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SPORE Supplemental Funding (09/2011 to 8/2012 – Year 4)

An Ethics Based Training Program for Rapid Autopsy in Lung Cancer SPOREs: Gwen Quinn


Major advances in screening and treatment for lung cancer have occurred through the use of tissue donation from patients. Repositories of blood and tissue samples combined with personal and medical information used for research is a growing resource for improvements in cancer detection and treatment. These repositories are thought to be a promising way to identify the links between genetic and environmental factors in relation to disease, particularly cancer. A less known research mechanism is the use of rapid autopsy, the procurement of ‘fresh’ tissue within 2-6 hours of the patient’s death. The fresh tissue yielded from rapid autopsies holds benefits not seen in frozen or paraffin embedded tissue samples and the ability to obtain fresh samples from patients with advanced and drug resistant disease provides tremendous research opportunities for new lung cancer cell lines and potential treatments. Rapid autopsies provide additional benefits from tissue harvested shortly after death which can be snap frozen and formalin fixed, as opposed to traditional autopsies which are performed up to a day after death. The goal of rapid autopsy programs are to obtain high quality tumor tissue that can serve as an invaluable resource for molecular and clinical studies; tissue that can be utilized to better understand primary and secondary tumor differences and to help understand the natural history of the disease. While the use of rapid autopsy has potential for improvements in basic science and clinical services to lung cancer patients, it is fraught with ethical concerns from both the patient and health care provider perspective. Additionally, rapid autopsy has garnered negative media attention which may impact patient’s views on participation. Patients are typically approached to participate in a rapid autopsy program at the time of diagnosis and thus the request may be perceived as ominous. Further, health care providers giving direct clinical care to patients must feel comfortable that their primary goal is to tend to the medical and psychosocial needs of their patients while they are living, and not as if they are a “vulture scientist” waiting for the death of the patient to enhance their own research.

To this end, we propose to develop a physician and advocate training program to initiate a rapid autopsy program (RAP) through the Moffitt Cancer Center Lung SPORE and to disseminate this training to the other institutions with Lung SPORE protocols. SPORE institutions are of particular importance as they house necessary resources to support a RAP. This training will provide a framework for a comprehensive bio repository wherein the RAP has a uniform approach, guided by ethical principles based on the Belmont Report and the Principalist approach. This will ensure that all patients, families and health care providers are participating in a program that is rooted in not only the best medical science, but also the highest ethical principles. Further, this training and rapid autopsy program will help unify all aspects of the current Lung SPORE, aiding basic science researchers in understanding ethical principles and using the expertise of our patient advocates. The primary aims of the Moffitt Cancer Center SPORE in Lung Cancer are to: 1) elucidate mechanisms of action of crucial molecules in lung carcinogenesis and tumor progression and investigate their impact on therapeutic efficacy and 2) prospectively assess the clinical utility of the molecules for therapeutic and prevention interventions. Our ultimate goal is to change the standard of care for people at risk for and with lung cancer. To this end, the goals of the current project are to:

Aim 1: Develop a uniform training program and curriculum for healthcare providers, research staff, and advocates involved in national SPORE protocols with the goal of enrolling eligible patients for a rapid autopsy program.

Aim 1A: Infuse the training program with patient advocate input on barriers and benefits of perceptions of a rapid autopsy program, utilizing ethical and cultural belief systems related to end-of-life issues.

Aim 1B: Infuse the training program with healthcare provider feedback on barriers and benefits of perceptions of rapid autopsy programs

Aim 2: Disseminate and evaluate the training program to other Lung SPORE sites through webinars, CME training.

