cancer chemoprevention & surrogate end point markers jianyu rao, m.d. associate prof. of...
TRANSCRIPT
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Cancer Chemoprevention & Surrogate End Point Markers
JianYu Rao, M.D.
Associate Prof. Of Pathology
UCLA
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CANCER PREVENTION
• PRIMARY• STOP THE EXPOSURE
• SECONDARY• INTERVENTION OR CHEMOPREVENTION
• TERTIARY• TREATMENT
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CHEMOPREVENTION
• Administrating specific amounts of a particular natural or synthetic chemical in an attempt to identify agents that will prevent, halt or reverse the process of carcinogenesis
• The basic assumption is that treating early stages of malignant process will halt the progression of malignancy
• The key is to define early lesions, and treat the malignant field
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Cancer
Precancerous Intraepithelial Lesions, (PIN, CIN, PaIN..)
Birth
Exposure to Carcinogen Additional Molecular Event
CHEMOPREVENTION
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Multiyear progression from initiation and early precancerous lesions to invasive disease in major
cancer target organs
Kelloff et al. 2000 (Fig. 1)
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THEORIES SUPPORT FOR CHEMOPREVENTION
• EPIDEMIOLOGICAL EVIDENCE:
• OVER 50% CANCERS HAVE NO KNOWN RISK FACTORS
• NUMEROUS EVIDENCE TO DEMONSTRATE THE INVERSE RELATIONSHIPS OF SOME NUTRIENT FACTORS WITH CANCER RISKS
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THEORIES SUPPORT FOR CHEMOPREVENTION (Cont.)• EXPERIMENTAL EVIDENCE:
• ALTHOUGH CARCINOGENESIS IS REGARDED AS NONREVERSIBLE PROCESS, STUDIES SHOWED THIS IS ONLY TRUE AT LATE STAGE. IN FACT, A LARGE PORTION OF THE LONG LATENCY PERIOD OF CARCINOGENIC PROCESS IS REVERSIBLE.
• IN VITRO CULTURE AND IN VIVO ANIMAL STUDIES IDENTIFIED NUMEROUS AGENTS THAT CAN REVERSE, OR HALT THE CARCINOGENESIS PROCESS, PARTICULARLY AT THE EARLY STAGE.
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THEORIES SUPPORT FOR CHEMOPREVENTION (Cont.)• CLINICALLY
• ADVANCES IN CERTAIN TYPES OF CANCER TREATMENT HAVE LIMITED SUCCESS IN REDUCING THE OVERALL INCIDENCE, OR EVEN MORTALITY OF CANCER.
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Chemoprevention:Some Terminologies
• INDIVIDUAL RISK AND STRATIFICATION
• INTERMEDIATE END POINT MARKER (SURROGATE END POINT MARKER)
• FIELD CANCERIZATION
• MULTI-PATH OF CARCINOGENESIS
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RISK STRATIFICATION
• Identification of AT-RISK subjects who are also SUSCEPTIBLE to treatment:
LEGEND:Not at risk to develop disease At risk of developing disease, biology A, responsive to agent XAt risk of developing disease, biology B, NOT responsive to agent X
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INTERMEDIATE END POINT MARKER (SURROGATE END POINT MARKER)
• These are prevention biomarkers which are specifically related to early stages of carcinogenesis.
• These markers are used to identify individual’s risk for developing cancer and to monitor the effectiveness of intervention methods.
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FIELD CANCERIZATION
• The whole field of tissue of a particular organ is exposed to the carcinogenic insult and is at increased risk for developing cancer.
• Although only a few foci eventually develop malignancy, the other areas are not necessary entirely “normal”.
• Most common epithelia cancers are developed through this mechanism. Examples of such cancers are: Head and neck ca, bladder ca, breast ca, lung ca, GI ca, etc.
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MULTI-PATH OF CARCINOGENESIS
• The current model of carcinogenesis is that cancer develops through multiple events which are not necessary through linear steps, but rather through overlapping networks.
