>> GLAD TO BE HERE AGAIN. THIS TAPESTRY ACTUALLY WAS WOVEN BY CLAIRE AND DENISE, AND ABOUT 10 YEARS AGO, THAT'S OBVIOUSLY A DNA STRAND. SO I'M GOING TO TALK ABOUT INFLAMMATION AND MICRO RNA, FREE RADICALS, SO CHRONIC INFLAMMATION AND INFECTION CAN INCREASE CANCER RISK, CAN BE LARGELY INHERITED, FOR EXAMPLE, HUMAN CHROM CHROATOSIS, INFLAMMATORY BOWEL DISEASE HAS A GENETIC COMPONENT, BUT THE VAST MAJORITY OF THE INFLAMMATION RELATED OR INFECTION RELATED CANCERS ARE DUE TO ACQUIRED INFECTIONS OR VIRUSES, BACTERIA, PARASITES, BUT MORE RECENTLY, IT'S BEEN RECOGNIZED THAT CHEMICAL, PHYSICAL AND METABOLIC CONDITIONS ARE ALSO CONDITIONS THAT CAUSE INFLAMMATION AND INCREASE CANCER RISK. A LITTLE LESS THAN A DECADE AGO, BERNIE STIRRIT AND PAUL ESTIMATED IN THE WORLD CANCER REPORT THAT'S PUBLISHED ABOUT EVERY TWO YEARS THAT ABOUT 18% OF HUMAN CANCERS OVER A MILLION AND A HALF A YEAR, ARE RELATED TO INFECTION. I DON'T WANT TO GIVE YOU THE IMPRESSION THAT ALL INFECTIONS ARE ASSOCIATED WITH CANCER OR ALL INFLAMMATORY DISEASES ARE ASSOCIATED WITH THE INCREASED RISK OF CANCER. FOR EXAMPLE, RHEUMATOID ARTHRITIS IS AN EXAMPLE OF CHRONIC INFLAMMATION DISEASE. IT HAS A SLIGHT INCREASE IN BRAIN DUE MORES BUT CERTAINLY NOT AN INCREASE IN SARCOMAS AT JOINTS AND WHERE MOST OF THE INFLAMMATION ARISES. HUMAN PAPILLOMA VIRUS IS NOT A VERY PRO-INFLAMMATORY AGENT, BUT IT MAY INTERACT WITH OTHER MICRO-ORGANISMS WHICH ARE HIGHLY INFLAMMATORY. SO I SAID OBESITY IS A GROWING CONCERN IN REGARDS TO IN DISEASE OF VARIOUS KINDS. THIS IS A CARTOON OUT OF "THE ECONOMIST" A FEW YEARS AGO, AND THAT'S MORE LIKE ME THAN THAT PERSON. OBESITY IS A CHRONIC INFLAMMATORY DISEASE. THE LANDMARK PAPERS THAT POINTED THIS OUT WERE IN 2003, IN WHICH BOTH OF THESE AUTHORS DESCRIBE THAT IN FAT, ONE FINDS AN INCREASE IN MACROPHAGES, AND THAT THESE MACROPHAGES INFILTRATE THE FAT, THEY'RE ACTIVATED AND THEY FORM PRO INFLAMMATORY LOOPS WITH DIPOCYTES, BUT THEY ALSO PRODUCE FREE RADICALS OF VARIOUS KINDS, THEY CAN BE EITHER OXYGEN-BASED FREE RADICALS OR NITROGEN BASE FREE RADICALS SUCH AS NITRIC OXIDE WHICH HAS A MUCH LONGER HALF-LIFE THAN THE OXYGEN-BASED FREE RADICALS. THESE FREE RADICALS CAN DIRECTLY DAMAGE DNA AND IF THAT DAMAGE ISN'T REMOVED, IT CAN CAUSE MUTATION, MOVED BY BASIC -- REPAIR BUT FREE RADICALS ALSO DAMAGE PROTEINS OF VARIOUS KINDS, INCLUDING DNA REPAIR PROTEINS AND ALSO CAPASES INVOLVED. THERE ARE INDIRECT EFFECTS OF FREE RADICALS, THOUGH, THEY CAN BE DNA OR THEY CAN LEAD TO LIPID OXIDATION AND -- AGAIN, REMOVED BY BASE BASE EXCISION REPAIR. GOES THROUGH COX 1 AND COX 2 AND CAN LEAD TO A NUMBER OF PHENOTYPIC EFFECTS INCLUDING CELL PROLIFERATION. THERE'S A CONNECTION BETWEEN THE NITRIC OXIDE PATHWAY AND THE COX 2 PATHWAY, AND THIS WAS ORNLLY ORIGINALLY DISCOVERED IN PAUL SNYDER'S LAB AT JOHNS HOPKINS IN BALTIMORE. AND THE TITLE MORE OR LESS SAYS IT. INDUCIBLE NITRIC OXIDE SYNTHASE BINDS TO S-NITROSYLATES AND ACTIVATES CYLOOXYGENASE-2. SO AGAIN, PHYSICAL INTERACTION LEADING TO FURTHER INCREASE IN COX-2. NOW LET ME GIVE YOU AN EXAMPLE OF A STUDY THAT WAS DONE IN OUR GROUP BY HERO, AND THAT'S USING AN ANIMAL MODEL, AND I'LL USE THE ANIMAL MODEL EXAMPLE BEFORE GOING TO THE CLINICAL STUDIES. THIS IS A WELL-KNOWN MODEL FOR LUNG CANCER THAT WAS DEVELOPED WHICH IS MUTATED BY KRAS, AND THE QUESTION THAT HERO ASKED IS WHETHER OR NOT NITRIC OXIDE ENHANCES KRAS-INDUCED TUMORIGENESIS AND INFLAMMATION. FIRST OF ALL HE AND PERVEZ ACTUALLY MADE INBRED STRAINS AND PUT THE KRAS INTO C57 BLACK INSTEAD OF 129/C57 BLACK AND THAT'S IMPORTANT FOR SEVERAL REASONS. I'LL GET TO IN A MOMENT. SO WHAT WERE THE RESULTS OF THIS STUDY? ONE IS THAT THERE WAS PROLONGED SURVIVAL IN DELAYED TUMOR GROWTH IN THE C57 BLACK ANIMALS, SO THIS IS 100% SURVIVAL, 0% SUR VEEFL O --SURVIVAL OF THESE ANIMALS. THIS IS TIME IN DAYS, AND IT TAKES QUITE A LONG TIME, SOMETHING THAT'S MORE REPRESENTATIVE OF WHAT HAPPENS IN HUMANS IN A PURE C57 BLACK BACKGROUND INSTEAD OF A 129 SLASH C57 BLACK. AS YOU CAN SEE HERE, THE NOS2 KNOCKOUT ANIMALS HAD A SIGNIFICANTLY BUT A MODEST DELAY IN -- OR INCREASE IN SURVIVAL COMPARED TO THOSE THAT HAVE A FULL COMPLEMENT OF NITRIC OXIDE. THE TUMORS WERE IN GENERAL SMALLER, AND IN THE NOS2 KNOCKOUT MICE, SO THIS IS WILD TYPE, KNOCKOUT, 2 TO 5-MILLIMETER IN SIZE, THIS IS WILD TYPE VERSUS KNOCKOUT IN GREATER THAN 5-MILLIMETER. YOU CAN ACTUALLY SEE THIS HERE WITH THESE DOTTED LINES IN THE WILD TYPE NOS2 WILD TYPE MICE, YOU SEE MULTIPLE AND QUITE LARGE TUMORS COMPARED TO THE KNOCKOUT ANIMALS. THE OTHER THING YOU'LL NOTICE IS THAT THE PROLIFERATION OF THE CELLS MEASURED BY KI67 IS MUCH MORE PROLIFERATION IN THE -- PARTICULARLY IN THE CARCINOMAS IN THE NOS2 WILD TYPE ANIMALS VERSUS THE NOS2 KNOCKOUT ANIMALS, AND YOU CAN VISUALLY SEE THAT. I'LL SHOW YOU SOME QUANTITY TAITION OF THAT I -- SOME QUANTITY TAITION OF THAT IN A MOMENT. THIS IS ESSENTIALLY A SCATTER GRAPH SHOWING THAT THE ADENOMAS, THERE WASN'T MUCH CHANGE BUT IN THE CARCINOMAS, THAT IN THE WILD TYPE ANIMALS, THEY HAD A FULL COMPLEMENT OF NITRIC OXIDE FROM NOS2, THERE WAS A HIGHER AMOUNT OF PROLIFERATION, QUANTITATION VERSUS THOSE THAT HAVE A KNOCKOUT. NOW, WHAT KIND OF CELLS WERE IN THE LUNG AS A RESULT OF THE INFLAMMATORY REACTION, IT'S KNOWN FOR QUITE SOME TIME THAT IN THIS ANIMAL MODEL AND MOST ANIMAL MODELS THAT USE KRAS, THERE'S AN INCREASE IN INFLAMMATION, AND YOU CAN EASILY SEE THIS IN THIS PHOTOGRAPH HERE, THAT THE ALVEOLAR SPACES ARE ESSENTIALLY FULL OF VARIOUS KIND OF CELLS COMPARED TO THE NOS2 KNOCKOUT ANIMAL, IN WHICH YOU CAN SEE THE ALVEOLAR SPACES AND THESE ARE THE TUMORS AND THIS IS THE -- MAGNIFICATION. THE AMOUNT OF CELLS YOU SEE HERE ARE MACROPHAGES, TYPES OF CELLS, THESE ARE THE ALVEOLAR CELLS AND THESE ARE NEUTROPHILS AND THESE ARE JUST THE QUANTITATION TO SHOW THAT THERE IS AN INCREASE IN THE INFLAMMATORY RESPONSE IF THE ANIMALS HAD AN INTACT INDUCIBLE NITRIC OXIDE SYSTEM. LOOKING IN MORE DETAIL OF THE DIFFERENT KINDS OF CELLS, THIS WAS DONE IN COLLABORATION WITH BOB WILLTROP'S LABORATORY. YOU CAN SEE THE MACROPHAGES HERE, STAINED, AND LARGER NUMBER THAN IN THE NOS2 KNOCKOUT ANIMALS. THERE WAS A SLIGHT INCREASE IN TREGS IN THE NOS2 KNOCKOUT ANIMALS COMPARED TO THE WILD TYPE ANIMALS BUT THE NUMBER OF GRANULOCYTES AND T-CELLS. IT WAS FOUND OUT IN DAVID BALTIMORE'S LAB THAT THERE ARE MICRO RNA'S ASSOCIATED WITH INFLAMMATION, INCLUDING MIR-21, AND THIS IS AN EXAMPLE IN A CRUDE WAY OF THE PATHWAY, AND WE, IN FACT, DID FIND AN INCREASE IN MIR-21 IN THE WILD TYPE ANIMALS VERSUS THE KNOCKOUT ANIMALS, AND VISUALLY YOU CAN SEE THIS BY IN SITU HYBRIDIZATION. SO THE CONCLUSIONS FROM THIS ANIMAL STUDY, I'VE SHOWN YOU JUST SOME OF THE DATA, IS THAT NOS-2 DEFICIENCY IN THE KRAS INDUCED LUNG CANCER LEADS TO DELAYED TUMOR GROWTH AND PROLONGED SURVIVAL TIME, THAT SUPPRESSED INFLAMMATION BY ATTENUATION OF MACROPHAGE RECRUITMENT INTO THE ALVEOLAR SPACES AND THE TUMOR MICRO ENVIRONMENT, THAT THERE IS A DECREASE IN CELL PROLIFERATION IN THE TUMOR THAT WAS ASSOCIATED WITH A REDUCED MIR-21, WHICH IS FREQUENTLY HIGHLY EXPRESSED IN VARIOUS CANCERS, NOT ONLY RODENT CANCERS BUT HUMAN, AND THAT THE ONCOGENIC KRAS AND NOS2 COOPERATE TO DRIVE TUMORIGENESIS AND INFLAMMATORY RESPONSE. SO ONE OF THE QUESTIONS IS COULD NOS IT BE A POTENTIAL TARGET FOR LUNG CANCER OR OTHER TYPES OF CANCERED INITIATED BY KRAS. IN FACT, THERE ARE SOME POLITICAL STUDIES THAT ARE BEING DISCUSSED RIGHT NOW TO PURSUE THIS. SO LET'S GO NOW TO SOMETHING MORE RELATED TO HUMANS. AND THAT'S THE INFLAMMATORY BOWEL DISEASE. ABOUT ONE IN 100 PEOPLE HAVE INFLAMMATORY BOWEL DISEASE, PRIMARILY ULCERATIVE COLITIS OR RARELY CROHN'S DISEASE. SO THIS IS LOOKING THROUGH A COLONOSCOPE, AND THIS IS HOW NORMAL COLONIC EPITHELIUM LOOKS LIKE. IN INFLAMMATORY BOWEL DISEASE, THIS HAPPENS TO BE ULCERATIVE COLITIS, YOU CAN SEE THE INFLAMMATORY X-RAY HERE, AND THE DIFFERENCE IN THE COLORS ASSOCIATED WITH INFLAMMATION. AND THESE PEOPLE ARE AT INCREASED RISK OF DEVELOPING CANCER AS SHOWN HERE. QUANTITATION OF THE RISK IS ILLUSTRATED WITH PROBABILITY CURVE, SO THIS IS ACCUMULATED PROBABILITY OF DEVELOPING COLON CANCER, AND THIS IS TIME FROM DIAGNOSIS. SO BY 20, 25 YEARS AFTER DIAGNOSIS OF ULCERATIVE COLITIS, IF THEY STILL RETAIN THEIR COLON, ABOUT 10% OF THESE INDIVIDUALS WILL HAVE COLON CAN CANCER. THIS IS RELATED ALSO TO THE NUMBER OF INFLAMMATORY EPISODES THEY HAVE AND THE DEGREE OF INFLAMMATION. I WAS TALKING ABOUT THE INFLAMMATORY CYTOKINES BUT I WANT TO GO BACK TO FREE RADICALS, PARTICULARLY NITRIC OXIDE NOW, AND THE SECOND POINT I WANT TO MAKE BEFORE SHOWING THE REST OF THE DATA IS ONE OF THE BARRIERS FOR GOING FROM A BENIGN TO MALIGNANT TUMOR IS SENESCENCE. IT CAN BE REPLICATED IN VARIOUS WAYS, SO THESE ARE SOME OF THE EXAMPLES OF INDUCERS OF SE NE SENSE, AS I SAID, REPLICATIVE OR TELOMERE SHORTENING OR P53 ISOFORM, WHICH INHIBITS MDM2, WILL INDUCE SENESCENCE, TELOMERE UNCAPPING, THERE ARE PROTEINS THAT OTHERS HAVE INVESTIGATED, AND THESE PROTEINS FORM A CAP AND A PROTECTION INCLUDING ALONG THE SINGLE STRAND OF DNA THAT IS PROTECTED BY PRIMARILY POT1 AND THEN INFLAMMATION, INTERLOU KEN # AND INTERLOU KEN 6 WILL CAUSE SENESCENCE OF CELLS. SO WITH THAT AS A BACKGROUND, JANE AND ERIN ASKED A QUESTION ABOUT THE EXPRESSION OF NITRIC OXIDE SIN TASTE TYPE 2, AND ULCERATIVE COLITIS VERSUS CROHN'S DISEASE, AND FOUND THAT IN ULCERATIVE COLITIS, THERE WAS A STRONG AMOUNT OF NOS2 IN THE COLONG EPITHELIUM COMPARED TO ULCERATIVE COLITIS. THAT LED TO A QUESTION, WELL, IS