British Journal of Cancer

PurposePARP inhibitors (PARPi) are effective in homologous recombination repair (HRR) defective (HRD) cancers. To (re)sensitise HRR proficient (HRP) tumours to PARPi combinations with other drugs are being explored. Our aim was to determine the mechanism underpinning the sensitisation to PARPi by inhibitors of cell cycle checkpoint kinase ATR, CHK1 and WEE1. Experimental designA panel of HRD and HRP cells (including matched BRCA1 or 2 mutant and corrected pairs) and ovarian cancer ascites cells were used. Rucaparib (PARPi) induced replication stress (RS) and HRR (immunofluorescence microscopy for {gamma}H2AX and RAD51 foci, respectively), cell cycle changes (flow cytometry), activation of ATR, CHK1 and WEE1 (Western Blot for pCHK1S345, pCHK1S296 and pCDK1Y15, respectively) and cytotoxicity (colony formation assay) was determined, followed by investigations of the impact on all of these parameters by inhibitors of ATR (VE-821, 1 M), CHK1 (PF-477736, 50 nM) and WEE1 (MK-1775, 100 nM). ResultsRucaparib induced RS (3 to10-fold), S-phase accumulation (2-fold) and ATR, CHK1 and WEE1 activation (up to 3-fold), and VE-821, PF-477736 and MK-1775 inhibited their targets and abrogated these rucaparib-induced cell cycle changes in HRP and HRD cells. Rucaparib activated HRR in HRP cells only and was (60-1,000x) more cytotoxic to HRD cells. VE-821, PF-477736 and MK-1775 blocked HRR and sensitised HRP but not HRD cells and primary ovarian ascites to rucaparib. ConclusionsOur data indicate that, rather than acting via abrogation of cell cycle checkpoints, ATR, CHK1 and WEE1 inhibitors cause an HRD phenotype and hence synthetic lethality with PARPi.

BackgroundPreclinical studies support targeting PI3K/AKT/mTOR signalling in platinum-resistant ovarian cancer (PROC). A phase I study of the dual mTORC1/mTORC2 inhibitor vistusertib with weekly paclitaxel (wP) showed activity. We report the results of Arm 1 of OCTOPUS, the first randomised trial of weekly paclitaxel and dual mTORC1/2 inhibition in ovarian cancer. MethodsPatients with platinum-resistant or refractory high grade serous carcinoma were randomised (1:1) to wP (80mg/m2 D1,8,15 of 28 day cycle) plus oral vistusertib (50mg BD) or placebo (P). The primary endpoint was progression-free survival (PFS). Secondary endpoints included response rate (RR) and overall survival (OS). Results140 patients (median age 63, range: 36-86; 18% platinum-refractory; 54% [≥]3 prior therapies) were randomised. There was no difference in PFS (median 4.5 vs 4.1m (HR 0.84; 80% CI (0.67, 1.07); 1-sided p=0.18), OS (median 9.7 vs 11.1m (HR 1.21; 80% CI (0.91, 1.60); 1-sided p=0.80) or RR (odds ratio 0.86; 80% CI (0.55, 1.36); 1-sided p=0.66). Grade 3/4 adverse events were 41.2% (wP+V) vs 36.7% (wP+P). Low tumour PTEN expression was associated with longer PFS in the wP+V arm (9.4 vs 4.1m p=0.003) but not in the wP arm (4.8 vs 4.2m p=0.60). Tumour genome-wide copy number (CN) analysis suggested that high CN signature 4 was associated with worse outcome in the wP+P arm (2.3 vs 4.6m p=0.018) but not the wP+V arm (5.4 vs 3.3m). ConclusionsVistusertib did not improve clinical activity of wP in PROC. However, low tumour cell PTEN expression may be a predictive biomarker for vistusertib activity. Translational RelevancePreclinical studies suggest that activation of the PI3K/AKT/mTOR signalling pathway contributes to platinum-resistance in ovarian high grade serous carcinoma (HGSC). Based on activity in a phase I study, we evaluated the clinical efficacy of the dual mTORC1/mTORC2 inhibitor vistusertib in combination with weekly paclitaxel in the OCTOPUS study - a multi-centre, randomised, placebo-controlled, phase II trial in platinum-resistant ovarian (HGSC). In the first randomised trial of weekly paclitaxel and dual mTORC1/2 inhibition in ovarian cancer, vistusertib did not improve clinical activity of weekly paclitaxel. However, translational analyses indicated that low tumour cell PTEN expression may be a predictive biomarker for vistusertib activity. We also showed genome-wide copy number (CN) analysis, in particular high exposure to CN signature 4, may also allow identification of patients with greater chance of benefit from dual mTORC inhibition. Potential predictive biomarkers identified in our study should be evaluated in ongoing/future studies.

