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Cerbone L, Delfanti S, Crivellari S, De Angelis AM, Mazzeo L, Proto C, Occhipinti M, Lo Russo G, Dellepiane C, Biello F, Alabiso I, Verderame F, Gauna R, De Simone I, Cuppone F, Petraglia S, Pasello G, Ceresoli GL, Garassino MC, Torri V, Grosso F. Nivolumab in pretreated pleural mesothelioma: Results from an observational real-world study of patients treated within the AIFA 5% Fund. TUMORI JOURNAL 2024; 110:168-173. [PMID: 38372045 DOI: 10.1177/03008916241229287] [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] [Indexed: 02/20/2024]
Abstract
BACKGROUND Pleural mesothelioma is a rare cancer with a dismal prognosis and few therapeutic options, especially in the pretreated setting. Immunotherapy with checkpoint inhibitors as single agents yielded interesting results in refractory pleural mesothelioma, achieving a response rate between 10-20%, median progression-free survival of 2-5 months and median overall survival of 7-13 months. PATIENTS AND METHODS A retrospective, multi-institutional study of pleural mesothelioma patients treated with nivolumab in second and further line was performed. The endpoints of the study are response rate, disease control rate, progression free survival and overall survival. RESULTS Sixty-five patients with pleural mesothelioma treated with nivolumab in second and further line were enrolled at seven Italian institutions. The response rate was 8%, disease control rate was 37%, median progression free survival was 5.7 months (95% CI: 2.9-9.0) and median overall survival was 11.1 (95% CI 6.2-19.9) months. A higher neutrophils and neutrophils to lymphocytes ratio at baseline were associated with worse prognosis. CONCLUSION Nivolumab as a single agent is fairly active in a cohort of unselected pretreated pleural mesothelioma patients. Further investigations on clinical and translational factors are needed to define which patient might benefit most from nivolumab treatment in pleural mesothelioma.
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Affiliation(s)
- Luigi Cerbone
- Mesothelioma Unit AO SS, Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sara Delfanti
- Mesothelioma Unit AO SS, Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Stefania Crivellari
- Mesothelioma Unit AO SS, Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
- Projects, Investigation and Innovation Unit, Ospedale Michele e Pietro Ferrero, Verduno, Italy
| | | | - Laura Mazzeo
- Medical Oncology Department 1, Fondazione IRCCS - Istituto Nazionale Dei Tumori, Milano, Italy
| | - Claudia Proto
- Medical Oncology Department 1, Fondazione IRCCS - Istituto Nazionale Dei Tumori, Milano, Italy
| | - Mario Occhipinti
- Medical Oncology Department 1, Fondazione IRCCS - Istituto Nazionale Dei Tumori, Milano, Italy
| | - Giuseppe Lo Russo
- Medical Oncology Department 1, Fondazione IRCCS - Istituto Nazionale Dei Tumori, Milano, Italy
| | - Chiara Dellepiane
- Lung Cancer Unit, Oncology Unit 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federica Biello
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Irene Alabiso
- Oncology Unit 2, Presidio Ospedaliero S. Giovanni Bosco, Azienda Sanitaria Locale Città Di Torino, Torino, Italy
| | - Francesco Verderame
- Medical Oncology Unit, Azienda Ospedaliera Ospedali Riuniti PO Vincenzo Cervello, Palermo, Italy
| | - Roberta Gauna
- Oncology Unit, Ospedale Degli Infermi, Ponderano, Italy
| | - Irene De Simone
- Clinical Oncology Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Federica Cuppone
- Pre-Authorisation Department, Italian Medicines Agency, Rome, Italy
| | - Sandra Petraglia
- Pre-Authorisation Department, Italian Medicines Agency, Rome, Italy
| | - Giulia Pasello
