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GENE EXPRESSION and FATIGUE in PUERTO RICAN MEN by Copyright 2015 VELDA J. GONZALEZ Submitted to the Graduate Degree Program In

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GENE EXPRESSION and FATIGUE in PUERTO RICAN MEN by Copyright 2015 VELDA J. GONZALEZ Submitted to the Graduate Degree Program In GENE EXPRESSION AND FATIGUE IN PUERTO RICAN MEN BY Copyright 2015 VELDA J. GONZALEZ Submitted to the graduate degree program in Nursing and the Graduate Faculty of the University of Kansas in partial fulfillment of the requirements for the degree of Doctor of Philosophy. _____________________________________________ Chairperson, Lauren S. Aaronson, PhD, RN, FAAN _____________________________________________ Marjorie Bott, PhD, RN _____________________________________________ Janet Pierce, PhD, APRN, CCRN, FAAN _____________________________________________ Leorey N. Saligan, PhD, RN, FAAN _____________________________________________ Brooke L. Fridley, PhD Date Defended: April 14, 2015 ii The Dissertation Committee for VELDA J. GONZALEZ Certifies that this is the approved version of the following dissertation: GENE EXPRESSION AND FATIGUE IN PUERTO RICAN MEN _____________________________________________ Chairperson, Lauren S. Aaronson, PhD, RN, FAAN Date approved: May 11, 2015 iii Abstract Background: Prostate cancer is the most frequently diagnosed cancer in men (40.6% in 2010) in Puerto Rico and external beam radiation therapy (EBRT) is the preferred form of treatment for one third of newly diagnosed prostate cancer patients in Puerto Rico. Puerto Ricans often experience ethnic disparities in cancer treatments and in their symptom experience. Purpose: This study will: (a) describe the trajectory of fatigue among Hispanic Puerto Rican men over the course of receiving EBRT for non-metastatic prostate cancer and compare these findings with historical data of fatigue symptoms of Caucasian men with prostate cancer during EBRT; (b) assess gene expression changes from baseline to midpoint of EBRT using microarray technology; and (c) determine the association between changes in genes expression and changes in fatigue score from baseline to midpoint of EBRT using an unbiased, hypothesis-generating approach. Methods: As a prospective exploratory and comparative design study, fatigue was measured using the Functional Assessment of Cancer-Therapy –fatigue from 26 Hispanic Puerto Rican men who were newly diagnosed with non-metastatic prostate cancer at three time points (baseline [prior to EBRT], midpoint [days 19-21], and end of EBRT [days 38-42]). Whole-blood samples also were collected at baseline and at midpoint of EBRT to explore the differential expression of genes using microarray. Functional networks of the differentially expressed genes were examined. Descriptive data were analyzed using t-test, Wilcoxon, and Friedman test for repeated measures. Gene expression data were analyzed using the LIMMA package in R and the functional network analysis was conducted using Ingenuity Pathway analysis. Findings: Subjects were ages 52-81 with fatigue scores that were unchanged during EBRT (baseline= 42.38, SD = 9.34; mid-point=42.11, SD = 8.93, endpoint= 43.04, SD = 8.62); iv Friedman's test: χ21.20[ df , 2], p=.55). Three hundred seventy-three genes (130 up regulated and 243 down regulated) were differentially expressed from baseline to mid-point of EBRT (FDR<0.01). The top distinct canonical pathways of the differentially expressed probesets (p< 0.0001) were: Phospholipase C Signaling, Role of NFAT in Regulation of the Immune Response, and Gαq Signaling. Conclusions: There were no changes in fatigue scores among Puerto Rican men during EBRT for prostate cancer. However, differentially expressed genes during EBRT suggest activation of immune response, which is a mechanism proposed to explain cancer-related fatigue. Further investigation is warranted to explain the disparity in fatigue symptoms reporting of Puerto Rican men from other ethnicities receiving the same treatment. v ACKNOWLEDGEMENTS Every day I give thanks to God for the life and the health, for my wonderful family, for the love, understanding and support of my husband for thirty-plus years Miguel (the best editor ever), for my princess Sara (who is going away to college soon) and my prince Luis Miguel (who grew up watching me in front of the computer)--I hope I have been able to inspire them to pursue higher education; for my precious mom, for having the opportunity to grow with the love of my Dad and my Brother (both passed away) who I know are proud of me, for my in-laws Miguel and Carmin, my sister-in-law Grissel, my nephews Daniel and Julio, and my niece Denisse, for their encouragement and caring for my kids every time I am away from home, and my brother- in-law Gerry, who provided me a home away from home every summer vacation. Many special people have been key to my success as a graduate student and in this dissertation project. At KU, thanks to: my dissertation