ObjectiveDiagnosing ovarian cancer in premenopausal women is challenging due to the rarity of cancer and the ubiquity of symptoms, ovarian cysts on ultrasound, and raised serum CA125 tumour marker levels. We investigated the accuracy of risk prediction models and scores for diagnosing ovarian cancer in premenopausal women presenting to secondary care with symptoms and abnormal tests. MethodsA cohort of premenopausal women presenting with non-specific symptoms, and raised CA125 or abnormal imaging, were prospectively recruited in 23 hospitals in the UK between June 2015 and March 2023, predominantly referred through the NHS urgent suspected cancer pathway from primary to secondary care. A head-to-head comparison of the accuracy of the six risk prediction models and scores was conducted using donated blood and ultrasound scans performed by NHS staff trained in the use of IOTA imaging terminology. Index tests (at pre-stated thresholds) were: RMI1 (200, 250); ROMA (7.4%, 11.4%, 12.5%, 13.1%); IOTA ADNEX (3%, 10%); IOTA SRRisk (3%, 10%); IOTA simple rules; and CA125 (87 IU/ml). Participants were classified as having primary invasive ovarian cancer versus having benign or normal pathology according to the reference standard determined from surgical specimens, biopsies or cytology, by histology if undertaken, or else by 12-month follow-up. After June 2018, because of COVID restrictions and concerns about sample size, ongoing recruitment was restricted to only women undergoing surgery within 3 months of presentation (a selected group in whom ovarian cancer was more likely). ResultsOf 1,211 premenopausal recruited women 88 were diagnosed with primary OC, 857 in the pre-June 2018 cohort (prevalence of 5.7% (49/857)) and 354 in the post-June 2018 cohort 11.0% (39/354). For the diagnosis of primary ovarian cancer, (n=799 women after exclusion of n=58 other diagnoses), RMI1 at the 250 threshold had a sensitivity of 42.6%, 95% confidence interval 28.3 to 57.8, and specificity of 96.5%, 94.7 to 97.8. Compared to RMI1/250, CA125 and all other models had higher sensitivity (CA125: 55.1%, 40.2 to 69.3, p=0.06; ROMA/11.4%: 79.2%, 65.0 to 89.5, p<0.0001; IOTA ADNEX/10%: 89.1%, 76.4 to 96.4, p<0.0001; IOTA SRRisk/10%: 83.0%, 69.2 to 92.4, p<0.0001; IOTA simple rules: 75.0%, 56.6 to 88.5, p=0.01) and lower specificity (CA125: 89.0%, 86.5 to 91.2, p<0.0001; ROMA/11.4%: 73.1%, 69.6 to 76.3, p<0.0001; IOTA ADNEX/10%: 75.1%, 71.4 to 78.6, p<0.0001; IOTA SRRisk/10%: 76.0%, 72.4 to 79.3, p<0.0001; IOTA simple rules 95.2%, 93.0 to 96.9, p=0.06). IOTA simple rules have inconclusive results in 120/799 of the participants. Analysis of the complete cohort (n=1,211) including the 354 premenopausal women with a higher likelihood of ovarian cancer, yielded similar results. ConclusionsCompared to RMI 250, the current test used in NHS secondary care to triage women to tertiary care, most tests improve sensitivity but reduce specificity. Ultrasound triage with the IOTA ADNEX model at 10% in secondary care demonstrated the highest sensitivity gain with a comparable decline in specificity to other comparator tests. Ultrasound with the IOTA ADNEX model at 10% should be considered the new standard of care triage test for premenopausal women in secondary care; implementation in practice should incorporate staff training and quality assurance. Trial registration - ROCkeTS is registered ISRCTN17160843

BackgroundMesonephric-like adenocarcinoma has been recently classified as a rare type of ovarian carcinoma. Description of these tumours have been rare and mostly covered in case reports. In some cases, molecular characterization by sequencing has been employed for guided therapy recommendations, however, functional chemosensitivity testing of targetable pathways using advanced in vitro cellular models such as organoids has not been reported so far. Here, we report on a case of ovarian cancer that was later identified as mesonephric-like adenocarcinoma at an advanced stage. MethodsThe tumour was characterized by molecular techniques including immunohistochemistry and whole-exome sequencing. At the same time, ovarian cancer organoids were established by adapting existing protocols for high-grade serous ovarian carcinoma. The organoids were subsequently used for functional in vitro chemosensitivity testing by treatment with standard-of-care chemotherapeutics cisplatin, paclitaxel, and the Poly (ADP-Ribose) Polymerase 1-inhibitor olaparib. Based on molecular characteristics, we also applied the inhibitor binimetinib, to target Mitogen-Activated Protein Kinase downstream of the KRAS Proto-Oncogene. Additionally, chemotoxicity testing with healthy fallopian tube organoids and high-grade ovarian cancer organoids was applied to determine the therapeutic window. ResultsImmunohistochemical analysis showed characteristic PAX8+, GATA3+, TFF1+, ER-, PR-, WT1- staining while the sequencing revealed mutations in 31 genes of which KRAS G12V and DYNC1H1 G4072S were annotated as (likely) pathogenic. The tumour was mismatch-repair proficient. Tumour-derived organoids proved to be highly resistant to standard-of-care chemotherapeutics cisplatin, paclitaxel, and olaparib, but sensitive to inhibition by binimetinib, which aligned well with the molecular characteristics. Direct comparison to healthy fallopian tube organoids and high-grade ovarian cancer organoids confirmed low cytotoxic potential underlining a feasible therapeutic window for binimetinib. ConclusionsFor the first time, we show that existing protocols for high-grade serous ovarian carcinoma can be used for the generation of organoids derived from mesonephric-like adenocarcinoma. These organoids could be used as an essential tool for functional precision medicine purposes. This functional data could be applied as an additional layer for molecular tumour boards diagnostics by supporting molecular datasets and even identify targetable pathways beyond genetic variations, thus offering novel therapeutic options particularly for rare and aggressive tumours.

