Susan Miesfeldt

cis-acting sequences required for inducible interleukin-2 enhancer function bind a novel Ets-related protein, Elf-1.

The recent definition of a consensus DNA binding sequence for the Ets family of transcription factors has allowed the identification of potential Ets binding sites in the promoters and enhancers of many inducible T-cell genes. In the studies described in this report, we have identified two potential Ets binding sites, EBS1 and EBS2, which are conserved in both the human and murine interleukin-2 enhancers. Within the human enhancer, these two sites are located within the previously defined DNase I footprints, NFAT-1 and NFIL-2B, respectively. Electrophoretic mobility shift and methylation interference analyses demonstrated that EBS1 and EBS2 are essential for the formation of the NFAT-1 and NFIL-2B nuclear protein complexes. Furthermore, in vitro mutagenesis experiments demonstrated that inducible interleukin-2 enhancer function requires the presence of either EBS1 or EBS2. Two well-characterized Ets family members, Ets-1 and Ets-2, are reciprocally expressed during T-cell activation. Surprisingly, however, neither of these proteins bound in vitro to EBS1 or EBS2. We therefore screened a T-cell cDNA library under low-stringency conditions with a probe from the DNA binding domain of Ets-1 and isolated a novel Ets family member, Elf-1. Elf-1 contains a DNA binding domain that is nearly identical to that of E74, the ecdysone-inducible Drosophila transcription factor required for metamorphosis (hence the name Elf-1, for E74-like factor 1). Elf-1 bound specifically to both EBS1 and EBS2 in electrophoretic mobility shift assays. It also bound to the purine-rich CD3R element from the human immunodeficiency virus type 2 long terminal repeat, which is required for inducible virus expression in response to signalling through the T-cell receptor. Taken together, these results demonstrate that multiple Ets family members with apparently distinct DNA binding specificities regulate differential gene expression in resting and activated T cells.

Association of Age, Gender, and Race with Intensity of End-of-Life Care for Medicare Beneficiaries with Cancer

PURPOSE To measure intensity of end-of-life (EOL) care for Medicare cancer patients and variations in care by age, gender, and race. PATIENTS AND METHODS This retrospective cohort analysis of Medicare claims (20% sample) examined 235,821 Medicare Parts A and B fee-for-service patients dying with poor-prognosis cancers between 2003 and 2007. Logistic regression models quantified associations between care intensity and age, gender, and race. Measures included hospitalizations, emergency department (ED) visits, intensive care unit (ICU) admissions, in-hospital deaths, late-life chemotherapy administration, overall and late hospice enrollment within six months of death. RESULTS Within 30 days of death, 61.3% of patients were hospitalized, 10.2% were hospitalized more than once, 10.2% visited an ED more than once, 23.7% had ICU admissions, and 28.8% died in-hospital. Within two weeks of death, 6% received chemotherapy. In their final six months, 55.2% accessed hospice, 15.1% within three days of death. Older age (≥75 versus <75) was associated with lower odds ratios (ORs) of 0.49 to 0.89 for aggressive care, and an OR of 0.92 (95% CI 0.89-0.95) for late hospice enrollment. Female gender was associated with lower ORs (0.82 to 0.86) for aggressive care, and an OR of 0.84 (95% CI 0.81-0.86) for late hospice enrollment. Black (versus nonblack) race was associated with higher ORs (1.08 to 1.38) for aggressive acute care, lower ORs for late chemotherapy, OR 0.76 (95% CI 0.71-0.81), and late hospice enrollment, OR 0.81 (95% CI 0.76-0.86). CONCLUSIONS Seniors dying with poor-prognosis cancer experience high-intensity care with rates varying by age, gender, and race.

Health Heritage© a web-based tool for the collection and assessment of family health history: initial user experience and analytic validity.

A detailed family health history is currently the most potentially useful tool for diagnosis and risk assessment in clinical genetics. We developed and evaluated the usability and analytic validity of a patient-driven web-based family health history collection and analysis tool. Health Heritage© guides users through the collection of their family health history by relative, generates a pedigree, completes risk assessment, stratification, and recommendations for 89 conditions. We compared the performance of Health Heritage to that of Usual Care using a nonrandomized cohort trial of 109 volunteers. We contrasted the completeness and sensitivity of family health history collection and risk assessments derived from Health Heritage and Usual Care to those obtained by genetic counselors and genetic assessment teams. Nearly half (42%) of the Health Heritage participants reported discovery of health risks; 63% found the information easy to understand and 56% indicated it would change their health behavior. Health Heritage consistently outperformed Usual Care in the completeness and accuracy of family health history collection, identifying 60% of the elevated risk conditions specified by the genetic team versus 24% identified by Usual Care. Health Heritage also had greater sensitivity than Usual Care when comparing the identification of risks. These results suggest a strong role for automated family health history collection and risk assessment and underscore the potential of these data to serve as the foundation for comprehensive, cost-effective personalized genomic medicine.