- Medical Oncology 2, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy 12Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | | | - Marina Chiara Garassino
- Department of Medicine, University of Chicago Comprehensive Cancer Center, University of Chicago, Illinois, USA
| | - Valter Torri
- Clinical Oncology Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Federica Grosso
- Mesothelioma Unit AO SS, Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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Guo Y, Pan Y, Wan J, Gong B, Li Y, Kan X, Zheng C. Prognosis stratification of cancer patients treated with immune checkpoint inhibitors through lung immune prognostic index: a meta-analysis and systematic review. BMC Cancer 2024; 24:523. [PMID: 38664760 PMCID: PMC11047037 DOI: 10.1186/s12885-024-12271-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Although numerous studies have reported the prognostic value of the lung immune prognostic index (LIPI) in non-small cell lung cancer (NSCLC) patients treated with immune checkpoint inhibitors (ICIs), the prognostic value of the LIPI in a pancancer setting remains unclear. METHODS A comprehensive search was conducted until July 2023 across the PubMed, Embase, Web of Science, and Cochrane Library databases to identify relevant studies evaluating the prognostic value of the LIPI in cancer patients treated with ICIs. The outcomes were overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR). We described and compared the pooled outcomes by stratifying the patients based on different groupings of LIPI (good vs. intermediate [0 vs. 1], good vs. poor [0 vs. 2], and good vs. intermediate / poor [0 vs. 1 + 2]). RESULTS A total of 9959 patients in 35 studies were included. A higher score of LIPI was associated with impaired OS. The pooled HRs were 1.69 (95% CI: 1.55-1.85, p < 0.001; 0 vs. 1), 3.03 (95% CI: 2.53-3.63, p < 0.001; 0 vs. 2), and 2.38 (95% CI: 1.97-2.88, p < 0.001; 0 vs. 1 + 2). A higher LIPI score was associated with shorter PFS. The pooled HRs were 1.41 (95% CI: 1.31-1.52, p < 0.001; 0 vs. 1), 2.23 (95% CI: 1.87-2.66, p < 0.001; 0 vs. 2), and 1.65 (95% CI: 1.46-1.86, p < 0.001; 0 vs. 1 + 2). Similarly, a higher LIPI score was associated with a lower ORR. The pooled ORs were 0.63 (95% CI: 0.54-0.75, p < 0.001; 0 vs. 1) and 0.38 (95% CI: 0.29-0.50, p < 0.001; 0 vs. 2). A higher LIPI score was associated with a lower DCR. The pooled ORs were 0.47 (95% CI: 0.35-0.61, p < 0.001; 0 vs. 1) and 0.19 (95% CI: 0.12-0.30, p < 0.001; 0 vs. 2). CONCLUSION In patients with NSCLC or other solid tumours, the lung immune prognostic index could robustly stratify the clinical outcomes into three groups among the patients who receive ICIs. LIPI is a low-cost, simple, accessible, and accurate prognostic tool in a pancancer setting and it may contribute to the evaluation of risk stratification in patients treated with ICIs.
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Affiliation(s)
- Yusheng Guo
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
- Hubei Key Laboratory of Molecular Imaging, 430022, Wuhan, China
| | - Yao Pan
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Fujian Medical University, 362000, Quanzhou, China
| | - Jiayu Wan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
- Hubei Key Laboratory of Molecular Imaging, 430022, Wuhan, China
| | - Bingxin Gong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
- Hubei Key Laboratory of Molecular Imaging, 430022, Wuhan, China
| | - Yi Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
- Hubei Key Laboratory of Molecular Imaging, 430022, Wuhan, China
| | - Xuefeng Kan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
- Hubei Key Laboratory of Molecular Imaging, 430022, Wuhan, China.
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
- Hubei Key Laboratory of Molecular Imaging, 430022, Wuhan, China.
