1. 1 RTOG 1115 Fatigue: Assessments & Considerations Mylin A. Torres, M.D.

2. 2 Background Fatigue is a frequent, distressing symptom related to cancer and its treatment Fatigue has profound effects on daily functions and activities 2.3 million survivors of prostate cancer Most of the research has been conducted in survivors of breast cancer

3. 3 Background Up to 80% of prostate cancer patients develop fatigue during radiotherapy (RT) As many as 40% of patients report clinically relevant fatigue 1 year after completing RT

4. 4 Background Up to 80% of prostate cancer patients develop fatigue during radiotherapy (RT) As many as 40% of patients report clinically relevant fatigue 1 year after completing RT However, fatigue has been rarely studied in patients undergoing combined RT and androgen deprivation therapy (ADT)

5. 5 Background Fatigue is one of the most common adverse effects of TAK-700 Phase I/II clinical trials in men with metastatic prostate cancer treated with TAK-700 found that fatigue developed in 16 of 26 patients with metastatic castration-resistant prostate cancer, but only one of these patients developed > Grade 3 fatigue

6. 6 Background The high prevalence of fatigue after combined modality therapy for prostate cancer and its association with poor quality of life mark it as a significant problem that requires further study

7. 7 Primary Objective To evaluate the difference in overall survival in men with clinically localized prostate cancer between a) standard treatment (ADT + RT) and b) standard treatment with the addition of 24 months of TAK-700

8. 8 Secondary Objective: Fatigue To measure the change in severity of fatigue from baseline to 1 year, as measured by PROMIS

9. 9 PROMIS Developed by the Patient-Reported Outcome Measurement Information System (PROMIS) Network Short Form consists of 7 items which were selected for consistency in the response scale, broad coverage across the fatigue continuum, and good precision of measurement The criteria for a minimally clinically important difference in patients with advanced-stage cancer is a 3 to 5 point difference in raw score

10. 10 PROMIS

11. 11 PROMIS Raw scores are converted to T-scores which rescale the raw score into a standardized score with a mean of 50 and a standard deviation of 10. A higher PROMIS T-score means more fatigue

12. 12 Fatigue Correlate Measures: Depression (EQ-5D)

13. 13 Fatigue Correlate Measures: Godin- Leisure Time Exercise Questionnaire

14. 14 Timing of Fatigue Assessments PROMIS-Fatigue EQ-5D PSQI GLTEQ Blood: 1. DNA* 2. Inflammatory Markers 3. NF-kB DNA Binding Baseline 1 wk prior to XRT Last wk of XRT 12mos post ADT start 30 mos post ADT start Prostate Cancer N=410 initially mandatory Legend: PROMIS-Fatigue (Patient-Reported Outcome Measurement Information System.; EQ-5D – EuroQol (Anxiety/Depression Item); PSQI – Pittsburgh Sleep Quality Index; GLTEQ – Godin Leisure-Time Exercise Questionnaire – level of physical activity measured using 3 items; ADT – androgen deprivation therapy *If site missed this collection time point, they may collect this specimen at any other time point. PROMIS-fatigue EQ-5D PSQI GLTEQ PROMIS-fatigue EQ-5D PSQI GLTEQ PROMIS-fatigue EQ-5D PSQI GLTEQ Blood: 1. Inflammatory Markers 2. NF-kB DNA Binding PROMIS-fatigue EQ-5D PSQI GLTEQ Blood: 1. Inflammatory Markers 2. NF-kB DNA Binding

15. 15 Timing of Fatigue Assessments PROMIS-Fatigue EQ-5D PSQI GLTEQ Blood: 1. DNA* 2. Inflammatory Markers 3. NF-kB DNA Binding Baseline 1 wk prior to XRT Last wk of XRT 12mos post ADT start 30 mos post ADT start Prostate Cancer N=410 initially mandatory Legend: PROMIS-Fatigue (Patient-Reported Outcome Measurement Information System.; EQ-5D – EuroQol (Anxiety/Depression Item); PSQI – Pittsburgh Sleep Quality Index; GLTEQ – Godin Leisure-Time Exercise Questionnaire – level of physical activity measured using 3 items; ADT – androgen deprivation therapy *If site missed this collection time point, they may collect this specimen at any other time point. PROMIS-fatigue EQ-5D PSQI GLTEQ PROMIS-fatigue EQ-5D PSQI GLTEQ PROMIS-fatigue EQ-5D PSQI GLTEQ Blood: 1. Inflammatory Markers 2. NF-kB DNA Binding PROMIS-fatigue EQ-5D PSQI GLTEQ Blood: 1. Inflammatory Markers 2. NF-kB DNA Binding

16. 16 Hypothesis Change in PROMIS fatigue scores between baseline and 1 year will not differ significantly between the control group and the experimental group receiving both a GnRH agonist and TAK-700

