Epigenetic modifications in solid tumor metastasis in people of African ancestry.

This review focuses on the critical role of epigenetic modifications in solid tumor metastasis, particularly in people of African ancestry. Epigenetic alterations, such as DNA methylation, histone modifications, alterations in non-coding RNAs, and mRNA methylation, significantly influence gene expression, contributing to cancer development and progression. Despite the primary focus on populations of European, American, and Asian descent in most cancer research, this work emphasizes the importance of studying the unique genetic and epigenetic landscapes of African populations for a more inclusive approach in understanding and treating cancer. Insights from this review have the potential to pave the way for the development of effective, tailored treatments, and provide a richer resource for understanding cancer progression and metastasis. Specific focus was placed on the role of DNA methylation, histone modifications, non-coding RNAs, and mRNA methylation in solid tumor metastasis, including how these modifications contribute to the regulation of tumor suppressor genes and oncogenes, influence cellular pathways and signaling, and interact with the immune system. Moreover, this review elaborates on the development of epigenetic-targeted therapeutic strategies and the current advances in this field, highlighting the promising applications of these therapies in improving outcomes for African ancestry populations disproportionately affected by certain types of cancer. Nevertheless, this work acknowledges the challenges that lie ahead, particularly the under-representation of African populations in cancer genomic and epigenomic studies and the technical complications associated with detecting subtle epigenetic modifications. Emphasis is placed on the necessity for more inclusive research practices, the development of more robust and sensitive methods for detecting and interpreting epigenetic changes, and the understanding of the interplay between genetic and epigenetic variations. The review concludes with an optimistic outlook on the future of epigenetic research in People of African ancestry, urging the concerted efforts of researchers, clinicians, funding agencies, and policymakers to extend the benefits of this research to all populations.

Effective Recruitment Strategies Utilized to Examine Dietary Practices of Blacks in New York City in the Midst of the COVID-19 Pandemic.

BACKGROUND: Black Americans have long been considered a hard-to-reach population for research studies, whether quantitative surveys or for clinical research. Studies have explored multiple rationales for why Blacks are hard to reach, and the explanations have included historical mistrust, the need to assess the benefits from participating in research, and the expense of spending time participating in research, among others. What has not been explored is the continuous merging of all individuals who identify as Black, particularly when exploring reasonings for a lower interest in participating in research. This paper addresses this issue by investigating the participation rate of individuals identifying as Black in New York City in a study exploring dietary practices as a predictor of colorectal cancer screening behavior. Participants were asked to self-report screening behavior, intent to screen, and dietary and other lifestyle practices. In this analysis, we discuss the unique experience encountered in recruiting Black American participants to participate in this study, particularly amid a worldwide pandemic of COVID-19. METHODS: The methodology for this study included a systematic review of the literature, a two-part recruitment process, and data analysis. The first part of the recruitment process involved registering individuals who were interested in participating in the study and consented to be contacted and reminded to come to the location where they were recruited on a scheduled date to complete the actual survey. With this part of the recruitment process, we engaged with n = 488 Black men and women between November 2019 and February 2020. The second part of the recruitment process utilized availability sampling outside of NYC subway stations and other high traffic areas as well as large community events. We engaged with n = 319 individuals. Total engagement with n = 807 individuals yielded a sample size for the survey of 504 completed surveys. RESULTS: Of the total engaged (n = 807), 14% declined to participate due to a lack of time, 11% chose not to participate in the study because the incentive was not enough to compensate for their time 0.02% declined due to not trusting institutions conducting research, and 0.03% did not feel comfortable understanding the questions due to a language barrier. We had a sample size of (n = 504) of the total 807 individuals engaged. CONCLUSIONS: Recruiting Black Americans into our colorectal cancer study did not prove to be challenging with the two-tiered model of recruitment that involved consistent engagement and having the primary researcher lead this recruitment process. Extracting within race differences is critical in demystifying the conclusion of numerous studies that African Americans specifically are hesitant to participate due to historical mistrust related to tragedies such as the Tuskegee Experiment and numerous other occurrences of African Americans being treated as guinea pigs for the advancement of research. This data contributes knowledge to this field regarding understanding recruitment challenges in the Black population, but further work needs to be conducted. Mistrust in this study primarily came from the individuals engaged in Caribbean neighborhoods, where many expressed more comfort with home remedies and bush doctors when asked about colorectal cancer screening and declined to participate. Innovative communication, qualitative research, and recruitment strategies tailored to the Caribbean population are needed in future studies to address this recruitment challenge that we experienced.