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Assié JB, Jean D. Pleural mesothelioma: a snapshot of emerging drug targets and opportunities for non-surgical therapeutic advancement. Expert Opin Ther Targets 2023; 27:1059-1069. [PMID: 37902459 DOI: 10.1080/14728222.2023.2277224] [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] [Received: 07/27/2023] [Accepted: 10/26/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Pleural mesothelioma is a rare and aggressive cancer originating in the pleura, with a devastating prognosis and limited treatment options. There have been significant advancements in the management of this disease in recent years. Since 2021, nivolumab and ipilimumab immune checkpoint inhibitors have become the new standard of care for first-line treatment of pleural mesothelioma. AREAS COVERED While a combination of chemotherapy and immune checkpoint inhibitors appears to be the next step, targeted therapies are emerging thanks to our understanding of the oncogenesis of pleural mesothelioma. Moreover, several new strategies are currently being investigated, including viral therapy, antibody-drug conjugates, and even cell therapies with CAR-T cells or dendritic cells. In this review, we will explore the various future opportunities that could potentially transform patients' lives in light of the clinical trials that have been conducted. EXPERT OPINION Future clinical studies aim to rebiopsy patients after disease progression to identify new molecular alterations and to be associated with ancillary studies, guiding subsequent therapy decisions. Predicting and investigating treatment resistance mechanisms will lead to innovative approaches and improved treatment outcomes.
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Affiliation(s)
- Jean-Baptiste Assié
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université Paris Cité, Functional Genomics of Solid Tumors Laboratory, Paris, France
- GRC OncoThoParisEst, Service de Pneumologie, Centre Hospitalier IntercommunaI, UPEC, Créteil, France
| | - Didier Jean
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université Paris Cité, Functional Genomics of Solid Tumors Laboratory, Paris, France
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The Genes-Stemness-Secretome Interplay in Malignant Pleural Mesothelioma: Molecular Dynamics and Clinical Hints. Int J Mol Sci 2023; 24:ijms24043496. [PMID: 36834912 PMCID: PMC9963101 DOI: 10.3390/ijms24043496] [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: 01/23/2023] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
MPM has a uniquely poor somatic mutational landscape, mainly driven by environmental selective pressure. This feature has dramatically limited the development of effective treatment. However, genomic events are known to be associated with MPM progression, and specific genetic signatures emerge from the exceptional crosstalk between neoplastic cells and matrix components, among which one main area of focus is hypoxia. Here we discuss the novel therapeutic strategies focused on the exploitation of MPM genetic asset and its interconnection with the surrounding hypoxic microenvironment as well as transcript products and microvesicles representing both an insight into the pathogenesis and promising actionable targets.
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Advances in pharmacokinetics and pharmacodynamics of PD-1/PD-L1 inhibitors. Int Immunopharmacol 2023; 115:109638. [PMID: 36587500 DOI: 10.1016/j.intimp.2022.109638] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/09/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are a group of drugs designed to improve the therapeutic effects on various types of malignant tumors. Irrespective of monotherapy or combinational therapies as first-line and later-line therapy, ICIs have achieved benefits for various tumors. Programmed cell death protein-1 (PD-1) / ligand 1 (PD-L1) is an immune checkpoint that suppresses antitumor immunity, especially in the tumor microenvironment (TME). PD-1/PD-L1 immune checkpoint inhibitors block tumor-related downregulation of the immune system, thereby enhancing antitumor immunity. In comparison with traditional small-molecule drugs, ICIs exhibit pharmacokinetic characteristics owing to their high molecular weight. Furthermore, different types of ICIs exhibit different pharmacodynamic characteristics. Hence, ICIs have been approved for different indications by the Food and Drug Administration (FDA) and National Medical Products Administration (NMPA). This review summarizes pharmacokinetic and pharmacodynamic studies of PD-1/ PD-L1 inhibitors to provide a reference for rational clinical application.
