The aims of this thesis were to increase the knowledge about the long-term psychological consequences in parents of children diagnosed with cancer, including parents of childhood cancer survivors (CCSs) and bereaved parents, and to take the first steps towards developing a psychological treatment for parents of CCSs. Study I was a systematic review synthesizing the literature on psychological long-term consequences in parents of CCSs. Study II had a longitudinal design assessing posttraumatic stress symptoms (PTSS) from shortly after the child’s diagnosis (T1, N=259) up to five years after end of the child’s treatment or death (T7, n=169). Study I and II concluded that while most parents show resilience in the long-term, a subgroup report high levels of general distress and/or PTSS. In Study III, interview data from the last assessment in the longitudinal project (T7, n=168) was used. Participants described particularly negative and/or positive experiences in relation to their child’s cancer, and results pointed to the wide range of such experiences involved in parenting a child with cancer. In Study IV and V, parents of CCSs reporting cancer-related psychological distress were included (N=15). In Study IV, a conceptualization of this distress was generated by aggregation of individual behavioral case formulations. The conceptualization consisted of two separate but overlapping paths describing development and maintenance of symptoms of traumatic stress and depressive symptoms. In Study V, cognitive behavior therapy (CBT) based on the individual case formulations were preliminarily evaluated in an open trial. The CBT appeared feasible, and at post-assessment participants reported significant decreases in PTSS (p<.001), depression (p<.001), and anxiety (p<.01) with medium to large effect sizes (Cohen’s d=0.65-0.92). Findings indicate that psychological long-term consequences in parents of children with cancer consist of a broad range of negative as well as positive experiences, and that while most parents show resilience in the long-term, a subgroup report high levels of psychological distress. For parents of CCSs this distress is suggested to primarily consist of symptoms of traumatic stress and depression, and a preliminary evaluation of CBT targeting hypothesized maintaining mechanisms showed promise in terms of feasibility and treatment effect. / Behandling av traumatisk stress hos föräldrar till cancerdrabbade barn med kognitiv beteendeterapi via internet / Förekomst, utveckling och behandling av posttraumatiskt stressymptom hos föräldrar till barn med cancer / Utveckling och utvärdering av ett webbaserat psykologiskt självhjälpsprogram för föräldrar till barn som tidigare behandlats mot cancer

Bakgrund: Cancerfallen i Sverige har fördubblats sedan 1970-talet och om cirka 20 år uppskattas 100 000 nya personer insjukna i cancer per år. Att drabbas av cancer anses vara en av de mest stressfyllda situationer en person kan uppleva och sjukdomen påverkar patienten både fysiskt, psykiskt och existentiellt. För att lättare hantera sin nya vardag kan patienten behöva tillämpa olika copingstrategier som används för att hantera svåra påfrestningar.  Syfte: Syftet med studien var att utifrån ett patientperspektiv beskriva copingstrategier som kan hjälpa patienter med avancerad cancer.  Metod: En litteraturstudie med 14 kvalitativa vetenskapliga artiklar genomfördes. Artiklarna analyserades utifrån Lundman och Hällgren-Graneheims (2017) manifesta innehållsanalys.  Resultat: Resultatet delades in i fyra kategorier och tretton underkategorier. Kategorierna som framkom var; Viljan att styra över sitt liv, uppmuntrande känslor, socialt stöd samt andligt stöd. Slutsats: Sjuksköterskan behöver agera på ett sådant sätt att patientens hälsa ökar och lidandet minskar. Sjuksköterskan behöver också utgå ifrån patientens unika och subjektiva livsvärld eftersom det är först då som patientens copingstrategier kan identifieras och stärkas. Tillgodosedda copingstrategier leder till att patientens vardag och liv kan genomsyras av en känsla av hanterbarhet, begriplighet och meningsfullhet.

