Mechanisms of Cancer Treatment Related Fatigue Lisa J

Mechanisms of Cancer Treatment Related Fatigue Lisa J. Wood Ph. D RN FAAN Amelia Peabody Professor for Nursing Research School of Nursing, MGH Institute of Health Professions

Fatigue: Definition “Cancer related fatigue is a distressing persistent subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning” National Comprehensive Cancer Network, 2011 http: //www. nccn. org/professionals/physician_gls/pdf/fatigue. pdf

Cancer Treatment Related Fatigue • Occurs in greater than 60% of cancer patients undergoing treatment with cytotoxic chemotherapy, and/or radiation therapy, or cytokine therapies. • Responsible for reduced Qo. L, reduced physical functioning, and is perceived as more distressing than pain, nausea and vomiting. • Patterns of fatigue during treatment, worse in the days following chemotherapy returning to baseline before the next infusion. • In approximately 20 -30% of cancer survivors, fatigue can persist for months or even years after treatment has ended. • • Fatigue is an obstacle for physical activity. Importance of understanding mechanisms.

Chemotherapy induced IL-1β as the trigger of cancer chemotherapy related fatigue Sickness Behavior Anemia Decreased Appetite Muscle Loss Chemotherapy IL-1β Systemic Inflammation Fatigue Difficulty Thinking Depression Sleep Problems Decreased Physical Activity

Interleukin-1β triggers sickness behavior Cytokines interact with specific populations of neurons in the brain to cause the signs and symptoms of sickness behavior. Harmful stimulus i. e. bacteria, tissue injury, Intracellular contents and other “Danger Signals” Release of mature IL-1β into the periphery stimulates the production of IL-1β and other inflammatory cytokines i. e. TNF-α. Production of acute phase reactants by the liver i. e. CRP and coagulation factors. Macrophage Gene expression IL-1 Receptor Increased production & maturation of immune cells Wood LJ, and Weymann K. Inflammation and neural signaling: Etiologic mechanisms of the cancer treatment related symptom cluster. Curr Opin Support Palliat Care, Curr Opin Support Palliat Care. 2013 Mar; 7(1): 54 -9

Identification of the “Fatigue” Neuron? Grossberg AJ, Zhu X, Leinninger GM, Levasseur PR, Braun TP, Myers MG, Jr, et al. Inflammation-induced lethargy is mediated by suppression of orexin neuron activity. J Neurosci 2011 Aug 3; 31(31): 11376 -11386. Orexin neurons regulate arousal and wakefulness. They are active during wakefulness and silent when asleep When orexin Neurons are active they make and secrete a neurotransmitter called orexin. Hypothalamus Inflammation causes orexin neurons to produce less orexin. Less orexin means more fatigue. Injecting orexin into the rodent brain decreases fatigue in rodents with sickness behavior 1.

Hypothesis Cancer chemotherapy causes fatigue by inducing inflammation and decreasing the activity of hypothalamic orexin neurons.

Does Chemotherapy trigger IL-1β production by immune cells and if so how? Incubate cells with different Chemotherapy drugs and inflammatory inhibitors. Collect macrophages From mice bone marrow Collect the culture fluid and cells and measure IL 1β levels. Macrophages from mice genetically engineered to lack specific proteins can be used to determine the specific role of these proteins in chemotherapy Induced IL-1β production.

Chemotherapy triggers IL-1β by macrophages Widespread cell death releases cell components which act as danger signals warning macrophages to take action. Toll-Like Receptors Cytotoxic Chemotherapy also activates the inflammasome which cleaves pro-IL-1β to its mature form. Chemotherapy activates an enzyme called ZAK which increases production of pro. IL-1β ZAK inhibitors nilotinib and sorafenib decrease IL-1β production. IL-1β Inflammasome macrophage � Gene expression Pro Pro IL-1β Sauter AD, Wood LJ, Wong J, Iordanov M, and Magun BE. Doxorubicin and daunorubicin induce processing and release of interleukin-1β through activation of the NLRP 3 inflammasome. Cancer Biol Ther. 2011 Jun 15; 11(12): 1008 -16. Wong J, Smith LB, Magun EA, Engstrom T, Kelley-Howard K, Jandhyala DM, Thorpe CM, Magun BE, Wood LJ. Small molecule kinase inhibitors block the ZAK-dependent inflammatory effects of doxorubicin. Cancer Biol Ther. 2013 Jan; 14(1): 56 -63

Does Chemotherapy Increase Circulating IL-1β? CAF or NS by Intraperitoneal injection Collect peripheral blood at 1, 3, 6, 14, and 24 hrs after injection. Measure serum levels of inflammatory cytokines and chemokines using bead based immunoassays (Milliplex, Millipore Inc. ) CAF: Cytoxan (167 mg/kg) + Adriamycin 4 mg/kg) + 5 -fluorouracil (167 mg/kg) NS: Normal Saline

CAF increases serum levels of IL-1β, TNF-α, and IL-6 Figure 1. CAF-induced IL-1β, TNF-α, and IL-6 production in mice. A) Fold increase in serum levels of IL-1β, TNF-α, and IL-6 in CAF-treated relative to NStreated mice sacrificed at 1, 3, 6, 14 and 24 hours post-injection. Smith LB, Leo MC, Anderson C, Wright TJ, Weymann KB, & Wood LJ. The role of IL-1β and TNF-α signaling in the genesis of cancer treatment related symptoms (CTRS); a study using cytokine receptor-deficient mice. Brain, Behavior & Immunity, 2014 Jan 7. [Epub ahead of print]. Elsea CR, Kneiss JK, & Wood LJ. Induction of IL-6 by cytotoxic chemotherapy is associated with cachexia in tumor-free female mice. (Acepted with revisions)

