Friday, March 4, 2016

Progress in ovarian cancer using the laying hen model. 

I was contacted recently from the Department of Defense ovarian cancer research program for an update on our progress.  We were first funded by the DOD in 2006 so this marks the 10th anniversary of working in the chicken model of ovarian cancer-- the only natural model of spontaneous ovarian cancer that replicates the human disease.  Our current efforts are focusing on development of biomarkers for early detection by mining the large archive we have of chicken tissues, collected from long-term longitudinal studies that enable us to look before, during and after ovarian cancer starts.  We are looking at the estrogen metabolite index (EMI), serum prostaglandin E2 (PGE2), soluble E-cadherin and micro RNA 200.  This is the report I generated for the DOD-- 20 papers and over 3 million dollars in extramural funding support.  I think the DOD got their money's worth, and receiving that first ovarian cancer grant from the DOD (a.k.a. Congressional Directed Medical Research Program) is what hatched the whole research endeavor in chicken ovarian cancer.   

For the first 15 years of my independent career the focus of my research was on the role of inflammation and oxidative stress in the regulation of male reproductive function.   A colleague of mine at UIC recruited me to help with his ovarian cancer project to help understand the role of oxidative stress and inflammation in the etiology of ovarian cancer.  He made the comment that he’d heard the only really good animal model for ovarian cancer was the laying hen.  I had a colleague at UIUC who was the world expert in chicken reproductive physiology so I approached Dr. Janice Bahr and she agreed to help provide access and her expertise so that we could look at ovarian cancer in the chicken.  What made all of the success we’ve had in this model possible, was the pilot grant I received from Department of Defense Ovarian Cancer Research Program (OCRP).  The funding enable me to collaborate with Dr. Barua at Rush University, who had expertise with chickens, knew about ovarian cancer, but had no funding.  With our collective expertise we have helped to establish the hen model as the best natural model of spontaneous ovarian cancer.  Notably, we published a high impact review article in Oncogene describing the hen model, to help the model gain wider acceptance.

Research findings based directly on CDMRP funded project.
1)      CYP1B1, the “P450 of cancer” is highly expressed in the post-ovulatory follicle of the normal hen ovary likely induced by the oxidative stress, inflammation and estrogenic microenvironment in the ovary after ovulation when the surface of the ovary is undergoing wound healing.  We hypothesize that the enzyme, a known estrogen hydroxylase, is positioned to oxidatively activate estrogens at the site where primary ovarian cancer originates.   {Zhuge, Y., Ansenberger, K., Mahon, C., Lagman, JA. J., Bahr, J., Hales, D.B. “Cyp1B1 Expression in Ovarian Cancer in the Laying Hen Gallus Dometicus.” Gynecological Oncology 112 (1):171-178 (2009)}
2)    CYP1B1, CYP1A1 and CYP3A4, which are P450 enzymes that hydroxylate estrogen in a region-specific way, are modulated by diets supplemented with flaxseed or the phytoestrogen lignan component of flaxseed, secoisolariciresinol.   CYP1B1 and CYP3A4 whose actions potentiate estrogen’s oncogenic effects, are down regulated by the flax diets, while CYP1A1 which renders estrogens harmless, is induced by these diets.  This work has led to the discovery that 2-methoxy-estradiol is a potent pro-apoptotic and anti-proliferative agent, that likely contributes directly to the anti-cancer effects of flaxseed.  { Dikshit, A, Adriao-Gomes Filho, M, Eilati, E, McGee, S, Small C, Gao, C, Klug, T, Hales DB, “Flaxseed reduces the pro-carcinogenic microenvironment in the ovaries of normal hens by altering the prostaglandin and estrogen pathways in a dose dependent manner” British Journal of Nutrition 113:1384-1395 (2015);  Dikshit, A, Gao C, Small, C, Hales, KH, Hales, DB “Flaxseed and its components cause differential effects on estrogen receptor expression and signaling pathways in the ovary of pre-cancerous laying hens.” J Steroid Biochemistry and Molecular Biology (in press 2016) DOI: 10.1016/j.jsbmb.2016.02.028.}

Based on our observations from the DOD funded project, we hypothesized that the inflammation and oxidative stress that results from ovulation, and induces CYP1B1, may be a druggable target.  We reasoned that if we could feed the hens a diet rich in natural antioxidants that target ovary, then the diet may reduce ovulation-associated inflammation and ameliorate ovarian cancer.  Omega-3 polyunsaturated fats were attractive because they were known to reduce oxidative stress and inflammation and at the same time be cardioprotective.  We found that the most effective way to deliver omega-3 to the hen was to feed them flaxseed.  Because hens fed flaxseed accumulate omega-3 in their yolk, we knew then that the ovary must be exposed to the omega-3.  We found that flaxseed supplemented diets do indeed reduce the severity and incidence of ovarian cancer in the hens. 

These findings have spawned several new research projects and helped me to garner several extramural awards.  Notably, we have been able to parlay work with the hen into two clinical studies.  We observed that the flax affects estrogen metabolism and determined that we could measure the different estrogen metabolites in the hens.  To test the clinical utility of this finding, we collaborate with the OB/GYN department at SIU School of Medicine, with Dr. Laurent Brard.  (Coincidently I first met Dr. Brard when we were both on the OCRP grant review panel in Reston, VA).  When women report to the clinic with an undiagnosed adnexal mass, Dr. Brard collects urine and sends it to my laboratory.  We analyze the estrogen metabolites and have determined the a shift in the ratio of 2 to 16 hydroxylated estrogens, with an increase in 16 relative to 2, is associated with gynecological pathology.  Based on these findings we are actively applying for funding to determine estrogen metabolite index can be used as biomarker for detection of ovarian and endometrial cancers. 

