Abstract LB173: AACR President's initiative - 2020 by 2020: Democratizing precision cancer medicine and advancing health equity in the black belt

African Americans (AA) have higher incidence and mortality rates for several cancer types in comparison to their European American (EA) counterparts. Increasing participation in clinical research and patient registries, related to precision cancer medicine, will significantly improve cancer health equity. Many AA cancer patients are treated in community oncology clinics. Unfortunately, these health systems have limited access to Clinical Laboratory Improvement Amendments (CLIA) next generation sequence (NGS) germline and somatic DNA and RNA testing that are used to inform oncologists on the best treatment and/or clinical trial options for cancer patients. Indeed, AA CLIA NGS sample sets are poorly represented, which could presumably result in incomplete knowledge of genomic variants that could affect their treatment and overall outcomes. Hence, it is crucial to implement CLIA NGS efforts for all cancer patients. To address these disparities, Morehouse School of Medicine has formed the Comprehensive Approach to Reimagine health Equity Solutions (CARhES) consortium with Tuskegee University that has engaged community oncology practices in Alabama and Georgia - two of five Black Belt states. The CARhES consortium aims to implement precision cancer medicine to underserved and underrepresented communities that will improve the standard of cancer care by providing access to CLIA NGS testing, clinical trials, and personalized cancer care. Here we describe the first proof of concept of this approach with community oncology partners, i.e., Grady Health System, Wellstar Health System, Georgia Urology, Midtown Urology, and Maui Memorial Medical Center. At the time of consent, saliva, buccal, and tumor samples were collected from participants. Germline and somatic CLIA NGS was performed, and medical reports were returned to practitioners within 14 days. Prior to the COVID pandemic, the study enrolled over 880 patients with a 88% consent rate (n = 1000) in the first 11months of the program. At the start of the COVID pandemic, recruitment efforts were suspended for four months with a slow restart by June 2020. A decrease in the number of staff, office visits (67% reduction), and increase in COVID cases significantly limited recruitment efforts. During this slowdown, we established and improved eConsenting capabilities, which exist today. Community anxiety, due to the pandemic and SARS-CoV-19 vaccine efforts, resulted in a significant reduction in consent rates (88% to 60%). Nevertheless, this study began in April of 2019 and consented 1,750 participants in less than 2 years. Taken together, our study shows that a community-focused precision medicine approach requires meeting people where they are and providing them with access and understanding the benefit of clinical trial participation. The approximate 2,000 clinically annotated genomic AA datasets will greatly contribute to our understanding of cancer health disparities and among the first steps to democratize precision medicine.

This study was funded by the American Association for Cancer Research, The Pelotonia Foundation, the M2Gen Foundation, and the National Cancer Institute (U54CA118638).

Citation Format: Latrisha L. Horne, Gabriella M. Oprea-Ilies, Eddie R. Stanley, Carla M. Holloway, Margaret P. Hooker, Amina Isom, Derrick J. Beech, Ana Gaonkar, Shavette Harden, Jeffrey F. Hines, LaTonya Randolph, James K. Bennett, Daniel Canter, Darrell J. Carmen, Pooja Mishra, Giuseppe Del Priore, Roland Matthews, Brian M. Rivers, James W. Lillard. AACR President's initiative - 2020 by 2020: Democratizing precision cancer medicine and advancing health equity in the black belt [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB173.

Terazosin for vesicosphincter dyssynergia in spinal cord-injured male patients

PURPOSE

Evaluation of the role of the long-acting alpha-adrenergic blocker, terazosin, in the treatment of vesicosphincter dyssynergia (VSD) in spinal cord-injured male patients.

PATIENTS AND METHODS

Sixty spinal cord-injured male patients with VSD were recruited prospectively. Their mean age was 37 years (range 15-70 years). Baseline evaluation included a thorough medical history, clinical examination, blood pressure measurement, intravenous urogram, and videourodynamics. The patients received terazosin for a 90-day period. Videourodynamic evaluation after completion of the study included cystometrogram, sphincter electromyography, maximum urethral pressure gradient (MUPG), and measurement of post voiding residual (PVR) urine volume. The findings were compared with the pretreatment values.

