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Pozzar RA, Wall JA, Tavormina A, Thompson E, Enzinger AC, Matulonis UA, Campos S, Meyer LA, Wright AA. Experiences of patients with peritoneal carcinomatosis-related complex care needs and their caregivers. Gynecol Oncol 2024; 181:68-75. [PMID: 38141533 PMCID: PMC10922890 DOI: 10.1016/j.ygyno.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/03/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Patients with peritoneal carcinomatosis (PC) frequently undergo palliative procedures, yet these patients and their caregivers report being unprepared to manage ostomies, drains, and other complex care needs at home. The purpose of this study was to characterize the unique needs of these patients and their caregivers during care transitions. METHODS Patients completed measures of health status and advance care planning, caregivers completed measures of preparedness and burden, and all participants completed measures of depression and anxiety. Participants detailed their experiences in individual, semi-structured interviews. We analyzed data using descriptive statistics and conventional content analysis. RESULTS Sixty-one patients and 39 caregivers completed baseline measures. Twenty-four (39.3%) patients acknowledged their terminal illness and seven (11.5%) had discussed end-of-life care preferences with clinicians. Most (26/39, 66.7%) caregivers provided daily care. Among caregivers who managed symptoms, few were taught how to do so (6/20, 30%). Seven patients (11.5%) and seven caregivers (17.9%) met case criteria for anxiety, while 15 patients (24.6%) and two caregivers (5.1%) met case criteria for depression. Interview participants described a diagnosis of PC as a turning point for which there is no road map and identified the need for health systems change to minimize suffering. CONCLUSION Patients with PC and their caregivers are highly burdened by symptoms and care needs. Patients' prognostic understanding and advance care planning are suboptimal. Interventions that train patients with PC and their caregivers to perform clinical care tasks, facilitate serious illness conversations, and provide psychosocial support are needed.
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Affiliation(s)
- Rachel A Pozzar
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Jaclyn A Wall
- University of Alabama, Birmingham, AL, United States
| | | | | | - Andrea C Enzinger
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Ursula A Matulonis
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Susana Campos
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Larissa A Meyer
- University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Alexi A Wright
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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Bratches RWR, Wall JA, Puga F, Pilonieta G, Jablonski R, Bakitas M, Geldmacher DS, Odom JN. Patient Portal Use Among Family Caregivers of Individuals With Dementia and Cancer: Regression Analysis From the National Study of Caregiving. JMIR Aging 2023; 6:e44166. [PMID: 38235767 PMCID: PMC10811454 DOI: 10.2196/44166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 08/10/2023] [Accepted: 08/25/2023] [Indexed: 01/19/2024] Open
Abstract
Background Family caregivers are often inexperienced and require information from clinic visits to effectively provide care for patients. Despite reported deficiencies, 68% of health systems facilitate sharing information with family caregivers through the patient portal. The patient portal is especially critical in the context of serious illnesses, like advanced cancer and dementia, where caregiving is intense and informational needs change over the trajectory of disease progression. Objective The objective of our study was to analyze a large, nationally representative sample of family caregivers from the National Study of Caregiving (NSOC) to determine individual characteristics and demographic factors associated with patient portal use among family caregivers of persons living with dementia and those living with cancer. Methods We conducted a secondary data analysis using data from the 2020 NSOC sample of family caregivers linked to National Health and Aging Trends Study. Weighted regression analysis by condition (ie, dementia or cancer) was used to examine associations between family caregiver use of the patient portal and demographic variables, including age, race or ethnicity, gender, employment status, caregiver health, education, and religiosity. Results A total of 462 participants (representing 4,589,844 weighted responses) were included in our analysis. In the fully adjusted regression model for caregivers of persons living with dementia, Hispanic ethnicity was associated with higher odds of patient portal use (OR: 2.81, 95% CI 1.05-7.57; P=.04), whereas qualification lower than a college degree was associated with lower odds of patient portal use by family caregiver (OR 0.36, 95% CI 0.18-0.71; P<.001. In the fully adjusted regression model for caregivers of persons living with cancer, no variables were found to be statistically significantly associated with patient portal use at the .05 level. Conclusions In our analysis of NSOC survey data, we found differences between how dementia and cancer caregivers access the patient portal. As the patient portal is a common method of connecting caregivers with information from clinic visits, future research should focus on understanding how the portal is used by the groups we have identified, and why.