Disparities in hospice care among older women dying with ovarian cancer

BACKGROUND Timely hospice referral is an essential component of quality end-of-life care, although a growing body of research suggests that for patients with various types of cancer, hospice referrals often occur very late in the course of care, and are marked by sociodemographic disparities. However, little is known about the ovarian cancer patient population specifically. We examined the extent and timing of hospice referrals in ovarian cancer patients over age 65, and the factors associated with these outcomes. METHODS We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 8211 women aged 66+ with ovarian cancer who were diagnosed between 2001 and 2005 and died by December 31, 2007. We excluded women who were not eligible for Medicare A continuously during the 6 months prior to death. Outcomes studied included overall hospice use in the last 6 months of life and late hospice enrollment, defined as within 3 days of death. We examined variations in these two measures based on year of diagnosis and sociodemographic characteristics (age, race, marital status, rural residence, income, education) and type of Medicare received (fee-for-service vs. managed care). RESULTS Among 8211 women in the cohort who died from ovarian cancer, 39.7% never received hospice care (3257/8211). Overall hospice care increased over the period of observation, from 49.7% in 2001 to 63.6% [corrected] in 2005, but the proportion of women receiving hospice care within 3 days of death did not improve. Among those who received hospice care, 11.2% (556/4954) and 26.2% (1299/4954) received such care within 3 and 7 days of death, respectively. A higher proportion of black women (46.5% vs. 38.4% among whites), women in the lowest income group (42.8% vs. 37.0% in the highest income group), and those receiving fee-for-service Medicare (41.3% vs.33.5% for women in managed care) never received hospice care. In multivariable models, factors associated with lack of hospice care included age younger than 80 years (OR 1.27, 95% CI 1.15-1.40), non-white race (OR 1.44, 95% CI 1.26-1.65), low income (OR 1.17, 95% CI 1.04-1.32) and enrollment in fee-for-service Medicare compared with managed care (OR 1.39, 95% CI 1.24-1.56). CONCLUSION More older women with ovarian cancer are receiving hospice care over time, however, a substantial proportion receive such care very near death, and sociodemographic disparities in hospice care exist. Our data also support the need to target lower-income and minority women in efforts to increase optimally timed hospice referrals in this population. Our finding that ovarian cancer patients enrolled in managed care plans were more likely to receive hospice care suggests the importance of health care system factors in the utilization of hospice services.

Development of fragment-specific osteopontin antibodies and ELISA for quantification in human metastatic breast cancer

BackgroundOsteopontin (OPN) is associated with human cancers, and circulating blood OPN may have diagnostic or prognostic value in clinical oncology.MethodsTo evaluate OPN as a cancer biomarker, we generated and characterized five novel mouse monoclonal antibodies against the human full-length OPN (fl-OPN). Epitopes recognized by four antibodies (2C5, 2F10, 2H9, and 2E11) map to N-terminal OPN (aa1-166); one (1F11) maps to C-terminal OPN (aa167-314). These antibodies recognize recombinant and native OPN by ELISA and immunoblot, cross reacting with human and mouse OPN. Two of these novel antibodies (2F10 and 1F11) were used to develop a quantitative enzyme linked immunosorbent assay (ELISA) for fl-OPN.ResultsIn comparison with commercially available ELISAs, our assay had high accuracy in measuring fl-OPN standards, and high sensitivity. Specifically, our ELISA has a linear dose response between 0.078 ng/ml-10 ng/ml, with a sensitivity of 13.9 pg/ml. We utilized this assay to quantify fl-OPN in the plasma of healthy volunteers in comparison with patients with metastatic breast cancer. The average circulating plasma fl-OPN in healthy volunteers was 1.2 ng/ml, compared to 4.76 ng/ml in patients with metastatic breast cancer (p = 0.0042). Although the increase in fl-OPN in cancer patients is consistent with previous studies, the measured quantity varied greatly between all existing fl-OPN ELISAs.ConclusionBecause OPN is a complex molecule with diversity from alternative splicing, post-translational modification, extracellular proteolytic modification, and participation in protein complexes, we suggest that further understanding of specific isoform recognition of multiple OPN species is essential for future studies of OPN biomarker utility.

Germline mutations in PTEN and SDHC in a woman with epithelial thyroid cancer and carotid paraganglioma.

Background A 43-year-old woman presented to a cancer genetics clinic for a genetic risk assessment because of her personal history of multiple neoplasias. At 37 years of age, she was diagnosed with multifocal papillary thyroid cancer, and within a year was further diagnosed with a paraganglioma of the left common carotid artery. Two years later, she was diagnosed with a paraganglioma of the right carotid body. All three tumors were treated with surgical resection. There was no family history of malignancy. Past medical history includes uterine leiomyoma and fibrocystic breast disease. Physical examination revealed macrocephaly and papillomatous papules.Investigations CT scan of the neck and thorax, 24-hour urine collection for measurement of metanephrines and catecholamines, MRI of the neck, thorax, and abdomen, metaiodobenzylguanidine scan, germline mutation analysis of PTEN, SDHB, SDHC and SDHD.Diagnosis Cowden syndrome due to a germline mutation of PTEN, and pheochromocytoma–paraganglioma syndrome due to a germline mutation of SDHC.Management Clinical surveillance for breast, endometrial, thyroid, and renal cell carcinoma risks associated with Cowden syndrome according to the National Comprehensive Cancer Network guidelines, annual MRI of the neck, thorax, abdomen and pelvis, annual metabolic screening, and where available, annual 18-fluorodopamine PET scanning, predictive genetic testing of both PTEN and SDHC for the patients daughter and parents.