Prostate cancer (PC) is characterised by dependence upon androgen receptor (AR) as its driving oncogene. When organ-confined, radical treatment can be curative, however there is no cure for advanced, castration-resistant prostate cancer (CRPC). There is therefore a need to better understand the biology of PC, and how influencing AR can modify disease progression. Estrogen is essential for prostate carcinogenesis with evidence from epidemiological, in vitro, human tissue and animal studies. Most suggests that estrogen receptor beta (ERβ) is tumour-suppressive, but trials of ERβ-selective agents have not improved clinical outcomes. ERβ has also been implicated as an oncogene, therefore its role remains unclear. Additional evidence suggests interplay between ERβ and AR, the mechanisms of which are uncertain. The study hypothesis ‘ERβ is an important modulator of prostate carcinogenesis’ was developed to establish whether targeting ERβ could affect PC progression. Much of the confusion around ERβ stems from use of inadequately validated antibodies and cell line models. The first phase of this work was to test ERβ antibodies using an ERβ-inducible cell system. Eight ERβ antibodies were assessed by multiple techniques, showing that commonly used antibodies are either non-specific or only specific in one modality. Two reliable antibodies were identified. Next, cell lines previously used to study ERβ were assessed using validated antibodies and independent approaches. No ERβ expression was detected; an important finding that casts doubt on previously published ERβ biology. Subsequently, a PC cell line with inducible ERβ expression (LNCaP-ERβ) was developed and validated to enable controlled experiments on the effects of ERβ on proliferation, gene expression and ERβ/AR genomic cross-talk. Phase three of this work focused on ERβ biology in PC and its relationship to AR. Interrogation of clinical datasets showed that greater ERβ expression associated with favourable prognosis. Gene expression data from men treated with androgen deprivation therapy revealed that AR represses ERβ. This was confirmed in vitro. The LNCaP-ERβ cell line was treated with androgen and/or ERβ-selective estrogen. Activated ERβ in the presence of androgen-stimulated AR inhibited cell proliferation and down-regulated androgen-dependent genes. Genome-wide mapping of ERβ binding sites reveals that ERβ antagonises AR through competition for shared DNA binding sites. In conclusion, ERβ expression is down-regulated by AR during malignant transformation of prostate epithelium. We reveal an antagonistic relationship between ERβ and AR whereby sustaining or replacing ERβ may inhibit tumour growth through down-regulation of AR-target genes. In future, an ERβ-selective compound may be used to slow or abrogate PC progression.

Having a child diagnosed with cancer is stressful and many parents of children on treatment for cancer report symptoms of posttraumatic stress (PTSS). The overall purpose was to, among parents of children on treatment for cancer, investigate the factor structure of PTSS; investigate the relationships between experiential avoidance (EA), rumination, PTSS and depression; and to develop, test, and evaluate a guided self-help intervention provided via the internet. In a longitudinal study with three assessments (n = 249-203) results indicated that a four-factor solution of PTSS including the factors re-experiencing, avoidance, dysphoria, and hyper-arousal provided best fit and that the pattern and size of factor loadings were equivalent across the three assessments (Study I). In a case study with pre-, post-, and follow-up assessments a guided self-intervention was well received with clinical significant and reliable improvements in PTSS, depression, and quality of life (Study II). Furthermore, in cross-sectional analyses (n = 79) EA and rumination were positively associated with PTSS and depression and provided incremental explanation in depression while controlling for demographic characteristics, anxiety, and PTSS. In longitudinal analyses (n = 20), EA but not rumination predicted PTSS and depression while controlling for initial levels (Study III). Finally, in a randomized controlled trial with parents fulfilling the modified symptom criteria on the PTSD-Checklist allocated to guided self-help via the internet (n = 31) or to a wait-list control condition (n = 27) there was a significant intervention effect with a large effect size for the primary outcome PTSS. Similar results were observed for the secondary outcomes depression and anxiety, but not for EA and rumination. Exploratory analyses suggested that the relationships between EA and PTSS and between EA and depression were weakened in the intervention group (Study IV). The studies included in the current thesis suggest that a four-factor solution should be used when assessing PTSS in parents of children on cancer treatment. Furthermore, rumination and EA in particular seem to be important constructs to consider when understanding PTSS and depression in this population. Finally, guided self-help via the internet shows promise in reducing PTSS and depression among parents of children on cancer treatment who report a high level of PTSS.

