Why Does the Incidence of Cancer Increase With Age


DNA methylation is one of several epigenetic mechanisms that can control gene expression without changes in DNA sequence.


It has been known for years that age is a leading risk factor for the development of many types of cancer, but why aging increases cancer risk remains unclear. Researchers suspect that DNA methylation, or the binding of chemical tags, called methyl groups, onto DNA, may be involved. Methyl groups activate or silence genes, by affecting interactions between DNA and the cell’s protein-making machinery. According to an article published online in the journal Carcinogenesis (28 November 2013), the accumulation of age-associated changes in a biochemical process that helps control genes may be responsible for some of the increased risk of cancer seen in older people. The study identified DNA methylation sites across the human genome that changed with age and demonstrated that a subset of those sites — the ones that become increasingly methylated with advancing age — are also disproportionately methylated in a variety of human cancers.


According to the authors one can think of methylation as dust settling on an unused switch, which then prevents the cell from turning on certain genes; and if a cell can no longer turn on critical developmental programs, it might be easier for it to become a cancer cell.


The study used blood samples from participants in the Sister Study, a nationwide research effort to find the environmental and genetic causes of breast cancer and other diseases. More than 50,000 sisters of women who have had breast cancer are participating in the study. The study analyzed blood samples from 1,000 women, using a microarray that contained 27,000 specific methylation sites. Results showed that nearly one-third of the sites showed increased DNA methylation in association with age. They then looked at three additional data sets from smaller studies that used the same microarray and found 749 methylation sites that behaved consistently across all four data sets. As an additional check, the authors consulted methylation data from normal tissues and seven different types of cancerous tumors in The Cancer Genome Atlas, a database funded by the National Cancer Institute and the National Human Genome Research Institute.


The authors hypothesized that DNA methylation appears to be part of the normal aging process and occurs in genes involved in cell development. Cancer cells often have altered DNA methylation, but the authors were surprised to find that 70-90% of the sites associated with age showed significantly increased methylation in all seven cancer types. This suggested that age-related methylation may disable the expression of certain genes, making it easier for cells to transition to cancer. The study also determined how fast these methylation events accumulate in cells and found that they occur at a rate of one per year.


For future work, the authors want to examine more samples, using a newer microarray that will explore methylation at 450,000 genomic methylation sites. The additional samples and larger microarray, which will provide 16 times more genomic coverage, will allow them to address whether environmental exposures during adulthood or infancy affect methylation profiles. These additional studies will help scientists better understand why methylation happens as people march toward their retirement years.

Multiple Phenotypes in Phosphoglucomutase 1 Deficiency

Congenital disorders of glycosylation are genetic syndromes that result in impaired glycoprotein production.


A study published in the New England Journal of Medicine (2014;370:533-542) evaluated patients who had a novel recessive disorder of glycosylation, with a range of clinical manifestations that included hepatopathy, bifid uvula, malignant hyperthermia, hypogonadotropic hypogonadism, growth retardation, hypoglycemia, myopathy, dilated cardiomyopathy, and cardiac arrest.


For the study, homozygosity mapping followed by whole-exome sequencing was used to identify a mutation in the gene for phosphoglucomutase 1 (PGM1) in two siblings. Sequencing identified additional mutations in 15 other families. Phosphoglucomutase 1 enzyme activity was assayed on cell extracts. Analyses of glycosylation efficiency and quantitative studies of sugar metabolites were performed. Galactose supplementation in fibroblast cultures and dietary supplementation in the patients were studied to determine the effect on glycosylation.


Results showed that phosphoglucomutase 1 enzyme activity was markedly diminished in all patients. Mass spectrometry of transferrin showed a loss of complete N-glycans and the presence of truncated glycans lacking galactose. Fibroblasts supplemented with galactose showed restoration of protein glycosylation and no evidence of glycogen accumulation. Dietary supplementation with galactose in six patients resulted in changes suggestive of clinical improvement. A new screening test showed good discrimination between patients and controls.


According to the authors, phosphoglucomutase 1 deficiency, previously identified as a glycogenosis, is also a congenital disorder of glycosylation., and that supplementation with galactose leads to biochemical improvement in indexes of glycosylation in cells and patients. In addition, supplementation with complex carbohydrates stabilizes blood glucose. While a new screening test has been developed, it has not yet been validated.

TARGET HEALTH excels in Regulatory Affairs. Each week we highlight new information in this challenging area.