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Affiliation(s)
- Reed W R Bratches
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - Jaclyn A Wall
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - Frank Puga
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - Giovanna Pilonieta
- Department of Neurology, University of Alabama at Birmingham, BirminghamAL, United States
| | - Rita Jablonski
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - Marie Bakitas
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - David S Geldmacher
- Department of Neurology, University of Alabama at Birmingham, BirminghamAL, United States
| | - J Nicholas Odom
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
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Wall JA, Lipking K, Smith HJ, Huh WK, Salter T, Liang MI. Moderate to severe distress in half of ovarian cancer patients undergoing treatment highlights a need for more proactive symptom and psychosocial management. Gynecol Oncol 2022; 166:503-507. [PMID: 35778291 PMCID: PMC9678245 DOI: 10.1016/j.ygyno.2022.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Distress screening and management is a recommended component of oncology care. Our objective was to evaluate distress rate, sources, and compliance with psychosocial follow-up among ovarian cancer patients receiving chemotherapy. METHODS We reviewed patient distress surveys completed by ovarian cancer patients receiving chemotherapy from 10/2017-6/2019. Lay or nurse navigators conducted screening with the NCCN Distress Thermometer from 0 (none) to 10 (highest distress). A distress score ≥ 4 (moderate/severe) was considered a positive screen. A recommendation for psychosocial follow-up was automatically generated in the treatment care plan based upon a yes response to any depression-related concern, independent of distress score. Documentation of referral to a mental health professional or social worker for counseling was considered compliant with psychosocial follow-up. We performed descriptive statistics and bivariate analyses. RESULTS 97/211 (46%) ovarian cancer patients screened positive for distress. Average score was 6.1 for those who screened positive and 3.3 for the entire cohort (range 0-10). Unmarried status (p < 0.01) was associated with positive screen, whereas non-white race (p = 0.26) and recurrent disease (p = 0.21) were not. Median age was older for patients with a positive distress screen (p < 0.01). Among screened patients, the most frequent sources of distress were: cognitive/physical (87%), psychosocial (62%), practical (84%), and family concerns (40%). Of 50 patients recommended to have psychosocial referral, 4 (8%) patients had documented psychiatric follow-up and 19 (38%) patients had documented psychosocial counseling by a social worker. CONCLUSIONS Nearly half of ovarian cancer patients screened positive for moderate/severe distress. Cancer/treatment-related cognitive/physical symptoms were the most frequent sources. Improved methods of symptom monitoring and management during treatment and resources to address psychosocial concerns are needed to improve distress management of ovarian cancer patients.
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Affiliation(s)
- Jaclyn A Wall
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, United States of America.
| | - Kelsey Lipking
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Haller J Smith
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, United States of America; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Warner K Huh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, United States of America; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Terri Salter
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Margaret I Liang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, United States of America; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
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Liang MI, Simons JL, Herbey II, Wall JA, Rucker LR, Ivankova NV, Huh WK, Pisu M. Navigating job and cancer demands during treatment: A qualitative study of ovarian cancer patients. Gynecol Oncol 2022; 166:481-486. [PMID: 35902296 PMCID: PMC10910482 DOI: 10.1016/j.ygyno.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Our objective was to obtain perspectives from ovarian cancer patients on job demands, cancer demands, and workplace or cancer resources and strategies to manage the cancer-work interface using the cancer-work management conceptual framework. METHODS We recruited ovarian cancer patients receiving systemic therapy who screened positive for financial distress using Comprehensive Score for Financial Toxicity <26. Interviews were conducted with participants about their costs of care, including employment concerns. Interviews were recorded, transcribed verbatim, and analyzed by three researchers using an inductive thematic analysis. RESULTS Of 22 participants, the average age was 57 years old, 36% were Black, 68% had income <$40,000, 41% had public insurance, and 68% were being treated for recurrent disease. Job demands included decreased productivity, inability to return to work, and worry about losing a job or employer-based health insurance coverage. Cancer demands included physical and cognitive limitations due to cancer treatment and reliance on caregivers, especially for transportation. Workplace resources/strategies including having a supportive employer, modifying job responsibilities, and utilizing family medical leave. Cancer care resources/strategies included planning appointments ahead of time and utilizing resources, such as disability. CONCLUSIONS Cancer care teams should consider screening patients for employment concerns; streamline care to minimize the side effects, time, and transportation demands of treatment on patients and caregivers; maximize utilization of available resources; and proactively communicate with employers to accommodate patients and caregivers who want or need to work.