Educating the next generation of cancer researchers: Evaluation of a cancer research partnership training program.

African American, American Indian and Alaska Native, Hispanic (or Latinx), Native Hawaiian, and other Pacific Islander groups are underrepresented in the biomedical workforce, which is one of the barriers to addressing cancer disparities among minority populations. The creation of a more inclusive biomedical workforce dedicated to reducing the burden of cancer health disparities requires structured, mentored research and cancer-related research exposure during the earlier stages of training. The Summer Cancer Research Institute (SCRI) is a multicomponent 8-week intensive summer program funded under the Partnership between a Minority Serving Institute and a National Institutes of Health-designated Comprehensive Cancer Center. In this survey study, we found that students who participated in the SCRI Program reported greater knowledge and interest in pursuing careers in cancer-related fields than their counterparts who did not participate in SCRI. Successes, challenges, and solutions in providing training in cancer and cancer health disparities research to improve diversity in the biomedical fields were also discussed.

Educating the Next Generation of Cancer Researchers: Evaluation of A Cancer Research Partnership Training Program.

African American, American Indian and Alaska Native, Hispanic (or Latinx), Native Hawaiian, and other Pacific Islander groups are underrepresented in the biomedical workforce, which is one of the barriers to addressing cancer disparities among minority populations. The creation of a more inclusive biomedical workforce dedicated to reducing the burden of cancer health disparities requires structured, mentored research and cancer-related research exposure during the earlier stages of training. The Summer Cancer Research Institute (SCRI), a multicomponent 8-week intensive summer program funded under the Partnership between a Minority Serving Institute and a National Institutes of Health-designated Comprehensive Cancer Center. This study assessed whether students who participated in the SCRI Program report greater knowledge and interest in pursuing careers in cancer-related fields than their counterparts who did not participate in SCRI. Successes, challenges, and solutions in providing training in cancer and cancer health disparities research to improve diversity in the biomedical fields were also discussed.

Destabilized 3'UTR elements therapeutically degrade ERBB2 mRNA in drug-resistant ERBB2+ cancer models.

Breast, lung, and colorectal cancer resistance to molecular targeted therapy is a major challenge that unfavorably impacts clinical outcomes leading to hundreds of thousands of deaths annually. In ERBB2+ cancers regardless of the tissue of origin, many ERBB2+ cancers are resistant to ERBB2-targeted therapy. We discovered that ERBB2+ cancer cells are enriched with poly U sequences on their 3'UTR which are mRNA-stabilizing sequences. We developed a novel technology, in which we engineered these ERBB2 mRNA-stabilizing sequences to unstable forms that successfully overwrote and outcompeted the endogenous ERBB2 mRNA-encoded message and degraded ERBB2 transcripts which led to the loss of the protein across multiple cancer cell types both in the wildtype and drug-resistance settings in vitro and in vivo, offering a unique safe novel modality to control ERBB2 mRNA and other pervasive oncogenic signals where current targeted therapies fail.

A Comparative Trial of Improving Care for Underserved Asian Americans Infected with Hepatitis B Virus.

BACKGROUND: Hepatitis B virus (HBV) is the leading cause of hepatocellular carcinoma (HCC). Asian Americans have the highest incidence and mortality rates of HCC among all US racial/ethnic groups. Inadequate monitoring and treatment of chronic hepatitis B contribute to poor health outcomes and increased healthcare costs among Asian Americans. AIMS: The goal of this study is to assess the effect of a patient-led strategy on chronic hepatitis B monitoring and treatment adherence specifically among Asian Americans with culturally tailored Patient Navigator-led Intervention. METHODS: From 2015 to 2018, 532 eligible participants living with chronic hepatitis B in the greater Philadelphia and New York city metropolitan areas were randomly assigned to either the intervention group or the control group. Generalized linear mixed-effects models were used to estimate the odds ratio (OR) for rates of doctor visits for chronic hepatitis B and rates of alanine aminotransferase testing for evidence of liver damage. RESULTS: Intervention group had higher rates of doctor visits than the control group at both 6-month (77.22% vs. 45.75%) and 12-month assessments (90.73% vs. 60.61%). Significantly more intervention group participants received ALT testing than control group participants at 6-month (52.90% vs. 25.10%) and 12-month (75.40% vs. 46.75%) follow-up. CONCLUSIONS: Culturally and linguistically appropriate intervention has strong effects on adherence to follow-up care among Asian American hepatitis B patients experiencing challenges to medication adherence and follow up care. These findings further identify opportunities for practical implementation of evidence-based intervention that could lead to reductions in disparities in chronic liver disease and liver cancer among high-risk, underserved populations.

