Background and Aims Osimertinib is a third-generation tyrosine kinase inhibitor targeting activating mutations of epidermal growth factor receptor with remarkable therapeutic efficacy against non-small cell lung carcinoma. However, its use has been limited by associated cardiotoxicity, primarily with heart failure. Herein, this study aims to better understand the mechanisms underlying osimertinib cardiotoxicity and explore cardioprotective strategies.Methods This study leverages an in vitro model of human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) and a clinically relevant in vivo mouse model of osimertinib cardiotoxicity by co-employing transverse aortic constriction to mimic haemodynamic stress in cancer patients.Results Osimertinib treatment leads to significant contractile dysfunction in mice without cell death, inflammation, or fibrosis. By leveraging single-nucleus RNA sequencing of mouse heart tissues and in vitro assays of human iPSC-CMs, the study reveals significant downregulation of MYLK3 and a subsequent decrease in MYL2 phosphorylation with marked sarcomere disarray as the main mechanism of osimertinib cardiotoxicity. GATA4 is further identified as a putative target of osimertinib, connecting its decreased phosphorylation to repressed MYLK3 transcription. The reversibility of osimertinib-induced cardiac dysfunction upon discontinuation of osimertinib treatment supports the hypothesis that transient sarcomere disruption, rather than permanent cellular damage, serves as the key underlying mechanism. Finally, the myosin activator omecamtiv is shown to be effective in preventing osimertinib cardiotoxicity.Conclusions These findings suggest that osimertinib causes reversible cardiac dysfunction by disrupting MYL2 phosphorylation via GATA4 dephosphorylation-mediated suppression of MYLK3 and highlight the potential of myosin activation as a preventive or rescue strategy for osimertinib cardiotoxicity.

Rationale:Ubiquitin-specific peptidase 22 (USP22), a deubiquitinase and component of the "Death-from-Cancer" 11-gene signature, is overexpressed in multiple malignancies and linked to recurrence, therapy resistance, and poor prognosis. Its role in KRAS/p53-driven lung cancer and the response to immune checkpoint inhibitors (ICIs) remains poorly defined. Here, we investigated USP22 as a potential therapeutic target in KRAS/p53-driven lung cancer. Methods:A conditional Usp22 knockout (Usp22-KO) was generated in the KRASG12D; p53-/- (KP) mouse model. Cancer progression was monitored by micro-computed tomography (micro-CT). Multiplex immunofluorescence (mIF), RNA sequencing, and spatial transcriptomics profiled cancer and tumor microenvironment (TME) changes. Responses to anti-PD-1/PD-L1 therapies were compared between KP and Usp22-KO KP (KPU-) lung cancers. Results:USP22 was highly expressed in early-stage KRAS/p53-driven mouse lung cancers and strongly correlated with proliferation marker Ki67. Usp22 deletion suppressed cancer growth, prolonged survival, and promoted cancer differentiation. Spatial transcriptomics and mIF revealed reduced CD206+ M2 macrophages, myeloid-derived suppressor cells (MDSCs), TGF-β1, and angiogenesis, along with increased functional CD8+ T cells. Mechanistically, USP22 regulated gene expression and protein stability, reducing c-Myc, PD-L1, TGF-β1, and SPARC upon Usp22 loss. Compared with KP cancer, KPU- and SPARC-knockdown KP cancers showed reduced macrophage chemotaxis and impaired basal- and TGF-β1-induced M2 polarization of RAW264.7 cells, suggesting that TGF-β1 and SPARC downregulation partially contributes to decreased M2 macrophage infiltration in KPU- cancers. Notably, Usp22 loss enhanced the efficacy of anti-PD-L1 and anti-PD-1 therapies in orthotopic and subcutaneous KP lung cancer models, respectively. USP22 and SPARC expression were also strongly correlated in human lung cancers. Conclusions:USP22 promotes progression and immune evasion in KRAS/p53-driven lung cancer. Targeting USP22 reprograms the TME, suppresses oncogenic signaling, and sensitizes tumors to ICI, establishing USP22 as a promising therapeutic target.