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Affiliation(s)
- Margaret I Liang
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, United States of America; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - J Leahgrace Simons
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Ivan I Herbey
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Jaclyn A Wall
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Lindsay R Rucker
- Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Nataliya V Ivankova
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Warner K Huh
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, United States of America; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Maria Pisu
- Division of Preventive Medicine, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
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Arend RC, Goel N, Roane BM, Foxall ME, Dholakia J, Londoño AI, Wall JA, Leath CA, Huh WK. Systematic Next Generation Sequencing is feasible in clinical practice and identifies opportunities for targeted therapy in women with uterine cancer: Results from a prospective cohort study. Gynecol Oncol 2021; 163:85-92. [PMID: 34372972 DOI: 10.1016/j.ygyno.2021.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/02/2021] [Accepted: 07/09/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Both incidence and mortality of uterine cancer are on the rise and mortality is higher for African American women. The aim of our study was to evaluate how Next Generation Sequencing (NGS) may facilitate identification of and intervention for treatment disparities when integrated into clinical workflows. RESULTS Our cohort included 159 uterine cancer patients with recurrent/progressive and newly diagnosed advanced stage and/or high-risk histology. The most common tumor histological subtypes included EEC (n = 67), SEC (n = 34), UCS (n = 20), and mixed (n = 14). Black patients were most likely to present with aggressive histology: (SEC, 34.0%) and carcinosarcoma (UCS, 14.0%). The four most common mutations across all subtypes were TP53, PIK3CA, PTEN, and ARID1A. There was racial disparity between Black versus non-Black patients who were initiated on targeted therapy (28.2% vs. 38.2%, respectively) and clinical trial (15% vs. 22.6%, respectively). Compared to non-Black patients, Black patients had a significantly higher percentage TP53 mutations (p < 0.05) and a significantly lower percentage ARID1A mutations (p < 0.05). CONCLUSIONS NGS for uterine malignancies provides actionable information for targetable mutations and/or clinical trial enrollment in most patients; further investigation is necessary to identify potentially modifiable factors contributing to current disparities that may improve targeted therapy uptake and clinical trial participation.
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Affiliation(s)
- Rebecca C Arend
- University of Alabama in Birmingham, Division of Gynecologic Oncology, Birmingham, AL, United States of America.
| | - Nidhi Goel
- University of Alabama School of Medicine, Birmingham, AL, United States of America
| | - Brandon M Roane
- University of Alabama in Birmingham, Division of Gynecologic Oncology, Birmingham, AL, United States of America
| | - McKenzie E Foxall
- University of Alabama in Birmingham, Division of Gynecologic Oncology, Birmingham, AL, United States of America
| | - Jhalak Dholakia
- University of Alabama in Birmingham, Division of Gynecologic Oncology, Birmingham, AL, United States of America
| | - Angelina I Londoño
- University of Alabama in Birmingham, Division of Gynecologic Oncology, Birmingham, AL, United States of America
| | - Jaclyn A Wall
- University of Alabama in Birmingham, Division of Gynecologic Oncology, Birmingham, AL, United States of America
| | - Charles A Leath
- University of Alabama in Birmingham, Division of Gynecologic Oncology, Birmingham, AL, United States of America
| | - Warner K Huh
- University of Alabama in Birmingham, Division of Gynecologic Oncology, Birmingham, AL, United States of America
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Goel N, Foxall ME, Scalise CB, Wall JA, Arend RC. Strategies in Overcoming Homologous Recombination Proficiency and PARP Inhibitor Resistance. Mol Cancer Ther 2021; 20:1542-1549. [PMID: 34172532 DOI: 10.1158/1535-7163.mct-20-0992] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/21/2021] [Accepted: 06/23/2021] [Indexed: 11/16/2022]
Abstract
Ovarian cancer is the second most common gynecologic malignancy in the United States and the most common cause of gynecologic cancer-related death. The majority of ovarian cancers ultimately recur despite excellent response rates to upfront platinum- and taxane-based chemotherapy. Maintenance therapy after frontline treatment has emerged in recent years as an effective tool for extending the platinum-free interval of these patients. Maintenance therapy with PARP inhibitors (PARPis), in particular, has become part of standard of care in the upfront setting and in patients with platinum-sensitive disease. Homologous recombination deficient (HRD) tumors have a nonfunctioning homologous recombination repair (HRR) pathway and respond well to PARPis, which takes advantage of synthetic lethality by concomitantly impairing DNA repair mechanisms. Conversely, patients with a functioning HRR pathway, that is, HR-proficient tumors, can still elicit benefit from PARPi, but the efficacy is not as remarkable as what is seen in HRD tumors. PARPis are ineffective in some patients due to HR proficiency, which is either inherent to the tumor or potentially acquired as a method of therapeutic resistance. This review seeks to outline current strategies employed by clinicians and scientists to overcome PARPi resistance-either acquired or inherent to the tumor.
