Feasibility and User Experience of Digital Patient Monitoring for Real-World Patients With Lung or Breast Cancer

BACKGROUND

Digital patient monitoring (DPM) tools can facilitate early symptom management for patients with cancer through systematic symptom reporting; however, low adherence can be a challenge. We assessed patient/healthcare professional (HCP) use of DPM in routine clinical practice.

MATERIALS AND METHODS

Patients with locally advanced/metastatic lung cancer or HER2-positive breast cancer received locally approved/reimbursed drugs alongside DPM, with elements tailored by F. Hoffmann-La Roche Ltd, on the Kaiku Health DPM platform. Patient access to the DPM tool was through their own devices (eg, laptops, PCs, smartphones, or tablets), via either a browser or an app on Apple iOS or Android devices. Coprimary endpoints were patient DPM tool adoption (positive threshold: 60%) and week 1-6 adherence to weekly symptom reporting (positive threshold: 70%). Secondary endpoints included experience and clinical impact.

RESULTS

At data cutoff (June 9, 2022), adoption was 85% and adherence was 76%. Customer satisfaction and effort scores for patients were 76% and 82%, respectively, and 83% and 79% for HCPs. Patients spent approximately 10 minutes using the DPM tool and completed approximately 1.0 symptom questionnaires per week (completion time 1-4 minutes). HCPs spent approximately 1-3 minutes a week using the tool per patient. Median time to HCP review for alerted versus non-alerted symptom questionnaires was 19.6 versus 21.5 hours. Most patients and HCPs felt that the DPM tool covered/mostly covered symptoms experienced (71% and 75%), was educational (65% and 92%), and improved patient-HCP conversations (70% and 83%) and cancer care (51% and 71%).

CONCLUSION

The DPM tool demonstrated positive adoption, adherence, and user experience for patients with lung/breast cancer, suggesting that DPM tools may benefit clinical cancer care.

ExplORRNet: An interactive web tool to explore stage-wise miRNA expression profiles and their interactions with mRNA and lncRNA in human breast and gynecological cancers

Background

MicroRNAs (miRNAs) are key regulators of gene expression that have been implicated in gynecological and breast cancers. Understanding the cancer stage-wise expression patterns of miRNAs and their interactions with other RNA molecules in cancer is crucial to improve cancer diagnosis and treatment planning. Comprehensive web tools that integrate data on the transcriptome, circulating miRNAs, and their validated targets to derive beneficial conclusions in cancer research are lacking.

Methods

Using the Shiny R package, we developed a web tool called ExplORRNet that integrates transcriptomic profiles from The Cancer Genome Atlas and miRNA expression data derived from various sources, including tissues, cell lines, exosomes, serum, and plasma, available in the Gene Expression Omnibus database. Differential expression analyses between normal and tumor tissue samples as well as different stages of cancer, accompanied by gene enrichment and survival analyses, can be performed using specialized R packages. Additionally, a miRNA-messenger RNA (mRNA)-long non-coding RNA (lncRNA) networks are constructed to identify regulatory modules.

Results

Our tool identifies cancer stage-wise differentially regulated miRNAs, mRNAs, and lncRNAs in gynecological and breast cancers. Survival analysis identifies miRNAs associated with patient survival, and functional enrichment analysis provides insights into dysregulated miRNA-related biological processes and pathways. The miRNA-mRNA-lncRNA networks highlight interconnected regulatory molecular modules driving cancer progression. Case studies demonstrate the utility of the ExplORRNet for studying gynecological and breast cancers.

Conclusion

ExplORRNet is an intuitive and user-friendly web tool that provides a deeper understanding of dysregulated miRNAs and their functional implications in gynecological and breast cancers. We hope our ExplORRNet tool has potential utility among the clinical and basic researchers and will be beneficial to the entire cancer genomics community to encourage and facilitate mining the rapidly growing public databases to progress the field of precision oncology. The ExplORRNet is available at https://mirna.cs.ut.ee.

Inhibition of epigenetic and cell cycle-related targets in glioblastoma cell lines reveals that onametostat reduces proliferation and viability in both normoxic and hypoxic conditions

The choice of targeted therapies for treatment of glioblastoma patients is currently limited, and most glioblastoma patients die from the disease recurrence. Thus, systematic studies in simplified model systems are required to pinpoint the choice of targets for further exploration in clinical settings. Here, we report screening of 5 compounds targeting epigenetic writers or erasers and 6 compounds targeting cell cycle-regulating protein kinases against 3 glioblastoma cell lines following incubation under normoxic or hypoxic conditions. The viability/proliferation assay indicated that PRMT5 inhibitor onametostat was endowed with high potency under both normoxic and hypoxic conditions in cell lines that are strongly MGMT-positive (T98-G), weakly MGMT-positive (U-251 MG), or MGMT-negative (U-87 MG). In U-251 MG and U-87 MG cells, onametostat also affected the spheroid formation at concentrations lower than the currently used chemotherapeutic drug lomustine. In T98-G cell line, treatment with onametostat led to dramatic changes in the transcriptome profile by inducing the cell cycle arrest, suppressing RNA splicing, and down-regulating several major glioblastoma cell survival pathways. Further validation by immunostaining in three cell lines confirmed that onametostat affects cell cycle and causes reduction in nucleolar protein levels. In this way, inhibition of epigenetic targets might represent a viable strategy for glioblastoma treatment even in the case of decreased chemo- and radiation sensitivity, although further studies in clinically more relevant models are required.

Factors associated with advanced-stage diagnosis of cervical cancer in Estonia: a population-based study

OBJECTIVES

Cervical cancer (CC) remains a crucial public health issue in Estonia, with high incidence and late diagnosis. The aim of this study was to examine time trends of stage-specific CC incidence in Estonia and factors associated with advanced-stage diagnosis of CC.