Why FDA Supports a Flexible Approach to Drug Development 

Target Health is thrilled that Dr. Margaret Hamburg quoted the approval of Elelyso (taliglucerase alfa) – for Gaucher disease as an example of FDA’s flexible approach to drug development. Target Health worked strategically with Protalix Biotherapeutics beginning in 2006, and managed the regulatory, nonclinical and clinical programs for this project. FDA approved this orphan drug in 2012 based on two trials with 56 patients.  Elelyso is marketed by Pfizer.


The following is based on Dr. Hamburg’s post in FDA Voice on February 6, 2014.



Margaret A. Hamburg, M.D., Commissioner of the US FDA


We all know that just as every person is different, so too is every disease and every drug. And so FDA was not surprised by the results of a new study published in the Journal of the American Medical Association. The study found that FDA used a range of clinical trial evidence when approving 188 novel therapeutic drugs for 208 indications (uses) between 2005 and 2012. According to Dr. Hamburg, these results are entirely consistent with their regulatory mandate and that these varying approaches to clinical studies to support drug approval is good news, rather than bad news.


Results from the publication in JAMA showed that data to support the approvals were based on a median of two pivotal trials per indication. A pivotal trial presents the most important data used by FDA to decide whether to approve a drug. But when the authors looked more closely, they found that more than a third of these drugs were approved on the basis of a single pivotal clinical trial, while still other trials involved only small groups of patients for shorter durations. Of the approvals studied, the new drug was compared with existing drugs on the market only about 40% of the time. The authors concluded that, based on these results, the ways in which FDA arrived at those approvals “vary widely in their thoroughness.“ Or, in the words of one study author, “Not all FDA approvals are created equally.“ While Dr. Hamburg does think it was actually the author’s intent, a number of commentators framed this as criticism. But Dr. Hamburg said that would be more troubling if FDA used a rigid, “one size fits all“ approach.


People with serious or life-threatening illnesses, particularly those who lack good alternatives, have told FDA repeatedly that they are willing to make some trade-offs in order to gain access. And, of course, “thoroughness,“ such as whether a clinical trial is large enough, is in the eyes of the beholder. There is no reason to expect drugs to be tested on similar numbers of patients, regardless of the disease.


According to Dr. Hamburg, variation in approach to clinical studies demonstrates FDA’s innovative and flexible approach to drug development and approvals. Such an approach was specifically adopted by Congress in the Food and Drug Administration Modernization Act in 1997 and, most recently, in the Food and Drug Administration Safety and Innovation Act in 2012. The FDA of today works with sponsors of new drugs to design a development and review pathway for each drug that best reflects the disease and patients it is intended to treat, the drug itself, and other treatment options. Some of the factors that enter into the calculus include whether the drug treats a rare or serious disease or addresses an unmet need and any previous knowledge we might have about the drug.


Thus, for example, FDA approved Imbruvica (ibrutinib), a treatment for mantle cell lymphoma, last year based on an “open-label, single-arm trial,“ which means that every patient received the treatment and both patients and researchers knew they were receiving it. The results were compared to how well the 111 participating patients had responded to previous treatment for their disease.


And Elelyso (taliglucerase alfa) – for Gaucher disease – was an orphan drug approved in 2012 based on two trials with 56 patients.


In contrast, some trials require large numbers of patients to demonstrate a drug’s effects. This is often the case in studies in patients with a chronic condition such as cardiovascular disease, where larger populations are studied to capture treatment effects. No matter what clinical trial design is chosen, the FDA always applies the same statutory approval standards of safety and efficacy to all drugs seeking to be marketed in the United States.


Increased flexibility does not mean abandoning standards, and it certainly does not mean abandoning science. Just the opposite. FDA needs to employ the best science in ways that will increase efficiency, productivity and its shared ability to find creative solutions to the challenges that confront us. At the end of the day, that is just smart regulation – ensuring that patients can more rapidly have access to the best that science has to offer.

Garlicky Orange Salad with Marcona Almonds, Black Olives and Spices


©Joyce Hays, Target Health Inc.


To lift you out of your winter doldrums, here is a sparkly salad that will perk you and your family up. Its bright hues and dark/light color contrasts, will lift your spirits. Your first bite of crunchy fresh ingredients will please your palate. If your taste buds are willing to accept a mild swirl of spice, enabling the earthiness of olives to mix with the sweetness of oranges (and the pronounced almond flavor of the gourmet Marconas). then, you’re in for an adventure in juxtaposed textures and flavors.