“Are You at Risk for Hereditary Breast Cancer?”: Development of a Personal Risk Assessment Tool for Hereditary Breast and Ovarian Cancer

Identification of risk for the hereditary breast and ovarian cancer syndrome (HBOC) is important, as research has demonstrated the benefits of risk-reducing interventions for women with or at risk for this disorder. Knowledge among women regarding risk factors for hereditary breast cancer and the existence of cancer genetics services appears limited. The goal of this project was to develop a tool to broaden women’s awareness regarding their potential risk for HBOC. A formal instructional design process was used to develop a brochure to facilitate recognition of HBOC risk among women attending a no-cost breast and cervical cancer screening clinic. Brochure development was guided by gathering feedback from potential users early and often. The resulting brochure included four parts: (1) a brief description of the impact of hereditary breast cancer risk on one’s health; (2) a personal and family history collection table; (3) a series of questions enabling the user to self-assess HBOC risk; (4) a list of resources for women at risk for HBOC. User feedback indicated that the brochure was easy to use. The project demonstrated that women can self-evaluate their risk for HBOC. Future work will evaluate this tool among a broader population of women.

Breast Cancer Knowledge, Beliefs, and Screening Practices among Women Seeking Care at District Hospitals in Dar es Salaam, Tanzania

Background Limited disease awareness among women may impact breast cancer stage-at-diagnosis in Tanzania, reducing survival. This study assessed breast cancer knowledge, screening practices, and educational preferences among outpatients at Tanzanian government-supported hospitals. Methods A convenience sample of women was surveyed regarding (1) knowledge/beliefs of breast cancer etiology, risk factors, symptoms, treatment, (2) early detection knowledge/practice, and (3) educational preferences. Results Among 225 respondents, 98.2% knew of breast cancer; 22.2% knew someone affected by breast cancer. On average, 30% of risk factors and 51% of symptoms were identified. Most accepted one or more breast cancer myths. Among 126 aware of breast self-exam, 40% did not practice it; only 0.9% underwent regular clinical breast examinations despite 68% being aware of the procedure. Among treatments, 87% recognized surgery, 70% radiation, and fewer systemic therapy. Preferred educational sources were group sessions, television/radio, and meetings with breast cancer survivors. Conclusions This work reveals incomplete breast cancer awareness among Tanzanian women and promises to inform development of user-focused educational resources.

Perceptions of high-risk care and barriers to care among women at risk for hereditary breast and ovarian cancer following genetic counseling in the community setting.

Data are limited regarding barriers to care among women, with or at risk for hereditary breast and ovarian cancer (HBOC), following genetic counseling in the community setting. Using a telephone survey, we retrospectively addressed perceptions of post-genetic counseling medical care and barriers to care among 69 at-risk women from the non-academic setting. Of these, all agreed that following cancer screening recommendations was better than not following them; none felt recommendations were too difficult to follow; all believed screening would help keep them healthy; 57% believed screening would prevent cancer. Twenty-five percent noted discomfort with breast imaging; 29% found ovarian cancer screening uncomfortable. Close to a quarter of participants reported difficulty deciding whether or not to undergo risk-reducing mastectomy while 10% noted difficulty deciding for or against bilateral salpingo-oophorectomy. There were no perceived major barriers to care, although 38% felt that screening reminders would be helpful, and 10% needed more help in following through with care. Overall, participants believed that they were benefiting from their post-genetic counseling medical care. This work identified HBOC-related support needs to include: informational resources that promote improved understanding of cancer risk and high-risk management; screening reminder systems; and decision support tools.

A novel BRCA1 mutation in an identical twin pair with similar clinical histories.

Factors affecting the penetrance and expression of BRCA1 are not understood. Breast cancer risk and ovarian cancer risk, in general, are known to be associated with non-Mendelian factors. However, whether and how these various factors influence tumor development in BRCA1 mutation carriers is not known. Here we report the breast and ovarian cancer syndrome in an identical twin pair. These female identical twins had remarkably similar clinical histories. Both twins developed histologically similar ovarian cancer in their mid-fifties. One twin was diagnosed with stage III disease and died of refractory metastatic disease. The other twin was diagnosed with stage I disease but ultimately died of recurrent disease. Neither twin developed breast or colon cancer. The twins have both similarities and differences in terms of nongenetic cancer-related risk factors. Results of BRCA1 analysis of DNA from both twins revealed a novel mutation, 2711delA, which resulted in a premature termination at codon 892. This report has intriguing implications concerning the role of genotype in the ultimate penetrance and expression of disease among BRCA1 mutation carriers.