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TARGET POPULATION
INDIVIDUALS AT RISK =
LATENCY (20 YEARS) x # EXPECTED TO DIE IN ONE YEAR
(1.1 MILLION)
= 22 MILLION
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CHEMOPREVENTION IN DIFFERENT RISK CATEGORIES
ParameterRisk category
General Population High Risk
Agent toxicity Trivial to none Slight
Selection method Public Health Clinical
Other consideration Use dietary supplements Need biomarkersmay be applicable
From lee W. Wattenberg, P.S.E.B.M., 1997 216:133-141.
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Phase I Trial
Objectives:• To determine the intervention’s short-term (<1
yr.) dose-toxicity relationship
• To determine the intervention’s human pharmacokinetics
Design:• Single arm, nonrandomized
• Multiple dose levels
• Less than 1 yr. duration
• Accrual 25-100
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Phase II Trial
Objectives:• To determine the intervention’s side effects
• To determine optimal recruitment methods of the target population
• To determine retention of study participants to the study intervention and procedures
• To determine optimal methods for the conducting of a phase III trial
• To determine the effect of the intervention on biomarkers of carcinogenesis (phase II b)
Design:• Randomized, double-blind, placebo-controlled
• Multiple dose levels or agents
• One to five years in duration
• Accrual 100s-1000s
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Phase III Trial
Objectives:• To determine the effect of the intervention on the cancer
incidence (total and specific cancer type)
• To determine the effect of the intervention on death rate and disease incidence
• To determine the long-term side effects of the intervention
• To determine the nature history of specific biomarkers of carcinogenesis (placebo group) and the effect of the intervention agent (treatment group) on these markers.
Design:• Randomized, double-blind, placebo-controlled
• Multiple dose levels or agents, alone or in combination
• Five to ten years in duration
• Accrual 1000s-10,000s
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UNIQUE FEATURES OF CHEMOPREVENTION
• Participants are usually healthy or at least “cancer free”
• The degree and incidence of side effects that are acceptable are low
• The end point is disease prevention, not disease response
• The incidence of the study end point is low
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CATEGORIES OF CHEMOPREVENTIVE AGENTS
• BLOCKING CARCINOGEN METABOLISM AND EXPOSURE
• INCREASE TISSUE RESISTANCE/DIFFERENTIAITON
• TARGETING ONCOGENIC PATHWAYS
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CATEGORIES OF CHEMOPREVENTIVE AGENTS
• BLOCKING AGENTS• Prevent metabolic activation of
carcinogens or tumor promoters
• Enhance detoxification
Glutathione-S-transferase,Oltipraz
• Trap reactive carcinogenic species:
Glutathione, N-Acetylcysteine
• Vaccines: HBV, HPV
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CATEGORIES OF CHEMOPREVENTIVE AGENTS (Cont.)
• INCREASING TISSUE RESISTANCE • Induce tissue maturation/differentiaiton
Pregnancy or hormonal induced maturation of terminal ducts of breast - decrease breast cancer
Retinoids, DMFO, etc
• Decrease target tissue functionCastration - reduce risk of prostate ca
• Decrease cell proliferationLow fat diet decrease epithelial proliferation rate in intestinal tract - reduce colon cancer risk
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CATEGORIES OF CHEMOPREVENTIVE AGENTS (Cont.)
• PATHWAY SPECIFIC AGENTS
• Cox-2 inhibitors
• Anti-angiogenesis
• Anti-EGFR
• Hormone antagonists
• Augmenting tumor suppressor functions
• Inhibiting oncogenic activities (e.g., Ras)
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CHEMOPREVENTION TO HUMANS - UPDATE
• BREAST CANCER• Two agents showed promising results:
Tamoxifen and retinoids
• Animal model well established• PROSTATE CANCER
• SCID model established
• Hormonal modulation may have potential • PCPT Trial – Finasteride (5-a-reductase, 5mg/day)
• 2-arm trial, 18,882 subjects, 7 yrs
• PCP=18.4% vs 24.8% in treated vs ctrl group
• Ongoing Trial: Selenium/Vit E trial
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CHEMOPREVENTION TO HUMANS - UPDATE (CONT.)
