Calreticulin and JAK2V617F Driver Mutations Induce Distinct Mitotic Defects in Myeloproliferative Neoplasms

Kristin Holl, Nicolas Chatain, Susanne Krapp, Anja Scheufen, Nathalie Brock, Steffen Koschmieder, Daniel Moreno-Andrés

Abstract
Myeloproliferative neoplasms (MPNs) encompass a diverse group of hematologic disorders driven by mutations in JAK2, CALR, or MPL. The prevailing working model explaining how these driver mutations induce different disease phenotypes is based on the decisive influence of the cellular microenvironment and the acquisition of additional mutations. Here, we report increased levels of chromatin segregation errors in hematopoietic cells stably expressing CALRdel52 or JAK2V617F mutations. Our investigations employing murine 32D MPL and human erythroleukemic TF-1MPL cells demonstrate a link between CALRdel52 or JAK2V617F expression and a compromised spindle assembly checkpoint (SAC), a phenomenon contributing to error-prone mitosis. This defective SAC is associated with imbalances in the recruitment of SAC factors to mitotic kinetochores upon CALRdel52 or JAK2V617F expression. We show that JAK2 mutant CD34 + MPN patient-derived cells exhibit reduced expression of the master mitotic regulators PLK1, aurora kinase B and PP2A catalytic subunit. Furthermore, the expression profile of mitotic regulators in CD34 + patient-derived cells allows to faithfully distinguish patients from healthy controls, as well as to differentiate primary and secondary myelofibrosis from essential thrombocythemia and polycythemia vera. Altogether, our data suggest alterations in mitotic regulation as a potential driver in the pathogenesis in MPN.

Introduction
Philadelphia chromosome-negative myeloproliferative neoplasms (Ph-neg. MPNs) are a heterogeneous group of clonal hematopoietic disorders clinically subdivided into polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF) [1]. The mutations in the genes of the Janus kinase 2 (JAK2), calreticulin (CALR), or the thrombopoietin receptor (TPOR/MPL) are driver mutations of these diseases [2, 3]. Their occurrence and variant allele frequency, together with specific bystander mutations, determine the clinical features, disease severity, and whether these disease evolve with dismal prognosis and decreased survival[3–6], towards secondary myelofibrosis (SMF), secondary acute myeloid leukemia and/or secondary solid tumors [7, 8]. The main pathogenic molecular signaling event of Ph-neg. MPNs is the constitutive activation of JAK2- STAT-dependent signaling pathways by mutations in CALR, JAK2 or the MPL receptor [2, 3]. Yet, noncanonical mechanisms of mutant JAK2[9], and CALR[10] have been recently linked to aspects of the disease pathology. However, the molecular mechanisms of the phase transition towards acute disease states are poorly defined [2, 5].

In contrast to other myeloid neoplasms such as primary acute myeloid leukemia (AML) [11, 12], myelodysplastic syndromes [13, 14] or chronic myeloid leukemia [15, 16], the cytology and molecular status of mitosis in Ph-neg. MPNs has not been studied in detail. However, karyotype abnormalities likely caused by chromatin segregation defects due to defective mitosis are present in up to 5% of ET, 20% of
PV, and 57% of PMF cases at the time of diagnosis [4, 17, 18] and accumulate over time, especially at blast-phase transformation[19–22] and frequently are associated with unfavorable prognosis and decreased survival[23–25]. Therefore, mitotic defects induced by driver Ph-neg. MPN mutations could play a role in the pathological mechanisms and contribute to the phase transition. Mitosis is tightly regulated by the crosstalk between the kinases Aurora B, CDK1 (cyclic dependent kinase 1)-Cyclin B1, and Polo-Like Kinase 1 (PLK1), and the protein phosphatase PP2A, as well as by the spindle assembly checkpoint (SAC) [26, 27]. The latter constitutes a protein network recruited to chromosome kinetochores to ensure proper chromosome-spindle attachments and accurate chromatin segregation. It includes several evolutionarily conserved proteins, like BubR1, Aurora B, MAD1, MAD2, MPS1, CDC20 and kinesin motor proteins, such as CENP-E, which are required for precise SAC function [26, 28]. Precise maintenance of the molecular equilibrium in gene expression and accurate subcellular positioning of these mitotic regulators play a critical role in preserving chromosome integrity and ensuring the stability of the karyotype [16, 28–30]. Consequently, defects in mitotic regulation promote chromosome instability (CIN), acquisition and evolution of heterogeneous karyotypes, inflammation, and epigenetic dysregulation. All these pathological mechanisms are linked to the malignant transformation in many solid cancers [31–33]. Similarly, hematological malignancies [16] such as AML [11, 12] and myelodysplastic syndromes [13, 14], show defects or dysregulation in crucial mitotic factors linked to CIN and heterogeneous karyotypes. Here, we have analyzed the mitotic cytology in murine and human cells stably expressing CALRdel52 or JAK2V617F and found error-prone mitosis. The examination of the molecular status of key mitotic regulators suggests defective SAC function. Also, CD34 + Ph-neg. MPN patient cells display differential expression profiles of a subset of important mitotic regulators, including the SAC components BUB1, MAD2L1, INCENP, CDC20, CDK1, PLK1 and Aurora A/B.

