, Toronto, ON M5G 1A8, Canada;
- Program in Molecular Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Jason T. Maynes
- Department of Biochemistry, University of Toronto, Toronto, ON M5G 1A8, Canada;
- Program in Molecular Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON M5G 1E2, Canada
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Yun HD, Goel Y, Gupta K. Crosstalk of Mast Cells and Natural Killer Cells with Neurons in Chemotherapy-Induced Peripheral Neuropathy. Int J Mol Sci 2023; 24:12543. [PMID: 37628724 PMCID: PMC10454469 DOI: 10.3390/ijms241612543] [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: 07/11/2023] [Revised: 08/04/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Chemotherapy-induced peripheral neuropathy (CIPN) is a major comorbidity of cancer. Multiple clinical interventions have been studied to effectively treat CIPN, but the results have been disappointing, with no or little efficacy. Hence, understanding the pathophysiology of CIPN is critical to improving the quality of life and clinical outcomes of cancer patients. Although various mechanisms of CIPN have been described in neuropathic anti-cancer agents, the neuroinflammatory process involving cytotoxic/proinflammatory immune cells remains underexamined. While mast cells (MCs) and natural killer (NK) cells are the key innate immune compartments implicated in the pathogenesis of peripheral neuropathy, their role in CIPN has remained under-appreciated. Moreover, the biology of proinflammatory cytokines associated with MCs and NK cells in CIPN is particularly under-evaluated. In this review, we will focus on the interactions between MCs, NK cells, and neuronal structure and their communications via proinflammatory cytokines, including TNFα, IL-1β, and IL-6, in peripheral neuropathy in association with tumor immunology. This review will help lay the foundation to investigate MCs, NK cells, and cytokines to advance future therapeutic strategies for CIPN.
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Affiliation(s)
- Hyun Don Yun
- Hematology, Oncology, Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA
- Division of Hematology, Oncology, Department of Medicine, School of Medicine, University of California, Irvine, CA 92617, USA; (Y.G.); (K.G.)
| | - Yugal Goel
- Division of Hematology, Oncology, Department of Medicine, School of Medicine, University of California, Irvine, CA 92617, USA; (Y.G.); (K.G.)
| | - Kalpna Gupta
- Division of Hematology, Oncology, Department of Medicine, School of Medicine, University of California, Irvine, CA 92617, USA; (Y.G.); (K.G.)
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Bradley A, Boland JW. Effects of Opioids on Immune and Endocrine Function in Patients with Cancer Pain. Curr Treat Options Oncol 2023; 24:867-879. [PMID: 37145383 PMCID: PMC10271882 DOI: 10.1007/s11864-023-01091-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/06/2023]
Abstract
OPINION STATEMENT Opioids are an important treatment in managing cancer pain. Uncontrolled pain can be detrimental to function and quality of life. Common adverse effects of opioids such as sedation, constipation and nausea are well recognised, but opioid effects on the endocrine and immune systems are less apparent. The evidence for the immunomodulatory effects of opioids suggest that some opioids might be immunosuppressive and that their use might be associated with reduced survival and increased rates of infection in patients with cancer. However, the quality of this evidence is limited. Opioid-induced endocrinopathies, in particular opioid-induced hypogonadism, may also impact cancer survival and impair quality of life. But again, evidence in patients with cancer is limited, especially with regard to their management. There are some data that different opioids influence immune and endocrine function with varying outcomes. For example, some opioids, such as tramadol and buprenorphine, demonstrate immune-sparing qualities when compared to others. However, most of this data is preclinical and without adequate clinical correlation; thus, no opioid can currently be recommended over another in this context. Higher opioid doses might have more effect on immune and endocrine function. Ultimately, it is prudent to use the lowest effective dose to control the cancer pain. Clinical presentations of opioid-induced endocrinopathies should be considered in patients with cancer and assessed for, particularly in long-term opioid users. Hormone replacement therapies may be considered where appropriate with support from endocrinology specialists.
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Affiliation(s)
- Anna Bradley
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, HU6 7RX, UK.
- Hull York Medical School, University of York, York, YO10 5DD, UK.
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Thomas TE, Bowers K, Gomez D, Morgan O, Borowsky PA, Dutta R, Abu Y, Roy S, Rojas KE. The association between perioperative opioids and breast cancer recurrence: a narrative review of the literature. TRANSLATIONAL BREAST CANCER RESEARCH : A JOURNAL FOCUSING ON TRANSLATIONAL RESEARCH IN BREAST CANCER 2023; 4:12. [PMID: 38751469 PMCID: PMC11093068 DOI: 10.21037/tbcr-23-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/23/2023] [Indexed: 05/18/2024]
Abstract
Background and Objective Opioid use disorder is an evolving crisis, and 17.2% of postsurgical patients continue to fill an opioid prescription one year after surgery. Preclinical studies suggest perioperative opioid use, defined here as opioids used in the setting of operative pain, may be linked to inferior oncologic outcomes. If this were true, opioid minimization strategies for surgical patients may reduce opioid-related deaths in more than one way. This review aims to describe the association between perioperative opioid use and breast cancer recurrence. Methods On November 1, 2021, we searched the Ovid and EMBASE databases for the terms "breast neoplasm", "opioid analgesics", "neoplasm recurrence", and "neoplasm metastasis". Of the 350 articles retrieved, 11 met our inclusion criteria. The review was undertaken using the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) checklist for quality. Key Content and Findings Clinical studies report no clear association between perioperative opioid use and local or distant breast cancer recurrence. Mixed results were found when assessing perioperative opioid use and overall survival. Multiple studies paradoxically found opioid use to be associated with lower recurrence rates, despite higher mortality rates. Most studies showed no difference in recurrence or survival in breast cancer surgery patients who did or did not receive opioid-containing analgesia, although most findings were limited by study design and low event rates in patients with breast cancer. Conclusions The lack of a clear connection between perioperative opioid use and breast cancer recurrence contradicts some preclinical data, which describes mechanisms through which opioids upregulate tumor proliferation which might worsen oncologic outcomes. Existing clinical literature is limited to mostly retrospective studies in patients with predominantly early-stage breast cancers, with low event rates. Given the worsening opioid epidemic and preclinical study findings, opioid minimization strategies should still be explored. Future work should be prospective and examine cancer recurrence in high-risk patients with more advanced tumor pathologies.
