Blood In Urine Cancer Symptoms

>> good afternoon. we will begin. for those of you who don't know what this is, i am not going to take time to explain this as a do every week. but it will be like a question on the final exam. the final exam will be on the

website sometime within the next couple /of weeks. it's a real killer. the series of true and false questions -- you can take it many times and hopefully it's in in/tporpformative and it's notintend intended to stress you. because we keep telling you

didn't have to sit here and take notes and everything. you should just get excited by what you hear. so hopefully that's what the exam contains. so those in the book have been to at least half the sessions and will eventually pass this

extremely difficult exam. you will get a certificate, and we hope you use it well. so what do these people have in common? well, you could do this for any kind of cancer, but sometimes it's interesting to look at the individuals who are involved,

because many of them -- because of their illness and sometimes their wealth and interest and -- have played -- played a significant role in foundations, research and they haven't hid their illness. so some of these individuals had cancer of the bladder, and i

believe they all died from it. now, there is a long list the of celebrities, but they're part of the iceberg. there are somewhere around 6 /0* 60,000, 70,000 people who have this disease, and about maybe 10 10,000, 15,000 or more actually die of it.

so this is something to think about. and in comparison to many other cancers think lung, pancreas, liver, kidney. the stomatology is usually note notably late in the stage of the disease. so in comparison with many other

-- not all, of course, cancers, bladder cancer seems to be relat relatively easy to detect. if everybody tested their urine every day and looked for red blood cells, that's probably as good as anything that can be offered. now, once it's detected, seems

to me, as /aa liver doctor, diagnosing it isn't such a huge problem. it's not like trying to diagnose pan /kracreatic cancer orsomething like that. because you do a kris scoscopyand it's all there. you all know where the bladder

is, i'm sure. now the problem is treating. so we will hear about that. but given this tri/a*pbagethere, what are the problems? do we cure people? and what are the challenges? it's obviously not simple. and this is the basis of today's

discussion. and we are very fortunate that two nih folks whose work touches on both sides of the bridge. and this is a little different. every week when we have a session, the concept of the bridge is slightly different. in /this case, this makes it ina

different category. and so what we're going to do, we're fortunate is to have a presentation, which will be given by andrea a/ppollo, who graduated from my favorite medical school, the albert /aoeueinstein college ofmedicine. took her intern and residency at

new york hospital, did an onc oncology fellowship at sloan ket ketering, not shabby places. came here, and she is an investigator in the gent /aalurine urinary malice -- ma/hreligiance-- ma/hreug /tphaplignancy branchat the cancer institute. she is particularly interested

in treatment, working on new treatments with collaborators working in different directions, to deal with some of the problems we are going to hear and she's been very kind to bring attention of hers, whom we are grateful for, who will briefly tell us all what her

reaction fothis -- to this disease is about, to sort of as someone told me several years ago, put a human face on a and then our second speaker is vad cosky, who is also a fizz physician. born in interfesiberia, startedmedical school there, finished in columb

columbia, and started in hemato hematoology and oncology research at salt lake city. tyke fellowship at the new england medical center in boston and hematoology oncology and after that spent several years in the rabbit -- laboratory of lou /kafrpt -- campley, who by

the way, yesterday won the guard gardener award. now this is the year that pi 3 kinase was discovered and he was in the right place at the right time and she participated in that discovery and in the understanding of what pi 3 kine kinase related to growth factor

signaling through oncogenesis and other aspects. and she worked in that field until she came here to the nih in roughly 2003 in the national cancer institute. and her work since then has focused on drug development, mechanisms or synergy and an tag

tagnism with recombination of molecularly targeted therapies and she's focused on drug resist resistance and also on stem cell biology. and then a few years ago she moved to the laboratory of re receptive biology in gene expression, headed by gordon hag

hager, where he specializes in chromatin biology. and over /the past couple /-of years, she has mastered techniques of looking at in in-depth bio/eupb /tporpl/ainformatic information of dnas, one access accessible sites on chromatin and variance -- varying

technology that gives a land landscape analysis of the access accessible genome at any one time. really amazing. and she has collaborated with an andrea in studies of brader cancer. so these are two very exciting

dimensions on either side of the bridge and we all look forward to hearing your talks. bladder. so would you like to interview -- >> can everyone hear me? excellent. okay.

thank you for /euinviting me tobe here today. i am looking forward to giving an overview of bladder cancer treatment and all the exciting things that are going on right now. but first, one /of my patients was kind enough to offer to come

and talk to you and discuss her journey through this experience and we're going to be asking some questions and she'll be telling you /kwr*you know, whather experience has been being diagnosed with bladder cancer, receiving the treatments that we gave for bladder cancer and how

this has im/pabpacted her life. so we're going to call her ms. m m. . thank you for being here today. >> you're welcome. >> so why don't we start you and you can tell us what symptoms led to the diagnosis of

blood -- brader cancer? >> it started actually two years before i was diagnosed. i had bladder symptoms of pain and urgency and it was substance subsequently thought to be initial kris atitis, which is a disease that's sort of diagnosed by symptoms alone and treated

through /stkpao*eufplt once i changed my diet and so-called irit's an, i thought i was safe. then it started bleeding. and that was it. i had a ssis os scopscopy doneand there was a tumor. >> and what happened after they found tumors in your bladder?

what treatment did you receive? >> the first treatment that i received is common for bladder cancer patients to receive is dc g, which is a tumer the lated live tb bacteria and it's in instilled into the bladder using the catheter one time a week for six weeks.

and then you go home and you lie down and you turn side to side so supposedly your bladder is covered and then you have another bladder biopsy, another sis scoscopy to take a look andsee if that has done the trick. >> okay, so you received this treatment. you did well with it?

>> no, actually, i did not. i failed that one. >> okay. in terms of your symptoms, how did you report -- tolerate the treatment? >> i tolerated it fine. it didn't bother me at all. for some people it does, but for

six weeks it was fine for me. so it was not all that bother medical -- bothersome. >> what happened after that? >> i failed the treatment. >> the treatment failed you. >> the treatment failed me for sure. and i went to hopkins after that

that. i had another pu /r-fpr done and another bladder biopsy and it showed cancer in the bladder. and then my surgeon discussed option s wis with me. and then i'm sure that they discussed chemotherapy and re removal of the bladder or maybe

some more therapy. >> if i had shown any change at all, they might have continued but it was felt to be -- it was invasive into the second layer. so he didn't feel that the bc g was appropriate. and basically we just discussed surgery.

that would be my best option. and surgery was planned. it wasn't several times while we decided for sure. i was scared to death, of course course. and decided that surgery was good. and then i had my first cat scan

right before surgery, and that's when it was discovered that the cancer was outside of the blad it was in my paraaortic and lower abnom -- ab/tkodominal and pelvic liymph node and suddenly my surgery was canceled and i met my oncologist and we went to chemotherapy.

and tell me about the chem how was that chemotherapy in infusion? how did you tolerate that? >> chemotherapy basically plays into the whole body. it's not an easy road to go. i was given six cycles over 18 weeks.

