Emily Bellavance

Rac1 promotes intestinal epithelial restitution by increasing Ca2+ influx through interaction with phospholipase C-γ1 after wounding

Intestinal mucosal restitution occurs as a consequence of epithelial cell migration and reseals superficial wounds after injury. This rapid reepithelialization is mediated in part by a phospholipase C-gamma1 (PLC-gamma1)-induced Ca(2+) signaling, but the exact mechanism underlying such signaling and its regulation remains elusive. The small GTP-binding protein Rac1 functions as a pivotal regulator of several signaling networks and plays an important role in regulating cell motility. The current study tests the hypothesis that Rac1 modulates intestinal epithelial cell migration after wounding by altering PLC-gamma1-induced Ca(2+) signaling. Inhibition of Rac1 activity by treatment with its inhibitor NSC-23766 or Rac1 silencing with small interfering RNA decreased store depletion-induced Ca(2+) influx and suppressed cell migration during restitution, whereas ectopic overexpression of Rac1 increased Ca(2+) influx and promoted cell migration. Rac1 physically interacted with PLC-gamma1 and formed Rac1/PLC-gamma1 complex in intestinal epithelial cells. PLC-gamma1 silencing in cells overexpressing Rac1 prevented stimulation of store depletion-induced Ca(2+) influx and cell migration after wounding. Polyamine depletion inhibited expression of both Rac1 and PLC-gamma1, decreased Rac1/PLC-gamma1 complex levels, reduced Ca(2+) influx, and repressed cell migration. Overexpression of Rac1 alone failed to rescue Ca(2+) influx after store depletion and cell migration in polyamine-deficient cells, because it did not alter PLC-gamma1 levels. These results indicate that Rac1 promotes intestinal epithelial cell migration after wounding by increasing Ca(2+) influx as a result of its interaction with PLC-gamma1.

Induced TRPC1 expression increases protein phosphatase 2A sensitizing intestinal epithelial cells to apoptosis through inhibition of NF-κB activation

Transient receptor potential canonical-1 (TRPC1) functions as a store-operated Ca2+ channel in intestinal epithelial cells (IECs), and induced TRPC1 expression sensitizes IECs to apoptosis by inhibiting NF-kappaB activation. However, the exact mechanism by which increased TRPC1 results in NF-kappaB inactivation remains elusive. Protein phosphatase 2A (PP2A) is a widely conserved protein serine/threonine phosphatase that is implicated in the regulation of a wide array of cellular functions including apoptosis. The present study tests the hypothesis that induced TRPC1 expression inhibits NF-kappaB activation by increasing PP2A activity through Ca2+ influx in IECs. The expression of TRPC1 induced by stable transfection with the wild-type TRPC1 gene increased PP2A activity as indicated by increases in levels of PP2A proteins and their phosphatase activity. Increased levels of PP2A activity in stable TRPC1-transfected IEC-6 cells (IEC-TRPC1) were associated with decreased nuclear levels of NF-kappaB proteins and a reduction in NF-kappaB-dependent transcriptional activity, although there were no changes in total NF-kappaB protein levels. Inhibition of PP2A activity by treatment with okadaic acid or PP2A silencing with small interfering RNA not only enhanced NF-kappaB transactivation but also prevented the increased susceptibility of IEC-TRPC1 cells to apoptosis induced by treatment with tumor necrosis factor-alpha (TNF-alpha)/cycloheximide (CHX). Decreasing Ca2+ influx by exposure to the Ca2+-free medium reduced PP2A mRNA levels, destabilized PP2A proteins, and induced NF-kappaB activation, thus blocking the increased sensitivity of IEC-TRPC1 cells to TNF-alpha/CHX-induced apoptosis. These results indicate that induced TRPC1 expression increases PP2A activity through Ca2+ influx and that increased PP2A sensitizes IECs to apoptosis as a result of NF-kappaB inactivation.