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Affiliation(s)
- Tanya E. Thomas
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Kara Bowers
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Daniel Gomez
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Orly Morgan
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | - Rajib Dutta
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Yaa Abu
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sabita Roy
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kristin E. Rojas
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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MOHANTI BIDHUKALYAN. Opioid: Plenitude versus pittance. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 35:303-307. [PMID: 37167507 DOI: 10.25259/nmji_539_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The opioid crisis in the USA and in other developed countries can potentially affect low- and middle-income countries (LMICs). The licit medical use of opioids has two sides. The USA and high-income countries maintain abundant supply for medical prescription. Between 1990 and 2010, the use of opioids for cancer pain relief was overtaken by a dramatic rise in the opioid prescriptions for non-cancer acute or chronic pain. The surge led to the opioid epidemic, recognized as social catastrophe in the USA, Canada and in some countries in Europe. From 2016, the medical community, health policy regulators and law-makers have taken actions to tackle this opioid crisis. On the other side, formulary deficiency and low opioid availability exists for three-fourths of the global population living in LMICs. Physicians and nurses in Asia and Africa engaged in cancer pain relief and palliative care face a constant paucity of opioids. Millions of patients in LMICs, suffering from life-modifying cancer pain, do not have access to morphine and other essential opioids, due to restrictive opioid policies. Attention will be needed to improve opioid availability in large parts of the world, even though the opioid crisis has led to control the licit medical use in the USA.
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Vijayakumar J, Haddad T, Gupta K, Sauers J, Yee D. An open label phase II study of safety and clinical activity of naltrexone for treatment of hormone refractory metastatic breast cancer. Invest New Drugs 2023; 41:70-75. [PMID: 36441436 PMCID: PMC10030534 DOI: 10.1007/s10637-022-01317-4] [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: 02/23/2022] [Accepted: 11/02/2022] [Indexed: 11/30/2022]
Abstract
The opioid receptor (OR) antagonist naltrexone inhibits estrogen receptor-α (ER) function in model systems. The goal of this study was to determine the clinical activity of naltrexone in patients with ER-positive metastatic breast cancer. Patients with hormone receptor positive metastatic breast cancer were enrolled on a phase II study of naltrexone. An escalating dose scheme was used to reach the planned dose of 50 mg daily. The primary objective of the study was to evaluate response to therapy as measured by stabilization or reduction of the tumor Maximum Standardized Uptake Value (SUVmax) at 4 weeks by PET-CT scan. The secondary objectives included safety assessment and tumor SUVmax at 8 weeks. Out of 13 patients we enrolled, 8 patients had serial PET-CT scans that were evaluable for response. Of these 8 patients, 5 had stable or decreased SUVmax values at 4 weeks and 3 had clinical or imaging progression. Median time to progression was short at 7 weeks. Naltrexone was well tolerated. There were no discontinuations due to toxicity and no grade 3 or 4 toxicities were noted. Naltrexone showed modest activity in this short study suggesting the contribution of opioid receptors in ER-positive breast cancer. Our data do not support further development of naltrexone in hormone refractory breast cancer. It is possible that more potent peripherally acting OR antagonists may have a greater effect. (ClinicalTrials.gov Identifier: NCT00379197 September 21, 2006).
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Affiliation(s)
- Jayanthi Vijayakumar
- Division of Hematology Oncology and Transplantation Department of Medicine, University of Minnesota, MN, Minneapolis, USA
| | | | - Kalpna Gupta
- Division of Hematology Oncology and Transplantation Department of Medicine, University of Minnesota, MN, Minneapolis, USA
- Division of Hematology/Oncology, Department of Medicine, University of California, CA, Irvine, USA
| | - Janet Sauers
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - Douglas Yee
- Division of Hematology Oncology and Transplantation Department of Medicine, University of Minnesota, MN, Minneapolis, USA.
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA.
- , 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
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Illias AM, Yu KJ, Wu SC, Cata JP, Tsai YF, Hung KC. Association of regional anesthesia with oncological outcomes in patients receiving surgery for bladder cancer: A meta-analysis of observational studies. Front Oncol 2023; 13:1097637. [PMID: 36910609 PMCID: PMC9992181 DOI: 10.3389/fonc.2023.1097637] [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: 11/14/2022] [Accepted: 02/09/2023] [Indexed: 02/25/2023] Open
Abstract
Background This meta-analysis was conducted to compare cancer recurrence and survival rates in patients with bladder cancer receiving surgery under general anesthesia alone (i.e., GA group) or regional anesthesia (RA) with or without GA (i.e., RA ± GA group). Methods Literature search on Cochrane library, EMBASE, Google scholar, and Medline databases was performed to identify all relevant studies from inception to April 30, 2022. The primary outcome was cancer recurrence rate, while the secondary outcomes included overall survival rate and cancer-specific survival rate. Subgroup analyses were performed based on study design [(Propensity-score matching (PSM) vs. no-PSM)] and type of surgery [transurethral resection of bladder tumor (TURBT) vs. radical cystectomy]. Results Ten retrospective studies with a total of 13,218 patients (RA ± GA group n=4,884, GA group n=8,334) were included. There was no difference between RA ± GA group and GA group in age, the proportion of males, severe comorbidities, the proportion of patients receiving chemotherapy, and the pathological findings (all p >0.05). Patients in the RA ± GA group had significantly lower rate of bladder cancer recurrence [odds ratio (OR): 0.74, 95%CI: 0.61 to 0.9, p=0.003, I2 = 24%, six studies] compared to those in the GA group. Subgroup analyses based on study design revealed a consistent finding, while the beneficial effect of RA ± GA on reducing cancer recurrence was only significant in patients receiving TURBT (p=0.02), but not in those undergoing radical cystectomy (p=0.16). There were no significant differences in overall survival rate and cancer-specific survival rate between RA ± GA and GA groups. Conclusions For patients receiving surgery for bladder cancer, the application of regional anesthesia with or without general anesthesia is associated with significant decrease in cancer recurrence, especially in patients undergoing TURBT for non-muscle invasive bladder cancer. Because of the limited number of studies included and potential confounding factors, our results should be interpreted carefully. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022328134.