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Guven DC, Sahin TK, Erul E, Rizzo A, Ricci AD, Aksoy S, Yalcin S. The association between albumin levels and survival in patients treated with immune checkpoint inhibitors: A systematic review and meta-analysis. Front Mol Biosci 2022; 9:1039121. [PMID: 36533070 PMCID: PMC9756377 DOI: 10.3389/fmolb.2022.1039121] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/08/2022] [Indexed: 08/15/2023] Open
Abstract
Background: The albumin levels may potentially be used as a prognostic biomarker in patients with cancertreated with immune checkpoint inhibitors (ICIs) due to its close relationship with nutritional and inflammatory status. However, the available data is limited with heterogeneous patient cohorts, sample sizes and variable cut-offs. Therefore, we conducted a systematic review and meta-analysis to evaluate the association between survival outcomes and albumin levels in patients treated with ICIs. Methods: We conducted a systematic review using the PubMed, Web of Science, and Embase databases to filter the published studies up to 1 June 2022. The meta-analyses were performed with the generic inverse-variance method with a random-effects model due to the high degree of heterogeneity. The primary outcome measure was hazard ratio (HR) with 95% confidence intervals (CI). The study protocol was registered with the PROSPERO registry (Registration Number: CRD42022337746). Results: Thirty-six studies encompassing 8406 cancer patients with advanced disease were included in the meta-analyses. Almost half of the studies were conducted in NSCLC cohorts (n = 15), and 3.5 gr/dL was the most frequently used albumin cut-off in the included studies (n = 20). Patients with lower albumin levels had a significantly increased risk of death (HR: 1.65, 95% CI: 1.52-1.80, p < 0.0001) than patients with higher albumin levels. Subgroup analyses for study location, sample size, tumor type and albumin cut-off were demonstrated consistent results. Furthermore, in the subgroup analysis of eight studies using albumin levels as a continuous prognostic factor, every 1 gr/dL decrease in albumin levels was associated with significantly increased risk of death by a factor of 10% (HR: 1.10, 95% CI: 1.05-1.16, p = 0.0002). Similar to analyses with overall survival, the patients with lower albumin levels had an increased risk of progression or death compared to patients with higher albumin levels (HR: 1.76, 95% CI: 1.40-2.21, p < 0.001). Conclusion: The available evidence demonstrates that albumin levels may be a prognostic biomarker in advanced cancer patients treated with ICIs. Further research is needed to delineate the role of albumin levels in patients treated with ICIs in the adjuvant setting, as well as the possible benefit of therapeutic approaches to improve hypoalbuminemia.
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Affiliation(s)
- Deniz Can Guven
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Taha Koray Sahin
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Enes Erul
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alessandro Rizzo
- Struttura Semplice Dipartimentale di Oncologia Medica per La Presa in Carico Globale Del Paziente Oncologico “Don Tonino Bello”, Bari, Italy
| | - Angela Dalia Ricci
- Medical Oncology Unit, National Institute of Gastroenterology, “Saverio de Bellis” Research Hospital, Castellana Grotte, Italy
| | - Sercan Aksoy
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Suayib Yalcin
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
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Lu H, Zhou L, Zhang B, Xie Y, Yang H, Wang Z. Cuproptosis key gene FDX1 is a prognostic biomarker and associated with immune infiltration in glioma. Front Med (Lausanne) 2022; 9:939776. [PMID: 36523779 PMCID: PMC9745336 DOI: 10.3389/fmed.2022.939776] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/26/2022] [Indexed: 07/27/2023] Open
Abstract
Recent studies have found that the protein encoded by the FDX1 gene is involved in mediating Cuproptosis as a regulator of protein lipoylation and related to immune response process of tumors. However, the specific biological function of FDX1 in glioma is currently unclear. To explore the potential function of FDX1, this study explored the correlation between the expression of FDX1 in cancers and survival prognosis by analyzing the public databases of GEPIA and Cbioportal. Immune infiltration was analyzed by the TIMER2.0 database in tumors. The possible biological processes and functions of FDX1-related in glioma were annotated through gene enrichment. Relationship between Cuproptosis and autophagy was explored through gene co-expression studies. Summary and conclusions of this study: (1) FDX1 is highly expressed in gliomas and associated with poor prognosis in low-grade gliomas (LGG). (2) Gene annotation indicates that FDX1 is mainly involved in the tumor protein lipoylation and cell death. (3) FDX1 expression is positively correlated with the infiltration of immune cells. (4) LIPT2 and NNAT, two other genes involved in lipoylation, may be unidentified marker gene for Cuproptosis. And the Cuproptosis genes related to FDX1 were positively correlated with the expression of autophagy marker genes Atg5, Atg12, and BECN-1. This evidence suggests that there may be some interaction between FDX1 mediated Cuproptosis and autophagy. In summary, FDX1 may serve as a potential immunotherapy target and prognostic marker for Glioma.
