- Steven Lipshultz, M.D.
- Jul 1, 2014
Recently published findings in Annals of Internal Medicine by Steven Lipshultz, M.D., Wayne State University professor and chair of pediatrics and pediatrician-in-chief at the Children’s Hospital of Michigan, part of the Detroit Medical Center, and colleagues could help to reduce health care charges while also protecting childhood cancer survivors from heart ailments caused by drug therapy.
That’s the “very exciting and very hopeful” bottom line of the recently published study, said co-author Dr. Lipshultz, who has spent more than 30 years studying the potential harmful impact -- or cardiotoxicity -- of drug therapies on the hearts of children who have survived cancer.
The study, “Cost-Effectiveness of the Children’s Oncology Group Long-Term Follow-up Screening Guidelines for Childhood Cancer Survivors at Risk for Treatment-Related Heart Failure,” reviewed data from patient histories to show that current standard medical guidelines for protecting childhood cancer survivors from drug treatment-related heart disease and heart failure later in life through periodic heart scans called echocardiographs are overly cautious.
According to the data, the frequency of such post-cancer screenings can be safely reduced for low-risk patients – with large cost-savings and little reduction in overall quality of patient care.
“The potential savings to be earned by reducing the frequency of echocardiographic screenings in patients who have survived childhood cancer seem quite promising,” Dr. Lipshultz said. “The data in our study on the cost-effectiveness of such screenings suggest that we could save 50 percent of the charges for this heart care screening, while also sparing these children from the rigors of needless heart scanning.”
While pointing out that total U.S. spending for health care exceeds $3 trillion a year and amounts to nearly 17 percent of the entire U.S. gross domestic product, Dr. Lipshultz described the breakthrough findings as “a classic example of how effective research in pediatric medicine can both assure the quality of patient care and help in the effort to keep medical costs under control.”
According to the findings, the guidelines for the frequency of heart scans among childhood cancer survivors – as devised in 2003 by the nation’s standard-setting Children’s Oncology Group – could be safely revised, so that instead of undergoing the scans every one, two or five years (depending on pertinent health factors), childhood cancer survivors would be scanned every two, four, five or 10 years.
While praising the study – http://annals.org/article.aspx?articleid=1872846 -- for its wide-ranging exploration of the issue, an accompanying AIM editorial noted that the new recommended frequency-of-scan schedule would lower “charges by 50 percent.”
The editorial went on to point out that “screening can be done cost-effectively and is highly likely to improve the quality and quantity of the patient’s life.”
The study has “important implications,” Dr. Lipshultz said, for the approximately 400,000 survivors of childhood cancer in the United States in 2014.
“The National Cancer Institute has estimated that one in every 530 young adults (ages 20 to 45) is a survivor of childhood cancer,” said the veteran researcher, who has published frequently over the years on the subject of cardiotoxic effects from cancer-related drug treatment in pediatric cancer survivors. “For these patients, making sure the long-lasting impact of drug therapy doesn’t lead to heart disease and heart failure later in life is vitally important.
“For childhood cancer survivors and their families, this new study is very good news, indeed – because it shows that many of them in the low-risk category can safely reduce the frequency of their heart screenings, with a significant reduction in accompanying costs.”
Dr. Lipshultz pointed out that asking childhood cancer survivors to undergo too-frequent heart scans also carries “a social cost.”
“The risk you run, if you ask these patients to have frequent scans, is that they may start to be seen by their friends and their families and their teachers at school as ‘different’ from the other kids around them. If that happens, these cancer survivors can even become youngsters whose lives are dominated by an exaggerated focus on their heart health.”
Dr. Lipshultz also said that the new study underlines the importance of “connecting research to clinical care in everything we do.
“If you want to see why that connection is so important,” he added, “just look at the ‘miracle’ in the treatment of pediatric leukemia care in this country during the past few decades. In 1970, only about 4 percent of childhood leukemia patients survived (the most prevalent form of the disease). But today, that same survival rate is over 90 percent. That’s been one of the biggest miracles in modern medicine – and it happened in large part because of a seamless connection that was achieved between research and clinical care.”
“As the pediatrician-in-chief, I feel very passionate about trying to connect research, education and quality patient care in every single thing we do at the Children’s Hospital of Michigan.”
- Fu-Shin Yu, Ph.D.
- Dec 12, 2013
Patients with DM may develop corneal complications and delayed wound healing. This slow wound healing contributes to increased infections and the formation of bed sores and ulcers. Corneal complications include diabetic neuropathies and ocular complications that often lead to reduced vision or blindness.