Results
CALRdel52 and JAK2V617F 32D MPL cells have a stresssensitive and error-prone mitosis To investigate chromatin segregation and the duration of mitosis, we performed long term live-cell imaging of murine 32D MPL cells (Fig. 1A) for a duration of 20 h followed by image analysis. In comparison with control 32D MPL (EV) cells, 32D MPL cells transduced with CALRdel52 or JAK2V617F showed a slight and non-significant increase in the numbers of chromatin bridges and lagging chromosomes (Fig. 1B). In contrast, the percentage of telophase micronuclei is significantly increased in the JAK2V617F mutant cell (p < 0.008, Fisher´s exact test). The occurrence of all three kinds of chromatin segregation errors further increases significantly in comparison to EV when DNA damage is induced with the chemotherapeutic agent doxorubicin [34] (p < 0.05, Fisher´s exact test), or SAC malfunction with the antimitotic drug NMS-P715 [35] (p < 0.02, Fisher´s exact test), which inhibits the checkpoint kinase MPS1 (Fig. 1B). The average mitotic timing in untreated cells or upon treatment with doxorubicin or MPS1 inhibitor is similar between mutants and control (EV) transfected cells (Supplementary Fig. S1). As expected, treatment the SAC inhibitor NMS-P715 reduced the mitotic timing with respect to untreated samples (Supplementary Fig. S1). These data suggest that mitosis in CALRdel52 and JAK2V617F mutant 32D MPL cells is stress sensitive. A weakened SAC contributes to error-prone mitosis in murine 32D
MPL CALRdel52 and JAK2V617F cells JAK2V617F [9, 36] and CALRdel52 [37] mutations have been linked to increased ROS production. In
addition, JAK2V617F is also linked to replication stress[38], and to lower p53 levels, a factor which is critical for the DNA damage response[39]. Replication stress and DNA damage signalling pathways, together with mitotic dysregulation, are well-known sources of karyotype aberrations such as aneuploidy, CIN, and genomic instability [40]. Therefore, we investigated whether the observed error-prone mitosis in CALRdel52 and JAK2V617F cells after doxorubicin treatment could be due to an altered response to DNA damage or replication stress.

First, we tested whether CALRdel52 or JAK2V617F transduced 32D MPL cells show increased levels of double-strand breaks during entry into mitosis as compared to control (EV) cells by immunofluorescence staining of γ-H2AX (H2AX S139ph) a well-described marker for DNA damage [41]. Visual inspection of γH2AX foci in untreated prometaphase EV and mutant cells revealed similar low levels of DNA damage. As
expected, the number of γ-H2AX foci increased to a similar extent in control (EV) and mutant cells after doxorubicin treatment (Supplementary Fig. S2A). In agreement with the literature [39], p53 basal levels in untreated JAK2V617F cells were much lower than in control EV cells or CALRdel52 (Supplementary Fig. S2B, Supplementary Figure S8). After doxorubicin treatment, p53 levels increased more than four-fold in all the cell lines. These results indicate that DNA damage is similarly induced by doxorubicin in control (EV) and mutant cells during mitotic entry and all cells showed a comparable functional stabilization of p53 after genotoxic stress. To test whether defects in SAC could contribute to the observed increase of chromatin segregation errors in CALRdel52 and JAK2V617F mutant cells, we challenged them with the spindle poison nocodazole. Cells with a weakened or defective SAC escape faster from the nocodazole induced mitotic arrest [29, 42]. Nocodazole treatment induced mitotic arrest in all three cell lines, but compared to control (EV) cells (257 ± 45 min), CALRdel52 (210 ± 36 min, p < 0.02 one-way ANOVA) or JAK2V617F (186 ± 35 min, p < 0.0001) transduced 32D MPL cells showed significantly shorter mitotic arrest and faster mitotic exit (Fig. 2A, B). The outcomes of mitotic arrest induced with microtubule inhibitors are diverse among cancer and normal cell lines due to the different pathways they induce [43, 44]. The current ‘competing networks-threshold’ model proposes that cell fate determination of – either cell death or extended survival – hinges on which of the two thresholds is reached first: either the activation of pro-apoptotic caspases or the degradation of cyclin B1 leading to mitotic slippage [43, 45]. To discriminate between these two options, we directly analyzed the fate of individual cells under mitotic arrest. The fraction of cells with mitotic death after mitotic arrest upon nocodazole treatment is very low (< 10%) and without significant differences between control (EV), CALRdel52, and JAK2V617F cells (two-way ANOVA with Dunnet post test) (Fig. 2C). In all conditions the arrested cells mostly escaped mitotic arrest by mitotic slippage without significant differences between the different cell types (two-way ANOVA with Dunnet post test) (Fig. 2C).

It has been proposed that murine cells are naturally more resistant than human cells to mitotic poisons due to the presence of clearance systems [46]. Therefore, we determined whether cyclin B1 accumulation was different between control (EV) and CALRdel52 or JAK2V617F cells after 3 hours of nocodazole treatment, which is the lower average time the cells (JAK2V617F cells, Fig. 2A) spend in mitotic arrest
before they undergo slippage. Cyclin B1 accumulated similarly in all three cell lines (Fig. 3A). Once accumulated, cyclin B1 was degraded faster in cells expressing CALRdel52 and JAK2V617F mutations (Fig. 3B; Supplementary Fig. S3; Supplementary Fig. S6) suggesting that a weakened SAC contributes to the error-prone mitosis in these cells.

