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Cell characterization of primary ovarian cancer cells by immunofluorescence.

Patient information

Legends for the supplementary figures

Method of immunofluorescence for the ovarian cancer cell identification

Biochemical properties of Cdc42 and Rac1 nucleotide binding

Cdc42 (cell division control protein 42) and Rac1 (Ras-related C3 botulinum toxin substrate 1) are attractive therapeutic targets in ovarian cancer based on established importance in tumor cell migration, adhesion, and invasion. Despite a predicted benefit, targeting GTPases has not yet been translated to clinical practice. We previously established that Cdc42 and constitutively active Rac1b are overexpressed in primary ovarian tumor tissues. Through high-throughput screening and computational shape homology approaches, we identified R-ketorolac as a Cdc42 and Rac1 inhibitor, distinct from the anti-inflammatory, cyclooxygenase inhibitory activity of S-ketorolac. In the present study, we establish R-ketorolac as an allosteric inhibitor of Cdc42 and Rac1. Cell-based assays validate R-ketorolac activity against Cdc42 and Rac1. Studies on immortalized human ovarian adenocarcinoma cells (SKOV3ip) and primary patient-derived ovarian cancer cells show that R-ketorolac is a robust inhibitor of growth factor or serum-dependent Cdc42 and Rac1 activation with a potency and cellular efficacy similar to small-molecule inhibitors of Cdc42 (CID2950007/ML141) and Rac1 (NSC23766). Furthermore, GTPase inhibition by R-ketorolac reduces downstream p21-activated kinases (PAK1/PAK2) effector activation by >80%. Multiple assays of cell behavior using SKOV3ip and primary patient-derived ovarian cancer cells show that R-ketorolac significantly inhibits cell adhesion, migration, and invasion. In summary, we provide evidence for R-ketorolac as a direct inhibitor of Cdc42 and Rac1 that is capable of modulating downstream GTPase-dependent, physiologic responses, which are critical to tumor metastasis. Our findings demonstrate the selective inhibition of Cdc42 and Rac1 GTPases by an FDA-approved drug, racemic ketorolac, that can be used in humans. Mol Cancer Ther; 14(10); 2215–27. ©2015 AACR.

Supplemental Figure S3. Racemic distribution of clinical drug.

Purpose: We previously identified the R-enantiomer of ketorolac as an inhibitor of the Rho-family GTPases Rac1 and Cdc42. Rac1 and Cdc42 regulate cancer-relevant functions, including cytoskeleton remodeling necessary for tumor cell adhesion and migration. This study investigated whether administration of racemic (R,S) ketorolac after ovarian cancer surgery leads to peritoneal distribution of R-ketorolac, target GTPase inhibition in cells retrieved from the peritoneal cavity, and measureable impact on patient outcomes.Experimental Design: Eligible patients had suspected advanced-stage ovarian, fallopian tube or primary peritoneal cancer. Secondary eligibility was met when ovarian cancer was confirmed and optimally debulked, an intraperitoneal port was placed, and there were no contraindications for ketorolac administration. R- and S-ketorolac were measured in serum and peritoneal fluid, and GTPase activity was measured in peritoneal cells. A retrospective study correlated perioperative ketorolac and ovarian cancer–specific survival in ovarian cancer cases.Results: Elevated expression and activity of Rac1 and Cdc42 was detected in ovarian cancer patient tissues, confirming target relevance. Ketorolac in peritoneal fluids was enriched in the R-enantiomer and peritoneal cell GTPase activity was inhibited after ketorolac administration when R-ketorolac was at peak levels. After adjusting for age, AJCC stage, completion of chemotherapy, and neoadjuvant therapy, women given perioperative ketorolac had a lower hazard of death (HR, 0.30; 95% confidence interval, 0.11–0.88).Conclusions: Ketorolac has a novel pharmacologic activity conferred by the R-enantiomer and R-ketorolac achieves sufficient levels in the peritoneal cavity to inhibit Rac1 and Cdc42, potentially contributing to the observed survival benefit in women who received ketorolac. Clin Cancer Res; 21(22); 5064–72. ©2015 AACR.

Supplemental methods, Supplemental tables S1-S3, Supplemental Figure S1-S8 Legends. Supplemental methods for IHC of patient TMA, qPCR of patient cDNA, HPLC protocol, and GTPase activity of patient cells. Figure legends for supplemental figures S1-S8 are included. Supplemental table S1 - Patient Characteristics for IHC Microarrays OV1005 and OV8010. Supplemental table S2 - Patient Characteristics for cDNA Microarray. Supplemental table S3 - Ketorolac enantiomer concentration in serum or peritoneal fluids

Supplemental Figures S4-S7. Supplemental Figure S4 - Survival estimates based on Cox-regression for Stage I (AJCC) with completion of chemotherapy. Supplemental Figure S5 - Survival estimates based on Cox-regression for Stage II (AJCC) with completion of chemotherapy. Supplemental Figure S6 - Survival estimates based on Cox-regression for Stage III (AJCC) with completion of chemotherapy. Supplemental Figure S7 - Survival estimates based on Cox-regression for Stage IV (AJCC) with completion of chemotherapy.