Backgroundintroduction of the poly(ADP-ribose) polymerase (PARP) inhibitors to clinical practice remarkably improved outcomes for advanced epithelial ovarian cancer (EOC) patients. We conducted this study to evaluate efficacy of frontline maintenance olaparib therapy in BRCA-mutated and/or HRD-positive EOC patients in real-world practice setting. Patients and methodswe enrolled patients with FIGO stage III-IV high-grade serous or endometrioid EOC with BRCA1/2 mutations and/or HRD-positive status with complete or partial response to frontline therapy, who were treated in 2014-2024. Main objective of this trial was to compare progression-free survival (PFS) of HRD+/BRCA-mutant advanced EOC patients treated with or without maintenance olaparib in well-balanced treatment arms. Cardinality matching was considered to ensure balancing of the study arms with 1:1 ratio of patients in trial arms. The groups were balanced according to the presence of residual tumor after initial treatment, platinum-free interval duration after frontline therapy, secondary local therapy for recurrent disease, treatment with platinum drugs for relapse and subsequent bevacizumab. The primary endpoint of the study was PFS. Resultscardinality matching with 1:1 ratio resulted in 282 matched patients for the analysis. Groups were well balanced in all baseline characteristics. Median age in both treatment arms was 50 years with no differences in patients age, surgical outcomes, prevalence of BRCA-mutated or HRD-positive disease and response to initial platinum-based therapy. With a median follow up of 37.2 mo. median PFS was 38.0 in the olaparib arm and 13.7 mo. in the control arm, respectively (HR 0.32; 95% CI 0.23-0.43; p<0.001). Estimated 3-year PFS was 50.9% and 11.5%, respectively. Median PFS2 was 49.5 mo. in the olaparib arm compared to 34.3 mo. in the control arm (HR 0.58; 95% CI 0.39-0.85; p=0.005). Conclusionthis study confirms the benefits of olaparib maintenance therapy in patients with HRD- -positive and/or BRCA-mutated advanced EOC in real-world setting. HighlightsO_LIUsing cardinality matching two cohorts of patients after frontline therapy were made (treated with maintenance olaparib vs not); C_LIO_LIMedian PFS was 38.0 in the olaparib arm and 13.7 mo. in the control arm, respectively (HR 0.32; 95% CI 0.23-0.43; p<0.001); C_LIO_LIThis data confirms efficacy of maintenance olaparib for BRCA/HRD-positive advanced epithelial ovarian cancer in routine clinical practice. C_LI

BackgroundUp to 74% of patients with cervical cancer (CC) may experience recurrence after their treatment, and most of them are identified late when only the clinical parameters are used, which decreases their chances of recovery. Molecular markers can improve the prediction of clinical outcome and identify therapeutic targets in CC. Glycolysis is altered in 70% of CCs, so it could be a metabolic pathway in which molecular markers associated with the aggressiveness of CC can be identified. MethodsThe expression of 14 glycolytic genes was analyzed in 118 CC samples by microarrays, and only LDHA and PFKP were validated by qRT-PCR (n=58) and in second and third replicates by Western blotting (n=69) and immunohistochemistry (n=18). ResultsLDHA and PFKP were associated with poor overall survival [OS: LDHA HR=3.0 (95% CI= 1.1-8.2); p=2.9 x 10-2; PFKP HR=3.4 (95% CI= 1.1-10.5); p= 3.5 x 10-2] and disease-free survival [DFS: LDHA HR=2.7 (95% CI= 1.6-6.3); p=2.6 x 10-2] independent of FIGO clinical stage. The risk of death was greater when both biomarkers were overexpressed than when using only FIGO stage [HR =7 (95% CI 1.6-31.1, p=1.0 x 10-2) versus HR=8.1 (95% CI=2.6-26.1; p=4.3 x 10-4)] and increased exponentially as the expression of LDHA and PFKP increased. ConclusionsLDHA and PFKP at the mRNA and protein levels were associated with poor overall survival, disease-free survival and increased risk of death of patients with CC regardless of FIGO stage. The measurement of expression of these two markers could be very useful to evaluate the clinical evolution and the risk of death from CC and to make better therapeutic decisions at the beginning of treatment.

Epithelial ovarian cancer (EOC) can be highly lethal, with limited therapeutic options for patients with non-homologous recombination deficient (HRD) disease. Folate receptor alpha (FOLR1/FR)-targeting agents have shown promise both alone and in combination with available therapies, but the relationship of FR to other treatment-driving biomarkers is unknown. The Cancer Genome Atlas (TCGA) was queried to assess protein and mRNA expression and mutational burden in patients with differential FR protein-expressing ovarian tumors, and the results referenced against the standard 324 mutations currently tested through FoundationOne Companion Diagnostics to identify targets of interest. Of 585 samples within TCGA, 121 patients with serous ovarian tumors for whom FR protein expression was quantified were identified. FR protein expression significantly correlated with FOLR1 mRNA expression (p=7.19x10- 14). Progression free survival (PFS) for the FR-high group (Q1) was 20.7 months, compared to 16.6 months for the FR-low group (Q4, Logrank, p=0.886). Overall survival (OS) was 54.1 months versus 36.3 months, respectively; however, this result was not significant (Q1 vs. Q4, Logrank, p=0.200). Mutations more commonly encountered in patients with high FR-expressing tumors included PIK3CA and FGF family proteins. Combinations of FR-targeting agents with PI3K, mTOR, FGF(R) and VEGF inhibitors warrant investigation to evaluate their therapeutic potential. Simple SummaryEpithelial ovarian cancer can be highly lethal, with limited therapeutic options for patients without BRCA mutations or non-homologous recombination deficient disease. Folate receptor alpha (FR)-targeting agents have shown promise in the setting of platinum-sensitive and platinum-resistant ovarian cancer, both alone and in combination with available therapies, but the relationship of FR to other treatment-driving biomarkers is unknown. This study identifies potential targetable mutations in FR-expressing tumors, including PIK3CA and FGF/R family proteins, and provides a basis for future investigations of novel combinations of FR-targeting agents with PIK3CA, mTOR, FGF/R, and VEGF inhibitors.