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Affiliation(s)
- Hanwen Lu
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
- Institute of Neurosurgery, School of Medicine, Xiamen University, Xiamen, China
| | - Liwei Zhou
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Bingchang Zhang
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yuanyuan Xie
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Huiyin Yang
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
- Institute of Neurosurgery, School of Medicine, Xiamen University, Xiamen, China
| | - Zhanxiang Wang
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
- Institute of Neurosurgery, School of Medicine, Xiamen University, Xiamen, China
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
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Graham PT, Nowak AK, Cornwall SMJ, Larma I, Nelson DJ. The STING agonist, DMXAA, reduces tumor vessels and enhances mesothelioma tumor antigen presentation yet blunts cytotoxic T cell function in a murine model. Front Immunol 2022; 13:969678. [PMID: 36466911 PMCID: PMC9716460 DOI: 10.3389/fimmu.2022.969678] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/20/2022] [Indexed: 08/22/2023] Open
Abstract
We assessed the murine Stimulator of Interferon Genes (STING) agonist, DMXAA, for anti-mesothelioma potential using the AE17-sOVA model that expresses ovalbumin (OVA) as a neo tumor antigen. Dose response experiments alongside testing different routes of administration identified a safe effective treatment regimen that induced 100% cures in mice with small or large tumors. Three doses of 25mg/kg DMXAA given intra-tumorally every 9 days induced tumor regression and long-term survival (>5 months). Re-challenge experiments showed that tumor-free mice developed protective memory. MTT and propidium-iodide assays showed that DMXAA exerted direct cytotoxic effects at doses >1mg/ml on the murine AE17 and AB1 mesothelioma cell lines. In-vivo studies using a CFSE-based in-vivo proliferation assay showed that DMXAA improved tumor-antigen presentation in tumor-draining lymph nodes, evidenced by OVA-specific OT-1 T cells undergoing more divisions. An in-vivo cytotoxic T lymphocyte (CTL) assay showed that DMXAA blunted the lytic quality of CTLs recognizing the dominant (SIINFEKL) and a subdominant (KVVRFDKL) OVA epitopes. DMXAA reduced tumor vessel size in-vivo and although the proportion of T cells infiltrating tumors reduced, the proportion of tumor-specific T cells increased. These data show careful dosing and treatment protocols reduce mesothelioma cell viability and modulate tumor vessels such that tumor-antigen specific CTLs access the tumor site. However, attempts to enhance DMXAA-induced anti-tumor responses by combination with an agonist anti-CD40 antibody or IL-2 reduced efficacy. These proof-of-concept data suggest that mesothelioma patients could benefit from treatment with a STING agonist, but combination with immunotherapy should be cautiously undertaken.
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Affiliation(s)
- Peter T. Graham
- School of Medicine, Curtin University, Bentley, WA, Australia
| | - Anna K. Nowak
- Medical School, University of Western Australia, Nedlands, WA, Australia
- National Centre for Asbestos Related Diseases, Nedlands, WA, Australia
- Institute of Respiratory Health, Nedlands, WA, Australia
| | | | - Irma Larma
- Becton Dickinson Pty Limited, Osborne Park, WA, Australia
| | - Delia J. Nelson
- School of Medicine, Curtin University, Bentley, WA, Australia
- Curtin Health Innovation Research Institute, Bentley, WA, Australia
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