We determined that flaxseed slows the progression of ovarian cancer by targeting inflammatory prostaglandins {Ansenberger, K., Richards, C., Barua, A., Bahr, J.M., Luborsky, J.L., Hales, D.B.  “Decreased severity of ovarian cancer and increased survival in hens fed a flaxseed enriched diet for one year”  Gynecological Oncology 117:341-347 (2010); Eilati, E, Pan, L, Bahr, JM, Hales, DB “Age dependent increase in Prostaglandin pathway coincides with onset of ovarian cancer in laying hens”  Prostaglandins, Leukotrienes & Essential Fatty Acids 87:177-184 (2012); Eilati, E, Bahr, JM, Hales, DB “Long Term Consumption of Flaxseed-Enriched Diet Decreases Ovarian Cancer Incidence and Prostaglandin E2 in Hens.” Gynecologic Oncology 130:620-628 (2013); Eilati, E, Zhuge, Y, Hales, KH, Ansenberger Fricano, K, Rui, Y, van Breemen, RB, Hales, DB “Flaxseed enriched diet-mediated reduction in ovarian cancer severity is correlated to the reduction of prostaglandin E2 in laying hen ovaries.” Prostaglandins, Leukotrienes & Essential Fatty Acids 89:179-87 (2013)}
Based on these studies, we hypothesized that flaxseed supplementation may help to prevent recurrence of ovarian cancer after women have undergone cytoreductive surgery and chemo-therapy.  These first line therapies are highly effective—initially, and after women recover from the surgery and chemo-therapy, they are essentially disease and symptom free for an average of 2 years.  Unfortunately the majority of these women get recurrent disease and many ultimately succumb because the recurrent cancer has become chemo-resistant.  Our clinical trial is designed to provide women in remission 20 grams of flaxseed per day in hope that this will delay or ideally prevent the recurrence of the disease.  { }. We obtained funding from the Simmons Cancer Institute at SIU School of Medicine for the initial study and are applying for NCI funding for this trial. 

Original peer-reviewed journal articles stemming from initial CDMRP funding for research using the chicken model of ovarian cancer.
1)    Stammer, K., Edassery, S.L., Barua, A., Bitterman, P., Bahr, J.M., Hales, D.B., Luborsky, J. “Selenium-Binding Protein 1 expression in ovaries and ovarian tumors of the laying hen, a spontaneous model of human ovarian cancer.”  Gynecologic Oncology 109(1):115-21 (2008)
2)    Hales, D.B, Zhuge, Y., Lagman, JA, Ansenberger, K, Mahon, C, Barua, A., Luborsky, J., Bahr, JM. Cyclooxygenase Expression and Distribution in the Normal Ovary and Their Role in Ovarian Cancer in Gallus Domesticus” Endocrine  33:235-24(4 2008)
3)    Barua, A., Edassary, S.L., Bitterman, P., Abramowicz, J.S., Dirks, A., Bahr, J.M., Hales, D.B., Bradaric, M.J., Luborsky, J.L. “Prevalence of anti-tumor antibodies in laying hen model of human ovarian cancer” Int  J Gyn Cancer 19(4):500-507 (2009)
4)    Barua A, Bitterman P, Abramowicz J, Bradaric MJ, Edassery SL, Dirks A, Hales DB, Bahr JM and Luborsky JL, (2008) Histopathology of ovarian tumors in laying hens, a preclinical model of human ovarian cancer. International Journal of Gynecological Cancer: 19(4):531-539 (2009)
5)     Zhuge, Y., Ansenberger, K., Mahon, C., Lagman, JA. J., Bahr, J., Hales, D.B. “Cyp1B1 Expression in Ovarian Cancer in the Laying Hen Gallus Dometicus.” Gynecological Oncology 112 (1):171-178 (2009)
6)    Barua A, Abramowicz JS, Bitterman P, Bahr JM, Hales DB, Luborsky JL. OP17.08: Transvaginal ultrasound predicts ovarian tumor associated neo-angiogenesis. Ultrasound Obstet Gynecol; 32:370 (2008)
7)    Ansenberger, K., Zhuge, Y., Lagman, J.A., Richards, C., Barua, A., Bahr, J.M., Hales, D.B., “E-cadherin Expression in Ovarian Cancer in the  Laying Hen, Gallus Domesticus, compared to Human Ovarian Cancer” Gynecologic Oncology 113: 362-369(2009)
8)    Barua, A., Bitterman,P., Bahr, J.M., Bradaric, M., Hales, D.B. Luborsky, J., Abramowicz, J. "Detection of tumor associated neo-angiogenesis by Doppler ultrasound during early stage ovarian cancer in laying hens: A preclinical model of human spontaneous ovarian cancer" American Journal of Ultrasound in Medicine (JUM) 29:173–182 (2010)
9)    Ansenberger, K., Richards, C., Barua, A., Bahr, J.M., Luborsky, J.L., Hales, D.B.  “Decreased severity of ovarian cancer and increased survival in hens fed a flaxseed enriched diet for one year”  Gynecological Oncology 117:341-347 (2010)
10) Barua A, Bitterman P, Bahr JM, Basu S, Sheiner E, Bradaric MJ, Hales DB, Luborsky JL, Abramowicz JS. Contrast-enhanced sonography depicts spontaneous ovarian cancer at early stages in a preclinical animal model. Journal of Ultrasound in Medicine.30:333-45 (2011)
11) Eilati, E, Pan, L, Bahr, JM, Hales, DB “Age dependent increase in Prostaglandin pathway coincides with onset of ovarian cancer in laying hens”  Prostaglandins, Leukotrienes & Essential Fatty Acids 87:177-184 (2012)
12) Machado, SA, Bahr, JM, Hales, DB,  Braundmeier, AD, Quade, BJ, Nowak, RA “Validation of the Aging Hen (Gallus gallus domesticus) as an Animal Model for Uterine Leiomyomas”  Biology of Reproduction 87 (4):1-11 (2012)
13) Eilati, E, Bahr, JM, Hales, DB “Long Term Consumption of Flaxseed-Enriched Diet Decreases Ovarian Cancer Incidence and Prostaglandin E2 in Hens.” Gynecologic Oncology 130:620-628 (2013)
14) Eilati, E, Zhuge, Y, Hales, KH, Ansenberger Fricano, K, Rui, Y, van Breemen, RB, Hales, DB “Flaxseed enriched diet-mediated reduction in ovarian cancer severity is correlated to the reduction of prostaglandin E2 in laying hen ovaries.” Prostaglandins, Leukotrienes & Essential Fatty Acids 89:179-87 (2013)
15) Eilati, E, Small, CF, McGee, SR, Kurrey, NK, Hales, DB  “Anti-inflammatory effects of fish oil in ovaries of laying hens target prostaglandin pathways.”  Lipids in Health and Disease 12 (1):152-163 (2013).
16) Lengyel, E, Burdette, JE, Kenny, HA, Matei, D, Pilrose, J, Haluska, P, Nephew, KP, Hales, DB, Stack, MS “Review: Epithelial ovarian cancer experimental models”  Oncogene 33:3619-3633 (2014)
17) Hales, K.H, Speckman S., Kurrey, N.K., Hales, D.B. “Uncovering Molecular Events Associated with Chemosuppressant Effects of Flaxseed: A Microarray Analysis in Laying Hen Model of Ovarian Cancer BMC Genomics 15 (1):709-713 (2014)
18) Dikshit, A, Adriao-Gomes Filho, M, Eilati, E, McGee, S, Small C, Gao, C, Klug, T, Hales DB, “Flaxseed reduces the pro-carcinogenic microenvironment in the ovaries of normal hens by altering the prostaglandin and estrogen pathways in a dose dependent manner” British Journal of Nutrition 113:1384-1395 (2015)
19) Dikshit, A, Gao C, Small, C, Hales, KH, Hales, DB “Flaxseed and its components cause differential effects on estrogen receptor expression and signaling pathways in the ovary of pre-cancerous laying hens.” J Steroid Biochemistry and Molecular Biology (in press 2016) DOI: 10.1016/j.jsbmb.2016.02.028
Davis, JE, Cain, J, Small, C, Hales, DB “Therapeutic effect of flax-based diets on fatty liver in aged 