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Incyte To Spotlight More Than 40 Hematology And Oncology Abstracts Including A Plenary Presentation At The ASH Annual Meeting

November 2, 2023

– Sixteen oral presentations, as well as a plenary session and poster presentations, highlight new advances across eight of the Company’s medicines

– Plenary Scientific Session will feature the full data from AGAVE-201 evaluating axatilimab, an anti-CSFR-1R monoclonal antibody, in patients with chronic graft-versus-host disease (GVHD)

– Incyte to host an in-person analyst and investor event on Monday, December 11, 2023 from 12:00-1:30 p.m. PT to discuss key data presentations at ASH

WILMINGTON, Del.–(BUSINESS WIRE)–Nov. 2, 2023– Incyte (Nasdaq:INCY) today announced that more than 40 abstracts highlighting data from eight of its hematology and oncology products will be presented at the upcoming 65th American Society of Hematology Annual Meeting 2023 (ASH 2023), held December 9-12, 2023, in San Diego and virtually.

“We have continued to make significant progress in advancing our hematology and oncology pipeline with the goal to deliver better medicines for a range of diseases that have limited treatment options, including myeloproliferative neoplasms (MPNs) and chronic graft-versus-host disease (GVHD),” said Pablo J. Cagnoni, M.D., President and Head of Research and Development, Incyte. “We are excited to showcase the depth of our portfolio and clinical progress at this year’s ASH congress. In particular, we look forward to the presentation of the axatilimab AGAVE-201 trial results in patients with chronic GVHD at the Plenary Scientific Session, as well as the numerous oral and poster presentations including new data for our mutant CALR, BET, ALK2 and CK0804 programs in MPNs. Additionally, we are proud that the first presentation of data for INCB160058, our new potentially disease modifying JAK2V617F therapy for patients with MPNs, will be at this year’s meeting.”

Select key abstract presentations from Incyte-developed and partnered programs include:

Plenary Scientific Session

Axatilimab

Safety and Efficacy of Axatilimab at 3 Different Doses in Patients with Chronic Graft-Versus-Host Disease (AGAVE-201)1 (Abstract #1. Plenary Scientific Session. Sunday, December 10, 5:00 p.m. – 7:00 p.m. ET)

Oral Presentations

Ruxolitinib (MPN)

A Real-World Evaluation of Risk Factors for Disease Progression in Patients with Polycythemia Vera (PV) Enrolled in REVEAL (Abstract #385. Session: 906. Outcomes Research – Myeloid Malignancies: Risk Factors and Health Disparities. Saturday, December 9, 7:00 p.m. ET)

Phase 1/2 Study of the Activin Receptor-Like Kinase-2 Inhibitor Zilurgisertib (INCB000928, LIMBER-104) as Monotherapy or with Ruxolitinib in Patients with Anemia Due to Myelofibrosis (Abstract #624. Session: 634. Myeloproliferative Syndromes: Clinical and Epidemiological: Charting The Future Of MPN Therapies. Sunday, December 10, 8:45 p.m. ET)

Bromodomain and Extra-Terminal (BET) Inhibitor INCB057643 (LIMBER-103) in Patients with Relapsed or Refractory Myelofibrosis (R/R MF) and Other Advanced Myeloid Neoplasms: A Phase 1 Study (Abstract #750. Session: 634. Myeloproliferative Syndromes: Clinical and Epidemiological: Treatment and Outcomes in MPNs. Monday, December 11, 2:45 p.m. ET)

Ruxolitinib (GVHD)

Ruxolitinib in Patients with Chronic Graft-Versus-Host Disease: Three-Year Final Analysis of Efficacy and Safety of the Phase 3 REACH3 Study2 (Abstract #654. Session: 722. Allogeneic Transplantation: Acute and Chronic GVHD, Immune Reconstitution: Innovative Approaches to GVHD Prevention and Treatment. Sunday, December 10, 8:45 p.m. ET)

Tafasitamab

Tafasitamab for the Treatment of Relapsed/Refractory (R/R) Diffuse Large B-cell Lymphoma (DLBCL) in the U.S. Real-World Setting (Abstract #265. Session: 905. Outcomes Research – Lymphoid Malignancies: Outcomes Research in Lymphoma/CLL: Biomarkers, Dosing Strategies, and Big-Data. Saturday, December 9, 5:00 p.m. ET)

Itacitinib

Itacitinib for the Prevention of Immune Effector Cell Therapy-Associated Cytokine Release Syndrome: Results from the Phase 2 INCB 39110-211 Placebo-Controlled, Randomized Cohort (Abstract #356. Session: 705. Cellular Immunotherapies: Late Phase and Commercially Available Therapies: Prediction and Management of CAR-T Cell Related Toxicity. Saturday, December 9, 7:15 p.m. ET)

INCB160058

Preclinical Evaluation of INCB160058 – A Novel and Potentially Disease-Modifying Therapy for JAK2V617F Mutant Myeloproliferative Neoplasms (Abstract #860. Session: 631. Myeloproliferative Syndromes and Chronic Myeloid Leukemia: Basic and Translational: Lineage Tracing and Novel Target Discovery. Monday, December 11, 6:00 p.m. ET)

Poster Presentations

Ruxolitinib (MPN)

Effect of New or Worsening Anemia on Clinical Outcomes in 2,233 Patients with Myelofibrosis (MF) Treated with Ruxolitinib in the Expanded-Access JUMP Study (Abstract #5174. Session: 906. Outcomes Research—Myeloid Malignancies: Poster III. Monday, December 11, 9:00 p.m. – 11:00 p.m. ET)

Ruxolitinib Treatment in Polycythemia Vera Results in Reduction in JAK2 Allele Burden in Addition to Improvement in Hematocrit Control and Symptom Burden (Abstract #4553. Session: 634. Myeloproliferative Syndromes: Clinical and Epidemiological: Poster III. Monday, December 11, 9:00 p.m. – 11:00 p.m. ET)

