Barriers and facilitators to cancer clinical trial enrollment and participation among rural populations: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to identify barriers and facilitators related to cancer clinical trial enrollment and participation among rural populations. INTRODUCTION: Advancing the effectiveness of cancer treatment and increasing early detection of cancer relies on enrollment and participation of individuals in cancer clinical trials. Lack of enrollment and participation in trials is a concern, and there is evidence that individuals living in rural areas are unlikely to participate in such trials. Information on barriers to, and facilitators of, enrollment and participation in cancer clinical trials is needed for the development of evidence-based interventions to increase the enrollment and participation of rural populations. INCLUSION CRITERIA: The review will consider studies on adults aged 18 years or older living in rural areas. Studies that report on barriers and facilitators to enrollment and participation in cancer clinical trials, including both cancer therapeutic and cancer early detection trials, will be included in the review. The review will consider quantitative, qualitative, and text and opinion papers for inclusion. METHODS: The search strategy will aim to locate published primary studies, reviews, and opinion papers, the latter including those by professional oncology organizations. The databases to be searched include MEDLINE, CINAHL, Embase, Web of Science, and Cochrane Library. Gray literature databases will also be searched. Two independent reviewers will retrieve full-text studies and extract data. The results will be presented in diagrammatic format with a narrative summary.

Barriers and facilitators for low-dose computed tomography lung cancer screening in rural populations in the United States: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to identify barriers and facilitators for low-dose computed tomography lung cancer screening uptake and adherence among rural populations in the United States. INTRODUCTION: Lung cancer is the leading cause of cancer-related death in the United States, and cancer patients from rural areas have poorer outcomes than those from metropolitan areas. Evidence exists that lung cancer screening by low-dose computed tomography significantly increases survival time but is also significantly underutilized. INCLUSION CRITERIA: Studies completed in the United States with adults who fit United States Preventive Services Task Force guidelines for lung cancer screening and who live in rural areas will be included. Studies published in English since 2013 that report on barriers and facilitators for low-dose computed tomography lung cancer screening uptake and adherence will be included in this review. Quantitative, qualitative, or mixed-methods studies will be included, along with opinion pieces published by government agencies or professional cancer-related organizations. METHODS: The search strategy will locate published primary studies, reviews, and opinion papers, including those by government and nonprofit agencies focused on cancer. The databases to be searched include MEDLINE, CINAHL Complete, Embase, Web of Science, and Cochrane Library. Gray literature databases and sources of unpublished studies will also be searched. Independent reviewers will be used throughout the search and selection process.

The College of American Pathologists Foundation's See, Test & Treat Program®: an Evaluation of a One-Day Cancer Screening Program Implemented in Mississippi.

Women in Mississippi experience significant barriers to healthcare that results in high incidence rates of late-stage breast, cervical, and oropharyngeal cancer. We implemented See, Test, & Treat, a cancer screening and education program, that was aimed at increasing access to cancer screening for underserved women in the Jackson Metropolitan Area. During the event, 103 women between the ages of 21 and 69 years old received breast, cervical, and/or oral cancer screenings. Quantitative and qualitative data were collected to evaluate the effect of the program on the participants' cancer screening knowledge, self-efficacy to obtain medical check-ups, and intentions to engage in health-enhancing behaviors. Of the 57 women who received a mammogram, 18 had abnormal results that required follow-up care. None of the women who received a Pap test had abnormal results, but 8 women were diagnosed with trichomoniasis. One woman was diagnosed with stage 4 oral cancer. The evaluation data indicated that participants found that free cancer screenings and receipt of results on the same day were primary benefits of the program.

Do We Need a New Approach to Cancer Biology Education for Radiation Oncology Residents?