i had two transfusions several times. some medication injectd to help pick /up your blood. my brood level still aheeadilywent down. i had intractable gnanausea. it was a very difficult road. i was very weak.

in fact, i had two dogs at home that i had to give to my friend, who is a breeder, because i couldn't even take care of my dog. i couldn't even make dinner for myself. akeemo is a hard road. but eventually they cut the chem

chemo slightly short because my blood levels were so low. however, testing afterwards, it was found it did take care of those cancers outside of the and my surgeon wanted to wait until my brood levels came up a little and if i was strong enough for /skpoeurpblg did not

-- then he did the sis hecanectomy. >> tell me about how that was going through the surgery, the le /* -- the radical sis he can'tomy where they remove your bladder and reconstruct your bladder out /of bowels? >> they removed your whole brad er and take a little piece of

the bowel and now your in/teft intestines have been insulted as well and this tach -- they a attach that ut -- utreter to the /skprafl attach that skin. the kind i chose was the one called an i wilio conduit, theone that you can recover from the fastest and that was my most at

the top of my head.^ i wanted to know what would give me the best chance to go on with my life the fastest. and i found it to be no problem with surgery. while expensive, it's not that difficult to -- you know, why -- if you're strong determined, you

can get over /the surgery andget back on your feet and get back to your life, and i found that there is only a few things that i can't do as a result from this this. >> how long did it take you to recover from the surgery? >> probably a good four months

to get my energy back. so you just have to keep at it. you have to be determined. it's like any surgery that you have. and then you have to learn sort of a new normal. and that's really not a problem either.

>> so you were diagnosed with a bladder cancer. you had bc g therapy and you had the scraping tumor recession. then you went ahead and had chem chemotherapy because they found that the disease was outside of the bladder, so essentially it was stage four at /tthat point.

how long ago? from when you were diagnosed with the disease to the cat scan? >> the second time. i'd had the surgery in december of 2013, and it was april of 20 2014, after another cat scan. >> the first test -- cat scan

before the surgery -- >> was clear. >> if it was one that showed that you had the lymph node outside of the bladder. >> during surgery. >> but before surgery too, correct? >> no.

you wouldn't -- we wouldn't have done surgery, he told me, unless we were clear. >> so before the chemotherapy did you. >> yeah. when was that? >> so the first chemotherapy or the second?

>> the first, before the first, yeah? >> about before -- before the first it started in february of 2014, was my first chemo. december of 2014 when's when i finally had surgery. >> right. and you started in february

until december. >> hmm-hmm. {}and the point that i'm trying to make is you were diagnosed with met static disease that the point, you had the chemotherapy, you respondd to it and then you had the surgery. >> correct.

>> to kind of consolidate everything. and then what happened after that? >> in april, i had had another scan and they found that there were you know, some more lymph nodes that were -- stage four at that time -- point.

>> and i asked them -- so okay. i was feeling good. i'd recovered from surgery and i heard this news. what do i do now? and found out nothing. there is nothing to do. you're at stage four met static there is essentially nothing to

do. i went in /sand saw myoncologist, of course and he said he would try the one -- i have to back up up. one /of my side effects fromchem chemo is newer opathy. i have it in both my hands and my feet and that means my hands

and feet are numb. newer op/stkph*eu it goes up my arm and up my leg. luckily i don't have the pain. i just have the numbness. because of that -- he thought he would give me just the one part of it with no real /haoep -- hope that it would make a

difference but he would try it. we were happy too much anything to do. and so started the gem cell, which looking half wway through,i think was a c /t-fpt -- itlooked like it was helping. it was reducing the size of the lymph nodes.

and that was all fine until my legs started swelling and finally had had to be stopped because i had high fevers and ended up in the emergency room due to the gem czar. then what happened? what led you here to the nih? my wonderful dr. /phmario ize/*epb

marioizeenberger, who did studies and thought i might be a good candidate for them. i am lucky to not have any other medical problems, other than sinus infections. and so he thought you know, i might be a good candidate and so i came and interviewed with you

and your team. >> tell us about your experience being at the nih as a patient. >> the nih is say wonderful place. people are so supportive and caring, and i know that in all honestly -- honesty i am just

another /tkpwa*eupb pig. and it's just -- more than that but i might be doing better. and i feel wonderful. i feel i can -- i look good. i have all my energy back. i am able to exercise and swim and do all the things that we like to do, with the one

exception of ballroom dancing because i have the newer opathy and i can't feel my feet really. but everybody here from the val valet to the phlebotomy mist to of course, my wonderful doctors, have been so supportive and help helpful, so communicateia -- commune /icative.

i'm never on the outside. it's wonderful. >> that's wonderful to hear. so ms. andrea has been an -- on our trial since october. she's currently on an/euinhibitor study and i'd like to approach -- she had a complete response eventually of her disease and

really had very little symptoms currently on the study. so was lucky that things are going really well. i just want /to ask you a couple more questions just -- tell me a little bit -- how this entire experience has im/pabpacted your life.

>> i think as /aa cancerpatient, you are never now not a cancer it's the first thing on your mind and the /hralast thing. it affects everything -- your planning, your vacations. should i really buy those shoes? they're on sale for winter. will i make it till next winter?

i mean, it's not like -- you're not sad all the time. you're just im/pabpact bid itall the time. it just affects your life. im/pabpacted by it. generally-speaking i am a very positive person, and so anything that tries time pact i try to

overcome it. so that's how i handle it. but a cancer patient is a cancer patient no matter what you have. >> so the last question. cancer is one of the most common cancers in the united states and really there has been a discord ance among the research team

done with bladder cancer compared to common cancers. a /rlot of people in theaudience are young sciences. -- scientists. do you have a message for them as /aa cancer patient? i do. i do.

we absolutely need more support and more support financially, more research done. i found out that bladder cancer is in the top ten of all cancers for both men and women. one in 16 chance that a man in his lifetime will get bladder cancer, and that is horrible.

and one in 90ness -- chance fire woman q and we need ang/hreuelina jolie or somebody to champion our cancer. it's a very expensive cancer, because we have to be more on theed all the time. and the tests that we have are not inexpensive.

so it's a very important cancer, and yet it has not had the attention that it needs. so anybody has an inkling -- it's not a very sexy cancer the, that's for sure. but it keib good one still. >> well, thank you so much. we really appreciate.