High Rate of Disease Progression in Patients with Low-Risk Myelofibrosis (MF) Enrolled in the Prospective, Real-World, MOST Study Abstract #3803. Session: 906. Outcomes Research—Myeloid Malignancies: Poster II. Sunday, December 10, 9:00 p.m. – 11:00 p.m. ET)

Progression to Myelofibrosis in Patients with Essential Thrombocythemia: A Real-World Analysis from the Prospective MOST Study (Abstract #2433. Session: 906. Outcomes Research—Myeloid Malignancies: Poster I. Saturday, December 9, 8:30 p.m. – 10:30 p.m. ET)

Clinical and Disease Characteristics of Patients With Myelofibrosis and Essential Thrombocythemia that Harbor a Calreticulin (CALR) Gene Mutation: Subanalysis of the MOST Study (Abstract #3812. Session: 906. Outcomes Research—Myeloid Malignancies: Poster II. Sunday, December 10, 9:00 p.m. – 11:00 p.m. ET)

Comparison of the Enzymatic and Cellular Profiles of Clinical JAK2 Inhibitors for the Treatment of Myelofibrosis (Abstract #4532. Session: 631. Myeloproliferative Syndromes and Chronic Myeloid Leukemia: Basic and Translational: Poster III. Monday, December 11, 9:00 p.m. – 11:00 p.m. ET)

ALK2 and JAK2 Inhibition for Improved Treatment of Anemia in Myelofibrosis Patients: Preclinical Profile of an ALK2 Inhibitor Zilurgisertib in Combination with Ruxolitinib (Abstract #1789. Session: 631. Myeloproliferative Syndromes and Chronic Myeloid Leukemia: Basic and Translational: Poster I. Saturday, December 9, 8:30 p.m. – 10:30 p.m. ET)

The Association between Blood Cell Counts and Thrombotic Events in Japanese Patients with Polycythemia Vera: A Retrospective Database Study2 (Abstract #3191. Session: 634. Myeloproliferative Syndromes: Clinical and Epidemiological: Poster II. Sunday, December 10, 9:00 p.m. – 11:00 p.m. ET)

Tafasitamab

Real-World Use of Tafasitamab (tafa) for Relapsed or Refractory (R/R) Diffuse Large B-cell Lymphoma (DLBCL) Among Racial and Ethnic Minorities in the United States (Abstract #2415. Session: 905. Outcomes Research – Lymphoid Malignancies: Poster I. Saturday, December 9, 8:30 – 10:30 p.m. ET)

Tafasitamab in Combination with a CD20xCD3 Bispecific T-cell Engager Significantly Prolongs Survival in Preclinical Lymphoma Models3 (Abstract #2813. Session: 605. Molecular Pharmacology and Drug Resistance: Lymphoid Neoplasms: Poster II. Sunday, December 10, 9:00 – 11:00 p.m. ET)

Pemigatinib

Deep and Durable Cytogenetic and Molecular Responses with Pemigatinib in Myeloid/Lymphoid Neoplasms with Fibroblast Growth Factor Receptor 1 Rearrangement: The FIGHT-203 Study (Abstract #4551. Session: 634. Myeloproliferative Syndromes: Clinical and Epidemiological: Poster III. Monday, December 11, 9:00 p.m. – 11:00 p.m. ET)

Ponatinib

Long-term Results From the OPTIC Trial: A Dose-Optimization Study of 3 Starting Doses of Ponatinib4 (Abstract #3164. Session: 632. Chronic Myeloid Leukemia: Clinical and Epidemiological: Poster II. Sunday, December 10, 9:00 – 11:00 p.m. ET)

Ponatinib Versus Imatinib in Patients with Newly Diagnosed Ph+ ALL: Subgroup Analysis of the Phase 3 PhALLCON Study4 (Abstract #2871. 614. Acute Lymphoblastic Leukemias: Therapies, Excluding Transplantation and Cellular Immunotherapies: Poster II. Sunday, December 10, 9:00 – 11:00 p.m. ET)

Itacitinib

Janus Kinase (JAK) 1 Inhibition Results in Significant Changes in Serum Proteins and Peripheral T-Cell Populations that Correlated with Clinical Scores in Chronic Graft-Versus-Host Disease (GVHD) Patients (an Analysis from GRAVITAS-309) (Abstract #2197. Session: 722. Allogeneic Transplantation: Acute and Chronic GVHD, Immune Reconstitution: Poster I. Saturday, December 9, 8:30 – 10:30 p.m. ET)

Axatilimab

Axatilimab Ameliorates Inflammation and Fibrosis by Targeting the Macrophages in a Preclinical Model of Chronic GVHD (Abstract #2540. Session: 201. Granulocytes, Monocytes, and Macrophages: Poster II. Sunday, December 10, 9:00 – 11:00 p.m. ET)

CK0804

A Phase 1b, Open-Label Study of Add on Therapy with CK0804 in Participants with Myelofibrosis and Suboptimal Response to Ruxolitinib5 (Abstract #1813. Session: 634. Myeloproliferative Syndromes: Clinical and Epidemiological: Poster I. Saturday, December 9, 8:30 – 10:30 p.m. ET)

More information regarding the congress is available on the ASH website: https://www.hematology.org/meetings/annual-meeting. This in-person event will be broadcast virtually and access to the meeting’s virtual platform is included with registration.

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Patients on Medicaid Disproportionately Affected by Drug Shortage

November 2, 2023

Brielle Benyon

A new survey conducted by the American Cancer Society Cancer Action Network (ASC CAN) found that many patients in active cancer treatment reported being affected by the ongoing drug shortage, with patients insured by Medicaid being disproportionately affected.