Decision-Making in the Surgical Treatment of Breast Cancer: Factors influencing women's Choices for Mastectomy and Breast Conserving Surgery

One of the most difficult decisions a woman can be faced with when choosing breast cancer treatment is whether or not to undergo breast conserving surgery or mastectomy. The factors that influence these treatment decisions are complex and involve issues regarding access to health care, concerns for cancer recurrence, and the impact of surgery on body image and sexuality. Understanding these factors will help practitioners to improve patient education and to better guide patients through this decision-making process. Although significant scientific and societal advances have been made in improving women’s choices for the breast cancer treatment, there are still deficits in the decision-making processes surrounding the surgical treatment of breast cancer. Further research is needed to define optimal patient education and shared decision-making practices in this area.

Palliative Interventions in Patients With Peritoneal Metastases and Malignant Bowel Obstruction

Peritoneal metastases are a common mode of tumor progression for patients with cancers of the GI tract, genitourinary cancers, peritoneal mesothelioma, and occasionally other primary sites. Once peritoneal metastases develop, patient morbidity and mortality are almost invariably a consequence of disease progression in the abdominal cavity. Options for therapeutic intervention include systemic combination chemotherapy and, in selected patients, operative cytoreduction with intraoperative or perioperative regional chemotherapy. Ultimately, the clinical sequelae of uncontrolled tumor progression in the peritoneal cavity from any primary tumor site include abdominal pain, distention, occasional ascites, weight loss, malignant bowel obstruction (MBO) and inanition. Successful palliative management of patients during the late stages of their disease course is clinically challenging. Intravenous hydration, intestinal decompression via a nasogastric or gastrostomy tube, analgesics, and other supportive measures are the norm. Based on their potent antisecretory properties, the use of somatostatin analogs to treat symptoms associated with MBO has been advocated for many years. There have been several small prospective random assignment trials generally showing some benefit to somatostatin analogs compared with anticholinergic agents or corticosteroids in this patient population. In the article accompanying this editorial Mariani et al reports the results of a phase III double-blind placebo controlled study assessing the efficacy of a single dose of intramuscular lanreotide, a long-acting somatostatin receptor analog, in palliating symptoms associated with MBO in hospitalized patients. Patients with peritoneal carcinomatosis who had symptoms of obstruction ( 2 episodes of vomiting per day or the presence of a nasogastric tube) were eligible for the study. The patient cohort was a group suffering from advanced cancer; none were on active therapy for their underlying malignancy, all had diminished performance status, none were considered operative candidates for palliation, and almost two thirds had nasogastric tubes. The primary outcome was improvement in symptoms based on diaries filled out by the patients through day 7 of the study; there were a number of secondary end points and supportive analyses. The authors conclude that lanreotide “has some efficacy and is safe in the symptomatic treatment of patients” with advanced malignant bowel obstruction. This study, testing a palliative intervention in symptomatic and clinically deteriorating patients with MBO from advanced cancer, exemplifies the many and unique challenges that are encountered with palliative care clinical research, in which the intent of therapy is solely to provide symptomatic improvement without any treatment directed against the underlying neoplastic process. There have been a number of publications that have described the unique considerations in designing and conducting prospective palliative care clinical research including identifying measurable, relevant, and generalizable end points; recruitment of study participants; addressing the unique ethical concerns such as minimizing the burden of participation, and study design. It has been noted that timely accrual to trials in palliative care clinical research is challenging and that eligibility criteria must be defined as broadly as possible to facilitate subject enrollment while maintaining as much patient homogeneity as possible so that the results are generalizable. While Mariani et al have done so by including patients with MBO secondary to any tumor histology, the 80-patient accrual in the current study still required a 5-year interval across over 20 hospitals in three countries (Belgium, France, and the Netherlands). Slow recruitment may also be due to inherent reluctance to enroll patients in a clinical study during the end stage of their malignant disease. Some would argue that these patients represent a vulnerable population who may be incapable of giving informed consent or should not be burdened with participating in a clinical research study while in the process of dying. In fact, 11 of the 80 enrolled patients died after enrollment but before the 7-day study end point. In palliative care research, study end points must be completed as soon as possible after enrollment due to the declining condition of the study population. Mariani et al should be lauded in that the study design included a 7-day end point. In addition, the investigators included a standardized, aggressive, and compassionate concomitant treatment regimen as baseline therapy for both groups, including unrestricted analgesic use, to minimize the chances that any study participant in either arm would suffer from uncontrolled symptoms or withdraw from the study prematurely. Despite this, almost 20% of randomized patients did require additional symptomatic interventions not prescribed in the protocol which confounded the outcome analysis. Study end points in palliative care research should be relevant and generalizable to a greater population of similarly afflicted patients. This patient cohort suffered from MBO secondary to a number of different neoplastic processes that are appreciated to have variable biologic behaviors. Over half the study population had ovarian or JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 30 NUMBER 35 DECEMBER 1