Traditional radiation oncology biology courses largely focus on radiation biology and oncology as needed for passing the boards. Changes in the landscape of oncology necessitate a broader scope. Radiotherapy is an important component of cancer care. Approximately 70% of all cancer patients receive radiotherapy during the course of their disease. With the revolution in precision medicine that is unfolding, genomics, proteomics, metabolomics, and microbiomics are being ever more integrated into the treatment of cancer. Comprehensive knowledge of cancer biology beyond traditional radiation biology is essential for future advances in radiotherapy and unavoidable for radiation oncology trainees. The importance of a newly designed curriculum to impart broader knowledge to future radiation oncologists is emphasized in this report. A paradigm shift in the approach to the traditional radiation biology course is required to train residents for the future of oncology.

70x2020: A Grassroots Effort to Increase Colorectal Cancer Screening and Prevention in a Rural Medically Underserved State.

This report describes the ongoing efforts of a voluntary statewide grassroots initiative to increase colorectal cancer (CRC) screening rates in a poor rural state with no established CRC screening programs for the poor and underserved. This report focuses on the tactics to increase stool-based CRC screenings through primary care providers.

The Impact of Colorectal Cancer (CRC) in Mississippi, and the need for Mississippi to Eliminate its CRC Burden.

Colorectal cancer (CRC), while highly preventable and highly treatable, is a major public health problem in Mississippi. This article reviews solutions to this problem, beginning with the relationship between modifiable behavioral risk factors and CRC incidence. It then describes the impact of CRC screening on national downward trends in CRC incidence and mortality and summarizes recent data on the burden of CRC in Mississippi. While other states have created Comprehensive Colorectal Cancer Control Programs in an organized effort to manage this public health problem, Mississippi has not. Responding to Mississippi's situation, the 70x2020 Colorectal Cancer Screening Initiative arose as an unconventional approach to increase CRC screening rates throughout the state. This article concludes by considering the current limits of CRC treatment success and proposes that improved clinical outcomes should result from research to translate recently-identified colorectal cancer subtype information into novel clinical paradigms for the treatment of early-stage colorectal cancer.

The impact of preventive screening resource distribution on geographic and population-based disparities in colorectal cancer in Mississippi.

BACKGROUND: The state of Mississippi has the highest colorectal cancer (CRC) mortality rate in the USA. The geographic distribution of CRC screening resources and geographic- and population-based CRC characteristics in Mississippi are investigated to reveal the geographic disparity in CRC screening. METHODS: The primary practice sites of licensed gastroenterologists and the addresses of licensed medical facilities offering on-site colonoscopies were verified via telephone surveys, then these CRC screening resource data were geocoded and analyzed using Geographic Information Systems. Correlation analyses were performed to detect the strength of associations between CRC screening resources, CRC screening behavior and CRC outcome data. RESULTS: Age-adjusted colorectal cancer incidence rates, mortality rates, mortality-to-incidence ratios, and self-reported endoscopic screening rates from the years 2006 through 2010 were significantly different for Black and White Mississippians; Blacks fared worse than Whites in all categories throughout all nine Public Health Districts. CRC screening rates were negatively correlated with CRC incidence rates and CRC mortality rates. The availability of gastroenterologists varied tremendously throughout the state; regions with the poorest CRC outcomes tended to be underserved by gastroenterologists. CONCLUSIONS: Significant population-based and geographic disparities in CRC screening behaviors and CRC outcomes exist in Mississippi. The effects of CRC screening resources are related to CRC screening behaviors and outcomes at a regional level, whereas at the county level, socioeconomic factors are more strongly associated with CRC outcomes. Thus, effective control of CRC in rural states with high poverty levels requires both adequate preventive CRC screening capacity and a strategy to address fundamental causes of health care disparities.

The geographic distribution of mammography resources in Mississippi.