“One of the most salient insights that we received here is that this is not affecting everybody equally,” Mark Fleury, policy principal for the ACS CAN said in an interview with CURE®.

A higher percentage of patients on Medicaid were affected by the cancer drug shortage than those who were insured by their employer.

The survey, which was conducted in September 2023, included survey responses from 1,222 patients and survivors of cancer who have been diagnosed with or treated for cancer within the last seven years. The findings showed that while 10% of overall patients in active treatment were affected by the chemotherapy shortage, patients insured by Medicaid were more impacted by it, with 18% stating that they were affected.

“We have a very tight supply chain. There’s really no buffer there, so every vial that’s made has to be distributed,” Fleury explained. “There are (cancer treatment) sites that are large enough to have someone keep an eye on shortages, but not every institution has that. … It seems that institutions that are maybe smaller or have fewer resources or personnel to be chasing down these drugs are the ones that are the most impacted. And institutions with less resources oftentimes are serving patients with less resources as well.”

Fleury mentioned that cancer drug shortages put unnecessary stress on patients and their families during an already stressful time, and patient-provider communication is key.

“Patients (should have) individual conversations with their providers about how to move forward, and obviously every patient and every cancer type is different. Some have appropriate solutions, and some don’t.”

Regardless of insurance type, the most common way people were affected by the drug shortage included:

  • Delayed or missed treatment (reported by 45% of respondents who were affected, including 38% of this population who faced delays of one month or longer)
  • Using an alternate drug (23%; with 68% reporting that they and their medical teams were not able to find an effective substitute)
  • Faced difficulty using their insurance to fill a prescription related to the shortage, such as delays in covering an alternative drug (35%)
  • Continued the medication with a dose change (6%)

The survey, which was published in October, also included quotes from patients who participated. One individual said, “My doctor’s office only gets enough for one patient a month. I’m currently set to get mine in over six months.” Another person said, “(The shortage) has extended my treatment, which adds to the stress level and horrible side effects.”

However, some individuals — approximately 40% of those surveyed — said that their issues related to cancer drug shortages have since been resolved and their drug is now available to them.

“I think we may be slowly moving away from reducing the number of patients who aren’t able to get the drugs that they need. But I think we’re just going up to that slightly better level where the system is still super fragile. And any additional disruptions … could bring us back and patients not getting them,” Fleury said, mentioning that the ACS CAN is investigating solutions that can fix this problem in a more robust way.

“There (are) short term fixes (for) people who need (cancer drugs) today. … It took us years and even decades to get here. It’s going to take us years to get us out. So we’re looking at both short, shorter and long-term solutions to try and get us away from the brink where we’ve been living, frankly, for quite a while.”

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Early to Bed, Early to Rise

By Natalie Giocondo

“Early to bed, early to rise, makes a man healthy, wealthy, and wise.” -Benjamin Franklin.

As the last few leaves of autumn fall, and we barrel headlong into the busyness of the holidays, let’s take a moment to welcome the shortening of days and changing seasons. Flowing from a time of harvest to a time of suspension Winter presents us with the opportunity to pause. Just as the animals hibernate and the plants go dormant, we too are invited by the late sunrises and early sunsets to tuck in for some deep relaxation and sleep.

Getting a good night’s rest promotes physical health and overall well-being; unfortunately, it can be a challenge and maybe particularly challenging for MPN patients. According to the National Institutes of Health (NIH), sleep affects every system in the body, and lack of sleep correlates with several issues of interest to the MPN community, including high blood pressure and cardiovascular disease. The NIH also suggests that insomnia is an unmet need in communities with chronic hematological cancers. In 2017, a study conducted by Dr. Krisstina Gowin echoed that unmet need when 52.1 % of her MPN participants reported trouble staying asleep, and another 33.7% said they had difficulty falling asleep, while 31.2% mentioned having insomnia. 

Here are some tried and true healthy sleep habits:

  • Stay on a sleep schedule. Go to bed and rise at the same time each day. I, for one, begin heading to bed earlier once the cold sets in and the roosters are crowing a little later in the morning. 
  • Create an environment for sleep. Dark, quiet, cool, and without electronics works best. 
  • Get enough exercise during the day. If you don’t already have an exercise routine, I highly recommend Justin Grinnell’s Moderate-Impact webinar to get you started. 
  • Avoid stimulation. This could be anything from caffeine to nicotine to watching the news or engaging in heated conversations too close to bedtime. 
  • Eat early. This point cannot be understated! Some patients with MPNs report digestive issues that interfere with sleep. Giving your body plenty of time to process before heading to bed may be worth a try.

Yoga Nidra

A less well-known practice to encourage deep rest and cultivate sleep is yoga nidra. The words yoga nidra mean yoga (to yoke) and nidra (to sleep). It brings up images of a little yogi cowboy lassoing sleep, or a sleep herder. This practice was brought to the US in the 1960s by Swami Satchidadnanda and popularized by practitioners like Nischala Joy Devi (Deep Relaxation), and Dr. Richard Miller (iRest Yoga Nidra).

The practice requires the practitioner to lie in a comfortable resting position while a guide verbally takes them on a gentle journey through 6 phases of meditation: preparation, intention, rotation of consciousness, breath awareness, sensation awareness, visualization, and dropped mind awareness.

While not studied in the MPN population, studies on yoga nidra have suggested benefits such as reduced perceptions of pain, positive effects on blood pressure, pulse, and respiration rates, reduction in erythrocyte sedimentation (which detects the level of inflammation in the body), and has cured chronic insomnia in some people. 

If you are curious about yoga nidra and would like a little taste, please join me on Thursday, November 16th at noon ET, when we will host a 30-minute guided yoga nidra practice. 