Thursday, May 14, 2015

Be Bopin' For the Cure

I was invited to give a talk at the Pink Out event in Harrisburg.  I asked if I needed to bring my own computer or if they were all set up.  She said "what do you need a computer for?"  PowerPoint?  So, I just realized I had agreed to give a speech, no slides, not a scientific presentation or lecture-- yikes just a talk.  They wanted me to talk about the advances in cancer care since the 1950s in keeping with the fund raising theme.  I told her I didn't do breast cancer research, but that I worked on ovarian cancer.  No problem, the entire audience will have ovaries.  So, I wrote the following speech.  I practiced at the lecturn in my office, tried it out on my lab group, and it seemed like I had dialed it in just right for the anticipated audience.  We packed flaxseed into about 200 eppendorf tubes as party favors, and the organizers put one at each place.  I went around to the vendors,introduced myself and handed out flaxseed samples.  One woman asked if it was a suppository.  Yikes!  It was quite an affair with vocal performances from music students at Southeastern Illinois College in Harrisburg.  Impressive!  Then after some more prefunctory comments, I took the microphone and delivered my spiel.  The 200 women in the audience sat quietly staring at me, with no emotion or response.  When I finished there was a brief delay, and then polite appluase.  The organizer took the mike, thank me and said "ooo, that was a lot of information!"  Too much I fear.  I guess I am not ready to hit the talk show circuit yet. 