5 navel oranges, peeled and diced
1 cup black salt-cured olives (I used Kalamata), pitted and cut in half
2 or 3 cloves garlic, minced (3 if you love garlic)
1/4 teaspoon kosher salt (optional)
2/3 cup fresh parsley, chopped (next time I’ll use fresh cilantro)
1 teaspoon sweet paprika
1/2 teaspoon ground cumin
Pinch cayenne pepper
2 Tablespoons extra-virgin olive oil
1 cup Marcona almonds, toasted

Combine all the ingredients in a bowl and toss well. Refrigerate to chill, then serve.


Believe it or not, this is easy and quick to make. I would suggest that this beautiful salad, become part of a totally veggie meal. Serve a chilled white wine, (we had a California Sauvignon blanc). with hummus and warm pita bread. Then the Orange/Almond/Olive salad. Serve your favorite pasta, like cappellini with pesto, and an assortment of cheeses with red grapes for dessert. (If you do want a protein, then serve a light white fish, or consider seafood)




Toast to Health, Love and Friendship!

The World Congress of Basic and Clinical Pharmacology


Our friend and colleague Bernd Rosenkranz, MD PhD, FFPM, moved to South Africa from Berlin awhile back and is now Professor and Head, Division of Clinical Pharmacology Department of Medicine, University of Stellenbosch, Tygerberg, Cape Town, South Africa. We worked with Bernd when has was at Jerrini AG and collaborated on their program in Hereditary Angioedema. The product is now marketed by Shire. Bernd told us about The World Congress of Basic and Clinical Pharmacology being held in South Africa this year so we would like to share the following:


The world’s leading pharmacologists are coming to South Africa in July 2014. The World Congress of Basic and Clinical Pharmacology (WCP2014) takes place in Africa for the first time and the five-day global forum will balance the latest scientific discoveries together with important pharmacological fundamentals. This is a unique opportunity to stay abreast of the latest industry developments and gain valuable insight into the African health sectors. Visit http://www.wcp2014.org/ to find out how you can participate in this high profile platform of scientific excellence.



View of Cape Town from the Sea – Courtesy Carolyn Ackerman – Scatterlings Conference and Events



ON TARGET is the newsletter of Target Health Inc., a NYC-based contract research organization (CRO), providing strategic planning, regulatory affairs, clinical research, data management, biostatistics, medical writing and software services, including the paperless clinical trial, to the pharmaceutical and device industries.


For more information about Target Health contact Warren Pearlson (212-681-2100 ext. 104). For additional information about software tools for paperless clinical trials, please also feel free to contact Dr. Jules T. Mitchel or Ms. Joyce Hays. The Target Health software tools are designed to partner with both CROs and Sponsors. Please visit the Target Health Website.


Joyce Hays, Founder and Chief Editor of On Target

Jules Mitchel, Editor

Vanessa Hays, Editorial Contributor




Anatomy of lacrimation, showing:

a) Lacrimal gland

b) Superior lacrimal punctum

c) Superior lacrimal canal

d) Lacrimal sac

e) Inferior lacrimal punctum

f) Inferior lacrimal canal

g) Nasolacrimal canal


Lacrimation, or lachrymation, (from Latin lacrima, meaning “tear“) is the secretion of tears, which serve to clean and lubricate the eyes. Strong emotions such as sorrow, elation, awe and pleasure, as well as irritation of the eyes, laughing, and yawning may lead to an excess production of 1) ___, or weeping. In humans, the tear film coating the eye, known as the precorneal film, has three distinct layers, from the most outer surface:



Name Container(s) Secretors Functions
Lipid layer Oils Meibomian glands (or tarsal glands) Coats the aqueous layer, provides a hydrophobic barrier that envelopes tears and prevents their spilling onto the cheek. These glands are found among the tarsal plates. Thus, the tear fluid deposits between the eye proper and oil barriers of the lids.
Aqueous layer Water and other substances such as proteins (e.g., lipocalin, lactoferrin, lysozyme, and lacritin) Lacrimal gland Promotes spreading of the tear film, the control of infectious agents and osmotic regulation.
Mucous layer Mucins Conjunctival goblet cells Coats the cornea, provides a hydrophobic layer and allows for even distribution of the tear film.



Having a thin tear film may prevent one’s ability to wear 2) ___ lenses, as the amount of oxygen needed is higher than normal, and contact lenses stop oxygen from entering the eye. Eyes with thin tear film will dry out while wearing contact lenses. Special eye drops are available for contact lens wearers. Certain types of contact lenses are designed to let more oxygen through to the eye. The lacrimal glands secrete lacrimal fluid, which flows through the main excretory ducts into the space between the eyeball and lids. When the eyes blink, the lacrimal fluid is spread across the surface of the eye. Lacrimal fluid gathers in the lacrimal lake, and is drawn into the puncta by capillary action, then flows through the lacrimal canaliculi at the inner corner of the eyelids entering the lacrimal sac, then on to the nasolacrimal duct, and finally into the 3) ___cavity. An excess of tears, as with strong emotion, can thus cause the nose to run.