• GASTRIC AND ESOPHAGEAL CANCER• A combination of beta carotene, vitamin E,
and selenium may be effective in early stage lesions, but not late severe dysplastic lesions.
• LUNG CANCER• Beta-carotene or alpha-tocopherol showed
reverse effect in lung cancer risk in heavy smokers in Finland
• Ongoing trials with COX-2 inhibitor in former smokers here at UCLA
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CHEMOPREVENTION TO HUMANS - UPDATE (CONT.)
• COLON CANCER
• Sulindac, a nonsteroidal anti-inflammatory compound hold great promise. Others, such as Oltiparz, selenium, and antioxidants vit. E/A, etc, may also be effective.
• HEAD AND NECK CANCER
• Retinoids showed promising results in both animal models and human studies.
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PROBLEMS OF CHEMOPREVENTION
• TOO LONG
• TOO LARGE COHORT
• TOO MUCH COST
ANSWER:
NEED TO DEVELOP RELIABLE SEMS
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BIOMARKERS OF CANCER
• CLINICAL SETTINGS (TUMOR MARKERS)
• EPIDEMIOLOGICAL AND PREVENTIVE SETTINGS (INTERMEDIATE END POINT OR SURROGATE END POINT MARKERS).
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CURRENT CLINICALLY USED TUMOR MARKERS
• PSA - Prostate Adenocarcinoma
• Alpha FP - Hepatoma & some Ovarian Ca
• HCG - Choriocarcinoma
• CEA - Ovarian CA
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BIOMARKERS
• Genetic susceptibility markers
• Markers of exposure
• Markers of biological effects
-Detect early lesions
-Prognostic indicators
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GENETIC SUSCEPTIBILITY MARKERS
• Glutathione S-transferase (GST) M1 and T1
• N-acetyl transferase (NAT)
• Cytochrome P-450
• DNA repair gene defect (Lynch syndrome)
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MARKERS OF EXPOSURE
• Metabolic product of carcinogen in urine
• DNA, RNA and hemoglobin adducts-Reflects only current exposure
-Only a small fraction of DNA adducts will result in mutation
• DNA repair targets
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BIOMARKERS OF EFFECT
• Reflect the interactions of genetics and exposures and so the first choice for SEM
• If they persist, may also be the markers of disease
• Histopathologic evaluation is the “gold standard”
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HOW TUMOR MARKERS ARE USED CLINICALLY
• Early detection
• Predict the biological potential of cancer (metastasize and recurrence)
• Monitor the effectiveness of therapy
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Cancer
Precancerous Intraepithelial Lesions, (PIN, CIN, PaIN..)
Birth
Genetic Suscep. Marker
Markers for Exposure
Markers ofEffect
Tumor Markers
Exposure to Carcinogen Additional Molecular Event
Surrogate End Point Markers
CHEMOPREVENTION
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CRITERIA FOR SELECTING SEM
• FITS EXPECTED BIOLOGICAL MECHANISM
• BIOMARKER AND ASSAY PROVIDE ACCEPTABLE SENSITIVITY, SPECIFICITY, AND ACCURACY
• BIOMARKER IS EASILY MEASURED
• BIOMARKER MODULATION CORRELATES TO DECREASED CANCER INCIDENCE
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FITS EXPECTED BIOLOGICAL MECHANISM
• DIFFERENTIALLY EXPRESSED IN NORMAL AND HIGH RISK TISSUE
• CLOSELY LINKED, EITHER DIRECTLY OR INDIRECTLY, TO CAUSAL PATHWAY FOR CANCER
• MODULATED BY CHEMOPREVENTIVE AGENTS
• LATENCY IS SHORT COMPARED WITH CANCER
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ASSAY VALIDITY
• ASSAY SHOULD BE STANDARDIZED AND VALIDATED
• DOSE-RELATED RESPONSE TO THE CHEMOPREVENTIVE AGENT IS OBSERVED
• STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN LEVELS IN TREATMENT GROUPS AND CONTROLS
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OTHER ASSAY ISSUES
• BIOMARKER CAN BE OBTAINED BY NON-INVASIVE TECHNIQUES
• ASSAY IS NOT TECHNICALLY DIFFICULT• MULTIPLE MARKERS CAN BE EVALUATED
SIMULTANEOUSLY IN LIMITED SAMPLE VOLUMES