/phra [applause] [could be a]. >> so i'll go ahead and start overview of bladder cancer and we named it a major disease because it's such a common disease in the united states, yet it really doesn't get the

funding that we talked about and the attention or the awareness from the community that it probably should. so a couple /of facts about blad bladder cancer or youaurothierial carcinoma. last year it affected 64,000 cases and there were 6 /0,000

attributed to bladder cancer. it's -- it is actually disease of older patients and all population ages that would be practiceder cancer because of the immediamedian age is 73. there is a 3-to-1 male-to-female crash and don't understand why and there is a lot /of research

going into it to understand it. the issue is that the duration of response is short. and the immediamedian survivalfor patients is about 12 to 14 months. we're currently in desperate need for better therapies for this disease.

so just to kind of put it in percespective, i've made up a chart of the fda-approved drug for tumors in the last nine years. it has seen 7 new drugs approved over /the /hraflast nine yearsby the fda. half the cancer has seen seven

new drugs approved by the fda for treatment of this disease. approved in 1998 for non-muscle invasive disease. so that was 17 years ago. so really we need more research. and our understanding of the path wway, we have been able to find therapy and our understand

understanding of the path wwaywe have been able to find better path wways and we need to understand what are the mech mechanisms governing the development of bladder cancer, some what causes brader cancer? smoking is one of the risk factors of developing bladder

cancer and j"jama" showed that women have just as high risk of developing bladder cancer from smoking. occupational hazards such as by products from leather, rubber. radiation, such as raidiation that men get from process state cancer and women get for serve

cervical cancer. and also causes a par /seasiticin infection that is very common in the nile river valley in aftrica can actually /stkauz bladder cancer, too.^ it tends to cause carcinoma and a transitional cell carcinoma type. quantityus sis /aoecystitisdeveloped in

bladder cancer and some genetic diseases and cancer with patients who have a higher chance of developing the tumor. so the most common cell type is transitional carcinoma. here in the united states, since we're talking about in aftrica, it's about 50/50 because more

prem smoking, transitional carc carcinoma is becoming more common. a/tkedenocarcinoma, here at thenih we see a lot /of patients. so when i think bladder cancer, i mean cancer anywhere in the urinary tract. so anywhere where there are

urinary cells, you can develop plaider cancer. so the pelvis, the utereter and bladder and eurethra. and whether you develop a tumor here or the actual bladder proper, the met static is very similar and we theat the patients the same.

so in terms of one of the most important factors in patient bladder cancer is /the depth of invasion. so brader cancer can develop as flat lesions called carcinoma in insitu and actually are pretty dangerous. these are high-grade and are

really hard to see. you put it up in the bladder and they are hard to see because basically it's like a /phreul area of redness and this area can progress into more invasive tumors. and the ta, which are non-/eupb non-in/sraeufts tumors dissolved

in the surface of the bladder. t 1 a, which is what our patient has, which is in the first layer of the bladder and invasion into the muscle and the con/teutiguous organis and as medicaloncologist oncologists, i tend to see the regions and here is the presentation.

if you have lymph node involvelet, you actually have met static disease. you don't see for example where cancer where you can have -- and still be stage 3. the bladder cancer, because it's an invested disease, anything outside of the bladder is

considered stage four. so bladder cancer prevents -- presents brood in the urine. and the most common /prepbgts, you can also get irritateive symptoms, some people get trace blood that you can find just from going to the doctor. microscopic hematouria and you

can have urinary infections that cause pain and discomfort. so essentially we categorize patients into 3 categories when they initially get diagnosed. nine months of invasive bladder cancer and met static brader cancer and i'll start off talking about non-muscle in

invasive bladder cancer. and this is handled by the ub ubologist. so the patient has brood in their /skpaourpb go to the ur urologist and take a look inside the bladder and see what is the invasion and they get a scraping, which we call bladder

tumor insection and some patients will not get. so this is what it looks like. this is a for example ssisscopscopy that has a little camera and you take a look inside the brad er and this is what a bladder tumor looks like. it looks actually like a flower

and the urologist will go ahead and scrape that under /apbs nese nesia and this is what that they try to get as much as possible, trying to get the muscle so they can assess the depth of invasion. and depending on the stage, you can satisfy patients if they are

low /h--grade. then scraping --. if immediamedium grade therapy. and high-grade you give therapy to the patients. not all patients need the therapy. generally it's patients that have a lot of the cancers.

bladder cancer is one of the most expensive cancers in the united states because of -- you have to follow up with every 3 months and are very expensive. so because of the post follow-up follow-up, it becomes a very expensive cancer. and so if there is recurrences,

you give therapy. here if there is a large tumor, there is a lesion into the first layer. if the patient has it, you go ahead and give therapy. and bc g is /the most common cheaper -- therapy that is given to patients and the one that is

most in-- effective and other therapies are also given, too, generally for less aggressive >> inaudib[inaudible] >> that's a great question. i think it was actually discovered accidental. oh you know what? let's see if we can cause

irritation in the bladder and therefore by direct exact -- contact. and what it actually does is the it pulls -- pools together a bunch of immune in/tpefiltratesthat cause an immune reaction, a non- non-specific inflammatory reaction and that's the theory.

but the true mechanism is so un unclear. so moving on from non-muscle in invasive brader cancer to muscle it used to be managed bid ur urologist. we take it out. but we've noted more -- and more just from following

patients fire /ropor a long timethat this is actually a systemic disease and 50% of the patients that have this radical surgery where the bladder is removed and they have reconstruction of the bladder still have their cancer come back. so the question is how do we do

better? large studies have shown that system /kwreuic therapy issimilar to removing the bladder is actually very helpful. and more and more of other methods are managed have looked at such as therapy where you actually try to keep the bladder

you radiate the bladder and along with chemotherapy and -- that is also an option here, that it's not processed as much in the united states. it's processed a lot in europe, but i think it's more and more patients are doing it now because patients want /to keep

their bladder. and if it's a possibility, then it's something that we're doing more and more research and more centers are becoming comfortable with offering the therapy for patients with the disease. so sis he canectomy is a bigsurgery. remove the bladder and lim of

nodes and remove the seminole vesical and in women you remove the /tphrofallopian tubes. it's a big surgery. and then you reconstruct. and there is a couple /ofurinary diversions that are available, and i am only /phepbgtsing tree of them, which is a little con

conduit. that's when you actually just put part of /aa diode andconnect it to the skin and the urine continues to flow from the kid kidney into the bowel out into the back. and that's the conduit and that's the easiest one to do and

that has less complications. there is also a res retire and pouch where a pouch is made aware little opening in the bell belly button. and then there is the bladder, which a lot /of people would prefer but not all patients can get it. it's a little bit more high-

high-maintenance. it really requires a lot /of limitations. it may not work well all the a pouch is made and it's actually connected to the eureth eurethra and the surgeon kind of makes this in the middle during the operation to make /shaosurethey

don't find anything and they connect this bowel pouch into the eurethra and the patient void and /skpraerpb time it and they void at a certain time. so there is a common diversion that is done. this is just a graph showing chemotherapy before surgery

actually improves survival. and we're going to look at why survival improved in patients. the patients that had response -- in terms of response to so moving on to met static blad so the met static bladder cancer is for the medical oncologist. that's me.