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Affiliation(s)
- Amina M Illias
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kai-Jie Yu
- Department of Urology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Yung-Fong Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan.,School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
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The other side of the coin: Positive view on the role of opioids in cancer. Eur J Pharmacol 2022; 923:174888. [PMID: 35367422 DOI: 10.1016/j.ejphar.2022.174888] [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: 12/18/2021] [Revised: 02/26/2022] [Accepted: 03/09/2022] [Indexed: 11/23/2022]
Abstract
Opioids have been used for medicinal purposes as an analgesic and recreational purposes as a euphorigenic throughout human history. Cancer patients are often treated with different doses of opioids concurrently with anti-cancer drugs for pain relief without exhibiting excessive adverse effects. The intersection of the biology of pain, opioid therapy, and disease progression represents the crux of the matters and is of potentially great importance in cancer care. For more than 20 years, multiple investigations have focused on the stimulatory effects of opioids on cancer cell growth, while in-depth studies on the inhibitory effects on cancer cell growth development have usually been neglected. This paper reviews the evidence regarding opioid therapies and their anti-cancer effects on various malignancies. Likewise, we have a glimpse into the molecular mechanisms necessary for pinpointing their positive or negative impacts on malignancies to raise awareness and stimulate more excellent dialogue regarding their carcinogenic/anticarcinogenic roles.
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Santoni A, Santoni M, Arcuri E. Chronic Cancer Pain: Opioids within Tumor Microenvironment Affect Neuroinflammation, Tumor and Pain Evolution. Cancers (Basel) 2022; 14:cancers14092253. [PMID: 35565382 PMCID: PMC9104169 DOI: 10.3390/cancers14092253] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Pain is a worrisome symptom that 60–80% of patients with cancer experience chronically. In the last twenty years, immunological and pain research have shown that cancer pain is attributable to the neuroinflammatory response driven by the cellular and soluble components of the tumor microenvironment, with features similar to that induced in many other painful chronic non-cancer diseases. Neuroinflammation leads to central sensitization and neuroplastic remodeling of the central nervous system with alteration of pain sensitivity (hyperalgesia), responsiveness (behavior), and drive (centralization). Engagement of opioid receptors by both endogenous and exogenous opioids, namely, the cornerstone of pain therapy morphine, results in modulation of pain intensity and quality, in addition to cancer growth and progression. The effects of opioids on the evolution of pain, (relief or immune-mediated hyperalgesia) and cancer (promotion or inhibition), are dual and ambiguous. This ambiguity currently represents a major limitation of long-term opioid therapy, and encourages novel immunotherapeutic strategies. Abstract Pain can be a devastating experience for cancer patients, resulting in decreased quality of life. In the last two decades, immunological and pain research have demonstrated that pain persistence is primarily caused by neuroinflammation leading to central sensitization with brain neuroplastic alterations and changes in pain responsiveness (hyperalgesia, and pain behavior). Cancer pain is markedly affected by the tumor microenvironment (TME), a complex ecosystem consisting of different cell types (cancer cells, endothelial and stromal cells, leukocytes, fibroblasts and neurons) that release soluble mediators triggering neuroinflammation. The TME cellular components express opioid receptors (i.e., MOR) that upon engagement by endogenous or exogenous opioids such as morphine, initiate signaling events leading to neuroinflammation. MOR engagement does not only affect pain features and quality, but also influences directly and/or indirectly tumor growth and metastasis. The opioid effects on chronic cancer pain are also clinically characterized by altered opioid responsiveness (tolerance and hyperalgesia), a hallmark of the problematic long-term treatment of non-cancer pain. The significant progress made in understanding the immune-mediated development of chronic pain suggests its exploitation for novel alternative immunotherapeutic approaches.
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Affiliation(s)
- Angela Santoni
- Department of Molecular Medicine, Sapienza University of Rome, Laboratory Affiliated to Istituto Pasteur Italia-Fondazione Cenci Bolognetti, Viale Regina Elena 291, 00161 Rome, Italy
- IRCCS Neuromed, 86077 Pozzilli, Italy
- Correspondence: ; Tel.: +39-366-634-3618
| | - Matteo Santoni
- Medical Oncology Unit, Macerata General Hospital, Via Santa Lucia 2, 62100 Macerata, Italy;
| | - Edoardo Arcuri
- IRCCS Regina Elena Cancer Institute, IFO, Via Elio Chianesi 53, 00128 Rome, Italy;
- Ars Medica Pain Clinic, Via Cesare Ferrero da Cambiano 29, 00191 Rome, Italy
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Kotlińska-Lemieszek A, Żylicz Z. Less Well-Known Consequences of the Long-Term Use of Opioid Analgesics: A Comprehensive Literature Review. Drug Des Devel Ther 2022; 16:251-264. [PMID: 35082488 PMCID: PMC8784970 DOI: 10.2147/dddt.s342409] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/07/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The adverse effects of short-term opioid analgesics are well known and acknowledged; however, the spectrum of the sequelae of long-term use seems less clear. Some effects may remain undetected but still have the potential to cause harm and reduce patients' quality of life. OBJECTIVE To review the literature on the adverse effects of long-term opioid therapy. METHODS We performed a quasi-systematic search, analyzing articles published in the MEDLINE database between January 2000 and March 2021 that identified adverse effects of opioids used for chronic pain treatment. RESULTS Growing evidence indicates that there are multiple serious adverse effects of opioid treatment. Long-term opioid use may have significant effects on the endocrine, immune, cardiovascular, respiratory, gastrointestinal, and neural systems. Studies show that long-term opioid treatment increases the risk of fractures, infections, cardiovascular complications, sleep-disordered breathing, bowel dysfunction, overdose, and mortality. Opioids may potentially affect cancer development. Most consequences of the long-term use of opioids have been identified in studies of patients with non-malignant pain. CONCLUSION Studies indicate that long-term use of opioids increases the risk of drug-related events in a significant number of patients. Clinicians should be aware of these complications associated with prescribing opioids, discuss them with patients, prevent complications, if possible, and diagnose them early and manage adequately. More human studies are needed to assess the risk, including trials with individual opioids, because they have different adverse effect profiles.