STUDY DESIGN

This was a nationwide population-based retrospective study.

METHODS

Data on CC cases diagnosed in Estonia in 2007-2018 were obtained from the Estonian Cancer Registry, including tumour, nodes, metastases stage at diagnosis. Sociodemographic data were obtained from the Population Registry. To estimate the risk of advanced-stage diagnosis (stages II-IV vs stage I) associated with sociodemographic factors, Poisson regression with robust variance was used to calculate univariate and multivariate prevalence ratios (PR) with 95% confidence intervals (CIs). Time trends of stage-specific CC incidence for 2005-2019 were examined with joinpoint analysis.

RESULTS

Incidence of stage I CC showed a significant decline of 4.9% per year since 2007, whereas no change was seen for other stages. Of the 2046 women diagnosed in 2007-2018, 1137 (55.6%) were diagnosed at an advanced stage; this proportion increased from 51% in 2007-2009 to 58% in 2015-2018 (P = 0.004). Multivariate regression analysis showed that advanced-stage diagnosis was associated with age (PR 2.16, 95% CI 1.87-2.49 for women aged ≥75 years compared with those aged 30-44 years), educational level (PR 1.32, 95% CI 1.15-1.51 for women with basic/primary education compared to university education) and marital status (PR 1.14, 95% CI 1.01-1.29 for single women compared to married/cohabiting women). No associations were observed by region of residence or nationality.

CONCLUSIONS

To reduce CC mortality, it is crucial to improve prevention and early diagnosis of CC in Estonia through human papillomavirus vaccination and effective and quality-assured screening particularly targeting high-risk groups as well as encouraging symptom awareness and regular check-ups among older women.

Exploring the Molecular Players behind the Potentiation of Chemotherapy Effects by Durvalumab in Lung Adenocarcinoma Cell Lines

Immune checkpoint inhibitors are increasingly used in combination with chemotherapy for the treatment of non-small cell lung cancer, yet the success of combination therapies is relatively limited. Thus, more detailed insight regarding the tumor molecular markers that may affect the responsiveness of patients to therapy is required. Here, we set out to explore the proteome of two lung adenocarcinoma cell lines (HCC-44 and A549) treated with cisplatin, pemetrexed, durvalumab, and the corresponding mixtures to establish the differences in post-treatment protein expression that can serve as markers of chemosensitivity or resistance. The mass spectrometry study showed that the addition of durvalumab to the treatment mixture resulted in cell line- and chemotherapeutic agent-dependent responses and confirmed the previously reported involvement of DNA repair machinery in the potentiation of the chemotherapy effect. Further validation using immunofluorescence also indicated that the potentiating effect of durvalumab in the case of cisplatin treatment was dependent on the tumor suppressor RB-1 in the PD-L1 weakly positive cells. In addition, we identified aldehyde dehydrogenase ALDH1A3 as the general putative resistance marker. Further studies in patient biopsy samples will be required to confirm the clinical significance of these findings.

Immune checkpoint inhibitors modulate the cytotoxic effect of chemotherapy in lung adenocarcinoma cells

Immunotherapy using immune checkpoint inhibitors (ICIs) has significantly improved survival in patients with non-small cell lung cancer (NSCLC), and ICIs are increasingly used in combination with cytotoxic treatments, such as chemotherapy. Although combined treatments are more effective, not all patients respond to the therapy; therefore, a detailed understanding of the effect of treatment combinations at the tumour level is needed. The present study aimed to explore whether ICIs could affect the cytotoxic effects of chemotherapy on lung adenocarcinoma cell lines with different PD-L1 expression levels (high, HCC-44; low, A-549). Using the resazurin-based assay, the efficacy of seven chemotherapeutic agents (cisplatin, etoposide, gemcitabine, pemetrexed, vinorelbine, docetaxel and paclitaxel) was compared in the presence or absence of the individually chosen single doses of four ICIs (nivolumab, pembrolizumab, atezolizumab and durvalumab). The results revealed that different ICIs can exhibit either potentiating or depotentiating effects, depending on the chemotherapy agent or lung adenocarcinoma cell line used. Durvalumab was the most promising ICI, which potentiated most chemotherapy agents in both cell lines, especially in the case of high PD-L1 expression. By contrast, nivolumab, exhibited depotentiating trends in several combinations. The immunostaining of γH2AX in treated cells confirmed that the potentiation of the chemotherapeutic cytotoxicity by durvalumab was at least partially mediated via increased DNA damage; however, this effect was strongly dependent on the chemotherapy agent and cell line used. Our future studies aim to address the specific mechanisms underlying the observed ICI-induced potentiation or depotentiation.

Conjugates of adenosine mimetics and arginine-rich peptides serve as inhibitors and fluorescent probes but not as long-lifetime photoluminescent probes for protein arginine methyltransferases

The conjugates of an adenosine mimetic and oligo-l-arginine or oligo-d-arginine (ARCs) were initially designed in our research group as inhibitors and photoluminescent probes targeting basophilic protein kinases. Here, we explored a panel of ARCs and their fluorescent derivatives in biochemical assays with members of the protein arginine methyltransferase (PRMT) family, focusing specifically on PRMT1. In the binding/displacement assay with detection of fluorescence anisotropy, we found that ARCs and arginine-rich peptides could serve as high-affinity ligands for PRMT1, whereas the equilibrium dissociation constant values depended dramatically on the number of arginine residues within the compounds. The fluorescently labeled probe ARC-1081 was displaced from its complex with PRMT1 by both S-adenosyl-l-methionine (SAM) and S-adenosyl-l-homocysteine (SAH), indicating binding of the adenosine mimetic of ARCs to the SAM/SAH-binding site within PRMT1. The ARCs that had previously shown microsecond-lifetime photoluminescence in complex with protein kinases did not feature such property in complex with PRMT1, demonstrating the selectivity of the time-resolved readout format. When tested against a panel of PRMT family members in single-dose inhibition experiments, a micromolar concentration of ARC-902 was required for the inhibition of PRMT1 and PRMT7. Overall, our results suggest that the compounds containing multiple arginine residues (including the well-known cell-penetrating peptides) are likely to inhibit PRMT and thus interfere with the epigenetic modification status in complex biological systems, which should be taken into consideration during interpretation of the experimental data.