Ubiquitin-specific protease 22 (USP22) regulates epigenetic gene expression by deubiquitinating histone H2B (H2Bub1) and upregulating oncogenic proteins and pathways, while antagonizing p53-mediated tumor suppression. USP22 is frequently overexpressed in cancers and associated with therapy resistance and poor prognosis yet remains largely untargeted pharmacologically. Here, using a fluorescence-based USP22 deubiquitinase assay to screen the LOPAC®1280 library, we identified β-Lapachone, a natural ortho-naphthoquinone with strong anticancer activities, as a potent USP22 inhibitor. β-Lapachone potently inhibited USP22 enzymatic activity, with a half-maximal inhibitory concentration (IC50) of ~0.75 μM, and molecular docking revealed its occupation of the catalytic pocket adjacent to the USP22 active-site triad, supporting a potential binding mode. Functionally, β-Lapachone suppressed proliferation and induced apoptosis in A549 and H1299 RAS-mutant lung adenocarcinoma (LUAD) cells, while USP22 knockout conferred marked resistance, indicating partial USP22 dependence. In patient-derived LUAD models, β-Lapachone inhibited sphere formation and reduced CD133+ cancer stem cell populations. Notably, it synergized with cisplatin to enhance DNA damage and apoptosis. In vivo, β-Lapachone significantly suppressed tumor growth in a syngeneic KRAS-mutant/p53-Null mouse lung cancer model and further potentiated cisplatin-induced antitumor effects. Collectively, these findings identify β-Lapachone as a potent inhibitor of USP22 and validate USP22 inhibition as a key mechanism underlying its anticancer activity in LUAD cells, both in vitro and in vivo.

Introduction:Lung cancers harboring sensitizing epidermal growth factor receptor (EGFR) mutations typically exhibit an initial response to osimertinib; however, the development of resistance is inevitable, and there are currently no approved targeted therapies available once resistance emerges. Accumulating evidence indicates that intra-tumoral bacteria can influence tumor biology and contribute to therapy resistance in several cancer types, including pancreatic and colorectal cancer. Despite these findings, whether intra-tumoral bacteria play a role in modulating response and resistance to osimertinib in EGFR-mutant lung adenocarcinoma remains largely unexplored. This study aims to investigate the contribution of intra-tumoral bacteria to osimertinib resistance, thereby providing new insights into resistance mechanisms and identifying potential therapeutic strategies. Methods:Bacteria previously identified in lung cancer tissue samples were cultured in liquid growth medium, and their preconditioned medium (PCM) was collected. PC9 cells were treated with PCM in the presence or absence of osimertinib to screen for bacteria capable of mediating resistance. Cell viability was assessed using Cell Counting Kit-8 assays. To investigate potential mechanisms, Western blotting and receptor tyrosine kinase (RTK) phosphorylation arrays were performed. Control groups included cells treated with osimertinib alone, PCM alone, or vehicle. Statistical analyses were conducted using Student's t-test as appropriate, with p < 0.05 considered statistically significant. Data represent mean ± SD from at least three independent experiments. Results:The addition of PCM from Chryseobacterium indologenes restored cell viability in EGFR-mutant lung adenocarcinoma cells treated with osimertinib. PCM exposure markedly increased insulin-like growth factor-1 receptor (IGF1R) phosphorylation levels. PCM did not enhance cell viability when IGF1R was silenced or inhibited with linsitinib, demonstrating the pathway's essential role. Proteinase K treatment abolished the ability of PCM to protect cells from osimertinib, and removal of proteins potentially interacting with IGF1R further diminished its efficacy. Finally, PCM also conferred resistance to osimertinib in patient-derived EGFR-mutant lung adenocarcinoma cell lines. Conclusion:Our study demonstrates that the intra-tumoral bacteria C. indologenes may significantly influence sensitivity to osimertinib or impart resistance in EGFR-mutant lung adenocarcinoma by activating the IGF1R signaling pathway.

Barriers to cancer care, including transportation and Internet insecurity, are of special concern in low-resource communities. A patient-centered, telehealth-based, barrier-focused lay navigator program may mitigate such barriers. We share insights from a quality improvement project wherein we developed and delivered a lay navigator program in a low-resource community in the Mojave Desert. We identified 68 patients scheduled for lung cancer detection/management at our institution, 55 of whom completed a barrier assessment, enrolled in the program, and could be evaluated. Participants were predominantly older (76%), White (84%), had a cancer diagnosis at enrollment (69%), and lived in socioeconomically disadvantaged neighborhoods. Thirty-three (60%) patients had ≥1 barrier, the most common being transportation (31%), Internet (24%), and financial (24%) concerns. These barriers were more frequent among patients with a lung cancer diagnosis at enrollment. Crisis-focused and after-hours encounters were more frequently initiated by older and advanced cancer patients. Transportation and Internet concerns were significantly associated with missed appointment rates. While the scope of our findings is limited, the delivery of a telehealth-based, barrier-focused lay lung navigator program in this low-resource setting was feasible. Neighborhood context and barrier resource planning are important for the implementation of similar programs within our institution’s clinical practice network.