ANY OF THIS RELATED TO THE MACROPHAGE INFILTRATION IN THESE INFLAMED COLONS, AND THIS IS THE QAWN TAITIOQUANTITATION OF THAT HERE, SO THIS IS NEGATIVE IN TERMS OF A MARKER OF SENESCENCE HP1 GAMMA, AND REGARDLESS OF THE DEGREE OF INFILTRATION BY MACROPHAGES, THERE WAS NO DIFFERENCE IN TERMS OF THE DEGREE OF SENESCENCE. HOWEVER, IN ULCERATIVE COLITIS, THERE WAS A DEPENDENCE ON THE AMOUNT OF MACROPHAGES THAT COULD BE FOUND IN THE TUMORS, TUMORS IN THE COLONIC EPITHELIUM. SO THIS IS ILLUSTRATED HERE, THESE BROWN ARE HP1 GAMMA, AND THERE'S SENESCENCE IN THE STROMA AS WELL IN THE EPITHELIUM, BUT IN CROHN'S, THERE'S SUBSTANTIAL MORE HP1 GAMMA, MORE SENESCENCE THAN IN ULCERATIVE COLITIS AND CERTAINLY MORE THAN IN NORMAL COLON. WELL, IS ANY OF THIS RELATED TO FREE RADICALS SUCH AS NITRIC OXIDE? ONE WAY OF TESTING THIS IS ACTUALLY EXPOSE CELLS TO NITRIC OXIDE AND ASK WHETHER OR NOT THIS INDUCES DNA DAMAGE AND SENESCENCE. ANOTHER STRATEGY IS TO DEVELOP CO-CULTURES OF MACROPHAGES THAT YOU ACTIVATE WITH INFLAMMATORY CYTOKINES, AND THEN YOU EXAMINE THE AMOUNT OF NITRIC OXIDE THAT'S PRODUCED AND WHETHER OR NOT THE TARGET CELLS IN THIS CASE FIBROBLASTS ARE INDUCED TO SENESCENCE, AND THEN COMPARE THESE WITH EACH OTHER AND THEN COMPARE THOSE WITH THE INFLAMMATORY BOWEL DISEASE OR IN VARIOUS ANIMAL MODELS OF INFLAMMATORY BOWEL DISEASE AND COLON CANCER, WHICH WE'VE DONE WITH MICROCARIN JUST RECENTLY. IT'S A CRUDE ATTEMPT TO LOOK AT CELL TO CELL INTERACTIONS. THESE ARE MOUSE MACROPHAGES WITH HUMAN FIBROBLASTS AND THEN ACTIVATING THE MACROPHAGES WITH INTERLOU KEN 1 BETA AND MEASURING THE A MY TRICK OXIDE. THE FUSIBLE AMOUNT OF NITRIC OXIDE WITH OR WITHOUT AN INHIBITOR. SO L NAME IS A CATALYTIC INHIBITOR, AT THIS CONCENTRATION, NOT TERRIBLY EFFECTIVE BUT IT'S ABOUT, OH, 40% REDUCTION HERE AND ABOUT 60% REDUCTION IN THIS EXPERIMENT WITH THE INHIBITOR WITH MACROPHAGES, SO THE NEXT QUESTION IS, WELL, IS THERE ANY EVIDENCE OF SENESCENCE? WE MEASURED SENESCENCE IN VARIOUS WAYS, INCLUDING INCREASE IN BETA -- ACTIVITY, ONE OF THE MEASURES OF SENESCENCE, AND WITH THE MACROPHAGES CO-CULTURED, THERE WAS AN INCREASE IN SENESCENCE OF THESE CELLS AND IF WE INHIBITED THE ENZYMATIC ACTIVITY, AT LEAST PARTIALLY BY LNAME, THERE WAS A DECREASE IN THE AMOUNT OF SENESCENCE AND THESE ARE TWO DIFFERENT STRAINS OF FIBROBLASTS AND THE DECREASE WAS -- OH, SOMEWHAT COMPARABLE WITH NITRIC OXIDE ALONE. INHIBITOR, I SHOULD SAY. A MORE DIRECT WAY IS ACTUALLY EXPOSING THE CELLS TO NITRIC OXIDE, AND THERE ARE DONORS THAT RELEASE NITRIC OXIDE AND THIS IS IN MICRO MOLAR CONCENTRATIONS BUT IT'S ACTUALLY IN NANO MOLARS THAT'S RELEASED IN A STEADY STATE WAY, IT'S A DOSE-RESPONSE RELATIONSHIP IN THE -- CELLS AND THE MRC5 CELLS. SO I MADE THE POINT A MOMENT AGO THAT BENIGN TUMORS SUCH AS COLON ADENOMAS, THERE ARE A LARGE NUMBER OF SE NE SENT CELLS. THERE ARE ALSO HIGH LEVELS OF I'L --WHEN THEY BECOME MALIGNANT, THEY PASS TWO SENESCENT BARRIERS. ONE IS A P53 NETWORK AND THE OTHER IS THE RB NETWORK, WHICH ARE ALMOST UNIVERSALLY INVOLVED, BOTH OF THEM, IN GOING FROM A BENIGN TO A MALIGNANT TUMOR. SO ANOTHER KIND OF QUESTION IS WHETHER OR NOT THERE IS AN INCREASED FREQUENCY OF MUTATIONS IN THESE INFLAMMATORY DISEASES. HE UTILIZED A VERY SENSITIVE AND QUANTITATIVE MEASURE OF MUTATIONS THAT WAS DEVELOPED IN PETER SERUDI'S LAB A NUMBER OF YEARS AGO AND FOUND AN INCREASED FREQUENCY OF P53 MUTANT CELLS IN HUMAN CHROME PTOSIS, CHRONIC HEPATITIS B VIRUS INFECTION, WILSON'S DISEASE, WHICH IS A COPPER OVERLOAD DISEASE, ULCERATIVE COLITIS, WHICH I WAS JUST TALKING ABOUT, AND ALSO IN TOBACCO SMOKERS IN THEIR LUNG AND IN THEIR PLASMA, AND THESE ARE PEOPLE WHO DID NOT HAVE CANCER AT THE TIME OF THESE ANALYSES WERE DONE. SO THERE IS A CORRELATION OF VARIOUS KINDS. TO SUMMARIZE THIS, CHRONIC INFLAMMATION THROUGH RELEASE OF CYTOKINES, IT LEADS TO INDUCTION OF THE INDUCIBLE NITRIC OX IKE SIN TASTE OR THE NOS2 TO PRODUCE HIGH LEVELS OF NITRIC OXIDE, AND THIS IS IMPORTANT FOR PROTECTION AGAINST MICRO-ORGANISMS, BUT IF IT BECOMES CHRONIC, CAN LEAD TO DAMAGE OF THE HOST, DNA DAMAGE, ACTIVATION P53 PATHWAY AND ANTICAR SI KNOWGENIC RESULTS. KATHY FORRESTER IN THE LAB A NUMBER OF YEARS AGO SHOWED THAT P53 CAN LEAD TO TRANSFERRED PRETION OF THE EXPRESSION OF INOS OR NOS2. DNA DAMAGE CAN LEAD TO MUTATION IN CANCER-RELATED GENES INCLUDING P53, AND I GAVE YOU SOME EXAMPLES JUST A MOMENT AGO. YOU LOSE THE ANTICAR SI KNOWGENIC EFFECTS YOU WOULD HAVE WITH THE WILD TYPE AND YOU HAVE PRO CARCINOGENIC EFFECTS, GENERALLY INSTABILITY AND DECREASED L CYCLE EP PTOSIS AND SI NE SENSE. THE OTHER THING THAT HAPPENS IS THAT YOU LOSE THIS NEGATIVE FEEDBACK LOOP SO YOU GET MUCH HIGHER LEVELS OF NITRIC OXIDE PRODUCED IN A CHRONIC WAY. NOW LET'S MOVE ON TO SOME TRANSLATIONAL STUDIES THAT WILL LINK MICRO RNAs AND INFLAMMATION. SO THESE KINDS OF STUDIES ARE ASKING VARIOUS KINDS OF QUESTIONS, QUESTIONS ABOUT RISK AND WHETHER YOU SHOULD DO MORE PREVENTION OR SCREENING AND STUDYING GENE ENVIRONMENT INTERACTIONS, PROGNOSIS, TREAT OR NOT TO TREAT, FOR EXAMPLE, AN EARLY STAGE CANCER, BECAUSE YOU WOULD LIKE TO, IF POSSIBLE, PREVENT MICRO OR MACRO METASTASES FROM OCCURRING, AND THEN THERAPEUTIC TARGETS, IS INFLAMMATION A POSSIBLE THERAPEUTIC TARGET, IS DNA REPAIR A POSSIBLE THERAPEUTIC TARGET OR MICRO RNAs A POSSIBLE THERAPEUTIC TARGET. I'LL GIVE YOU SOME EXAMPLES OF THAT. SO THIS IS A COUPLE STUDIES DONE BY A COUPLE STUDIES DONE BY SHARON PINE WHEN SHE WAS IN THE LAB AND OTHERS, JUST ASKING THE QUESTION IN A PROSPECTIVE STUDY, WHICH WAS CALLED PLCO, PROSTATE, LUNG, COLON, AND OVARY, THAT WAS CONDUCTED BY THE PEOPLE OVER IN ECEG, IN WHICH THEY COLLECTED PLASMA AND SERUM FROM ABOUT CLOSE TO 100,000 PEOPLE AND THEN FOLLOWED THEM OVER THE NEXT 10, 15, 20 YEARS. SO THERE ARE MULTIPLE SAMPLES THAT WERE TAKEN, AND SHARON EXAMINED THOSE FOR VARIOUS CYTOKINES, PARTICULARLY PRO INFLAMMATORY CYTOKINES, AND FOUND THAT IL8 WAS ACTUALLY ELEVATED, IN SOME CASES, 5 OR 8 YEARS PRIOR TO THE DIAGNOSIS OF CANCER. THIS IS LUNG CANCER. IL8 AND IL6 WERE INCREASED AT THE -- ALSO AT THE TIME OF DIAGNOSIS, BUT IT WAS PREDICTED BY IL6 AND N MANOS BINDING L-2. SO -- ARE ASSOCIATED WITH INCREASED RISK OF CANCER ASSOCIATED WITH DIAGNOSIS OR IN SOME CASES ASSOCIATED WITH PROGNOSIS. THERE ARE MULTIPLE CLASSES OF NON-COATINNON-CODING RNA -- THE REST OF THE DNA USED TO BE CALLED JUNK DNA, BUT IN REALITY, MUCH OF THAT IS TRANSCRIBED. IT'S TRANSCRIBED PRIMARILY INTO RNAs THAT ARE NON-CODING BUT HAVE MULTIPLE FUNCTION. AND THEY CAN BE RELATIVELY SMALL OR RELATIVELY LARGE, MOST OF THE WORK THAT'S ASSOCIATED WITH CANCER HAS BEEN FOCUSING ON MICRO RNAs, BUT THESE OTHER -- HAVE -- LARGE NON-CODING RNAs INCLUDE THE LNC RNAs, THIS IS THE ACTUAL NAME HERE, AND THEY MAY OR MAY NOT BE ASSOCIATED WITH CANCER, BUT CERTAINLY ASSOCIATED WITH CERTAIN DEVELOPMENTAL DISEASES. SO LET'S FOCUS ON MICRO RNAs. THESE ARE SMALL NON-COATING RNAs THAT ARE EVOLUTIONARY CONSERVED. THEY WERE ORIGINALLY FOUND IN CELEGANCE, AND THIS IS IN 1992, THEY CONTINUED STUDYING THEM, AND THEN ABOUT THE YEAR 2000, THEY WERE FOUND TO BE EXPRESSED IN HUMAN CELLS. SO THIS IS A BASIC RESEARCH FINDING IN CELEGANCE MADE 10 YEARS AGO OR SO, BUT THIS IS A VERY OLD EP GENETIC MECHANISM OF CONTROL MESSAGE STABILITY OR TRANSLATION. SO THIS MECHANISM CAN BE FOUND IN PLANTS AS WELL AS ALL THE WAY TO HU HUMANS. THEY REGULATE GENE EXPRESSION, AND THEY REGULATE THE GENE EXPRESSION, I'LL SHOW YOU A SLIDE IN A FEW MINUTES, BY INTERACTING WITH MESSAGES AND EITHER INHIBITING THEIR TRANSLATION AND/OR INCREASING THE INSTABILITY OF THE MESS ANL. THEY AFFECT HUNDREDS OF MESSAGES, NOT JUST ONE. SO THOSE WHO WORK IN THE LABORATORY AND USE AB TIE -- OF VARIOUS KINDS, YOU DO EVERYTHING POSSIBLE TO SHOW THAT THERE'S NO OFF TARGET EFFECTS, AND THAT'S WHY YOU'D LOOK AT SEVERAL DIFFERENT SHRNAs, FOR EXAMPLE, AND YOU HAVE VARIOUS CONTROLS. BUT FROM AN EVOLUTIONARY STANDPOINT, MICRO RNAs EVOLVED NOT TO AFFECT A SINGLE MESSAGE OR A SINGLE GENE AND ITS PRODUCT, BUT TO AFFECT HUNDREDS. WE CAN DISCUSS IF ANYONE IS INTERESTED WHY THAT MIGHT BE THE CASE, BUT BUT A MAJOR MECHANISM FOR CONTROLLING GENE EXPRESSION AND PROTEIN EXPRESSION. SO AS I MENTIONED IN ABOUT 2000, IT WAS FOUND TO -- MICRO RNAs WERE FOUND IN HUMAN CELLS, AND THAT LED TO A STUDY SHOWING DIFFERENTIALLY EXPRESSIONED IN HUMAN CANCERS, CHRONIC LYMPHOCYTIC LEUKEMIA. THOSE FINDINGS LET CARLO AND MANY OTHER PEOPLE INCLUDING OURSELVES TO INVESTIGATE MICRO RNAs AND RELATED TO CANCER RISK, DIAGNOSIS, PROGNOSIS OR THERAPEUTIC TARGETS. AND SINCE CARLOS' PAPER IN 2003 OR 2004, THERE ARE MORE THAN 2,000 PAPERS THAT HAVE BEEN PUBLISHED LINKING MICRO RNAs AND CANCER. FROM THAT STANDPOINT, IT'S A HOT AREA OF RESEARCH. SO THERE ARE GENES TRANSCRIBED BY PAUL 2, MAKING THESE PRIOR MICRO RNA STRUCTURES, LOOPS, AND THESE INTERACT WITH AN RNA CALLED DORSCHER, A MUCH LARGER COMPLEX THAT IS SHOWN HERE. AND P53 PLAYS A ROLE INTERACTING WITH AN RNA HELOCASE, AND CARRIES THE HELICASE TO THE COMPLEX AND PRESUMABLY PLAYS A ROLE IN UNWINDING THESE STRUCTURES. THE PREMICRO RNA THEN IS EXPORTED TO THE CYTOPLASM AND INTERACTS WITH ANOTHER RNA CALLED DYSER WHICH IS REGULATED BY A NUMBER OF TRANSCRIPTION FACTORS INCLUDING P63, A MEMBER OF THE P53 FAMILY AND THEN FORMS A COMPLEX WITH THE MESSAGE TO EITHER INHIBIT THE TRANSLATION OF THE MESSAGE OR CAUSE INSTABILITY OF THE MESSAGE. SO WHAT HAPPENS SO WHA IF THERE'S MUTANT P53? A GROUP IN JAPAN FOUND THERE'S AN INHIBITION IN PROCESSING OF MICRO