17. 17 Fatigue: Inflammatory Mechanisms & Mediators

18. 18 Macrophage Local Systemic Local Effects - Increased vascular permeability - Vasodilation - Chemokine production - Expression of adhesion molecules - Pain Effects on Brain - Fever - Fatigue - Anorexia - Anhedonia - Altered sleep Innate Immunity/Inflammation Acute Phase Response - C-reactive protein - serum amyloid A Effects on Liver Chemokines Stromal cell Endothelial cell TNF, IL-1, IL-6 IFN-alpha Adhesion molecules Leukocyte Diapedesis Toll-like receptors (TLRs) Antigen (e.g. bacteria, ADT) TNF IL-1 IL-6 IFN-alpha NF-κB sickness behavior tumor rubor calor dolor Conservation of energy resources to promote increased metabolic demands of fighting infection and mounting a fever Courtesy of Andrew H. Miler M.D.

19. 19 Fatigue & Inflammation Growing evidence that pro-inflammatory cytokines play a role in cancer-related fatigue Most commonly implicated cytokines are IL-1, IL-6, TNF alpha, sTNFr2, and IFN alpha with the majority of data from breast cancer studies

20. 20 Fatigue & Inflammation Growing evidence that pro-inflammatory cytokines play a role in cancer-related fatigue Most commonly implicated cytokines are IL-1, IL-6, TNF alpha, sTNFr2, and IFN alpha with the majority of data from breast cancer studies Small pilot studies of circulating cytokines, RT, and fatigue in men with prostate cancer, but there is very little data on the relationship between circulating inflammatory markers and fatigue in men undergoing ADT

21. 21 Fatigue, Inflammatory Markers, and Radiation Bower et al. Clinical Cancer Research 2009

22. 22 Single Nucleotide Polymorphisms and Fatigue SNPs in the promoters of cytokine genes, IL6, IL1, and TNF alpha have been associated with fatigue in breast and prostate cancer survivors SNPs found in genes integral to the inflammatory response will be assessed to identify patients at risk for fatigue development

23. 23 Single Nucleotide Polymorphisms, ADT, & Fatigue Jim et al. Brain, Behavior, and Immunity 2012

24. 24 Single Nucleotide Polymorphisms, ADT, & Fatigue Jim et al. Brain, Behavior, and Immunity 2012

25. 25 NF-Kappa B NF-Kappa B DNA Binding has been found to correlate with fatigue in women undergoing breast RT Increased transcripts with response elements for Nf-kappa B previously found in fatigued vs. non-fatigued breast cancer survivors

26. 26 1.Collect ~6 ml whole blood with purple top tube 2.Dilute blood 1:1 with phosphate buffered saline (PBS) 3.Carefully add diluted blood on top of lymphocyte separation medium (LSM, aka Ficoll), avoid mixing 4.Centrifuge (see before/ after figure at right). 5.Collect PBMCs 6.Wash PBMCs twice with PBS 7.Store PBMCs in freezing serum at -80°C 8.Refer to detailed protocol for more information B = Whole Blood F = Ficoll (aka Lymphocyte Separation Medium) P = Plasma W = PBMCs R = Red Blood Cells/Ficoll mixture Before After Before and After Centrifugation (Step 4) PBMC Isolation

27. 27 Fatigue & Inflammation Activation of the inflammatory response may be a fundamental consequence of ADT and RT leading to fatigue

28. 28 Clinical Relevance 1.Inform patients and providers about the trade-off between QOL and enhanced survival. 2.Longitudinal research in cooperative group setting provides an ideal platform to study the natural history of cancer-related fatigue and confirm the association between inflammatory markers and fatigue in the context of combined therapy for prostate cancer 3.Findings from this research could inform the timing of intervention to alleviate fatigue 4.Findings may facilitate rational, evidence-based intervention for cancer-related fatigue.

29. 29 Thank You

30. 30 Inflammatory Markers 5 mL of anticoagulated whole blood in EDTA tube (purple/lavender top) Centrifuge within one hour of collection in a standard clinical centrifuge at ~2500 RPM for 10 minutes at 4 degrees celsius preferred Submit as frozen plasma samples containing 0.5mL per aliquot in 1mL cryovials (5 to 10) Send on dry ice via overnight carrier to the RTOG Biospecimen Resource

31. 31 NF-κB DNA binding ELISA Active Motif Peripheral Blood Mononuclear Cells p65/p50

32. 32 1.Lymphocyte separation medium, 100 ml 2.1 X PBS, 500 ml 3.Pack of 50 ml conical tubes (8 per pack) 4.Pack of 15 conical tubes (32 per pack) 5.Blunt transfer pipettes (8 per pack) 6.Thin tip transfer pipettes (8 per pack) 7.Freezing serum, 12 ml 8.2 ml cryovials (8 per pack) PBMC Kit Contents

33. 33 SNP Analysis DNA will be extracted from whole blood. Send on dry ice via overnight carrier to the RTOG Biospecimen Resource Center DNA will be extracted from the buffy coat

34. 34 Fatigue & Prostate Cancer Survivors Krydalen et al. The Prostate 2010