Background: The authors assessed the feasibility, acceptability, and impact on cancer worry of a cancer screening program using multicancer early detection (MCED) tests and whole-body magnetic resonance imaging (WBM) in individuals at high cancer risk because of family history or germline variants in cancer-susceptibility genes. Methods: This prospective trial enrolled participants aged 50 years and older who had a significant family history of cancer or a cancer-susceptibility gene variant. Participants underwent noncontrast WBM and MCED testing. The results were shared with participants, and further imaging or consultations were conducted as needed. Surveys assessing anxiety, cancer worry, and acceptability of the intervention were completed at baseline and 6 months after testing. Results: One hundred participants were enrolled: 98 completed both WBM and MCED testing, and 89 completed their 6-month follow-up. The median age of participants was 62 years (range, 51-83 years), and 64% were women. Four participants (4%) were diagnosed with cancer based on WBM findings and subsequent work-up, and all four underwent surgical resection. Two intraductal papillary mucinous neoplasms of the pancreas were detected and are being monitored. MCED testing was positive in four participants, none of whom had suspicious findings on magnetic resonance imaging. One participant with a JAK2 mutation and thrombocytosis is under monitoring for potential hematologic malignancy. Sixty-two participants (85%) somewhat/strongly agreed that study participation reduced cancer worry. Composite Cancer Worry Scale scores demonstrated decreased worry at 6 months compared with baseline (51% vs. high worry in 69%; p < .001). Conclusions: MCED and WBM testing were feasible, acceptable, and were associated with decreased cancer worry at 6 months

Background Lung cancer screening (LCS) is severely underutilized in low-resource communities. Health outcomes in these communities are further exacerbated by barriers to healthcare, such as transportation concerns, poor healthcare availability, and lack of access to the internet. We set out to develop a program at City of Hope (COH) to improve the early detection of lung cancer and patient outcomes in a low-resource community with a high rate of smoking – the Antelope Valley (AV) region in Southern California. The present work highlights the outcomes and impact of this program at COH-AV. Methods To improve LCS volume in AV, we organized physician- and community-focused LCS-related outreach events. To improve patient outcomes, a community-based lay navigator identified patients with a new lung cancer diagnosis or suspicious radiographic findings, conducted a needs assessment to identify potential barriers to care, and scheduled follow-up encounters to provide interventions. We tracked program outcomes such as timeliness of care and percentage of no-show appointments. We also gathered reflections of the navigator on the patients’ lived experience during their enrollment in the program. Results LCS volume increased during the program period, although a direct impact of the program could not be established. Over 60% of patients who were navigated by our lay navigator had ≥ 1 barriers, which were resolved through services (transportation gift cards and loaner tablets) or referrals. Notably, 85% of the patients who did not have a cancer diagnosis at the start of the program completed their diagnostic evaluation. Moreover, 72% of the participants who had stage I-IIIa lung cancer initiated treatment within 12 weeks of diagnosis. The mean percentage of no-show appointments was 31% lower (non-significant) among navigated patients than a comparable cohort of unnavigated patients. Additionally, participants responded favorably toward telehealth and appreciated the lay navigator’s ability to provide emotional support and compassionate interactions, financial assistance and guidance, and assistance in navigating the complexities of healthcare. Conclusions Our results demonstrate the feasibility and potential impact of a community-based navigation program in improving care coordination, timeliness of care, and access while fostering a more supportive patient experience for individuals with lung cancer in a low-resource region served by COH.