RNAs INCLUDING SOME OF THE RNA THAT HAVE SUPPRESSOR-LIKE -- SO THAT'S AN INTERESTING AREA THAT WE'RE QUITE FASCINATED ABOUT IN DOING STUDIES RIGHT NOW. SO THIS IS IZUMO, WHO'S BACK IN JAPAN NOW, HE DID THE INITIAL STUDY IN OUR GROUP ASKING THE HYPOTHESIS THAT MICRO RNAs ARE ASSOCIATED WITH LUNG CANCER DIAGNOSIS AND PROGNOSIS AND HE FOUND MICRO RNA PROFILES ARE SIGNIFICANTLY DIFFERENT BETWEEN CANCERS AND CORRESPONDING NON-CANCERS OF LUNG TISSUE, SO YOU CAN DISTINGUISH SQUAMOUS CELL FROM ADENO FROM SMALL CELL. HE ALSO FOUND THERE WAS INCREASED MIR-21 WHICH I MENTIONED EARLIER NA N EARLIER IN THAT MOU SE STUDY, AND DECREASE LET-7 INCLUDING DIAGNOSIS AND PROGNOSIS INCLUDING EARLIER STAGE OF LUNG CANCER. THE LET-7 RESULTS ACTUALLY CONFIRMED STUDIES DONE BY TAKAHASHI THAT TERRY AND I KNOW FROM ONCOLOGY DAYS, AND FRANK SLACK, WHO IS IN -- WHO'S AT YALE AT THIS POINT. SO THEY LOOKED AT THREE DIFFERENT COHORTS AND IT'S VERY IMPORTANT WHEN YOU'RE DOING THESE KINDS OF MARKER STUDIES TO LOOK AT MULTIPLE COHORTS, BLINDED WAY, AND ALSO MAYBE LOOK AT DIFFERENT ETHNIC GROUPS. SO THESE ARE PLOTS AGAIN, 100% SURVIVAL, FEWER PERCENT SURVIVAL, THIS IS TIME IN MONTHS, OUT HERE ABOUT FIVE YEARS, AND SO HIGH LEVELS OF MIR-21, THIS IS A COHORT THAT WE HAVE IN BALTIMORE AT UNIVERSITY OF MARYLAND, HAD POOR PROGNOSIS THAN HAVING ABOVE THE MEDIAN LOW LEVELS, AND THE NORWAY COHORT DONE IN OUR COLLABORATION WITH COLLEAGUE HOGAN, AGAIN SIMILAR RESULT, HIGH LEVELS OF MIR-21 EXPRESSION IN THE LUNG CAB SER, POOR PROGNOSIS, AND THIS IS A JAPANESE COHORT, SIMILAR FINDINGS, THIS IS A COHORT THAT HAS A LARGER NUMBER OF STAGE 1A, THE EARLIEST STAGE OF LUNG CANCER. NOW ALL THIS CAME ABOUT IN PART BECAUSE OF STUDY THAT WE DID -- PART OF THIS TOO AND SHIN LONG, JUST ASKING A VERY SIMPLE QUESTION AT THAT TIME, THIS WAS 2005, 2006. THE QUESTION WAS IF YOU TAKE SIX MAJOR TYPES OF HUMAN CANCER, BREAST CANCER, COLON, LUNG, PANCREAS, PROSTATE AND STOMACH CANCER -- THERE WERE ABOUT 280 KNOWN AT THAT TIME, NOW THERE ARE WELL OVER A THOUSAND ANSWER THE QUESTION WHICH OF THOSE MICRO RNAs ARE THE MOST HIGHLY EXPRESSED IN ALL SIX TYPES OF CANCER, IN FIVE OF THE SIX, FOUR OF THE SIX, SO FORTH. IF YOU WANT SOME LOW HANGING FRUIT, ALONG WITH A FEW OTHER PEOPLE TO INVESTIGATE THE IMPORTANCE OF MIR-21 AND THE FUNCTION OF MIR-21. SINCE OUR INITIAL STUDY, IT'S BEEN FOUND THAT IN MULTIPLE CANCER TYPES, ACTUALLY 12 DIFFERENT CANCER TYPES FOLLOWING OUR STUDY OF LUNG AND COLON CANCERS, THAT HIGH LEVELS OF MIR-21 IN EACH OF THE CASES LEADS TO A POORER PROGRESS. IN ALMOST ALL OF THESE HAVE BEEN VALIDATED BY OTHER STUDIES. THIS IS ANOTHER EXAMPLE OF DOING VALIDATION, SO THIS IS OUR INITIAL INVESTIGATION IN COLON CANCER AT A MARYLAND COHORT IN HONG KONG, COHORT, AND AGAIN, HIGH LEVELS OF MIR-21, POOR PROGNOSIS IN BOTH COHORT, AND SINCE THOSE WERE PUBLISHED, THERE ARE THREE OTHER STUDIES THAT HAVE FOUND SIMILAR THINGS IN OTHER COHORTS. SO THAT GIVES YOU SOME CONFIDENCE THAT THE RESULTS ARE BELIEVABLE AND REAL AND REPRODUCIBLE IN MULTIPLE PEOPLE'S HAND AND IN MULTIPLE POPULATIONS. NOW LET'S GO BACK TO INFLAMMATION AND ASK THE QUESTION OF WHETHER OR NOT IN THE -- IN INFLAMMATION, PLAYS A ROLE IN MICRO RNA EXPRESSION AND THAT INFLAMMATORY-RELATED GENES MIGHT BE ALSO BIOMARKERS AND INDEPENDENT BIOMARKERS WITH MICRO RNAs IN PREDICTING PROGNOSIS. SO THIS IS JANE AND ERIN, AND HYPOTHESIS WITH INFLAMMATION RELATED GENES ARE ASSOCIATED WITH CANCER RELATED DIAGNOSIS AND PROGNOSIS AND THEY LOOKED AT 24 DIFFERENT INFLAMMATORY-RELATED GENE EXPRESSION IN TUMOR AND NON-TUMOR, AND DEVELOPED AN IMMUNO SCORE OR INME IMMUNO -- FOUND IN THE NON-TUMOR PORTION IN MATCHED PAIRS, THAT THERE WERE CHANGES IN EXPRESSION OF CERTAIN GENE, AND THESE COOPERATED WITH WHAT WAS FOUND IN THE COLON CANCER IN WHICH THERE WAS EGGS PRETION OEXPRESSION OF A VARIETY OF GENES INCLUDING AISLE 23 WHICH STIMULATE -- IL23WHICH STIMULATES THE PROD UCTION OF T-CELLS IN IL17. SO BOTH OF THESE TOGETHER WERE MORE POWERFUL THAN JUST LOOKING AT TUMOR ALONE, AND OF COURSE IL10 IS AN ANTI-INFLAMMATORY GENE. SO THIS LED TO THE HYPOTHESIS THAT THE COMBINATION OF INFLAMMATORY RISK SCORE OR -- MIR-27 IS A BETTER CLASS FIRE THAN EITHER ONE ALONE. SO LET'S LOOK AT SOME DATA. SO THIS IS THE INFLAMMATORY RISK SCORE, IN WHICH A LOW INFLAMMATORY RISK SCORE, BETTER PROGNOSIS -- AND THIS IS PRIMARILY MADE UP OF PRO INFLAMMATORY GENE EXPRESSION, SO 50% DEATH RATE WAS ABOUT 30 MONTHS HERE. IN THE SAME INDIVIDUALS, MIR-21 EXPRESSION WAS MEASURED IN THE TUMOR, SO YOU CAN SEE THE HIGH MIR-21 LEVELS. IT WAS ALSO SHOWN PREVIOUSLY ASSOCIATED WITH POOR PROGNOSIS. AND THEN THE NEXT QUESTION IS PUT THE TWO TOGETHER, SO IF YOU PUT LOW INFLAMMATORY RISK SCORE AND LOW MIR-21 BOTH TOGETHER, FAIRLY GOOD PROGNOSIS. IF EITHER ONE WAS HIGH, POOR PROGNOSIS. IF BOTH WERE HIGH, AS YOU CAN SEE HERE, IT'S DOWN TO ABOUT 15 OR 18 MONTHS SURVIVAL VERSUS 30 OR 24 THERE. SO THAT GAVE SOME CLUE THAT THESE MIGHT BE INDEPENDENT OF EACH OTHER, AND HAVE AN IMPROVED CLASS FIRE, BUT ONE NEEDS TO DO STATISTICAL ANALYSIS AND YOU CAN DO THIS BY UNI VARIANT AND MULTI-VARIANT ANALYSIS WHICH ALLOWS YOU TO ASK THE QUESTION ARE THE COVARIANTS -- OF EACH OTHER FROM A STATISTICAL STANDPOINT. SO THESE ARE HAZARD RATIOS, SO INFLAMMATORY RISK SCORE, IF IT'S HIGH, HAZARD RATIO IS POOR, MIR-21 IS HIGH, HAZARD RATIO IS ALSO HIGHER, TM STAGE HIGHER -- HAZARD RATIO IS HIGHER BUT LIKE EACH ONE OF THESE IS INDEPENDENT OF THE OTHERS. SO WHAT IS THE PRINCIPAL BEING INVESTIGATED HERE? SO ONE IS THINKING NON-CODING AND CODING RNAs THAT CAN GIVE SOME INDICATION OF PROGNOSIS, COMBINING THEM TO GET THIS KIND OF CURVES WHICH WAS SHOWN IN THE PREVIOUS SLIDE, BUT WHEN THEY'RE BOTH IN AGREEMENT, IT GIVES YOU MUCH HIGHER CONFIDENCE, BUT WHY SHOULD THEY BE A BETTER CLASS FIRE TOGETHER. THAT IS THAT THEY MISCLASSIFY SOME OF THE PATIENTS BUT THEY MISCLASSIFY DIFFERENT PATIENTS, SO THESE ARE MISCLASSIFIED BY NON-CODING AND THIS IS MISCLASSIFIED BY CODING. SO TWO TOGETHER IS BETTER THAN ONE. AND THE QUESTION IS, IS THREE BETTER THAN TWO, AND THAT'S BEING INVESTIGATED NOW. SO THIS PROOF OF PRINCIPLE, IS IT ONLY TRUE FOR COLON CANCER, IS IT TRUE FOR OTHER KINDS OF CANCERS AND WE'VE SHOWN THAT ESOPHAGEAL CANCER, IT IS TRUE. OR CONSISTENT IS A BETTER WORD. AND IN LUNG CANCER, WE HAVEN'T PUBLISHED THESE DATA BUT I'LL SHOW YOU SOME DATA THAT WE'RE ABOUT READY TO SUBMIT. AND THIS IS USING A LUNG CANCER POPULATION THAT'S STAGE 1, AND A 4 CODING GENE CLASS FIRE WHICH IS DOWN HERE. THESE ARE HIGHLY EXPRESSED, THERE IS POOR PROGNOSIS. 100%, 0% SURVIVAL, SO IT'S AROUND 24 OR SO. MIR-21, IF THAT'S HIGHLY EXPRESSED, POOR PROGNOSIS. AND AGAIN, THE 50% CUTOFF RIGHT HERE IN TERMS OF SURVIVAL WAS ABOUT 30, I GUESS, OR SO, AND THE TWO TOGETHER, IF THEY'RE BOTH HIGH -- OR EXCUSE ME, IF THEY'RE BOTH LOW IN TERMS OF THE CODING EEN GENE, NON-CODING GENE, VERY GOOD SURVIVAL. HIGH, INTERMEDIATE SURVIVAL, AND IF BOTH ARE HIGH, POOR SURVIVAL. IF YOU COMPARE STAGE 1A VERSUS 1B LUNG CANCER, THE MAIN DIFFERENCE HERE IS THE NODES APPEAR TO BE NEGATIVE BUT THE STAGE 1A ARE LESS THAN 3 CENTIMETERS IN SIZE AND STAGE 1B ARE HIGHER, BUT I SAID THE NODES ARE NEGATIVE AND THE SURGICAL INTENT IS CURATIVE, AND THE SURGEON MIGHT COME TO THE DAD AND SAY MR. JONES, I THINK WE CURED IT ALL BECAUSE THE NODES ARE NEGATIVE AND IT'S A SMALL TUMOR, AND THINGS MIGHT BE OKAY. HOWEVER, I'M GOING TO ASK YOU TO MEET WITH TERRY, MY MEDICAL ONCOLOGIST, OR CURT, TO GIVE YOU A LITTLE MORE ADVICE. THE ADVICE IS STAGE 1 LUNG CANCER, 40% OF THOSE PEOPLE ARE GOING TO BE DEAD IN FIVE YEARS. AND THEY'RE GOING TO BE DEAD FOR MICRO METASTASES THAT HAVEN'T BEEN ASCERTAINED.ED. SO THAT'S WHY IT'S IMPORTANT THAT WE DEVELOP BIOMARKERS FOR EARLY STAGE CANCER, AND ASK -- USE THAT INFORMATION TO EITHER IMPROVE SCREENING OR TO GIVE ADJUVANT THERAPY. RIGHT NO KNOW ONE GIVES PEOPLE STAGE 1 LUNG CANCER ADJUVANT THERAPY THAT I KNOW OF. SO THIS SORT OF ILLUSTRATES THIS POINT, THESE ARE STAGE ONE PATIENTS, ANALYZE THEM, THERE'S A GROUP IN PEOPLE THAT HAVEN'T BEEN OFFERED ADJUVANT THERAPY AND PEOPLE THAT ARE LOWER RISK THAT PROBABLY SHOULDN'T RECEIVE ADJUVANT THERAPY. SO LET'S END UP WITH A LITTLE BIT MORE INFORMATION ABOUT MIR-21, AND 1 OF THE QUESTIONS IS CAN IT BE AN ONCOGENE AND IS THERE EVIDENCE OF ONCOGENE ADDICTION. I'LL SHOW YO WHAT THAT MEANS IN A MOMENT, AND MIGHT IT BE A PREVENTION OR THERAPEUTIC TARGET. THESE ARE ALL STUDIES IN ANIMAL MODELS, AND THIS IS AN ANIMAL MODEL FOR EXPRESSION, A MIR-21, SHOWING IN FRANK SLACK'S LABORATORY THAT THERE WILL BE PRELIM FOE MAS THAT OCCUR AND MIR-21 IS OVEREXPRESSED. IF YOU TURN IT OFF, OR YOU PREVENT IT FROM BEING EXPRESSED, IT'S THE SAME AS CONTROL, AND THESE ARE -- MARKERS. SO IS THERE ONCOGENE ADDICTION, ONE WAY OF TESTING THIS IS THAT YOU INDUCE THE TUMORS, IN THIS CASE WITH MIR-21, AND THEN TURN MIR-21 OFF AND ASK THE QUESTION, WILL THE TUMORS STOP GROWING OR ACTUALLY REGRESS? IN THIS CASE, THEY REGRESS, GET SMALLER AND SMALLER, AND THESE ANIMALS, FAIRLY SMALL STUDY, LIVE, BUT IF YOU LEAVE THE MIR-21 BEING EXPRESSED, THEY GO AHEAD AND DIE. SO THAT'S A LYMPHOMA, WHAT HAPPENS IN CARCINOMAS, THIS IS A KRAS MODEL AGAIN DONE BY TIM HADLEY AND CO-WORKERS. SO OVEREXPRESSION OF MIR-21 AS A TRANSGENE, THESE KRAS MODELS, GIVES YOU MORE LESIONS PER LUNG, YOU CAN SEE THEM HERE, ACTUALLY COUNT THEM ON THE SURFACE OF THE LUNG. SO OVEREXPRESSION OF MIR-21 INCREASES THE ONCOGENICITY OF RAS IN THE LUNG, SO WHAT HAPPENS IF YOU DELETE