Real-world implementation and user experience of tailored digital patient monitoring (DPM) modules for patients (pts) with locally advanced/metastatic (LA/M) cancer: Early readout analysis from a feasibility study

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Background: Poor control of disease- and treatment-related symptoms can impact negatively on quality of life and clinical outcomes in pts with cancer. DPM can improve cancer care by facilitating earlier symptom management, and reducing symptom burden and the need for emergency visits/consultations. However, adherence is a challenge for digital health solutions. We assessed adoption/adherence, duration of use, user experience, and perceived clinical impact of treatment-/disease-specific DPM modules in pts with LA/M non-small/small cell lung or HER2-positive breast cancer. Methods: Eligible pts were treated with locally approved and reimbursed drugs alongside use of the DPM modules. Pts could use Roche (drug-/drug class-specific) or Kaiku (drug class-specific only) DPM modules, all hosted on the Kaiku Health DPM platform. Respective thresholds for positive adoption and week 1–6 adherence (primary objectives) were 60% and 70%. Secondary objectives were user experience and clinical impact. Data were collected via questionnaires or extracted directly from the DPM platform. Results: At data cutoff (December 1, 2021), 93 pts were enrolled in eight clinics in Estonia, Finland, Greece, Norway, and Spain. The majority of pts had lung cancer, 52/79 (65.8%) had stage IV cancer, 72/79 (91.1%) had an Eastern Cooperative Oncology Group performance status of 0/1, and 30/52 (57.7%) were aged ≥60. Of the 52 pts and 20 healthcare professionals (HCPs) who completed a user experience questionnaire at Week 6, 37% and 30%, respectively, had previous experience with DPM. Pt adoption was 83.8% and adherence in weeks 1–6 was 73.4%. Average weekly time on the platform was ≤18 minutes for pts (median: 1–5 minutes per symptom questionnaire). HCPs spent a weekly average of 1–6 minutes per pt reviewing symptom reports on the platform. Most pts (87%) and HCPs (82%) were satisfied/very satisfied with the service and found it easy/very easy to use. Symptoms were described as fully/mostly covered by the tailored symptom questionnaire by 81% of pts and 71% of HCPs. Upon completion of a symptom questionnaire, pts received tailored feedback, on which half took action, most often with self-management instructions for mild/moderate symptoms. After 6 weeks of use, most pts and HCPs agreed that the Roche and Kaiku Health DPM service helps pts to be better informed about their disease/care (71% and 95%, respectively), facilitates better pt–care team discussions (79% and 81%), and improves cancer care (60% and 71%). Conclusions: The tailored DPM modules had high pt adoption/adherence in the first 6 weeks of use. Most pts and HCPs had positive user experiences with the DPM platform. Care impact experience was positive for both pts and HCPs in terms of improved pt education, pt–HCP communication, and overall cancer care.

Revisiting the Resazurin-Based Sensing of Cellular Viability: Widening the Application Horizon

Since 1991, the NAD(P)H-aided conversion of resazurin to fluorescent resorufin has been widely used to measure viability based on the metabolic activity in mammalian cell culture and primary cells. However, different research groups have used divergent assay protocols, scarcely reporting the systematic optimization of the assay. Here, we perform extensive studies to fine-tune the experimental protocols utilizing resazurin-based viability sensing. Specifically, we focus on (A) optimization of the assay dynamic range in individual cell lines for the correct measurement of cytostatic and cytotoxic properties of the compounds; (B) dependence of the dynamic range on the physical quantity detected (fluorescence intensity versus change of absorbance spectrum); (C) calibration of the assay for the correct interpretation of data measured in hypoxic conditions; and (D) possibilities for combining the resazurin assay with other methods including measurement of necrosis and apoptosis. We also demonstrate the enhanced precision and flexibility of the resazurin-based assay regarding the readout format and kinetic measurement mode as compared to the widely used analogous assay which utilizes tetrazolium dye MTT. The discussed assay optimization guidelines provide useful instructions for the beginners in the field and for the experienced scientists exploring new ways for measurement of cellular viability using resazurin.

Viability fingerprint of glioblastoma cell lines: roles of mitotic, proliferative, and epigenetic targets

Despite the use of multimodal treatment combinations, the prognosis of glioblastoma (GB) is still poor. To prevent rapid tumor recurrence, targeted strategies for the treatment of GB are widely sought. Here, we compared the efficacy of focused modulation of a set of signaling pathways in two GB cell lines, U-251 MG and T98-G, using a panel of thirteen compounds targeting cell cycle progression, proliferation, epigenetic modifications, and DNA repair mechanism. In parallel, we tested combinations of these compounds with temozolomide and lomustine, the standard chemotherapy agents used in GB treatment. Two major trends were found: within individual compounds, the lowest IC₅₀ values were exhibited by the Aurora kinase inhibitors, whereas in the case of mixtures, the addition of DNA methyltransferase 1 inhibitor azacytidine to lomustine proved the most beneficial. The efficacy of cell cycle-targeting compounds was further augmented by combination with radiation therapy using two different treatment regimes. The potency of azacytidine and lomustine mixtures was validated using a unique assay pipeline that utilizes automated imaging and machine learning-based data analysis algorithm for assessment of cell number and DNA damage extent. Based on our results, the combination of azacytidine and lomustine should be tested in GB clinical trials.