 

Supporting the Patient’s Psychosocial Needs Throughout MPN Treatment

October 31, 2o23

Rebecca Testi, MSN, APN, APN-G

Patients with myeloproliferative neoplasms (MPNs) — a rare form of blood cancer — may lack specific met needs when it comes to psychological care. Providers and caregivers can start by validating patients with MPN to help diminish psychosocial needs, according to Rebecca Testi, MSN, APN, APN-G, Hackensack Meridian Health.

“I think education is really key with the patients, you as the nurse or nurse practitioner clinician really need to be able to tell patients, the depression is a side effect of the disease itself. Not you necessarily being sick, but truly like an underlying disease process. So I think it all starts with really good education, about disease process, treatment, support options, things like that,” explained Testi.

With patients who have MPNs, psychosocial help can be rare, causing patients to lack proper resources. Getting patients to normalize utilizing help can go unmanaged.

“I think we as providers could definitely be better about addressing it, explained Testi, who added that although its normal for patients to feel this way, it is important to find ways to help patients manage it so they can live a more normal life.

“Most cancer centers have really good social workers on staff that are designated to that particular division,” she said. “Where I work, we have dedicated social work for all liquid tumor patients, and most institutions will be able to connect you with a peer-to-peer support group. If patients agree, we’ll often connect one MPN patient with another who’s willing to have their information shared so that they can talk to each other share their feelings.”

Testi also highlighted the importance of caregiver support groups.

“Another thing that’s really important is caregiver support groups,” she said. “Their families can interact and share how having a loved one with this defeat disease affects them. It is often just as hard on the family members and caregivers as it is on the patient.”

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Patients With MPN-Related Fatigue ‘Know Their Bodies Very Well’

October 27, 2023

Ashley Chan

Patients with myeloproliferative neoplasms (MPNs) may experience a number of symptoms, with fatigue being one of them.

MPNs are types of blood cancer and occur when there is an abnormal change in stem cells within the bone marrow, according to Leukemia and Lymphoma Society. This abnormal change can lead to increased amounts of white blood cells, red blood cells and platelets. The main three types of MPNs are essential thrombocythemia, myelofibrosis and polycythemia vera.

MPN-related fatigue can take a toll on a patient’s quality of life, notably because of the change in the blood’s consistency.

“Fatigue has a profound effect on patients’ quality of life. A lot of people don’t realize that if you have chronic fatigue, especially from MPNs, because your condition is unchecked, then a lot of times it can actually be debilitating,” Patrick Buxton, a clinical nurse coordinator in the hematology department at Fred Hutchinson Cancer Center in Seattle, Washington, said during an interview with CURE®.

“(Patients are) not having the energy to go out and work, participate in family events and just (engage with) life in general. And they just don’t really feel well overall,” Buxton said. “And so, it’s important to monitor these patients’ labs to make sure that they stay within the range for their condition to ensure that they don’t end up developing those symptoms again, because when (a patient’s) blood counts become so high that (their) blood basically becomes a sludge, (they) definitely feel it. And it can cause a whole lot of problems centered around fatigue, but not just fatigue. It can cause a lot of inflammation issues.”

To work through the weight of fatigue, Buxton urged patients to hydrate, eat nutritious food and exercise.

“Especially with MPN, patients maintaining good hydration and adequate nutrition is very important. Because once (patients) kind of get stuck in a downward spiral, it can be very hard to get out,” he noted. “So, making sure that … patients are trying to get a good amount of exercise daily, even if it’s just getting out of bed, pushing (themselves) a little bit each day to try to get that energy going again and making sure that (they) eat and drink enough to keep going.”

Staying hydrated is essential for patients with MPNs, Buxton emphasized.

“Hydration cannot be stressed enough. A lot of people don’t hydrate with water, as I have come to realize, and so there’s been a lot of education patients have like, ‘Oh, I drink all the soda.’

And I’m like, ‘That’s not really helping. You need to drink water, especially when you have this condition, you need to keep on top of things.’”

For patients with MPNs who experience fatigue, Buxton advised them to have open communication with their care teams.

“That line of communication is very important. And even if the patients don’t think it’s important, they know their bodies very well. So, if something is not working right, communicate that to the team,” he said. “And know that it really is a lot of teamwork with the nurses, the patients, the doctors, that the patient is an integral part of the team; without the patient, we wouldn’t be here.

“So, know that (patients are) the center of all of this, and we are here to help, but if (they) don’t report these issues (to us) and just let them be then we won’t know. So, with that information, be a good self-advocate, because that’s how (they’re) going to get better care is being an active participant. Don’t let small things go because sometimes small stuff adds up to something big. And especially with fatigue — patients know their bodies well. So, follow up. Make sure that you are getting the care that you need.”

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Understanding the Three Types of MPNs

October 26, 2023

Darlene Dobkowski, MA

Understanding which of the three types of myeloproliferative neoplasms (MPNs) a patient has can help guide them to receive the appropriate treatment and management of the disease.

Of note, MPNs are a group of rare blood disorders where the bone marrow creates too many blood cells. This can lead a patient to have an imbalance of red blood cells, white blood cells and platelets, all of which can lead to several symptoms. These can include feeling tired, issues with clotting or bleeding and potentially an enlarged spleen.

Unfortunately, the number of patients diagnosed with MDS in the United State each year is not exactly known, according to the American Cancer Society. The organization notes that estimates start at 10,000 and can increase from there. The risk for MDS increases as a patient ages and diagnosis of the disease is uncommon before age 50, according to the American Cancer Society, with most patients diagnosed in their 70s.