MIR-21, SO THESE ARE MIR-21 KNOCKOUT MICE, CARRYING THE KRAS, AND THEY GET VERY FEW TUMORS COMPARED TO THOSE THAT HAVE WILD TYPE MIR-21 EXPRESSION. SO THERE'S BEEN LOTS OF STUDIES ON THE FUNCTIONS OF MIR-21 AND WAYS OF INHIBITING IT OR INDUCING IT, SO MIR-21, THE GENE CAN BE AMPLIFIED AND THIS IS FREQUENTLY AMPLIFIED IN DIFFERENT KINDS OF CANCERS, TO BE SILENCED BY DEMETH LAITION, I SHOWED YOU CAN INCREASE MIR-21 AND WE SHOWED A FEW YEARS AGO NOW THAT EGFR MUTATIONS, LUNG CANCER CASES, IN ABOUT 10% OF THE PEOPLE COMING INTO THE CLINIC NOW ARE NEVER SMOKERS, WILL LEAD TO HIGH LEVELS OF MIR-21. IL6 AND INTERFEWER ON THROUGH STAT 3 TRANSCRIPTION FACTOR WILL LEAD TO AN INCREASED MIR-21. DIFFERENT KINDS OF GEE KNOW TOXIC STRESS, SOME STUDIES WERE DONE WITH NICOLE SIMON WHEN SHE WAS HERE, WILL LEAD TO THE INCREASE OF MIR-21. SO WHAT'S DOWNSTREAM FROM MIR-21? I SAID THERE WERE PROBABLY HUNDREDS OF GENES, BUT THESE ARE JUST A LISTING OF SOME OF THOSE THAT HAVE BEEN VALIDATED EXPERIMENTALLY AND ARE RELATED TO PRIMARILY METASTASES IN HUMAN CANCER. SO IT LEADS TO A DECREASE IN THE MESSAGE LEVEL AND TRANSLATION OF THESE GENES THAT ARE INVOLVED IN TUMOR GROWTH, PROTEASES, FOCAL ADHESION, ANCHORAGE INDEPENDENT GROWTH. I'VE ADDED LAST ONE, MISMATCHED REPAIR GENE AND PROTEIN, MSH2, AND THAT CARLO CROCHE AND COLLEAGUES HAS SHOWN A FEW YEARS AGO. SO THIS MICRO RNA ALONG WITH MIR-155 MAY LEAD TO DECREASE IN DEFICIENCY OF -- WHICH HAS SHOWN TO BE ASSOCIATED WITH INCREASED INCREASED -- COLON CANCER RISK. ONE I IS COMBINATION STUDIES, IF YOU HAVE STATISTICALLY DIFFERENT BIOMARKERS, YOU PUT THEM TOGETHER, YOU MIGHT HAVE BETTER PROGNOSTIC CLASS FIRES AND DIAGNOSTIC CLASS FIRES. FUNCTIONAL MECHANISTIC STUDIES OF PARTICULAR BIOMARKERS, DOING PROSPECTIVE OR PREDICTIVE STUDIES, WHICH ARE DIFFERENT FROM THE RETROSPECTIVE STUDIES THAT I WAS TALKING ABOUT IN THE PREVIOUS SLIDES, AND WERE, IN FACT, CONDUCTING THOSE NOW IN PART IN CLAB LAITION WITH MD ANDERSON AND ALSO AT THE UNIVERSITY OF MARYLAND. SO THE IMPLICATIONS OF WHAT I'VE BRIEFLY DISCUSSED TODAY IS INSIGHT INTO CASCADES INVOLVED IN CARS KNOW GENESIS AND TUMOR PROGRESSION, IMPLICATIONS ABOUT PREVENTION OF CANCER AND DIAGNOSIS OF CANCER, WE'RE PARTICULARLY INTERESTED IN PREDICTION OF PROGNOSIS, PARTICULARLY EARLY STAGE CANCER, AND PREDICTION OF THERAPEUTIC OUT COME, AND THEN SECONDLY, INFLAMMATORY AGENTS OR MICRO RNAs, ARE THEY TARGETS FOR THERAPY, AND THAT'S QUITE AN ACTIVE AREA NOW IN PRECLINICAL STUDIES, AND THERE ARE SOME CLINICAL STUDIES THAT ARE ONGOING. SO THESE ARE THE PEOPLE I THINK I MENTIONED ALL OF THEM, WHILE I WAS PRESENTING THE RESULTS. WE'VE COLLABORATED WITH THESE INDIVIDUALS OVER HERE, AND I'VE LEARNED A GREAT DEAL FROM ALL THESE PEOPLE. PROBABLY MUCH MORE THAN I'VE TAUGHT THEM. I APPRECIATE THE OPPORTUNITY TO COLLABORATE THEM, AND I APPRECIATE THE FACT THAT SOME OF YOU ARE HERE AND SOME OF YOU ARE SOMEWHERE WATCHING YOUR TELEVISION SCREEN HAVING A BEER. [APPLAUSE] QUESTIONS? [INAUDIBLE] >> THAT'S A VERY GOOD QUESTION. SO THERE ARE ANTIMIRs, AND THESE ARE SMALL NUCLEOTIDES, WHICH CAN BE AS SMALL AS FIVE BASE PAIRS. WHICH WILL BIND TO THE MICRO RNA AND INHIBIT ITS FUNCTION. IT'S QUITE REMARKABLE THAT THIS ACTUALLY -- PEOPLE, AND THE INITIAL STUDIES WERE DONE IN MONKEYS, THAT WERE -- WITH HEPATITIS C VIRUS, AND ONE OF THE MICRO RNAs MIR122, I BELIEVE IT IS, OR MIR123 -- PROLIFERATION -- THAT WAS THE STUDY THAT WAS PUBLISHED IN SCIENCE AND LITERATURE, AND I'LL GET OUT OF YOUR WAY. SO NOW THERE'S A PHASE 1 AND PHASE 2 STUDY BEING DONE IN HUMANS, AND THOSE RESULTS SHOULD BE PUBLISHED QUITE SOON. BUT IT LOOKS LIKE IT'S EFFECTIVE. THAT'S WITH INFECTIOUS DISEASE. HOW ABOUT CANCER? AND MY PREDICTION IS THAT ONE OF THE MICRO RNAs THAT WILL BE TARGETED FIRST IS GOING TO BE MIR-21, BECAUSE IT'S SO INVOLVED IN SO MANY DIFFERENT KINDS OF CANCERS, AND IT'S A VERY ATTRACTIVE THERAPEUTIC TARGET. THOSE STUDIES HAVE NOT BEGUN YET IN CANCER, BUT I THINK IN PROBABLY THE NEXT TWO, THREE YEARS, THEY WILL. [INAUDIBLE] >> WELL, THAT'S A VERY INTERESTING QUESTION. IF THE TUMOR IS IN THE LIVER, OR IT'S A METASTASES LIVER, YOU GET VERY EFFECTIVE TARGETING JUST BY INJECTION INTO THE BLOOD. IF THEY'RE IN OTHER SITES, THEN THAT'S A MUCH MORE SERIOUS PROBLEM, AND THAT'S THE PROBLEM PEOPLE HAVE HAD WITH INTERFERING RNAs, AND SO PEOPLE ARE USING NANOPARTICLES AND VARIOUS OTHER WAYS OF TRYING TO TARGET THEM, BUT IF IT'S IN THE LIVER, COLON CARCINOMA THAT'S METASTASIZED TO THE LIVER, THAT'S, AGAIN, THE LOW HANGING FRUIT THAT I'M SURE WILL BE PURSUED FIRST. YES. [INAUDIBLE] >> SO IT WOULD BE NICE IF THERE WERE GOOD THERAPIES FOR A KRAS. PEOPLE HAVE BEEN TRYING FOR 25 YEARS, 30 YEARS, RIGHT? BUT THERE ARE GOOD DRUGS TO INHIBIT NOS2. SO IT'S -- AND THERE ARE ANIMAL MODELS THAT WE AND OTHER PEOPLE HAVE STUDIED IN WHICH IF YOU INHIBIT NOS2 WITH THESE DRUGS, YOU HAVE FEWER TUMORS. AND BETTER PROGRESS KNOW SEES. PROGNOSIS. SO FROM A THERAPEUTIC STANDPOINT, SMALL MOLECULES AFFECTING NITRIC OXIDE SYNTASE IS THE WAY TO GO. I'LL MAKE ONE OTHER COMMENT ABOUT THAT. THAT IS IN GLIOMAS AND GLIOBLASTOMAS, STEM CELLS, CANCER STEM CELLS FROM THOSE TUMORS, JEREMY RICH HAS SHOWN, THE GROWTH OF THOSE CANCER STEM CELLS, AND THESE ARE PRIMARY CELLS FROM THE TUMORS, IS MODULATED BY NITRIC OXIDE. SO THEY REQUIRE NITRIC OXIDE TO GROW. IF YOU INHIBIT NITRIC OXIDE, THEY STOP GROWING. SO WHETHER THAT'S GOING TO BE TRUE IN OTHER CANCER TYPES OR NOT REMAINS TO BE SEEN, BUT THAT WAS AN UNEXPECTED FINDING THAT RICH FOUND. AND I'M SURE HE AND OTHER PEOPLE ARE PURSUING THAT FOR BRAIN TUMORS. WE'RE DONE? THANK YOU. THE MICROPHONE. YEAH, YOU CAN HAVE THAT. >> OKAY. WELL, WE HAVE OVER HALF A MILLION PEOPLE IN THIS COUNTRY DYING FROM CANCER EVERY YEAR, WE COME UP WITH TREATMENTS AND THEY STILL DIE, AND MOST PEOPLE SAY THE WAY TO REALLY REDUCE THE NUMBER OF CANCER DEATHS IS TO PREVENT THEM FROM HAPPENING. SO WE HAVE SOMEONE TO TALK TO US ABOUT PREVENTION OF NON-SMALL CELL LUNG CANCER. >> THANK YOU. SO THAT'S PREVENTION AND TREATMENT. CAN EVERYBODY HEAR ME? ALL RIGHT. CAN YOU HEAR ME? AY. SO NOT EVEN A BREAK TO VISIT THE LADIES ROOM AND THE MEN'S ROOM? HARD CORE. OKAY. VERY GOOD. ALL RIGHT. SO FIRST OF ALL, THANK YOU FOR ALL OF YOU WHO ARE HERE AND WHEREVER YOU MAY BE. I'M GOING TO BE TALKING ABOUT NON-SMALL CELL LUNG CANCER. FOCUS ON PREVENTION, BUT NOT JUST PREVENTION. REALLY FOCUS ON TREATMENT AS WELL. SO LET'S GO AHEAD AND START WHERE TERRY LEFT OFF. THE ESTIMATES ARE OVER 220,000 NEW CASES OF LUNG CANCER IN THE UNITED STATES, OVER 160,000 DEATHS FROM THIS DISEASE. THIS IS SEVERAL TYPES OF LUNG CANCER. BUT THE BOTTOM LINE IS THAT LUNG CANCER IS THE LEADING CAUSE OF CANCER DEATHS, MORE DEATHS FROM LUNG CANCER THAN THE NEXT THREE CAUSES OF CANCER ADDED TOGETHER, BREAST AND PROSTATE AND COLON. NOW THE DEATH RATE IS ACTUALLY DECREASING FAIRLY SUBSTANTIALLY, BUT IT'S A HUGE, HUGE DEATH RATE STILL. SO A LOT MORE PROGRESS IS NEEDED. THE SURVIVAL HAS ONLY INCREASED INCREMENTALLY, AND NOT U.S. FI SHENTLY IN THE PAST 50, 60 YEARS. IT USED TO BE 5% IN THE 1950s. WE ARE NOW UP TO ABOUT 16% OVERALL SURVIVAL, AND THAT'S BECAUSE MOST LUNG CANCER DOES NOT PRESENT WHEN IT'S EARLY. LUNG IS AN INTERNAL ORGAN, GENERALLY CANCER HAS SPREAD, AT LEAST LOCALLY, BEFORE IT'S DETECTED. SO THIS IS THE GRAPH SHOWING YOU HOW LUNG CANCER DEATH RATES ARE FALLING. IN MEN, THEY'VE FALLEN QUITE SUBSTANTIALLY OVER THE PAST 30 OR SO YEARS. IN WOMEN, WHO STARTED SMOKING LATER AND, THEREFORE, THE CANCER DEATHS PEAKED LATER, THAT PEAK HAS REALLY JUST OCCURRED AND ONLY NOW ARE WE STARTING TO SEE A DECREASE, BUT YOU CAN'T SEE IT THAT WELL ON THIS GRAPH. THE BOTTOM LINE IS THAT IT'S STILL -- LUNG CANCER FAR OUTPACES ALL OTHER CAUSES OF CANCER DEATHS. HERE'S THE REASON WHY. THIS IS ONE OF MY FAVORITE SLIDES. IT SHOWS YOU A LOT ABOUT LUNG CANCER. SO THERE'S YOUR CANCER. THERE'S A NODULE, THIS IS A CAT SCAN. HERE IS SOME OF THE REASONING WHY THIS PERSON HAS COPD, HERE IS SOME FIBROSIS, HERE IS SOME AREAS THAT ARE LESS DENSE SO THEY'VE GOT EMPHYSEMA OR CHRONIC OBSTRUCTIVE PULMONARY DISEASE, AND HERE'S THEIR PACK OF CIGARETTES. SO EVEN WHEN THEY HAVE THEIR LUNG CANCER, THEY CAN'T GET TO THEIR CT WITHOUT HAVING THAT CIGARETTE RIGHT NEARBY SO THEY CAN START SMOKING THE MOMENT THEY'RE OUT OF THE MACHINE. AND THAT'S REALLY THE PROBLEM WITH LUNG CANCER. IT'S NOT JUST A CANCER OF SMOKERS. ABOUT 20 TO 25,000 CASES OCCUR IN NEVER SMOKERS, BUT NEVERTHELESS, EVERYTHING PALES COMPARED TO THE SMOKERS. SO ABOUT 85% OF ALL LUNG CANCER IS DUE TO TOBACCO. THAT INCLUDES PASSIVE SMOKING. A LOT OF LUNG CANCER IS ASSOCIATED WITH A PRIOR -- BUT MOST OF THAT IS, AGAIN, DUE TO SMOKING, SO SOMEBODY WHO HAS A HEAD AND NECK CANCER IS MUCH MORE LIKELY TO HAVE SUBSEQUENT LUNG CANCER, ABOUT 3 TO 6% PER YEAR, BUT MOST OF THOSE PEOPLE HAVE BEEN SMOKERS. THERE IS A DISPROPORTIONATE INCREASE IN LUNG CANCER RISK IN PEOPLE WHO HAVE CHRONIC OBSTRUCTIVE PULMONARY DISEASE, AND THAT'S SEPARATE FROM JUST THE SHARED PATHOGENESIS DUE TO SMOKING. SO THERE ARE CASES OF COPD THAT ARE INHERITED, AND THERE'S AN INCREASED RISK OF LUNG CANCER THERE TOO, EVEN IF THE PERSON NEVER SMOKED. IT'S AN INDEPENDENT RISK FACTOR. THERE ARE A HOST OF OTHER EXPOSURES THAT I LIST THERE, ASBESTOS IS THE BEST CHARACTERIZED ONE. AND THERE ARE SOME GENETIC PREDISPOSES. PREDISPOSITIONS. LUNG CANCER ASSOCIATED WITH CHANGES IN 6Q23, THE RECEPTOR SUBUNIT, ASSOCIATED WITH SLIGHTLY INCREASED RISK OF LUNG CANCER, AS WELL AS OF COPD, AND THERE