Background: As the population in the United States grows, diversifies, and lives longer, the number of cancer survivors is expected to increase from 15.5 million (2016) to an estimated 20.3 million by 2026. Cancer survivors require surveillance for recurrent and subsequent malignancies, management of long-term and late effects of cancer treatment, consistent care to address comorbid conditions, health promotion and care coordination. Current survivorship care relies on distribution of a highly formulaic survivorship care plans. It likewise lacks mechanisms for communication between the oncology care team and patients’ primary care providers who see them for follow up care. Such service limitations hinder patient-responsive care for ethnically/racially, geographically, culturally and socioeconomically diverse cancer patients. Methods: Between 2020 and 2021, we convened a socio-demographically diverse Patient Advisory Board (PAB) to explore ways to improve survivorship care. All PAB members had breast or gynecological cancer diagnoses within the past five years. The research team developed discussion guides prior to each meeting to facilitate a wide ranging conversation. We conducted five PAB meetings via Zoom, maintained communication via email, and distributed four surveys on the web-based Snap Survey platform to discuss topics brought up during previous meetings or to introduce ideas for in-depth discussion at next meetings. We recorded conversations, transcribed them, and used thematic coding to identify key points for care transformation. Results: PAB members highlighted three key ideas to improve survivorship care. 1) It should not begin after treatment concludes, instead, it is a continuum with three distinct stages: diagnosis, treatment, and post-treatment. 2) Tailored documents should be generated for each patient at each stage containing stage specific medical information as well as guidance and resources on topics aligned with the patient’s unique goals for recovery. 3) Communication between a patient’s PCP and the oncology care team should begin at diagnosis and continue post-treatment, and include the patient. The PAB and research team envisioned a “Chipotle” model whereby patients have the opportunity to customize their care needs by choosing from a menu of options. The foundation (or “tortilla”) of this model allows for standard medical information to be included and serve as the foundational layer. At each survivorship stage, patients could add selected “toppings” as needed (i.e., mental health services, financial counseling, nutrition, sexual health and education, and exercise and well-being) to encourage cancer recovery. PAB members suggested that this model would allow them to play an active role in their survivorship care journeys. Conclusion: The PAB outlined a clear potential design to improve cancer survivorship care. Future work should pilot this new design to determine the acceptability and usefulness of such a model. Citation Format: Shoshana Adler Jaffe, Stephanie Rieder, Amy C. Gundelach, Tawny Boyce, Teresa Rutledge, Zoneddy Dayao, Andrew L. Sussman, Miria Kano. Patient perspectives on reimagining survivorship care: A “Chipotle” model to enhance personalized cancer recovery [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B069.

Simple Summary We conducted a survey to identify the key aspects that influence cancer care for racial/ethnic and geographically diverse low-risk breast and gynecologic cancer patients. New Mexico is a large state with many ethnic and racially diverse communities who reside in rural areas. Data obtained through our New Mexico Tumor Registry show that these patients often have different and worse cancer health outcomes. To learn more about how to improve their care, we surveyed patients regarding their access to primary care (PC); compliance with screening recommendations; treatment for conditions other than cancer (e.g., diabetes, obesity, heart problems, etc.); difficulties attending their clinic visits; and whether or not they received information about their survivorship care in the form of a survivorship care document (SCD). We found that the majority of the 150 patients surveyed reported having a Primary Care Provider (PCP). Many had health complications other than cancer, those who resided in rural areas had more difficulties getting to their cancer follow-up appointments, and nearly half had not received SCDs. We used these survey results to develop an oncology/PCP care coordination intervention to improve the oncology and cancer survivorship care for those who were at low risk of recurrence. Abstract We conducted a survey to characterize the key attributes of racial/ethnic and geographically diverse low-risk breast and gynecologic cancer patients. We collected data regarding patients’ access to primary care (PC); compliance with screening recommendations; treatment for comorbidities; logistical barriers to clinic visits; and receipt of survivorship care documentation (SCD). Survey findings informed the development of an oncology/Primary Care Provider (PCP) care coordination intervention to improve care. We distributed a cross-sectional survey among a convenience sample of 150 cancer survivors. Responses were calculated using descriptive statistics and compared based on the distance participants traveled to their appointments at the cancer center (≤30 vs. >30 miles). Of the 150 respondents, 35% traveled >30 miles for follow-up care and 78% reported having one or more comorbid condition(s). PC utilization was high: 88% reported having a PCP, and 91% indicated ≤1 yearly follow-up visit. Participants traveling >30 miles reported higher rates of logistical challenges associated with cancer center visits compared to those traveling ≤30 miles. Nearly half of respondents (46%) had not received SCD. In conclusion, survey studies such as these allow for the systematic assessment of survivor behaviors and care utilization patterns to inform the development of care coordination interventions for diverse, low-risk cancer patients.

Objective To assess whether the addition of oncolytic reovirus (Reolysin®) to weekly paclitaxel prolonged progression-free survival (PFS) in the treatment of women with recurrent or persistent ovarian, tubal or primary peritoneal cancer. Patients and methods Patients with recurrent or persistent epithelial ovarian, tubal, or peritoneal carcinoma, measurable or detectable disease, and three or fewer prior regimens were randomly assigned to paclitaxel (80mg/m 2 intravenously days 1, 8, and 15 every 4weeks) or the combination of paclitaxel (80mg/m 2 intravenously days 1, 8, and 15) plus reovirus 3×10 10 TCID 50 /day intravenously on days 1–5, both every 4weeks until disease progression or toxicity. The primary end point was PFS. The study was designed with 80% power for a one-sided alternative at a 10% level of significance to detect a reduction in the hazard by 37.5%. Results The study accrued 108 patients, 100 of whom were evaluable for toxicity. Median PFS was 4.3months for paclitaxel and 4.4months for paclitaxel plus reovirus (hazard ratio, 1.11; 90% two-sided CI, 0.78 to 1.59; one-sided P=0.687). The proportion responding (overall response rate) to paclitaxel was 20% among 45 patients with measurable disease receiving paclitaxel alone, and 17.4% among the 46 patients treated with the combination. The asymptotic relative probability of responding was 0.87 (90% CI, 0.42 to 1.79). Severe adverse events were more common in the combination regimen than in paclitaxel arm for severe neutropenia (grade≥4, 12% versus 0%), and severe respiratory adverse events (grade≥3, 25% versus 2%). No deaths were considered treatment related. Conclusion The addition of reovirus to weekly paclitaxel in the treatment of women with recurrent or persistent ovarian, tubal or peritoneal cancer did not sufficiently reduce the hazard of progression or death to warrant further investigation.