and what are the treatments for bladder cancer? essentially it's not curable. and the treatment is chem and implication has a function, which a lot /of times theydon't. but they have kidney functions, we can do a combination. and if they don't, we do a non-

non-re/skpweupbgs that's it. if you already got chemotherapy, like our patients had chem chemotherapy before surgery, way was appropriate, then -- and the cancer comes back, then you are kind of left with what do we do now? and that's where we need more

research. that's where there has been -- i have some updates to give, and there is a lot /of exciting things coming up that i think that will change our paradigm and the way that we treat blad bladder cancer in the next ten so where do chemotherapy studies

come from? and doctors developed back in the late 80s and 90's where they compare the drugs to chem chemotherapy regimen. and comparing it to regular -- is it any better? yes, there is a little bit of /proeufplt in survival in these

first initial studies. but combination compared to others. combinations and survival benefits. then there was a ot the -- large study, a phase three study that compared a combination of drugs that had become the standard

just to see if two drugs is as good as the fourth drugs and found that the drugs were as good with similar overall survival, similar response rate and similar kinds /ofregression. essentially the two drug reg regimens became the standard of care and that's what our

patients receiveed.^ a lot less toxicity, so that was important and is that regimen has a lot of toxicity and the vomiting and the fatigue and the fevers and the hospitalizations happen. the two combination is easier to give and patients shared with you her experience and how hard

it was for her. so what is new in systemic therapy carc moma? we are currently in the beginning of an immunotherapy resolution in oncology and therapy has benefited significant clinical activities in tumors and we have found that

ped /kwia one is highlyexpressed in carcinoma and it correlates with path /hropbologic stage withhigher path /hropbologic stage, havehigher expressions of pl 1, and it correlates with overall survival survival. so let's talk about the td 1 path wway.

it expresses in t cells and pd l 2 inhibits cells. and ma/kcrophages -- so over/-the last year, this just happened in the last year, so there were two studies that were reported of checkpoint inhibitors in brader cancer patients. and these are waterfall bars and

each bar represents one patient. and this is the longer the bar goes down, it means that the tumor shrinks by a person -- certain percentage. so this is tumor-slihrinking. so using an immunotherapy and met stat study in bladder cancer is novel.

that is a big deal because nothing worked. so the fact that we got these tumors /shr*eurpbging in patients with advanced disease that were re/tprabfractory tostandard chemotherapy is very exciting. and two drugs, small studies were tested.

one is 3280 and that was testing a group of six to eight patients patients. and small studies but the excitement is immense right now in the bladder cancer world because that means these drugs worked. and my patients is on one /of

these drugs. another company. and she has six months. really very little side effects. and that is the excitement about it's not so much the percentage of people that responds because actually not everybody responds. it's actually about a quarter

right now. i don't think i have a part of it -- it's about 25% of the patients that have a high expression of us c /tk-fpd l 1are responding. so it's not a high number of patients that responds responds. but the excitement is that the

toxicity is low, and is that the response duration seems to be long. and that was one of the therapies and get these great responses but the cancer comes back in seven months. and the second study the cancer comes back in four months.

so say rot of these therapies right now, they are reporting patients one-year and ten months out and they are still responding, that's really exciting. but because of that right now there are many clinical trials that are ongoinging with

checkpoint inhibitors alone or in combination with other agents agents. including two phase three /soeudz. that is -- this is un/haeheardof in two phase studies in patients studying agents that we just mentioned in the small studies.

now they are being studied in patients and even moving along an earlier study with non-/eupb non-invasive disease are in combinations. for example, combined with etg to see if we can enhance the immune response. and there is a thought that

perhaps we can improve the response and combine them. and there has been a lot /of clinical data showing that immunotherapy response is enhanced if you add a vaccine or another checkpoint inhibitor. there are studies in mel gnomea comparing to the inhibitors

showing actually -- so that's cell transfer. giving -- given a certain dose. about we have a trial here /tin kinase inhibitor and we did /krabtive work /sand found there is changes that willin/tpefiltrate 100 bladder cancer patients and decreased the t regs and

expression in the t reg and 4 expression. so we have hypothesized that it has immunomod latry properties that may tend to -- suppression for strategy that's one that has we have seen some very nice clinical responses of this agent in patients here that are

receiving this drug with some nice regression. either tumors that are essentially catatateed. perhaps combined two acid agents together, we get back. so the theory is that potentially increasing the t cell in/tpefiltration to tumorsand

many of the therapies find the tumor for /aa better response to check for /euinhibitor. so we have to of course worry about toxicity. i am just going to transition this talk a little bit on genome genomics to lead into my next speaker and kind of talk about

where are we in genomics and and i have to say many targeted agents have been studied in blad bladder cancer with disappointing results. very, very low response rates, zero response rates, 2% and really no change in overall and in other solid tumors but

they haven't shown activity in and we rationaleized that. bladder cancer and stratifying the patients correctly. we tend to treat patients by hist /olodggic pathology, andtreat them with a targeted agent. but we should be stratifying patients with genomic pathology

and look at what agents are being activateed and treat them according to those that they have. and one of the biggest efforts so far that has been done is to /traotry tounderstand the genomic pathology in bladder and the tcga reported last year in january found a finding and

reported on 32 commonly mutated genes and studied 131 bladder cancer patients and many of those genes -- the great thing about it is 69% of the tumors that they studied have is a potential for /aa therapeutic target. so that's importantment and 76%

of the tumors had chromatin levels. so these ep/skwrepigeneticalterations for brader cancer treatments. these genes have /popbgs path pathways that can be targeted. and many are already in development in clinical trials so that's really exciting.

and one of the new ways that we are developing clinical trials in bladder cancer is kind of doing a mutational analysis and treating patients based on their mutations. and one of the reasons we want to do trials that are ongoing right now is because bladder

cancer will get pushed out by lung cancer and you'll have a huge study of mutations and there will be ten brader patients in there. so we want to do all our studies and this is an effort that is currently being initiated by the group where they will look at

mutations and screen patients for molecular screening and depending on their -- treat them with corresponding inhibitors. we also have a study that is currently ongoing using a different method, using a toxin method, which uses a molecular profile based on cell line to

predict tumor activity of the tumor, whether it's in response to chemotherapy right on -- not. and this is a study of invasive disease but is rand /o*omizedfor right before the drug regimen to see if it can predict which of these drugs will do best. so this ed soed so i is ongoing.

we're about to open here at the nci, which i am going to use the coxin and run it tru the certainly profile. then get a coxin for 76 approved drugs and see where they went in the tumor in terms of resistance and go through a molecular tumor board to decide the next best

treatment for the patient based on the tumor sensitivity. so very exciting. so we have a team here at the nc nci that is very active, with the help of my newurologist. i don't know if he's here. right now we've had many clinical /traoeutrials that areeither

finished, ongoing, or in development and not only met static disease but also in non- non-muscle invasive disease. so i think we've came long way, including genomic medicine and immunotherapy, and we still have a rong way /stkpaorbgs i think it's a really exciting time to

be doing research now. with that, i want to say thank you for your attention. >> we have time for /aa few questions. and we would /hraoeulike you tobe brief and talk into the micro microphones is that people who are listening can hear the

questions as well as the answer. >> thank you so much. and thanks to your patient also for coming out. we really appreciate it. it makes a difference. in terms of looking at sobciodem /kpwrafbgz, race andeth/tphenicity, any changes or differences you

see? do you have any comments? >> we have a little bit of data data, not a lot. it seems /tthat bladder cancer affects mostly white men. but in women that are diagnosed, they tend to be diagnosed at higher stage, later.