Keynote address at Be-boppin’ for the cure 

Harrisburg, IL March 7, 2015

We are all here because in one way or another cancer has touched our lives.  To those of you who are survivors, congratulations—I wish you the best in your continued recovery.  About the worst possible news anyone can get from their doctor is the cancer diagnosis.  You know that your life and lives of your family, friends, and associates—are all now changed by the elephant in the room.  From that moment the journey begins.  For some that journey is all too short, but more and more, every day that journey continues for years, for decades, for the rest of your natural long life.  My mother died of cancer when I was 16.  Two of my sisters are breast cancer survivors, each having survived recurrent disease.  Everyone is touched by this monster.  But there is hope and the tide is turning.
Because of our nation’s investment in cancer research, more people are surviving cancer than ever before.  Today, 2 out of 3 people live at least 5 years after the cancer diagnosis.  In the 1970s, only 1 out of 2 survived that long.  The death rate has dropped nearly 20% since the 1990s—finally reversing decades of increases.  This progress reflects advances in every area of cancer care—prevention, screening, chemotherapy, surgery, radiation and increasingly molecularly targeted treatments.  These advances continue to bring new hope every day and mark a change in our thinking—we now know that the cure for cancer is prevention.  The War on Cancer, launched by President Nixon in the 1970s was a milestone in the national investment, as was the doubling of the NIH budget during President Clinton’s administration.  Another significant landmark was the sequencing of the human genome in the early 2000s and we continue to draw new insights and develop new targeted therapies from genetics—at an accelerating rate with the development of new more powerful gene sequencing technologies. 
Thinking back on previous milestones—in the 1880s William Halsted was first to usher in more aggressive surgical approaches—the radical mastectomy in which the entire breast, surrounding lymph nodes and chest muscles were removed—to prevent recurrence by removing the cancer beyond the margins.  He was quoted as saying he was “loathe to disfigure a woman” but knew he had to, to save her life.  In the 1970s more limited surgery was introduced—total mastectomy, which set the stage for more modern breast conserving surgeries such as lumpectomy. 
In 1903 after Marie Curie discovered radium, radiation therapy for solid tumors was introduced.  Radiation therapy continues to be an important tool in for the oncologist with methods of precisely targeting and delivering the radioactivity to the tumor but sparing adjacent tissues.   Radiation therapy following breast conserving surgery is highly effective in treating breast cancer.
With the introduction of the Pap test, named after George Papanicolaou, cervical cancers can be detected and removed before they have a chance to spread.  Since the 1950s, widespread use of the Pap test has helped to reduce cervical cancer rates by more than 70%.  The key to this success is early detection and effective screening strategies.  Certainly early detection for breast cancer (mammography 1970s), prostate cancer (PSA, 1986), colorectal cancer (fecal occult blood test, 1967—are key to the ever better news for these cancers.  Regular screening leads to the detection of highly treatable early cancer, and this is why the cancer statistics for these cancers have improved so dramatically—screening and effective early detection.
In 1947 chemotherapy was added to the armament of the physician—the use of nitrogen mustard, the same lethal compound used in WWI—mustard gas, was shown to effectively kill cancer cells by modifying their DNA.  Hodgkin’s lymphoma is still treated today by a modified variant of nitrogen mustard.  But as is the case with all chemotherapies—the fast growing cells are killed, usually cancer cells, but unfortunately these are deadly toxic poisons that kill normal healthy cells—and almost kill the patient in the process of delivering the cure.  In the 1950s when my mother’s cancer was discovered, she suffered through nitrogen mustard treatments.  I was too young to know what she was going through but she later told me how sick it made her.  It worked though—she lived for 15 years with her cancer.
In 1958 combination chemotherapy was introduced and has proven to highly effective in treating many cancers, especially leukemia and other cancers of the blood.  These early findings set the stage for the modern era of chemotherapy when multiple drugs at specific times and dose intervals are proving effective against many cancers. 
In the 1950s everyone smoked cigarettes, but the probable connection with lung cancer was first suggested—then in the 1960s the link to smoking was widely accepted, and today, lung cancer is still the most preventable form of cancer—prevention is the cure—quit smoking!  Asbestos, other environmental toxins are now also known to cause very specific cancers—again all curable by prevention.  Sun exposure’s link to melanoma revealed another environmental cause of cancer.
In the 1970s adjuvant chemotherapy was introduced—chemotherapy following surgery was shown to increase survival in breast cancer.  Now adjuvant chemotherapy is widely used, especially in the treatment of ovarian cancer. This has proven to be one of the most important advances—9 out of 10 women with breast cancer survive more than 5 years because of this innovation.
In the 1980s vaccines against specific cancers ushered in the age of immunotherapy.  Hepatitis B vaccination prevents a majority of liver cancers.  In 2006 vaccination against human papillomavirus (HPV) was shown to completely prevent cervical cancer. 
Chemotherapy in the modern era was ushered in with the discovery of taxanes in the early 1990s, highly effective as adjuvant therapy for breast and ovarian cancer, now available as the synthetic paclitaxel.  Taxanes were discovered as a natural product isolated from the bark of the yew tree.  The development of the synthetic assuaged fear that the natural source of the drug would be exhausted due to the demand. 
In the wake of the human genome project and with every more sophisticated understanding of cancer biology, the 21st century heralds the era of targeted therapeutics which specifically attack the cancer without attacking the innocent bystander.  Gleevac, rutisumab, trastuzumab (Herceptin), imatanib, gefintinib, avastin--- all are “pathway specific” drugs, either immune based or activity based therapies.  Other important adjuvant therapies such as tamoxifen for estrogen sensitive breast cancers are also proving to be powerful additions to the oncologist’s toolbox. 
One of the most significant findings, which I believe heralds the new era of cancer prevention medicine, was the discovery of the link between obesity and cancer in 1998, and then the link of diabetes to cancer—leading to our understanding of the role of inflammation, obesity and diet in cancer.  The idea that diet can cause—or prevent cancer is not new.  But the actual use of “dietary intervention” for cancer therapy is still an idea that is gaining acceptance.  The concept that we can target the inflammation that causes cancer with diet is the very essence of the research in my lab. 
It has long been known that ovulation—when the egg leaves the ovary to enter the Fallopian tube—is an inflammatory event.  The ovary is wounded by when it expels the egg, and then has to heal—a classic inflammatory event.  Repeated rounds of this tear and repair cycle, every month year after year creates a ripe environment for the cancer to start.  It’s been said the cancer is the wound that will not heal.  There is a very strong link between the number of ovulations and ovarian cancer.  The best way to prevent the disease is to limit ovulations—multiple pregnancies, breast feeding, contraceptives are all protective against the disease.  The more ovulations, the more inflammation and rounds of wound healing.  We had a simple goal, find natural product antioxidants that we can use to target the inflammation in hopes we could attack the disease.   
One of the reasons that so little progress has been made in ovarian cancer is because there are very few adequate animal models for studying the disease.  Rodents do not get ovarian cancer unless you cause them to get it, either by manipulating them genetically, or by causing it with chemicals or drugs.  These are useful models for studying therapies for late disease, but can’t help us understand what causes the disease—because the investigator has to induce the cancer.  Amazingly, chickens are the only animal that gets the same kind of ovarian cancer that women get, and importantly they are afflicted with the cancer spontaneously—so we can study old, cancer prone hens which have ovulated every day for over 2 years, and study the earliest stages of ovarian cancer, to help us find a way to prevent it from starting and also to develop tests for early detection.  Prevention and early detection are both seriously lacking in the treatment of ovarian cancer. 
There is a lot of public interest in omega-3 fats—fish oil is known to be cardioprotective and potent anti-inflammatories.  We were considering how to give chickens fish oil, to give them omega-3 fats, when I discovered “omega eggs” in the dairy case at the health food store.  Wow, I thought, if the chickens accumulate omega-3 in the eggs, the ovary has to see it too.  How do they get all that omega 3 into eggs?? They feed the chickens flaxseed!  I thought that surely there must be a lot known about the health benefits of feeding hens flaxseed, after all the omega egg business represents about 15% of the shell eggs sold in Canada, and about 3 % in the USA.  Nothing was known about flax effects on hens.  All that the large scale egg producers care about are the eggs, not the chickens.  So we decided to see if we fed hens flaxseed if it might not have some beneficial effects and maybe even prevent or reduce ovarian cancer.  We conducted a series of studies to fine tune the feeding and analysis, and then embarked on a one year study where we fed 400 chickens 10% flaxseed for one year.  The diet had profound effects.  The flax fed hens looked better, maintained the same lean body weight throughout the study, far fewer of them died—their overall wellbeing was much improved by the diet.  But the important finding was that the severity of the disease was significantly reduced by the diet.  There was a 70% reduction in the severity of the cancer, the hens that did get cancer presented with early stage disease.  This exciting finding indicated that flaxseed reduced the inflammation that drives the cancer, and causes it to slow to the point that the cancer was no longer lethal to the hens! 
These exciting findings enable us to attract substantial funding from the NIH to conduct more studies on how the flaxseed works to treat the disease.  These studies are ongoing in my laboratory at the SIU School of Medicine in Carbondale.  We are finding some very exciting things, including possibly identifying a potential biomarker to help detect early disease, and we are just now starting a clinical trial to test the effectiveness of flaxseed in women who are in remission after initial surgery and chemotherapy for ovarian cancer.