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Affiliation(s)
- Aleksandra Kotlińska-Lemieszek
- Chair and Department of Palliative Medicine, Pharmacotherapy in Palliative Care Laboratory, Poznan University of Medical Sciences, Poznan, Poland.,Heliodor Święcicki University Hospital, Poznan, Poland
| | - Zbigniew Żylicz
- Institute of Medical Sciences, Medical College, University of Rzeszów, Rzeszów, Poland
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14
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Yoneda T, Hiasa M, Okui T, Hata K. Sensory nerves: A driver of the vicious cycle in bone metastasis? J Bone Oncol 2021; 30:100387. [PMID: 34504741 PMCID: PMC8411232 DOI: 10.1016/j.jbo.2021.100387] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/04/2022] Open
Abstract
Bone is one of the preferential target organs of cancer metastasis. Bone metastasis is associated with various complications, of which bone pain is most common and debilitating. The cancer-associated bone pain (CABP) is induced as a consequence of increased neurogenesis, reprogramming and axonogenesis of sensory nerves (SNs) in harmony with sensitization and excitation of SNs in response to the tumor microenvironment created in bone. Importantly, CABP is associated with increased mortality, of which precise cellular and molecular mechanism remains poorly understood. Bone is densely innervated by autonomic nerves (ANs) (sympathetic and parasympathetic nerves) and SNs. Recent studies have shown that the nerves innervating the tumor microenvironment establish intimate communications with tumors, producing various stimuli for tumors to progress and disseminate. In this review, our current understanding of the role of SNs innervating bone in the pathophysiology of CABP will be overviewed. Then the hypothesis that SNs facilitate cancer progression in bone will be discussed in conjunction with our recent findings that SNs play an important role not only in the induction of CABP but also the progression of bone metastasis using a preclinical model of CABP. It is suggested that SNs are a critical component of the bone microenvironment that drives the vicious cycle between bone and cancer to progress bone metastasis. Suppression of the activity of bone-innervating SNs may have potential therapeutic effects on the progression of bone metastasis and induction of CABP.
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Key Words
- AN, autonomic nerve
- BDNF, brain-derived neurotrophic factor
- BMP, bone morphogenetic protein
- BMSC, bone marrow stromal cells
- Bone microenvironment
- CABP, cancer-associated bone pain
- CALCRL, calcitonin receptor-like receptor
- CAP, cancer-associated pain
- CCL2, C–C motif chemokine 2
- CGRP, calcitonin gene-related peptide
- CNS, central nervous system
- COX, cyclooxygenase
- CREB, cyclic AMP-responsive element-binding protein
- CRPC, castration-resistant prostate cancer
- CXCL1, C-X-C Motif Chemokine Ligand 1
- CXCL2, C-X-C Motif Chemokine Ligand 2
- Cancer-associated bone pain
- DRG, dorsal root ganglion
- ERK1/2, extracellular receptor kinase ½
- G-CSF, granulocyte colony-stimulating factor
- GDNF, glial-derived neurotrophic factor
- HGF, hepatocyte growth factor
- HIF-1α, hypoxia-inducible transcription factor-1α
- HMGB-1, high mobility group box-1
- HSCs, hematopoietic stem cells
- HUVECs, human umbilical vein endothelial cells
- IL-1β, interleukin 1β
- MM, multiple myeloma
- MOR, mu-opioid receptor
- NE, norepinephrine
- NGF, nerve growth factor
- NI, nerve invasion
- NPY, neuropeptide Y
- NSAIDs, nonsteroidal anti-inflammatory drugs
- Nociceptors
- OA, osteoarthritis
- OPG, osteoprotegerin
- PACAP, pituitary adenylate cyclase-activating peptide
- PD-1, programmed cell death-1
- PD-L1, programmed death-ligand 1
- PDAC, pancreatic ductal adenocarcinoma
- PGE2, prostaglandin E2
- PNI, perineural invasion
- PanIN, pancreatic intraepithelial neoplasia
- Perineural invasion
- RAGE, receptor for advanced glycation end products
- RAMP1, receptor activity modifying protein 1
- RANKL, receptor activator of NF-κB ligand
- RTX, resiniferatoxin
- SN, sensory nerves
- SP, substance P
- SRE, skeletal-related event
- Sensory nerves
- TGFβ, transforming growth factor β
- TNFα, tumor necrosis factor α
- TRPV1
- TrkA, tyrosine kinase receptor type 1
- VEGF, vascular endothelial growth factor
- VIP, vasoactive intestinal peptide
- a3V-H+-ATPase, a3 isoform vacuolar proton pump
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Affiliation(s)
- Toshiyuki Yoneda
- Department of Biochemistry, Osaka University Graduate School of Dentistry, Osaka, Japan
| | - Masahiro Hiasa
- Department of Biomaterials and Bioengineerings, University of Tokushima Graduate School of Dentistry, Tokushima, Japan
| | - Tatsuo Okui
- Department of Oral and Maxillofacial Surgery and Biopathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Kenji Hata
- Department of Biochemistry, Osaka University Graduate School of Dentistry, Osaka, Japan
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15
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Chamberlain BH, Rhiner M, Slatkin NE, Stambler N, Israel RJ. Subcutaneous Methylnaltrexone for Treatment of Opioid-Induced Constipation in Cancer versus Noncancer Patients: An Analysis of Efficacy and Safety Variables from Two Studies. J Pain Res 2021; 14:2687-2697. [PMID: 34512008 PMCID: PMC8420564 DOI: 10.2147/jpr.s312731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Methylnaltrexone inhibits opioid-induced constipation (OIC) by binding to peripheral µ-opioid receptors without impacting central opioid receptor mediated analgesia. This analysis compared methylnaltrexone efficacy and safety among advanced illness patients with and without active cancer and OIC. Patients and Methods This post hoc analysis included two multicenter, randomized, double-blind, placebo-controlled studies in adults with advanced illness and OIC who received subcutaneous methylnaltrexone. Efficacy endpoints included the proportion of patients achieving rescue-free laxation (RFL), time to RFL, weekly laxations within 24 hours after dosing, rescue laxative use, and pain scores. Adverse events were monitored for safety. Results After pooling, 178 patients received methylnaltrexone (n = 116 with cancer) and 185 received placebo (n = 114 with cancer). Median baseline daily opioid morphine equivalents (mg/d) were higher in cancer (methylnaltrexone: 180; placebo: 188) versus noncancer patients (methylnaltrexone: 120; placebo: 80). The proportions of patients achieving RFL within 4 hours after ≥2 of the first 4 doses were significantly greater with methylnaltrexone (cancer: 56.9%; noncancer: 58.1%) versus placebo (cancer: 5.3%; noncancer: 11.3%; P < 0.0001). The median time to laxation within 24 hours after the first methylnaltrexone dose was significantly shorter in cancer and noncancer patients versus placebo (cancer: 0.96 vs 22.53 hours, P < 0.0001; noncancer: 1.25 vs >24 hours, P = 0.0002). The mean number of weekly laxations within 24 hours after dosing by week 2 was significantly higher in methylnaltrexone- vs placebo-treated cancer and noncancer patients (cancer: 7.9 vs 4.9, P < 0.0001; noncancer: 8.4 vs 5.0, P < 0.0001). Methylnaltrexone reduced rescue laxative use without impacting pain scores. Consistent with previous data, methylnaltrexone was well tolerated in cancer and noncancer patients, and the AE profile did not suggest symptoms of opioid withdrawal. Conclusion Methylnaltrexone reduced RFL time in advanced-illness patients with and without active cancer, while maintaining pain control with opioid treatment despite higher baseline opioid use among cancer patients.