BACKGROUNDHigh-grade serous ovarian cancer (HGSOC) is characterized by elevated replication stress and an immunosuppressive microenvironment. A synergistic combination of checkpoint kinase 1 inhibitor (CHK1i) with low-dose hydroxyurea (LDHU) promotes a unique ATR-independent moderate replication stress response with potent anti-tumour effects. The ability of this approach to reprogram the tumour immune microenvironment (TIME) to overcome the immunosuppression and promote an anti-tumour immune response in HGSOC is the focus of this study. METHODSWe investigated the therapeutic potential of CHK1i+LDHU in established HGSOC cell cultures, fresh tumour cell explants from HGSOC patient ascites, and syngeneic mouse models, assessing tumour cell killing, immunogenic cell death, pro-inflammatory cytokine/chemokine expression, and anti-tumour immune responses. RESULTSCHK1i+LDHU effectively killed ovarian cancer cells regardless of chemotherapy resistance, BRCA2 mutation and homologous recombination repair status in vitro. In vivo, treatment significantly reduced tumour burden and ascites accumulation. CHK1i+LDHU enhanced expression of pro-inflammatory cytokines/chemokines and triggered immunogenic cell death in tumour. In syngeneic models, treatment promoted CD8+ cytotoxic T cell-dependent anti-tumour responses and reduced immunosuppressive signalling within the TIME. CONCLUSIONSCHK1i+LDHU is a promising therapy for chemotherapy-resistant HGSOC, combining direct cytotoxic effects with reprogramming the TIME to reduce immunosuppression and activate a CD8+ T cell-dependent anti-tumour response.

BackgroundAbout 70% of ovarian cancer (OC) patients relapse after initial chemotherapy, making it crucial to predict survival before second-line treatment. Our previous work discovered a blood-based DNA methylation prognostic signature (PLAT-M8) that uses 8 CpG sites related to chemoresistance. We aim to validate this biomarker and its correlation with clinicopathological features and treatment profiles in additional cohorts. MethodsExtracted DNA from whole blood was provided from the BriTROC 1 (n=47) and OV04 cohorts (n=57) upon the first relapse. Additional samples from Hammersmith Hospital (n=100) were collected during first-line chemotherapy (cycles 3-4 and 6). Bisulphite pyrosequencing was used to quantify DNA methylation at the previously identified 8 CpG sites. The methylation data obtained were combined with previous data from ScoTROC 1D and 1V (n=141) and OCTIPS (n=46). Cox regression was used to assess overall survival (OS) after relapse concerning clinicopathological characteristics. The DNA methylation Class (Class 1 vs 2) was determined by consensus clustering. FindingsBlood DNA methylation at relapse predicts better clinical outcomes. Methylation Class shows no association with outcome during first-line chemotherapy treatment. Methylation Class 1 is associated with shorter survival, as indicated by a meta-analysis of five cohorts (OS: HR 2.54, 1.67-3.85). Class 2 patients on carboplatin monotherapy have the best prognosis, while Class 1 patients on the same treatment have the poorest prognosis (OS: aHR 9.69, 2.38-39.47). Class 1 is linked to older patients (>75 years) with advanced-stage, platinum-resistant cases, correlating with residual disease, and shorter progression-free survival. In contrast, Class 2 of PLAT-M8 is linked to platinum-sensitive patients, and higher complete response rates by RECIST criteria, but shows no correlation with CA-125. These findings emphasise the potential of PLAT-M8 in guiding second-line chemotherapy decisions. InterpretationPLAT-M8 methylation biomarker is associated with survival in OC patients with relapse and hypothetically may predict platinum treatment response at second-line chemotherapy. FundingThis work was supported by funding from Ovarian Cancer Action ("Risk and Prevention" programme grant), Cancer Research UK programme grant (A13086) with support from the Cancer Research UK Imperial Centre, the National Institute for Health Research Imperial Biomedical Research Centre and the Ovarian Cancer Action Research Centre. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSThere is a strong association between platinum-based chemotherapy and DNA methylation changes in blood DNA during ovarian cancer relapse. Previous findings identified eight specific CpG methylation changes (known as PLAT-M8) in blood at relapse following platinum-based chemotherapy that were associated with overall survival in patients enrolled in the ScoTROC 1 trial and the OCTIPS cohort. Using an ovarian cancer cell line model, the study also showed that functional DNA mismatch repair increased the frequency of platinum-induced methylation, providing insights into the observed epigenetic changes. Added values of this studyOur current study validates in five large relapsed ovarian cancer cohorts that: (1) PLAT-M8 is associated with various clinicopathological characteristics, such as age, stage, platinum sensitivity, RECIST response, and progression time; (2) PLAT-M8, particularly from blood samples taken at the time of the first relapse before second-line chemotherapy, can serve not only as prognostic indicators for overall survival but also time to death after relapse in ovarian cancer patients; (3) PLAT-M8 does not have prognostic value when blood samples are taken during first-line chemotherapy before relapse, after initial diagnosis; and (4) PLAT-M8 may stratify overall survival and time to death after relapse based on the second-line treatment received by patients. These findings pave the way for our ongoing research, showcasing the potential of this non-invasive approach in predicting second-line treatment response, guiding decisions, and enhancing outcomes for relapsed ovarian cancer patients. Implications of all the available evidenceThe lack of biomarkers guiding treatment decisions during second-line therapy highlights the need for more reliable biomarkers. As a prognostic biomarker, PLAT-M8 is considered simple yet impactful, as it only requires one blood sample taken before second-line treatment at the time of relapse. The advantages of this research include developing personalised treatment approaches, minimizing side effects and wasted time from ineffective medications, reducing the likelihood of subsequent relapse episodes, and improving clinical outcomes for patients. Ultimately, the use of biomarkers has the potential to reduce hospital stays and healthcare costs by optimizing treatment effectiveness and efficiency, while also enhancing the quality of life for patients.