The use of taxane and platinum based therapy post-surgery (i.e. adjuvant therapy) has proven to be highly successfully in the initial treatment of ovarian cancer but the standard of care and outcomes for ovarian cancer have not significantly improved for the last four decades.  The initial round of therapy is successful and provides on average two years of disease free living—but in some 75% of women the disease returns, and the recurrent disease, again treated with combinations of chemotherapeutics with good success—but eventually in the majority of cases, the disease will return, and now be resistant to chemotherapy, and the woman will ultimately succumb to the cancer.  We have just started a new clinical trial for women who are in remission post initial therapy to try and prevent the disease from returning.  Instead of just waiting, we are giving these women a daily dose of flaxseed, 20 grams a day, every day in hopes that this simple dietary supplement will keep the disease at bay.  Based on the success of our trials in the cancer prone hens, where the flax significantly reduced the progression of the cancer, we are hopefully that this intervention will prove to be effective for women.  Our goal is to turn ovarian cancer into a disease women can live with instead of die from.  Talk to me if you know someone who would like to enroll in this trial.

Friday, June 1, 2012

Report on CCOCR 2012

Report on the Canadian Conference on Ovarian Cancer Research May 27-30, 2012

These are exciting times in ovarian cancer research.  We just attended the Canadian Conference on Ovarian Cancer Research (CCOCR  in Quebec City, Quebec, Canada and the theme of the conference was “Where there is a molecular path, there is a way.”  Surprisingly there were only three or four presentations which utilized animal models, the rest of the conference including oral, poster and plenary talks were based on clinical research.  The further analysis of ovarian cancer subtypes and defining each of the subtypes by their genomic signatures, phenotypic and morphological  features, and anatomical location to give insight into the potential site from which the cancers originate, but more importantly, to devise effective “personalized” therapies.  It now appears that ovarian cancer may be described as possibly 8 distinct cancers.  Impressive technology is being brought to bear on this disease.  The use of next-generation, massively parallel deep sequencing of the tumors brings new insight into the complex changes underlying the cancers.  Instead of considering the cancers from the viewpoint of single gene mutations, it is clear that pathways instead of individual genes need to be targeted.  Combined targeted therapies are bringing improved patient outcomes—but these are often marginal gains.  Increasing progression free survival by 3 months is still considered a major therapeutic advance.  Beyond gene signatures, investigations reveal alteration in copy number of certain genes and specific chromosomal rearrangements.   Certain of these cancer subtypes feature considerable genomic instability, especially the biggest killer of them all, “high grade serous” cancer—of which more than 70% of ovarian cancer victims succumb. 

Yet lacking from these enlightened discussions and state-of-the art technological advances is an increase in our understanding of the underlying cause of ovarian cancer.  While it appears that the fimbriae of the Fallopian tube is the origin of high grade serous cancers which are proposed to spread from tube to ovary to the peritoneum, it remains an open question—what event caused the neoplastic transformation in the first place?  The so called incessant ovulation hypothesis, proposed in 1971 by Fathalla is no longer favored by the gynecologic oncologists, largely because of the postulate that the ovarian surface epithelium the OSE is the origin of the disease.  This idea is challenged the evidence that serous disease my arise from the tubal epithelium, and also the emerging idea that other forms of the disease may arise from endometriosis associated lesions.  The gifted gynecologic surgeons who are “debulking” these cancers observe the similarity in appearance and presentation of the endometrioid cancer with the endometriomas and propose a causal relationship.  The molecular signature of the endometrial cancers and the endometrioid ovarian tumors supports the clonal origins of the disease and help the physicians devise targeted combinatorial therapies for the afflicted women. 

We still favor the basic postulate set forth in the incessant ovulation hypothesis—that ovulation is an inflammatory event and the associated oxidative stress and inflammation is the molecular insult that initiates the transformation.  The endometriosis origin when examined carefully also supports inflammation as the prime driver of the disease—moreover, only endometriomas are associated with endometrioid type of ovarian cancer, and these are endometriosis lesions on the ovary itself—so called “chocolate cysts.”  The fimbriae is in close physical proximity to the surface of the ovary and the insult associated with ovulation exposes the tubal epithelium to the same inflammatory milieu as the OSE.  Tubal, endometriotic or ovarian surface—the inflammatory insult is the common culprit.

Chemoresistance, recurring disease, poor prognosis—all the unfortunate hallmarks of ovarian cancer.  Molecular medicine advances the therapeutic options and outcomes are improving.  Yet there is no better cure for the disease than prevention.  And here is probably the single most important feature of the chicken model of ovarian cancer—it provides the opportunity to devise effective interventions that are potentially able to prevent the disease in the first place.  Furthermore, the hens provide us with a tool to look at the very first initiating events.  What prevents ovarian cancer?  Reducing the number of life time ovulations is the best intervention thus far described.  Parity, breast feeding, steroidal contraceptives—all lead to significant reductions in cancer incidence.  Reducing the inflammation associated with ovulation maybe another effective preventative.  Also reducing the inflammation associated with endometriosis is also likely to have important effects on ovarian cancer reduction.  And we propose that dietary intervention with natural foods rich in antioxidants with anti-inflammatory properties will provide the population with a significant reduction in ovarian cancers when adopted.  This hypothesis has substantial support from dietary intervention studies in hens, and provides the foundation for clinical trials in women.