There are three very basic types of tears:



Category Description
Basal tears In healthy mammalian eyes, the cornea is continually kept wet and nourished by basal tears. They lubricate the eye, and help to keep it clear of dust. Tear fluid contains water, mucin, lipids, lysozyme, lactoferrin, lipocalin, lacritin, immunoglobulins, glucose, urea, sodium, and potassium. Some of the substances in lacrimal fluid (such as lysozyme) fight against bacterial infection as a part of the immune system. Lysozyme does this by dissolving a layer in the outer coating, called peptidoglycan, of certain bacteria. It is a typical body fluid with a salt content similar to blood plasma. Usually, in a 24-hour period, 0.75 to 1.1 grams (0.03-0.04 ounce avoirdupois) of tears is secreted; this rate slows with 4) ___.
Reflex tears The second type of tears results from irritation of the eye by foreign particles, or from the presence of irritant substances such as onion vapors, tear gas, or pepper spray in the eye’s environment, including the cornea, conjunctiva, or nasal mucosa, which trigger TRP channels in the ophthalmic 5) ___. It can also occur with bright light and hot or peppery stimuli to the tongue and mouth. It is also linked with vomiting, coughing and yawning. These reflex tears attempt to wash out irritants that may have come into contact with the eye.

The third category, in general, referred to as crying or weeping, is increased lacrimation due to strong emotional stress, pleasure, anger, suffering, mourning, or physical pain. This practice is not restricted to negative emotions; many people cry when extremely happy such as during times of intense humor and laughter. In humans, emotional tears can be accompanied by reddening of the face and sobbing ? cough-like, convulsive breathing, sometimes involving spasms of the whole upper body. Tears brought about by emotions have a different chemical make-up than those for lubrication; emotional tears contain more of the protein-based hormones prolactin, adrenocorticotropic hormone, and leucine enkephalin (a natural painkiller) than basal or reflex tears. The limbic system is involved in production of basic emotional drives, such as anger, fear, etc. The 6) ___ system, to be specific, the hypothalamus, also has a degree of control over the autonomic system. The parasympathetic branch of the autonomic nervous system controls the lacrimal glands via the neurotransmitter acetylcholine through both the nicotinic and muscarinic receptors. When these receptors are activated, the lacrimal gland is stimulated to produce tears.

Crying or weeping (psychic tears)  



A toddler producing tears due to emotional stress or pain



The trigeminal V1 (fifth cranial) nerve bears the sensory pathway of the tear reflexes. When the trigeminal nerve is cut, tears from reflexes will stop, but not emotional tears. Likewise, application of cocaine to the surface of the eye, due to its paralyzing effect on the sensory nerve endings, inhibits the reflex even under exposure to strong tear gases. The motor pathway is autonomic (involuntary), and, in general, uses the pathway of the facial (seventh) nerve in the parasympathetic division. In parasympathetic imitators (such as acetylcholine), more tears are produced, and an anticholinergic drug like atropine inhibits tear production. A newborn infant has insufficient development of nervous control, so s/he “cries without weeping.“ If lacrimal gland malfunctions or is damaged (e.g. by surgery), but does not cause any severe drying of the cornea, it is not a serious matter, for the accessory glands are enough for general secretion. In reflex situations, copious tears are produced mainly in emergencies.


Quality of vision is affected by the stability of the tear film.

“Crocodile tears syndrome“ is an uncommon consequence of nerve regeneration subsequent to Bell’s palsy or other damage to the facial nerve in which efferent fibers from the superior salivary nucleus become improperly connected to nerve axons projecting to the lacrimal 7) ___, causing one to shed tears (lacrimate) during salivation while smelling foods or eating. It is presumed that one would also salivate while crying due to the inverse improper connection of the lacrimal nucleus to the salivary glands, but this would be less noticeable.


Keratoconjunctivitis sicca, known as dry eye, is a very common disorder of the tear film. However, sufferers can experience watering of the 8) ___, which is in fact a response to irritation caused by the original tear film deficiency. Lack of Meibomian gland secretion can mean the tears are not enveloped in a hydrophobic film coat, leading to tears spilling onto the face. Familial dysautonomia is a genetic condition that can be associated with a lack of overflow tears (alacrima) during emotional crying.