BackgroundUveal melanoma is an aggressive ocular malignancy. Early molecular characterisation of primary tumours is crucial to identify those at risk of metastatic dissemination. Although tumour biopsies are being taken, liquid biopsies of ocular fluids may form a less invasive but relatively unexplored alternative. In this study, we aim to evaluate the DNA content of vitreous fluid from eyes with a uveal melanoma to obtain molecular information from the tumour. MethodsDNA was isolated from 65 vitreous fluid samples from enucleated eyes with a uveal melanoma and studied using digital PCR. Primary and additional driver mutations (in GNAQ, GNA11, PLCB4, CYSLTR2, BAP1, SF3B1 and EIF1AX) were investigated using accustomed targeted and drop-off assays. The copy numbers of chromosome 3p and 8q were measured using multiplex and single-nucleotide polymorphism-based assays. Our findings were compared to the molecular profile of matched primary tumours and to the clinicopathological tumour characteristics. ResultsAlmost all (63/65) vitreous fluids had measurable levels of DNA, but melanoma-cell derived DNA (containing the primary driver mutation) was detected in 39/65 samples (median proportion 18%, range 0.2%-94%) and was associated with a larger tumour prominence, but not with any of the molecular tumour subtypes. Among the vitreous fluids with melanoma-cell derived DNA, not all samples harboured (analysable) other mutations or had sufficient statistical power to measure copy numbers. Still, additional mutations in BAP1, SF3B1 and EIF1AX were detected in 13/15 samples and chromosome 3p and 8q copy numbers matched the primary tumour in 19/21 and 18/20 samples, respectively. Collectively, a clinically-relevant molecular classification of the primary tumour could be inferred from 27/65 vitreous fluids. DiscussionThis proof-of-concept study shows that substantial amounts of DNA could be detected in vitreous fluids from uveal melanoma patients, including melanoma-cell derived DNA in 60% of the samples. Prognostically-relevant genetic alterations of the primary tumour could be identified in 42% of the patients. A follow-up study is needed to evaluate our approach in a prospective clinical context.

BackgroundLow-grade serous ovarian carcinoma (LGSOC) is a distinct, under-investigated and relatively chemotherapy-resistant ovarian cancer type. Understanding the molecular landscape is crucial to maximise the impact of molecularly-targeted therapy. MethodsWhole exome sequencing and copy number data were integrated with histopathological patterns, ER/PR expression, and detailed clinical annotation, including survival, in a carefully curated LGSOC cohort. Results63 tumours were analysed in the largest comprehensive genomic LGSOC study to date. Three genomic subgroups were identified: canonical MAPK mutant (cMAPKm: 52%, KRAS/BRAF/NRAS), MAPK-associated mutation (27%, 14 MAPK-associated genes) and MAPK wild-type (MAPKwt: 21%). MAPKwt patients were younger at diagnosis (median 47 versus 62 years in the cMAPKm subgroup) and demonstrated shorter survival [multivariable HR (mHR) 4.17]. The inferior survival in the MAPKwt subgroup was due to shorter post-relapse survival (mHR 5.22) rather than shorter time to first progression (mHR 1.15). Patients in the MAPK-associated mutation subgroup had similar survival to cMAPKm cases. The cMAPKm subgroup more frequently demonstrated macropapillary invasion. Desmoplasia and micropapillary invasion were independently associated with poor survival. NOTCH pathway activation occurred independently of MAPK subgroup. ConclusionsLGSOC comprises multiple genomic subgroups with distinct clinical, molecular and histopathological features. True MAPKwt cases represent around a fifth of patients: they are younger but have poorer survival. New therapeutic strategies with activity in this subgroup are urgently required. NOTCH inhibitors represent a therapeutic strategy worthy of exploration.