• COST• FALSE POSITIVE OR FALSE NEGATIVE
RESULTS ARE LESS IMPORTANT, IN COMPARING WITH CLINICAL TUMOR MARKERS
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CATEGORIES OF SEM
• HISTOLOGICAL AND MORPHOMETRIC MARKERS
• PROLIFERATION, DIFFERENTIATION AND INVASION MARKERS
• SPECIFIC ONCOGENES/GROWTH REGULATORS
• MARKERS OF GENETIC AND EPIGENETIC INSTABILITY
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POTENTIAL SEMS FOR BREAST, COLON AND PROSTATE
Breast ColonProstate
Histological DCIS, LCIS, ADHAdenomatous polyps
Aberrant polyps PIN
Proliferation S-phase fraction S-phase fraction PCNAKi-67 Brdu Uptake, PCNA Ki-67
Differentiation Myoepithelial (s-100 BGA, Mucin core ag HM CytokVimentin), etc Cytokeratins BGA, actin
Genetic Onc (erb-2, myc Onc (ras, myc, src) Onc (erb-2)fos, ras) Suppressor (p53,Suppressor (p53) DCC)
Biochemical Estradiol Ornithine Decarboxylase Polyamine TGF-beta, PSA
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SEM Modulation in Chemoprevention
• Complete Phenotypic Response -idea
• Less Than Complete Phenotypic Response -Genotypic markers to distinguish chemoprevention from selecting regressing of existing disease
– true effect is seen if post-treated lesion has less genotypic change than baseline or control)
• No Response.
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Genome Wide Genotypic SEM Analysis
• Identify high risk population
• Identify individuals with genetic susceptibility for treatment (pharmacogenomics)
• Monitoring/analyzing individual’s treatment response
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Issues in Using SEM
• The observed SEM change may not correlate with end point (cancer incidence).
• Can not measure the quality of life.
• Adverse effect may not be observed in short term SEM studies.
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Lessons learned from SELDI-TOF
• Initial study on patient serum from cancer patients (ovarian, prostate, etc) versus cancer showed very promising results (nearly 100% sensitivity/specificity to separate cancer from normal)
– Used case-control design
– Only 2 group-comparison (cancer vs. normal)
– No validation
• However, recent validation studies were rather disappointing
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Biomarker-Directed Targeted Design
• Increase the efficiency of the trial, but depends on:
– The performance of the biomarker test (sensitivity/specificity)
– Size of the treatment effect for target-negative patients
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BIOMARKER STUDY DSEIGN
a. Untargeted Design:
Register Randomize
Treatment
Control
b. Untargeted Design:
Register Randomize
Treatment
Control
Test Biomarker
Biomarker +
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BIOMARKER STUDY DSEIGN
Biomarker by Treatment Interaction Design:
Register
Randomize
Treatment
Control
Test Biomarker
Biomarker +
Stratify
Biomarker -
Randomize
Treatment
Control
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BIOMARKER STUDY DSEIGN
Biomarker Based Strategy Design:
Register Randomize
Treatment A
No BiomarkerEvaluation
Test Biomarker
Biomarker +
Biomarker -
Treatment B
Treatment B
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BIOMARKER STUDY DSEIGN
Modified Biomarker Based Strategy Design:
Register Randomize
Treatment A
No BiomarkerEvaluation
Test Biomarker
Biomarker +
Biomarker -
Treatment B
Treatment B
Randomize
Treatment A
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Actin Remodeling As a Target for Biomarker
Development
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NORMAL CA
Morphological hallmarks of cancer cells:
•Altered N/C-ratio•Altered membrane (cytoplasmic and nuclear)•Loss of cell adhesion•Increased motility/invasion/met.•etc..
ALMOST All ARE RELATED TO ACTIN REMODELING
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WHAT TO DO WITH THIS?