so there is a question is this the biology of the disease, or is it just the diagnosis? because they will go to a ob ob/kpw*eupb. african-american men tend to do poorly, as they do in other diseases, too. and is it a social issue?

is it availability of care? i think we are still trying to find out. but there hasn't been a study looking at the biology. that would be interesting. that's a great question. >> go ahead. >> the bladder tumors.

could you comment on the significance in terms of classification and which /wuoneis using -- /kout is more important important? >> the question is what are -- what is the difference between pap /hrillary and non-pap/hraillary because it tends to classify it

as pap rary. pap /hrillary means that thetumor comes with a -- so they tend to be earlier stages tumors. so the tumors tend door pap lary lary. the tumors -- so what is the difference? pap /hrillary has biggest -- big

potential to grow more commonly and non-pap /hrillary includes t cell masses which don't have a neck. they are kind of ingrown /pwhrao -- into the lining of the blad and in terms of one is more aggressive than the other. pap /hrillary diseases are more

aggressive. >> one last presentation. >> how well-documented is /the first treatment, as described by the patient? >> how well-documented? i mean -- >> the therapy? bc g therapy has been around

from 1976, the first time that it was studied, and it has shown that it actually reduces re recurrences and that it can get non-/euinvasive treatment. it only works fornon-/euinvasive once a tumor becomes invasive into the muscle, it doesn't work anymore.

and it's being compared to other chem therapies. can we do better? and all studies so /tpfar showthat bc g is better than other chem therapies that are found inside the bladder. >> andrea, have people been saving samples from surgery?

not now but during all the years control trials and so forth? or genomic studies? >> not enough. >> that's too bad. >> and brader cancer is so accessible because you can actually get a tumor but there really hasn't been -- we don't

have is a tissue bank that other tumors do have. >> because you know -- >> now we are. now the tumor banks that are becoming available, we are trying to save more and more and understand how important it is to get a tumor fray patient but

we don't have like -- where all of this is located. >> in relation to the bladder >> having ulcers? >> hunner. >> not really. inflammation, having just -- fellow, not so much. but it does require surveillance

to make /shaosure that thosearen't >> okay, i think wield told -- hold any questions >> thank you. well, in the next 20 minutes, we are going to dwell into the new area of the molecular biology of brader cancer. in f we know and what we

don't and what we need to know to im/proprove our therapies. and from my point of view as an oncologist now involved in data science research, this is really a very, very important question and /aa good tumor to look at because pretty much nothing is known.

so here we go. so we are going to look at our analysis of the molecular alt alterations and many tumor types types. and just to have an idea what is unique about bladder? why we know so much about other tumors and not so much about

bladder? and also, what are the genomic, ep/skwrepigenetic chromatinmutations if that tumor? what is known, and what is new? so i think 20 minutes may not be enough. i will try to go through the /sraoeudz and literature for you

and then welcome some questions. so what is the genomic rand escape of bladder cancer? first, let's look at other cancers and see where we stand in bladder cancer compared to other tumors. so p /kr-fpcga, which is a groupof con consortia, made out /of -- quick

quickly on this one -- in institution was established in 2005 with an idea that will be a correct -- collective group connecting different -- and most genomics and some of the prot proteomics and some of the other molecular i /tkpwguess skin -- different cancer types.

i am so going to review some of the latest publications about cancer types and there is a review how /to use that for cancer genome biologists. so this is a very important figure in that paper, which gives you a really good idea of comparing different tumor cells.

and we have lieu /kaoeeukemia,breast, o ovarian, and the other tumors. so this is kidney. glial blast /oeoma. common brain tumor. col /orechtal and rechtal cancerand and two types of cancer. so in /this analysis, we are looking at the number of mute

mutations per megabase of dna. there are in each tumor. and then you see that the lowest is am l. and brader cancer is with the -- bladder cancer is with the group of lung, which has the highest number of negative. so am l is /the lowest mutation,

maybe one or negative. then you have this the highest number with lung cancer and brader. and just think about it. it's what we believe and exposed to various carcinogens in the air and what the brader ac accumulates, which what we eat and drink and that is a source

probably of carcinogenics. thinking that cancer and col /o* colorectal and rechtal cancer have a high number of different clusters. a number of patients have mutate mutated fephenotypes, whichmeans they have more than 150 mutation mutations they could have above

any other tumors. and that's another issue by itself. and interestingly, what we can see that lung cancer has an in increased g transer,. if you look at the bottom of this slide, there is really very important information

bruthere is this transition between right be and the green one is /the transversion. and for those of you who are not molecular biologists by birth -- i am not -- i am going to put this slide just to remind you what /i mean. in order to acquire a transition

between them, all that is required is put in /aa groupamino group. and then there is no way to get it back. they're not really capable of making it transition back. so this is a very common transition, where methylation is

a normal process of the dna meth methylation and yet it may lead to permanent mutation. most of them are silent, because the body tolerates now genomics tolerates these types of transitions. but some of them lead to permanent change of growth --

and mutations. germs of transversion, you have to -- in terms of transversion, that's most common with oxidate oxidative stress and other injury. so we have a methylation and i am going to set your mind on that in terms of bladder cancer.

and in brader cancer we actually have both. there is a significant number of transversion, as well as methyl methylation induced transition. and -- in the bladder. oxidative and dna methylation tumor in general. so this is another way to look

at it. and it is looking at the number in tumors and looking at 147 most commonly mutated genes in all of those 12 cancers. so out /of that, you can take a look that bladder cancer and ut utterine cancer contains the highest number of these mutation

so in general, we have tumor, but bladder and utterrine have the highest. so we are -- here again we are dealing with an organi that is exposed by location through a number of carcino/skpwrepb injuries. so carcinogen and injuries.

so a rather simple organiegon -- organi. it's a conduit that contains urine. however, it's not so simple. it has a transition between the bladder into the eurethra and the two utreters coming from the top and the /pwopbottom.

but here you have a really very nice view of what the muscle layer is and multiple cells that contains the connective tissue, the layer of the ep/thaoitheliumand then the muscle layer under neath the bladder. and in terms of progression of the -- thon slide because andrea

explained it very nicely. but somewhere between stage one and stage two, the invasion into this deeper layer really in terms -- determines the's response to therapy. low grade and high grade and what is that transition? as we are looking at molecular

components and into molecular mutations, within those tumors, you can -- you will see that there isn't much difference. so let's take a look at what we we traditional rithought that the non-muscle invasive has a type, which is the number of chromosomes s, normal and very

few genomic mutations. and the muscle invasive bladder cancer has everything. they have the chromosome number changes, which is called fluid fluidity, too few or more than necessary for normal types -- fephenotypes. an /sproegs of chromosomes by

the time they come together and multiple arrangements. there is a number of chromosomes and so on, if the cell survives. and then also repairs in dna and in activating polluteations in dna repair genes and-damage -- damage control, which andrea pointed out also inep/skwrepigenetic

modifies and that's a very large group of genes. we'll see that recurrently in this more recent general study. so what are we missing? how do we study bladder cancer? this seems to be so complex and so beyond what we actually talk about it -- thought about it

before and has as a model say breast cancer. targeted therapies. we are not there in brader just think my entire talk that we are talking about at least five to seven new patients per tumor, cell patients, -- inaudib[inaudible].