Tuesday, February 7, 2012

Chicken research and Omega 3s-- best hope for prevention of ovarian cancer?

golden flax:
Linum usitatissimum

Ovarian cancer is a deadly disease, often referred to as the “silent killer” due to the late stage of detection when treatment options are limited and the prognosis of the patient is poor.  More than 24,000 women will be diagnosed with ovarian cancer in the United States in 2012, and it is likely that at least 16,000 women will die from this awful disease.  If ovarian cancer is detected in its early stages the prognosis is excellent and the 5 year survival rate is 95%.  But if the disease is discovered in later stages the 5 year survival rate is less than 30%.  Due to the lack of symptoms and early detection markers, ovarian cancer will go undiagnosed until women present with seemingly unrelated symptoms such as bloating or gastrointestinal distress, and upon further examination advanced disease is only then discovered.  Certainly one of the most important advances needed in ovarian cancer is a method for early detection.  Many of the most promising methods for early detection are unreliable with unacceptably high false positive rates, or are too expensive and impractical for population wide screening.  Thus an emerging emphasis in ovarian cancer research is on prevention, in lieu of reliable early detection. 

Progress in ovarian cancer research has been hampered by lack of suitable animal models.  Certainly there are many advances being made in the treatment of late stage ovarian cancer using rodent models.  But mice do not spontaneously get the disease; it has to be introduced via genetic manipulation, by exposure to chemical carcinogens, or by surgically implanting tumor xenografts into recipient mice.  Ovarian cancer is a complex disease with different subtypes that have distinct tissue-type appearances.  Specific genetic signatures have been described in each of these cancer subtypes, and genetically manipulating mice to mimic these gene signatures will result in the development of ovarian cancer in the mice that phenotypically resembles the subtype of ovarian cancer with that particular gene signature.  Great insight into the genetic lesions associated with the ovarian cancer subtypes has thus been derived.  None the less, the initial events that cause the disease remain obscure in these models because the investigators caused the cancer, in order to study therapy and progression.  Strikingly, the chicken is afflicted with ovarian cancer that closely resembles the human disease, and old laying hens contract the disease spontaneously.  The similarities between human and hen ovarian cancer include the spontaneous development of each of the tumor subtypes, gross pathological appearance of the disease with profuse abdominal ascites and extensive dissemination of metastases throughout the peritoneal cavity.  Moreover, hens, like women, lack any symptoms of early disease.  However, upon necropsy, early ovarian cancers in hens may be detected either upon gross inspection, or further detailed histological analysis will reveal early neoplasms, occult lesions, or pre neoplastic changes.  Analysis of these early lesions provides a unique opportunity to gain new insight into early stage ovarian cancers. 

The reason hens are believed to be such a good model, is that after two years of laying eggs, which happens nearly every day, the hen has ovulated 400 or so times, comparable to the menopausal woman.  Thus the hen after her 2nd year of lay has the same reproductive age as women at the end of their reproductive years. Approximately 50% of ovarian cancers in women are detected in women 62 years or older.  The incidence of ovarian cancer in hens is about 4% in 2 year old hens but when the hens are 4 or 5 years old nearly 50% of them have the disease.  Thus in this 2 year interval the progression of the entire disease can be studied.  The number of lifetime ovulations appears to be correlated with the incidence of ovarian cancer.  This observation forms the basis of the incessant ovulation theory, and posits that women usually get ovarian cancer after a life time of ovulations, which, is caused by the tear and repair of the ovarian surface.  Each time an egg is ovulated it bursts through the surface of the ovary where it is swept into the Fallopian tubes and transported to the uterus.  The surface cells undergo rapid repair and the wound of ovulation is healed.  These events create a pro-inflammatory environment rendering the surface cells susceptible to cancerous transformation.  After three or four hundred of these events the probability of cancer increases and then, on menopause when the ovaries become quiescent and the pituitary hormones (LH and FSH) are secreted excessively (unopposed by estrogen from the ovary), this signals to the ovarian surface cells and causes them to grow.  If any of the cells have acquired a mutation, then this may result in the initiation of ovarian cancer.  It starts on the surface cells of the ovary, and perhaps also in the fimbriae of the oviducts, and then the cancer begins.  It will likely remain dormant or grow very slowly for many years.  The hen, which ovulates every day, provides support for the incessant ovulation hypothesis. 

Working with the chicken model of ovarian cancer also provides the opportunity for large scale dietary intervention studies at relatively little cost.  In order to obtain statistically significant data on dietary effects, a large number of individuals in each diet group have to be studied.  Reasoning that the inflammatory conditions associated with ovulation might be target for prevention, we wanted to test the effectiveness of a diet rich in omega-3 fatty acids.  An effective way to increase omega-3 fatty acid consumption in hens is to feed them a diet enriched with flaxseed, the richest vegetable source of these potent, natural anti-inflammatory fats.  The "omega eggs" in the dairy case of the grocery store come from hens fed flaxseed to increase omega-3s in their eggs.  We were funded by the American Institute for Cancer Research (AICR) and then later by the National Center for Complementary and Alternative Medicine (an NIH institute) to explore the flaxseed diet on ovarian cancer.  We conducted an initial study in which we fed several hundred old hens flaxseed for one year.  We discovered many exciting things from this study.  The hens maintained the same lean weight throughout the study and the flax hens had much better overall health.  While over 50% of the control fed hens died of all causes combined only 20% of the flax hens died.  But the most exciting finding was that while there was no change in cancer incidence, the flax fed hens that did have ovarian cancer mostly only had early stage disease, but the control hens had predominantly late stage disease.   The flax diet significantly reduced the progression of the disease. Flaxseed not only improved the overall well being of the hens, it ameliorated the severity of ovarian cancer.   This gives us great hope that we might be turn ovarian cancer into a disease that women die WITH not from.   Awareness of the importance of diet rich in antioxidants and anti-inflammatory omega-3 fatty acids may be our first best hope for prevention, and suppression of this deadly disease.   Ongoing studies are designed to determine which components of flaxseed in addition to the omega-3s are important in the anti-cancer actions.   Studies are also examining the efficacy of fish oil derived omega-3s, as well as exploring the role of diet and metabolism in the anti-cancer actions of natural products.  