OBJECTIVE: To determine whether the availability of mammography resources affected breast cancer incidence rates, stage of disease at initial diagnosis, mortality rates and/or mortality-to-incidence ratios throughout Mississippi. METHODS: Mammography facilities were geocoded and the numbers of residents residing within a thirty minute drive of a mammography facility were calculated. Other data were extracted from the Mississippi Cancer Registry, the U.S. Census, and the Mississippi Behavioral Risk Factor Surveillance Survey (BRFSS). RESULTS & DISCUSSION: There were no statistically-significant differences between breast cancer incidence rates in Black versus White females in Mississippi; however, there were significant differences in the use of mammography, percentages of advanced-stage initial diagnoses, mortality rates, and mortality-to-incidence ratios, where Black females fared worse in each category. No statistically-significant correlations were observed between breast cancer outcomes and the availability of mammography facilities. The use of mammography was negatively correlated with advanced stage of disease at initial diagnosis. By combining Black and White subsets, a correlation between mammography use and improved survival was detected; this was not apparent in either subset alone. There was also a correlation between breast cancer mortality-to-incidence ratios and the percentage of the population living below the poverty level. CONCLUSIONS: The accessibility and use of mammography resources has a greater impact on breast cancer in Mississippi than does the geographic resource distribution per se. Therefore, intensified mammography campaigns to reduce the percentage of advanced-stage breast cancers initially diagnosed in Black women, especially in communities with high levels of poverty, are warranted in Mississippi.

Loss of STAT3 in mouse embryonic fibroblasts reveals its Janus-like actions on mitochondrial function and cell viability.

STAT3 has been implicated in mitochondrial function; however, the physiological relevance of this action is not established. Here we studied the importance of STAT3 to the cellular response to stimuli, TNFα and serum deprivation, which increase mitochondrial reactive oxygen species (ROS) formation. Experiments were performed using wild type (WT) and STAT3 knockout (KO) mouse embryonic fibroblasts (MEF). Both WT and STAT3 KO MEF expressed similar levels of tumor necrosis factor receptor 1 (TNFR1) and exhibited comparable IκBα degradation with TNFα. However, in the absence of STAT3 nuclear accumulation of NFκB p65 with TNFα was attenuated and induction of the survival protein c-FLIPL was eliminated. Nonetheless, WT MEF were more sensitive to TNFα-induced death which was attributed to necrosis. Deletion of STAT3 decreased ROS formation induced by TNFα and serum deprivation. STAT3 deletion was associated with lower levels of complex I and rates of respiration. Relative to WT cells, mitochondria of STAT3 KO cells released significantly more cytochrome c in response to oxidative stress and had greater caspase 3 cleavage due to serum deprivation. Our findings are consistent with STAT3 being important for mitochondrial function and cell viability by ensuring mitochondrial integrity and the expression of pro-survival genes.

Overview: cellular plasticity, cancer stem cells and metastasis.

Recently, a number of hypotheses have converged into a unified theoretical framework which addresses the most vexing aspects of cancer: metastasis, relapse and therapeutic resistance. The central component of this framework is the new paradigm of cellular differentiation, once viewed as a unidirectional process, but now recognized as a plastic process in which cancer cells can dedifferentiate into more primitive, stem-like phenotypes. This plasticity is controlled by both intrinsic biochemical processes and bi-directional environmental cues involving cancer-associated non-cancerous cells. Such plastic phenotypic shifts may influence the discontinuous behavior of cancers, in which some cancers remain dormant for months or years after therapy, only to relapse and wreak havoc. This Special Issue of Cancer Letters assembles a collection of mini-reviews describing the current knowledge of cellular plasticity and its relationship to cancer "stemness" and progression, illuminating how progress in this field may yield major benefits in overcoming resistance and thwarting metastasis.

Redox regulation of Janus kinase: The elephant in the room.

The redox regulation of Janus kinases (JAKs) is a complex subject. Due to other redox-sensitive kinases in the kinome, redox-sensitive phosphatases, and cellular antioxidant systems and reactive oxygen species (ROS) production systems, the net biological outcomes of oxidative stress on JAK-dependent signal transduction vary according to the specific biological system examined. This review begins with a discussion of the biochemical evidence for a cysteine-based redox switch in the catalytic domain of JAKs, proceeds to consider direct and indirect regulatory mechanisms involved in biological experiments, and ends with a discussion of the role(s) of redox regulation of JAKs in various diseases.

Depletion of cellular glutathione modulates LIF-induced JAK1-STAT3 signaling in cardiac myocytes.

