Smoking and cervical cancer health disparity Subhash C. Chauhan Sanford Research/USD May 31, 2013

Over-view: • Sanford Heath and Sanford Research/USD

Sanford Health and Sanford Research/USD •

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Sanford Health is an integrated health system headquartered in the Dakotas and is now the largest rural, not-for-profit health care system in the nation with locations in 126 communities in seven states Sanford Health includes 35 hospitals, 140 clinic locations and nearly 1,200 physicians in 70 specialty areas of medicine. With more than 25,000 employees, Sanford Health is the largest employer in North and South Dakota. The system is experiencing dynamic growth and development in conjunction with Denny Sanford's nearly $700 million in gifts, the largest ever to a health care organization in America. These gifts are making possible the implementation of the several initiatives including global children's clinics, multiple research centers and finding a cure for type 1 diabetes and breast cancer.

http://www.sanfordhealth.org/About

• South Dakota: Population of 824,000 • Native American: 8.9 % (73,300 people)

Cervical Cancer • Globally: Cervical Cancer is the 2nd most common cancer among women – Per year, approximately 470,000 new cases, 233,000 deaths – Majority of cases occur in the developing world – In many developing countries, cervical cancer is the leading cause of cancer mortality in women – Screening programs have not been successfully established • In the United States, during 2011 – ~ 12,710 cases of invasive cervical cancer were diagnosed – ~ 4,290 women in the US died • Strong correlation between infection with a high risk genotype of Human Papillomavirus and Cervical Cancer • Development of the GARDASIL HPV vaccine (targeting HPV 16/18 and 11/6) prevents HPV infection and therefore reduces cervical cancer and genital warts caused by these genotypes of HPV – Promising, however, cervical cancer screening will still be important… http://www.cancer.org Cancer Statistics, 2011. Siegel et al. CA Cancer J Clin 2011;61:212-236

Cervical Cancer 1999–2008 Incidence Rates* by Race and Ethnicity, U.S.,

Rate per 100,000

Average Incidence and Mortality of Cervical Cancer in South Dakota (2007 - 2009) 25

Mortality Rates* by Race and Ethnicity, U.S.,

20 15 10

5 0 Incidence Mortality Caucasian American Indian

Data from SD Department of Health (2007 to 2009).

US Data retrieved 10/23/12 from http://www.cdc.gov/cancer/cervical/statistics/race.htm

Percentage of U.S. Women Aged 18 Years and Older Who Have Had a Pap Test in the Last 3 Years by Race and Ethnicity

Available data suggests a similar or higher rate of cervical cancer screening is obtained for American Indian women living in South Dakota. Data retrieved 10/23/12 from http://www.cdc.gov/cancer/cervical/statistics/screening.htm

HPV is more commonly detected in AI women and HPV Positive AI women have higher rates of abnormal PAP tests Prevalence of HPV 48 %

% Positive

50 40 30

23 %

20 10 0 Caucasian

AI

% of HPV Positive Women

60

HPV Positive Women with an Abnormal PAP Test 30 25% 25 20 15

12%

10

5 0 Caucasian

AI

Smoking Rates Prevalence of Smoking Percent

60

49%

40

20

12%

0 Caucasian

AI

Percent HPV Positive by Age Group 80% 60% 40% 20%

0% 18-24

25-34

35-44

Caucasian

45-+

18-24

25-34

35-44 AI

45-+

% of HPV infections 30

0 6 11 16 18 26 31 33 35 39 40 42 45 51 52 53 54 55 56 58 59 61 62 64 66 67 68 69 70 71 72 73 81 82 83 84 IS39 CP6108

Prevalence of HPV Genotypes (% Based on Positives) Caucasian AI

25

20

15

10

5

Natural Progression of HPV Infection and a Role for Chemoprevention…

Maher et al, Advances in Gynecological Oncology; 2010 Control of Human Papillomavirus gene expression by transcription factors and the upstream regulatory region

• HPV E6/E7 from high risk HPV genotypes are required for the development of cervical cancer – Most famous pathways • E6 – degrades p53 (tumor suppressor) • E7 – interferes with retinoblastoma protein (tumor suppressor) – Other important pathways • E6 – activation of telomerase, degradation of proteins with PDZ domains (roles in cell signaling and adhesion) • E7 - up-regulation of AKT pathway, and interactions with various cell signaling molecules (cyclin A and E, p27, p21 etc.)

• Reducing the amount of HPV E6/E7 should be beneficial in interrupting the development of invasive cervical cancer.

Curcumin (diferuloyl methane)

Maheshwari, et al. 2006. Life Sciences.

Curcumin treatment suppresses cervical cancer cell growth in monolayer and organotypic raft culture systems B. SiHa SW756 HeLa C33A Caski

120 100

% Change

* 80

*

60

C.

DMSO

2 µM Curcumin

40

Caski SiHa

1.0

* 5 µM Curcumin

*

1.2

10 µM Curcumin

*

20

Clonogenic Potential

A.

0.8

*

0.6

*

0.4

*

0.2

*

0.0 0

0 10

D.

20 40 Curcumin (µM) DMSO Control

Collagen

80

20 µM Curcumin

Collagen

Maher et al, Molecular Carcinogenesis, 50:47–57 (2011)

5 10 Curcumin (µM)

40 µM Curcumin

Collagen

15

A PLGA nano-formulation of Curcumin effectively suppresses cervical cancer cell growth 120 100

% Change

80 5 10 15

60 40 20 0 DMSO

Curcumin

PLGA

Micromolar concentrations

MTS assay 24 hours after treatment

Nanocurcumin

Curcumin treatment induces apoptosis in cervical cancer cells via caspase-mediated signaling. 24 hr

A. DMSO

B. 10 µM

24 hr 7AAD Staining

50 *

116 kDa 89 kDa

% Dead Cells

35 kDa Caspase 3

*

30

40 µM

24 hr D 10 20 40

PARP

40

20 µM

C.

17/19 kDa

20 Caspase 9

10

47 kDa 37 kDa 17 kDa

0 DMSO

10 20 µM Curcumin

40

β-actin

45 kDa

*p