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HYPOTHESIS/RATIONALE
• Altered cytoskeletal proteins, e.g., actin remodeling, is the foundation for malignant morphological phenotype
• Thus, signaling pathways associated actin remodeling may provide a potential target for anti-cancer drug development as well as biomarkers for a more objective assessment of malignant transformation and progression
• These targets can be identified through genomic/proteomic approach
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VASP
TenuinF-Actin
Zyxin
Actinin
p-Tyr?
Vinculin
- Ras Sup. Family (Rac/Rho/CDC42)- pp60sro
- pp125FAK-Abl
PM
Substrate
ECM Integrin b a b a
Talin R/E/M
Paxillin
Tensin
Model in Focal Adhesions
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ACTIN ASSCOIATED MOLECULARS IMPLICATED IN
MALIGNANT TRANSFORMATION
• Oncogene signal transduction pathways
– Ras family ( GTPase):• Rho (stress fibers)
• Rac (lamellipodia)
• Cdc42 (filopodia)
– Src family (tyrosine kinase)*
– FAK** Relate to intergin signaling
• Tumor Suppresor
– Gelsolin*
– Tropomyosin/merlin
– Alpha-actinin*
– E-cadhelin
– Beta-Catanin
– Vinculin
– Fodrin**Implicated in apoptosis
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Increased cellular F-actin is a marker of cellular differentiation
Using leukemic cell lines:HL-60- Transformed/Differentiable
Daudi- Transformed/Undifferentiable
RPMI - Nontransfomed
We demonstrated that increased F-actin content is associated with cellular differentiation
(J. Rao, Cancer Res., 1990)
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In contrast, loss of F-actin is a marker for cellular transformation and bladder cancer risk
Bladder wash samples from a spectrum of cases with various risk for TCC show a strong correlation of loss of cellular F-actin contents with increased bladder cancer risk.
(J. Rao, Cancer Res., 1991)
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Furthermore, actin alteration is a field disease marker for bladder cancer
A careful mapping analysis on touch prep slides obtained from distant, adjacent and tumor tissues showed that increased G-actin is seen in over 50% of the distant field epithelial cells of cancer bearing bladder.
(J. Rao, P.N.A.S., 1993)
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QFIABiomarker Profile
G-actin: Texas-Red conjugated DNase I
M344: FITC (or Rhodamin) 3-Step
Immunofluorescence DNA: Hoechst or DAPI
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Test Our Biomarker Profile
to Detect Bladder Cancer
in Workers Exposed to
Cancer Causing Chemicals
Test Our Biomarker Profile
to Detect Bladder Cancer
in Workers Exposed to
Cancer Causing Chemicals
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Study Design in Worker Risk Assessment Study
373controls
1788 Workers
Screen Workers Markers Exposure Physical Exam Questionnaire Smoking Asses.
Monitor in 1 yr
Monitor in 3 yrs
Positive TREATVery High Risk
High Risk
Moderate Risk
Low Risk
Classify Risk
Action/Intervention
Negative
Cystoscopy
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Procedures in Screening Program
Notification of exposed workers.Selection of matching controls.Administration of questionnaire.
Occupational history.Medical history.Genitourinary tract history.Smoking assessment.
Physical examination.UrinalysisPapanicolaou cytologyDNA, M344, G-actin biomarkers
Notification of exposed workers.Selection of matching controls.Administration of questionnaire.
Occupational history.Medical history.Genitourinary tract history.Smoking assessment.
Physical examination.UrinalysisPapanicolaou cytologyDNA, M344, G-actin biomarkers