Objectives This study describes patient and provider attitudes on transitioning cancer surveillance visits and treatment of comorbid conditions to the primary care setting in a rural patient population as a strategy for minimizing financial and travel related barriers for patients while simultaneously enhancing quality and availability of health care options. Methods Focus group discussions and telephone interviews were conducted with endometrial cancer (EC) survivors and primary care providers (PCPs) to provide insights into post-treatment follow-up practices and the acceptability of transitioning follow-up to primary care setting utilizing a cancer survivorship care plan model. Results EC survivors expressed high levels of satisfaction with their oncology care and suggested that transitioning to PCPs for follow-up care would be convenient yet challenging. Challenges cited include: 1) patient perceptions of deficits in PCP's understandings of cancer surveillance; 2) inability to identify a personal PCP; and 3) lack of communication between oncologists and PCPs. PCP participants similarly identified the need for extensive EC training and effective communication strategies with oncologists as necessary factors for accepting responsibility for EC follow-up care. Both groups offered strategies to create a more team based approach to EC survivorship care. Conclusions Increasing the role of the PCP in the ongoing care of EC survivors was generally considered acceptable by both patients and providers in both rural and urban women. Successful coordination of care between cancer survivors, oncologists and PCPs will be a critical step in improving the cancer care delivery of our rural patient and provider population.

NRG Oncology conducted a phase II trial to assess the antitumor activity and tolerability of copanlisib, a selective inhibitor of PIK3CA, in persistent or recurrent endometrial carcinoma harboring hotspot PIK3CA mutations.Eligible patients had endometrial cancer with endometrioid, serous or mixed histology, a somatic PIK3CA gene mutation, measurable disease, and GOG performance status ≤2. Treatment consisted of IV copanlisib (60 mg weekly, day 1, 8 and 15 of 28-day cycle) until disease progression or prohibitive toxicity. The primary endpoints of the study were objective tumor response as assessed by RECIST 1.1 and to determine the nature and degree of toxicity of copanlisib as assessed by CTCAE version 4. The study used a 2-stage group sequential design.Eleven patients were enrolled onto stage I of the treatment trial. Five patients had endometrioid, four serous and two had a tumor of mixed histology. The most common PIK3CA mutation was Q546X (n = 3) in exon 9. The most common grade 3 or 4 AE was hyperglycemia. No grade 5 adverse events were reported. No clinical responses were detected. Six patients had a best overall response of stable disease. Of 11 who initiated treatment, 10 progressed on treatment. One patient with stable disease on copanlisib withdrew from treatment secondary to relocation. The median progression-free survival (PFS) was 2.8 months; at 6 months 27% were alive, progression-free. The median overall survival (OS) was 15.2 months. Due to the lack of CR/PR continuation of accrual to the second stage of accrual was not warranted.Copanlisib is well tolerated but has limited activity as a single agent in this population.

There are currently over 15 million cancer survivors in the US, and this number is expected to exceed 20 million by 2026 due to population aging and growth. The majority of these patients are older; many are ethnically diverse and face unique health care challenges and comorbidities due to their cancer treatment. Despite this recognition, research clearly documents the persistence of unmet needs among cancer survivors, including less than optimal preventive and cancer surveillance screening rates. Several barriers have been identified in the effort to achieve optimal survivorship care: the current health care system is fragmented, difficult to navigate, and communication between oncologists and primary care providers is often minimal. While research has been devoted to developing integrated care models, systematic reviews conclude that no standard of care exists for survivorship models. Further, given the variability of cancer survivors in terms of health needs, socioeconomic circumstances, and health care environment, it is likely that such models will need to be adaptive. Building on prior formative research, our research team at the University of New Mexico Comprehensive Cancer Center (UNMCCC) is creating a survivorship care model for implementation. New Mexico, a large, rural, minority-majority state, with deep socioeconomic disparities that limit access to care, presents an ideal environment to address the current evidence gap in survivorship care transitions. Our developing research program features the following major components to this survivorship care model: 1) identifying risk-stratified patients at the UNMCCC and delivering a survivorship care plan; 2) using the Project ECHO telementoring platform, implement a survivorship care training curriculum with primary care providers; 3) an oncology nurse navigator based at the UNMCCC will actively navigate patients to the community-based providers; and 4) all components of the model will be assessed using implementation science research and evaluation strategies. We are in the early phases of developing and implementing this model and we will report on the content and process associated with each of the major components. Identified outcomes pertain to feasibility and acceptability of implementation, and we will categorize these using the RE-AIM and Consolidated Framework for Implementation Research frameworks. Citation Format: Andrew L. Sussman, Teresa Rutledge, Zoneddy Dayao, Miria Kano, Amy Gundelach, Stephanie McGirt, Jolene Lobo, Shiraz Mishra. Women in survivorship health using Project ECHO: Creating a model for navigated care transitions [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B015.