Backgroundrecurrent ovarian cancer (OC) patients with platinum-free interval (PFI) <6 mo. are usually considered platinum-resistant and treated with non-platinum based chemotherapy. However, this was never confirmed in proper-conducted randomized trials. Methodswe queried the PubMed database for all full-text articles and abstracts on the treatment of patients with platinum-resistant ovarian cancer (PROC) in 01/01/2000-01/06/2019 timeframe. The PRISMA tool was used to ensure transparent reporting of the results. Inclusion criteria were: 1) morphologically confirmed epithelial ovarian cancer; 2) recurrent disease within 6 months after completion of platinum-based chemotherapy; 3) treatment with platinum- or non-platinum chemotherapy with agents that are routinely used for OC; 4) no concomitant therapy with targeted or investigational agents or non-platinum doublets; 5) defined response rate (RR) and assessment criteria. Proportion meta-analysis (random-effect model) and beta-regression were conducted to assess the impact of platinum agents on response rate as well as significance of other variables. In the beta-regression model response rate was a dependent variable, while platinum agents (yes or no), used non-platinum drugs and method of response assessment were independent variables. Statistical analysis was dose with meta, metafor and betareg packages of R software. Resultswe identified 7156 articles and screened them for title and abstract, 157 studies for further analysis. Overall, 6327 patients were included in the analysis, efficacy of non-platinum- and platinum-based therapy was assessed in 113 (n = 5272) and 44 (n = 1055) trials respectively. In meta-proportion random-effect model RR among patients treated with platinum-based and non-platinum chemotherapy RR was 36% (95% CI 30-41; I2 = 62%) and 16% (95% CI 14-19; I2=70%) respectively. For sensitivity analysis various regression models were made with different subsets of the trials and additional variables (including year of the trial, percentage of serous subtype of OC and median of prior therapy lines). Platinum was the strongest predictor of response in every developed model. Conclusionthis meta-analysis shows that patients with platinum-resistant ovarian carcinoma may derive significant benefit from reintroduction of platinum agents. These results support recent ESMO-ESGO consensus on treatment of recurrent ovarian cancer.

BackgroundOvarian cancer treatment includes cytoreductive surgery, platinum-based chemotherapy, and often poly (ADP-ribose) polymerase (PARP) inhibitors. Homologous recombination (HR)-deficiency is a well-established predictor of therapy sensitivity. However, over 50% of HR-proficient tumors also exhibit sensitivity to standard-of-care treatments. Currently, there are no biomarkers to identify which HR-proficient tumors will be sensitive to standard-of-care therapy. Replication stress may serve as a key determinant of response. MethodsWe evaluated phospho-RPA2-T21 (pRPA2) foci via immunofluorescence as a potential biomarker of replication stress in formalin-fixed, paraffin-embedded tumor samples collected at diagnosis from patients treated with platinum chemotherapy (discovery cohort: n = 31, validation cohort: n = 244) or PARP inhibitors (n = 87). Recurrent tumors (n = 37) were also analyzed. pRPA2 scores were calculated using automated imaging analysis. Samples were defined as pRPA2-High if > 16% of cells had [&ge;] 2 pRPA2 foci. ResultsIn the discovery cohort, HR-proficient, pRPA2-High tumors demonstrated significantly higher rates of pathologic complete response to platinum chemotherapy than HR-proficient, pRPA2-Low tumors. In the validation cohort, patients with HR-proficient, pRPA2-High tumors had significantly longer survival after platinum treatment than those with HR-proficient, pRPA2-Low tumors. Additionally, the pRPA2 assay effectively predicted survival outcomes in patients treated with PARP inhibitors and in recurrent tumor samples. ConclusionOur study underscores the importance of considering replication stress markers alongside HR status in therapeutic planning. Our work suggest that this assay could be used throughout a patients treatment course to expand the number of patients receiving effective therapy while reducing unnecessary toxicity.

BackgroundClear cell carcinomas (CCCs) are a distinct histopathological subtype defined by a clear cytoplasm comprised of glycogen and lipids and characterised by poor prognosis and widespread chemoresistance. In the present work we investigate glycogen metabolism as a targetable modality for these cancers. Methods and ResultsAdopting the indole carboxamide site pan-glycogen phosphorylase inhibitor CP91149 against clear cell ovarian and renal cancer cell line models, we note antiproliferative and antimigratory effects, as well as energetic stress reflected by reduced ATP pools and increased superoxide-derived reactive oxygen species. Following this, using the agent alongside standard of care chemotherapies for clear cell ovarian (ccOC) and renal cell carcinoma (ccRCC), we note specific synergy with microtubule disrupting chemotherapy paclitaxel, a phenomenon retained in ccOC lines made stably resistant to paclitaxel. Rescue experiments, as well as phenotypic assays suggest that combination-treated cells undergo ferroptotic cell death. We postulate this synergistic efficacy to arise from subjecting the already hypersensitive clear cell cancers to the mitochondrial stress elicited by taxol chemotherapy alongside the oxidative stress augured by glycogen phosphorylase inhibition. ConclusionsGiven that CCCs are widely chemoresistant, the present work potentially presents a novel therapeutic avenue for this shared histotype.

