Wangensteen, Kirk J.

PURPOSE To develop an electronic health record (EHR)–based clinical decision support (CDS) tool to promote guideline-recommended cancer risk management among patients with Lynch syndrome (LS), an inherited cancer syndrome that confers an increased risk of colorectal and other cancer types. MATERIALS AND METHODS We conducted a cross-sectional study to determine the baseline prevalence and predictors of guideline-recommended colonic surveillance and annual genetics program visits among patients with LS. Multivariable log-binomial regressions estimated prevalence ratios (PRs) of cancer risk management adherence by baseline sociodemographic and clinical characteristics. These analyses provided rationale for the development of an EHR-based CDS tool to support patients and clinicians with LS-related endoscopic surveillance and annual genetics program visits. The CDS leverages an EHR platform linking discrete genetic data to LS Genomic Indicators, in turn driving downstream clinician- and patient-facing CDS. RESULTS Among 323 patients with LS, cross-sectional adherence to colonic surveillance and annual genetics program visits was 69.3% and 55.4%, respectively. Patients with recent electronic patient portal use were more likely to be adherent to colonic surveillance (PR, 1.67; 95% CI, 1.11 to 2.52). Patients more recently diagnosed with LS were more likely to be adherent to annual genetics program visits (PR, 0.58; 95% CI, 0.44 to 0.76 for 2-4 years; PR, 0.62; 95% CI, 0.51 to 0.75 for ≥4 compared with <2 years). Our EHR-based CDS tool is now active for 421 patients with LS throughout our health system. CONCLUSION We have successfully developed an EHR-based CDS tool to promote guideline-recommended cancer risk management among patients with LS.

Importance Given the burden of chronic liver disease on the health care system, more information on the hepatoprotective association of statins in the general population is needed. Objective To examine whether regular statin use is associated with a reduction in liver disease, particularly hepatocellular carcinoma (HCC) and liver-related deaths, in the general population. Design, Setting, and Participants This cohort study used data from the UK Biobank (UKB) (individuals aged 37-73 years) collected from baseline (2006-2010) to the end of follow-up in May 2021, from the TriNetX cohort (individuals aged 18-90 years) enrolled from baseline (2011-2020) until end of follow-up in September 2022, and from the Penn Medicine Biobank (PMBB) (individuals aged 18-102 years) with ongoing enrollment starting in 2013 to the end of follow-up in December 2020. Individuals were matched using propensity score matching according to the following criteria: age, sex, body mass index, ethnicity, diabetes with or without insulin or biguanide use, hypertension, ischemic heart disease, dyslipidemia, aspirin use, and number of medications taken (UKB only). Data analysis was performed from April 2021 to April 2023. Exposure Regular statin use. Main Outcomes and Measures Primary outcomes were liver disease and HCC development as well as liver-associated death. Results A total of 1 785 491 individuals were evaluated after matching (aged 55 to 61 years on average, up to 56% men, and up to 49% women). A total of 581 cases of liver-associated death, 472 cases of incident HCC, and 98 497 new liver diseases were registered during the follow-up period. Individuals were aged 55-61 years on average, with a slightly higher proportion of men (up to 56%). In UKB individuals (n = 205 057) without previously diagnosed liver disease, statin users (n = 56 109) had a 15% lower hazard ratio (HR) for the association of developing a new liver disease (HR, 0.85; 95% CI, 0.78-0.92; P &amp;lt; .001). In addition, statin users demonstrated a 28% lower HR for the association with liver-related death (HR, 0.72; 95% CI, 0.59-0.88; P = .001) and a 42% lower HR for the development of HCC (HR, 0.58; 95% CI, 0.35-0.96; P = .04). In TriNetX individuals (n = 1 568 794), the HR for the association of HCC was reduced even further for statin users (HR, 0.26; 95% CI, 0.22-0.31; P = .003). The hepatoprotective association of statins was time and dose dependent, with a significant association in PMBB individuals (n = 11 640) for incident liver diseases after 1 year of statin use (HR, 0.76; 95% CI, 0.59-0.98; P = .03). Taking statins was particularly beneficial in men, individuals with diabetes, and individuals with a high Fibrosis-4 index at baseline. Carriers of the heterozygous minor allele of PNPLA3 rs738409 benefited from statin use and had a 69% lower HR for the association with HCC (UKB HR, 0.31; 95% CI, 0.11-0.85; P = .02). Conclusions and Relevance This cohort study indicates substantial preventive associations of statins against liver disease, with an association with duration and dose of intake.