Highlights • Endometrial cancer commonly harbors hotspot mutations in the PIK3CA gene. • NRG-GY008 evaluated the activity of copanlisib, an inhibitor of PIK3CA, in recurrent endometrial cancer patients. • Copanlisib has an acceptable safety profile but low antitumor activity in endometrial cancer. • Combinations of copanlisib may be necessary to increase clinical responses in endometrial cancer patients., Purpose NRG Oncology conducted a phase II trial to assess the antitumor activity and tolerability of copanlisib, a selective inhibitor of PIK3CA, in persistent or recurrent endometrial carcinoma harboring hotspot PIK3CA mutations. Patients and methods Eligible patients had endometrial cancer with endometrioid, serous or mixed histology, a somatic PIK3CA gene mutation, measurable disease, and GOG performance status ≤2. Treatment consisted of IV copanlisib (60 mg weekly, day 1, 8 and 15 of 28-day cycle) until disease progression or prohibitive toxicity. The primary endpoints of the study were objective tumor response as assessed by RECIST 1.1 and to determine the nature and degree of toxicity of copanlisib as assessed by CTCAE version 4. The study used a 2-stage group sequential design. Results Eleven patients were enrolled onto stage I of the treatment trial. Five patients had endometrioid, four serous and two had a tumor of mixed histology. The most common PIK3CA mutation was Q546X (n = 3) in exon 9. The most common grade 3 or 4 AE was hyperglycemia. No grade 5 adverse events were reported. No clinical responses were detected. Six patients had a best overall response of stable disease. Of 11 who initiated treatment, 10 progressed on treatment. One patient with stable disease on copanlisib withdrew from treatment secondary to relocation. The median progression-free survival (PFS) was 2.8 months; at 6 months 27% were alive, progression-free. The median overall survival (OS) was 15.2 months. Due to the lack of CR/PR continuation of accrual to the second stage of accrual was not warranted. Conclusion Copanlisib is well tolerated but has limited activity as a single agent in this population.

We previously reported high rates of urinary incontinence among gynecologic cancer survivors and aimed to evaluate the effectiveness of a simple intervention for treatment of urinary incontinence in this population.We recruited 40 gynecologic cancer survivors who reported urinary incontinence on a validated questionnaire. Women were randomized to either pelvic floor muscle training/behavioral therapy (treatment group) or usual care (control group). The primary outcome measure, assessed at 12 weeks post intervention, was a 40% difference in the validated Patient Global Impression of Improvement (PGI-I) score. Fisher's exact test was used to identify differences between groups for frequency data; two-sample t-test was conducted for continuous measurements.Mean age of this cohort was 57 (range: 37-79). The majority of the survivors had uterine cancer (60%), 18% had received radiation therapy, 95% had received surgical therapy, and 35% had received chemotherapy. At three months, 80% of the treatment and 40% of the control group reported that their urinary incontinence was "much better" or "very much better" as evaluated by the Patient Global Impression of Improvement scale (p=0.02). Brink's scores were significantly improved in the treatment group as compared to those of the controls (p0.0001). Treatment group adherence was high; the treatment group performed exercises with an average of 22 days/month.Urinary incontinence negatively affects quality of life, and despite a high prevalence among gynecologic cancer survivors, it is often under-assessed and undertreated. We found a simple intervention that included pelvic floor muscle training and behavioral therapy, which significantly improved cancer survivor's urinary incontinence.

Ovarian cancer metastasis to the spinal cord is quite rare, and few case reports have been published previously. Herein, we present a case of a patient who was treated for ovarian cancer and was thought to be disease free for 17 months, then presented with lower limb weakness. She was found to have a T11-T12 metastatic intramedullary spinal cord lesion. On pathology, the diagnosis of metastatic ovarian adenocarcinoma was made. This report highlights the importance of maintaining a low threshold for ovarian cancer metastases to the spinal cord when patients present with neurologic sequelae, even in the setting of normal laboratory values, as early detection can prevent permanent neurological consequences.

Background Suppression of neoangiogenesis and pegylated liposomal doxorubicin (PLD) each contribute to the management of platinum-resistant/refractory ovarian cancer. The aim of this study is to test the combination of bevacizumab and PLD in women with resistant or refractory ovarian cancer. Methods Eligibility criteria were no more than two prior treatments with platinum-containing regimens and one additional regimen, without anthracyclines. Treatment was administered every 3 weeks (bevacizumab 15 mg/kg beginning on cycle 2 and PLD 30 mg/m2). The primary end point was progression-free survival (PFS) at 6 months; the secondary end points included side-effects, overall response rates (ORR) and survival (OS). Results Forty-six patients were enrolled. The average number of courses administered was 7. The median PFS was 6.6 months (range 1–24.6 months) according to Gynecologic Cancer Intergroup Committee (GCIC) criteria and 7.8 months (range 2–13.3 months) according to Response Evaluation Criteria in Solid Tumors (RECIST). The median OS was 33.2 months (range 3–37.5+ months). The ORR was 30.2% [95% confidence interval (CI) 17.2–46.1] and the clinical benefit rate (CBR) was 86.1% (95% CI 72.1–94.7). Adverse events included mucosal and dermal erosions (30% grade 3) and asymptomatic cardiac dysfunction. Additional toxic effects included hypertension, headache, renal dysfunction and proteinuria, wound healing delay, and one episode each of central nervous system (CNS) ischemia and hemolytic uremic syndrome. Conclusion PLD with bevacizumab has improved activity in recurrent ovarian cancer with increased toxicity.

Objective. To examine surgico-pathologic outcomes following extraperitoneal para-aortic lymph node dissection (EPLND) via pfannenstiel compared to paramedian incision prior to radiation in patients with cervical cancer. Methods. At our institution, patients with locally advanced cervical cancer undergo, EPLND. From 1990 to 2000, EPLND was performed via paramedian incision (PM) primarily to identify positive para-aortic lymph nodes (PALN). From 2000 to present, a complete pelvic and para-aortic lymphadenectomy was performed via pfannenstiel incision (PF). Records for all patients undergoing EPLND were reviewed. Pathologic findings, post-operative complications, and time to initiation of radiation (TRT) were abstracted. Results. 93 patients underwent EPLND, 48 via PF and 45 via PM incision. The mean age and body mass index did not differ between the two groups. Stage distribution was similar: IB2 8 vs. 0%; IIB 44 vs. 44%; IIIA/B 35 vs. 44%; IVA 13 vs. 11%, respectively. Positive PALN were identified in 44% of PF patients and 29% of PM patients (p=ns). TRT was not significantly different at 36.4 vs. 28.8 days, respectively. There were more complications among the PF group including cellulitis and lymphocyst formation. Pre-treatment computed tomography (CT) scan had positive and negative predictive values of only 86 and 66% for evaluation of PALN involvement. Conclusions. We present an extraperitoneal method for removal of the pelvic and para-aortic lymph nodes with acceptable complications and no significant delay to initiate chemoradiation. Accurate assessment of lymphatic metastases results in modification of the radiation field, which, along with surgical debulking, may impact overall survival.