ARE VERY -- NOT ON THE SLIDE, VERY RARE FAMILIES WITH EGFR MUTATION, GERM LIKE EGFR MUTATION THAT IS ASSOCIATED WITH LURNG CANCELUNG CANCER AND NEVER SMOKERS. DR. HARRIS REFERRED TO THIS BEFORE. THIS IS THE OLD TMM, TUMOR NODE METASTATIC STAGING OF LUNG CANCER. IT HAS BEEN SOMEWHAT UPDATED, BUT I LEAVE IT HERE TO SHOW YOU HOW AWFUL THE STATISTICS ARE. STAGE 1A LUNG CANCER, WHICH IS LESS THAN 3 CENTIMETER TUMOR, NO LYMPH NODES, THE FIVE-YEAR SURVIVAL IS STILL ONLY ABOUT 60%. AND MUCH OF THAT IS DUE TO LUNG CANCER DEATH, NOT DUE TO OTHER DISEASES, WHICH SMOKERS ARE SUBJECT TO, SUCH AS HEART DISEASE. SO THE STATISTICS ARE PRETTY HORRIBLE, AND OF COURSE MOST LUNG CANCER IS DIAGNOSED IN B STAGES, WHEN YOU HAVE EITHER SPREAD TO THE LYMPH NODES OR METASTASIS, OUTSIDE THE CHEST. SO IT'S JUST A LITTLE PRIMER ABOUT LUNG CANCER, NON- -- THERE ARE THREE MAIN HIS TOE LOGIC TYPES. WE USED TO THINK ABOUT LUNG CANCER PRIMARILY IN A HIS TOE LOGIC WAY, ALTHOUGH WE WOULD REALLY GROUP ALL THESE GROUPS TOGETHER INTO THE NON-SMALL CELL, BUT 40% THESE DAYS ARE WHAT'S CALLED AN ADENOCARCINOMA, THERE'S A LITTLE PICTURE, THESE TEND TO BE PERIPHERAL NODULES AND METASTASIZE EARLY. ABOUT 20% -- AND THESE COULD BE -- THESE ARE ASSOCIATED WITH SMOKING BUT ALSO THAT'S THE PREDOMINANT FORM IN NEVER SMOKERS. ABOUT 20% ARE SQUAMOUS CELL CARCINOMAS. THESE TEND TO BE MORE CENTRAL. THEY ARISE FROM THE BRONG YOE LAR EPITHELIUM, THESE ARE MUCH MORE HIGHLY ASSOCIATED WITH SMOKING, A LITTLE BIT RARE REMEMBER IN NEVER SMOKERS, IN FACT. LARGE CELL IS A LITTLE BIT LESS COMMON, SQUAMOUS CELL USED TO BE THE MOST COMMON FORM OF LUNG CANCER, NON-SMALL CELL, AND IT'S STILL MORE COMMON IN HIGHLY SMOKING SOCIETIES SUCH AS IN ASIA, AND EUROPE STILL, AS OPPOSED TO HERE IN AMERICA, WHERE WE SEE MUCH MORE ADENOCARCINOMA. LARGE CELL WHICH ALSO TENDS TO BE MORE PRO LIVE RAL, 15%, AND THEN THERE ARE OTHER RARE OR MORE RARE HISTOLOGIES. AND THAT'S IN CONTRAST TO SMALL CELL, NOTICE I CALLED ALL THE OTHERS NON-SMALL CELL, WHICH IS REALLY A MUCH DIFFERENT APPEARING AND ACTING BEAST, SO TO SPEAK. IT'S ABOUT 20% OF ALL CANCERS THESE DAYS. TEND TO BE CENTRAL TUMORS, SO NOT FAR IN THE PERIPHERY OF THE LUNG, AND EXTREMELY FAST GROWING, AND I THINK THAT YOU'VE HAD A DISCUSSION OF THESE. THEY ARE MUCH MORE CHEMO-SENSITIVE, SO THEY'RE TREATED QUITE DIFFERENTLY THAN NON-SMALL CELLS. SO WHEN I THINK ABOUT LUNG CARCINOGENESIS, I DON'T THINK ABOUT LUNG CANCER. I THINK ABOUT THE PROCESS THAT TAKES MANY YEARS WITH AN EVOLUTION OF HISTOLOGIC AND MOLECULAR CHANGES THAT CULMINATE IN SOMETHING THAT YOU CAN SEE ON A CAT SCAN OR UNDERNEATH THE MICROSCOPE AFTER IT HAS SPREAD FROM THE ORIGINAL SITE, FROM THE EPITHELIUM, AND THEN SPREADS THROUGHOUT THE BODY. AND THERE ARE OPPORTUNITIES FOR DOING GOOD TO TREAT AND TO PREVENT. SO I'M GOING TO START FIRST WITH TREATMENT, WHICH ARE THE LATE STAGES, AFTER, AGAIN, YOU'VE GONE THROUGH THE BASEMENT MEMBRANE AND SPREAD TO THE LYMPH NODES, THE BLOOD, ET CETERA, TO OTHER SITES. AND THEN I WILL TALK ABOUT PREVENTION AND A LITTLE BIT ABOUT EARLY DETECTION. SO THE TREATMENT STRATEGIES ARE VERY MUCH ANATOMICALLY DRIVEN. FOR EARLY STAGES OF NON-SMALL CELL -- AND THE REST OF THIS TALK IS GOING TO BE ONLY ABOUT NON-SMALL CELL. FOR EARLY STAGES, IT IS SURGERY. FOR EARLY STAGES THAT CAN STILL BE RESECTED, BUT REFERENCES LYMPH NODES ARE INVOLVED, ADJUVANT CHEMOTHERAPY IS GIVEN. EVEN WHEN YOU THINK THAT YOU'VE GOTTEN ALL THE TUMOR, YOU KNOW THAT THERE ARE MICRO METASTASES THAT YOU CAN'T DETECT AND THAT'S THE GOAL OF ADJUVANT CHEMOTHERAPY, AND IT'S BEEN SHOWN TO GIVE ABOUT A 5% ABSOLUTE DECREASE RISK OF DEATH IN THESE CASES. IF THERE IS REGIONAL SPREAD, BY REGIONAL, I MEAN YOU'RE NOW INVOLVED IN THE MEDIA STIENL LYMPH NODES, CHEMOTHERAPY AND RADIATION, GENERALLY GIVEN CON CONCOMITANTLY, SOMETIMES SURGERY CAN STILL BE DONE, BUT USUALLY WE GO STRAIGHT TO CHEMO RADIATION ALONE, AND IF THERE IS SPREAD, WHAT USED TO BE CALLED STAGE III B WET, SO PLURAL EFFUSION, WHICH MEANS THAT THERE IS THE LINING OF THE -- THE PLURAL LINING OF THE LUNG IS INVOLVED OR SPREAD OUTSIDE THE CHEST, THEN CHEMOTHERAPY IS THE ONLY OPTION, IT IS NEVER CURATIVE. RADIATION IS USED A AS NEEDED FOR PAL YAITION AND FOR LOCAL CONTROL, AND IN RARE CASES, WE WILL DO ACTUALLY SURGERY FOR AN ISOLATED METASTASIS IF EVERYTHING ELSE IS CONTROLLED. SO FOR SMALL CELL, IT'S ALL CHEMOTHERAPY PLUS OR MINUS RADIATION IN THE APPROPRIATE SETTINGS. SO LET ME TALK A LITTLE BIT THEN ABOUT -- I'M A MEDICAL ONCOLOGIST, SO THE MEDICAL APPROACHES REALLY STAGE IV NON-SMALL CELL LUNG CANCER. AND IN THE 20-SOME-ODD YEARS THAT I'VE KNOWN DR. MOODY WHEN PRACTICING MEDICINE, THE APPROACH TO LUNG CANCER HAS DRASTICALLY CHANGED. NOW WE'RE STILL NOT CURING PEOPLE, BUT WE ARE ENABLING MUCH LONGER AND BETTER QUALITY LIVES IN CERTAIN SUBSETS AND SO THAT'S WHAT I WANT TO TALK TO YOU ABOUT BEFORE WE GET TO PREVENTION. SO LUNG CANCER AND EVEN LUNG ADENOCARCINOMA IS NOT ONE DISEASE. WE USED TO LUMP EVERYTHING TOGETHER BECAUSE THERE WERE -- THERE WAS NOT MUCH WE COULD DO AND THERE WAS THE SAME POOR RESPONSE TO CHEMOTHERAPY ONCE SURGERY WAS NO LONGER AN OPTION, BUT WE NOW KNOW THAT THERE ARE DIFFERENT MECHANISMS LEADING -- MOLECULAR MECHANISMS LEADING TO SPECIFIC LUNG CANCERS AND OUR THERAPEUTIC APPROACHES ARE ACTUALLY QUITE DIFFERENT. HONESTLY, IT'S EXCITING. SO LET'S START WITH THE EPIDERMAL GROWTH FACTOR, EGFR RECEPTOR, WHICH IS A VERY IMPORTANT SIGNALING MOLECULE THAT IS INVOLVED IN CRITICAL LIFE PROCESSES, ALSO HAVE EGFR SIGNALING ONGOING THAT'S INVOLVED IN GROWTH AND SURVIVAL, ET CETERA. IT'S BEEN FOUND THAT IN ABOUT 10% OF LUNG CANCERS AND THIS IS MAINLY IN NEVER SMOKERS, THE EPIDERMAL GROWTH FACTOR RECEPTOR IS ACTUALLY MUTATED. MUTATED IN A NUMBER OF PREDICTABLE WAYS. THIS PARTICULAR SUBSET OF PEOPLE, THERE IS A GROUP OF DRUGS KNOWN AS THE EGFR INHIBITORS, THESE DRUGS CAN TAKE SOMEBODY WHO IS ON DEATH'S DOOR AND THEY BECOME FULLY FUNCTIONAL WITH NO -- CAN BECOME FULLY FUNCTIONAL WITH NO SYMPTOMS WHATSOEVER FOR SOME PERIOD OF TIME. SO REALLY QUITE MIRACULOUS FOR A VERY SMALL SUBGROUP OF PEOPLE. THESE EGFR INHIBITORS ESSENTIALLY ONLY WORK IN PEOPLE WHO HAVE SPECIFIC MUTATIONS, WHICH ARE THE MAJORITY OF DE NOVO MUTATIONS. THEY WORK FOR ABOUT EIGHT TO 14 MONTHS AND THEN RESISTANCE DEVELOPS. GENERALLY WITH A SECOND EGFR MUTATION, THE T790M MUTATION, AS IT'S KNOWN, BUT ALSO THROUGH A VARIETY OF OTHER MECHANISMS. SO THIS GROUP OF AGENTS HAS NOW BECOME VERY IMPORTANT IN THE TREATMENT OF LUNG CANCER. IT'S ALSO -- IS APPROVED FOR SECOND AND THIRD LINE TREATMENT. AND THIS IS JUST ONE GRAPH TO SHOW YOU, SO THESE ARE ALL PATIENTS WITH STAGE IV LUNG CANCER WHO HAVE MUTATED EGFR WHO WERE RAN COMIZE RANDOMIZED TO STANDARD CHEMOTHERAPY BUT THE SAME -- WHAT YOU SEE, THAT THE PROGRESSION PRESURVIVAL, SO THE PERIOD OF CONTROL OF DISEASE, IS ESSENTIALLY DOUBLE, IT'S ABOUT FIVE MONTHS WITH CHEMOTHERAPY BEFORE THE LUNG CANCERS START TO GROW. HERE IT'S 10 MONTHS. THAT'S FAIRLY TYPICAL. THE RESPONSE RATES ARE MORE THAN DOUBLE. WE GENERALLY QUOTE 60 TO 80% RESPONSE RATES TO PEOPLE WHO HAVE AN EGFR MUTATION. AND THE MEDIAN SURVIVAL IS -- THIS IS NOW STAGE IV, IS ACTUALLY QUITE LONG. IN THIS PARTICULAR STUDY, THERE'S NO DIFFERENCE BETWEEN GIVING CHEMO OR NO STATISTICAL DIFFERENCE BETWEEN GIVING CHEMO VERSUS -- UP FRONT BECAUSE THEN YOU FLIP, SO WHETHER YOU GET THE EGFR INHIBITOR EARLY ON OR LATER IN THE COURSE OF THE DISEASE, AS LONG AS YOU GET IT, IT GIVES YOU THE SAME LEVEL OF EFFICACY. SO NOW WHAT WE DO HAVE, THAT'S THE FIRST THING WE CHECK IN PEOPLE WHO HAVE LUNG CANCER, IF THEY HAVE AN EGFR MUTATION, THEY WILL GET -- BEFORE THEY GET CHEMO. A SECOND MUTATION, WHICH IS ALSO REVOLUTIONIZED CARE IN LUNG CANCER, IS SOMETHING CALLED THE ELM4 ELK FUSION GENE OR TRANSLOCATION. THIS IS SORT OF THE POSTER CHILD FOR TARGETED THERAPY, BECAUSE THIS ABNORMALITY WHICH OCCURS ONLY IN ABOUT 5% OF NON-SMALL CELL LUNG CANCERS, MAINLY IN NEVER SMOKERS, THIS WAS ONLY IDENTIFIED FIVE YEARS AGO. IT IS IN RETROSPECT ASSOCIATED WITH A DISTINCT HISTOLOGY BUT IT'S NOT LIMITED TO THIS RATHER RARE -- HISTOLOGY, BUT AGAIN, THERE ARE DRUGS, THERE IS A DRUG THAT CAN TARGET THIS AB ABNORMALITY, AND IT'S A VERY SIMILAR PICTURE AS WITH -- AND EGFR MUTATIONS, YOU GET ABOUT A 60% RESPONSE RATE. AND IT LASTS ALSO ABOUT EIGHT MONTHS BEFORE YOU GET RESISTANCE RESISTANCE. I DON'T KNOW WHETHER YOU'VE HAD A BREAST CANCER TALK YET, BUT -- IS AN IMPORTANT GENE FOR BREAST CAR SI KNOW GENESIS. IN A SMALL NUMBER OF PEOPLE, MAYBE 4% OF ALL NON-SMALL CELL LUNG CANCERS, THERE'S A MUTATION HRTUNU IN THE TUMORS IN ABOUT 2 TO 5%, THERE IS AMPLIFICATION. THERE ARE STUDIES THAT I CAN POINT TO SHOWING THAT USING AN AGENT AVAILABLE, HERCEPTIN OR -- WHICH TARGETS -- SO I HAVE TO GO TO A CASE REPORT WHICH WAS ACTUALLY ONE OF OUR PATIENTS TB YEARS OLD AT THE TIME, WHO PRESENTED IN 2007 WITH STAGE IV LUNG CANCER, SORT OF AN ODD HISTOLOGY, WAS TREATED IN THE USUAL WAY, HAD A PARTIAL RESPONSE BUT THEN PROGRESSED, ACTUALLY CAME TO OUR CLINIC FOR A STUDY THAT USED A PAN HR INHIBITOR SO IT WAS FOR PEOPLE WHO HAD PROGRESSED BUT IT ALSO HAPPENED TO TARGET HER2/NEU. WHAT WE FOUND WAS HE HAD A PRETTY NICE RESPONSE, ALTHOUGH NOT LONG LASTING, ABOUT SIX OR SEVEN MONTHS, IF I RECALL, BUT WE FOUND THAT HE HAD HER2 LEVELS IN HIS BLOOD THAT WENT DOWN, THAT BASELINE, THEY WERE UP WITH THERAPY THAT WENT DOWN WHEN HE PROGRESSED, THEY WENT BACK UP, AND SO WE CHANGED HIM OVER TO HERCEPTIN, AN APPROVED DRUG. ACTUALLY