Increased understanding of the molecular mechanisms underlying cancer development has shifted drug discovery towards target driven drug development the last decades, but the development of effective cancer drugs has been hampered by the lack of predictive preclinical models. 3-D cultures, considered to more accurately reflect solid tumors in vivo, have been proposed as one way to increase the predictability of clinical efficacy in cancer drug discovery and development. The aims of this thesis were to improve preclinical models for cancer drug development, with focus on colorectal cancer (CRC) and use of multicellular tumor spheroids (MCTS), and also to mechanistically characterize some potentially new anticancer drugs (papers I – IV). The most important technical improvement was the development of direct measurement of green fluorescent protein (GFP) marked cells in spheroids, simplifying live collection of viability data and enabling high-throughput screening (HTS) in the MCTS model (paper I). In paper III and IV, the 3-D model was adapted to enable studies on the interaction between drugs and radiation. Two potentially new anticancer drugs, VLX50 and VLX60, were mechanistically characterized. VLX60, a novel copper containing thiosemicarbazone, induced reactive oxygen species (ROS) formation, was selectively active against BRAF mutated colon cancer cells and exhibited anticancer activity in vivo (paper II). Furthermore, two potentially new anticancer drugs were found suitable for further development for use in combination with radiation (papers III and IV). In paper III, synergy with radiation in spheroids compared to monolayer cultured colon cancer cells was shown with the novel iron-chelating inhibitor of oxidative phosphorylation, VLX600. In paper IV, the antiprotozoal drug nitazoxanide was shown to sensitize quiescent clonogenic colon cancer cells to radiation. In conclusion, introduction of measurement of fluorescence of GFP marked cells in spheroids makes clinically relevant 3-D models feasible for HTS experiments and characterization of candidate drugs and radiosensitizers in early cancer drug discovery and development. VLX60 has several characteristics suitable for further development into a cancer drug, notably against BRAF mutated colorectal cancer cells. VLX600 and nitazoxanide show radiosensitizing properties making them promising for further development for use as cancer drugs in combination with radiation.

Duktal bröstcancer är den vanligaste formen av invasiva brösttumörer. Graderingssystemet för bröstcancer har definierats av Elston och Ellis och är baserat på tre parametrar. En av dessa är räkning av antal mitoser på preparat färgade med Hematoxylin och Eosin (HE). Som ett komplement vid bedömning av bröstcancer analyseras Ki67, en proliferationsmarkör, med hjälp av immunhistokemi (IHC).  Fosfohiston H3 (pHH3) är ett histonprotein som finns i cellkärnan. Proteinet tros vara en specifik markör för mitos eftersom den är fosforylerad enbart under M-fasen och i slutet av G2-fasen. Syftet med studien var att utvärdera pHH3 som potentiell markör för mitos vid diagnostiseringen av duktal bröstcancer. Syftet var även att jämföra metoden med räkning av antal mitoser och Ki67-positiva celler, samt att studera den interindividuella skillnaden vid bedömningen av preparaten. Materialet bestod av 20 sektorresektat med invasiv duktal bröstcancer. Preparaten färgades med IHC och bedömdes mikroskopiskt. Celler som var positiva för pHH3 och Ki67 samt antal mitoser räknades, av tre läkare. Ett medelvärde för varje patientfall och metod beräknades från läkarnas bedömningar. Metodernas variationskoefficienter och dess medelvärden beräknades. Variationskoefficienterna uppvisade medelvärden på 0,21 för Ki67 +/- 0,10 SD, 0,33 för pHH3 +/- 0,14 SD och 0,46 för mitosräkning +/- 0,34 SD. Korrelationskoefficienterna för metoderna och respektive läkare uppvisade en spridning. Korrelationerna uppvisade medelvärden på r = 0,78 för Ki67 och pHH3, r = 0,74 för Ki67 och mitos samt r = 0,83 för pHH3 och mitos. Enligt studien verkar antipHH3 vara ett bra komplement vid bedömning av duktal bröstcancer. Dock krävs tydliga kriterier för vad som ska räknas som en