Cdc42 (cell division control protein 42) and Rac1 (Ras-related C3 botulinum toxin substrate 1) are attractive therapeutic targets in ovarian cancer based on established importance in tumor cell migration, adhesion, and invasion. Despite a predicted benefit, targeting GTPases has not yet been translated to clinical practice. We previously established that Cdc42 and constitutively active Rac1b are overexpressed in primary ovarian tumor tissues. Through high-throughput screening and computational shape homology approaches, we identified R-ketorolac as a Cdc42 and Rac1 inhibitor, distinct from the anti-inflammatory, cyclooxygenase inhibitory activity of S-ketorolac. In the present study, we establish R-ketorolac as an allosteric inhibitor of Cdc42 and Rac1. Cell-based assays validate R-ketorolac activity against Cdc42 and Rac1. Studies on immortalized human ovarian adenocarcinoma cells (SKOV3ip) and primary patient-derived ovarian cancer cells show that R-ketorolac is a robust inhibitor of growth factor or serum-dependent Cdc42 and Rac1 activation with a potency and cellular efficacy similar to small-molecule inhibitors of Cdc42 (CID2950007/ML141) and Rac1 (NSC23766). Furthermore, GTPase inhibition by R-ketorolac reduces downstream p21-activated kinases (PAK1/PAK2) effector activation by >80%. Multiple assays of cell behavior using SKOV3ip and primary patient-derived ovarian cancer cells show that R-ketorolac significantly inhibits cell adhesion, migration, and invasion. In summary, we provide evidence for R-ketorolac as a direct inhibitor of Cdc42 and Rac1 that is capable of modulating downstream GTPase-dependent, physiologic responses, which are critical to tumor metastasis. Our findings demonstrate the selective inhibition of Cdc42 and Rac1 GTPases by an FDA-approved drug, racemic ketorolac, that can be used in humans. Mol Cancer Ther; 14(10); 2215–27. ©2015 AACR.

Objective . To evaluate how the independent predictors of recurrence for stage IB2 cervical cancers treated with up-front radical hysterectomy apply to established risk models. Methods . Patients with IB2 cervical cancers diagnosed from 1990 to 2000 were identified from tumor registries of two institutions. Patients were classified into risk groups: high-risk (HR) (positive nodes, parametria, or margins), intermediate-risk (IR) (positive lymph vascular space involvement (LVSI) with any cervical stromal invasion (CSI), or (−) LVSI and > middle- CSI), or low-risk (LR) (absence of HR or IR characteristics). Disease-free survival (DFS) was estimated by Kaplan–Meier method and comparisons between subgroups were studied by log rank. A Cox proportional hazards model was used to determine independent predictors of recurrence. Results . We identified 86 patients with stage IB2 tumors treated by RH. We found 34% of patients to be HR, 60% IR, and 6% LR. Of the 52 IR patients, 28 had (+) LVSI with superficial, middle, and outer 1/3 CSI, and 24 had (−) LVSI with middle or outer 1/3 invasion. Overall, postoperative adjuvant radiation (PRT) was used in 52% of the 86 patients, including 0/5 LR, 16/52 IR, and 29/29 HR patients. Univariate predictors of recurrence were pelvic nodal disease, (+) LVSI, (+) parametria, outer 1/3 CSI, and tumor size > 6 cm. Age, grade, histology, and the use of postoperative radiation were not associated with recurrence. Multivariate analysis identified LVSI as the only independent predictor of recurrence (RR 5.2, P = 0.03). Two-year DFS for LR, IR, and HR patients was 100%, 83%, and 60%, respectively. Only 4/24 (17%) IR patients with (−) LVSI got PRT compared with 12/28 (43%) of IR patients with (+) LVSI. The 2-year DFS for IR patients with (−) LVSI was 96%. IR (+) patients recurred more frequently with a 2-year DFS of 71%. Conclusions . Overall, 66% of patients with IB2 disease were classified as having low or intermediate-risk disease. IR patients with (−) LVSI and all LR patients did well with surgery alone. This study defines the independent importance of LVSI and questions the utility of published IR models when applied to stage IB2 cervical cancer.