RESULTS

Of the 60 patients, 35 completed the study. According to response to treatment, two groups were identified: Group A = responders (N = 17; 49%) and Group B = nonresponders (N = 18, 51%). In Group A, there was a significant decrease in the maximum detrusor pressure, from a mean of 105.3 to 73.9 cm H(2)O, and in MUPG, from a mean of 84.7 to 54.1 cm H(2)O. The bladder capacity and PVR did not change significantly in either group. The time since injury was significantly longer in Group A than in Group B.

CONCLUSIONS

Terazosin in a dose of 10 mg/day was well tolerated and effective in reducing bladder outlet obstruction in many spinal cord-injured patients, as reflected by a decrease in maximum detrusor pressure and MUPG in 49% of the patients. Patients with a weak or negative response initially may respond later. Terazosin should be considered a first-line treatment of VSD prior to contemplating surgery.

A whole-glove method for the evaluation of surgical gloves as barriers to viruses

BACKGROUND

Today, because of the wide variety of infectious agents encountered in the health care environment, clinicians must be particularly concerned about the potential for small-sized virus penetration through glove defects.

OBJECTIVE

To describe a method for testing gloves that evaluates the entire glove and allows for detection of low levels of virus penetration. Ten sets of 10 different gloves from 4 manufacturers were evaluated using this method.

METHODS

Barrier properties were evaluated using the bacteriophage, phiX174. Gloves were filled with surfactant solution placed in flasks containing 10(6) viruses per mL. Flasks were agitated at 37 degrees C +/- 2 degrees C and assayed for 180 minutes.

RESULTS

Virus penetration was detected in 8% of the 100 gloves tested using the quantitative assay. The qualitative assay determined that 14% of the gloves tested allowed penetration.

Sphincteric stent versus external sphincterotomy in spinal cord injured men: prospective randomized multicenter trial

PURPOSE

In a prospective randomized multicenter trial we compared the treatment results of conventional external sphincterotomy with those of UroLume sphincteric stent prosthesis placement in men with spinal cord injury and external detrusor-sphincter dyssynergia.

MATERIALS AND METHODS

We randomized 57 men with spinal cord injury in whom urodynamics verified external detrusor-sphincter dyssynergia into 2 groups to undergo either sphincter defeating procedure. We compared the primary urodynamic parameter of maximum detrusor pressure, and secondary urodynamic parameters of bladder capacity and post-void residual urine volume in men who underwent sphincterotomy or sphincteric stent placement. Parameters were measured preoperatively, and 3, 6, 12 and 24 months postoperatively. Patients completed questionnaires regarding voiding sensation and quality of life issues at each followup visit.

RESULTS

Demographic data of the 26 patients treated with sphincterotomy and the 31 treated with sphincteric stent placement were statistically similar. Preoperatively mean maximum detrusor pressure plus or minus standard deviation in sphincterotomy and stent cases was 98.3 +/- 27.6 and 95.7 +/- 27.7 cm. water, respectively (p = 0.73). At 12 months mean maximum detrusor pressure decreased to 48.9 +/- 16.4 and 52.6 +/- 31.6 cm. water in the sphincterotomy and stent groups, respectively (p = 0). Preoperatively mean bladder capacity in sphincterotomy and stent cases was 245 +/- 158 and 251 +/- 145 ml., respectively (p = 0.87). Bladder capacity did not change significantly in either treatment group throughout followup. Preoperatively mean post-void residual urine volume in the sphincterotomy and stent groups was 212 +/- 163 and 168 +/- 114 ml., respectively (p = 0.33). Residual urine volume decreased in each group at some but not all followup evaluations. The duration of hospitalization was greater for sphincterotomy than stenting (p = 0.036). Six stents required explantation.