In nearly all cultures, crying is seen as a specific act associated with tears trickling down the cheeks and accompanied by characteristic sobbing sounds. Emotional triggers are most often sadness and grief, but crying can also be triggered by anger, happiness, fear, laughter or humor, frustration, remorse, or other strong, intense emotions. In many cultures, crying is associated with babies and children. Some cultures consider crying to be undignified and infantile, casting aspersions on those who cry publicly, except if it is due to the 9) ___ of a close friend or relative. In most cultures, it is more socially acceptable for women and children to cry than men. In some Latin regions, crying among men is acceptable.


Some modern therapy movements such as Re-evaluation Counseling teach that crying is beneficial to health and mental well-being, encouraging it positively. An insincere display of grief or dishonest remorse is sometimes called crocodile tears in reference to an Ancient Greek anecdote that crocodiles would pretend to weep while luring or devouring their prey. In addition, in medical terms, someone is said to have 10) ___tears syndrome as an uncommon consequence of recovery from Bell’s palsy, in which faulty regeneration of the facial nerve causes sufferers to shed tears while eating.


In a research study conducted by the Weizmann Institute of Science in Rehovot, Israel, emotional tears from women have been found to reduce arousal in 11) ___. Also, emotional tears are made up of a different chemical component than those evoked by eye irritants and can relay chemical messages to others. The change in libido could be attributed to a drop in testosterone provoked by the tear chemicals, reducing 12) ___. In the animal world, it has been found that some blind mole rats rub tears all over their bodies as a strategy to keep aggressive mole rats away.


Tear composition varies from tear types. Mainly, tears are composed of water, salts, antibodies and lysozymes (antibacterial enzymes). According to a discovery by Dr. William H. Frey II, a bio-chemist from St. Paul Ramsey medical center in Minnesota, the composition of tears caused by emotion differs from that of tears as a reaction to irritations, such as onion fumes, dust or allergy. Emotional tears are composed of more protein-based hormones, such as prolactin, andrenocorticotropic, and leucine enkephalin (a natural pain killer), which is suggested to be the mechanism behind the experience of crying from emotion making an individual feel better.


Lacrimosa (Requiem) – Wolfgang Amadeus Mozart (lyrics)

(can you listen without shedding a tear?)


ANSWERS: 1) tears; 2) contact; 3) nasal; 4) age; 5) nerve; 6) limbic; 7) glands; 8) eyes; 9) death; 10) Crocodile; 11) men; 12) aggression

William H. Frey II, PhD, and Biological Role of Emotional Tears



Although Charles Darwin, the father of evolutionary theory, thought the crying process itself relieved suffering, he regarded emotional tears as an incidental and purposeless secretion. “This is not an easy view for me to accept,“ Dr. Frey said in an interview here. “Darwin himself showed that evolution doesn’t favor purposeless processes.“ The only other theory of emotional crying, offered by the anthropologist Ashley Montagu, saw tears as a means of lubricating upper respiratory passages that would otherwise be dried out by sobbing. Yet, Dr. Frey pointed out, “Most crying episodes are not associated with sobbing, and sobbing, when it occurs, doesn’t always come before the tears. Also, people who exercise vigorously breathe a lot but without crying.“ Understanding why people cry, Dr. Frey said, is especially important because “in our society men in particular are discouraged from crying. If crying reduced the effect of stress, by suppressing tears we may be increasing our susceptibility to stress-related disorders.“


To gain a better understanding of the role crying plays in human life, Dr. Frey studied “normal“ crying behavior in adult men and women. The several hundred emotionally healthy volunteers were asked to keep a complete record of any tears they shed over the course of a month. As might be predicted, the women in the study reported crying on an average five times more often than the men -five times a month versus approximately once a month. Furthermore, a much higher percentage of men than women did not cry at all in the course of the month. Forty-five percent of the men, but only 6% of the women, shed no emotional tears in the 30-day study. There was also a wide range in crying frequency. Some women did not cry at all and other women cried nearly every day. “These were all normal people without any psychological problems,“ Dr. Frey said. Women reported feeling a “lump in their throat“ when they cried much more often than men did. Women shed flowing tears in about half their crying episodes, but in only 29% of the male episodes did tears actually flow. In the rest, the eyes welled up with tears but the tears were not shed.