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Affiliation(s)
| | - Michelle Rhiner
- Loma Linda University Health, Department of Family Medicine, Loma Linda, CA, USA
| | - Neal E Slatkin
- University of California Riverside, School of Medicine, Riverside, CA, USA.,Salix Pharmaceuticals, Medical Affairs, Bridgewater, NJ, USA
| | - Nancy Stambler
- Progenics Pharmaceuticals, Inc., a subsidiary of Lantheus Holdings Inc., Clinical Research, New York, NY, USA
| | - Robert J Israel
- Bausch Health US, LLC, Clinical and Medical Affairs, Bridgewater, NJ, USA
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16
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Decavèle M, Similowski T. Dyspnoea upon hospital admission: listen to the bird of ill omen! Eur Respir J 2021; 58:58/3/2100988. [PMID: 34475114 DOI: 10.1183/13993003.00988-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France .,Département R3S (Respiration, Réanimation, Réhabilitation respiratoire, Sommeil), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
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17
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Sagi V, Mittal A, Tran H, Gupta K. Pain in sickle cell disease: current and potential translational therapies. Transl Res 2021; 234:141-158. [PMID: 33711512 PMCID: PMC8217144 DOI: 10.1016/j.trsl.2021.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/02/2021] [Accepted: 03/06/2021] [Indexed: 12/26/2022]
Abstract
Pain is a major comorbidity of sickle cell disease (SCD). Patients with SCD may suffer from both acute and chronic pain. Acute pain is caused by recurrent and unpredictable episodes of vaso-occlusive crises (VOC), whereas the exact etiology of chronic pain is still unknown. Opioids are the mainstay for pain treatment, but the opioid epidemic has significantly altered access to prescription opioids and has brought concerns over their long-term use into the forefront, which have negatively impacted the treatment of sickle pain. Opioids remain potent analgesics but growing opioid-phobia has led to the realization of an unmet need to develop nonopioid therapies that can provide relief for severe sickle pain. This realization has contributed to the approval of 3 different drugs by the Food and Drug Administration (FDA) for the treatment of SCD, particularly to reduce VOC and/or have an impact on the pathobiology of SCD. In this review, we outline the challenges and need for validation of side-effects of opioids and provide an update on the development of mechanism-based translational therapies, specifically targeting pain in SCD.
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Affiliation(s)
- Varun Sagi
- School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Aditya Mittal
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Huy Tran
- School of Medicine, Kansas City University, Joplin, Missouri
| | - Kalpna Gupta
- Hematology/Oncology, Department of Medicine, University of California, Irvine and Southern California Institute for Research and Education, VA Medical Center, Long Beach, California.
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18
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Crawford GB, Dzierżanowski T, Hauser K, Larkin P, Luque-Blanco AI, Murphy I, Puchalski CM, Ripamonti CI. Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines. ESMO Open 2021; 6:100225. [PMID: 34474810 PMCID: PMC8411064 DOI: 10.1016/j.esmoop.2021.100225] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 02/08/2023] Open
Abstract
•This ESMO Clinical Practice Guideline provides key recommendations for end-of-life care for patients with advanced cancer. •It details care that is focused on comfort, quality of life and approaching death of patients with advanced cancer. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the authors’ collective expert opinion.