IT DIDN'T DO ANYTHING, BUT THEN WE GAVE HIM HERCEPTIN AND A CHEMO AGENT, USED FOR LUNG CANCER, AND HE HAD A NEAR COMPLETE RESPONSE FOR 13 MONTHS. SOMETHING THAT IS ESSENTIALLY UNHEARD OF WITH -- ALONE. IN FACT THIS, GENTLEMAN IS STILL ALIVE IN 2012, FIVE YEARS LATER, THREE YEARS, I THINK, SINCE HE WAS STARTED ON HER2 DIRECTED THERAPIES, AND HE'S BEEN TREATED WITH VARIOUS COMBINATIONS OF EITHER HERCEPTIN AND SOME CHEMOTHERAPY AGENT, LAPATMED, ANOTHER HER2/NEU AGENT AND CHEMOTHERAPY, AND SO THIS IS REALLY QUITE THE OUTLIER IN OUR EXPERIENCE. THE REASON I BRING THIS UP IS THAT THESE ARE THE RARE CASES, AND THAT'S THE COMPLEXITY OF LUNG CANCER, THE COMMON ABNORMALITIES, THAT'S EGFR, THAT'S 10%. THAT'S LIKE A HIT. NOW WE'RE TALKING ABOUT 2, 3, 5% OF CASES. ROS1 IS A -- KINASE, PART OF THE INSULIN RECEPTOR FAMILY. LESS THAN 2% OF NON-SMALL CELL LUNG CANCERS HAD REARRANGEMENTS, A WHOLE VARIETY, THAT INVOLVE ROS1. THERE IS A CASE REPORT AGAIN OF A PATIENT TREATED WITH THE EML4 ELK, IT'S ACTUALLY A MET INHIBITOR ALSO BUT IT HAS MULTIPLE -- KINASE INHIBITING ACTIVITY AND HERE'S AN EXAMPLE OF A PATIENT WHO HAD A MAJOR RESPONSE WITH THIS ORAL AGENT IN THIS SETTING OF ROS-1 ABNORMALITIES AS THOSE STUDIES ARE ONGOING. EVERYTHING I TOLD YOU SO FAR REALLY REFERS TO NON-SMALL CELL LUNG CANCER. SMALL CELL HAS BEEN A LITTLE BIT MORE DIFFICULT TO CHARACTERIZE, ALTHOUGH NOW THERE HAVE BEEN MAJOR SEQUENCING EFFORTS THAT IS SHOWN AMONG OTHER THINGS THE FIBROBLAST RECEPTOR -- IS AMPLIFIED IN ABOUT -- IN A FIFTH OF SMALL CELL CARCINOMAS. USUALLY NOT AN ADENOCARCINOMA. AND THERE ARE AGENTS THAT ARE CURRENTLY IN DEVELOPMENT THAT INHIBIT FGFR1 SO THERE IS HOPE THAT WE WILL GET TO TARGETED THERAPIES IN THIS POPULATION. EDR2 IS ANOTHER ABNORMALITY, ANOTHER TYROSINE KINASE THAT HAS MEMUTATIONS IN ABOUT 4% OF SQUAMOUS CELLS. REMEMBER I TOLD YOU THAT'S ONLY ABOUT 20% OF ALL SMALL CELLS SO WE'RE TALKING ABOUT A PRETTY SMALL NUMBER OF -- PRETTY SMALL PERCENTAGE OF CASES, BUT NOT IN A SIGNIFICANT NUMBER OF PATIENTS WHO HAVE THESE ABNORMALITIES. AND IN VITRO, YOU HAVE SENSITIVITY TO DIFATINIB, FOR CHRONIC MY LODGE NUSS LEUKEMIA, A MULTI- -- KINASE INHIBITOR. SO WE ARE SLOWLY MOVING TOWARDS TARGETED THERAPIES. SO LET ME JUST SUM UP. THE APPROACH TO METASTATIC NON-SMALL CELL, FRONT LINE THERAPY, EVEN TODAY, IN 2012, IS ESSENTIALLY CHEMOTHERAPY, CYST PRA TIN OR CAR BOW PLA TICK USUALLY IN COMBINATION WITH ANOTHER AGENT, DOESN'T REALLY MATTER WHICH THAT SECOND AGENT IS, THERE ARE SOME NUANCES DEPENDING ON HISTOLOGY, WHICH -- PREFER, GIVING -- YOU ONLY DO CASES THAT ARE NOT SQUAMOUS IN HISTOLOGY. HOWEVER, WHAT WE NOW ARE STARTING TO DO, AND THAT'S NOT JUST US HERE BUT EVERYWHERE, IS SOME LIMITED MOLECULAR PROFILING. AND SO PEOPLE -- WE LOOK VERY ROUTINELY FOR EGFR ACTIVATING MUTATIONS OR EML4 ELK TRANSLOCATIONS, AND IF THOSE ARE PRET, THEN THE FRONT LINE THERAPIES AND ORAL AGENT THAT TARGETS ONE OF THOSE TWO ABNORMALITIES ABNORMALITIES. GENERALLY, AGAIN, THEY ONLY LAST FOR A PERIOD OF TIME, AND THEN PEOPLE GO ON TO CHEMOTHERAPY. MAINTENANCE CHEMOTHERAPY IS A NEW THING AFTER THE INITIAL TREATMENT. THERE IS SOME LIMITED ADVANTAGE TO SURVIVAL, ALTHOUGH MOST OF US BELIEVE THAT IF YOU FOLLOW PEOPLE CAREFULLY AND INSTITUTE SECOND LINE CHEMOTHERAPY SHORTLY AFTER PROGRESSION, THAT YOU CAN SALVAGE. MOST PEOPLE GIVE THEM SOME TIME OFF TREATMENT, SO THAT'S A LITTLE BIT MORE CONTROVERSIAL. WE DO GIVE MULTIPLE LINES OF TREATMENT, THERE ARE SEVERAL AGENTS APPROVED FOR SECOND LINE. NOT NECESSARILY IN THE SETTING OF AN EGR MUTATION. SO THAT'S SORT OF THE BASIC BIRD'S-EYE VIEW OF LUNG CANCER TREATMENT. WHAT I'D LIKE TO TURN TO NOW IS REALLY PREVENTION PRIMARILY, AND EARLY DETECTION. SO WA CAN YOUR WHAT CAN YOU ACTUALLY DO TO REDEUTS CANCER MORTALITY? IT'S NOT BY TREATMENT OF METASTATIC DISEASE. YOU DON'T REDUCE MORTALITY. YOU EXTEND LIFE BUT YOU DON'T REDUCE OVERALL MORTALITY. IT'S REALLY THROUGH PREVENTION OR EARLY DETECTION THAT YOU CAN ACTUALLY MAKE A DENT ON THOSE HORRIBLY LARGE NUMBERS. SO I'M NOW GOING TO TURN TO THE EARLY PHASES OF LUNG CAR SIN KNOCARCINOGENCYST, GENERALLY FROM TOBACCO, THAT CAUSE IT TO BECOME ABNORMAL. BOTH HISTOLOGICALLY AND MOLECULARLY. SO THE FIRST QUESTION, OF COURSE, IS IF YOU KNOW WHAT THE OFFENDING AGENT IS, FOR 85% OF LUNG CANCERS OR 80% OF LUNG CANCER IS TOBACCO, IS IT -- WHY DON'T YOU JUST STOP SMOKING, RIGHT? A NO-BRAINER, BUT A LITTLE BIT MORE COMPLICATED THAN YOU THINK. SO THIS IS A STUDY CALLED THE LUNG HEALTH STUDY. THIS HAS 14 1/2 YEARS OF FOLLOW-UP. AND WHAT THIS SHOWS IS THAT -- IT WAS A COMPLICATED STUDY IN COPD, BUT THE BOTTOM LINE IS THAT THEY LOOKED AT PEOPLE WHO WERE SUSTAINED QUITTERS, TOBACCO, WHO WERE INTERMITTENT QUITTERS, SO THEY WOULD RELAPSE, WHICH IS A VERY COMMON THING, OR CONTINUE TO SMOKE. AND AFTER 15 YEARS, WHAT YOU SEE IS THAT THE RATE OF DEATH PER 1,000 IS ABOUT HALF IN THE SUSTAINED QUITTERS COMPARED TO THE CONTINUING SMOKERS, AND THERE'S EVEN SOME BENEFIT IN INTERMITTENT QUITTING, ALTHOUGH OBVIOUSLY IT'S NOT ENOUGH. THERE'S OBVIOUSLY BENEFITS FOR CARDIOVASCULAR DISEASE, THOSE HAPPEN QUITE EARLY. WHAT I'M NOT SHOWING YOU IS THE FIVE-YEAR FOLLOW-UP, WHERE THERE IS ABSOLUTELY NO DIFFERENCE IN THE RATE OF DEATHS FROM LUNG CANCER IN SUSTAINED QUITTERS COMPARED TO THE CONTINUING SMOKERS. WHY IS THIS? BECAUSE WHEN YOU SMOKE, YOU SUSTAIN DAMAGE TO YOUR BRONCHIAL EPITHELIUM, AND THAT DAMAGE DOESN'T GET EASILY FIXED. THE MORE YOU SMOKE, THE MORE DAMAGE YOU GET, THE MORE YOUR RISK GOES UP. IT REALLY TAKES QUITE A LONG TIME TO UNDO THE RISK OR TO AVOID THE RISK OF THAT CONTINUING DAMAGE. SO IT'S A LITTLE BIT OF A HARD CONCEPT. I DON'T WANT ANYBODY TO THINK THAT YOU SHOULDN'T STOP SMOKING. YOU'RE NOT GOING TO KIE KEEL OVER FROM YOUR HEART ATTACK TWO YEARS FROM NOW, BUT THE RISK OF LUNG CANCER CONTINUES TO GO UP, AND IT GOES UP BY LARGE AMOUNT, AND IF YOU WANT TO AVOID THE RISK OF DEATH THROUGHOUT YOUR LIFETIME, YOU NEED TO QUIT EARLY. YOU NEED TO NEVER START, BUT THERE ARE THINGS YOU CAN DO, JUST THE EARLIER YOU QUIT, THE MORE LIKELY YOU ARE GOING TO HAVE A BENEFIT. CHANGING BEHAVIOR IS HARD, IT'S CERTAINLY NOT OUR EXPERTISE HERE, SO WE TURN TO THE MEDICAL MODEL, CANCER CHEMO PREVENTION. WHAT THIS IS, THIS CONCEPT, IS IT'S THE USE OF VARIOUS STRATEGIES TO SUPPRESS OR REVERSE THE PROCESS OF CARCINOGENESIS. SO TAKING THOSE LESIONS AND REGRESSING THEM, PREVENTING THEIR DEVELOPMENT IN THE FIRST PLACE, OR SUPPRESSING THE OCCURRENCE OF TRUE NEOPLASTIC LESIONS. SO THE RATIONALE FOR LUNG CANCER CHEMO PREVENTION IS THE FIRST HALF OF THIS TALK. METASTATIC CANCER IS REALLY NOT CURABLE. BUT WE KNOW FROM OTHER DISEASES THAT CANCER IS PREVENTABLE, AND WE KNOW FROM ANIMAL STUDIES, WHICH I'LL SHOW YOU SOME OF, THAT YOU CAN, IN FACT, PREVENT THE DEVELOPMENT OF CANCER EVEN IN THE SETTING OF THE APPROPRIATE CARCINOGENIC EXPOSURE OR MOLECULAR ABNORMALITY IN TRANSGENIC ANIMALS. AND WE ALSO KNOW THAT YOU DON'T GET LUNG CANCER TWO YEARS AFTER YOU START SMOKING, YOU GET IT AFTER A LIFETIME OF SMOKING. IT REALLY STARTS TO GO UP WHEN YOU'RE IN YOUR 50s AND YOU'VE HAD 20, 30-PLUS YEARS OF TOBACCO EXPOSURE. SO THERE IS THIS LONG TIME FRAME FOR -- THAT ONE CAN USE TO INTERVENE. SO THAT'S THE RATIONALE. NOW, IF WE COULD INTERVENE BY CURING CANCER WE WOULDN'T BE TALKING ABOUT TRYING TO PREVENT IT, BUT WE BELIEVE -- WELL, SINCE WE KNOW WE CAN'T CURE CANCER, WE BELIEVE THAT THE EARLIER PHASES, WHICH ARE LESS MOLECULARLY COMPLEX, ARE LIKELY TO BE MORE TREATABLE THAN THE LATE PHASES, WHERE YOU'VE GOT TUMORS THAT WILL GROW ANYWHERE AND EVERYWHERE. SO THERE'S A RATIONALE FOR GOING EARLY. WE ALSO KNOW THE TOXICITY OF THE INTERVENTION IS A VERY IMPORTANT COMPONENT OF OUR THOUGHT PROCESS AS WE CONTEMPLATE PREVENTION. HIGH TOXICITY IS CERTAINLY ASSOCIATED WITH CHEMOTHERAPY AND EVEN WITH THE TARGETED THERAPY TREATMENTS. THAT'S NOT APPROPRIATE FOR SOMEBODY WHO MAY OR MAY NOT DEVELOP LUNG CANCER OR WHO MAY DEVELOP LUNG CANCER BUT IT WON'T BE UNTIL 20 YEARS LATER. SO WHAT KIND OF INTERVENTIONS WE USE ARE DEFINITELY MODULATED BY WHEN DURING THE COURSE OF CARCINOGENESIS. WE INTERVENE, AND WE ALSO KNOW THAT A LOT OF PEOPLE SMOKE, THERE ARE OVER 90 MILLION CURRENT AND FORMER SMOKERS IN THE U.S. RIGHT NOW, BUT NOT NEARLY ALL OF THEM DEVELOP LUNG CANCER. IT'S ABOUT 15% OF ALL SMOKERS. SO MANY ARE AT RISK, RELATIVELY FEW GET CANCER EACH YEAR, AND WE CAN'T RIGHT NOW FIGURE OUT WHICH OF THE SMOKERS ARE THE TRULY HIGH RISK ONES. SO WE NEED TO TARGET OUR INTERVENTIONS APPROPRIATELY, AND THERE IS A LOT OF WORK BEING DONE. THAT'S WHAT I'M GOING TO DESCRIBE TO YOU, BECAUSE THERE IS NO APPROVED CANCER-PREVENTIVE THERAPY RIGHT NOW. OKAY. SO THE MINIMAL REQUIREMENTS FOR PREVENTIVE STRATEGIES, BENEFIT, RIGHT, YOU HAVE TO HAVE EFFICACY IN PREVENTING CANCER AND ITS ASSOCIATED MORBIDITY AND MORTALITY, AND YOU BALANCE THAT WITH RISK. THE LACK OF ADVERSE SIDE EFFECTS THAT INCREASE MORBIDITY AND MORTALITY FROM OTHER DISEASES. IF YOU SUBSTITUTE A HEART ATTACK FOR LUNG CANCER, YOU'RE PROBABLY NOT DOING A GOOD THING. AND THEN THERE'S ALSO THE ISSUE OF TOLERABILITY, YOU KNOW, SO WHAT EVER YOU DO TO A PERSON, THEY'RE GOING TO HAVE SIDE EFFECTS OR SOME PEOPLE WILL HAVE A SIDE EFFECT. THOSE SIDE EFFECTS AFFECT COMPLIANCE. IF I TELL YOU YOU'RE GOING TO HAVE 10 BOWEL MOVEMENTS A DAY, YOU CAN DEAL WITH IT, CHANCES ARE YOU'RE NOT GOING TO TAKE THAT INTERVENTION, AT LEAST NOT FOR LONG. OKAY. SO HOW DO WE GO ABOUT, THEN, IDENTIFYING AGENTS? KNOWLEDGE OF MECHANISM, I DON'T KNOW