Sunday, January 29, 2012

True Science: The Woman on the Street test.

These are very exciting times in the Hales lab. Bolstered by the promising results from our pilot one year flax feeding study our work has gained some media exposure. The idea that simple dietary changes like including flax seed and other rich source of omega-3 and natural antioxidants can result in significant improvements in ovarian cancer prognosis really speaks to people. Hope springs eternal, as they say, and being able to make ovarian cancer a disease women die with, but not from, brings hope to us all. This is important work and we have had great fortune in receiving major NIH funding to continue the studies. The National Center for Complementary and Alternative Medicine (NCCAM, an NIH Center) and the National Cancer Institute (NCI) have both recently funded our research. The NCCAM funded project exams the different constituents of flax seed to assess their relative contributions to the therapeutic actions of flax seed-- the omega-3 fatty acids in the germ of the seed, or the phytoestrogen antioxidants in the hull? We propose that they act synergistically to quell the inflammation and ameliorate the progression of ovarian cancer. If flax oil supplemented with lignan proves to be the most effective, a new therapeutic regimen could be tested in the clinic. It may prove that the omega-3 is the most important ingredient. To test this we will be looking at the effects of fish oil derived omega 3s to contrast and compare to flax seed derived omega 3s. These studies are funded by the NCI.

News of this funding has prompted a flurry of media attention:

Monday, January 18, 2010

Dietary intervention for the prevention and treatment of Ovarian Cancer: just the flax, mamm

A typical Western diet, which is high in meats and low in vegetables, may be positively associated with ovarian cancer incidence. An imbalance of omega 3 (OM-3FA) and omega 6 (OM-6FA) fatty acids contributes to excess cancer risk. Studies indicate that populations that consume high amounts of OM-3FA have lower incidences of breast, prostate and colon cancers than do those that consume less OM-3FA. Thus increasing the consumption of OM-3FA may be a nontoxic way to prevent or suppress ovarian cancer, augment cancer therapy and to significantly increase life span. Flaxseed is an excellent source of dietary fiber, the OM-3FA a-linolenic acid (ALA), and phytoestrogen lignans. ALA is the precursor for the essential omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) The lignans in flaxseed secoisolariciresinol (SECO) secoisolariciresinol diglycoside (SDG) are metabolized in the digestive tract to enterodiol (END) and enterolactone (ENL), which are potent anti-estrogens that have been shown to have anti-proliferative and pro-apoptotic activities in certain cancers. Consumption of the phytoestrogen lignans has been associated with alterations in gene expression and estrogen metabolism which may result in decreased disease risk.

Model of Flax action in the prevention and suppression of cancer: omega-3 fatty acids in the seed germ and phytoestrogen lignan in the seed hull act synergistically on separate pathwaysAs research into the role of nutrition in cancer continues, it is increasingly evident that nutrition plays a major role in cancer. It has been estimated by the American Institute for Cancer Research that 30-40 percent of all cancers can be prevented by appropriate diets, physical activity and maintenance of appropriate body weight . Obesity, nutrient sparse foods such as concentrated sugars and refined flour products, low fiber intake, consumption of red meat, and imbalance of omega 3 (OM-3FA) and omega 6 (OM-6FA) fats all contribute to excess cancer risk. OM-3FA and OM-6FA are polyunsaturated fats that are referred to as essential fatty acids because they cannot be synthesized by mammals and must be obtained from the diet.

The OM-3FAs a-linolenic acid (ALA; 18:3n:3), eicosapentaenoic acid (EPA; 20:5n:3), and docosahexaenoic acid (DHA; 22:6n:3) have been shown in animal studies to protect from cancer, while the OM-6FAs linoleic acid (LA; 18:2n:6), and arachidonic acid(AA; 20:4n:6) have been shown to be cancer promoting fats. EPA and DHA are both found primarily in oily cold-water fish such as tuna, salmon, and mackerel. ALA is found primarily in dark green leafy vegetables, flax seed oils, and certain vegetable oils. GI enzymes convert ALA to EPA and DHA, and all three OM-3FAs are important to human health. Excessive amounts of OM-6FAs and a very high OM-6FA/OM-3FA ratio have been linked with pathogenesis of many diseases, including cardiovascular disease, cancer, and inflammatory and autoimmune diseases. The ratio of OM-6FA to OM-3FA in modern diets is approximately 15:1, whereas ratios of 2:1 to 4:1 have been associated with reduced mortality from cardiovascular disease, suppressed inflammation, and decreased risk of cancer. OM-3FAs reduce inflammation and OM-6FAs tend to promote inflammation. OM-3FA have been shown to have a protective effect against ovarian cancer in population based studies. In fact, OM-3FA have been proposed as possible non-toxic chemopreventative agents for epithelial ovarian cancer. Recently, OM-3FA were shown to inhibit the proliferation, induce apoptosis, and suppress VEGF production in ovarian cancer cells in vitro—biological endpoints for chemopreventative trials. Moreover, it is clear that OM-3FAs have demonstrated significant anti-proliferative effects in vitro in many cancer cell lines, most notably breast and colon. Clearly there is an important need for preclinical studies to definitively evaluate the efficacy of OM-3FA as a chemopreventative regimen for ovarian cancer.