Ethical Considerations in Clinical Research

In the May 8, 2011 issue of Annals of Surgical Oncology, Guest et al. published two papers summarizing their results of a single-institution survey reporting the prevalence of burnout, psychiatric morbidity, and quality of life of 97 surgeons at Memorial Sloan Kettering Cancer Center (MSKCC). Of the 72 respondents, 42% reported burnout, 27% reported psychiatric distress, 30% screened positive for ‘‘potentially problematic alcohol use,’’ and 13% reported the use of sleep medications. Very importantly, as Drs. Balch and Shanafelt point out in their accompanying editorial, these factors can adversely affect ‘‘patient safety, quality of patient care, and even contribute to medical errors.’’ In addition to reporting the prevalence of burnout, the authors attempt to identify modifiable aspects of the work environment. One of these modifiable factors related to the taboo associated with burnout; 32% of participants reported a great need to change the ‘‘taboo to discuss personal distress and the culture of bravado.’’ One could argue that the open publication of these results from a prestigious and internationally recognized cancer institution, which demonstrate consistency with national data on surgeon burnout, will help in deconstructing the taboo and stigmatization associated with addressing personal distress in the workplace. Unfortunately, acknowledgment of the prevalence and associated stigma of physician burnout and the desire to lessen that stigma are not sufficient measures to remove the stigma—at least not immediately. The current reality is that burnout, psychiatric distress, and ‘‘potentially problematic alcohol use’’ are emotionally charged subjects that can have significant social implications including the stigmatization and marginalization of a community. In this case, the community in question is alarmingly specific—an identified institution’s surgery department with fewer than 100 members. In all population-based research and especially with community-based research addressing behavioral issues, the question has been asked: Can a community’s right to privacy be violated even if individuals within the community have consented to the disclosure of information? We believe that the referenced studies indicate the answer is ‘‘yes’’; that by identifying the department of surgery by institution, this community’s privacy has been compromised. Furthermore, the published results focus on psychosocial issues that could potentially lead to the stigmatization of this select group of surgeons, placing at risk the welfare of both the individuals who participated in the survey and, importantly, the 25 surgeons who did not. Therefore, we believe that these publications highlight important topics relating to the ethical conduct of clinical research. The guiding principles of clinical research in this country: respect for persons, beneficence, and justice, are based on the fundamental tenets historically promoted by the Nuremburg Code, the Helsinki Declaration, and the U.S. National Commission that issued the Belmont Report in 1979 and are now set forth in the Code of Federal Regulations. These principles are designed to protect human subjects with institutional assurances through formal institutional review board (IRB) review and informed consent obtained by the principal investigator or his or her designee. It certainly appears that the investigators took precautions to protect the rights of individual participants and thus uphold the Belmont principles. IRB approval and the voluntary nature of the survey study are documented in the methods section of the publications, suggesting that subjects were informed that their voluntary participation implied consent and that the results of the survey could be used for future publications. Because of sensitivity to the small sample size of a specific department and in order to Society of Surgical Oncology 2011

Ethical Considerations of Medical Photography in the Management of Breast Disease