pHH3-positiv cell. Intervariabiliteten verkar bli mindre med anti-pHH3 än vid räkning av mitoser, som är mer tidskrävande. Minst intervariabilitet ses vid bedömning av anti-Ki67 som en proliferationsmarkör. / Ductal carcinoma of the breast is the most common form of invasive breast tumours. The grading system for breast cancer is defined by Elston and Ellis and is based on three criterions. One of these criterions is the mitotic count in pathological sections of breast carcinomas stained with Hematoxylin Eosin. A common method often applied as a complement in diagnosis of breast carcinoma is immunohistochemical staining with use of antibodies directed against Ki67, a proliferation marker. Phosphohistone H3 is a histone protein that is located in the cell nucleus. The protein is believed to be a specific marker for mitosis since it only is phosphorylated during mitosis, and to some extent at the end of the G2-phase. The purpose of this study was to evaluate pHH3 as a potential marker for mitosis when diagnosing ductal breast cancer. The purpose was also to compare the method to mitotic figuring and the count of Ki67-positive cells, and to study the inter-individual variability when assessing the histological sections. The material consisted of 20 biopsies containing invasive ductal breast cancer. The sections were stained using IHC and all sections were evaluated microscopically. Cells positive for pHH3, Ki67 and mitotic cells were quantified, by three doctors. From the doctors results an average value was determined for each case and method. To be able to compare the methods the coefficient of variation was calculated. The average value of the coefficient of variation was determined for each method and also the standard deviation (SD). The coefficient of variation showed average values of 0,21 for Ki67 +/- 0,10 SD, 0,33 for pHH3 +/- 0,14 SD and 0,46 for mitotic figuring +/- 0,34 SD. The correlation coefficients for the methods and each doctor showed dispersion. The correlations showed average values of r = 0,78 for Ki67 and pHH3, r = 0,74 for Ki67 and mitosis and r = 0,83 for pHH3 and mitosis. According to this study it seems as though anti-pHH3 could complement the other methods. However explicit criteria which defines a threshold value of which cells should be considered pHH3-positive needs to be established. The inter-individual differences seem to decrease using antipHH3 compared with mitotic counting, which is more time consuming. Although the minimum difference can be seen when assessing anti-Ki67 as a proliferation marker.

Bakgrund: Varje år insjuknar ca 320 barn mellan 0-18 år av cancer i Sverige vilket innebär att många syskon kan få en förändrad vardag. Cancer orsakas av att celler i kroppen börjar dela sig okontrollerat samt ökar i storlek, vilket resulterar i en cancertumör. Hur ett syskon reagerar när en bror eller syster får sin cancerdiagnos är beroende på ålder och tidigare erfarenheter. I mötet med ett sjukt barn och dess familj är det viktigt att som sjuksköterska stötta och hantera hela familjens upplevelser i den rådande situationen. Syfte: Syftet med studien var att beskriva syskons upplevelse av att ha en bror eller syster med cancer samt att studera de inkluderade artiklarnas undersökningsgrupp. Metod: En deskriptiv litteraturstudie som inkluderar elva vetenskapliga artiklar som söktes via databasen Medline via PubMed. Artiklarna analyserades med hjälp av Polit och Becks niostegsmodell för ett objektivt urval. Huvudresultat: Syskon som hade en bror eller syster med cancer upplevde många omställningar i livet, både emotionellt, fysiskt och psykiskt. Resultatet visar tre centrala stora upplevelser som syskonen upplevde, ”Känslosamma ögonblick”, “Att rätt information skapar trygghet” samt “Att leva i en förändrad tillvaro”. Undersökningsgrupperna i de inkluderade artiklarna var individer mellan 6-22 år och både pojkar och flickor samt att antalet varierade mellan 6-125 deltagare. Slutsats: Ett syskon till en bror eller syster med cancer upplever många känslor och förändringar samt påverkas av den nya tillvaron som uppstår efter cancerbeskedet. Detta innebär att familjesituationen, relationer och skolan påverkas på olika sätt.