ObjectivesThe COVID-19 pandemic profoundly affected healthcare systems and patients. There is a pressing need to comprehend the collateral effects of the pandemic on noncommunicable diseases. Here we examined the impact of the COVID-19 pandemic on shortterm cancer survival in the United Kingdom (UK). We hypothesised that short-term survival from nine cancers would be reduced during the pandemic, particularly cancers that benefit from screening and early detection (e.g., breast and colorectal cancer). DesignPopulation-based cohort study. SettingElectronic health records from UK primary care Clinical Practice Research Datalink (CPRD) GOLD database. ParticipantsThere were 12,259,744 eligible patients aged [&ge;]18 years with [&ge;]one year of prior history identified from January 2000 to December 2021. Main outcome measuresWe estimated age-standardised incidence rates (IR) and short-term (one- and two-year) survival of several common cancers (breast, colorectal, head and neck, liver, lung, oesophagus, pancreatic, prostate, and stomach cancer) from 2000 to 2019 (in five-year strata) compared to 2020 to 2021 using the Kaplan-Meier method. ResultsApart from pancreatic cancer, IRs decreased for all cancers in 2020 and recovered to different extents in 2021. Short-term survival improved for most cancers between 2000 to 2019, but then declined for those diagnosed in 2020 to 2021.This was most pronounced for colorectal cancer, with one-year survival falling from 79.3% [95% confidence interval: 78.5%-80.1%] in 2015 to 2019 to 76.3% [74.6%-78.1%] for those diagnosed in 2020 to 2021. ConclusionShort-term survival for many cancers was impacted by the management of the COVID-19 pandemic in the UK. This decline was most prominent for colorectal cancer, with reductions in survivorship equivalent to returning to mortality seen in the first decade of the 2000s. These results illustrate the need for an immediate and well-funded investment in resolving the current backlog in cancer screening and diagnostic procedures in the UK National Health Service to improve patient outcomes.

BackgroundMutations in UGT1A gene have been associated with the development and prognosis of urinary bladder cancer (UBC). UGT1A proteins are involved in a spectrum of detoxification processes, hence the biological mechanism between UGT1A and UBC is difficult to elucidate. Concurrently, mild hyperbilirubinemia, caused by alterations in UGT1A, has been associated with multiple health outcomes. We have investigated the potential effect of mild hyperbilirubinemia on UBC risk and prognosis, using a Mendelian Randomization (MR) approach in the UK Biobank. MethodsData on 1,281 UBC patients and 4,071 controls was available for a two-stage least squares MR estimation with rs6742078 as an instrumental variable. First, linear regression was fitted to establish the relationship between the rs6742078 and bilirubin levels (total and unconjugated). Secondly, bilirubin values were used to predict tested outcomes under a logistic model. Both stages were adjusted for participant sex, smoking status, and age. ResultsMR analysis showed no significant effects of bilirubin levels on UBC risk (total bilirubin: OR=1.02, 95% CI: 0.99-1.04; unconjugated bilirubin: OR=1.02, 95% CI: 0.99-1.05). No effects were observed for events of UBC recurrence, progression, or survival. ConclusionOur study suggests mild hyperbilirubinemia is not associated with urinary bladder cancer risk and prognosis.

Hormone replacement therapy (HRT) with oestrogen and progestogen is a common medical treatment for alleviating symptoms of menopause. Since 2015, its use has been increasing in the UK. Unscheduled bleeding can be a symptom of endometrial cancer, and guidelines state that women experiencing this should have an urgent referral for suspected endometrial cancer. However, unscheduled bleeding is also common in women taking HRT, particularly in the first few months after starting HRT or if there is a change in regimen. Current guidelines may result in women on HRT receiving referrals that are not necessary and undergoing unpleasant and invasive tests such as hysteroscopy. However, there is a lack of current information to guide recommendations. This protocol describes a cohort study in the ORCHID-e database of anonymised patient records from English primary care. We will use a cohort of women aged over 40 years starting on HRT with oestrogen and progestogen, age matched to women who have not started HRT. Exposure will be a prescription for oestrogen containing HRT with no previous prescription for oestrogen containing HRT in the previous year. Index date in each matched set will be the date of this prescription. Prescriptions for progestogen containing drugs will not be used to define the exposure, but this information will be extracted to describe the study population and for sensitivity analyses. Outcomes will be consultations for unscheduled bleeding, urgent referrals for suspected endometrial cancer, and diagnosis of endometrial cancer. Women will be followed up until they change exposure status or are otherwise censored. Women who start taking HRT in follow-up will re-enter the cohort in the exposed group. We will describe proportions of women with a code for consulting with unscheduled bleeding, proportions of those women referred for further investigation on the pathway for suspected endometrial cancer, and proportions diagnosed with endometrial cancer within one year of referral. We will investigate the diagnostic accuracy of unscheduled bleeding for endometrial cancer separately for women on HRT and those not on HRT. Analyses will be done by 6-month categories of time since index, age, calendar year, sociodemographic variables, risk factors for endometrial cancer, type of HRT.