Each of the three types of MPNs have their own set of symptoms and management strategies, highlighting the importance of knowing which disease a patient has.

Polycythemia Vera

In patients with polycythemia vera, the bone marrow produces too many red blood cells, which typically carry oxygen throughout the body. This overproduction of red blood cells can thicken a patient’s blood, leading to issues like blood clots and an increased risk for stroke.

The exact cause of polycythemia vera is often not clear, but it is typically related to genetic mutations in the bone marrow cells, particularly in a gene called JAK2. Diagnosis is typically made through blood tests that reveal elevated red blood cell counts, hematocrit levels and the presence of the JAK2 mutation.

Patients with polycythemia vera may experience symptoms like fatigue, headaches and redness or itching of the skin. Treatment for this type of MPN often involves medications and occasionally procedures to reduce the number of red blood cells a patient’s body makes. In particular, treatment for polycythemia vera may include phlebotomy (removing excess blood), medications to reduce blood cell production and management of symptoms and complications.

Essential Thrombocythemia

With essential thrombocythemia, the bone marrow creates too many platelets, which are the cells that help blood clot. Too many platelets can lead patients to experience clotting and bleeding issues. In particular, blood may clot too easily, which can block blood vessels and cause issues like strokes or heart attacks. Paradoxically, patients may also experience bleeding problems because the blood doesn’t clot properly in some cases.

The exact cause of essential thrombocythemia is not well understood, but it is often associated with genetic mutations, particularly in genes like CALR, JAK2 or MPL.

Some patients with essential thrombocythemia may not have any symptoms or they may experience things like headache, dizziness or red spots on their skin.

Patients are recommended to work with their care team to manage the disease and potentially reduce the risk for complications, both of which may be achieved with medications or procedures like plateletpheresis (when platelets are filtered from a patient’s blood through a machine) to control the number of platelets in the blood.

Myelofibrosis

In patients with myelofibrosis, the bone marrow becomes scarred and experiences difficulty in creating enough healthy blood cells, which may lead to fatigue, anemia, an enlarged spleen and an increased risk for infections. Symptoms may also include pain and early satiety, or feeling full even when the patient has not eaten much.

Similar to essential thrombocythemia, myelofibrosis may also be linked to specific genetic mutations like CALR, JAK2 or MPL.

A patient’s care team may manage myelofibrosis with blood transfusions to manage anemia, supportive care to address symptoms, medications to reduce the size of the spleen or, if necessary, a bone marrow transplant.

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Managing Early Satiety in MPNs

October 26, 2023

Alex Biese

Early satiety is one of the symptoms faced by patients with myeloproliferative neoplasms (MPNs) — a set of blood cancers that cause the bone marrow to overproduce red or white blood cells or platelets. Polycythemia vera, essential thrombocythemia and myelofibrosis are all MPNs.

Early satiety means that you feel full really soon after you start eating,” explained Amanda Smith, a registered nurse at the Huntsman Cancer Institute at the University of Utah. “There are a lot of implications for this. Nutrition is a really big deal, especially when you have a blood disorder or a cancer, so it’s definitely something to be aware of.”

In an interview with Oncology Nursing News, Smith discussed the impact that early satiety can have on patients with MPNs and the role nurses playing in helping patients manage this symptom.

Oncology Nursing News: What kind of impact on quality of life and nutritional intake can this have on patients? And then how can both of those things affect patient outcomes overall?

Smith: If you are not able to eat, it can be really frustrating. Anyone who has ever had a short period of time where they have been unable to eat, knows how run down you can feel, and the lack of energy. You are not getting energy from food as you normally would. And so, it can compound with other things to make you feel just really extra run down. Nutrition is important for our immune systems and it can really have a spiraling effect if we cannot get it under control.

Part of the reason it happens in MPNs is because of splenomegaly, [which] is when your spleen is enlarged. That can happen for a few different reasons, but one of the jobs of the spleen is to filter the blood. When you have an MPN and you have too many platelets or other types of blood cells, then your spleen is — in the simplest terms— working so hard to try and filter all those cells, and it gets too big. Then there is just not room in your abdomen. There’s not enough room in there. That is why it happens.

Patients with MPNs can go through long asymptomatic periods, which is one of the things that makes MPNs really tricky to diagnose and manage. Can this early fullness be a warning sign for patients?

Yes. I know that our providers ask about it every time, so if it’s important enough that they are wanting to know if there have been any changes in that in that area, then yes. Some people can be very stable with this symptom for a long time. As with a lot of things in medicine, the important thing to watch out for is change. You can have a symptom, and it can be stable and may or may not be something to worry about. But if you’ve had an acute change—if something gets a lot worse—it’s definitely something that we would want to know about.

How can nurses help patients manage this issue with things like maximizing their nutritional intake?

The higher calorie foods that you can get down, we would encourage that. We’re also looking at electrolytes a lot, so we’re wanting to make sure those are balanced. High-protein, high-fat types of things, but also just things that you are able to eat. So, it can be really tricky.

A lot of our medications can help shrink the spleen, so medication adherence is huge. Often people feel so much better that they don’t need to be reminded, [but] it’s so critical to stay on the regimen that the doctor prescribes.

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Thromboembolic Events Characterized in Patients with MPNs

October 26, 2023

By Patrick Daly

According to a single-center, retrospective analysis in Hämostaseologie, myeloproliferative neoplasm (MPN)-associated arterial thromboembolic events (ATEs) and venous thromboembolic events (VTEs) are frequent, and “while [polycythemia vera (PV)] patients or generally JAK2-mutated MPN patients had a significantly increased risk of such vascular events, this risk was reduced in CALR-mutated MPN patients.”