Expression of immune checkpoint PD-1 in non-small cell lung cancer is associated with tumor cell DNA-dependent protein kinase

Immunotherapy using immune checkpoint inhibitors has demonstrated durable responses and has significantly improved survival in patients with non-small cell lung cancer (NSCLC). Moreover, immunotherapy is increasingly used in combination with cytotoxic treatments such as chemotherapy and radiotherapy. Although the combined treatments are more effective, the underling mechanisms that lead to higher antitumor activity are not fully understood. Therefore, the aim of the current retrospective study was to determine the relationship between expression of immune checkpoints [programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1)] and the enzyme DNA-dependent protein kinase (DNA-PK), which is part of a key pathway involved in the repair of cytotoxic cancer therapy induced damage. Surgically excised NSCLC tissues (n=121) were histologically examined for overall extent of inflammation (score 0-3). Expression levels of PD-1 (number of PD-1 positive cells), PD-L1 [tumor proportion score (TPS); %] and DNA-PK (proportion of DNA-PK positive tumor cells; %) were determined using immunohistochemistry. Expressions of these markers were compared in different clinicopathological subgroups and later used for nonparametric Spearman correlation analysis to determine associations. In patients with NSCLC, PD-1 was significantly expressed in males (P=0.030) and in patients with no or trivial inflammation scores (P=0.030). PD-L1 expression was also significantly higher in current smokers (P=0.025). Correlation analysis was based on the individual values of patients and revealed a significant association between one of the targets of immune checkpoint inhibitors and tumor cell DNA-PK. Tumors with higher numbers of PD-1 positive cells also demonstrated higher tumor cell DNA-PK expressions (P=0.027). The results demonstrated a significant positive correlation between the PD-1/PD-L1 axis and tumor cell DNA-PK expression in patients with NSCLC. Further studies are required to clarify the significance of this correlation and its effect on the efficacy of immunotherapy and cytotoxic cancer therapy combinations.

Exploratory composite endpoint demonstrates benefit of trilaciclib across multiple clinically meaningful components of myeloprotection in patients with small cell lung cancer

Chemotherapy-induced myelosuppression is an acute, dose-limiting toxicity of chemotherapy regimens used in the treatment of extensive-stage small cell lung cancer (ES-SCLC). Trilaciclib protects haematopoietic stem and progenitor cells from chemotherapy-induced damage (myeloprotection). To assess the totality of the myeloprotective benefits of trilaciclib, including analysis of several clinically relevant but low-frequency events, an exploratory composite endpoint comprising five major adverse haematological events (MAHE) was prospectively defined: all-cause hospitalisations, all-cause chemotherapy dose reductions, febrile neutropenia (FN), prolonged severe neutropenia (SN) and red blood cell (RBC) transfusions on/after Week 5. MAHE and its individual components were assessed in three randomised, double-blind, placebo-controlled Phase 2 trials in patients receiving a platinum/etoposide or topotecan-containing chemotherapy regimen for ES-SCLC and in data pooled from the three trials. A total of 242 patients were randomised across the three trials (trilaciclib, n = 123; placebo, n = 119). In the individual trials and the pooled analysis, administering trilaciclib prior to chemotherapy resulted in a statistically significant reduction in the cumulative incidence of MAHE compared to placebo. In the pooled analysis, the cumulative incidences of all-cause chemotherapy dose reductions, FN, prolonged SN and RBC transfusions on/after Week 5 were significantly reduced with trilaciclib vs placebo; however, no significant difference was observed in rates of all-cause hospitalisations. Additionally, compared to placebo, trilaciclib significantly extended the amount of time patients remained free of MAHE. These data support the myeloprotective benefits of trilaciclib and its ability to improve the overall safety profile of myelosuppressive chemotherapy regimens used to treat patients with ES-SCLC.

Trilaciclib prior to chemotherapy and atezolizumab in patients with newly diagnosed extensive-stage small cell lung cancer: A multicentre, randomised, double-blind, placebo-controlled Phase II trial

Trilaciclib is an intravenous CDK4/6 inhibitor administered prior to chemotherapy to preserve haematopoietic stem and progenitor cells and immune system function from chemotherapy-induced damage (myelopreservation). The effects of administering trilaciclib prior to carboplatin, etoposide and atezolizumab (E/P/A) were evaluated in a randomised, double-blind, placebo-controlled Phase II study in patients with newly diagnosed extensive-stage small cell lung cancer (ES-SCLC) (NCT03041311). The primary endpoints were duration of severe neutropenia (SN; defined as absolute neutrophil count <0.5 × 109 cells per L) in Cycle 1 and occurrence of SN during the treatment period. Other endpoints were prespecified to assess the effects of trilaciclib on additional measures of myelopreservation, patient-reported outcomes, antitumour efficacy and safety. Fifty-two patients received trilaciclib prior to E/P/A and 53 patients received placebo. Compared to placebo, administration of trilaciclib resulted in statistically significant decreases in the mean duration of SN in Cycle 1 (0 vs 4 days; P < .0001) and occurrence of SN (1.9% vs 49.1%; P < .0001), with additional improvements in red blood cell and platelet measures and health-related quality of life (HRQoL). Trilaciclib was well tolerated, with fewer grade ≥3 adverse events compared with placebo, primarily due to less high-grade haematological toxicity. Antitumour efficacy outcomes were comparable. Administration of trilaciclib vs placebo generated more newly expanded peripheral T-cell clones (P = .019), with significantly greater expansion among patients with an antitumour response to E/P/A (P = .002). Compared with placebo, trilaciclib administered prior to E/P/A improved patients' experience of receiving treatment for ES-SCLC, as shown by reduced myelosuppression, and improved HRQoL and safety profiles.