Genome scale CRISPR Cas9a knockout screen reveals genes that control glioblastoma susceptibility to the alkylating agent temozolomide.

Glioblastoma is the most fatal of all primary human brain tumors with 14 months median survival. The mainstay therapy for this tumor involves temozolomide, surgery, radiotherapy and tumor treating electric field. Cancer resistance to commonly available chemotherapeutics remains a major challenge in glioblastoma patients receiving treatment and unfavorably impact their overall survival and outcome. However, the lack of progress in this area could be attributed to lack of tools to probe unbiasedly at the genome wide level the coding and non-coding elements contribution on a large scale for factors that control resistance to chemotherapeutics. Understanding the mechanisms of resistance to chemotherapeutics will enable precision medicine in the treatment of cancer patients. CRISPR Cas9a has emerged as a functional genomics tool to study at genome level the factors that control cancer resistance to drugs. Recently, we used genome wide CRISPR-Cas9a screen to identify genes responsible for glioblastoma susceptibility to etoposide. We extended our inquiry to understand genes that control glioblastoma response to temozolomide by using genome scale CRISPR. This study shows that the unbiased genome-wide loss of function approach can be applied to discover genes that influence tumor resistance to chemotherapeutics and contribute to chemoresistance in glioblastoma.

Dietary behavior and urinary gallic acid concentration differences among underserved elder racial and ethnic minorities in New York City.

PURPOSE: Diet and nutrition are important for cancer prevention. To investigate associations between dietary behavior, demographics, and risk of cancer, we assessed dietary behavior and urinary concentration of gallic acid, a polyphenol with anticancer properties found in various fruits and vegetables, in racial and ethnic minorities. METHODS: Ninety-one (91) participants were recruited from senior centers in East Harlem, New York City, a racially diverse and underserved community. A National Institute of Health (NIH)-validated dietary survey questionnaire-was used to collect dietary fruits and vegetables consumption data. Demographic and cancer information were also collected. All 91 participants completed the survey and forty-five (45) participants provided urine samples for gallic acid analysis. RESULTS: Gender differences were significantly associated with dietary behavior and urinary gallic acid concentration (UGAC). Female participants had a higher total daily intake of fruits and a significantly higher UGAC compared to male participants (p < 0.05). Age was negatively associated with the serving quantity of French fries/fried potatoes and white potatoes (p < 0.05), while positively associated with the daily intake frequency and daily intake of fruits (p < 0.05). Furthermore, Asian race was associated with higher daily intake frequencies of fruits and vegetable soup (p < 0.05), compared to other races. In a multivariate analysis, a significant association was observed between the serving quantities of fruits and other vegetables and UGAC (p < 0.05) after controlling for demographic characteristics. CONCLUSION: The observed differences in dietary behavior and UGAC in this study provide limited information on the association between demographic differences and cancer prevalence in elder racial and ethnic minorities. Future research should investigate this association further for potential implications in cancer prevention.

Increased risk of COVID-19-related admissions in patients with active solid organ cancer in the West Midlands region of the UK: a retrospective cohort study.