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Pathology Summary
30 Cancers detected29 Transitional Cell Carcinoma 1 Squamous Cell Carcinoma
4 Cases of Muscle Invasion (>T2)
20 Cases Grades 1-2; 8 Cases Grade 3.
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Incidence Rate (per 100,000 person-year) of Bladder
Cancer in the Cohort Exposed to Benzidine ( 1991-1997)
CohortNo. of
Subjects Followed
Age ( Mean ± SD )Cancer Cases
Incidence
Unexposed 373 57.7 ± 10.8 2 87.23
Exposed 1788 55.4 ± 10.5 28 263.35
Total 2161 55.8 ± 10.5 30 232.11
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TEST POSITIVE PRIOR TO OR AT THE TIME OF DIAGNOSIS
TEST POSITIVE PRIOR TO OR AT THE TIME OF DIAGNOSIS
BIOMARKERS NO. OF
POSITIVE/NO. OF CASES
RATE POSITIVE %
QFIA HIGH OR MODERATE
RISK28/29 96.5
PAP CYTOLOGY
15/28 53.6
HEMATURIA 4/28 14.3
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Biomarker Results of Cohort StudyBiomarker Results of Cohort Study Detection Detection
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Biomarker Results of Cohort StudyBiomarker Results of Cohort StudyRisk AssessmentRisk Assessment
Sensitivity Specificity OR PPV
DNA 88 87 46 2.7
M344 50 98 46 9.1
High Risk 63 91 17.3 2.9
HM or P 88 70 16.6 1.3
PAP 14 99 24.7 6.7
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Cox Proportional Regression Model with Cox Proportional Regression Model with Time Dependent CovariatesTime Dependent Covariates
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Lead Time to Tumor Detection During the Follow-up (1991-1997)
Total Cases=25*
N % CasesMean
Months
Moderate Risk 10** 40 33
High Risk 23 92 15
Pap 16 64 8
Hematuria 4 16 3
** 8 out of 10 cases progressed to high risk prior to tumor detection.
* 4 cases were excluded due to their detection at the initial screen. 1 case was excluded due to the error of sample collection.
** 8 out of 10 cases progressed to high risk prior to tumor detection.
* 4 cases were excluded due to their detection at the initial screen. 1 case was excluded due to the error of sample collection.
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Abnormal G-actin in the Field Predicts Tumor Recurrence
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Cellular actin levels can be used to monitor the effectiveness of chemoprevention
•Cellular F/G-actin levels in the non-tumor field epithelial cells after tumor was removed by TUR predicted the recurrence potential of the tumor.
•In addition, cellular F/G-actin levels fluctuate from abnormal to normal as results of chemopreventive effect of differentiation agent DMSO.
(G.P. Hemstreet, J. Rao, Cancer Det. And Prev., 1999)
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SUMMARY: Actin Remodeling in Cancer • Actin remodeling as a generalized marker for:
– Cancer field changes
– Precancerous lesions
– and thus, a candidate for chemopreventive SEM
• However:
– Measuring actin remodeling is technically challenging
• New method/tools are needed
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Nanomechanical analysis of cancer cell softness/elasticity
• Atomic Force Microscope:
– A new tool for cancer research– Ideal for analyzing the functional role of
actin remodeling in various cellular events in single living cells
– Combine functional analysis with morphology at nanometer level
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NEWS HEADLINES
• Nanotechnology shows cancer cells are 'softer' than normal cells
• Microscopic 'tools' can identify cancer cells by 'feel‘
• Nano breakthrough in cancer detection: study
• ….
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Fig. 1. Schematic of an AFM tip (a) approaching, (b) indenting and (c) retracting from a cell
(a)
(b) (c)Force
Displacement
(a)
(b)
(c)
(a)
(b) (c)Force
Displacement
(a)
(b)
(c)Force
Displacement
(a)
(b)
(c)
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A v e r a g e Y o u n g ’ s M o d u lu s ( E ) va lu e s fo r A 5 4 9 h u m a n lu n g a d e n o c a r c in o m a c e l ls t r e a te d w ith o r w ith o u t ( c tr l ) 4 0 u g / m L g r e e n te a e x tr a c t ( G T E ) fo r 6 a n d 1 2 h o u r s , r e s p e c t iv e ly .