SPORE Supplemental Funding (9/2009-8/2011 – Years 2 & 3)

  • Project 3 - TGFßSignaling Overcomes Tyrosine Kinase Inhibitor Resistance in Lung Cancer: Teresita Muñoz-Antonia
  • Project 4 - Lung Cancer Chemoprevention with Enzastaurin: Jhanelle Gray
  • Project 5 - P53 based Vaccine for Small Cell Lung Cancer: Alberto Chiappori
Project 3 - TGFßSignaling Overcomes Tyrosine Kinase Inhibitor Resistance in Lung Cancer: Teresita Muñoz-Antonia
The SRC inhibitor, dasatinib, is only effective in killing EGFR mutant cells (Song et al., 2006), which account for 10% of the non-small cell lung cancers. While first identified as a SRC inhibitor, it has subsequently been recognized that dasatinib has targets other than SRC. Experiments using drug affinity chromatography to identify molecules that interact directly with dasatinib have identified over 40 kinases, including tyrosine kinases, receptor tyrosine kinases, serine/threonine kinases, and MAP kinases (Li, 2009). One of the serine/threonine kinases identified using this approach was the TGF-ß type I receptor. To determine the potential biological relevance of this association, we are studying the combined effect of dasatinib and TGF-ß on WT EGFR lung cancer cells. We found that cells incubated with 100 nM dasatinib had 35% less growth than untreated cells. However, when we added TGF-ß to the dasatinib, there was a significant reduction in cell number (73% decrease) that correlated with the induction of apoptosis in A549 cells. In this cell line, dasatinib or TGFß alone did not induce apoptosis as measured by PARP cleavage; it was only with the combination treatment that apoptosis occurred. Incubation with an EGFR inhibitor (erlotinib) or another SRC inhibitor (AZD0530) did not result in PARP cleavage. Treatment with TGF-ß for 48 hours results in elongation of the A549 cells, and a decrease in e-cadherin expression. A549 cells treated with dasatinib alone, did not exhibit a decrease in e-cadherin expression. However, dasatinib was not able to inhibit the TGF-ß effects on e-cadherin expression, as cells incubated with both TGF-ß and dasatinib also showed a decrease in e-cadherin expression. These observations appear to be cell line-specific, as WT EGFR H292 cells, are not growth inhibited by TGF-ß, and incubation with TGF-ß does not result in a decrease in e-cadherin expression. However, the growth inhibition seen when cells are incubated with dasatinib alone (58% inhibition) decreases when cells are incubated in the presence of both TGF-ß and dasatinib (27% inhibition).

These data suggest that there might be previously unidentified cross-talk between the TGF-ß pathway and other pathways that might determine the response to dasatinib in EGFR WT lung carcinoma lines. We will investigate this by looking at the effect of dasatinib in other TGF-ß responses and the pathways associated with it. This information together with the use of the Bio-Plex system (BioRad) to measure the activation state of multiple proteins will provide some initial information as to which pathways are involved in these responses. Our observations suggest that lung cancers can be manipulated to render them sensitive to killing by dasatinib, which could have important implications for devising innovative potentially more efficacious treatment strategies for this disease.

Project 4 - Lung Cancer Chemoprevention with Enzastaurin: Jhanelle Gray

Lung cancer is a good target for chemoprevention as it has a high incidence, a well defined high-risk population, and high mortality. Excision repair cross-complimenting group 1 (ERCC1), a component of the nucleotide excision repair (NER) complex, has prognostic ability in patients with advanced NSCLC. Given the prognostic nature of ERCC1 in those with lung cancer, its potential as a prognostic marker for lung carcinogenesis should be explored by determining whether significant expression of ERCC1 in metaplastic or dysplastic bronchial epithelial tissue of high-risk smokers can be detected and quantified. MCM2 is a new proliferation marker and one of six members of the minichromosome maintenance (MCM) protein family. It is found on premalignant lung cancer cells and is an investigational surrogate endpoint biomarker for lung cancer proliferation. A double-blind, placebo-controlled, randomized phase II clinical trial to evaluate the chemopreventive effects of enzastaurin versus placebo on lung carcinogenesis in former smokers is being performed on participants with bronchial metaplasia or dysplasia.