Clinical oncology module for the ESTRO core curriculum

INTRODUCTION

Clinical oncologists are physicians with the competencies to manage cancer patients through the entire disease pathway combining the competencies of radiation and medical oncologists. The 4th edition of the European Society for Radiotherapy and Oncology Core Curriculum for Radiation Oncology/Radiotherapy (ESTRO curriculum) has received wide support by the clinical oncology community. The aim was to develop a clinical oncology module that could be combined with the ESTRO curriculum to enable clinical oncology trainees to follow a single curriculum.

MATERIALS AND METHODS

A range of stakeholders including National Society representatives, an oncologist from a low- middle-income country, and a recently appointed specialist, developed and commented on iterations of the curriculum. Further modifications were made by the ESTRO Education Council.

RESULTS

The module is based on the CanMEDS 2015 framework and identifies 20 enabling competencies in the Medical Expert role that are required in addition to the ESTRO curriculum for the training of clinical oncologists. Recommendations are made for the levels of Entrustable Professional Activities (EPAs) to be attained by the end of training.

CONCLUSIONS

The Clinical Oncology module, when combined with the ESTRO curriculum, covers the entire cancer pathway rather than being modality specific. It is hoped it will aid in the development of comparable standards of training in clinical oncology across Europe and may also have utility in low- and middle-income countries as well as providing a single curriculum for trainees.

PD-L1 induction in tumor tissue after hypofractionated thoracic radiotherapy for non-small cell lung cancer

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Radiotherapy induced high PD-L1 expression in initially PD-L1 negative metastatic nsclc patient.

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High PD-L1 expression was also evident in gut metastasis that developed after radiotherapy.

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Due to high PD-L1 expression, immunotherapy has been effective even after 4 lines of chemotherapy.

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Radiotherapy might have a potential to increase the efficacy of checkpoint inhibitors.

We report on a 67-year old male with advanced stage lung adenocarcinoma (initially PD-L1 negative, EGFR and ALK negative) diagnosed in 2014. The patient received 4 lines of palliative chemotherapy from 2014 to 2017, however the disease progressed. In 2015, he also received palliative hypofractionated radiotherapy to a mediastinal mass, which was causing discomfort and pain. Since there was some data, that radiotherapy could induce PD-L1 expression, a new biopsy was taken in 2017 from the irradiated mediastinal mass. Subsequent pathologic report revealed that PD-L1 status was turned to be highly positive, with tumor proportion score of 100%. Similar high expression of PD-L1 was detected in a new metastasis in the duodenum, which was excised due to a duodenal perforation in 2017. From October 2017 to October 2019, the patient had 2-years of treatment (32 courses) with pembrolizumab and has had a positive effect (partial response) on all the lesions and following stabilization of the disease. Currently, this patient is under follow up and he is in a good condition without any complaints. Last CT-scan in March 2020 showed persisting partial response.

Recommended ESTRO Core Curriculum for Radiation Oncology/Radiotherapy 4th edition

INTRODUCTION

In 2017 it was decided to revise the European Core Curriculum for Radiation Oncology/Radiotherapy to produce a 4th edition. The aims of the ESTRO curriculum are to develop comparable standards for training across Europe and to facilitate free movement of specialists across borders. It is also hoped that it will improve the level of training across Europe and will make the non-medical expert roles more explicit.

MATERIALS AND METHODS

A wide range of stakeholders including National Society representatives, trainees, recently appointed specialists, members of the European Union Medical Specialists Radiotherapy section, an RTT, a radiobiologist, a physicist and lay members from ESTRO staff developed and commented on iterations of the curriculum.

RESULTS

The 4th edition is based on the CanMEDS 2015 framework and identifies 14 Entrustable Professional Activities (EPAs) and the competencies required to perform these. The manager role is replaced by competencies related to leadership. The levels of proficiency required for tumour sites is defined as levels of EPAs.

CONCLUSIONS

It is hoped that the inclusive method of developing the 4th edition has resulted in a document that will have utility in the wide range of environments in which radiation oncology is practised in Europe.

Gastric cancer trends in Estonia 1995-2014 by age, subsite, morphology and stage

BACKGROUND

Gastric cancer (GC) is among the most common cancers and one of the leading causes of cancer deaths globally. In general, the incidence of GC has declined and survival improved in Europe. Nevertheless, previous analysis has shown that survival of GC patients in Estonia is still significantly lower compared to some European countries. Therefore, to improve patient outcomes, better overview of GC epidemiology is needed. The aim of this study was to describe the incidence and survival of GC in Estonia 1995-2014 in relation to age, subsite, morphology, and the extent of disease.

MATERIAL AND METHODS

We used data from the population-based Estonian Cancer Registry on all incident cases of GC diagnosed in 1995-2014. Incidence rates and relative survival were calculated. Joinpoint regression modeling was used to estimate annual percentage change for incidence trends. Data were analyzed by age, sex, subsite, morphology, and the extent of disease. Changes between 1995-1999 and 2010-2014 were assessed.

RESULTS

The overall incidence of GC in Estonia decreased in 1995-2014. The age-standardized (world) incidence declined significantly for both sexes, for patients below 70 years of age, adenocarcinomas, NOS and other morphologies, non-cardia and unspecified cases, and for all known stages. Approximately 40% of GC cases were diagnosed with distant metastasis. Overall age-standardized 5-year relative survival of GC patients increased from 20% to 28%. Survival improved the most in age group 50-69 years. A large survival gain was also seen for localized (from 55% to 70%) and locally/regionally spread disease (from 23% to 37%).

CONCLUSIONS

In Estonia, the incidence of GC has declined and relative survival increased. However, special emphasis needs to be put on improving survival among men, elderly and in patients with metastatic disease.

Suppression of Taxanes Cytotoxicity by Citrus Flavonoid Hesperetin in PPC-1 Human Prostate Cancer Cells

BACKGROUND/AIM

More than half of prostate cancer patients use, in addition to conventional therapies, some kind of complementary medicine, including flavonoid-rich products. However, knowledge about the co-effects of flavonoids with cytotoxic chemotherapies is still rather poor. Therefore, this study was undertaken to assess the cytotoxic activity of flavonoids and their interactions with taxanes in human advanced prostate cancer cells.