“Not only do men cry less often than women but their crying is also less obvious,“ Dr. Frey remarked. Sobbing occurred in only 14% of the women’s crying episodes and 10% of the men’s. More men than women said they were able to stop themselves from crying, and many women said they could make themselves cry without an external cause by thinking sad thoughts. Although men cry less often than women, when they do cry, the crying episodes last as long as a woman’s -about six minutes on the average, Dr. Frey’s study showed. Dr. Frey also explored the relationship between personality and crying behavior and, to his surprise, found absolutely no correlation between various personality characteristics and the frequency of crying. For example, no higher crying frequency was found among people who scored high on scales of stress, alienation, impulsiveness, social distance and social impotence. On average, those who showed some evidence of current depression cried more often, but other depressed people did not cry at all. Nor was any genetic factor revealed in studies of crying behavior among identical and fraternal twins. “This tells us crying frequency is environmentally determined,“ Dr. Frey concluded. The most frequent triggers of crying episodes were interpersonal relations – such as arguments – and watching a movie or television. Accordingly, Dr. Frey said, the peak time for crying was between 7 and 10 P.M. “when people are most likely to be with their significant others and to watch TV or a movie.“


Sadness was the emotion most often associated with crying episodes, accounting for nearly half the total. One in five crying episodes was provoked by happiness, one in 10 by anger, one in 15 by sympathy, one in 20 by anxiety and one in 30 by fear. Eighty-five percent of the women and 73% of the men said they felt better after crying. If Dr. Frey’s theory about the purpose of emotional tears is substantiated by further studies, he said, it bodes ill for societal admonitions like “big boys don’t cry“ and such comforting words as “now, now, don’t cry.“ “We should comfort people without telling them to stop crying,“ Dr. Frey observed. “They do stop crying when they’re comforted.“


While the eyes of all mammals are moistened and soothed by tears, only human beings shed tears in response to emotional stress. Although this fact has been known for hundreds, if not thousands, of years, science has until recently shed little light on the reasons for this uniquely human behavior. In fact, notes Dr. William H. Frey, until last week no study had ever been reported of how often and under what circumstances adults cry. Dr. Frey, a self-appointed student of “psychogenic lacrimation,“ as he calls emotionally induced tears, decided many years ago that it was time to find out why people cry. His theory, for which there is now some indirect evidence, is that tears help to relieve stress by ridding the body of potentially harmful stress-induced chemicals. Dr. Frey, a biochemist, is director of the Psychiatry Research Laboratories at St. Paul-Ramsey Medical Center here. Thus far he has shown that emotionally induced tears have a higher protein content than tears produced in response to eye irritation, such as that caused by a cut onion. And while he has not yet been able to do the costly analyses needed to determine the identity and levels of stress-related chemicals in human tears, at least one new report suggests that people with stress-related illnesses cry less than their healthy counterparts.


Dr. Margaret Crepeau of Marquette University College of Nursing studied 100 men and women with stress-related disorders – 50 with ulcers, 50 with colitis, an inflammation of the colon. She compared them to 50 healthy persons of similar age and life circumstances. As she reported to the American Psychological Association meeting last week in Washington, those with the two stress-related disorders were more likely than the healthy people to regard crying as a sign of weakness or loss of control. And, according to their own reports, those who were ill were less likely to cry in a variety of situations. “What now needs to be done is a study of the actual crying behavior of people with stress-related illnesses,“ Dr. Frey remarked. “People say they feel better after crying, and our data show this is so,“ he continued. He also noted that children with a rare inherited disease called familial dysautonomia show two characteristics that may be related: They cry without tears and they have a highly exaggerated reaction to mild stress.


“Crying is an exocrine process,“ Dr. Frey explained, “that is, a process in which a substance comes out of the body. Other exocrine processes, like exhaling, urinating, defecating and sweating, release toxic substances from the body. There’s every reason to think crying does the same, releasing chemicals that the body produces in response to stress.“ Dr. Frey sees such research as a route to understanding the biochemical basis of emotion and changes in emotional states. He said, “If we can measure the body’s specific excretion in response to stress, it may be a clue to the biochemical changes involved in sadness and joy. By measuring what comes out of the body in response to emotion, we may find out what is happening in the brain.“


QUESTION: Is it true that women’s tears contain an enzyme that can be released only by crying, meaning they are quicker to cry under emotional stress?


ANSWER: A large body of historical research has attributed the difference in men’s and women’s crying habits to social pressures. But one prominent tear researcher, William H. Frey II, who theorized three decades ago that crying had a stress-relieving excretory function, thinks there is a hormonal difference at work as well.


Both men and women have more of certain chemicals in the tears they shed because of emotional reasons, as opposed to those shed in response to physical stimuli, like onion fumes. Among these substances are the hormones prolactin (associated with milk production) and adrenocorticotropic hormone (ACTH), and the neurotransmitter leucine enkephalin, all of which are released when the body is under stress.