Abstract Hepatocellular Carcinoma (HCC) is the most prevalent type of liver cancer and the third leading cause of cancer deaths worldwide. Drugs approved for first- and second-line therapy extend survival by only several months. Hence, there is still a pressing need for new and effective treatments. Sequencing technologies applied to human HCC tissues have identified hundreds of genes that undergo amplification and that may be correlated with mortality. Nevertheless, correlation does not equate to functionality. We aim to annotate gene function by employing an innovative approach with Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) and catalytically dead version of CRISPR-associated endonuclease (dCas9) in a CRISPR/dCas9 activation (CRISPRa) screen to identify driver genes of HCC tumorigenesis in mice. We deliver to the liver’s hepatocytes a gRNA library targeting genes of interest on plasmids that contain: (1) a transposon system for stable integration of DNA sequences into the cell genome, (2) Myc to drive hyperproliferation, as MYC is frequently over-expressed in human HCC, (3) synergistic activation mediator complex sequences for transcriptional activation of target genes, and (4) the gRNA sequence, the only variable sequence in the library. Using datasets from the Cancer Genome Atlas, we identified 51 genes that are both enriched and amplified in HCC patients. We included gRNAs targeting Tert, Vegfa, and Ccnd1, as control genes with known roles in driving HCC. In total, the screening library contained 290 gRNAs targeting 51 genes and 3 controls. After delivery of the plasmid library to the liver, the Myc gene provided a baseline level of oncogenic hyperproliferation, and the readout was gRNA prevalence pre- and post-proliferation via next-generation sequencing. We found that the combination of Myc and CRISPRa gRNA library led to a large number of expansive tumors in the liver as compared to Myc or the CRISPRa gRNA library only, which contained few to no tumors. gRNAs targeting control genes Ccnd1 and Vegfa were enriched as expected, validating our approach to annotate gene function during tumorigenesis. Additionally, we identified enrichment in gRNAs targeting genes Zbtb7b, Vps72, and Gba in multiple tumors, implicating a role in liver tumorigenesis. ZBTB7B and GBA expression levels are increased in patients with HCC recurrence as compared to patients in remission (data from BIOSTORM trial), while VPS72 is an unfavorable prognostic marker for HCC (data from The Human Protein Atlas). In this study, we have established a novel model of liver cancer that combines the Myc oncogene with a CRISPRa gRNA library to annotate driver genes in human HCC. Additionally, we identified several promising targets for the treatment of HCC. Ultimately, this study has the potential to impact on the care of patients with HCC in the US and worldwide. Citation Format: Alexandra Mariel Vázquez Salgado, Shirui He, Kirk J. Wangensteen. Identifying drivers of liver cancer using CRISPR activation screening in vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 250.

PURPOSEHepatocellular carcinoma (HCC) has well-defined environmental risk factors. In addition, epidemiologic studies have suggested hereditary risk factors. The goals of this study were to determine the rate of pathogenic and likely pathogenic (P/LP) germline variants in cancer predisposition genes in patients with HCC, possible enrichment of P/LP variants in particular genes, and potential impact on clinical management.MATERIALS AND METHODSA prospective study at a tertiary medical center enrolled 217 patients with a personal history of HCC. Multigene panel testing was performed for 134 cancer predisposition genes in all patients. The rate of P/LP variants was compared with population rates. A separate retrospective cohort included 219 patients with HCC who underwent testing at a commercial laboratory.RESULTSIn the prospective cohort, P/LP germline variants were identified in 25 of 217 patients with HCC (11.5%). Four patients (1.8%) had P/LP variants in the highly penetrant cancer genes BRCA2 (n = 2), MSH6 (n = 1), and PMS2 (n = 1). In addition, multiple patients had P/LP variants in FANCA (n = 5) and BRIP1 (n = 4), which were significantly enriched in HCC compared with the general population. Detection of P/LP variants led to changes in clinical management in regard to therapy selection, screening recommendations, and cascade testing of relatives. In a separate retrospective analysis of 219 patients with HCC, 30 (13.7%) were positive for P/LP variants including 13 (5.9%) with highly penetrant genes APC (n = 2), BRCA1 (n = 1), BRCA2 (n = 6), MSH2 (n = 2), or TP53 (n = 2).CONCLUSIONP/LP germline variants in cancer predisposition genes were detected in 11%-14% of patients with HCC. Inherited genetics should not be overlooked in HCC as there are important implications for precision treatment, future risk of cancers, and familial cancer risk.

Abstract Insertional mutagenesis screens play an integral part in the annotating of functional data for all sequenced genes in the postgenomic era. Chemical mutagenesis screens are highly efficient but identifying the causative gene can be a laborious task. Other mutagenesis platforms, such as transposable elements, have been successfully applied for insertional mutagenesis screens in both the mouse and rat. However, relatively low transposition efficiency has hampered their use as a high-throughput forward genetic mutagenesis screen. Here we report the first evidence of germline activity in the mouse using a naturally active DNA transposon derived from the medaka fish called Tol2, as an alternative system for high-throughput forward genetic mutagenesis screening tool.