MATERIALS AND METHODS

Cytotoxicity of different flavonoids and their effects on the efficacy of docetaxel and cabazitaxel were studied in the human metastatic prostate cancer cell line PPC-1, using MTT colorimetric assay.

RESULTS

Both taxanes suppressed the viability of PPC-1 cells with IC₅₀ values in the nanomolar range. Tested flavonoids exerted cytotoxic activity only at high micromolar concentrations or revealed no remarkable effect on cell survival. Simultaneous treatment of cells with taxanes and flavonoids baicalein, chrysin, luteolin, fisetin, quercetin, genistein or daidzein did not lead to any change in chemotherapy-induced cytotoxicity. However, simultaneous exposure of cells to hesperetin and taxanes resulted in 9.8- and 13.1-fold reduction in cytotoxicity of docetaxel and cabazitaxel, respectively.

CONCLUSION

Flavonoid hesperetin remarkably suppressed the cytotoxic efficacy of taxanes in prostate cancer cells. Therefore, caution is required from prostate cancer patients who take hesperetin-containing oral supplements.

Cytotoxic action of methylquercetins in human lung adenocarcinoma cells

Lung cancer is the malignant disorder associated with a high number of fatalities in women and men worldwide. Despite continuous improvements in diagnostic strategies and therapeutic modalities over the past decades, the prognosis and survival rate of patients suffering from lung cancer are still unsatisfactory and suggest the requirement for further molecular studies with different lung cancer models. In the present study, the anticancer action of two methylated metabolites of quercetin, isorhamnetin and tamarixetin, was assessed by studying their antiproliferative and apoptosis-inducing potential in human lung adenocarcinoma cell lines, A549 and HCC-44. Both methylquercetins decreased the viability of lung cancer cells at doses significantly lower than those effective for parent quercetin. The IC50 values measured for isorhamnetin were 26.6 and 15.9 µM in A549 and HCC-44 cells, respectively. For tamarixetin, the IC50 values were 19.6 and 20.3 µM in A549 and HCC-44 cells, respectively. These results were many-fold lower than the respective values for quercetin (72.2 and 107.6 µM for A549 and HCC-44 cells, respectively). Based on the activation of caspase family members, both metabolites induced apoptotic cell death in the tested cell lines, predominantly via the extrinsic pathway in A549 cells and in both intrinsic and extrinsic pathways in HCC-44 cells. As A549 and HCC-44 lines were originally established from a male and female patient, current data may suggst some gender differences in the action of quercetin derivatives. Addition of a methyl group in the 3'- or 4'-position of the B-ring of quercetin significantly increased the anticancer activity of this flavonol towards lung adenocarcinoma cells, which demonstrated that these compounds may be considered as potential novel candidates for the development of future chemotherapeutics in the fight against lung cancer.

Resection of unicentric interlobar Castleman disease with following adjuvant radiotherapy

A 22-year-old female patient with rare interlobar unicentric Castleman disease is presented. The tumour was discovered incidentally and thoracoscopic biopsy was planned to rule out malignancy. Due to dense adhesions to the adjacent anatomical structures and diffuse bleeding when mobilizing the tumour, a thoracoscopic approach was converted to thoracotomy. The tumour was removed without lung resection. Adjuvant radiotherapy was used to avoid possible recurrence of the disease. During the follow-up of 6 years, the patient remains free of any symptoms and evidence of recurrence.

Impact of tumor infiltrating CD63 positive cells on survival in patients with glioblastoma multiforme

BACKGROUND

Glioblastoma multiforme (GBM) is the most aggressive type of brain cancer in adults. It is suggested that tumour microenvironment might influence treatment outcome. The aim of the study was to evaluate the impact of tumor infiltrating CD63 positive (CD63+) inflammatory and immune cells on treatment response and survival of GBM patients.

METHODS

Forty patients were operated and received postoperative radiotherapy (±chemotherapy for recurrent disease). In surgically excised GBM tissues, the number of CD63+ cells per microscopic field was determined and correlated with patient's survival.

RESULTS

Immunohistochemical parameters were examined by two independent researchers whose results were in good accordance (R=0.8, P<0.001). Median survival time of the study group was 10.0 months (95% CI 9.0-11.0). However, the survival time clearly depended on the number of CD63+ cells in GBM tissue (log rank test, P=0.003). Median survival times for patients with low (<median) and high (≥median) number of CD63+ cells were 9.0 months (95% CI 8.1-9.9) and 12.0 months (95% CI 8.5-15.5) respectively. In multivariate analysis, the number of CD63+ cells emerged as a significant independent predictor for overall survival (HR 2.4, 95% CI 1.2-5.1, P=0.02).

CONCLUSIONS

The higher number of tumor infiltrating CD63+ inflammatory and immune cells in GBM tissue corresponded to better survival after postoperative radiotherapy. Since radiotherapy is one of the cornerstones of adjuvant treatment in GBM, further studies are needed for better understanding of GBM biology.

Radiotherapy staffing in the European countries: final results from the ESTRO-HERO survey

BACKGROUND

The ESTRO Health Economics in Radiation Oncology (HERO) project has the overall aim to develop a knowledge base of the provision of radiotherapy in Europe and build a model for health economic evaluation of radiation treatments at the European level. The first milestone was to assess the availability of radiotherapy resources within Europe. This paper presents the personnel data collected in the ESTRO HERO database.

MATERIALS AND METHODS

An 84-item questionnaire was sent out to European countries, through their national scientific and professional radiotherapy societies. The current report includes a detailed analysis of radiotherapy staffing (questionnaire items 47-60), analysed in relation to the annual number of treatment courses and the socio-economic status of the countries. The analysis was conducted between February and July 2014, and is based on validated responses from 24 of the 40 European countries defined by the European Cancer Observatory (ECO).