Lead author Kai Wille, MD, of the Johannes Wesling Medical Center Minden at the University of Bochum in Germany, wrote that patients with BCRABL-negative MPN frequently experience morbidity and mortality due to these events; however, few studies have reviewed both MPN-associated ATEs and VTEs across all MPN subtypes.

Uncontrolled MPN at Higher Risk of VTE, ATE

Among 892 patients with MPNs with a median follow-up of 6.6 years (range, 0.0-37.6 years), researchers identified 180 first TEs comprising 105 VTEs and 75 ATEs. The probability of an event by the end of the follow-up period was 36.2%, and the incidence rate for any first TE was 2.43% patient/year.

The most frequent VTE type was deep vein thrombosis with or without pulmonary embolism at a rate of 0.59% patient/year, and the most frequent ATE was stroke at a rate of 0.32% patient/year.

Between the 180 patients with a TE and the 652 without, patients with PV had a significantly increased risk of a TE (hazard ratio [HR], 1.660; 95% CI, 1.206-2.286) compared with other MPN subtypes. Conversely, CALR-mutated MPN had a significantly reduced risk of thromboembolism compared with JAK2-mutated MPN (HR, 0.346; 95% CI, 0.172-0.699).

“In summary, our study shows a significantly increased risk of VTE and ATE (often at “unusual” sites) in MPN patients compared with the healthy population, and this risk seems to be particularly increased in newly diagnosed and/or uncontrolled MPN.” Dr. Wille concluded.

Reference

Wille K, Deventer E, Sadjadian P, et al. Arterial and venous thromboembolic complications in 832 patients with BCR-ABL-negative myeloproliferative neoplasms. Hamostaseologie. 2023. doi:10.1055/a-2159-8767

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The Effects of Aging on Profiling Epigenetic Changes in Myeloproliferative Neoplasms

October 24, 2023

Pearl Steinzor

Epigenetic changes in myeloproliferative neoplasms (MPNs) have been identified and characterized regarding the effects of aging and therapeutic pathways, according to a recent review. These changes help researchers understand how epigenetic changes affect patients with MPNs and the progression of this rare disease.

In the current study, researchers aimed to review the current knowledge and understanding of epigenetics in patients with MPNs to evaluate and improve management of the disease.

“Reversible epigenetic changes and epigenetic regulation are part of the pathogenesis of MPNs both in the disease development and in progression,” the researchers wrote. “Epigenetic changes in MPN have been investigated with a variety of results.”

Epigenetic changes are reversible modifications to chromatin structure, histone modifications, and DNA methylation, and they are responsible for how genes are either expressed or silenced. Alterations in these structures may result in downstream gene expression changes that may influence the initiation, maintenance, or progression of a malignant cell.

In MPNs, the 3 most common pathogenetic mutations identified were epigenetic regulators: TET2, ASXL1, and DNMT3A, which were present at frequencies above 5% in an unselected MPN patient population. Additionally, EZH2 occurred in approximately 2% of patients with MPN overall and appear particularly important in determining disease progression. The mutations affect the regulation of DNA histone methylation in the hemopoietic stem cell (HSC) compartment. Furthermore, ASXL1, EZH2, IDH1/2, and TET2 were implicated in the progression to fibrotic leukemic transformations and reduced survival.

Additionally, the researchers identified nuclear factor erythroid 2 (NFE2) as a transcription factor that was overexpressed in most patients with MPN. One study found insertions and deletions of NFE2 were described in approximately 2% of patients with MPN. Furthermore, NFE2 mutations were found to be a predictive variable in determining the risk of fibrotic transformation among a large cohort of patients with MPNs with chronic stage disease.

Most studies on DNA methylation have been conducted on a gene-by-gene basis, as well as in comprehensive methylation profiling studies. In a global DNA methylation study of patients with polycythemia vera, essential thrombocythemia, myelofibrosis, including some patients who had transformed to acute myeloid leukemia (AML), MPN samples showed an aberrant methylation pattern compared with control samples. However, samples were similar across the 3 disease types. Furthermore, patients with transformed AML had an increased number of differently methylated regions compared with chronic cases. Therefore, the researchers believe that altered DNA mutations may be associated with the pathogenesis of leukemic transformations in MPNs.

DNA methylation was found to be affected by aging, lifestyle, diet, and disease, so methylation age may be a more accurate describer of disease than chronological age. Studies have found an older methylation age in patients with a higher JAK2V617F allelic burden and in those with a longer disease duration. Patients with polycythemia vera had an older methylation age than predicted, but methylation age was younger than predicted in patients with essential thrombocythemia, which may be attributed to the mutant allele burden.

Additionally, treatment with vorinostat (Zolinza) resulted in younger methylation age in patients with polycythemia vera and an older methylation age in patients with essential thrombocythemia, contributing to an overall trend to normal chronological age. Furthermore, nonresponse to treatment was associated with a younger than predicted methylation age in patients with essential thrombocythemia and an older predicted age in patients with polycythemia vera.

Overall, the researchers believe that these studies show the effect of aging and treatment on the epigenetic changes in MPNs.

“However, there is room for much greater investigation and understanding of epigenetic changes and events involved in progression,” wrote the researchers. “Investigation of the epigenome shows that there are a variety of therapeutic pathways available and that can be explored further leading to targeted therapy.”

Reference

Greenfield G, McMullin MF. Epigenetics in myeloproliferative neoplasms. Front Oncol. 2023;13:1206965. doi:10.3389/fonc.2023.1206965

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