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Affiliation(s)
- Nidhi Goel
- University of Alabama School of Medicine, Birmingham, Alabama
| | - McKenzie E Foxall
- Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carly Bess Scalise
- Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jaclyn A Wall
- Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rebecca C Arend
- Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, Alabama.
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Wall JA, Meza-Perez S, Scalise CB, Katre A, Londoño AI, Turbitt WJ, Randall T, Norian LA, Arend RC. Manipulating the Wnt/β-catenin signaling pathway to promote anti-tumor immune infiltration into the TME to sensitize ovarian cancer to ICB therapy. Gynecol Oncol 2020; 160:285-294. [PMID: 33168307 DOI: 10.1016/j.ygyno.2020.10.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/25/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Immune checkpoint blockade (ICB) therapy shows limited efficacy in ovarian cancers due to the "cold" immune phenotype surrounding these tumors. Previous studies have shown that in ovarian cancer Wnt/β-catenin pathway activation contributes to this immune phenotype. Here, we evaluated the anti-tumor and immune-enhancing properties of the Wnt inhibitor, CGX-1321, used alone or in combination with either DKN-01 or anti-PD-1 therapy, in pre-clinical ovarian cancer models. METHODS The parental ID8 murine ovarian cancer model harboring a knock-out of p53 (ID8p53-/-) and MISIIR-Tag spontaneous ovarian cancer models were used to test the effects of CGX-1321 alone or in combination therapies on tumor burden and immune cell landscape in the tumor microenvironment (TME). Flow cytometry and NanoString analyses were used to characterize the changes in tumor-intrinsic signaling and immune-related profiles in the TME of ovarian cancer in response to treatments. RESULTS CGX-1321 significantly reduced tumor burden and constrained tumor progression in the ID8p53-/- and MISIIR-Tag models. Furthermore, CGX-1321 increased infiltrating CD8+ T cells in the TME. Combining CGX-1321 with either DKN-01 or anti-PD-1 therapy also decreased tumor burden and increased CD8+ T cell infiltration in the omentum TME but did not do so to a greater extent that CGX-1321 monotherapy. CONCLUSIONS CGX-1321 significantly reduced tumor burden and enhanced CD8+ T cell levels in ovarian cancer, nevertheless the addition of DKN-01 or anti-PD-1 therapies did not enhance these effects of CGX-1321. Further investigation is needed to determine if CGX-1321 + DKN-01 combination treatment sensitizes pre-clinical ovarian cancer to ICB therapy.
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Affiliation(s)
- J A Wall
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - S Meza-Perez
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - C B Scalise
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - A Katre
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - A I Londoño
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - W J Turbitt
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - T Randall
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - L A Norian
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35294, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - R C Arend
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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Gentry ZL, Wall JA, Ostby SA, Michael Straughn J, Leath CA. Invasive Procedure Use for Symptomatic Ascites and Pleural Effusions Management in Recurrent Epithelial Ovarian Cancer Patients in the Era of Vascular Endothelial Growth Factor (VEGF) Inhibitor Therapy. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Betella I, Turbitt WJ, Szul T, BinghaoWu, Martinez A, Katre A, Wall JA, Norian L, Birrer MJ, Arend R. Corrigendum to 'Wnt signaling modulator DKK1 as an immunotherapeutic target in ovarian cancer' [Gynecologic Oncology 157 (2020) 765-774]. Gynecol Oncol 2020; 159:295. [PMID: 32839025 DOI: 10.1016/j.ygyno.2020.07.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ilaria Betella
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America; Department of Gynecologic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - William J Turbitt
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Tomasz Szul
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - BinghaoWu
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States of America
| | - Alba Martinez
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Ashwini Katre
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Jaclyn A Wall
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Lyse Norian
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Michael J Birrer
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Arkansas Winthrop P. Rockefeller Cancer Institute, United States of America
| | - Rebecca Arend
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America.