WHETHER YOU'VE HAD A CERVICAL CANCER TALK, BUT HPV, HUMAN PAPILLOMA VIRUS, IS ABSOLUTELY REQUIRED FOR CARCINOGENESIS. HPV VACCINE THAT PREVENTS INFECTION THAT PREVENTS THE INTRAEPITHELIAL -- AND CERVICAL CANCER. IF YOU HAVE THAT KIND OF CAUSALITY AND CAN DESIGN AN INTERVENTION, THAT WOULD BE GREAT. WE DON'T KNOW THAT FOR LUNG CANCER. BUT THAT'S WHAT WE'RE LOOKING FOR. SO WE TEND TO TURN TO PRECLINICAL MODELS, IN VITRO AND ANIMAL MODELS, WHICH HAVE BEEN SHOWN TO BE EFFECTIVE IN, FOR INSTANCE, PREVENTING COLORECTAL CANCER PREVENTION STRATEGY SUCH AS ASPIRIN AND OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS. WE GO TO OBSERVATIONAL EP DEEM YOL, LOOKING TO SEE WHETHER THERE'S ANY ASSOCIATION BETWEEN THE USE OF CERTAIN DRUGS OR CERTAIN FOODS, ET CETERA, AGAIN, THE ABILITY OF NSAIDS TO PREVENT COLON CANCER INDENSE AND MORTALITY IS WELL REPRESENTED IN THE EPIDEMIOLOGIC LITERATURE. WE ALSO LOOK AT SECONDARY END POINTS FROM CLINICAL TRIALS, INCLUDING THOSE FOR OTHER DISEASES. AND I'LL SHOW YOU A LITTLE BIT OF THAT WITH REGARD TO ASPIRIN AND LUNG CANCER. BUT THAT HAS SERVED US WELL IN THE PAST WITH TAMOXIFEN AND RALOXIFENE, WHICH ARE APPROVED AGENTS FOR BREAST CANCER RISK REDUCTION. SO TO CONTINUE THE THEME THAT DR. HARRIS BEGAN, INFLAMMATION IS KNOWN TO BE VERY IMPORTANT FOR LUNG CARCINOGENESIS, AND ONE OF THE MAIN AREAS THAT WE'VE BEEN WORKING IN IS TARGETING INFLAMMATION FOR LUNG CANCER PREVENTION. WHAT ARE THE DATA? SO THERE ARE MANY ANIMAL STUDIES SHOWING THAT STEROIDS, WHICH DOWNREGULATE INFLAMMATION, CAN BE VERY EFFECTIVE CANCER PREVENTIVE AGENTS. EVEN INHALED, USING INHALED STEROIDS IN LUNG MODELS. THE EPIDEMIOLOGICAL LITERATURE IS NOT AS ROBUST. MOST OF THE STEROIDS ARE INHALED GENERALLY USED FOR ASTHMA, A LITTLE BIT LESS FOR EMPHYSEMA, WHICH IS THE SMOKING-RELATED DISEASE, BUT THERE IS ONE STUDY OUT THERE THAT SHOWED NEARLY -- ABOUT A 60% DECREASE IN RISK OF LUNG CANCER IN PRIMARILY MEN WHO HAD COPD WHO USE INHALED STEROIDS AS OPPOSED TO OTHER ANTIEMPHYSEMA DRUGS. SO THAT'S THE EPI DATA. RILE SHOI'LL SHOW YOU ONE ANIMAL STUDY HERE, WHICH IS USING VINYL CARBOMATE, WHICH IS A CARCINOGEN THAT CAN LEAD TO NOT JUST LUNG ADENOMAS IN MICE BUT LUNG ADENOCARCINOMAS. WHAT YOU SEE HERE IS THAT IN MICE THAT WERE TREATED WITH DIFFERING REGIMENS OF STEROID, BUDESONIDE, IN THIS CASE, ORALLY, YOU CAN GET AS MUCH AS AN 80% DECREASE IN THE NUMBER OF TUMORS, AND THOSE TUMORS ACTUALLY ARE MAINLY ADENOMAS AND NOT CARCINOMAS, SO THE TOTAL NUMBER HAS DECREASED BY 80% AND OF THOSE THAT ARE LEFT, THEY'RE PRIMARILY ADENOMAS AND NOT CARCINOMAS. SO YOU SHIFT THE HISTOLOGY BACKWARDS. SO BASED ON THESE TWO TYPES OF DATA, WE PERFORM A STUDY WITH THE BRITISH COLUMBIA CANCER AGENCY, STEVEN LAM, AND THIS IS HOW A TRUE LUNG CANCER PREVENTION STUDY GOES. SO DR. LAM SCREENED ABOUT A THOUSAND PEOPLE BY SPUTUM PSYCHOLOGY. THOSE WHO HAD ATYPIA, SO ABNORMALITIES IN THE SPUTUM, THEN UNDERWENT BRON COSTCO PEE. BRON COST COST PEE. THAT'S ABOUT HALF OF THEM. IF THEY HAD ABNORMALITIES IN THE BRONG YELL EP THEEL YA, THEN THEY WENT ON TO THE STUDY. SO OUT OF THE THOUSAND WHO WERE SCREENED, 112 EFFICIENTLY WENT ON THE INTERVENTION, AND THIS WAS A BLINDED STUDY. THEY ALSO UNDERWENT HELICAL CT TO LOOK AT THEIR PERIPHERAL LUNG. THEY WERE TREATED FOR SIX MONTHS AND THEN THEY UNWENT A SECOND KRON COSTCO PEE WITH A PRIMARY END POINT OF LOOKING AT THE NUMBER OF SITES AND THE GRADE OF DYSPLASIA. UNFORTUNATELY, WHAT WE FOUND, THIS IS A FAIRLY LARGE UNDERTAKING, THAT THERE WAS NO EFFECT ON DYSPLASIA AFTER SIX MONTHS, BUT THE CT DETECTED LUNG MODULES, THERE WAS A SIGNIFICANT DECREASE IN THE NUMBER OF NODULES. THERE WAS A VERY SIMILAR STUDY PERFORMED IN EUROPE BY ANOTHER GROUP USING A DIFFERENT INHALED STEROID WHERE AGAIN THEY SAW SOMETHING VERY SIMILAR, DECREASE IN THE LUNG NODULES, BUT NOT IN THE KRON KIE BRONCHIAL DYSPLASIA. SO CURRENTLY, THE NEXT STUDY THAT WE DID, WHICH IS NOW THE WAY THAT I THINK WE'RE GOING TO GO FORWARD, AT LEAST FOR TWO OR THREE MORE STUDIES, IS WE DECIDE TO LOOK AT THE PERIPHERAL LUNG. IN THE PERIPHERAL LUNG, WHICH YOU NOW CAN LOOK AT WITH HELICAL CT, WHICH IS A SINGLE BREATHHOLD AND IT'S LOWER RADIATION THAN A REGULAR CT, IT'S QUITE QUICK, YOU CAN OFTEN FIND LITTLE NODULES, 20 TO 30% OF PEOPLE WILL HAVE -- SMOKERS WILL HAVE SOME NODULES. SO WE TEAMED UP WITH JULIA AND COLLEAGUES IN EUROPE IN ITALY TO LOOK AT THESE PERIPHERAL NODULES IN PEOPLE WHO ARE UNDERGOING CT SCREENING. SO THEY WERE GETTING YEARLY CTs, AND THOSE WHO HAD A PERIPHERAL NODULE WERE THEN RANDOMIZED EITHER TO -- PLACEBO FOR A YEAR, AND THEN AT THE NEXT SCREENING, WE WOULD SEE. NO BIOPSIES, JUST LOOKING AT THE NODULES. AND WHAT WE SAW WAS ACTUALLY THE FIRST TIME ANYBODY HAD EVER LOOKED AT THE PERIPHERAL LUNG, BUT WHAT WE SAW GAVE US HOPE, EVEN THOUGH IT WASN'T A HOME RUN. SO THERE ARE THREE DIFFERENT KINDS OF NODULES THAT YOU FIND IN THE LUNG. ONE IS THE SOLID LITTLE THING, ONE IS THE NON-SOLID OR GROUND GLASS-TYPE NODULE, AND THEN THERE'S A COMBINATION. AND WHAT WE SAW IS THAT IN THE NON-SOLID, THE GROUND GLASS OPACITIES, THERE WAS A SIGNIFICANT SHRINKAGE IN THE NODULES, LESS SO IN THE PARTIALLY SOLID AND ABSOLUTELY NO CHANGE IN THE SOLID NODULES. SO OVERALL THE STUDY WAS ALSO NEGATIVE, BUT THERE WAS THIS TREND, AND WHAT IT SHOWS IS WE WERE PROBABLY NOT FOCUSING ON THE RIGHT NODULES, BECAUSE THE SOLID NODULES ARE PROBABLY A LITTLE BIT OF FIBROSIS AFTER SOME PREVIOUS INJURY, WHEREAS THESE GROUND GLASS NODULES, WHICH YOU CAN SEE NOT VERY WELL UP HERE, THIS IS WHAT SOME OF THEM LOOK LIKE UNDER THE MICROSCOPE. SOME OF THEM, ABOUT A QUARTER TO A HALF OF THEM, ARE A PRECURSOR TO ADENOCARCINOMA, SOMETHING KNOWN AS A TYPICAL ADENOMATOUS HYPERPLASIA. NOW AGAIN, WE'RE SEEING ONLY THE CT MANIFESTATION, BUT FOR THE NEXT STUDY, WHAT WE'LL BE LOOKING AT IS THESE KINDS OF NODULES. BECAUSE THAT'S WHERE THE ACTION IS, AND THOSE ARE THE ONES THAT, AFTER TWO YEARS, STILL CONTINUE TO GROW SO PULMONOLOGISTS FOLLOW THESE NODULES REALLY INDEFINITELY AT THIS STAGE. SO WHERE ARE WE GOING WITH STEROIDS? WHY WAS THE STUDY NEGATIVE? IT'S ALWAYS POSSIBLE THAT THE INTERVENTION DOESN'T WORK OR THAT THE FORMULATION DIDN'T GO PERIPHERALLY ENOUGH OR FAR ENOUGH OR THAT WE GAVE IT AT THE WRONG TIME, BUT I THINK WE REALLY FOCUSED ON THE WRONG COHORT, THAT WAS THE FIRST STUDY EVER DONE, SO IN THE NEXT STUDY, WE WILL BE LOOKING AT THESE GROUND GLASS OPACITIES. WE ALSO NEED TO DO A LOT OF WORK TO FIGURE OUT WHAT THESE SMALL GROUND GLASS OPACITIES ARE AND WE'RE DOING SOME LONG-TERM FOLLOW-UP. SO WHAT IS GOING TO BE THE NEXT STUDY? IT'S GOING TO BE ASPIRIN. WHY ASPIRIN? AGAIN, AN ANTI-INFLAMMATORY. THIS IS A META ANALYSIS. THIS IS INDIVIDUAL PATIENT DATA FROM A VARIETY, OVER A DOZEN TRIALS OF PEOPLE WHO WERE GIVEN ASPIRIN VES VERSUS A PLACEBO. ALMOST ALL OF THEM, I THINK AMERICA ALL OF THEM, WERE DONE FOR CARDIOVASCULAR PROTECTION, BUT THEY'D HAVE TO COME FROM SOMEWHERE. WHAT YOU SEE IS IF YOU ACTUALLY READ ONE PAPER ABOUT CANCER PREVENTION, I'D SAY READ THIS ONE, THIS LANCET PAPER FROM PETER ROTH WELL, BECAUSE WHAT HE SHOWED IS WITH MORE THAN FIVE YEARS OF FOLLOW-UP, YOU START TO GET DECREASE IN LUNG CANCERS AND ACTUALLY A VARIETY OF OTHER CANCERS. IN FACT, VARIETY OF ADENOCARCINOMAS, NOT SQUAMOUS CELL CARCINOMAS. THIS IS ABOUT A 30% DECREASE OVER TIME. SO THIS IS PATIENT-LEVEL DATA. SO IF YOU START TO SEE A BENEFIT FIVE YEARS, THIS IS DEATH FROM LUNG CANCER, THEN THESE PEOPLE SH YOU WOULD THINK WOULD BE IDENTIFIED AS HAVING LUNG CANCER WITHIN TWO OR THREE YEARS AS THE LEAD TIME, SO THOSE PREMALIGNANCIES, THOSE LITTLE GROUND GLASS OPACITYS THAT WE WERE MEASURING WOULD HAVE BEEN PRESENT AT TIME ZERO RIGHT HERE. SO WE'RE GOING TO TEST THIS HIGH POTASSIUHYPOTHESIS AND PERFORM THIS STUDY NEXT, AND TWO OR THREE YEARS FROM NOW, I'LL HAVE DATA FOR YOU. OKAY. LET ME SWITCH GEARS. I'M GOING TO TELL YOU ABOUT TWO OTHER DRUGS WHICH WE ARE ACTIVELY STUDYING WHICH I THINK ARE PARTICULARLY INTERESTING. IT'S A GLUCOSE ICE MER, ACTUALLY PRESENT IN FOOD, ADDED TO BABY MILK FORMULA. I'M SURE THAT IT HAS TOXICITIES AS EVERYTHING ELSE. BUT NEVERTHELESS, IT'S A DIETARY COMPONENT THAT IS, QUOTE, GENERALLY REGARDED AS SAFE, GRAPHS, SO THAT'S AB FDA DESIGNATION THAT YOU DON'T HAVE TO DO SPECIAL -- YOU DON'T HAVE TO GET AN INVESTIGATION OR HUGE DRUG APPROVAL FROM FDA TO STUDY THIS DRUG. SO ALL SORTS OF -- SEVERAL SECOND MESSENGERS AND IS INVOLVED IN SIGNALING. IT'S BEEN STUDIED NOT VERY WELL IN A VARIETY OF CONDITIONS. BUT WORK THE LEE WATTENBERG WHO IS ONE OF THE GRANDADDIES OF LUNG CANCER PREVENTION AS FAR AS ANIMAL STUDIES ARE CONCERNED, SHOWED THAT IT CAN INHIBIT CARS GENERAL-INDUCED TUMORS IN MICE, ESPECIALLY WHEN YOU COMBINE THAT WITH BUDEASAMIDE. IT'S ALSO EFFECTIVE IN SMOKING INDUCED MICE TOO, THAT'S A HARD MODEL, BUT THIS IS ONE OF THE FEW AGENTS THAT WAS EFFECTIVE IN THIS SMOKE-EXPOSED MODEL. AND IT'S AS I SAID A FAIRLY SAFE AND RELATIVELY CHEAP DRUG. SO AGAIN WITH STEVEN LAMM AND BRITISH COLUMBIA CANCER AGENCY, WE PERFORMED A PHASE ONE STUDY TO TRY TO IDENTIFY THE RIGHT DOSE -- ACTUALLY WE WENT AT IT THE WAY WE GO THROUGH THEME THERAPY. THE MAXIMAL TOLERATED DOSE, WHICH MAY NOT BE THE RIGHT DOSE BUT AT LEAST IT'S A STARTING PLACE. SO WE FOUND YOU CAN GIVE UP TO 18 GRAMS A DAY, AND IN AN UNCONTROLLED STUDY, AND I DO WANT TO STRESS UNCONTROLLED, EVERY ONE WAS GIVEN IT IN THIS STUDY, WHEN WE COMPARED TO THE SAME POPULATION THAT DR. LAM HAD STUDIED PREVIOUSLY, THE REGRESSION RATE WAS SIGNIFICANTLY -- REGRESSION RATE OF DYSPLASIA WAS SIGNIFICANTLY INCREASED. AGAIN, THIS STUDY WAS MEANT TO LOOK AT SAFETY, IT WAS NOT MEANT TO LOOK AT RESPONSE, BUT WE DID SEE WHAT LOOKED LIKE A PROMISING RESPONSE. ANOTHER INTERESTING SIDE POINT IS WE ACTUALLY SAW A DECREASE IN BLOOD PRESSURE, AND THIS IS NOT A DECREASE TO ABNORMAL BLOOD PRESSURE, BUT MANY ADULTS, BLOOD PRESSURE IS MAYBE A LITTLE BIT LESS THAN -- A LITTLE BIT HIGHER THAN 120/80, WHICH IS THE TEXTBOOK VALUE, SO THIS LEVEL OF BLOOD PRESSURE DECREASED, SO IT WAS AN INTERESTING SIDE EFFECT AND ONE THAT COULD BE A POSITIVE, BECAUSE LOWER BLOOD PRESSURES ARE GOOD FOR CARDIOVASCULAR RISK REDUCTION. SO FROM THIS SMALL STUDY, WE HAD THE GOOD FOREIGN OF TEAMING UP WITH -- WHO LOOKED AT GENE EXPRESSION PATHWAYS, PATHWAYS TO GENE EXPRESSION PROFILES IN THIS PATIENT SUBSET. TO JUST SORT OF GIVE YOU A LOT OF WORK IN A NUTSHELL, WHAT HE FOUND WAS THAT THE PI3 KI KINASE PATHWAY WAS ACTIVATED IN LURNG CANCERS, THE NORMAL EP THEE EPITHELIUM IN SMOKERS WITH LUNG CANCER AND ALSO IN SMOKERS WITH DYSPLASIA COMPARED TO SMOKERS WHO HAD NO EVIDENCE OF DYSPLASIA ON BRON COSTCO PEE AND -- INHIBITED ACTIVATION, SO IT UNDID THIS JUNE SIGNATURE IN PEOPLE FOR WHOM DYSPLASIA REVERSED. SO THIS, I THINK, IS A VERY EXCITING WAY TO HOPEFULLY POINT US TO A FUTURE MORE TARGETED AND MORE MOLECULARLY ORIENTED STUDIES. THE PATHWAY AB ACTIVATION TRULY IDENTIFIED THE SMOKERS AT RISK? IF SO, THAT'S THE POPULATION WE NEED TO STUDY. IT'S EASIER TO GET AT THE NORMAL -- THAN TO ACTUALLY IDENTIFY DYSPLASIAS, WHERE YOU HAVE TO DO MULTIPLE BIOPSIES AND YOU HAVE TO FIND THEM AND THEY'RE NOT ALWAYS THAT VISIBLE DURING BRON COSTCO PEE. YOU ALSO AREN'T REMOVING THE DYSPLASIAS DURING THE BRONCOSCOPIES SO THERE IS A BETTER WAY TO DO THE STUDIES, BUT THE GOAL IS IT HAS THE POTENTIAL TO IDENTIFY THE RIGHT COHORT, BUT IT ALSO GIVES US AN OPPORTUNITY TO DO A NEW KIND OF CLINICAL TRIAL TO LOOK AT THE PATHWAY ANALYSIS PRE AND POST INTERVENTION, LOOKING AT SMALLER NUMBERS OF PARTICIPANTS, SHORTER INTERVENTIONS, IDENTIFYING THE MECHANISMS OF THESE INTERVENTIONS. SO THIS IS WHAT THE SMALL STUDY OPENS AS POSSIBILITIES. WE'RE NOT THERE YET. WHERE WE ARE IS PERFORMING THE STUDY IN A LARGE COHORT IN A BLINDED FASHION, AND THIS STUDY IS CURRENTLY ONGOING WHERE WE'RE AGAIN TARGETING 30-PLUS PACK A YEAR SMOKERS WOULD HAVE DYSPLASIA, WHO ARE GOING TO UNDERGO BRON COSTCO PEE AND HELICAL CT, TREATMENT FOR SIX MONTHS, REPEAT BRONCOSCOPY, AND WE'RE ALSO GOING TO DO THOSE NORMAL BRUSHINGS TO SEE WHETHER THAT PI3 KINASE SIGNATURE IS REALLY THERE, AND WHETHER IT GETS REVERSED WITH SUCCESSFUL REVERSAL OF DYSPLASIA. THIS STUDY IS ABOUT THREE QUARTERS APPROVED AT THIS POINT. OKAY. ONE LAST SHORT STORY. AS TO WHAT ELSE WE'RE STUDYING AND THEN WE'LL BE DONE. SO -- IS ALSO AN INTERESTING TARGET FOR PREVENTION OF LUNG CANCER AND ACTUALLY HEAD AND NECK CANCER. THERE ARE SEVERAL DRUGS, MAINLY ONE STILL BEING USED FOR THE TREATMENT OF TYPE 2 DIABETES MELLITUS. YEARS AGO, I ACTUALLY STUDIED THIS IN VITRO IN CELL LINES AND WE SHOWED THAT THEY CAN INDUCE GROWTH ARREST AND MODULATE THE EXPRESSION OF VARIOUS ANTIGENS THAT ARE CONSISTENT WITH DIFFERENTIATION. THERE ARE ANIMAL MODELS THAT SHOW YOU CAN DECREASE THE INCIDENCE OF HEAD AND NECK TUMORS, TONGUE TUMORS, ALSO LUNG TUMORS, AND THERE'S EPIDEMIOLOGY SHOWING THAT, AGAIN, GOING TO A VETERANS' ADMINISTRATION DATABASE, DIABETICS WHO USED THIS GROUP OF AGENTS COMPARED TO THOSE WHO USED OTHER AGENTS HAD DECREASED RISK OF LUNG CANCER. THAT WAS NOT TRUE FOR COLON OR PROSTATE CANCER. SO WE PERFORMED A SMALL STUDY, THIS IS DONE WITH FRANK ANDRE AT THE UNIVERSITY OF MINNESOTA, AND INSTEAD OF GOING DIRECTLY TO LUNG, WE WENT ACTUALLY TO SOMETHING CALLED ORAL LEUKOMAKE YA, WHICH IS A HEAD AND NECK PRECURSOR LEAGUES. IT'S A PRECURSOR LEAGUES TO ORAL CANCER. AND IN A SMALL PILOT STUDY, OPEN LABEL AGAIN, 22 PATIENTS, THE RESPONSE RATE WAS REMARKABLY HIGH. 80% OF PATIENTS HAD A DECREASE, MORE THAN 50% DECREASE IN SIZE, WHICH GAVE US ENOUGH REASON TO THEN LOOK AT THIS FOR HEAD AND NECK CANCER PREVENTION, BUT ALSO POTENTIALLY FOR LUNG CANCER PREVENTION. SO THESE ARE NOW ANIMAL STUDIES SHOWN IN A LITTLE BIT MORE DETAIL, SHOWING THAT IF YOU USE THESE EITHER IN THE TREATMENT SETTING, SO IN A XENOGRAPH, YOU CAN DELAY THE GROWTH OF TUMORS, OR IN THE SAME FINAL -- TREATED MOUSE ADENOMA ADENOCARCINOMA MODEL, YOU CAN MARKEDLY REDUCE A TUMOR BURDEN IN ANIMALS, AND ALSO IN ANIMALS THAT HAVE P53 MUTATIONS, WHICH ARE MORE PRONE TO DEVELOP LARGER AND FASTER-GROWING TUMORS. SO WE HAVE TWO STUDIES THAT ARE CURRENTLY ONGOING. ONE OF WHICH IS THE ORAL LEUKOMAKE YA PHASE 2B STUDY USING THE MAXIMAL DOSE THAT'S FDA-APPROVED FOR SIX MONTHS, AND WE'RE LOOKING FOR REGRESSION OF THESE ORAL PREMALIGNANT LESIONS, AND THEN WE HAVE A PILOT LUNG STUDY WHERE WE'RE LOOKING AT 20 PEOPLE WHO ARE GOING TO HAVE LUNG CANCER SURGERY, AND WE ARE DOING GENE EXPRESSION ANALYSIS BEFORE AND AFTER TREATMENT, IT'S A SHORT TREATMENT, TWO TO SIX WEEKS PRIOR TO DEFINITIVE SURGERY, AS WELL AS LOOKING AT MULTIPLE OTHER BIOMARKERS IN THE BRONCHIAL EP THEEL WU EPITHELIUM AND IN TH E TUMOR ITSELF. I'M GOING TO VERY BRIEFLY TALK ABOUT EARLY DETECTION BECAUSE THAT'S ACTUALLY THE ONE AREA WHERE THERE HAS BEEN A VERY SIGNIFICANT POSITIVE OVER THE PAST YEAR. LEST YOU THINK THERE'S ANY FREE LUNCH, THERE IS NO FREE LUNCH WHEN IT COMES TO ANY KIND OF INTERVENTION INCLUDING SCREENING. AND THE ISSUES WITH SCREENING ARE THAT EVERYTHING THAT YOU FIND IS NOT NECESSARILY A CANCER, AND EVEN IF IT'S A CANCER, IT MAY NOT BE THE CANCER THAT KILLS YOU. SO IT'S REALLY IMPORTANT TO REMEMBER THAT THERE ARE VARIOUS BIASES THAT ALL SCREENING IS PRONE TO. THERE'S SOMETHING CALLED LEAD TIME BIAS, WHERE YOU GET THE EARLIER DIAGNOSIS, BUT YOU DON'T ACTUALLY POSTPONE DEATH. SO THE SURVIVAL APPEARS SMALLER, BUT PEOPLE STILL -- APPEARS LONGER BUT PEOPLE STILL DIE WHEN THEY WOULD HAVE DIED ANYWHICH BECAUSE YOU DON'T CHANGE THE NATURAL HISTORY OF THE DISEASE. THERE'S SOMETHING CALLED LENGTH BIAS WHERE YOU DIAGNOSE THE MORE INDOLENT DISEASE BECAUSE IT DON'T PODOESN'T POP UP BETWEEN SCREENINGS, THIS HAS A LONGER CLINICAL PHASE SO YOU'RE ABLE TO IDENTIFY IT, WHICH GIVES IT BETTER PROGNOSIS AND A BETTER OUTCOME, BUT IN FACT WHAT YOU'RE MISSING ARE ALL THOSE RAPIDLY PROGRESSIVE CANCERS THAT YOU CAN'T SCREEN FOR. THEN THERE'S SOMETHING CALLED OVERDIAGNOSIS, WHERE YOU IDENTIFY CLINICALLY UNIMPORTANT CANCERS THAT WOULD NOT BE DIAGNOSED OTHERWISE AND WOULD NOT KILL THE PERSON. SO MANY OF YOU MAY KNOW THAT IN PROSTATE CANCER, IF YOU LOOK AT THE PROSTATES OF 80-YEAR-OLD MEN WHO DIE, ALMOST ALL OF THEM HAVE PROSTATE CANCER, AND THE VAST MAJORITY OF THOSE MEN WERE NEVER DIAGNOSED BECAUSE THAT'S NOT WHAT THEY DIE FROM. FROM SOME EXTENT, THIS ACTUALLY OCCURS IN LUNG CANCER, AND WE'RE JUST NOW TRYING TO FIGURE OUT HOW MUCH IT OCCURS. SO THOSE ARE THE THINGS YOU NEED TO KEEP IN MIND, AND THAT'S WHY YOU NEED TO STRUCTURE THE STUDIES APPROPRIATELY. SO THERE HAVE BEEN TWO MAJOR STUDIES THAT REPORTED OVER THE PAST TWO YEARS. ONE IS THE PLCO, THE PROSTATE LUNG COLORECTAL OVARIAN SCREENING TRIAL. WHICH LOOKED AT FOR THE LUNG PART, IT LOOKED AT CHEST X-RAYS VERSUS NO CHEST X-RAYS, USUAL CARE. THIS STUDY HAD 154,000 PARTICIPANTS, ALMOST 155,000. FOUR SCREENS, LONG FOLLOW-UP, AND WHAT YOU SEE HERE, FAIRLY DEFINITIVELY, IS THAT THERE'S NO EFFECT ON LUNG CANCER MORTALITY. THERE'S ALWAYS AN EFFECT ON LUNG CANCER INCIDENCE. YOU DIAGNOSE MORE WITH CHEST X-RAY THAN WITH NOTHING. THAT HAD BEEN SHOWN PREVIOUSLY, BUT YOU DON'T CHANGE DEATH. BUT THE STUDY THAT HAS MADE A HUGE IMPACT, AND WE'RE NOT TRYING TO INCORPORATE THAT INTO ROUTINE CARE, IS THE NATIONAL LUNG SCREENING TRIAL, WHICH LOOKED AT ALMOST 54,000 CURRENT AND FORMER SMOKERS, HIGH RISK, IN THE PAST 15 YEARS, AND WHO UNDERWENT -- WHO HAVE QUIT IN THE LAST 15 YEARS, AND WHO UNDERWENT HELICAL OR SPIRAL CT VERSUS CHEST X-RAY. THE REASON I SHOWED YOU THE PLCO BEFORE WHICH WAS NEGATIVE IS TO SHOW YOU THAT THIS COMPARISON BETWEEN HELICAL CT AND CHEST X-RAY IS STILL A VALID COMPARISON TO NO CARE. THE NLSG RESULTS WHICH WERE REPORTED LAST YEAR, THERE'S A 20% DECREASE IN LUNG CANCER DEATH. AS WELL AS AN OVERALL REDUCTION IN MORTALITY IN THE CT ARM. SO IT'S NOT JUST LUNG CANCER INCIDENCE. FEWER PEOPLE DIED FROM LUNG CANCER. AND THIS IS QUITE SIGNIFICANT. NOW IT COMES AT A COST. 24% OF PEOPLE HAD A POSITIVE TEST. WA DOES A POSITIVE TEST MEAN? IT MEANS THAT THERE'S SOMETHING THERE THAT REQUIRES MORE CTs AND MAYBE A BIOPSY. SO THERE'S A COST TO ALL SCREENING. BUT EVEN WITH THAT TAKEN IN MIND, THERE IS A CLEAR REDUCTION, AND HERE THE -- AND YOU SEE THAT THERE IS A DECREASE IN LUNG CANCER, THAT'S THIS ONE, AND THERE'S A DECREASE IN OVERALL DEATHS -- NO, NO. I'M SORRY. THIS IS THE NUMBER OF CASES, AND THIS IS THE NUMBER OF DEATHS. OKAY? AND THIS WAS ALL DONE THROUGH THREE YEARLY SCREENINGS. SO LOTS OF QUESTIONS REMAIN. HOW DO YOU REALLY MOVE THIS OUT TO THE 90 MILLION CURRENT AND FORMER SMOKERS IN THE UNITED STATES, HOW DO YOU MOVE THIS OUT INTO LOW RESOURCE COUNTRIES, WHO DO YOU REALLY NEED TO SCREEN, HOW LONG DO YOU SCREEN, WHAT HAPPENS AFTER THREE YEARS, IF YOU CONTINUE SCREENING, SHOULD YOU NOT. SO LOTS OF QUESTIONS. BUT THIS IS A SEMINAL RESULT, IT IS CHANGING HOW WE DO BUSINESS, AND IT HAS GREAT POTENTIAL TO REDUCE THE NUMBER OF DEATHS FROM LUNG CANCER. WITH THAT I'M GOING TO STOP AND TAKE ANY QUESTIONS. [APPLAUSE] IT'S BEEN A LONG DAY. THANK YOU FOR STAYING FOR SO LONG.