Is CAF induced inflammation associated with fatigue? Assess voluntary wheel running activity (VWRA), food intake and body weight in female mice administered 4 doses of CAF at 21 -day intervals. Minimitter, Bend Oregon

Patterns of change in fatigue, body weight, & food intake in mice administered CAF or NS CAF-induced changes in CTRS in mice. A. ) Daily VWRA, body weight, and food intake during baseline (B), and 4 cycles (C 1 C 4) of CAF (n= 17, filled square) or NS (n=17, open diamond). Each data point represents the mean of each value. *p<0. 05 Acute No Persistent MCP-1 KC IL-7 IL-9 GCSF IP 10 - -

Blocking the CAF-induced inflammatory response • IL-1 type 1 receptor (IL 1 R 1: B 6. 129 S 7 -Il 1 r 1 tm 1 Imx) • IL 1 R 1 and TNF-α p 55 (type 1) receptor (TNFR 1: B 6; 129 S-Tnfrsf 1 atm 1 Imx Il 1 r 1 tm 1 Imx/J) • Jackson Laboratories, Bar Harbor Maine. www. Jax. org

Blocking IL-1β and TNF-α activity dampens CAF-induced inflammation 12 Fold increase (Relative to Controls) 10 Normal (7, 7) IL-1 receptor deficient (5, 5) IL-1 and TNF-deficient (7, 7) *** 8 *** 6 * 4 2 *** ** ** * 0 -2 GCSF IL-6 KC MCP-1 Fold increase in serum levels of GCSF, IL 6, KC and MCP-1 in CAF-treated relative to NS-treated WT, IL-1 R 1 - and IL-1 R 1/TNFR 1 -deficient mice sacrificed 16 hours postinjection. The number of mice in the NS and CAF treated groups for each genotype are indicated in parentheses respectively. (*p < 0. 05, **p<0. 001, ***p<0. 0001).

Blockade of IL-1β and TNF-α signaling reduces survival in CAF treated mice 80 80 60 p=0. 197 40 20 0 Normal Saline (n=9) Normal Chemo (n=9) IL-1 R 1 null Saline (n=9) IL-1 R 1 null Chemo (n=9) 1 2 3 Treatment Cycle % Survival 100 60 40 20 4 p=0. 003 0 Normal Saline (n=9) Normal Chemo (n=9) TNF/IL-1 Rnull Saline (n=9) TNF/IL-1 Rnull Chemo (n=9) 1 2 3 Treatment Cycle 4

Targeting the “Fatigue” Neuron? Inflammation Hypothalamus Awake Fatigued Grossberg AJ, Zhu X, Leinninger GM, Levasseur PR, Braun TP, Myers MG, Jr, et al. Inflammation-induced lethargy is mediated by suppression of orexin neuron activity. J Neurosci 2011 Aug 3; 31(31): 11376 -11386.

CAF reduces CSF orexin-A ip CAF/ IHC sham (Ox. A/c. Fos) CSF-AM lights off 1630 1930 1800 0600 CSF Ox-A CAF [Ox. A]-RIA Diurnal pattern: CSF Orexin-A highest at end of active period Weyman KB, Wood LJ, Zhu X, & Marks DL. A role for orexin in cytotoxic chemotherapy-induced fatigue. Brain, Behavior & Immunity (In Press).

CAF reduces c-Fos Expression in Orexin Neurons PFA LHA Sham DMH CAF 3 V Orexin c. Fos Orexin Ab stains orexin neurons green c. Fos Ab stains active cells Weyman KB, Wood LJ, Zhu X, & Marks DL. A role for orexin in cytotoxic chemotherapy-induced fatigue. Brain, Behavior & Immunity (In Press).

Ox-A replacement restores activity in CAF-treated rats icv Ox. A 1730 ip. CAF 24 h ambulatory act. lights off 1800 IHC (Ox. A/c. Fos) 1930 CSF-AM [Ox. A]-RIA lights on 0600 Weyman KB, Wood LJ, Zhu X, & Marks DL. A role for orexin in cytotoxic chemotherapy-induced fatigue. Brain, Behavior & Immunity (In Press).

Suppressed orexin neuron activity in persistently fatigued mice PFA LHA CAF Sham DMH Orexin c. Fos Orexin Ab stains orexin neurons green c. Fos Ab stains active cells Weyman KB, Wood LJ, Zhu X, & Marks DL. A role for orexin in cytotoxic chemotherapy-induced fatigue. Brain, Behavior & Immunity (In Press).

Conclusions • Chemotherapy triggers IL-1β production by immune cells which leads to a systemic inflammatory response. • Acute fatigue is associated with increased circulating levels of inflammatory markers but not persistent fatigue. • Blocking chemo-induced inflammation decreases survival. • Targeting neural effectors of inflammatory cytokines may be a more beneficial approach to decreasing chemo-related fatigue. • Acute chemo-related fatigue is associated with decreased orexin in the CSF and orexin replacement decreases acute chemo-related fatigue.

The Team Lillian M. Nail Ph. D RN FAAN Professor OHSU SON Logan Smith Ph. D Kris B. Weymann Ph. D RN MS Instructor OHSU SON John Wong Ph. D Assistant Professor IHP SON Daniel Marks Professor OHSU SOM Bruce Magun Ph. D Professor, IHP SON

Acknowledgements • Xinxia Zhu • Caroline Anderson BSN • Teresa Wright BSN Funding • NINR NR 012479 (LJW) • NRSA NINR F 31 NR 013299 (KW, Nail/Wood Mentors)

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