A team of Wayne State University researchers recently developed several diabetic models to study impaired wound healing in diabetic corneas. Using a genome-wide cDNA array analysis, the group identified genes, their associated pathways and the networks affected by DM in corneal epithelial cells and their roles in wound closure. The findings may bring scientists one step closer to developing new treatments that may slow or thwart DM’s impact on vision.
The team, led by Fu-Shin Yu, Ph.D., professor of ophthalmology and director of research at the Kresge Eye Institute, has discovered transforming growth factor β (TGFβ) signaling as a major pathway affected by hyperglycemia in DM corneal epithelial cells. In addition, Dr. Yu and his team identified for the first time that wound-induced upregulation of TGFβ3 is dampened by hyperglycemia and that by adding TGFβ3 to the wound, epithelial wound closure was accelerated.
This discovery, published on line in the prestigious scientific journal Diabetes, may provide new treatment options for diabetic wound healing in tissues such in the cornea and skin.
“Delayed wound healing are major complications of diabetes, often leading to severe end results such as diabetic ulcers, losing a limb or going blind,” said Joan Dunbar, Ph.D., associate vice president for Technology Commercialization at Wayne State University. “Dr. Yu’s discovery of the genome-wide transcriptional analysis has allowed the development of composition and methods to treat negative effects of diabetes, which may ultimately promote healing of wounds, reduce the negative effects of diabetic neuropathies, and promote the health of the eye and maintenance of eye sight in diabetics. The findings in the cornea have a strong implication in the skin as they both have neuropathy and delayed wound healing.”
Wayne State University has filed a U.S. Provisional Patent application on Dr. Yu’s technology discovery.
Dr. Yu’s research was funded by a grant from the National Eye Institute of the National Institutes of Health, award number EY01869 and Research to Prevent Blindness.
- Kezhong Zhang, Ph.D.
- Oct 23, 2013
The team led by Dr. Zhang, associate professor of Molecular Medicine and Genetics and of Immunology & Microbiology, and the team led by Deyu Fang, Ph.D., associate professor of pathology at Northwestern University Feinberg School of Medicine, worked together to discover the key inflammatory stress response that drives the development of rheumatoid arthritis. Their studies revealed that inflammatory stimuli trigger cell surface toll-like receptors of macrophages, the white blood cells that subsequently activate the Unfolded Protein Response transducer IRE1a to promote arthritis syndrome in the tissues around the joints.
Their work identified a specific IRE1a inhibitor that can efficiently prevent arthritis in animal models.
The study, “Toll-like receptor-mediated IRE1a activation as a therapeutic target for inflammatory arthritis,” was published in the prestigious scientific journal EMBO. Dr. Zhang served as a corresponding author. The study can be read at http://www.nature.com/emboj/journal/v32/n18/full/emboj2013183a.html.
“This is a notable work in the understanding of the stress mechanism for the development of rheumatoid arthritis,” Dr. Zhang said. “For the first time, we revealed the molecular targets of Unfolded Protein Response and Toll-like Receptor signaling and their interaction mechanism in the progression of inflammatory arthritis. Our study not only identified previously unknown molecular targets, but also pointed out a specific inhibitor that can efficiently suppress arthritis.”
Dr. Zhang said the next step toward the development of therapeutics may be testing the effects of specific inhibitors of Unfolded Protein Response in curing inflammatory arthritis with animal models and clinical trials.
Rheumatoid arthritis is an autoimmune disease that causes a chronic, systemic inflammatory disorder that can affect many tissues and organs, but principally flexible joints. Rheumatoid arthritis is one of the most common rheumatic diseases, affecting approximately 1.3 million people in the United States. The disease is three times more common in women than men and afflicts people of all races. The disease can begin at any age, but it often occurs in adults after age 40 and before age 60. The cause is unknown.
The disease is a costly one for the nation. According to the Arthritis Foundation, arthritis and rheumatic conditions cost the U.S. economy $128 billion annually, including $80.8 billion in medical expenditures and $47 billion in lost earnings.
Additional personnel at WSU who participated in this project include graduate students Ze Zheng and Aditya Dandekar.
Parts of this research were supported by National Institutes of Health grants (AI079056, DK083050, DK090313 and ES017829) and an American Heart Association grant (09GRNT2280479).
- Omar Khan, M.D.
- Sep 17, 2013
“This is a novel approach in the treatment of multiple sclerosis, which is characterized by diffuse demyelination and axonal loss in the central nervous system,” said Dr. Khan, who also serves as director of the Multiple Sclerosis Center and director of the Sastry Foundation Advanced Imaging Laboratory. “In this study, we are targeting remyelination in the central nervous system.”