The author of “Crying: The Mystery of Tears“ (Winston, 1985), Dr. Frey speculates that because women’s tears show significantly higher levels of prolactin between the ages of 15 and 30, the difference could be associated with frequent tears, to excrete the excess. It has also been suggested that prolactin itself stimulates tears in both genders.

TCGA Bladder Cancer Study Reveals Potential Drug Targets


Approximately 72,000 new cases of bladder cancer will be diagnosed in the United States in 2014 and is estimated to cause more than 15,000 deaths. Tobacco is a major risk factor for bladder cancer; more than 70% of the cases analyzed in this study occurred in former or current smokers.


The Cancer Genome Atlas (TCGA) Research Network is a collaboration jointly supported and managed by the National Cancer Institute (NCI) and the National Human Genome Research Institute (NHGRI), both parts of the National Institutes of Health. According to a study published online in Nature (29 January 2014), investigators with the TCGA Research Network have identified new potential therapeutic targets for a major form of bladder cancer, including important genes and pathways that are disrupted in the disease. The study examined bladder cancer that invades the muscle of the bladder, the deadliest form of the disease. The current standard treatments for muscle-invasive bladder cancer include surgery and radiation combined with chemotherapy. There are no recognized second-line therapies — second choices for treatments when the initial therapy does not work — and no approved targeted agents for this type of bladder cancer. The authors also discovered that, at the molecular level, some subtypes of bladder cancer — also known as urothelial carcinoma — resemble subtypes of breast, head and neck and lung cancers, suggesting similar routes of development.


The study analyzed DNA, RNA and protein data generated from the study of 131 muscle-invasive bladder cancer from patients who had not yet been treated with chemotherapy. The authors found recurrent mutations in 32 genes, including nine that were not previously known to be significantly mutated. They discovered mutations in the TP53 gene in nearly half of the tumor samples, and mutations and other aberrations in the RTK/RAS pathway (which is commonly affected in cancers) in 44% of tumors. TP53 makes the p53 tumor suppressor protein, which helps regulate cell division. RTK/RAS is involved in regulating cell growth and development.


The authors also showed that genes that regulate chromatin — a combination of DNA and protein within a cell’s nucleus that determines how genes are expressed — were more frequently mutated in bladder cancer than in any other common cancer studied to date. These findings suggest the possibility of developing therapies to target alterations in chromatin remodeling.


Overall, the authors identified potential drug targets in 69% of the tumors evaluated. They found frequent mutations in the ERBB2, or HER2, gene. The authors also identified recurring mutations as well as fusions involving other genes such as FGFR3 and in the PI3-kinase/AKT/mTOR pathway, which help control cell division and growth and for which targeted drugs already exist.


Because the HER2 gene and its encoded protein, HER2 — which affects cell growth and development — are implicated in a significant portion of breast cancers, scientists would like to find out if new agents under development against breast cancer can also be effective in treating subsets of bladder cancer patients.


The authors also uncovered a potential viral connection to bladder cancer. It is known that animal papilloma viruses can cause bladder cancer. In a small number of cases, DNA from viruses — notably, from HPV16, a form of the virus responsible for cervical cancer — was found in bladder tumors. This suggests that viral infection can contribute to bladder cancer development.

NCI Launches Trial to Assess the Utility of Genetic Sequencing to Improve Patient Outcomes


Very few types of tumors have just one mutated gene that triggers cancer progression. Once a gene is mutated, it can lead to the activation of multiple pathways, resulting in disease progression and potentially requiring multiple interventions.


A pilot trial to assess whether assigning treatment based on specific gene mutations can provide benefit to patients with metastatic solid tumors is being launched this month by the National Cancer Institute (NCI), part of the National Institutes of Health. The Molecular Profiling based Assignment of Cancer Therapeutics, or M-PACT, trial is one of the first to use a randomized trial design to assess if assigning treatment based on genetic screening can improve the rate and duration of response in patients with advanced solid tumors. A trial in which patients are randomly assigned to various treatment options is the gold-standard method for determining which treatment option is best.


The study hopes that, in addition to the knowledge gained from the trial about assigning therapy based on results of genetic sequencing of tumors, this trial could identify patient sub-groups that are likely to benefit from certain treatments and result in new treatments being developed quickly for some cancers. This could ultimately lead to smaller, more definitive clinical trials, which would be helpful to clinicians and patients in terms of cost and time.