Previously we reported that the sesquiterpene lactone parthenolide induces oxidative stress in cardiac myocytes, which blocks Janus kinase (JAK) activation by the interleukin 6 (IL-6)-type cytokines. One implication suggested by this finding is that IL-6 signaling is dependent upon cellular anti-oxidant defenses or redox status. Therefore, the present study was undertaken to directly test the hypothesis that JAK1 signaling by the IL-6-type cytokines in cardiac myocytes is impaired by glutathione (GSH) depletion, since this tripeptide is one of the major anti-oxidant molecules and redox-buffers in cells. Cardiac myocytes were pretreated for 6h with l-buthionine-sulfoximine (BSO) to inhibit GSH synthesis. After 24h, cells were dosed with the IL-6-like cytokine, leukemia inhibitory factor (LIF). BSO treatment decreased GSH levels and dose-dependently attenuated activation of JAK1, Signal Transducer and Activator of Transcription 3 (STAT3), and extracellular signal regulated kinases 1 and 2 (ERK1/2). Addition of glutathione monoethyl ester, which is cleaved intracellularly to GSH, prevented attenuation of LIF-induced JAK1 and STAT3 activation, as did the reductant N-acetyl-cysteine. Unexpectedly, LIF-induced STAT1 activation was unaffected by GSH depletion. Evidence was found that STAT3 is more resistant than STAT1 to intermolecular disulfide bond formation under oxidizing conditions and more likely to retain the monomeric form, suggesting that conformational differences explain the differential effect of GSH depletion on STAT1 and STAT3. Overall, our findings indicate that activation of both JAK1 and STAT3 is redox-sensitive and the character of IL-6 type cytokine signaling in cardiac myocytes is sensitive to changes in the cellular redox status. In cardiac myocytes, activation of STAT1 may be favored over STAT3 under oxidizing conditions due to GSH depletion and/or augmented reactive oxygen species production, such as in ischemia-reperfusion and heart failure.

Identification of a redox-sensitive switch within the JAK2 catalytic domain.

Four cysteine residues (Cys866, Cys917, Cys1094, and Cys1105) have direct roles in cooperatively regulating Janus kinase 2 (JAK2) catalytic activity. Additional site-directed mutagenesis experiments now provide evidence that two of these residues (Cys866 and Cys917) act together as a redox-sensitive switch, allowing JAK2's catalytic activity to be directly regulated by the redox state of the cell. We created several variants of the truncated JAK2 (GST/(NΔ661)rJAK2), which incorporated cysteine-to-serine or cysteine-to-alanine mutations. The catalytic activities of these mutant enzymes were evaluated by in vitro autokinase assays and by in situ autophosphorylation and transphosphorylation assays. Cysteine-to-alanine mutagenesis revealed that the mechanistic role of Cys866 and Cys917 is functionally distinct from that of Cys1094 and Cys1105. Most notable is the observation that the robust activity of the CC866,917AA mutant is unaltered by pretreatment with dithiothreitol or o-iodosobenzoate, unlike all other JAK2 variants previously examined. This work provides the first direct evidence for a cysteine-based redox-sensitive switch that regulates JAK2 catalytic activity. The presence of this redox-sensitive switch predicts that reactive oxygen species can impair the cell's response to JAK-coupled cytokines under conditions of oxidative stress, which we confirm in a murine pancreatic ß-islet cell line.

JAKs go nuclear: emerging role of nuclear JAK1 and JAK2 in gene expression and cell growth.