BackgroundWe previously established an ovarian carcinoma (OC) BRCA-like genomic copy number aberration profile classifier ("BRCA-like classifier"), which identifies tumors with deleterious mutations and epigenetic alterations in the homologous recombination pathway (1). We explored whether the classifier may also be predictive for therapies targeting tumors with homologous recombination deficiency (HRD) such as olaparib, a PARP inhibitor with synthetic lethal interaction with HRD, in combination with bevacizumab. MethodsAs part of the ENGOT (European Network of Gynaecological Oncological Trial groups) HRD initiative, the OC BRCA-like classifier was evaluated using tumor-derived DNA samples from 469 out of 806 patients enrolled in the PAOLA-1/ENGOT-ov25 trial. PAOLA-1 is a randomized, double-blind, international phase 3 trial (NCT02477644) including advanced high grade OC patients. Prolonged progression-free survival (PFS) and overall survival (OS) was observed for patients treated with maintenance olaparib and bevacizumab versus placebo and bevacizumab, and particularly for those patients tested HRD positive according to Myriad MyChoice(R) CDx HRD test. ResultsResults were obtained for 442 patients (failure rate of 6%, 27 of 469 samples). A survival benefit from adding maintenance olaparib was observed in the 298 (67%) patients with a BRCA-like tumor (hazard ratio (HR) for PFS: 0.49, 95% confidence interval (CI) 0.37-0.65, p = 0.01; OS: 0.64, 95% CI 0.45-0.90, p < 0.01). No benefit was detected in patients with a non-BRCA-like tumor when treated with olaparib (HR for PFS: 1.02, 95% CI 0.68-1.51, p = 0.93; OS 1.48, 95% CI 0.94-2.33, p = 0.09). P values for interaction between BRCA-like status and olaparib for PFS and OS were both 0.004. Multivariate analysis revealed comparable results. The concordance rate with the Myriad test was 77% in samples that were successfully analysed with both assays. In the survival analyses, the CIs of the BRCA-like classifier and the Myriad test overlap. ConclusionThe BRCA-like classifier is a high-sensitive predictive biomarker for survival benefit of olaparib/bevacizumab as maintenance therapy in advanced ovarian carcinoma with a low drop-out rate.

BackgroundProstate cancer (PCa) is one of the most common cancers globally. The potential for polygenic risk scores (PRSs) to improve risk stratification for early detection of PCA in screening interventions is of considerable interest. We evaluated the cost- effectiveness of PRS-guided screening strategies. MethodsThe Prostata microsimulation model, calibrated to UK-specific epidemiological and clinical data, simulated individual life histories, including disease onset and progression, tumour characteristics by Gleason score, and metastatic status. The model incorporated both measured and unmeasured components of polygenic risk for incident PCa, and included ancestry-specific strata. Screening strategies were compared against a no-screening baseline. We modelled one-off, age-based prostate specific antigen screening at 50, 60, or 70 years, as well as repeated uniform screening every 4 or 2 years from age 50 to 69 with and without PRS stratification. ResultsQuality-adjusted life years were similar across all screening strategies, while differences in costs were more pronounced. A "no screening" strategy had the lowest lifetime cost of all strategies and (very marginally) the shortest life expectancy. Realistic PRS implementations were dominated (less effective and more expensive) in all scenarios, and may not provide greater cost-effectiveness than a single PSA screen at age 50 or compared to no screening at all. ConclusionOur study found little evidence that PRSs would be cost-effective in pragmatic PCa screening settings.

BackgroundPlatelet count and C-reactive protein (CRP) are blood tests commonly used in primary care as part of diagnostic work up for symptomatic patients. Abnormal results of these tests can indicate an undetected cancer; however, it is not known whether the association between an abnormal test result and cancer risk varies by patient ethnicity. MethodsThis cohort study used routinely collected primary and secondary health care records in England with linkage to national cancer registry data. Included patients had a record of ethnicity, no prior malignancy, a platelet count or CRP record between 1st January 2010 and 31st December 2017, and were aged 40 years or over at the time of that test. Ethnicity was categorised as White, Asian, Black, Other, and Mixed. Multi-level logistic regression models estimated cancer incidence within one-year of testing, adjusted for age, sex, comorbidities, BMI, deprivation, and year of test. ResultsAmong 4,948,342 patients with a platelet record and 811,559 with a CRP record, one-year cancer incidence was highest among White patients and lowest among Asian patients. Following a normal platelet count, cancer incidence was 1.3% (95% CI 1.3-1.3%) for White patients and 0.63% (0.60-0.66%) for Asian patients; following thrombocytosis, incidence increased to 4.1% (4.0-4.2%) and 1.8% (1.5-2.0%), respectively. After a normal CRP result, cancer incidence was 1.5% (1.4-1.5%) for White patients and 0.79% (0.71-0.88%) for Asian patients, rising to 3.6% (3.5-3.7%) and 1.9% (1.7-2.2%) for a high CRP result, respectively. No significant interactions were found between ethnicity, blood test result, and overall cancer diagnosis, and similar diagnostic odds ratios (dOR) were observed across all ethnic groups. However, for colorectal cancer, Black patients with abnormal results showed higher diagnostic odds ratios (dOR) compared with White patients, relative to a normal result. The dOR for thrombocytosis was 11.1 (7.8-15.6) for Black patients versus 5.7 (5.4-6.0) for White patients (interaction p-value <0.001), and for raised CRP was 4.1 (2.6-6.6) for Black patients versus 2.5 (2.3-2.7) for White patients (interaction p-value=0.043). ConclusionThis large primary care study underscores the need for ethnically diverse cohorts when evaluating diagnostic tests to avoid widening healthcare inequalities.