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Affiliation(s)
- G B Crawford
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia; Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - T Dzierżanowski
- Department of Social Medicine and Public Health, Medical University of Warsaw, Warsaw, Poland
| | - K Hauser
- Palliative and Supportive Care Department Cabrini Health, Prahran, Victoria, Australia
| | - P Larkin
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - A I Luque-Blanco
- Palliative Care Unit, Hospital Sant Joan de Déu, Palma de Mallorca, Spain
| | - I Murphy
- Marymount University Hospital and Hospice, Curraheen, Cork, Ireland
| | - C M Puchalski
- Department of Medicine and Health Sciences, The George Washington University School of Medicine and Health Sciences, Washington, USA
| | - C I Ripamonti
- Oncology-Supportive Care in Cancer Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale dei Tumori Milano, Milan, Italy
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19
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Uc A, Andersen DK, Apkarian AV, Bellin MD, Colloca L, Drewes AM, Dunbar EK, Forsmark CE, Goodman MT, Kapural L, Koob GF, Palermo TM, Pandol SJ, Pasricha P, Phillips AE, Piomelli D, Saloman JL, Schwarzenberg SJ, Singh VK, Sowa G, Strouse T, Treisman GJ, Windsor JA, Yadav D. Pancreatic Pain-Knowledge Gaps and Research Opportunities in Children and Adults: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2021; 50:906-915. [PMID: 34643606 PMCID: PMC10273134 DOI: 10.1097/mpa.0000000000001899] [Citation(s) in RCA: 6] [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: 12/12/2022]
Abstract
ABSTRACT A workshop was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases to focus on research gaps and opportunities in pancreatic pain. The event was held on July 21, 2021, and structured into 4 sessions: (1) pathophysiology; (2) biomarkers, mediators, and pharmacology of pain; (3) pain assessment; and (4) pain treatment challenges and opportunities. The current state of knowledge was reviewed; many knowledge gaps and research needs were identified that require further investigation. Common themes included the need to better understand the underlying mechanisms of pain in pancreatic diseases, the relationship of visceral neural pathways and central pain centers, the role of behavioral factors and disorders on the perception of pain, and differences in pain perception and processes in children when compared with adults. In addition, the role of genetic risk factors for pain and the mechanisms and role of placebos in pain treatment were discussed. Methods of pain assessment including quantitative sensory testing were examined, as well as the process of central sensitization of pain. Finally, newer approaches to pain management including cognitive behavioral therapy, nerve stimulation, experimental (nonopioid) drugs, and cannabinoid compounds were covered.
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Affiliation(s)
- Aliye Uc
- From the Division of Gastroenterology, Hepatology, Pancreatology and Nutrition, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - A Vania Apkarian
- Departments of Physiology, Anesthesiology, Physical Medicine and Rehabilitation, and Center for Translational Pain Research, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Melena D Bellin
- Departments of Pediatrics and Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | | | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Florida, Gainesville, FL
| | - Marc T Goodman
- Cancer Prevention and Control Program, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - George F Koob
- National Institute on Alcohol Abuse and Alcoholism and Intramural Research Program, National Institute on Drug, National Institutes of Health, Bethesda, MD
| | | | - Stephen J Pandol
- Division of Gastroenterology, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Pankaj Pasricha
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anna E Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
| | - Daniele Piomelli
- Departments of Anatomy and Neurobiology, Biological Chemistry, and Pharmacology, University of California, Irvine School of Medicine, Irvine, CA
| | - Jami L Saloman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
| | - Sarah Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gwendolyn Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas Strouse
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Glenn J Treisman
- Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
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20
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Lu H, Zhang H, Weng ML, Zhang J, Jiang N, Cata JP, Ma D, Chen WK, Miao CH. Morphine promotes tumorigenesis and cetuximab resistance via EGFR signaling activation in human colorectal cancer. J Cell Physiol 2021; 236:4445-4454. [PMID: 33184860 DOI: 10.1002/jcp.30161] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/31/2020] [Accepted: 11/03/2020] [Indexed: 02/06/2023]
Abstract
Morphine, a mu-opioid receptor (MOR) agonist, has been extensively used to treat advanced cancer pain. In particular, in patients with cancer metastasis, both morphine and anticancer drugs are given simultaneously. However, evidence showed that morphine might be a risk factor in promoting the tumor's malignant potential. In this study, we report that treatment with morphine could activate MOR and lead to the promotion of proliferation, migration, and invasion in HCT116 and DLD1 colorectal cancer (CRC) cells with time-concentration dependence. Moreover, morphine can also contribute to cetuximab's drug resistance, a targeted drug widely used to treat advanced CRC by inducing the activation of epidermal growth factor receptor (EGFR). The cell phenotype includes proliferation, migration, invasion, and drug resistance, which may be reversed by MOR knockdown or adding nalmefene, the MOR receptor antagonist. Receptor tyrosine kinase array analysis revealed that morphine selectively induced the transactivation of EGFR. EGFR transactivation resulted in the activation of ERK1/2 and AKT. In conclusion, morphine induces the transactivation of EGFR via MOR. It activates the downstream signal pathway AKT-MTOR and RAS-MAPK, increases proliferation, migration, and invasion, and promotes resistance to EGFR inhibitors in a CRC cell line. Furthermore, we verified that EGFR inhibition by cetuximab strongly reversed the protumoral effects of morphine in vitro and in vivo. Collectively, we provide evidence that morphine-EGFR signaling might be a promising therapeutic target for CRC patients, especially for cetuximab-resistant CRC patients.