OBJECTIVE: Susceptibility of patients with cancer to COVID-19 pneumonitis has been variable. We aim to quantify the risk of hospitalisation in patients with active cancer and use a machine learning algorithm (MLA) and traditional statistics to predict clinical outcomes and mortality. DESIGN: Retrospective cohort study. SETTING: A single UK district general hospital. PARTICIPANTS: Data on total hospital admissions between March 2018 and June 2020, all active cancer diagnoses between March 2019 and June 2020 and clinical parameters of COVID-19-positive admissions between March 2020 and June 2020 were collected. 526 COVID-19 admissions without an active cancer diagnosis were compared with 87 COVID-19 admissions with an active cancer diagnosis. PRIMARY AND SECONDARY OUTCOME MEASURES: 30-day and 90-day post-COVID-19 survival. RESULTS: In total, 613 patients were enrolled with male to female ratio of 1:6 and median age of 77 years. The estimated infection rate of COVID-19 was 87 of 22 729 (0.4%) in the patients with cancer and 526 of 404 379 (0.1%) in the population without cancer (OR of being hospitalised with COVID-19 if having cancer is 2.942671 (95% CI: 2.344522 to 3.693425); p<0.001). Survival was reduced in patients with cancer with COVID-19 at 90 days. R-Studio software determined the association between cancer status, COVID-19 and 90-day survival against variables using MLA. Multivariate analysis showed increases in age (OR 1.039 (95% CI: 1.020 to 1.057), p<0.001), urea (OR 1.005 (95% CI: 1.002 to 1.007), p<0.001) and C reactive protein (CRP) (OR 1.065 (95% CI: 1.016 to 1.116), p<0.008) are associated with greater 30-day and 90-day mortality. The MLA model examined the contribution of predictive variables for 90-day survival (area under the curve: 0.749); with transplant patients, age, male gender and diabetes mellitus being predictors of greater mortality. CONCLUSIONS: Active cancer diagnosis has a threefold increase in risk of hospitalisation with COVID-19. Increased age, urea and CRP predict mortality in patients with cancer. MLA complements traditional statistical analysis in identifying prognostic variables for outcomes of COVID-19 infection in patients with cancer. This study provides proof of concept for MLA in risk prediction for COVID-19 in patients with cancer and should inform a redesign of cancer services to ensure safe delivery of cancer care.

NSUN6, an RNA methyltransferase of 5-mC controls glioblastoma response to temozolomide (TMZ) via NELFB and RPS6KB2 interaction.

Nop2/Sun RNA methyltransferase (NSUN6) is an RNA 5-methyl cytosine (5mC) transferase with little information known of its function in cancer and response to cancer therapy. Here, we show that NSUN6 methylates both large and small RNA in glioblastoma and controls glioblastoma response to temozolomide with or without influence of the MGMT promoter status, with high NSUN6 expression conferring survival benefit to glioblastoma patients and in other cancers. Mechanistically, our results show that NSUN6 controls response to TMZ therapy via 5mC-mediated regulation of NELFB and RPS6BK2. Taken together, we present evidence that show that NSUN6-mediated 5mC deposition regulates transcriptional pause by accumulation of NELFB and the general transcription factor complexes (POLR2A, TBP, TFIIA, and TFIIE) on the preinitiation complex at the TATA binding site to control translation machinery in glioblastoma response to alkylating agents. Our findings open a new frontier into controlling of transcriptional regulation by RNA methyltransferase and 5mC.

MicroRNA-1205 Regulation of FRYL in Prostate Cancer.

High mortality rates of prostate cancer (PCa) are associated with metastatic castration-resistant prostate cancer (CRPC) due to the maintenance of androgen receptor (AR) signaling despite androgen deprivation therapies (ADTs). The 8q24 chromosomal locus is a region of very high PCa susceptibility that carries genetic variants associated with high risk of PCa incidence. This region also carries frequent amplifications of the PVT1 gene, a non-protein coding gene that encodes a cluster of microRNAs including, microRNA-1205 (miR-1205), which are largely understudied. Herein, we demonstrate that miR-1205 is underexpressed in PCa cells and tissues and suppresses CRPC tumors in vivo. To characterize the molecular pathway, we identified and validated fry-like (FRYL) as a direct molecular target of miR-1205 and observed its overexpression in PCa cells and tissues. FRYL is predicted to regulate dendritic branching, which led to the investigation of FRYL in neuroendocrine PCa (NEPC). Resistance toward ADT leads to the progression of treatment related NEPC often characterized by PCa neuroendocrine differentiation (NED), however, this mechanism is poorly understood. Underexpression of miR-1205 is observed when NED is induced in vitro and inhibition of miR-1205 leads to increased expression of NED markers. However, while FRYL is overexpressed during NED, FRYL knockdown did not reduce NED, therefore revealing that miR-1205 induces NED independently of FRYL.

Prostac: A New Composite Score With Potential Predictive Value in Prostate Cancer.