e17052 Background: With evidence that BRCA dysfunction is associated with increased T cell recruitment to tumor sites, and that PARP-inhibition may increase the immunogenicity of tumor cells, we evaluated the combination of a PARP-inhibitor and CTLA4 immune checkpoint antibody in BRCA1- ovarian cancer models. Our results demonstrated significant therapeutic synergy and durable treatment responses in preclinical studies. Based on this, a Phase I study was conducted to assess the tolerability of this regimen in women with BRCA mutation-associated recurrent ovarian cancer. Methods: Eligibility criteria included a documented BRCA1 or BRCA2 germline mutations and a diagnosis of recurrent ovarian, tubal, or primary peritoneal cancer with measurable disease. Both platinum-sensitive and platinum resistant patients were eligible. Patients with prior exposure to PARP-inhibitors or to immune therapy with the exception of CTLA4 antibodies were also eligible. Exclusion criteria included current use of anti-inflammatory agents or a prior history of autoimmune disease. Treatment consisted of Olaparib at 300mg twice daily, as well as monthly infusions of Tremelimumab at a dose of 10mg/kg, with plans for a dose reduction if toxicity was encountered. Patients completing two full treatment cycles were evaluated for evidence of toxicity, particularly immune-related adverse events, to define a dose for Phase II testing. Results: Three women were treated at the starting dose of 300mg BID of Olaparib and 10mg/kg monthly of Tremelimumab for two cycles without evidence of any dose-limiting toxicities or grade 3 adverse events. All patients experienced grade 1 and 2 toxicities, including immune related toxicities consistent with prior studies of immune checkpoint inhibitors. All three patients showed evidence of treatment response by cycle 3 based on CA125 levels and a decrease in tumor size on CT scans. Conclusions: The combination of PARP-inhibition and CTLA-4 blockade is tolerable in heavily pre-treated women with recurrent BRCA-associated ovarian cancer. Preliminary results also demonstrate evidence of therapeutic effect, supporting ongoing evaluation of this regimen in Phase II trials. Clinical trial information: NCT02571725.

BACKGROUND The number of women diagnosed with gynecologic cancers in the U.S. is increasing rapidly. The American Society of Clinical Oncology predicts a 48% increase in the number of people developing cancer by the year 2020. Yet the numbers of oncologists and available services are rising much more slowly; data indicates an increase in the workforce of only 14% by 2020. This workforce shortage may lead to challenging conditions for optimal survivorship care, particularly in rural and other underserved areas. Although endometrial cancer survivors (EC) often receive favorable prognoses, they remain vulnerable as many suffer health challenges due to comorbidities that can be more life threatening than the cancer itself. Adequate treatment for these comorbid conditions requires regular clinician oversight, yet many rural EC survivors travel hours for follow-up care in oncology settings, and comorbidities are often unaddressed. Although transition from oncology specialty care to primary care seems an obvious solution, acceptance of this transition by EC survivors and primary care providers (PCPs) has not been well studied. METHODS We conducted a qualitative study with 53 EC survivors and 16 PCPs to identify barriers and facilitators to optimal EC survivorship care. Between October 2014 and September 2015, we conducted 9 focus groups with EC survivors in rural and urban communities, and 3 focus groups with PCPs from across New Mexico. Focus groups were designed to elicit information specific to routine cancer follow-up care from patient and provider perspectives as well as to ascertain patient willingness to, and provider readiness for, transition of EC survivors from oncology clinics to primary care practices for post-treatment cancer care. Focus groups were digitally recorded and iteratively reviewed for development of initial coding structures. The transcripts were reviewed by the research team and a thematic analysis was performed. Transcripts were imported into NVivo 10, a qualitative data analysis program, for final coding and data analysis. RESULTS Twenty-one (40%) of the EC survivor participants were Hispanic origin and 55% resided in rural communities. 37.5% of the provider participants served rural regions. EC survivors expressed high levels of satisfaction with their oncology care and suggested that transitioning to PCPs for follow-up care would be convenient yet challenging. Challenges cited include: 1) patient perceptions of deficits in PCP's understandings of cancer surveillance; 2) inability to identify a personal PCP; and 3) lack of communication between oncologists and PCPs. PCP participants similarly identified the need for more extensive EC training and more effective communication strategies with oncologists as necessary factors for accepting responsibility for EC follow-up care. Both EC patients and PCPs offered strategies to improve the coordination of care and create a more team based approach to EC survivorship care. Strategies discussed include: 1) develop survivorship care plans to improve communication for both patients and provides; 2) ensure easy access back to oncologist; and 3) provide supportive care services. CONCLUSIONS The transition from cancer treatment to cancer survivor care is a complex time for the patient. Increasing the role of the PCP in the ongoing care of EC survivors was generally considered acceptable by both patients and providers in both rural and urban women. Findings from our study did inform strategies to facilitate this transition. Successful coordination of care between cancer survivors, oncologists and PCPs will be a critical step in improving the cancer care delivery of our rural patient and provider population. Citation Format: Teresa Rutledge, Miria Kano, Dolores Guest, Andrew Sussman, Anita Kinney. Optimizing endometrial cancer follow-up and survivorship care for rural and other underserved women: Patient and provider perspectives. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B20.

This open-label, two-arm, phase II clinical trial evaluated the antitumor activity and safety profile of PM00104 (Zalypsis(®)) administered as a 1-h, weekly, intravenous infusion (days 1, 8 and 15; every 4 weeks) at a dose of 2 mg/m(2) to patients with advanced and/or metastatic endometrial (EC) or cervical cancer (CC) after one previous line of systemic chemotherapy. Twelve patients (median age, 61.5 years) with pretreated EC received a median of 2 treatment cycles (range 1-5) and seven patients (median age, 38 years) with pretreated CC received 2 treatment cycles. None achieved objective tumor response. Median progression-free survival (PFS) was 1.8 months, and median overall survival (OS) was 5.5 months in EC (median follow-up = 20.1 months); median PFS was 1.5 months, and median OS was 5.6 months in CC (median follow-up = 17.1 months). The most common toxicities reported were mild to moderate asthenia, nausea, vomiting and diarrhea. Despite PM00104 showing mostly mild, predictable, manageable and reversible toxicity, protocol criteria for further recruitment were not met in EC, a futility analysis was done and recruitment was stopped; a low patient recruitment rate together with no evidence of activity in CC resulted in early study closure.

The numerous advances in the surgical care of gynecologic oncology patients are allowing clinicians to offer improved quality of life while maintaining excellent cancer outcomes. Advances in technology and disease understanding will only enhance our surgical abilities beyond what can be imagined today. Surgeons have a responsibility to evaluate new technology critically and incorporate the technology into patient care safely and efficiently.