so this is -- we have done some process in microwave technology and have seen is a lot /oftumors vague lot /of help with microa microarray. there was a very nice study on bladder and one /of them showed that there is a to microarray genes 20, that seem to correlate

the survival with response to that are prove good. that was in 2011. however, a larger study -- no correlation. so you couldn't rely on microa microarray analysis either. so there is a number of papers came in the last two years

showing that you aurothelialcancer shows something different and what avenue -- we have is nuke nucleotides and heterogeneity and involvement of chromatin modeling genes and we have frequency modifications on some of the genes that we have not suspected to be mutated in order

-- in other tumors. so i am going to review for you the tcga studies that showed 131 patients that have not been treated with bladder cancer and it's a pretty stenextensivestudy with they found 39,000 mutations in these tumors and with average of 302 total

it's quite a lesson, which is considered to be the most -- type of tumors but it's pretty large and also alterations in all the genetic materials. slide and i will go through tai little slower. this is a slide that shows that all of these tumors.

if you look at smoking, you look at age and gender, they are all over /the place. there was no correlation looking at /this large number ofpatients by genomic signature that it would assign actually smoking is a risk factor, not anymore. and one of the genes that mutate

mutated most frequently is p 53 and p 53 oxidases for -- where -- we know a lot about p 53s and molecule of the year in 1989, i think and it tends to gain with rb 1, is one of the most commonly mutated genes and it can spread out between a few different groups.

however, this study tries to correlate the mutational analysis can -- with by itself without putting it together with smoking and gender and other sections. it's kind of divideed itself into three groups. so the red group -- it was called the process state

amplified and it's enriched in photo somatic copy -- and simple simplification. but it also includes chromatin modelers and here is the interesting thing. these are the genes of the group that is the largest gene group in all of them.

and it's very much enriched in each one of these three groups. i just want /to keep that inmind mind. the brupart is a group -- blue part is a group that is enriched with gf 3 mutation. perhaps this is a mutation that makes a gf receptor superactive

and there is a specific inhibit and/or pointed out there is a number of clinical /traoeutrialsthat will be targeting this about 15% of those tumors. so they might be amenable and the green one is p 53 mutant but again look at /this. this is not a dimension -- even

mentioned in the study because they really don't know what to do with it. now go back to /tthat a little later. this is another study that also shows that the genomic landscape is similar. actually this is comparing super

super/tpeurficial and invasivetumor and as you see, no difference. we have superficial -- super super/tpeurficial and maybe thisis a little bit more of invasive tumor. but look at super/tpeurficialtumor cycles. they are all over /the genomic

landscape. and here /tin /tthis study aswell, we can see that conduits as well as these genes are a part of the chromatin modeling, along with the mostly known gene p 53 rd family in gf 3. so tumor data, very much similar similar.

so another way to look at it are they mutually exclusive? what is this chromatin modeling? are they on the same revel with the kinase mutations, with ras mutations mix? it looks like they are, because they are mutually exclusive with kinase mutations.

in other words, if they are there -- certainly a very important part of my career. but also a combination of rd 1. quite surprising that you don't have the similar way of genomic landscape. and this is quite well-separated between those two groups.

overall, we can see that p 53 and d /ph-fpm mutations is about80%, as andrea pointed out as well. the chromatin modelers. so that was really surprising. we have never previously addressed chromatin modelers as a target for therapy. how we are going to do it?

how we are going to study chromatin modeling as /aa target for tumors? so this is one of the slides just to show you that the mute mutations in these genes -- one of them is /the associated a approach in one, p /tk-fpd/ph-fplm 6 a and multiple sites.

this isn't like one spot that all the mutations owccur. they occur all over /-the gene, including per mutations. so there are various sites that activate the genes in many ways that make it participate in the genomics of the arrangement. and here is c /tk-fpd /ph-fplm 6a and /aea group

institute at nci, led by nickle nickleson, have looked at it specifically and really is a tumor suppressor gene? is it really inactivating that gene to develop? and cause the brader cancer to develop? of course i am going give you a

slide of this -- all the complex complexity of chromatin modelers and there is a number of genes that participate in chromatin muteation and they have to do with dna manipulation, histone and chromatin remodeler complex and include rnas and micro micro/r-fp(micro)rnas

(micro)rnas. and what i want you to think about is dna now -- if it exists exists, it will be broken. if it's a string, highly protect protected and wrapped up along the histone. so in order for the histones to open up a little bit, the

proteins can come up and initiate subscription of genes, they have to be -- but at the same time, some proteins are always going to be bound with that dna. just to have it. so it will be broken. so we have these -- these

proteins that i have mentioned to you -- nnl, a /tk-fpd/ph-fplm as well as complex -- they are all complex in modifyingep/skwrepigenetically the actual chromatin structure. and especially this complex of s snf, which is contained at any point anywhere from 40 to 6 /0 proteins, is /the one thatpushes

it to the left, pushes it to the right, trying to make space for other proteins to come out to initiate transcription to modify the transcriptional event. the other concepts that you should think about it is that all of this man manipulations occur way before

we see rna, dna and most of them will not lead to rna transcription or make any other rna. it are just modify so the complexes can be assemble and re reassembled and at some place along the dna not strand, it will be rna aase.

so we think about this process as occurring before rna and certainly way before any protein is ever made. so kidium is a histone 3 k 27 important marker or initiation of gene transcription. and is this investigators -- one is a hypothesis for expression

of cd n 6 and the other one was negative and we play a usual game. we constitute it, look at the biological behavior of that cell cell. and here is the result of when you are taking /aa cell line and the one that is normal

expression now suddenly this cell grows and much more number of colonies. that means oncogenesis growth is increased and when you take a cell line that doesn't have it, it -- the /kpwrougt is suppress suppressed. so if it's suppressed in the

cell line that didn't suppress -- express it normally, the growth is suppressed. how about proliferation in vi vitro? nope. there is no change. they grow at the same line. however, when you knock out the

cell line that has normal 6 a but you knock it out, you no longer can grow tumors. so for really clear separations between tumor cells that normally grow in mice and these tumor cells that last 6 a. but this experiment really show that -- there has -- there have

not been done any of the studies that showed this before. so a summary of part one /of my talk more speaks with mutation in bladder cancer and are not the driver mutation that's we understand, that we can target with drugs that we know that work as /aa single drug.