Prostate cancer (PCa) is the most commonly diagnosed solid organ cancer in men worldwide. Current diagnosis of PCa includes use of initial prostate specific antigen assay which has a high false positive rate, low specificity, and low sensitivity. The side effects of unnecessary prostate biopsies that healthy men are subjected to, often result in unintended health complications. New PCa biomarkers are being discovered to address this unmet need. Here, we report on the creation of a composite score (Prostac) based on three recently discovered PCa biomarkers, Plasmacytoma Variant Translocation 1 (PVT1) exons 4A, 4B, and 9. Statistical analysis of copy numbers derived from a real-time quantitative polymerase chain (qPCR) reaction - based assay, showed these PCa biomarkers to be linearly separable and significantly over expressed in PCa epithelial cells. We train a supervised learning algorithm using support vector machines to generate a classification hyperplane from which a user-friendly composite score is developed. Cross validation of Prostac using data from prostate epithelial cells (RWPE1) and PCa cells (MDA PCa 2b) accurately classified 100% of PCa cells. Creation of the Prostac score lays the groundwork for clinical trial of its use in PCa diagnosis.

Targeting PVT1 Exon 9 Re-Expresses Claudin 4 Protein and Inhibits Migration by Claudin-Low Triple Negative Breast Cancer Cells.

PVT1 is a long non-coding RNA transcribed from a gene located at the 8q24 chromosomal region that has been implicated in multiple cancers including breast cancer (BC). Amplification of the 8q24 chromosomal region is a common event in BC and is associated with poor clinical outcomes. Claudin-low (CL) triple negative breast cancer (TNBC) is a subtype of BC with a particularly dismal outcome. We assessed PVT1 exon 9 expression in the T47D estrogen receptor positive BC cell line, and in the MDA MB 468 and MDA MB 231 TNBC cell lines, followed by the assessment of the expression of claudins 1, 3, 4 and 7, in MDA MB 468 and MDA MB 231 (TNBC) cells. We found that MDA MB 231 TNBC cells significantly express less claudin 1, 3, 4, and 7 than MDA MB 468 TNBC cells. PVT1 exon 9 is significantly upregulated in MDA MB 231 CL TNBC cells, and significantly downregulated in MDA MB 468 claudin high (CH) TNBC cells, in comparison to T47D estrogen receptor positive BC cells. We then analyzed the functional consequences of siRNA targeting of PVT1 exon 9 expression in the MDA MB 231 CL TNBC cells. Notably, siRNA targeting of PVT1 exon 9 expression in the MDA MB 231 CL TNBC cells led to a significant reduction in migration and the re-expression of claudin 4. Taken together, our data indicate that PVT1 exon 9 regulates claudin 4 expression and migration in CL TNBC cells, and may have clinical implications in CL TNBC.

Leptin activates Akt in oesophageal cancer cells via multiple atorvastatin-sensitive small GTPases.

Obesity is a risk factor for Barrett's oesophagus and oesophageal adenocarcinoma. Adipose tissue secretes the hormone leptin. Leptin is a growth factor for several cell types, including Barrett's cells and oesophageal adenocarcinoma cells. Statins are associated with reduced rates of Barrett's oesophagus and oesophageal cancer and exhibit anti-cancer effects in vitro. The mechanisms of these effects are not fully established. We have examined the effects of leptin and the lipid-soluble statin, atorvastatin, on signalling via monomeric GTP-binding proteins and Akt. Proliferation and apoptosis were assessed in OE33 cells. Akt activity was quantified by cell-based ELISA and in vitro kinase assay. Specific small-molecule inhibitors and a dominant-negative construct were used to reduce Akt activity. Small GTPases were inhibited using transfection of dominant-negative plasmids, prenylation inhibitors and pretreatment with atorvastatin. Leptin stimulated Akt activity and cell proliferation and inhibited camptothecin-induced apoptosis in an Akt-sensitive manner. Leptin induced phosphorylation of Bad and FOXO1 in an Akt-sensitive manner. Leptin activated Ras, Rac, RhoA and cdc42. Transfection of dominant-negative plasmids confirmed that leptin-induced Akt activation required Ras, RhoA cdc42 but not Rac. Atorvastatin inhibited leptin-induced activation of Ras, RhoA, cdc42 and Akt. Co-treatment with mevalonate prevented these effects of atorvastatin. The protein kinase Akt is essential to the growth-promoting and anti-apoptotic effects of leptin in oesophageal adenocarcinoma cells. Akt is activated via Ras-, Rho- and cdc42-dependant pathways. Atorvastatin reduces leptin-induced Akt activation by inhibiting prenylation of small GTPases. This may explain the reduced incidence of oesophageal adenocarcinoma in statin-users.