Wednesday, November 19, 2008

CancerChix: Cancer research using the laying hen, Gallus Domesticus

Inflammation and oxidative stress in Ovarian Cancer

The current focus of research in the lab is on the etiology of Ovarian Cancer. This project utilizes the laying hen Gallus domesticus, the only animal model for spontaneous ovarian epithelial carcinoma. The focus of our research is on understanding the role that extrinsic factors, inflammation and oxidative stress play in the pathogenesis of hormonal carcinogenesis. Projects include evaluation of dietary intervention in the prevention of ovarian cancer using flax seed enriched diets, the richest vegetable source of omega-3 fatty acids and lignans which are phytoestrogens that block estrogen actions; dietary intervention with broccoli which contains potent antioxidants; understanding the role of CYP1B1 which converts estrogen directly into a genotoxic carcinogen, independently from binding to the estrogen receptor. Recent publications from our lab have examined the prostaglandin producing enzymes called cyclooxygenases (COX-1 and COX-2): "Cyclooxygenases expression and distribution in the normal ovary and their role in ovarian cancer in the domestic hen (Gallus domesticus)", and on CYP1B1 in ovarian cancer in the hen model . We have established a very fruitful collaboration with Janice Bahr at UIUC, the world's foremost expert on the reproductive biology of the chicken, who gives us access to the experimental poultry farm at UIUC where our experimental hens are housed. Drs. Barau and Luborsky at Rush Univeristy Medical Center in Chicago provide essential insight and expertise in the laying hen model, especially Dr. Barau who studied with Dr. Yoshimura in Japan, the foremost expert on avian immunology. We are now publishing at a brisk pace in collaboration with the UIUC and Rush groups. Our first important goal is the validation of the hen model for ovarian cancer. In 'Histopathology of ovarian tumors in laying hens, a preclinical model of human ovarian cancer" (International Journal of Gynecological Cancer, 2009 in press). We document the histopathological similarity between human and hen ovarian cancer.

As we prepare our presentations, either posters for meetings or various talks either me or one o my students might give, we say in a light-hearted way "Ovarian cancer is a really bad disease." This of course is the the devastating truth, but our statement is a synopsis, a short hand way of doling out the facts about this deadly disease. More than 24,000 women in the USA are diagnosed with ovarian cancer every year, and more than half of these women will die from their disease. Stage I ovarian cancer is curable in 95% of cases, but due to inadequate screening tools, ovarian cancer is usually detected at a late stage when the prognosis is poor. Most patients who present with ovarian cancer complain of GI problems, abdominal discomfort, feelings of being bloated an irregular-- not symptoms they would suspect were caused by ovarian cancer. Upon examination the distended abdomen is found to be due to a large accumulation of ascites fluid from the ovarian tumor. The cancer has progressed and metastasized throughout the abdominal cavity and the cancer cells are producing large volumes of the ascites fluid. After draining the fluid and surgical removal of the primary tumor and chemotherapy with taxol and carboplatin drugs, the disease will go into remission. about chemotherapy Sadly though, in more than 60% of the cases, the disease will return in a more aggressive and now chemoresistant way-- the growing tumors are no longer sensitive to the chemicals and continue to grow and spread until the women succumbs to the disease. It is indeed a very bad disease.

While there has been significant progress in curing other forms of cancer, ovarian cancer lags behind. The key to the cure is early detection-- for breast, prostate and colon cancers, early detection and treatment provide the patient with an excellent prognosis for long term cancer free survival. And certain other cancers are entirely preventable-- lung cancer is the single most preventable disease correlated to not smoking or quiting cigarette smoking. Cervical cancer is caused by human papalloma virus and vaccination against HPV is very successful in preventing the disease. Cancer biologists have exploited animal models to understand the etiology or cause of these diseases, and have been able to test therapies and perfect therapies while gaining further insight into these cancers. But ovarian cancer research has been hampered by a lack of suitable animal models. In the past ten years several important rodent models for ovarian cancer have been developed in which a tumor suppressor is knocked out and an oncogene is targeted to the ovary-- but these transgenic models are by their nature blind to the cause of the cancer. Ovarian cancer is of epithelial origin, arising from the specialized tissue that covers the ovary, the so called ovarian surface epithelium. Certain of the transgenic models have successfully targeted the surface epithelium by injection of oncogenes under the ovarian bursa, and the resulting disease closely mimics the human disease. These models provide a testing ground for therapies and enable investigation into the progression of later stage disease-- where all of the therapies are targeted. But the cause of the disease can not be determined from this approach.

With the exception of the laying hen, no other accessible animal model recapitulates the human disease. Laying hens get ovarian cancer spontaneously and it is of epithelial origin, just like in humans. The prevailing theory about the cause of ovarian cancer is the so called "incessant ovulation theory" set forth by Fathalla in 1971. The theory postulates that continuous "tear and repair" of the ovarian surface epithelium, which happens every time an egg is ovulated, provides a rich environment for the initiation of the cancer. Ovulation has long been considered to be an inflammatory process, analogous to wound healing. The mature follicle ruptures, bursting through the surface epithelium releasing the egg which is swept into the oviduct. The process is the same in chickens as in humans. In chickens, though, this happens every day-- yes every time a chicken lays an egg it was necessarily preceded by ovulation. Of course what happens to the ovulated oocyte is remarkably different in the chicken. In the oviduct the yolk is surrounded by albumin and then in the shell gland, analogous to the uterus, the hard shell is formed. The post ovulatory ovary is different too-- in the mammal a corpus luteum is formed, and if the egg gets fertilized, the corpus luteum will provide estrogen and progesterone to prepare the uterus for implantation and maintain the early embryo. Fertilized or not, the chicken's egg gets laid, or in the parlance of the poultry scientist, undergoes oviposition.

Despite the differences between the hen and women, the process at the surface of the ovary are essentially identical. Since hen's ovulate every day, by the time they've completed their second year of lay, they have approximately the same reproductive age as a menopausal woman, each having ovulated 450 to 500 times. That is a lot of tear and repair and it is a this time that both women and hens are usually afflicted with ovarian cancer. The incidence in a 2 year old hen is 4%, but in a 6 year old hen, the incidence of ovarian cancer approaches 50%. This provides a relatively short period of time in which the entire disease can be studied. We've made substantial progress already in defining the earlies steps in ovarian cancer in the hen, and them after examining surgical specimens from women, have observed very similar events. Our long term goal to is characterize these events, determine what factors and mediators are involved in driving these first early steps, and then devise a screening strategy based on our understanding of the mechanism through which normal surface epithelial cells become transformed into malignant ovarian cancer cells.

Another advantage of working with the hen, is the opportunity to do large scale interventions are relatively little cost-- compared to doing similar studies in rodents. Stay tuned for a subsequent post in where I will describe these intervention strategies based on functional food enriched diets.

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