not produced substantial results that we can do any diagnosis or bladder cancer has more than five mutations per tumor and sometimes think about 10 and 20 and the most prominent group of genes are p 53 rd and the chromatin life cycles are the next group that has -- that have

a very unique role and are also mutually exclusive with p 53 are the kinase mutations. so we have some work to do. so how do we study chromatin remodeling? so here we are joining a new frontier, which i think should afford the understanding of

human biology of tumors. and first when -- dna strand telling you there was rna, proteins and now i will have to look at how it's regulated? how are cells and our kidney and our bladder and our skin are are the same dna content? but think about it most of the

why do they make completely different proteins? why do they respond to completely different to drugs? if we treat the patient with as asthma with cord /koeudz, that make it better because the immune system die and another cells grew -- grow in response.

so since joined gordon's laboratory, it became clear that perhaps the way to go about it is looking at chromatins by -- now -- dna hypersensitivity mapping. as a mentioned to you, dna does not exist faked. before it is protected by the

histones, which is wrapped around each one of the dna. and -- not clear? but nucleosomes are open and chromatin remodelers help to push them around a little bit. we have dna-binding proteins. and that's where the transcriptional activation owe

occurs. so which is more hypersensitive to dnas are promoters, but also enhancers. so this is a whole new field, because even when we do sequence sequencing, most of the laboratories the studies i showed you before have done

excellent sequencing. we don't know what is out there unless we look for it. and there are very few techniques which we can use to look at those dna regions. so enhancers are different /skpaoeupbdz we are just going to call them for today enhancers

so each cell type has a unique profile of landscape. and so cells in our bodies, in our brains, in our lungs, in our bladers, have completely different chromatin landscapes and they have different regions of dna hypersensitivity mostly because they make different

proteins and are prepared to do different functions and different responses. so i am not going to go into detail how dna hypersensitivity is performed, but basically exposure to enzymes like dnas. there are a variety of other dna asednaases or enzymes that can

cause similarly but that's for practical purposes, i am going to describe dna once. it cuts this region and of course their right particular region in the middle, which is more open, is going to be cut in many ril pieces. cut in less pieces.

and what we do is to collect all the pieces and collect them through grainedients and do massive parallel sequencing. so we have less little pieces and fewer bigger pieces. and then we'll have the entire genome. we can after sequencing,

actually align the entire gent genetic information oncogenomes. and this is shown over /the quality control data that we do before studying for sequencing. so this is how it pretty much looks. we have lots of small pieces. and fewer larger pieces. then we

can align it and make you call the density. so now we have regions of dna that are cut frequently and regions that are not cut at all or cut very seldom. the exposure to dnas is tree minutes. others require similar or

slightly different kinase but it's really, really short because the way it sits with the dna is going to cut everything. so it's no longer --/tphrau[inaudible] [inaudible]. so over 100,000 dna hypersense hypersensitivity types are identified in each cell type.

so you can damage -- imagine the amount of bio/eupb /tporpl/ainformatics that is required to pair it down to die digestive -- die /swreft it to understand what is the minuimum necessary component. i will show you a little bit of that. so these sites identify all active components.

whether they are involved in direct transcriptional dna or not. it is immaterial. if it is active, it becomes active for whatever reason, we are going to see it. so one single layering of sequencing we have so much

material that we would never have it in /tphany other type of access. so here is an example. here is a cell exposed to cord coid, and without it and you see there is one type that appears. it appears after the response to meth zone and it appears only in

-- cell lines. they are both responseive to corticoids. they pretty much have different ways to respond to it /skpwr-fpt so this gene can be related at this site at /this cell but the same gene may be proliferated at a different site in /aadifferent

so other ways to prove is to do chip, that is a chromatin assay, where we can look at a group of receptors bound to one /of these that are open and bound to sun single -- one single site and open /skwraoeufplt they have nothing to do with cord cort corticoid response and only in

this side bound to response. so we can really at least follow the dna hypersensitivity and distinguish the site from those that truly are changing over so we decided to set up our bear bearing to look at two progressions because now we have a way to start with the same

cell and follow the same cell, which is pretty much the same cell, along tumor progression. and it is important, as a mentioned, because otherwise we need hundreds of tumors to make sense /of one stage and the next stage. but before we do that, this is

what we did. we picked up a cell line that is 30.4 developed by dan's lab in colorado and it is grown in a culture and developed from a female patient with muscle in invasive grade 3 bladder cancer but it doesn't grow in mice. so they kept putting it in mice

and putting it in mice and then finally one mouse grew them. so now we had tumorojgenic met static potential cell line. and from that they took the cells and they injected them in in/ttragenius --in/trtravenously into the /sphraoefpblt and the cells going directly through the

spleen and migrating into the liver, now we have a cell line that was targeted along the river. and by multiple re/euinjectionof this cell, now we have cells that exclusive riwent either too so these are from the long and spleen and police officer fene

phenotype that was only to the liver. and i am not going to give you much, but this is how the lung looks like after single in injection. that is a passage to the lung and this is a passage to the so now we have met static to the

plunge and liver. and these all started with one single cell type. so this is now we are talking about met static progression. i'll concentrate on the analysis of these three to show you some of the data. so they were -- they were vected

in/sreu vivo and that wasanother issue. they were selected by pathogens to mice and maintained some of their toxicity. and how about mutations? first of all, what they have? they have ep 300 and fgf recept receptor 3.

they have p /tk-fpd /ph-fplm 6 aand multiple methylations chromatin remodel remodeling and p 53. l is heterogeneity of the wild type and this is homozygous for the cdk. so similar to tumors i showed you in large panel studies that representation of what we expected to see.

did they acquire a huge number of mutations? no. they acquired two mutation re remodeling gene specifications and that is very interesting. and they only showed up in the p 24 and then there wasn't much change between the liver and

lungs. so what is different between those two tumor types? so what we are going to look at is this verse -- versus the two met static-potential cells. and after we look at /this, hundreds of -- and hundreds of cells and dna hypersensitivity

sites, we concentrated on this number of dna hypersensitivity that were consistent among experiments and unique and different from the others. and 13,000 were unique to it with overlap to the lung met static. i don't want to you look at numbers but just look at some

of these cells of this whole slide. if you see that lung and liver met static cells have a very large overlapping dna progression hypersensitivity sites, while these are quite the same among them. all three of them have about 6,000 hypersense

hypersensitivity sites that over overlap. so the other thing that we could do is to look at those sites and see what are they in the genome? are they in chromatin? are they enhancer? remember we were talking that promoters were supposedly more

sensitive to dna hypersense hypersensitivity. well, surprise, surprise. the majority of those cells are not promoters. they are hasnenhancers. so that whole genome state occupied by enhancers is a very large space with dna hypersense

hypersensitivity occurs very frequently and much more frequently, except for this lung fephenotype. it is much more frequent in the other cell types. so i will show you some of the examples. how does dna hypersensitivity

looks like? so here is an example of /aa complex where you see that the cell line disappears -- two. here is also from encode database there is information on methylation of hist ohms h 3 as well as hist ohms h 327 methyl methylation and methylation 1.