Biomarkers in Colorectal Cancer: Current Research and Future Prospects.

Colorectal cancer (CRC) is a leading cause of death worldwide, despite progress made in detection and management through surgery, chemotherapy, radiotherapy, and immunotherapy. Novel therapeutic agents have improved survival in both the adjuvant and advanced disease settings, albeit with an increased risk of toxicity and cost. However, metastatic disease continues to have a poor long-term prognosis and significant challenges remain due to late stage diagnosis and treatment failure. Biomarkers are a key tool in early detection, prognostication, survival, and predicting treatment response. The past three decades have seen advances in genomics and molecular pathology of cancer biomarkers, allowing for greater individualization of therapy with a positive impact on survival outcomes. Clinically useful predictive biomarkers aid clinical decision making, such as the presence of KRAS gene mutations predicting benefit from epidermal growth factor receptor (EGFR) inhibiting antibodies. However, few biomarkers have been translated into clinical practice highlighting the need for further investigation. We review a range of protein, DNA and RNA-based biomarkers under investigation for diagnostic, predictive, and prognostic properties for CRC. In particular, long non-coding RNAs (lncRNA), have been investigated as biomarkers in a range of cancers including colorectal cancer. Specifically, we evaluate the potential role of lncRNA plasmacytoma variant translocation 1 (PVT1), an oncogene, as a diagnostic, prognostic, and therapeutic biomarker in colorectal cancer.

Circulating Tumor Cell Migration Requires Fibronectin Acting through Integrin B1 or SLUG.

Fibronectin (FN1) is an extracellular matrix protein gaining increasing attention for its multifaceted roles in cancer progression. Using our recently established circulating tumor cell (CTC) lines, we had demonstrated increased FN1 expression and enhanced migration in CTC lines, in comparison to primary tumor cell lines. Whether increased FN1 expression is directly required for CTC migration, and the specific role of FN1's regulation of integrin B1 (ITGB1) and SLUG (SNAI2) in CTC migration remains unclear. Here, for the first time, we report that the knockdown of FN1, ITGB1, or SLUG expression in CTCs leads to a significant decrease in CTC migration. Knocking down two or all three of these proteins simultaneously did not further inhibit migration. We observed a corresponding increase in CTC migration when recombinant FN1 was added to CTCs. This effect was significantly impeded by prior knockdown of ITGB1 or SLUG. Using knock down experiments and western blotting analysis, we confirmed FN1's regulation of ITGB1 and SLUG to occur via two separate, independent pathways. Consequently, we can conclude that FN1-dependent enhanced migration of CTCs requires downstream signaling through either ITGB1 or SLUG and that FN1 regulation of ITGB1 and SLUG may have important implications for cancer progression and metastasis.

Online versus in-person training of community health workers to enhance hepatitis B virus screening among Korean Americans: Evaluating cost & outcomes.

From 2014 to 2018, we developed and implemented culturally appropriate interventions delivered by community health workers (CHWs) in Pennsylvania and New Jersey. To determine the most cost-effective approach, we recruited 40 predominantly foreign-born Korean American CHWs and used cluster sampling to assign them into two training groups (online training vs. in-person training). We prospectively assessed the cost of training 40 Korean American CHWs and the cost of subsequent HBV educational workshops delivered by the CHWs. We also assessed these costs relative to the success of each training approach in recruiting participants for HBV screening and vaccination. We found that the training costs per participant were higher for in-person training ($1.71 versus $1.12), while workshop costs per participant were lower for in-person training ($2.19 versus $4.22). Workshop attendee costs were comparable. After accounting for site clustering, there were no significant differences in total costs per participant ($24.55 for the online-trained group and $26.05 for the in-person group). In-person trained CHWs were able to generate higher HBV screening and vaccination rates (49.3% versus 21.4% and 17.0% versus 5.9%, respectively) among their participants compared with online-trained CHWs. Given better outcomes and no differences in costs, in-person training dominated the online training option. Despite the potential for efficiency to be gained with online training, CHWs who attended live training outperformed their online-trained colleagues. Elements of the didactic approach or practice with peers in the live session may have contributed to the superior training effectiveness and, ultimately, improved cost-effectiveness of the in-person approach.