45 participants’ samples from the first interim analysis of that study will be analyzed for ERCC1 and MCM2 detection and quantification of protein expression using the novel accurate quantitative analysis (AQUA) technology. From the pre- and post enzastaurin bronchial biopsies, the metaplastic/dysplastic lesion will be analyzed at several points of interest on the slide for ERCC1 and MCM2 and the results will be averaged. We will then develop ERCC1 expression distributions for pre- and post-enzastaurin samples as potential prognostic indicators.

Specific Aim 1: To determine the distribution of expression of ERCC1 in metaplastic or dysplastic bronchial epithelial tissue of former smokers.

Specific Aim 2: To determine if a correlation exists between replication, as assessed by MCM2 expression and ERCC1 expression.

Project 5 - P53 based Vaccine for Small Cell Lung Cancer: Alberto Chiappori

Given the heterogeneity of cancer(s) and our initial, limited understanding of cancer biology, a major challenge confronting investigators engaged in the development of new therapies has been the design of clinical trials that can assess the efficacy of a specific therapy against a specific cancer. Recent improvements in understanding the molecular biology of cancer cells, however, has identified a series of independent pathways with specific procarcinogenic functions that also work redundantly as part of the general function of normal cells. Many of these pathways are dysregulated and therefore involved in the malignant phenotype of tumor cells. They can be targeted for disruption with new anticancer therapies and used to assess the specific effect of this disruption in the cancer cell (early or predictive biomarker of efficacy).

Thus, the new challenge for clinical investigators is to identify the most active agent(s) against a specific tumor and to identify predictive biomarker(s) that would allow for drug efficacy evaluation, long before any clinical efficacy endpoint can be reached. This approach should reduce both the duration and cost of the clinical trial and, more importantly, reduce the exposure of patients to potentially ineffective treatments. The impact that the identification of these drug-biomarker “dynamic duos” may have, i.e., the selection of an effective treatment in an appropriately sensitive tumor, equates to a major step forward toward the ultimate goal of improving outcome in cancer patients, through “personalization” of treatment.

Cancers with frequent pathway dysregulations that are shown to be critical to the malignant phenotype are the ones most likely to benefit from this approach. This is particularly true for cancers with a high incidence and a poor prognosis due to poorly effective or limited therapeutic options. A disease that meets these criteria is small cell lung cancer (SCLC).

In 2009 it is estimated that 215,020 new cases of lung cancer will be diagnosed in the United States. SCLC accounts for =15% of them but represents the sixth most commonly diagnosed cancer. Given its recognized initial chemosensitivity, considerable survival improvements are achieved with chemotherapy. However, most SCLC patients relapse and rarely survive beyond 2 years (median survival time = 7-10 months and 2-year survival =20%). Some of the dysregulated pathways in SCLC are autocrine growth factor, signal transduction loops like the insulin growth factor-1 receptor (IGF-1R) pathway, which transmit proliferative stimuli through the MAPK cascade. Furthermore, IGF-1 is an important growth factor with a prominent role in the growth and survival of SCLC by activating, very potently, through the IGF-1R, the PI3K-AKT signal transduction pathway.

Rationale and Hypothesis: There has been a lack of improvement in the treatment of SCLC, and literature has shown the importance of the IGF-1R pathway in the pathogenesis and progression (cell growth and proliferation) of the disease, supporting the use of therapies with agents that interfere with this pathway to evaluate their potential (1) clinical benefit (anti-tumor activity) and (2) predictive biomarker value.

Hypothesis: We propose a phase II trial with IMC-A12, a monoclonal antibody inhibitor of IGF-1R, as single agent, in patients with recurrent SCLC. Our hypothesis is that inactivation of the IGF-1R pathway using IMC-A12 will lead to cell cycle arrest and apoptosis, which will result in prolonged tumor stabilization (and possibly tumor regression) with subsequent prolongation of progression-free survival, median survival time, and 1-year survival. We further hypothesize that predictive biomarkers of IGF-1R inhibition can be found in plasma, peripheral blood, and/or circulating tumor cells or by a new ex-vivo methodology.

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