Dr. Khan noted that there are 10 United States Food and Drug Administration-approved treatments for multiple sclerosis, none with any well-characterized reparative or remyelinating potential. Those treatments primarily focus on altering the behavior of the immune system and target inflammation.
However, this new approach targets remyelination in the central nervous system using a humanized monoclonal antibody that binds to the semaphorin 4D, a member of the semaphorin family of proteins and an important mediator of axonal growth cone guidance. Semaphorin-induced signaling also has been shown to induce growth cone collapse of neurons and apoptosis of neural precursors, and to induce process extension collapse and apoptosis of oligodendrocytes. Semaphorins consist of a family of soluble and membrane-bound proteins that were originally defined as axonal-guidance factors. These proteins play important roles in establishing precise connections between neurons and their appropriate targets.
“Therefore, it is a plausible target with the realistic goal of achieving remyelination,” Dr. Khan said. “This is a paradigm shift and the start of the next generation of therapies to treat multiple sclerosis that will change its focus to repair rather than inflammation.”
The brain can largely be divided into gray and white areas. Neurons are located in the gray area, and the white parts are where neurons send their axons – similar to electrical cables carrying messages – to communicate with other neurons and bring messages from the brain to muscles. The white parts of the brain are white because a cell type called oligodendrocytes makes a cholesterol-rich membrane called myelin that coats the axons. The myelin’s function is to insulate the axons, similar to the plastic sheath coating electrical cables. In addition, the myelin speeds communication along axons and makes that communication more reliable. In patients with MS, their immune system attacks the myelin sheathing. The subsequent degradation leads to the messages from the brain to other parts of the body leaking and derailing from their intended target.
Restoring the myelin sheathing is the goal of Dr. Khan’s new study.
The Wayne State University Multiple Sclerosis Center, in collaboration with Vaccinex, a privately-held biotechnology company headquartered in Rochester, N. Y., initiated this early stage dose-defining study, monitored by the FDA.
“If successful, this will lead to large scale studies with this molecule targeting remyelination in the brain as a primary focus, detected by advanced imaging techniques such as magnetization transfer ratio,” Dr. Khan said. “The real challenge will be to reverse or reduce conduction blocks in the demyelinated nerve that may translate into neurologic improvement. If we could achieve that with this approach, it opens the door for hundreds of thousands of multiple sclerosis patients for whom no therapy is currently effective. This may also provide a unique opportunity in combining therapies with different mechanistic approaches.”
WSU is home to the only MS center in Michigan and among the 10 sites in the world undertaking this translational initiative. The center is among the top five MS centers in the U. S., with more than 4,000 patients. The center is involved in cutting-edge immunologic, genetic, MR imaging and therapeutic studies.
Dr. Khan said only three molecules in the world, including this monoclonal antibody, are being investigated in patients with multiple sclerosis that focus on remyelination.
“It is humbling to lead such a unique groundbreaking effort and that Wayne State University is one of the few centers in the world that are participating in this next true generation translational research,” he said. “The patients are observed over night at Harper University Hospital, which has been a great partner in facilitating this research endeavor.”
Multiple sclerosis affects more than 500,000 people (or one in 600) in the U.S. and more than 2 million worldwide. After trauma, it is the most common cause of disability in young adults. While there is no cure, several treatments are approved for the relapsing form of multiple sclerosis that reduces the frequency of flare-ups and slows disease progression.
For further information regarding the Wayne State University Multiple Sclerosis Center and this study, call 313-745-7186. To make an appointment with the neurologists of the Wayne State University Physician Group specializing in multiple sclerosis, call 313-745-4275.
- Research Spotlight: Avraham Raz, Ph.D.
- Sep 16, 2013
In the realm of biotherapeutics and natural plant therapy, holy basil could be the next big breakthrough in the field’s bustling anticancer movement.
A team of Wayne State University School of Medicine and Barbara Ann Karmanos Cancer Institute researchers in Detroit has shown in an experimental tumor system that ocimum gratissimum, also known as African basil, inhibits the growth of human breast carcinoma cells.
The discovery could lead to clinical trials using the plant in concentrated form for treatment of breast cancer, and possibly other types of cancer.
Even cooking with the plant or eating it raw could have health benefits, said principal investigator Avraham Raz, Ph.D., a professor of pathology, radiation oncology and oncology in the WSU School of Medicine.