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Affiliation(s)
- Jaclyn A Wall
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca C Arend
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
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Betella I, Turbitt WJ, Szul T, Wu B, Martinez A, Katre A, Wall JA, Norian L, Birrer MJ, Arend R. Wnt signaling modulator DKK1 as an immunotherapeutic target in ovarian cancer. Gynecol Oncol 2020; 157:765-774. [PMID: 32192732 DOI: 10.1016/j.ygyno.2020.03.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/04/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Wnt pathway mutations are a hallmark of endometrioid and clear cell subtypes of epithelial ovarian carcinoma (EOC). However, no drugs targeting the Wnt pathway in EOC are FDA-approved. Dickkopf-related protein 1 (DKK1), a modulator of the Wnt pathway, has emerged as a promising therapeutic target. We aimed to examine the role of DKK1 and the effects of a monoclonal antibody against DKK1 (DKN-01) in vivo and in a murine model of ovarian cancer. METHODS We examined in vitro the role of DKK1 and the effects of DKK1 inhibition in EOC cell lines. We then studied in vivo the role of DKN-01 and DKK1 overexpression on tumor burden and anti-tumor immune cell populations using the ID8 syngeneic mouse model. RESULTS DKN-01 did not phenotypically alter ES2 cells in vitro; however, DKK1 inhibition promoted Wnt signaling. Tumor burden and immune populations were unchanged in ID8 challenged mice treated with mDKN01. Mice challenged with ID8 cells overexpressing DKK1 had tumor burden similar to controls (p = 0.175). However, the overexpression of DKK1 decreased CD45+ leukocyte infiltration into the peritoneum (p = 0.008) and omentum (p = 0.032), reducing both natural killer (NK) and CD8 T cells, and reducing interferon-gamma (IFNγ) expression on activated CD8 T cells. CONCLUSIONS Our results suggest that DKK1 inhibition does not affect tumor growth in the ID8 ovarian cancer model. DKK1 overexpression alters anti-tumor immune populations within the tumor microenvironment. Thus, our findings confirm DKK1 as a new therapeutic target in EOC and suggest that DKK1 inhibition may function best in a combinatorial, immune-modulatory therapy.
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Affiliation(s)
- Ilaria Betella
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America; Department of Gynecologic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - William J Turbitt
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Tomasz Szul
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Binghao Wu
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States of America
| | - Alba Martinez
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Ashwini Katre
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Jaclyn A Wall
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Lyse Norian
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Michael J Birrer
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Arkansas Winthrop P. Rockefeller Cancer Institute, United States of America
| | - Rebecca Arend
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America.
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Abstract
INTRODUCTION The Wnt/beta-catenin pathway is a complex signaling pathway known to be dysregulated in several cancers; Dickkopf-1 (Dkk1) is an inhibitor of canonical Wnt signaling via negative feedback. Elevated Dkk1 is associated with a poor prognosis in several cancers, including gynecologic and gastroesophageal malignancies. This review focuses on the potential therapeutic benefit of targeting Dkk1 with the IgG4 monoclonal antibody, DKN-01. AREAS COVERED We highlight current treatment approaches for advanced gynecologic and esophageal malignancies highlighting the need for more effective therapies, specifically improved immune-modulating agents and combinations. Our discussion of DKN-01 addresses the rationale for targeting Dkk1, available safety, pharmacokinetic and efficacy data. EXPERT OPINION DKN-01 presents an interesting therapeutic consideration in advanced gynecologic and gastroesophageal malignancies. It has been especially promising in patients with high-Dkk1-expressing tumors or known Wnt mutations. We postulate that the complementary mechanisms, limited adverse effects and emerging biomarker data position DKN-01 as a promising agent for combination therapy in patients with advanced malignancies. Specifically, we believe this occurs through an immuno-modulatory effect, primarily acting through the innate arm of the immune system. This highlights the possibility for addressing innate immune resistance and expanding the portion of patients who may benefit, possibly in a biomarker-selected manner.