RESULTS

A large variation between countries was found for most parameters studied. Averages and ranges for personnel numbers per million inhabitants are 12.8 (2.5-30.9) for radiation oncologists, 7.6 (0-19.7) for medical physicists, 3.5 (0-12.6) for dosimetrists, 26.6 (1.9-78) for RTTs and 14.8 (0.4-61.0) for radiotherapy nurses. The combined average for physicists and dosimetrists is 9.8 per million inhabitants and 36.9 for RTT and nurses. Radiation oncologists on average treat 208.9 courses per year (range: 99.9-348.8), physicists and dosimetrists conjointly treat 303.3 courses (range: 85-757.7) and RTT and nurses 76.8 (range: 25.7-156.8). In countries with higher GNI per capita, all personnel categories treat fewer courses per annum than in less affluent countries. This relationship is most evident for RTTs and nurses. Different clusters of countries can be distinguished on the basis of available personnel resources and socio-economic status.

CONCLUSIONS

The average personnel figures in Europe are now consistent with, or even more favourable than the QUARTS recommendations, probably reflecting a combination of better availability as such, in parallel with the current use of more complex treatments than a decade ago. A considerable variation in available personnel and delivered courses per year however persists among the highest and lowest staffing levels. This not only reflects the variation in cancer incidence and socio-economic determinants, but also the stage in technology adoption along with treatment complexity and the different professional roles and responsibilities within each country. Our data underpin the need for accurate prediction models and long-term education and training programmes.

Rare thoracic cancers, including peritoneum mesothelioma

Rare thoracic cancers include those of the trachea, thymus and mesothelioma (including peritoneum mesothelioma). The aim of this study was to describe the incidence, prevalence and survival of rare thoracic tumours using a large database, which includes cancer patients diagnosed from 1978 to 2002, registered in 89 population-based cancer registries (CRs) and followed-up to 31st December 2003. Over 17,688 cases of rare thoracic cancers were selected based on the list of the RACECARE project. Mesothelioma was the most common tumour (19 per million per year) followed by epithelial tumours of the trachea and thymus (1.3 and 1.7, respectively). The age standardised incidence rates of epithelial tumours of the trachea was double in Eastern and Southern Europe versus the other European regions: 2 per million per year. Epithelial tumours of the thymus had the lowest incidence in Northern and Eastern Europe and UK and Ireland(1) and somewhat higher incidence in Central and Southern Europe.(2) Highest incidence in mesothelioma was seen in UK and Ireland(23) and lowest in Eastern Europe.(4) Patients with tumours of the thymus had the best prognosis (1-year survival 85%, 66% at 5 years). Five year survival was lowest for the mesothelioma 5% compared to 14% of patients with tumours of the trachea. Mesothelioma was the most prevalent rare cancer (12,000 cases), followed by thymus (7000) and trachea (1400). Cancer Registry (CR) data play an important role in revealing the burden of rare thoracic cancers and monitoring the effect of regulations on asbestos use and smoking related policies.

Radiation effects on cellularity, proliferation and EGFR expression in mouse bladder urothelium

This study was designed to determine changes in cell numbers, proliferation (using Ki-67) and EGFR expression in mouse bladder urothelium during the early and late radiation response. Groups of mice were irradiated with a single dose of 20 Gy and assayed 0-360 days later. Urothelial cells were counted. After immunohistochemistry, the absolute and relative numbers of Ki-67(+) and EGFR(+) cells were analyzed. Radiation exposure resulted in a decrease in total urothelial cell numbers to 49% by day 31, with restoration of cellularity by day 180. In contrast, at day 360, an increase in total cell number (143%) was seen. Slightly increased Ki-67 expression was found at days 120 and 180 after treatment, followed by a pronounced elevation at days 240 and 360. Compared to controls, higher EGFR expression was detected up to day 360 after irradiation. A positive correlation was found between total urothelial cells numbers and Ki-67 as well as EGFR expression. Radiation exposure results in an increased urothelial expression of EGFR that precedes urothelial restoration, indicating a contribution of the EGF/EGFR system to urothelial proliferation and differentiation. Further studies are needed to evaluate the impact of EGFR inhibition on radiation effects in the urinary bladder.

Early and long-term effects of radiation on intercellular adhesion molecule 1 (ICAM-1) expression in mouse urinary bladder endothelium

The aim was to assess the effect of irradiation on intercellular adhesion molecule 1 (ICAM-1) expression in endothelial cells of vessels in mouse urinary bladder and to compare endothelial ICAM-1 expression with changes in bladder function (storage capacity) during the early and late radiation response phases. Female C3H/Neu mice were irradiated with doses of either 20 or 0 Gy. For assessment of ICAM-1 expression, which was measured by the intensity of the immunohistochemical staining signal in bladder endothelium, an arbitrary semiquantitative score (0 - 3) was applied. Bladder storage function was assessed by transurethral cystotonometry. A positive functional radiation response, defined as a reduction in bladder capacity by > 50%, between days 0 and 15 or 16 and 30 was found in 40 and 64% of the animals, respectively. A late functional response was observed in 71% of the animals sacrificed after day 180. Minor constitutive expression of ICAM-1 was observed in bladder endothelial cells. After irradiation, an increase in staining signal by day 2, with a maximum on day 4, and on days 16 - 28 was found, which preceded the functional radiation effects. A permanent increase in ICAM-1 staining signal was observed in the late phase on top of an age-related rise. ICAM-1 expression was significantly higher in animals with a positive late response on day 90, i.e. during the initial late phase. Irradiation induces significant early and chronic variations in ICAM-1 expression in bladder endothelium, which preceded the functional response. This suggests that endothelial ICAM-1 is involved in the pathogenesis of both the early and late phases of radiation-induced urinary bladder effects.