The four Janus kinases (JAKs) comprise a family of intracellular, nonreceptor tyrosine kinases that first gained attention as signaling mediators of the type I and type II cytokine receptors. Subsequently, the JAKs were found to be involved in signaling downstream of the insulin receptor, a number of receptor tyrosine kinases, and certain G-protein coupled receptors. Although a number of cytoplasmic targets for the JAKs have been identified, their predominant action was found to be the phosphorylation and activation of the signal transducers and activators of transcription (STAT) factors. Through the STATs, the JAKs activate gene expression linked to cellular stress, proliferation, and differentiation. The JAKs are especially important in hematopoiesis, inflammation, and immunity, and aberrant JAK activity has been implicated in a number of disorders including rheumatoid arthritis, psoriasis, polycythemia vera, and myeloproliferative diseases. Although once thought to reside strictly in the cytoplasm, recent evidence shows that JAK1 and JAK2 are present in the nucleus of certain cells often under conditions associated with high rates of cell growth. Nuclear JAKs have now been shown to affect gene expression by activating other transcription factors besides the STATs and exerting epigenetic actions, for example, by phosphorylating histone H3. The latter action derepresses global gene expression and has been implicated in leukemogenesis. Nuclear JAKs may have a role as well in stem cell biology. Here we describe recent developments in understanding the noncanonical nuclear actions of JAK1 and JAK2.

Activation loop tyrosines allow the JAK2(V617F) mutant to attain hyperactivation.

A gain-of-function mutation (V617F) in the pseudokinase domain of JAK2 is frequently present in patients with myeloproliferative disorders such as polycythemia vera, essential thrombocythemia, and primary myelofibrosis. This mutation might serve as an important diagnostic biomarker for these uncommon diseases and may represent a target for novel therapy. It is imperative that a well-defined molecular mechanism be provided to account for the gain of function. This manuscript focuses on whether the V617F mutation is sufficient to cause constitutive activation of the enzyme. The evidence presented suggests that the V617F mutation would not cause constitutive activation because its hyperactivating effect is not observed when the mutation is combined with the YY1007,1008FF mutations. The phosphorylation of these two tyrosines within the activation loop is generally accepted as an essential step in the enzyme's normal transition from a basal state of activity to a fully active catalytic state following cytokine receptor stimulation. These observations are consistent with an interpretation that V617F-induced hyperactivation does not supersede the requirement for receptor-mediated activation, as others have shown by combining the V617F mutation with critical mutations in the enzyme's FERM domain. Thus, JAK2(V617F) should be considered as a hyperactive kinase rather than a constitutively active kinase.

Multiple cysteine residues are implicated in Janus kinase 2-mediated catalysis.

The redox regulation of Janus kinase 2 (JAK2) is poorly understood, and there are contradictory reports as to whether the enzyme's activity is inhibited or stimulated by oxidizing conditions in the cell. Here we demonstrate that multiple cysteine residues within the JAK2 catalytic domain may be crucial for enzymatic activity. The enzyme is catalytically inactive when oxidized; activity can be restored via reduction to the thiol state. A series of recombinant variants of JAK2 were overproduced using the baculoviral expression vector system. A truncated variant of JAK2, GST/(NDelta661)rJAK2, provided evidence that the amino-terminal autoinhibitory domain was not essential for direct redox regulation and that only nine cysteine residues were potentially involved. The effect of individually and combinatorially altering these nine cysteines was examined via cysteine-to-serine mutagenesis. This identified four cysteine residues in the catalytic domain (Cys866, Cys917, Cys1094, and Cys1105) that cooperatively maintain JAK2's catalytic competency. Our data are consistent with a direct mechanism for redox regulation of JAK2 via oxidation and reduction of critical cysteine residues.

Cloning of the cDNA for murine von Willebrand factor and identification of orthologous genes reveals the extent of conservation among diverse species.