The occurrence of lung adenocarcinoma (LUAD) is approximately 68.3 per capita for Black men and 61.5 per capita for White men, reflecting an 11% higher rate in the former. Black patients experience a poorer prognosis and significantly higher mortality rates compared to their White counterparts. Purpose. Understanding the genetic and molecular foundations that underly racial health inequities is essential for developing comprehensive interventions and advancing more precise therapeutic modalities for diverse patient populations. Single Nucleotide Polymorphisms (SNPs) can influence oncogenic transformation and may be associated with distinct molecular landscapes in tumors and adjacent TME. Furthermore, ancestry may play a pivotal role in shaping individual susceptibility and risk for mitochondrial dysfunction and ensuing oncogenic transformation. We employed germline VCFs for ancestry analysis of 36 LUAD patients (18 Black and 18 White) from the ORIEN data set, while genotype data from the 1000 Genomes Project phase 3, grouped by super population served as reference. Oncoplots were generated using a combination of patients’ somatic VCF and metadata from ORIEN. Regression analysis adjusting for age, staging, and gender was performed to determine association between ancestry and gene mutations. Global admixture was estimated using STRUCTURE v2.3.4 with k=5, NUMREPS=2000, and BURNIN=50000. VCFs were subset and merged by 1126 ancestry-informative markers (AIMs) and converted to STRUCTURE format with PLINK. PCA was conducted using R. Local ancestry analysis was performed with LAMP-LD v1.3 using a window length of 50 SNPs and 20 states, based on 20, 803 SNPs. Results were visualized with ggplot2 in R. In Black patients, admixture analysis showed predominant AFR genetic similarity with varying proportions of EUR, AMR and SAS similarity. Local ancestry analysis using LAMPLD reveals admixture across different regions of the genome illustrating the variation in ancestral contributions within and between individuals of the same cohort and compared to counterparts in other populations. Mutations in ACADVL, HK2, SREBF1, COX6L, BID, POLG2, SLC2A2, SLC22A5, and ACKR1 are associated with AFR status >/= 0.5. Mutations in ACADSB, HK3, PPARGC1A are associated with AFR status < 0.5. Mutations in metabolic and mitochondrial genes emerged as being highly enriched in LUAD patients with high relative to low African genetic ancestry, suggesting opportunities for improved risk-prediction and therapeutic targeting in this subpopulation. Benecia A. Jackson, Yuxin Jin, Yonatan Amzaleg, Angel Perez Hunt, Nikita Jinna, Dan Raz, Loretta Erhunmwunsee, John Carpten, Aaron Neely. Exploring the impact of ancestry on metabolic dysregulation in lung adenocarcinoma: Implications for racial health inequities and targeted therapeutics [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 1 (Regular Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_1):Abstract nr 1056.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Lung Cancer Screening provide criteria for selecting individuals for screening and offer recommendations for evaluating and managing lung nodules detected during initial and subsequent annual screening. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines for Lung Cancer Screening.

With a median age at diagnosis of 70, lung cancer remains a significant public health challenge for older Americans. Surgery is a key component in treating most patients with non-metastatic lung cancer. These patients experience postoperative pain, fatigue, loss of respiratory capacity, and decreased physical function. Data on quality of life (QOL) in older adults undergoing lung cancer surgery is limited, and few interventions are designed to target the needs of older adults and their family caregivers (FCGs). The primary aim of this comparative effectiveness trial is to determine whether telephone-based physical activity coaching before and after surgery will be more beneficial than physical activity self-monitoring alone for older adults and their FCGs. In this multicenter comparative effectiveness trial, 382 older adults (≥ 65 years) with lung cancer and their FCGs will be recruited before surgery and randomized to either telephone-based physical activity coaching or physical activity self-monitoring alone. Participants allocated to the telephone-based coaching comparator will receive five telephone sessions with coaches (1 pre and 4 post surgery), an intervention resource manual, and a wristband pedometer. Participants in the self-monitoring only arm will receive American Society of Clinical Oncology (ASCO) physical activity information and wristband pedometers. All participants will be assessed at before surgery (baseline), at discharge, and at days 30, 60, and 180 post-discharge. The primary endpoint is the 6-minute walk test (6MWT) at 30 days post-discharge. Geriatric assessment, lower extremity function, self-reported physical function, self-efficacy, and QOL will also be assessed. The trial will determine whether this telephone-based physical activity coaching approach can enhance postoperative functional capacity and QOL outcomes for older adults with lung cancer and their FCGs. Trial results will provide critical findings to inform models of postoperative care for older adults with cancer and their FCGs. ClinicalTrials.gov Identifier: NCT06196008.