CONCLUSIONS

The UroLume stent is as effective as conventional external sphincterotomy for treating external detrusor-sphincter dyssynergia. However, sphincteric stent placement is advantageous because it involves shorter hospitalization and is potentially reversible.

Treating urinary incontinence in the elderly population: accepting the challenge

Health care professionals who choose to treat the elderly have a responsibility to be knowledgeable about incontinence. The elderly present challenging and complex problems that may require a collaborative approach from a dedicated team, to include family members, home health nurses, continence nurses, physical therapists, as well as primary care physicians, geriatricians, urologists, and gynecologists. The elderly patient should be reminded that they are a member of that team and their commitment and participation will facilitate successful outcomes.

Epidemiology of current treatment for sexual dysfunction in spinal cord injured men in the USA model spinal cord injury centers

This study is a prospective multicenter cooperative survey of the evaluation and treatment of erectile dysfunction in men with spinal cord injury (SCI). Uniform database questionnaires were completed prospectively by patients seeking therapy for erectile dysfunction. Eighty-five SCI men aged 17-68 years (mean age = 26 +/- 17) were enrolled. Mean duration of traumatic SCI was 3 +/- 3.2 years (Range = 0.3-18 years). The level of injury was cervical in 20 patients, thoracic in 31, lumbar in 29 and sacral in five. Patients were fully evaluated and then counseled as to their therapeutic options. Twenty-eight chose to use a vacuum erection device (VED), 26 preferred pharmacological penile injection and five used both intracorporeal therapy and VED. The remainder were managed with marriage and sexual counseling in 10 patients, three underwent penile prosthesis placement and two used topical pharmacotherapy. Four patients used other forms of treatment and in nine no therapy was recommended. Of the patients that used pharmacologic injection only, 74 percent used papaverine as a single agent, 20 percent used papaverine with phentolamine, five percent used prostaglandin E (PGE1) alone and one percent used a mixture. Patients using injection therapy report sexual intercourse a mean of 3 +/- 3.4 times per month as compared with 5 +/- 3.2 times per month in those using VED. Five intracorporeal injection patients developed priapism while two patients using the VED developed subcutaneous bleeding and one developed penile ischemia. We conclude that although a spectrum of erectile dysfunction treatment is present among SCI centers, VED and pharmacological penile injection are by far the two most popular methods of treatment and papaverine is the most common drug. The incidence of complications is small in the model centers.

Reversible clinical outcome after sphincter stent removal

PURPOSE

We determined whether the self-expanding sphincter stent, a potential alternative to conventional external sphincterotomy for the treatment of detrusor external sphincter dyssynergia, causes a permanent effect on the lower urinary tract.

MATERIALS AND METHODS

Four spinal cord injured men with voiding symptoms of detrusor external sphincter dyssynergia as noted by complete urological evaluation, including a video urodynamic study, were treated with the self-expanding sphincter stent. However, the device was explanted 6 months or longer after insertion in all 4 cases due to stent migration (3) and difficulty with condom catheter urinary drainage (1).

RESULTS

All stents were removed completely without damage to the urethra. Mean voiding pressure decreased from 62.5 +/- 39.4 to 20.7 +/- 6.5 cm. water after sphincter stent placement. One year after stent explantation mean voiding pressure remained unchanged from preoperative values of 58.5 +/- 21.5 cm. water. No patient had stress urinary incontinence or endoscopically apparent urethral strictures.

CONCLUSIONS

The stent can be removed even after complete epithelialization and an extended interval without damage to external sphincter function or urethral stricture formation. The urinary sphincter stent is an effective, reversible treatment for patients with detrusor external sphincter dyssynergia.