BackgroundMedical photography has become an important component of the evaluation and management of patients across many specialties. It is increasingly utilized in contemporary practice with modern smartphones and enhanced digital media. Photography can enhance and improve treatment plans and communication between providers and patients. Additionally, photography supplements education, research, and marketing in both print and social media. Ethical and medicolegal standards for medical photography, specifically for patients with breast disease, have not been formally developed to guide medical providers.PurposeTo provide guidelines for breast care physicians using medical photography, the Ethics Committee of the American Society of Breast Surgeons presents an updated review of the literature and recommendations for ethical and practical use of photography in patient care.MethodsAn extensive PubMed review of articles in English was performed to identify studies and articles published prior to 2018 investigating the use of medical photography in patient care and the ethics of medical photography. After review of the literature, members of the Ethics Committee convened a panel discussion to identify best practices for the use of medical photography in the breast care setting. Results of the literature and panel discussion were then incorporated to provide the content of this article.ConclusionThe Ethics Committee of the American Society of Breast Surgeons acknowledges that photography of the breast has become an invaluable tool in the delivery of state-of-the-art care to our patients with breast disease, and we encourage the use of this important medium. Physicians must be well informed regarding the concerns associated with medical photography of the breast to optimize its safe and ethical use in clinical practice.

Patient-reported Adherence to Adjuvant Aromatase Inhibitor Therapy Using the Morisky Medication Adherence Scale: An Evaluation of Predictors.

Objectives: Endocrine therapy is part of standard adjuvant therapy for patients with hormone receptor-positive breast cancer and has been shown to improve recurrence-free and overall survival. However, adherence to endocrine therapy is suboptimal and is difficult to measure. In this study we evaluate the feasibility of using the Morisky Medication Adherence Scale (MMAS) to assess patient adherence to aromatase inhibitor (AI) therapy. Methods: Patients with stage 1 to 3, hormone receptor-positive breast cancer receiving adjuvant AI therapy were prospectively enrolled on an Institutional Review Board approved protocol. The MMAS questionnaire was administered to each patient and adherence was measured. Information on duration of AI therapy, patient and tumor characteristics, and treatment was collected. A multivariable logit model approach was utilized to evaluate potential barriers to adherence. Results: Between 2011 and 2014, 100 patients were enrolled. The distribution of adherence levels was 13% low, 37% medium, and 50% high. High adherence was reported more frequently in white women (58%), patients with stage 2 and 3 disease (54%), and patients who did not receive chemotherapy (62%). Multivariable analysis demonstrated that higher adherence was more likely in white women compared with African American women (estimated odds ratio=2.8). Conclusions: Using the MMAS, only 50% of women with stage 1 to 3 breast cancer reported high adherence to AI therapy, consistent with other reports showing suboptimal adherence to adjuvant endocrine therapy. The MMAS allows for the rapid assessment of adherence to oral adjuvant endocrine therapy and is valuable in a busy clinical setting.

Effect of reduction mammoplasty on acute radiation side effects and use of lumpectomy cavity boosts

PURPOSE Reduction mammoplasty (RM) during breast-conserving surgery is popular among women with large-volume breasts because it reduces redundant breast folds and may decrease skin-related morbidity from radiation therapy. However, RM may obscure the lumpectomy cavity (LC) and pose challenges to administering an LC boost, potentially affecting local control. We investigated the impact of RM on acute side effects and use of LC boosts. METHODS AND MATERIALS The records of 645 consecutive women treated with whole-breast irradiation at an urban university and 2 community practices between January 2012 and December 2014 were reviewed on an institutional review board-approved study. The primary endpoint was grade ≥3 radiation dermatitis; the secondary endpoint was use of LC boost. Student 2-sample t tests, Pearson χ2 tests, Fisher exact tests, and univariate and multivariable logistic regression analyses were performed. RESULTS Forty-three (7%) RMs were performed in 650 treated breasts. No significant differences in grade 3 toxicities were identified among RM and non-RM patients. LC boost was delivered to 474 breasts. Fewer (16/43) RM patients received LC boosts compared with non-RM patients (458/607), P = .0001. RM patients were more likely to have neoadjuvant chemotherapy, stage III or multifocal disease, higher body mass index, larger planning treatment volumes, and conventional fractionation (P < .05). CONCLUSIONS RM was associated with decreased use of LC boost without significant differences in acute toxicities. Further investigation to delineate LCs in patients undergoing RM or identify alternative strategies for delivering LC dose is needed.