Interaction of von Willebrand factor (VWF) with circulating platelets promotes hemostasis when a blood vessel is injured. The A1 domain of VWF is responsible for the initial interaction with platelets and is well conserved among species. Knowledge of the cDNA and genomic DNA sequences for human VWF allowed us to predict the cDNA sequence for murine VWF in silico and amplify its entire coding region by RT-PCR. The murine VWF cDNA has an open reading frame of 8,442 bp, encoding a protein of 2,813 amino acid residues with 83% identity to human pre-pro-VWF. The same strategy was used to predict in silico the cDNA sequence for the ortholog of VWF in a further six species. Many of these predictions diverged substantially from the putative Reference Sequences derived by ab initio methods. Our predicted sequences indicated that the VWF gene has a conserved structure of 52 exons in all seven mammalian species examined, as well as in the chicken. There is a minor structural variation in the pufferfish Takifugu rubripes insofar as the VWF gene in this species has 53 exons. Comparison of the translated amino acid sequences also revealed a high degree of conservation. In particular, the cysteine residues are conserved precisely throughout both the pro-peptide and the mature VWF sequence in all species, with a minor exception in the pufferfish VWF ortholog where two adjacent cysteine residues are omitted. The marked conservation of cysteine residues emphasizes the importance of the intricate pattern of disulfide bonds in governing the structure of pro-VWF and regulating the function of the mature VWF protein. It should also be emphasized that many of the conserved features of the VWF gene and protein were obscured when the comparison among species was based on the putative Reference Sequences instead of our predicted cDNA sequences.

Kinase activity and subcellular distribution of a chimeric green fluorescent protein-tagged Janus kinase 2.

Janus kinase 2 (JAK2) is an essential intracellular signal transducer for numerous cytokines and hormones. To examine how JAK2 structural modifications can affect cellular physiology, we created expression vectors for chimeric proteins containing an enhanced green fluorescent protein (EGFP) fused to rat JAK2 (EGFP/rJAK2), and a kinase-inactive variant, EGFP/rJAK2(K882E). The properties of EGFP/rJAK2 were examined following transient transfection of COS-7 cells. EGFP/rJAK2 was expressed throughout the cell, and was found in subcellular membrane, cytosolic and nuclear fractions. Interestingly, EGFP/rJAK2 phosphorylated other proteins in situ without additional cytokine stimulation. Furthermore, despite a much higher level of tyrosine phosphorylation arising from in situ autophosphorylation, the in vitro radiolabelling autokinase activity of EGFP/rJAK2 was significantly less than that of the endogenous JAK2. These results reveal a technical limitation of the application of the "conventional" in vitro radiolabelling autokinase assay to hyperphosphorylated forms of the enzyme and illustrate the potential weaknesses in individual assays commonly used to determine JAK2's enzymatic activity and subcellular distribution. We also suggest that the EGFP/rJAK2 model can be very useful in studying JAK2-related cancers, because its ubiquitous distribution and abnormal constitutive hyperphosphorylation may distinguish it from the cytokine-regulated, membrane-proximal form of JAK2 associated with normal physiology.

Tyrosine phosphorylation of the Janus kinase 2 activation loop is essential for a high-activity catalytic state but dispensable for a basal catalytic state.

The phosphorylation of an "activation loop" within protein kinases is commonly associated with establishing catalytic competence, and phosphorylation of the Tyr(1007) residue in the activation loop of Janus kinase 2 (JAK2) has been shown to be essential for intracellular propagation of cytokine-initiated signaling. We provide evidence for the presence of a basal activity state of JAK2, which was observed in the absence of activation loop phosphorylation. Phosphorylation of the JAK2 activation loop was essential for conversion to the high-activity state, characterized by high-efficiency ATP utilization during autophosphorylation. Mutagenesis of activation loop tyrosine residues Tyr(1007/1008) to phenylalanine residues impaired, but did not abolish, the enzyme's ability to autophosphorylate. The activation loop mutant JAK2 could also transphosphorylate an inactive JAK2 fragment coexpressed in Sf21 cells, providing evidence of exogenous substrate phosphorylation. The mutant enzyme remained in a basal activity state characterized by low-efficiency ATP utilization during autophosphorylation. Mutagenesis of a critical Lys(882) residue to a glutamate residue abolished all evidence of kinase activity, confirming that the observed activity of Tyr-to-Phe mutants was not due to another kinase. Our data are consistent with the proposal that JAK2 is an inefficient but active enzyme in the absence of activation loop phosphorylation and is capable of conversion to a high-activity state by autophosphorylation under physiological ATP concentrations. This theoretically precludes the need for an upstream activating kinase. The activation process of JAK2 may be envisioned as a multistate process involving at least two kinetically distinct states of activity.