“We will know after the clinical trial. This drug can be consumed continuously, as it has no side effects and it is non-toxic,” Dr. Raz said.
The study, “Ocimum gratissimum retards breast cancer growth and progression and is a natural inhibitor of matrix metalloproteases,” is on the May cover of the science journal Cancer Biology & Therapy.
The plant, a dietary herb from the mint family Lameacea, is already used for its pharmacologic properties, including anticancer activity. It is absent in the continental United States but grows wild in Hawaii, according to the U.S. Department of Agriculture’s Natural Resources Conservation Service.
The WSU study shows that the herb inhibits the degrading enzyme responsible for facilitating breast cancer invasion and metastasis to other parts of the body, Dr. Raz said. The enzyme, matrix metalloproteases, or MMPs, is a family of at least 28 structurally and functionally-related zinc-dependent endoproteinases, which selectively degrade various components of extracellular matrix and lead to cancer cell growth according to the study article. Of the various MMP types thought to be involved in cancer, the WSU team focused on MMP-2 and MMP-9, because they are overexpressed in a variety of malignant tumors, and their expression and activities are often associated with aggressive tumors and a poor prognosis for patients. Elevated levels of both are found in breast, brain, ovarian, pancreas, colorectal, bladder, prostate, lung cancers and melanoma. The study reports that ocimum gratissimum inhibits cancer grow, partly due to its property as a natural, non-toxic inhibitor of MMP-2 and MMP-9.
The study is on the cutting edge of plant therapy and the biotherapeutics revolution, Dr. Raz said.
"Many traditional or folk remedies have a basis in reality – that is, they work – and are the backbone of modern medicine,” he added.
In addition to Dr. Raz, the study team included researchers from the WSU School of Medicine’s Department of Pathology and Department of Oncology; the WSU College of Engineering’s Department of Biological and Chemical Engineering; the WSU College of Liberal Arts and Sciences’ Department of Chemistry, as well as a researcher from the Chongqing University of Education in China.The study was funded by a National Cancer Institute grant (R37CA046120-19).
- Andre Konski, M.D., M.B.A.
- May 30, 2013
Women undergoing radiotherapy for locally advanced esophageal cancer are three and a half times more likely to develop treatment-related heart problems than their male counterparts, said researchers at the Wayne State University School of Medicine.
“It’s a women’s health issue,” said Andre Konski, M.D., M.B.A., professor and chair of the WSU Department of Radiation Oncology. “In the theme of personalized medicine, we need to personalize not only for diseases, but for the gender of the patients.”
Dr. Konski, a member of the Barbara Ann Karmanos Cancer Institute, presented the results of the study, “Dosimetric modeling of cardiac toxicity in patients with esophageal cancer receiving chemoradiotherapy,” at the European Society for Radiotherapy and Oncology forum April 19-21 in Geneva, Switzerland.
The study is the largest of its kind to date. The study helps set the stage to help understand how the role new drugs for locally advanced esophageal cancer, including trastuzumab (brand name Herceptin), may play in increased cardiac toxicity rates.
The basic toxicity rates noted in the presentation are in line with other published studies in the United States. But the gender-biased results were a surprise to Dr. Konski and his study colleagues.
“This just sort of came out. We saw it and thought, ‘Wow, that’s interesting.’ We weren’t even looking for it, to be honest,” he said.
The group retrospectively reviewed the clinical information of 37 females and 113 males from 37 to 87 years old with locally advanced esophageal cancer undergoing pre-operative or definitive chemoradiotherapy from June 2002 to November 2012 at the Barbara Ann Karmanos Cancer Center in Detroit or the Fox Chase Cancer Center in Philadelphia. Chemotherapy was at the discretion of the treating medical oncologist. Of that group, 34 patients, or 23 percent, developed some form of cardiac toxicity from 1.2 to 28.9 months after treatment, including 13 females and 21 males. The women developed the toxicity at a lower dose of radiation compared to the men. Twenty-seven of the 34 patients developed radiation-induced pericardial disease, or fluid around the heart.
“Most of these patients were without symptoms,” he said. “If the pericardial effusion gets large, it can be life-threatening.”
Two patients developed radiation-induced coronary artery disease, three patients developed cardiomyopathy and two patients developed problems in the heart’s conduction system. While the presentation was received with interest, more evidence is needed to support changes to the current standard of care for patients, Dr. Konski said. In a study abstract, the researchers suggest further work be done, both to clarify the dose resulting in toxicity to each cardiac structure necessary to result in cardiac toxicity, and to understand why the difference in men and women exists. The researchers are now working on a manuscript for publication.