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Affiliation(s)
- Jaclyn A Wall
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama , Birmingham, AL, USA
| | - Samuel J Klempner
- Division of Hematology-Oncology, Massachusetts General Hospital Cancer Center , Boston, MA, USA.,Department of Internal Medicine, Division of Hematology-Oncology, Harvard Medical School , Boston, MA, USA
| | - Rebecca C Arend
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama , Birmingham, AL, USA
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Arend RC, Beer HM, Cohen YC, Berlin S, Birrer MJ, Campos SM, Rachmilewitz Minei T, Harats D, Wall JA, Foxall ME, Penson RT. Ofranergene obadenovec (VB-111) in platinum-resistant ovarian cancer; favorable response rates in a phase I/II study are associated with an immunotherapeutic effect. Gynecol Oncol 2020; 157:578-584. [PMID: 32265057 DOI: 10.1016/j.ygyno.2020.02.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/24/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Report final results of a phase I/II study of VB-111, a targeted anti-cancer gene therapy with a dual mechanism: anti angiogenic/vascular disruption and induction of an anti-tumor directed immune response, in combination with paclitaxel in patients with platinum-resistant ovarian cancer. METHODS Study NCT01711970 was a prospective, open label, dose escalation study assessing combination treatment of VB-111 and weekly paclitaxel. In the Phase I part of the study, patients were treated with escalating doses of intravenous VB-111 and paclitaxel. In Phase 2, patients were treated with therapeutic doses of VB-111 and paclitaxel 80 mg/m2. Assessments included safety, overall survival (OS), progression free survival (PFS), and tumor response (CA-125 and RECIST). RESULTS 21 patients with recurrent platinum-resistant ovarian cancer were enrolled. 17/21 received the therapeutic dose. Patients had a median of 3 prior lines of therapy. Half of the subjects were platinum refractory, and half were previously treated with antiangiogenics. No DLTs were observed. VB-111 was well tolerated and associated with mild flu-like symptoms. In the therapeutic dose cohort, a 58% CA-125 GCIG response rate was seen in evaluable patients. The median OS was 16.6 months in patients treated with therapeutic dose compared to 5.8 months in sub-therapeutic dose (p = 0.028). Tumor specimens taken after treatment demonstrated tumor infiltrated with cytotoxic CD8 T-cells in regions of apoptotic cancer cells. CONCLUSIONS Treatment with VB-111 in combination with paclitaxel was safe and well tolerated. Favorable tumor responses and overall survival outcomes were associated with induction of an immunotherapeutic effect.
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Affiliation(s)
- Rebecca C Arend
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Hannah M Beer
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | | | | | - Michael J Birrer
- University of Arkansas for Medical Sciences, Little Rock, AK, USA
| | | | | | | | - Jaclyn A Wall
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - McKenzie E Foxall
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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Goldsberry WN, Meza-Perez S, Londoño AI, Katre AA, Mott BT, Roane BM, Goel N, Wall JA, Cooper SJ, Norian LA, Randall TD, Birrer MJ, Arend RC. Inhibiting WNT Ligand Production for Improved Immune Recognition in the Ovarian Tumor Microenvironment. Cancers (Basel) 2020; 12:cancers12030766. [PMID: 32213921 PMCID: PMC7140065 DOI: 10.3390/cancers12030766] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/21/2022] Open
Abstract
In ovarian cancer, upregulation of the Wnt/β–catenin pathway leads to chemoresistance and correlates with T cell exclusion from the tumor microenvironment (TME). Our objectives were to validate these findings in an independent cohort of ovarian cancer subjects and determine whether inhibiting the Wnt pathway in a syngeneic ovarian cancer murine model could create a more T-cell-inflamed TME, which would lead to decreased tumor growth and improved survival. We preformed RNA sequencing in a cohort of human high grade serous ovarian carcinoma subjects. We used CGX1321, an inhibitor to the porcupine (PORCN) enzyme that is necessary for secretion of WNT ligand, in mice with established ID8 tumors, a murine ovarian cancer cell line. In order to investigate the effect of decreased Wnt/β–catenin pathway activity in the dendritic cells (DCs), we injected ID8 cells in mice that lacked β–catenin specifically in DCs. Furthermore, to understand how much the effects of blocking the Wnt/β–catenin pathway are dependent on CD8+ T cells, we injected ID8 cells into mice with CD8+ T cell depletion. We confirmed a negative correlation between Wnt activity and T cell signature in our cohort. Decreasing WNT ligand production resulted in increases in T cell, macrophage and dendritic cell functions, decreased tumor burden and improved survival. Reduced tumor growth was found in mice that lacked β–catenin specifically in DCs. When CD8+ T cells were depleted, CGX1321 treatment did not have the same magnitude of effect on tumor growth. Our investigation confirmed an increase in Wnt activity correlated with a decreased T-cell-inflamed environment; a relationship that was further supported in our pre-clinical model that suggests inhibiting the Wnt/β–catenin pathway was associated with decreased tumor growth and improved survival via a partial dependence on CD8+ T cells.