What is the impact of reduction mammoplasty for women undergoing breast-conserving surgery for breast cancer?

49 Background: Reduction mammoplasty (RM) at time of breast conserving surgery (BCS) is an increasingly popular procedure that reduces redundant breast folds and skin toxicity from whole breast irradiation (WBI). However, the tissue manipulation may obscure the lumpectomy cavity (LC) and hinder the ability to deliver a radiation boost to the LC, potentially impacting local control. We studied the impact of RM on acute radiation side effects and the use of LC boost. METHODS From Jan 2012 to Dec 2014, 652 consecutive women with DCIS or Stage I-III invasive cancer were treated with curative intent BCS and WBI at an urban university and 2 community practices. We reviewed the charts on an IRB-approved study with the primary endpoint of ≥ grade 3 radiation dermatitis scored via the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Secondary endpoint was the use of LC boost. Tested variables included age, race, body mass index, menopausal status, multi-focal disease, stage, tumor grade, receptor status, chemotherapy administered, specimen volume, 3D or intensity modulated radiation, fractionation, nodal irradiation, and planning treatment volume (PTV). Students t-tests and Pearsons chi-square tests were utilized. RESULTS Forty-three (7%) of 652 patients underwent RM. Larger volumes of tissue were removed from the RM patients (median 366.5 g v 35.3 g, P= 0.0001). No grade 4 toxicities and few (2-3%) grade 3 toxicities were seen, P= 1.00. Narcotic use was similar (4-5%), P= 0.70. A LC boost was used in 476 (73%) patients; RM significantly decreased the use of a boost [16/43 (37%) v 460/609 (76%)], P= 0.0001. RM patients were more likely to have neoadjuvant chemotherapy, stage III or multi-focal disease, higher BMI, nodal irradiation, and conventional fractionation (P< 0.05). Subgroup analysis of the patients with available PTVs (67%) revealed similar volumes (P= 0.16). CONCLUSIONS RM was associated with a decrease in the use of LC boost without significant differences in acute toxicities; however, the result is not surprising given that PTVs were similar. Further investigation is needed to better delineate LCs in patients undergoing RM to increase the use of LC boosts.

M1731 Sphingosine-1-Phosphate Regulates Barrier Function in Cultured Intestinal Epithelial Cells and Murine Intestinal Tissue

assessed by stable isotope methodology after administration of U-13C-glucose and 1-13Clactose. Concentrations of the EFA linoleic acid (LA), and the enzyme activity and mRNA expression of lactase, were measured in the mucosa of proximal, mid and distal small intestine. Results: Mice fed the EFA-deficient diet were markedly EFA-deficient (triene/ tetraene ratio 0.23±0.06 vs. 0.01±0.00 in controls, p<0.05) with a profound lower fat absorption of dietary fat (81±3 vs. 99±0% in controls, of ingested amount, p<0.05). EFA deficiency did not affect the histology or proliferative capacity of the small intestine as demonstrated by the histological and proliferative staining, and by the morphometrcal measurements of the small intestinal villi. Blood C6-glucose appearance and disappearance were similar in both groups, indicating unaffected monosaccharide absorption. In contrast, blood appearance of 13C-glucose, originating from 13C-lactose, was delayed in EFA-deficient mice. EFA deficiency profoundly reduced lactase activity (-58%, p<0.01) and mRNA expression (-55%, p<0.01) in mid small intestine. Both lactase activity and its mRNA expression strongly correlated with mucosal LA concentrations (r=0.89 and 0.79, resp., p< 0.01). Conclusions: EFA deficiency in mice inhibits the capacity to digest lactose, but does not affect small intestinal histology. These data underscore the observation that EFA deficiency functionally impairs the small intestine, possibly mediated by low LA levels in the enterocytes. This research was funded by the Dutch Digestive Foundation (MWO 04-38).