so you can see those are very active areas of regulation by both methylation as well as dna this is another example of dna damage response enzyme. and that is also -- we want /to suppress it maybe in the met static fephenotype. and pnf interestingly enough a

appears mostly in the liver, and it's sort of unique that whole pathway is very busy in the lim lymph fephenotype of the liverof induced inflammatory response. and they found one 59 and /aafew others are unique por their own so they are unique sites and i just want /to give you anexample

example. so how do we actually put it together? this is a /ppuzzle that i put it separately. one of the ways that we wanted to do it is correlate the dna hypersensitivity with the gene expression by microassembly plus

microarray analysis by putting first this vast number of genes that are modified or in the vicinity of those vast number of genes modification and correlate with microarray. so what we did was adapted path way to lines this data and we putting into it all dna hyper

hypersensitivity sites account accounting for all the genes within 50 kd of each dna hyper hypersensitivity site. so multiple genes that could be modified within the distance of the dna hypersensitivity. so we have a number of genes that could fall into that

category. so we can identify biological pathways by progression met stat static fephenotype, by merging this dna hypersensitivity by microarray by path wway. so this is the cata. i don't want to do it in too much detail but /pwaefpbg when

we take dna hypersensitivity just by itself and feed it into the /sprapl say, tell me what do you think about this 20,000, 30 30,000 type of genes that are potentially involved just by the -- by detecting the chromatin modification and that was a real surprise.

because when we compare lung met static fephenotype to its cell line, with a high score of p value or whatever and hypermajor hypermajoric. so from all the literature that has been published out there and thousands and thousands of genes that were fed into the program,

i didn't tell them. the machine -- the program responded, long hyper hyper/kpwhraeupblg is number one and there were carcinoma for lung cancer. so that came in with a very high score. how about met static cells

compared to some cells that have /# 2 -- 24 p? first high score newurogentical -- cancer and second score g.i. and liver and specifically liver inflammation carcinoma, et cetera. for some reason, love your neighbor perhaps?

the liver met static cells expressed more liver-like genes that were modified in that group of thousands and thousands of genes with cancers, in the vicinity of those genes. so this is the -- actually when we look at the network -- inaudib[inaudible] -- res/prepiratory

disease for the lung cancer and inflammation in the liver met static. we did much better with this than microarray. this is what microarray showed. the path wway the usual place in doesn't tell us anything about signaling cancer.

dna represelication,recombination. so here is what i am going to tell you is that perhaps we have an opportunity to have a better diagnostic and response prediction tool using this enhancer region and dna hyper hypersensitivity region f we use them.

we will understand how /to -- so this is one example of the network that i showed you. what are the genes that we identified within the thousands of genes that would feed into it and specifically modified in the enhancer region? and in the center of this is --

and one and two. but it's the group of genes that is interesting that they would pick out out /of this program. and so happens with others? just this gene within expression and look what happened. the majority of these genes have

changes in gene expression, quite profound changes in gene although we're looking just as enhancement. i am not going to -- i am just looking at enhancers. anything that is in /this distance beyond 2 1/2 kb from transcription assay and the

majority of them are change expression. so this is very exciting for us to see that the correlation with gene expression that we're looking at the right pattern of modification of the genes. and it is important for progression.

so conclusion from all of this is that chromatin remodeling en enzymes have emerged as /aamajor group of genes involved in the new driver. and they specifically are emerge emerging in cancer that's don't have the normal driver mutations mutations, they might be drivers

by themselves. and dna hypersensitivity and specifically use envelope analysis of tumor progression so we can -- and can identify sub-- transcriptions and do sequence ing to look at the actual fene phenotypes in those regions that are digested by dna so we can

see the entire sequence how /to look at drug response? because then we can look at before and after the drugs and see what change is predict? is it going to be /aa good drugto treat the patient or not? the most important thing that our lab is now working on right

now is /the diagnostic potential to have a signature of dna hyper hypersensitivity sites, which we can -- other tumors predict is it going to respond or is it going to be /aa very aggressive tumor? so some have been useful because they allow us the bioanalysis of

dna hypersensitivity and the genes correlate with expression. so the last thing i want to /add to is that one /of our lab members who just left minutes ago is involved in using human biopsies from bladder cancer also from process state and other cancers to do this type of

analysis because we have no technology that allows us to use very few cells that is used in -- than using the dna as an en enzyme as a marker. but the idea is there and we are working very hard. so thank you for your attention. and this is the lab, which i am

a happy member and hoping to do my -- which isfapharmacogenomics, ep/skwraoeigenomics. so thank you very much. >> thank you very much. that was very exciti. yes, sir the? yes, sir? >> inaudib[inaudible].

you mentioned that the high mute mutation rate in the utterrine cancer and the bladder cancer. so there are the ep/thaoithelial cells and except except one /of them is -- inaudib[inaudible]. and the other is -- >> the question? >> the question isinaudib[inaudible]

>> it's very likely. the exposure to carcinogens and the time that it is exposed to. and we know that even in tissues tissues, we can expose to carc carcinogens. but i would keep it for /aawhile. >> and the other question you mentioned is /the dna hypersense

you looked at -- is it present in all segments of dna or in a particular gene? >> it's profiled in one state of hypersensitivity, which is you take 100,000 sites of completely different among each cell in the body. right and also, you started with

the human tissue and then you went to the mouse. there are doesn't matter. all mammal iian cells have the same pattern of hypersensitivity sites but -- because if you think about it, our cells do different things and respond different ways to drugs and to

the functions. so in order to use the same dna to perform different functions, they have this regulatory kind of mechanism of chromatin re remodeling. >> developed in human stem cell cells -- /phauinaudiblemutations -- rare lot /of that data is

available on the -- combine all of this information. >> a lot /of pills and a lot/-of food put metabolites into the is there any information on whether significant mutajens among them? >> i am going to defer to you. >> we know certain chemicals

are definitely more likely to cause -- >> >> we have not found that other drugs -- there was -- i believe that some anti-diabetic drugs may cause brader cancer, and there has been large studies now that are still in/kopb/khraoconclusive

about that and is still being debated in courtrooms. >> that are in the urine, right right. >> it's not the actual drug. >> potentially. >> i want to ask something very interesting. andrea mentioned that the ratio

of male-to-female bladder cancer is 3-to-1. in the past we used to think that that ratio is because -- however, the women are working just as well as men do. interestingly enough, two of the most frequently mutated chromat chromatin remodelers are on

chromosome xy so the males don't have the protection of the other chromosomes. and that might be the missing link of the gender difference in at least account /ing for someof it. >> one of the mutations that was found is in a transfer aasein

now this gets back to the question we're asking because this is a major non-oxidateer drug /h--met /pwraoeuzingsystem. and is it really true that they lead to susceptibility or is that just an /aerroneous report? >> so perfect person to answer. >> i work on genetics for brad

brader cancer and studies showed that all three systems which are providing data specification any of potential carcinogens. so if gc m -- so all of them have genetic variance which in increase susceptibility to blad because we continually drink and eat and smoke and everything has

to be detoxified and removed. and if we have genetic variance germ wiwise, variance in these systems, you have in-- >> does that answer your question? >> is gs t tied to one /ofthese these? >> gs t is a very significant

reed to bladder cancer. >> okay, the hour is late. thank you very much.