Abstract Demonstrating a combination of high prevalence, late detection, and low survival, Lung cancer is the leading cause of cancer related deaths worldwide (Sainz de Aja J, 2021) and Lung Adenocarcinoma (LUAD) is its most prevalent pathologic subtype (Zhou, 2021). Emerging from within the distal alveolar epithelium, LUAD presents with vast heterogeneity in histology, mutational spectra, and epigenomic dysregulation (Sainz de Aja J, 2021) (Zhou, 2021). Additionally, LUAD’s considerable intratumoral heterogeneity manifests vast genomic and phenotypic diversity across tumor cells and cellular components of the tumor microenvironment (TME) within the same tumor tissue. LUAD also reveals significant racial disparities in incidence, survival and mortality rates between White and Black men in the United States. The occurrence of LUAD is approximately 68.3 per capita for Black men and 61.5 per capita for White men, reflecting an 11% higher rate in the former. Further, survival outcomes indicate that Black men generally exhibit lower 5-year relative survival rates compared to White men, highlighting greater mortality risk and conspicuously poorer prognosis (Siegel RL et al., 2023). While addressing the social determinants of health is vital for the mitigation of health disparities, understanding the genetic and molecular foundations that underly racial health inequities is essential for developing comprehensive interventions and advancing more precise therapeutic modalities for more diverse patient populations. Single Nucleotide Polymorphisms (SNPs) can influence oncogenic transformation and may be associated with distinct molecular landscapes in tumors and adjacent TME. Furthermore, ancestry may play a pivotal role in shaping individual susceptibility and risk for mitochondrial dysfunction and ensuing oncogenic transformation. To elucidate the biological underpinnings of racial health disparities in LUAD, 10 Black and 10 White male LUAD patients’ tumor and normal corresponding adjacent tissues underwent molecular profiling for KRAS mutation status, Whole Exome Sequencing (WES) to determine ancestry, and analysis of associated LUAD induced Mitochondrial Somatic Nucleotide Variants (mtSNVs). We also employed the 10X Visium HD spatial transcriptomic platform to evaluate spatially resolved molecular and cellular differences in KRAS mediated LUAD between Black and White men. Hypothesis: Thus, we propose that global ancestry is associated with variations in intratumoral heterogeneity, TME composition, and mitochondrial dynamics, indicating a potential role in the observed disparities in susceptibility, malignancy and mortality in LUAD across diverse patient populations. Citation Format: Eun Kyu Sung, Yuxin Jin, Yonatan Amzaleg, John Carpten, William Dean Wallace, Dan Raz, Aaron M. Neely. Investigating the effects of ancestry in KRAS mediated lung adenocarcinoma: Exploring intratumoral heterogeneity and mitochondrial dynamics [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C169.

10520 Background: Multi-cancer Early Detection tests (MCED) and whole-body imaging are being increasingly utilized for early cancer detection but are not included in cancer screening guidelines. Our aims were to 1) determine the feasibility of MCED testing and whole-body MRI (WBM) to screen people at high-risk for cancer after germline testing and cancer genetics evaluation and 2) understand the impact of MCED and WBM on cancer worry and anxiety. Methods: We conducted a feasibility trial of people >50 years old with a strong family history of cancer and/or a pathogenic/likely pathogenic germline variant in a cancer susceptibility gene for which WBM is not part of standard risk management. Participants completed a baseline survey including the SF12, State Trait Anxiety Index (STAI), and modified cancer worry scale (CWS). They then underwent non-contrast whole body 3T MRI and liquid biopsy using DEEPGEN, a mutational-based MCED. Results were reported to participants and additional imaging studies or consultations were obtained as needed. Participants were surveyed 6 months after testing using SF12, STAI, CWS, and a questionnaire on acceptability of the intervention. Results: 100 participants were enrolled; 73 have completed 6-month follow-up. Median age was 62 years (IQR 57-66) and 64% of participants were women. MCED was positive in 4 participants, none of which had suspicious findings on WBM. 27 (27%) underwent additional imaging to further evaluate findings identified on WBM. 4 (4%) had cancer diagnosed based on WBM findings and subsequent work up (lung adenocarcinoma, prostate cancer, duodenal neuroendocrine carcinoma, and ovarian Brenner tumor); all 4 underwent surgical resection. One participant underwent bone marrow biopsy due to JAK2 mutation and thrombocytosis (evaluation ongoing) and one participant had a thyroid biopsy for a benign nodule. 62 (85%) somewhat/strongly agreed that study participation reduced cancer worry. Composite CWS scores showed decreased worry at 6 months compared with baseline (12.7 vs 13.7, p=0.003). At baseline, 30 (41%) reported that they somewhat/very often worry about getting cancer, compared with 14 (18%) at 6 months (p<0.001). 8 (11%) reported at baseline that cancer worry affected their mood somewhat/very often, compared with 2 (3%) at 6 months (p<0.001). There were no significant differences in STAI or SF12 composite scores between baseline and 6 months. 69 (95%) somewhat/strongly agreed that they would like to participate in future testing with WBM and MCED. Conclusions: MCED and WBM testing is feasible and was associated with decreased cancer worry at 6 months. In this high-risk cohort, cancer was detected in 4% of patients. Further evaluation of cancer screening in high-risk populations using WBM and MCED testing is warranted particularly with respect to patient-centered outcomes, cancer outcomes, and healthcare resource utilization. Clinical trial information: NCT05868486 .