Collagen injections for intrinsic sphincter deficiency in the neuropathic urethra

Twelve subjects experiencing stress urinary incontinence caused by spinal injury or myelomeningocele were treated by periurethral injection of a bulking agent, glutaraldehyde cross-linked (GAX) collagen. Of the 11 subjects who completed the program, seven were either cured or improved and four were only slightly improved or no better following injection. The valsalva (abdominal) leak point pressure (LPP) rose an average of 57 cm H2O (pre-treatment mean of 60 cm H2O versus post-treatment mean of 117 cm H2O) and none of the patients experienced significant complications during the mean follow-up period of 24 months. Every subject injected was able to maintain an intermittent catheterization program after treatment. These data support the use of GAX collagen as an alternative or adjunct therapy to pharmacotherapy, surgical reconstruction or implantation of a prosthesis in the management of stress urinary incontinence in the neuropathic urethra.

The nonrefluxing ileal conduit: a new form of urinary diversion

PURPOSE

We describe a variation of the ileal conduit that includes a nonrefluxing nipple valve designed to protect the upper urinary tracts.

MATERIALS AND METHODS

A total of 13 patients underwent urinary diversion with the nonrefluxing ileal conduit. The nonrefluxing nipple valve is created by intussuscepting the ileum into the conduit.

RESULTS

Followup ranged from 3 to 35 months. No patient demonstrated radiographic deterioration of the upper tracts or a clinically significant increase in serum creatinine level during followup.

CONCLUSIONS

The nonrefluxing ileal conduit appears to be a viable treatment option in select patients with neurogenic bladder dysfunction.

Management of sphincter dyssynergia using the sphincter stent prosthesis in chronically catheterized SCI men

This effort represents a subset analysis of the long-term Multicenter North American Trial of the UroLume sphincter stent prosthesis to determine the effect of the sphincter stent prosthesis in SCI men afflicted with detrusor-external sphincter dyssynergia (DESD) and chronically managed with an indwelling urinary catheter. Forty-one of 153 male patients in this study were evaluated urodynamically before and after placement of the sphincter stent prosthesis. Of the 41 patients, 34 (81 percent) suffered cervical-level injury while 10 patients (25 percent) had been treated previously with external sphincterotomy. Forty patients (98 percent) were troubled with recurrent urinary tract infections (UTI), with a mean of 4.6 +/- 3 episodes of UTI per year. Seven patients (17 percent) demonstrated hydronephrosis prior to stent placement. Follow-up ranged from six to 44 months. Voiding pressures decreased from a mean of 77 +/- 23 cmH2O preoperatively to 35 +/- 18 cmH2O at 12 months (n = 34) and 33 +/- 20 cmH2O at 24 months (n = 22) after stent insertion (p = 0.001). Post-void residual urinary volume decreased from 202 +/- 187 ml preinsertion to 64 +/- 69 ml at 24 months (p = 0.001) postinsertion. Maximum cystometric capacity remained constant at 201 +/- 144 ml preinsertion to 203 +/- 79 ml at 24 months (p = 0.75) postinsertion. No significant changes in any of the urodynamic parameters occurred after 24 months of follow-up between patients with (n = 10) and without (n = 31) previous external sphincterotomy. Neither hemorrhage requiring blood transfusion, obstructive hyperplastic epithelial overgrowth, stent encrustation or stone formation, nor soft tissue erosion occurred in any patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Electroejaculation in combination with in vitro fertilization and gamete micromanipulation for treatment of anejaculatory male infertility

OBJECTIVE

Failure to ejaculate may be overcome by use of electroejaculation. However, such semen samples are often unsuitable for therapies like intrauterine insemination. The combination of electroejaculation with in vitro fertilization, including gamete micromanipulation, should improve chances of fertilization and pregnancy in such cases.

STUDY DESIGN

Within a private infertility clinic electroejaculation in combination with intrauterine insemination was carried out in 18 cycles (10 couples). Four couples went on to receive therapy by electroejaculation plus in vitro fertilization, along with six other couples (15 cycles total) with semen too poor for intrauterine insemination.