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MESH Headings
- Animals
- Antineoplastic Agents, Immunological/pharmacology
- Cell Movement/drug effects
- Cell Proliferation/drug effects
- Cetuximab/pharmacology
- Colorectal Neoplasms/drug therapy
- Colorectal Neoplasms/genetics
- Colorectal Neoplasms/metabolism
- Colorectal Neoplasms/pathology
- Drug Resistance, Neoplasm
- ErbB Receptors/antagonists & inhibitors
- ErbB Receptors/metabolism
- Extracellular Signal-Regulated MAP Kinases/metabolism
- HCT116 Cells
- Humans
- Male
- Mice, Inbred BALB C
- Mice, Nude
- Morphine/toxicity
- Neoplasm Invasiveness
- Proto-Oncogene Proteins c-akt/metabolism
- Receptors, Opioid, mu/agonists
- Receptors, Opioid, mu/genetics
- Receptors, Opioid, mu/metabolism
- Signal Transduction
- TOR Serine-Threonine Kinases/metabolism
- Xenograft Model Antitumor Assays
- ras Proteins/metabolism
- Mice
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Affiliation(s)
- Hong Lu
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, ZhongShan Hospital, Fudan University, Shanghai, China
| | - Hao Zhang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, ZhongShan Hospital, Fudan University, Shanghai, China
| | - Mei-Lin Weng
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jin Zhang
- Key Laboratory of Metabolism and Molecular Medicine, Ministry of Education, Department of Biochemistry and Molecular Biology, Collaborative Innovation Center of Genetics and Development, Institutes of Biomedical Science, School of Basic Medical Science, Fudan University, Shanghai, China
- Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Nan Jiang
- Key Laboratory of Metabolism and Molecular Medicine, Ministry of Education, Department of Biochemistry and Molecular Biology, Collaborative Innovation Center of Genetics and Development, Institutes of Biomedical Science, School of Basic Medical Science, Fudan University, Shanghai, China
- Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Anaesthesiology and Surgical Oncology Research Group, Houston, Texas, USA
| | - Duan Ma
- Key Laboratory of Metabolism and Molecular Medicine, Ministry of Education, Department of Biochemistry and Molecular Biology, Collaborative Innovation Center of Genetics and Development, Institutes of Biomedical Science, School of Basic Medical Science, Fudan University, Shanghai, China
- Institute of Biomedical Science, Fudan University, Shanghai, China
- Children's Hospital, Fudan University, Shanghai, China
| | - Wan-Kun Chen
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, ZhongShan Hospital, Fudan University, Shanghai, China
| | - Chang-Hong Miao
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, ZhongShan Hospital, Fudan University, Shanghai, China
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21
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Chen W, Xu Y, Zhang Y, Lou W, Han X. Positive Impact of Intraoperative Epidural Ropivacaine Infusion on Oncologic Outcomes in Pancreatic Cancer Patients Undergoing Pancreatectomy: A Retrospective Cohort Study. J Cancer 2021; 12:4513-4521. [PMID: 34149915 PMCID: PMC8210573 DOI: 10.7150/jca.57661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/09/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Previous literatures have demonstrated that regional anesthesia such as epidural anesthesia may affect long-term survival of cancer patients. In the present study, we conducted a retrospective cohort study to investigate the survival impact of intraoperatively epidural ropivacaine infusion on pancreatic ductal adenocarcinoma (PDAC) patients. Methods: PDAC patients who underwent pancreatic surgery in Zhongshan Hospital Fudan University from January, 2015 to June, 2018 were included. The surgical procedure was performed under combined endotracheal general anesthesia and thoracic epidural anesthesia, and patient-controlled epidural analgesia (PCEA) with 0.12% ropivacaine was given after surgery for further pain control. Patients were divided into two groups according to their intraoperative epidural ropivacaine concentration: high (0.375%-0.5%) and low (0.15%-0.25%). Survival outcome was compared between groups. Results: A total of 215 patients were enrolled and their baseline characteristics were balanced between groups, except that patients with high concentration ropivacaine received higher total dose opioid and had longer operative time. Resected PDAC patients who were administrated with high concentration ropivacaine through epidural catheter intraoperatively had improved overall survival (median overall survival, mOS, high VS low, 37.6 VS 23.7 months, p=0.04). High epidural ropivacaine concentration was an independent prognostic factor (hazard ratio [HR]=0.65, 95% confidence interval [CI], 0.44-0.94; p=0.03). Subgroups analyses shown that T3M0 PDAC patients with preoperative CA 19-9 higher than 200 U/ml, negative resection margin, and those without tumor deposit and adjuvant radiotherapy could benefit from high concentration of ropivacaine. Conclusion: Intraoperatively epidural infusion with high concentration of ropivacaine was associated with improved OS in PDAC patients undergoing pancreatectomy.
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Affiliation(s)
- Wannan Chen
- Department of Anesthesiology, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, China
| | - Yaolin Xu
- Department of General Surgery, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, China
| | - Yueming Zhang
- Department of General Surgery, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, China
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, China
| | - Xiaodan Han
- Department of Anesthesiology, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, China
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22
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Siddappa PK, Hawa F, Prokop LJ, Murad MH, Abu Dayyeh BK, Chandrasekhara V, Topazian MD, Bazerbachi F. Endoscopic pancreatic duct stenting for pain palliation in selected pancreatic cancer patients: a systematic review and meta-analysis. Gastroenterol Rep (Oxf) 2021; 9:105-114. [PMID: 34026217 PMCID: PMC8128017 DOI: 10.1093/gastro/goab001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 12/15/2022] Open
Abstract
Background Abdominal pain is a debilitating symptom affecting ∼80% of pancreatic cancer (PC) patients. Pancreatic duct (PD) decompression has been reported to alleviate this pain, although this practice has not been widely adopted. We aimed to evaluate the role, efficacy, and safety of endoscopic PD decompression for palliation of PC post-prandial obstructive-type pain. Methods A systematic review until 7 October 2020 was performed. Two independent reviewers selected studies, extracted data, and assessed the methodological quality. Results We identified 12 publications with a total of 192 patients with PC presenting with abdominal pain, in whom PD decompression was attempted, and was successful in 167 patients (mean age 62.5 years, 58.7% males). The use of plastic stents was reported in 159 patients (95.2%). All included studies reported partial or complete improvement in pain levels after PD stenting, with an improvement rate of 93% (95% confidence interval, 79%–100%). The mean duration of pain improvement was 94 ± 16 days. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) were post-sphincterotomy bleeding (1.8%), post-ERCP pancreatitis (0.6%), and hemosuccus pancreaticus (0.6%). AEs were not reported in two patients who underwent endoscopic ultrasound-guided PD decompression. In the 167 patients with technical success, the stent-migration and stent-occlusion rates were 3.6% and 3.0%, respectively. No AE-related mortality was reported. The methodological quality assessment showed the majority of the studies having low or unclear quality. Conclusion In this exploratory analysis, endoscopic PD drainage may be an effective and safe option in selected patients for the management of obstructive-type PC pain. However, a randomized–controlled trial is needed to delineate the role of this invasive practice.