chair Dr. Lauren Aaronson, for her mentorship each step of the way on my grant applications and dissertation using every opportunity she had to make this a productive, learning, meaningful and smooth experience; Dr. Marjorie Bott, who not only supported me in my grant submissions, guided my first step in multiple linear regression, but listened and was there for me when I needed her; Dr. Janet Pierce, who during the first week at KU inspired me to become a nursing scientist, introduced me to the world of genetics, and always motivated me with her support; Dr. Brook Fridley, who made bioinformatics friendly and provided me with all the support of her department; Dr. Sue Popkess-Vawter, for serving in my program committee; and Dr. Phoebe Williams for serving as my program and minor advisor and for guiding my first steps in research, first at the University of Florida, and then at KU; and Shirley, my classmate, for cheering me up during this dissertation journey. At the National Institute of Nursing Research, thanks to Dr. Ann Cashion vi for opening the doors of NINR to me; everlasting gratitude to Dr. Leorey N. Saligan for his motivation to inquire the world of genomics and symptom science, without his support the genomic piece of this dissertation would have not been possible, for his mentorship and encouragement during my grant applications and dissertation, opening his lab to me, providing me with all the support and amazing training opportunities from his staff, for his unbelievably fast response to my emails or texts, and for the future collaborations; to Christiana, Alexandra and Kristin for their work on the microarray experiments. At the University of Puerto Rico Medical Sciences Campus, thanks to: Noel J. Aymat, DMD FAAPD JD, Chancellor; Lic. Lilia Figueroa; Dr. Suane Sanchez, Dean of the School of Nursing; and Dr. Gloria Ortiz--for the opportunity of a Faculty Position at the School of Nursing; Dr. Augusto Elias, for his understanding and support, to be able to attend the Summer Genetics at NINR; and Dr. Glorisa Canino, for all her encouragement; Dr. Hector Banchs, for his longstanding mentorship, support, and friendship; I extend a big thanks to the staff of the U-54, especially to the bioinformatics consultant, Dr. Humberto Diaz, and the administrator, Ms. Evelyn Rivera, who always listened. At Tome and Ubiñas Radiotherapy Center, I would also like to thank: Dr. Tome and Dr. Ubiñas, for giving me access to their patients; and Noemi, Jesenia, and all the staff who facilitated this process. I could not have done this study without the “participants,” my deepest appreciation to the volunteers of this study that did not hesitate to participate and provide blood samples. Lastly, this work was supported in part by the National Institute of Nursing Research Intramural Program at NIH, the ONS Foundation/ONS Foundation Endowment Dissertation Research Grant, the Kansas University, School of Nursing, the Crighton Award, the Ruth O. McKibben Alumni Research Award, and the Sousa Award of Excellence; KU National Institute vii of Health grant awards P30 CA168524 and P20 GM103418R01 GM28157, U19 GM61388; and, UPR National Institute of Health grant awards 2U54MD007587 and CA096297/CA096300. viii Table of Contents ABSTRACT .................................................................................................................................. iii ACKNOWLEDGEMENTS ......................................................................................................... v LIST OF ABBREVIATIONS ..................................................................................................... xi LIST OF FIGURES .................................................................................................................... xii LIST OF TABLES ..................................................................................................................... xiii CHAPTER I INTRODUCTION .................................................................................................. 1 Background ................................................................................................................................ 1 Purpose of Study ....................................................................................................................... 2 Fatigue during EBRT ............................................................................................................... 2 Biological basis for EBRT-related Fatigue ............................................................................. 3 Conceptual Framework ............................................................................................................ 5 Study Aims .................................................................................................................................6 Design Overview .......................................................................................................................
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