Radiation‐induced variations in urothelial expression of intercellular adhesion molecule 1 (ICAM‐1): association with changes in urinary bladder function

PURPOSE

To assess the effect of single-dose irradiation on intercellular adhesion molecule 1 (ICAM-1) expression in the urothelium of mouse urinary bladder and to correlate ICAM-1 variations with fluctuations in storage capacity during the early and late radiation response.

MATERIALS AND METHODS

Groups of female C3H mice were subjected to irradiation with either 20 or 0 Gy. The intensity of immunohistochemical ICAM-1 staining in the urothelium was assessed in a semiquantitative way applying an arbitrary score (0-5). Changes in bladder storage function were assessed by transurethral cystometry.

RESULTS

For the early radiation response phase, a reduction in bladder capacity by >50%, i.e. a positive functional radiation response, was seen in 40% of the irradiated animals between days 0 and 15, and in 64% of animals during days 16-30. During the late response phase, 71% of the animals sacrificed after day 180 developed a positive functional response. Urothelial cells were found to express ICAM-1 constitutively. Irradiation resulted in an early rise in staining signal by day 2, with a maximum on day 4 and a return to control values on day 13. A permanent increase in ICAM-1 staining signal was observed in the late phase, from day 90 to 360 after irradiation. The expression of ICAM-1 in animals with a positive late response was 4.2+/-1.2 (mean+/-standard deviation), compared with 2.6+/-1.0 in non-responders (p=0.0009).

CONCLUSION

Irradiation induces significant acute and chronic changes in urothelial ICAM-1 expression indicating that the urothelium contributes to the pathogenesis of both acute and late radiation effects in the urinary bladder.

Effect of recombinant human keratinocyte growth factor (rHuKGF, Palifermin) on radiation-induced mouse urinary bladder dysfunction

PURPOSE

To determine the effect of Palifermin (rHuKGF) on acute and late radiation effects in mouse urinary bladder.

METHODS AND MATERIALS

Graded radiation doses were applied on day 0. Single subcutaneous injections of Palifermin (15 mg/kg) were given on day -2 or day +2. Changes in bladder function (i.e., a reduction in bladder volume by >or=50% of the individual preirradiation value) were assessed by cystometry.

RESULTS

Early changes in mouse bladder after irradiation occur in two phases. In the first early phase, a single injection of Palifermin on day -2 increased the ED(50) (dose associated with a positive bladder response in 50% of the mice) from 20.0 +/- 3.3 Gy to 27.1 +/- 6.9 Gy (p < .0051). Palifermin given on day +2 was not beneficial. No significant effects of Palifermin were seen in the second early phase. However, Palifermin administration before, but not after, irradiation, also modified late radiation effects, with an ED50 of 22.2 +/- 4.8 Gy compared with 16.2 +/- 4.9 Gy in control animals (p < .0187).

CONCLUSIONS

Initial early functional changes in the mouse urinary bladder after irradiation as well as late effects can be significantly reduced by a single administration of Palifermin before irradiation.

Radiation Induced Late Damage to the Barrier Function of Small Blood Vessels in Mouse Bladder

PURPOSE

We identified changes in vascular barrier function in relation to collagen deposition during the late radiation response of mouse bladders. In this study albumin leakage was assessed as a marker of blood vessel barrier disruption.

MATERIALS AND METHODS

Female C3H/Neu mice were irradiated with a single dose of 20 Gy and sacrificed for (immuno) histological studies after 90, 120, 180, 240 and 360 days. The fractional area of subepithelial tissue with extravascular albumin signal was defined. Moreover, the amount of collagen was determined after Masson's trichrome staining on an arbitrary score of 0 to 3.

RESULTS

Subepithelial albumin infiltration due to leakage from the blood vessels was seen in irradiated animals during the entire late phase. It was most pronounced at days 120 and 180 after treatment (vs control p <0.0001). Similarly an increase in collagen deposition in the bladder wall was seen during the whole late radiation phase but with increasing values toward the end of the experiment (day 360 vs control p <0.0001).

CONCLUSIONS

Irradiation of the bladder results in late damage to the barrier function of small subepithelial blood vessels, causing pronounced albumin leakage at the early steps of the chronic radiation reaction, clearly preceding excessive collagen deposition in the bladder wall. Current data suggest a vascular component in the development of late radiation induced changes in the bladder.

Radiation Induced Inflammatory Changes in the Mouse Bladder: The Role of Cyclooxygenase-2

PURPOSE

We assessed the effect of irradiation on COX-2 expression in blood vessels of the mouse bladder wall during the early and late radiation response phases. Vasodilatation was quantified as an additional marker of inflammation related to COX-2 activity.

MATERIALS AND METHODS

Female C3H/Neu mice were irradiated with a single dose of 20 Gy. The intensity of the COX-2 immunohistochemical staining signal was assessed using an arbitrary semiquantitative score of 0 to 3. To evaluate vasodilatation the percent of the bladder wall covered by the lumen of the blood vessels, depicted as vascular area, was determined.

RESULTS

Constitutive COX-2 expression was found in the tunica intima and media of bladder blood vessels. During the early response significant biphasic changes were detected in the COX-2 staining signal as well as in the vascular area with peak values on days 4 and 16 after irradiation. A significant association was found between vascular area and COX-2 expression in blood vessels during the early radiation response (p <0.0001). No changes in COX-2 expression were observed during the late phase, that is between days 90 and 360 after irradiation. Minor vasodilatation seen during the late phase did not correlate with COX-2 activity.

CONCLUSIONS

Irradiation resulted in pronounced COX-2 dependent inflammatory changes in the bladder wall during the early but not during the late radiation reaction. Therefore, a potential effect of COX-2 inhibition on early radiation side effects in the bladder can be proposed.