RESULTS

One term pregnancy arose in the electroejaculation-intrauterine insemination group, and one term pregnancy plus one continuing pregnancy arose from two couples (three cycles) who underwent in vitro fertilization with conventional insemination after electroejaculation. Six couples (nine cycles) had embryos arising only from gamete micromanipulation transferred, and this yielded two term pregnancies, one spontaneous abortion, and a biochemical pregnancy. Two couples (three cycles) failed to achieve fertilization even with micromanipulation; however, donor-inseminated eggs gave rise to two term pregnancies and one continuing pregnancy in these patients.

CONCLUSIONS

This report confirms the feasibility of in vitro fertilization in conjunction with electroejaculation and extends the therapy to incorporate gamete micromanipulation.

The value of urodynamics and bladder management in predicting upper urinary tract complications in male spinal cord injury patients

A review of 160 male patients admitted to the Shepherd Spinal Center was completed to determine the influence of urodynamic findings and choice of bladder management program on the risk of developing upper urinary tract distress following acute spinal injury. Within the context of this investigation, upper urinary tract distress was defined as presence of hydronephrosis, febrile urinary tract infection, urolithasis or vesicoureteral reflux. Three groups were identified according to the urodynamic findings and the bladder management program. Thirty-four subjects with preservation of detrusor function managed their bladders by spontaneous voiding. Seventy patients with detrusor areflexia managed their bladders via intermittent catheterization; and 56 males who had detrusor hyperreflexia on urodynamics were managed by a reflex voiding program with condom drainage. None of the subjects with preservation of spontaneous voiding function experienced upper tract distress. Seven percent of those on intermittent catheterization and 32% of those managed by a reflex voiding program experienced upper tract distress. The presence of detrusor hyperreflexia with or without vesicosphincter dyssynergia influenced the likelihood that subjects would experience upper urinary tract distress following spinal injury. While traditional urodynamics failed to distinguish patients managed by a reflex voiding program who experienced upper tract distress from those who did not, calculation of a new urodynamic variable, the urethral pressure gradient, was found to assist in this prediction.

Age-dependent changes in activity of mallard plasma cholinesterases

Plasma acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activity was measured repeatedly in 27 mallard (Anas platyrhynchos) ducklings between 7 and 85 days of age to determine age-dependent changes in enzyme activity. Plasma AChE, BChE, and total cholinesterase (ChE) activity decreased significantly with age. The relative proportion of AChE in total ChE activity also decreased slightly with age. Since some anti-ChE chemicals can selectively inhibit AChE or BChE activity, characterization of age-dependent changes in the activity of each enzyme may be necessary to accurately identify the occurrence of pesticide exposure.

Nonmetastatic bladder cancer associated with hypercalcemia, thrombocytosis and leukemoid reaction

We reviewed 4 patients with urothelial bladder cancer and hypercalcemia but without evidence of bony metastasis. Of the patients 2 presented with a leukemoid reaction (1 also had thrombocytosis). None of the patients had evidence of bone metastases or other causes of hypercalcemia, such as hyperparathyroidism, sarcoidosis or vitamin D intoxication. All 4 patients received aggressive therapy for the tumors. In each instance the serum calcium returned to normal following radiation therapy or tumor removal, lending support to the theory of humoral hypercalcemia of cancer. A diagnostic and therapeutic approach to such patients is outlined.

Urachal adenocarcinoma presenting as vesicoenteric fistula

We report a case, which we believe to be the first, of urachal carcinoma presenting as vesicoenteric fistula.

10-year experience with adenocarcinoma of the bladder

Adenocarcinoma is an uncommon form of bladder carcinoma. We review our 10-year experience with primary adenocarcinoma of the bladder in 28 patients who were managed by a wide range of therapeutic modalities. Our data reaffirm the highly aggressive nature of this lesion. However, aggressive therapy is justified when feasible.