E f f e c t s o f G T E o n t h e m i g r a t i o n o f A 5 4 9 c e l l s . C o n fl u e n tm o n o l a y e r s o f c e l l s w e r e m a i n t a in e d in a s e r u m f r e e m e d i a a n d a l a n e w a s s c r a p e d t h r o u g h t h e m o n o l a y e r s o f t h e c e l l s w i t h a p l a s t i c m ic r o p i p e t t e t i p . T h e c e l l s w e r e a l l o w e d t o m i g r a t e a c r o s s t h e l a n e a t 3 7 o C f o r 6 o r 2 4 h i n t h e p r e s e n c e ( 4 0 µ g /m l ) o r a b s e n c e o f G T E . T h e d i s t a n c e th a t c e l l s m i g r a t e d i n t o th e a r e a o f t h e w o u n d a t d i f f e r e n t p o i n t s w a s p h o t o g r a p h e d u s i n g a c o m p u t e r i m a g i n g s y s t e m . T o p p a n e l s : G T E u n t r e a t e d ; l o w e r p a n e l s : G T E t r e a t e d ( 4 0 μ g /m l ) .
0 h r 6 h r 2 4 h r
C t r l
G T E
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0 50 100 150 200 250 300 350 4000
1
2
3
4
5
6
7
8
Co
un
ts
Young's Modulus (E)
Adhesion Force Measured between Mesothelial Cells and Cancer Cells
050
100150200250300
E AF
AFM MeasurementsM
easu
rem
ent
Mesothelial cells Cancer cells
A B
C DPhase-contrast
Mesothelial cells
Tumor
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c
db
(i)(ii)
a
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“Chemoprevention of Superficial Bladder Cancer in Former Smokers”
Parallel, Randomized, Double-blind, Placebo-Controlled, Phase II Adjuvent Studies of Erlotinib and Polyphenol E to Prevent the Recurrence and Progression of Tobacco-Related, High-grade
Superficial Bladder CancerU01-CA-96116
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Study Objectives
• Primary:
– To evaluate the effects of a daily dose of PE, Erlotinib, and placebo on tumor recurrence for pts with superficial bladder ca (former smokers)
• Secondary:
– To assess toxicities of PE and Erlotinib
– To correlate the modulation of biomarkers with tumor recurrence/progression
– To assess the effects of PE and Erlotinib on tumor progression
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Study Design• Phase II, randomized, double-blinded,
placebo-controlled, 3-arm trials• A random permuted study design with one
stratification factor (Ta vs T1 vs CIS)• Two agents: PE- 800mg/daily, Erlotinib
(up to 100mg/daily• 330 former smokers (<12 months) with
prior superficial bladder ca
StageTa T1CIS
Placebo TreatmentPE Erlotinib
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Specimen Types
• Blood
• Urine cytological specimens
– Voided urine– Catheterized urine– Bladder wash
• Tissue
– Biopsy– Cystectomy specimen
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Key Secondary Biomarkers
• Cytology
• QFIA Profile:
– DNA & G-actin by LSC– M344/19A211/LDQ10 by Immunocyt kit
• Microsatellite Instability Markers (M.S.I.)
• bFGF
• Survivin
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Biomarker Core
Urinary Cytology(VU/CU/BW, 100 cc each)
Tissue(ca, random)
Blood(20 cc)
10 cc 2-bFGFBrook’s labThin Prep (3)
1 slide 2 slide
2-QFIARao’s Lab
2- Cytology
Extract Genomic DNA
2- M.S.I.(Core facility)
3- Genetic Polymorphism(Zhang’s lab)
Fresh Frozen
Store(Rao’s lab)
ParaffinEmb.
1- Histology
3- Tissue ArrayEGFR, Ki67, Gelsolin, p53, etc(Seligson’s lab)
Leukocyte
3- Genetic Polym.(Zhang’s lab)
4- Polyphenol(Heber’s lab)
Plasma
Store
5 cc
1- Primary end point2- Secondary end point3-Tertiary end point4- Compliance marker
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Summary • Biomarker is needed in Chemoprevention Trial to:
– Detect early preventable lesions – Monitoring the efficacy
• Actin remodeling and associated cellular nanomechanical changes provide a wealth of targets for chemopreventive biomarker selection:
– Actin change occurs in premalignant field lesion– Chemopreventive agents (e.g., green tea) modulates
actin remodeling– Actin change can be detected either by traditional
biochemical assays or AFM measurements of cellular nanomechanics