The M-PACT trial is designed to determine whether people with specific mutations that have been demonstrated in laboratory systems to affect drug effectiveness will benefit from a specifically chosen targeted intervention and if these interventions lead to better outcomes. Ater screening hundreds of people, 180 patients with advanced refractory solid tumors (those resistant to standard therapy) will be enrolled based on their genetic profile. During the screening process, samples of the tumors will be genetically sequenced to look for a total of 391 different mutations in 20 genes that are known to affect the utility of targeted therapies. If mutations of interest are detected, using a molecular sequencing protocol for tumor biopsy samples evaluated by the U.S. FDA, those patients will be enrolled in the trial and randomly assigned to one of two treatment arms to receive one of the four treatment regimens that are part of this study.


To ensure that patients receive the best treatment already known to provide benefit, patients with specific tumor types should have received certain therapies prior to being enrolled in NCI’s M-PACT. For instance:


1. Patients with melanoma whose tumors have mutations in the V600E region of the BRAF gene should have received and progressed on a specific BRAF inhibitor therapy to be eligible for NCI’s M-PACT trial.

2. Patients with lung cancer should have had their tumors tested for the presence of EGFR and ALK gene mutations, and, if mutations were detected, they should have received and progressed on therapies targeting EGFR or ALK, respectively.


Patients with all types of solid tumors will be considered for trial eligibility. For the randomization, patients will be assigned to Arm A (they will receive a treatment regimen prospectively identified to target their specific mutation or relevant pathway) or Arm B (they will receive a treatment regimen not prospectively identified to target their specific mutation or relevant pathway). Patients in Arm B will have the option to cross over to Arm A to receive therapy identified to target their specific mutation or relevant pathway if their disease progresses on their initial study treatment. As of January 2014, the study is open for patient accrual. Clinicians hope that they can rapidly enroll patients and report results of their findings by 2017.

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FDA Approves First Treatment for Non-24 hour Sleep-Wake Disorder in Blind Individuals


Although most people who are totally blind still can perceive light well enough to prevent Non-24-hour sleep-wake disorder (non-24), there may be as many as 100,000 individuals in the United States with this condition who can’t perceive enough light to establish a normal night sleep schedule.


Non-24 is a chronic circadian rhythm sleep disorder, classified within Chapter VI, Diseases of the Nervous System, in the ICD-10. It is defined as a “complaint of insomnia or excessive sleepiness related to abnormal synchronization between the 24-hour light-dark cycle and the endogenous circadian rhythms of sleep and wake propensity.“ Symptoms result when the non-entrained (free-running) endogenous circadian rhythm drifts out of alignment with the desired or conventional sleep-wake schedule. However, the sleep pattern can be quite variable; some individuals adopt a sleep pattern that is congruent with their free-running circadian clock, shifting their sleep times (usually later), thereby minimizing their sleep symptoms but suffering major social and occupational consequences. The majority of patients with non-24 are totally blind, and the failure of entrainment is explained by an absence of photic input to the circadian clock. However, the disorder can also occur in sighted people for reasons that are not well understood. Non-24 can occur at any age.


Though often referred to as non-24, it is also known by the following terms:

1. Free running disorder (FRD)

2. Hypernychthemeral disorder

3. Circadian rhythm sleep disorder – free-running type

4. Circadian rhythm sleep disorder – nonentrained type

5. Non-24-hour circadian rhythm disorder


The FDA has approved Hetlioz (tasimelteon), a melatonin receptor agonist, to treat non-24 in totally blind individuals. This is the first FDA approval of a treatment for the disorder. Those with non-24 may have difficulty falling asleep or staying asleep, and may wake up groggy or feeling as if they need more rest. People with non-24 may find their sleep patterns reversed — needing to sleep during the day and to be awake at night.


The effectiveness of Hetlioz was evaluated in 104 participants in two clinical trials of totally blind individuals with non-24 disorder. In the trials, treatment with Hetlioz resulted in significant improvement compared to placebo (inactive pill), both in increasing nighttime sleep and decreasing daytime sleep duration. In clinical trials, the most common side effects reported by patients treated with Hetlioz were headache, elevated liver enzymes (alanine aminotransferase) in the blood, nightmares or unusual dreams, disturbed night’s sleep, upper respiratory or urinary tract infection, and drowsiness. Hetlioz can impair activities that require complete mental alertness and should be taken at the same time every night before bedtime and activities should be limited after taking the drug.


Hetlioz was reviewed under priority review. Priority review provides for an expedited review of drugs that treat serious conditions and have the potential to provide significant improvement in safety or effectiveness of the treatment, diagnosis, or prevention of such serious conditions. Hetlioz also received orphan-product designation by the FDA because it is intended to treat a rare disease or condition.


Hetlioz is manufactured by Vanda Pharmaceuticals, Inc. of Washington, D.C.

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