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Affiliation(s)
- Pradeep K Siddappa
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Fadi Hawa
- Department of Internal Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Argueta DA, Aich A, Lei J, Kiven S, Nguyen A, Wang Y, Gu J, Zhao W, Gupta K. β-endorphin at the intersection of pain and cancer progression: Preclinical evidence. Neurosci Lett 2020; 744:135601. [PMID: 33387660 DOI: 10.1016/j.neulet.2020.135601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/20/2022]
Abstract
We examined the association between endogenous opioid β-endorphin, cancer progression and pain in a transgenic mouse model of breast cancer, with a rat C3(1) simian virus 40 large tumor antigen fusion gene (C3TAg). C3TAg mice develop ductal epithelial atypia at 8 weeks, progression to intra-epithelial neoplasia at 12 weeks, and invasive carcinoma with palpable tumors at 16 weeks. Consistent with invasive carcinoma at 4 months of age, C3TAg mice demonstrate a significant increase in hyperalgesia compared to younger C3TAg or control FVBN mice without tumors. Our data show that the growing tumor contributes to circulating β-endorphin. As an endogenous ligand of mu opioid receptor, β-endorphin has analgesic activity. Paradoxically, we observed an increase in pain in transgenic breast cancer mice with significantly high circulating and tumor-associated β-endorphin. Increased circulating β-endorphin correlates with increasing tumor burden. β-endorphin induced the activation of mitogenic and survival-promoting signaling pathways, MAPK/ERK 1/2, STAT3 and Akt, observed by us in human MDA-MB-231 cells suggesting a role for β-endorphin in breast cancer progression and associated pain.
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Affiliation(s)
- Donovan A Argueta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA, USA
| | - Anupam Aich
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA, USA
| | - Jianxun Lei
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Stacy Kiven
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA, USA
| | - Aithanh Nguyen
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ying Wang
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Department of Anesthesia, Stark Neuroscience Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Joshua Gu
- Sue and Bill Gross Stem Cell Research Center, University of California, Irvine, CA, USA; Chao Family Comprehensive Cancer Center, University of California, Irvine, CA, USA; Department of Biological Chemistry, University of California, Irvine, CA, USA
| | - Weian Zhao
- Sue and Bill Gross Stem Cell Research Center, University of California, Irvine, CA, USA; Chao Family Comprehensive Cancer Center, University of California, Irvine, CA, USA; Department of Biological Chemistry, University of California, Irvine, CA, USA; Department of Pharmaceutical Sciences, University of California, Irvine, CA, USA; Edwards Life Sciences Center for Advanced Cardiovascular Technology, University of California, Irvine, CA, USA; Department of Biomedical Engineering, University of California, Irvine, CA, USA
| | - Kalpna Gupta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA, USA; Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Southern California Institute for Research and Education, VA Medical Center, Long Beach, CA, USA.
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24
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Privorotskiy A, Bhavsar SP, Lang FF, Hu J, Cata JP. Impact of anesthesia and analgesia techniques on glioblastoma progression. A narrative review. Neurooncol Adv 2020; 2:vdaa123. [PMID: 33205044 PMCID: PMC7653686 DOI: 10.1093/noajnl/vdaa123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Glioblastoma (GBM) is an aggressive malignant CNS tumor with a median survival of 15 months after diagnosis. Standard therapy for GBM includes surgical resection, radiation, and temozolomide. Recently, anesthetics and analgesics have received attention for their potential involvement in mediating tumor growth. This narrative review investigated whether various members of the 2 aforementioned classes of drugs have a definitive impact on GBM progression by summarizing pertinent in vitro, in vivo, and clinical studies. Recent publications regarding general anesthetics have been inconsistent, showing that they can be pro-tumoral or antitumoral depending on the experimental context. The local anesthetic lidocaine has shown consistent antitumoral effects in vitro. Clinical studies looking at anesthetics have not concluded that their use improves patient outcomes. In vitro and in vivo studies looking at opioid involvement in GBM have demonstrated inconsistent findings regarding whether these drugs are pro-tumoral or antitumoral. Nonsteroidal anti-inflammatory drugs, and specifically COX-2 inhibitors, have shown inconsistent findings across multiple studies looking at whether they are beneficial in halting GBM progression. Until multiple repeatable studies show that anesthetics and analgesics can suppress GBM growth, there is no strong evidence to recommend changes in the anesthetic care of these patients.
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Affiliation(s)
| | - Shreyas P Bhavsar
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Frederick F Lang
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jian Hu
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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25
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Association between intraoperative intravenous lidocaine infusion and survival in patients undergoing pancreatectomy for pancreatic cancer: a retrospective study. Br J Anaesth 2020; 125:141-148. [DOI: 10.1016/j.bja.2020.03.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/06/2020] [Accepted: 03/17/2020] [Indexed: 12/20/2022] Open
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26
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Cata JP, Guerra C, Soto G, Ramirez MF. Anesthesia Options and the Recurrence of Cancer: What We Know so Far? Local Reg Anesth 2020; 13:57-72. [PMID: 32765061 PMCID: PMC7369361 DOI: 10.2147/lra.s240567] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/23/2020] [Indexed: 12/24/2022] Open
Abstract
Surgery is a critical period in the survival of patients with cancer. While resective surgery of primary tumors has shown to prolong the life of these patients, it can also promote mechanisms associated with metastatic progression. During surgery, patients require general and sometimes local anesthetics that also modulate mechanisms that can favor or reduce metastasis. In this narrative review, we summarized the evidence about the impact of local, regional and general anesthesia on metastatic mechanisms and the survival of patients. The available evidence suggests that cancer recurrence is not significantly impacted by neither regional anesthesia nor volatile or total intravenous anesthesia.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Carlos Guerra
- Department of Anesthesia, Pain Management, and Perioperative Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - German Soto
- Department of Anesthesiology, Hospital Eva Perón, Rosario, Santa Fe, Argentina
| | - Maria F Ramirez
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
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27
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Pain, opioids, and survival in patients with cancer. Pain 2020; 161:875. [PMID: 32195785 DOI: 10.1097/j.pain.0000000000001794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Novy DM, Nelson DV, Koyyalagunta D, Cata JP, Gupta P, Gupta K. Reply to Boland and Bennett. Pain 2020; 161:875-876. [PMID: 32195786 DOI: 10.1097/j.pain.0000000000001795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Diane M Novy
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - David V Nelson
- Department of Psychology and Philosophy, Sam Houston State University, Huntsville, TX, United States
| | - Dhanalakshmi Koyyalagunta
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Juan P Cata
- Departments of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Pankaj Gupta
- Hematology/Oncology Section, Veterans Affairs Long Beach Health Care System, Long Beach, CA, United States
| | - Kalpna Gupta
- Department of Medicine, University of California Irvine, Irvine, CA, United States
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29
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