This review focuses on the different modes of expression of the epidermal growth factor receptor (EGFR). All methods used to assess EGFR expression are critically analyzed and insights into the use of inhibitors of EGFR for treatment of cervical cancer are discussed. Currently, expression of EGFR as a biomarker for prognosis or for treatment of cervical cancer is not defined for clinical use.

Objective The purpose of this study was to assess the prevalence of pelvic floor disorders and sexual function in survivors of gynecologic cancer. Study Design We surveyed survivors of gynecologic cancer (survivors) and women seeking gynecologic care (control patients) who were >30 years old. All survivors were disease- and treatment-free for ≥1 year. Validated questionnaires were used to evaluate pelvic floor disorders. Results One hundred eight control patient and 260 survivor questionnaires were completed. A high prevalence of pelvic floor disorders was observed in both groups; 56% of control subjects and 70% of survivors reported moderate to severe urinary incontinence ( P > .05). Survivors were more likely to experience fecal incontinence (42% vs 32%; P = .02). Survivors reported less sexual desire ( P = .04) and less ability to climax ( P = .04), despite no difference in dyspareunia. Conclusion Fecal incontinence and sexual dysfunction are significant problems in survivors of gynecologic cancer.

Primary carcinoma of the fallopian tube (PCFT) accounts for perhaps 1% of genital tract cancers. The investigators undertook a matched, case-control comparison of 96 women with a diagnosis of PCFT and 189 control women having ovarian carcinoma (OC). The groups were matched for age, tumor stage, and the presence of residual disease. All patients were surgically staged and, if indicated, given platinum-based chemotherapy. Fifty early-stage (FIGO stage I or II) cases of PCFT were matched with 97 OC patients. A regimen of carboplatinum and paclitaxel was used in more than 80% of cases. Median follow-up intervals for the PCFT and OC groups were 57 and 42 months, respectively. The respective 5-year overall survival rates were 95% and 76%. Excluding cases of stage IA PCFT, the 5-year survival rate was 92% for patients with PCFT and 70% for those with OC. Progression-free 5-year survival rates were 62% and 50%, respectively, not a significant difference. Excluding early-stage PCFT cases that were found incidentally during surgery for benign conditions or at the time of salpingo-oophorectomy, 5-year survival was 97% for PCFT cases and 77% for cases of OC. When 46 cases of stage III/IV PCFT were matched with 92 OC cases and followed up for nearly 3 years, the 3-year overall survival rate was 59% for both groups. Progression-free 3-year survival rates were 26% for PCFT patients and 21% for control patients with OC (P = 0.46). These findings should lead clinicians to be assured that treatment of PCFT should mirror that of OC.

Purpose of the study: Although Rac1 and Cdc42 are considered attractive therapeutic targets, no selective inhibitors of these GTPases are in clinical trials. The Ras-homologous (Rho) family GTPases Rac1 and Cdc42 contribute to metastatic dissemination through regulation of actin reorganization, cell motility, cell-cell and cell-extracellular matrix adhesion. Using high throughput screening and cheminformatics, we identified the R-enantiomer of ketorolac as a novel inhibitor of Rac1 and Cdc42. R-enantiomers of nonsteroidal anti-inflammatory drugs are poor inhibitors of cyclooxygenase (COX) activity, yet little is known about the pharmacologic activities or targets of the R-enantiomers. The purpose of this study was to investigate the effects of R-ketorolac on ovarian cancer. Experimental procedures: GTPase target expression and activity was determined by immunohistochemistry, RT-PCR and enzymatic assays. The effects of racemic, R- and S-ketorolac on proliferation, adhesion and migration were investigated using human ovarian tumor cells (OvCA 429 and SKOV3ip). In vivo effect of ketorolac treatments was determined in a xenograft model using SKOV3ip cells. Pharmacokinetic and pharmacodynamic assessments of racemic R/S-ketorolac (Toradol®) in patients were conducted in women with suspected advanced stage ovarian, fallopian tube or primary peritoneal cancer with planned optimal cytoreductive surgery. Ascites samples were obtained for measurement of cell adhesion and drug inhibition of GTPase activity. After placement of an IP port the recommended dose of IV racemic ketorolac was administered and blood and peritoneal fluid were obtained at T=0, 1h, 6h and 24h. R- and S-ketorolac concentrations in serum and peritoneal fluid were measured by HPLC. GTPase inhibitory activity of ketorolac was assessed in peritoneal tumor cells. Summary of the data: Elevation of Cdc42 protein and expression of the constitutively active Rac1b splice variant of Rac1 were detected in ovarian cancer specimens providing the first evidence for dysregulation of these GTPase targets in ovarian cancer. R-ketorolac, and not S-ketorolac, inhibits Rac1 and Cdc42 activity demonstrating an unexpected pharmacologic activity for the R-enantiomer. R-ketorolac, but not S-ketorolac, inhibits cell adhesion and migration, and reduced peritoneal tumor implantation in a mouse xenograft model. In the clinical studies using R/S-ketorolac for post-operative pain management, we found that ketorolac distributed to peritoneal fluids within 6 hours and fluids were highly enriched in the R-enantiomer compared to the S-enantiomer. Rac1 and Cdc42 activity was inhibited in ovarian tumor cells retrieved from the peritoneal cavity post-ketorolac administration. Cell adhesion was decreased by R-ketorolac in patient-derived ovarian tumor cells. Conclusions: The findings show R-ketorolac is a novel inhibitor of Rac1 and/or Cdc42, and active in ovarian cancer model systems. The favorable distribution of R-ketorolac in the peritoneal cavity coupled with GTPase inhibition in cells retrieved from the intraperitoneal compartment support the potential benefit of R-ketorolac for ovarian cancer patients. Citation Format: Hudson LG, Kenney SR, Guo Y, Adams S, Rutledge T, Muller CY, Wandinger-Ness A. Rho-family GTPases as therapeutic targets in ovarian cancer [abstract]. In: Proceedings of the 10th Biennial Ovarian Cancer Research Symposium; Sep 8-9, 2014; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(16 Suppl):Abstract nr POSTER-BIOL-1320.