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Affiliation(s)
- Whitney N. Goldsberry
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (A.I.L.); (A.A.K.); (B.T.M.); (B.M.R.); (N.G.); (J.A.W.); (M.J.B.); (R.C.A.)
- Correspondence:
| | - Selene Meza-Perez
- Division of Immunology & Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (S.M.-P.); (T.D.R.)
| | - Angelina I. Londoño
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (A.I.L.); (A.A.K.); (B.T.M.); (B.M.R.); (N.G.); (J.A.W.); (M.J.B.); (R.C.A.)
| | - Ashwini A. Katre
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (A.I.L.); (A.A.K.); (B.T.M.); (B.M.R.); (N.G.); (J.A.W.); (M.J.B.); (R.C.A.)
| | - Bryan T. Mott
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (A.I.L.); (A.A.K.); (B.T.M.); (B.M.R.); (N.G.); (J.A.W.); (M.J.B.); (R.C.A.)
| | - Brandon M. Roane
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (A.I.L.); (A.A.K.); (B.T.M.); (B.M.R.); (N.G.); (J.A.W.); (M.J.B.); (R.C.A.)
| | - Nidhi Goel
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (A.I.L.); (A.A.K.); (B.T.M.); (B.M.R.); (N.G.); (J.A.W.); (M.J.B.); (R.C.A.)
| | - Jaclyn A. Wall
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (A.I.L.); (A.A.K.); (B.T.M.); (B.M.R.); (N.G.); (J.A.W.); (M.J.B.); (R.C.A.)
| | - Sara J. Cooper
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA;
| | - Lyse A. Norian
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35294, USA;
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Troy D. Randall
- Division of Immunology & Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (S.M.-P.); (T.D.R.)
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Michael J. Birrer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (A.I.L.); (A.A.K.); (B.T.M.); (B.M.R.); (N.G.); (J.A.W.); (M.J.B.); (R.C.A.)
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Rebecca C. Arend
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA; (A.I.L.); (A.A.K.); (B.T.M.); (B.M.R.); (N.G.); (J.A.W.); (M.J.B.); (R.C.A.)
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Abstract
This research examined conflicts that occur across organizational boundaries, specifically between managed care organizations and health care providers. Using boundary spanning theory as a framework, the authors identified 3 factors in the 1st study (30 interviews) that influence this conflict: (a) organizational power, (b) personal status differences of the individuals handling the conflict, and (c) their previous interactions. These factors affected the individuals' behavioral responses or emotions, specifically anger. After developing hypotheses, the authors tested them in a 2nd study using 109 conflict incidents drawn from 9 different managed care organizations. The results revealed that organizational power affects behavioral responses, whereas status differences and previous negative interactions affect emotions.
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Affiliation(s)
- R R Callister
- Department of Management and Human Resources, Utah State University, Logan 84322, USA.
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Collins VP, Peterson M, Wall JA, Janes OG. A study of anatomy and dosimetry in the treatment of carcinoma of the uterus. Am J Roentgenol Radium Ther Nucl Med 1972; 114:123-30. [PMID: 5009404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Erez S, Kaplan AL, Wall JA. Clinical staging of carcinoma of the uterine tube. Obstet Gynecol 1967; 30:547-50. [PMID: 4167155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Wall JA, Collins VP, Kaplan AL, Hudgins PT. Adenocarcinoma of the endometrium. A review of 20 years' experience in private practice. Am J Obstet Gynecol 1967; 97:787-99. [PMID: 6019925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Wall JA, Kaplan AL, Janes G. Surgery in the management of carcinoma of the cervix. Tex Med 1966; 62:66-71. [PMID: 5980427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Wall JA, Collins VP, Hudgins PT, Kaplan AL, Adams RM. Carcinoma of the cervix. Review of clinical experience during a 20 year period (1946-1965). Am J Obstet Gynecol 1966; 96:57-63. [PMID: 5914607 DOI: 10.1016/s0002-9378(16)34641-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Kaplan AL, Wall JA. Pelvic exenteration: appraisal. Tex Med 1966; 62:46-8. [PMID: 5946336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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