To compare stages IB1 and IB2 cervical cancer, the authors conducted a review of all patients with stage IB cancer of the cervix who underwent a type III radical hysterectomy with bilateral pelvic lymphadenectomy at theirinstitutions between 1990 and 2000. They identified 195 patients who had no gross extrauterine disease and sufficient data for analysis. One hundred seventy-seven (91%) subjects also underwent a bilateral paraaortic lymphadenectomy. No patient received preoperative radiation therapy. The mean age of the study subjects was 41.3 years. One hundred nine patients with tumor size 4 cm or less were identified as stage IB 1 and 86 whose tumor was larger than 4 cm were considered stage IB2. Tumor characteristics included lymphovascular space involvement in 98 women (53%), parametrial involvement in 31 (15.9%), and outer two thirds cervical stromal involvement in 110 (58.2%). Histologic cell type was squamous in 144 (73.8%) patients, adenocarcinoma in 37 (19%), adenosquamous in 10 (5.1%), and a mixture of small and clear in 4 (2.1%). Tumor grade was identified in 189 patients, of whom 9 (4.7%) were grade 1, 92 (47.1%) were grade 2, and 88 (45.1%) were grade 3. Stage IB1 and IB2 patients had a similar cell type and grade distribution, but those with stage IB2 had a significantly greater number of high-risk factors. Lymphovascular space involvement, outer two thirds cervical invasion, parametrial involvement, and nodal involvement were all more common in these women. There were no significant differences seen in rates of perioperative or postoperative complications, except that more patients with stage IB2 disease who received adjuvant radiation therapy were more likely to develop a postoperative bowel obstruction. Univariate analysis found no factors that were significant predictors of surgical complications. Positive pelvic nodes were seen in 38 (19.5%) patients, of whom 14 (12.8%) were stage IB1 and 24 (27.9%) were stage IB2. Two women with stage IB1 and 7 with stage IB2 disease had parametrial involvement. Univariate analysis of clinicopathologic factors identified lymphovascular space invasion (P = 0.001), >2/3 depth of invasion (P = 0.011), parametrial involvement (P = 0.001), disease stage (P = 0.008), and age of patient (P = 0.048) to be significant predictors of nodal involvement. After multivariate analysis, lymphovascular space involvement and parametrial involvement emerged as highly significant predictors of nodal involvement (odds ratios, 6.4; CI = 2.4-1.7 and 8, CI = 3.1-20, respectively). Median follow up in this series was 35 months. In that time, 10 patients with stage IB1 and 20 with stage IB2 tumors had disease recurrence. The overall disease-free survival was 92.5% for stage IB1 patients and 74.3% for stage IB2 patients (P = 0.009 for difference). Univariate analysis found that nodal positivity, lymphovascular space involvement, parametrial involvement, and outer two thirds stromal involvement were all significantly associated with disease-free survival, regardless of disease stage. After univariate analysis, lymphovascular involvement and outer two thirds stromal involvement were identified as independent predictors of disease-free survival. The relative risks were 7.75 (CI = 2-27; P = 0.0001) and 5.8 (CI = 2-20; P = 0.0029), respectively.

Background: Erlotinib (E), a tyrosine kinase inhibitor of EGFR, is approved for non-small cell lung cancer. 5-Azacytidine (AZA) is approved for leukemia. AZA traps DNA methyltransferase (DMT) in a covalent complex with DNA resulting in a progressive loss of DNA methylation, at concentrations that do not cause major suppression of DNA synthesis. Hypomethylation reactivates previously quiescent genes and may restore the function of genes that control cell proliferation and differentiation, such as EGFR. Methods: A standard 3+3 phase I study of the combination of E and AZA was planned in patients with incurable solid tumors. E was given at full dose (150 mg/day continuously). Vidaza was given intravenously every 2 weeks at a starting dose of 75 mg/m2/day ×1 day. Increments were by number of AZA days: The second cohort received 2 consecutive days of Vidaza, the third, 3 days, the fourth, 4 days. One course was 4 weeks. Standard grade 3 and 4 DLTs (CTCAE version 3) were recorded on the first course of treatment. RECIST criteria were used to determine response. Results: 18 adult patients (pt) have been enrolled. Cohort 1: 6 pt; cohort 2, 3 pt; cohort 3, 6 pt; cohort 4, 3 pt. DLTs included eye infection (1 pt in cohort 1) and a neutropenic sepsis in cohort 3. Both cohorts were expanded. Overall AEs were: grade 3 rash, diarrhea, and hypokalemia (1 each (5%)); grade 1–2 rash (60%), nausea/vomiting (38%), diarrhea (38%), fatigue (33%), mouth sores and dysgeusia (22% each), hypokalemia (16%), transaminase increase (11%), neutropenia (5%), pneumonitis (5%), urticaria (5%). The maximum tolerated dose has not been reached at 75 mg/m2/day × 4 days every 2 weeks. Enrollment will continue until AZA 100 mg/m2/day × 4 days is reached. ORR is 5% with a clinical benefit rate of 40%, and the median number of courses given is 2 (range 1–6). Conclusions: The combination of E and AZA is well tolerated with no synergistic toxicities. The main AEs are rash and gastrointestinal. E+AZA has modest but definite activity in patients with refractory tumors, and long disease stabilization are observed in selected patients. Citation Information: Mol Cancer Ther 2009;8(12 Suppl):A184.