Background and aims: The clinical course of prostate cancer is highly variable and difficult to predict.Stage at presentation, grade and PSA at diagnosis are traditionally used to predict outcome. The aimof this thesis was to identify strategies for improved survival prediction in men with prostate cancer.The way in which prostate cancer affects a population based‐cohort and how routinely measuredvariables can be used to predict survival in an intermediate to long follow‐up period were explored.From this large cohort we separately evaluated how survival can be predicted in men with incidentalcarcinoma (T1a and b) and locally advanced disease (lymph node‐ positive). Immunohistochemistrywas added to routinely measured variables in the subgroup of men with incidental carcinoma.Furthermore, we assessed how the outcome of metastatic disease may be predicted from informationavailable at diagnosis, and during the first six months after treatment. Finally we predicted survivalfor men with metastatic hormone‐refractory prostate cancer (HRPC). Material and methods: From the Swedish South‐East Region Prostate Cancer Register data on 8887men were studied and the impact of tumour grade, serum PSA concentration, TNM classification andtreatment was studied in relation to survival.Furthermore, an evaluation of the disease‐specific mortality of conservatively managed incidentalcarcinoma in relation to T‐category, Gleason score, p53, Ki‐67, Chromogranin A and serotonin wasmade. From the same register we studied whether common predictive factors such as serum‐PSA, Tcategoryand biopsy tumour grade could be used to better assess the prognosis of men with nodepositiveprostate cancer. Using data from the clinical trial SPCG‐5 we studied the possibility of serialmeasurements of PSA and ALP being to predict survival early in the course of hormone‐treatedmetastatic prostate cancer. From the same trial, we also assessed the value of PSA kinetics inpredicting survival and related this to baseline variables in men with metastatic HRPC. Results: In the South–East Region, where screening was seldom done the median age at diagnosisand death was 75 and 80 years respectively, and 12% were diagnosed before the age of 65 years. Hightumour grade, high serum PSA and high T category were associated with poor outcome. The projected 15‐year disease‐specific survival rate was 44% for the whole population. In total, 18% ofpatients had metastases at diagnosis and their median survival was 2.5 years. In the cohort of men with incidental carcinoma, 17% died of prostate cancer. Of 86 patients withGleason score ≤5, three died of prostate cancer. Independent predictors of disease‐specific mortality inmultivariate analysis were category T1b prostate cancer, Gleason score >5 and high immunoreactivityof Ki‐67. Men with lymph‐node positive disease have a median cancer‐specific survival of 8 years.Preoperatively known factors such as PSA, T‐category, age, mode of treatment, failed to predictoutcome, but there was a weak, not statistically significant difference in cancer‐specific survival inrelation to tumour grade. Initial ALP, and ALP and PSA after 6 months of treatment were the serum markers that provided thebest prognostic information about the long‐term outcome of metastatic prostate cancer. In men withHRPC, PSA velocity alone gave a better prediction of survival than all other PSA kinetic variables. Conclusion: In an almost unscreened population, prostate cancer is the elderly mans disease but themortality is high. Ki‐67 may be of value in addition to stage and Gleason score for predicting theprognosis in men with incidental carcinoma.The impact of lymph node metastases on survival overrides all other commonly used prognosticfactors. By following ALP and PSA for 6 months it is possible to predict outcome in metastatic prostate cancer.This gives a much better prediction than baseline PSA and helps to select men with a poor prognosis.By combining PSAV with the variables available at baseline, a better ground for treatment decisionmakingin men with HRPC is achieved.

One-carbon metabolism, a network of enzymatic reactions involving the transfer of methyl groups, depends on B-vitamins as cofactors, folate as a methyl group carrier, and amino acids, betaine, and choline as methyl group donors. One-carbon metabolism influences many processes in cancer initiation and development such as DNA synthesis, genome stability, and histone and epigenetic methylation. To study markers of one-carbon metabolism and inflammation in relation to colorectal cancer (CRC) risk, we used prediagnostic plasma samples from over 600 case participants and 1200 matched control participants in the population-based Northern Sweden Health and Disease Study cohort. This thesis studies CRC risk with respect to the following metabolites measured in pre-diagnostic plasma samples: 1) folate, vitamin B12, and homocysteine; 2) components of one-carbon metabolism (choline, betaine, dimethylglycine, sarcosine, and methionine); and 3) three markers of different aspects of vitamin B6 status. In addition, this thesis examines three homocysteine ratios as determinants of total B-vitamin status and their relation to CRC risk. In two previous studies, we observed an association between low plasma concentrations of folate and a lower CRC risk, but we found no significant association between plasma concentrations of homocysteine and vitamin B12 with CRC risk. We have replicated these results in a study with a larger sample size and found that low folate can inhibit the growth of established pre-cancerous lesions. Using the full study cohort of over 1800 participants, we found inverse associations between plasma concentrations of the methionine cycle metabolites betaine and methionine and CRC risk. This risk was especially low for participants with the combination of low folate and high methionine versus the combination of low folate and low methionine. Well-functioning methionine cycle lowers risk, while impaired DNA synthesis partly explains the previous results for folate. We used the full study cohort to study associations between CRC risk and the most common marker of vitamin B6 status, pyridoxal' 5-phosphate (PLP), and two metabolite ratios, PAr (4-pyridoxic acid/(PLP + pyridoxal)) estimating vitamin B6 related inflammatory processes and the functional vitamin B6 marker 3-hydroxykynurenine to xanthurenic acid (HK:XA). Increased vitamin B6-related inflammation and vitamin B6 deficiency increase CRC risk. Inflammation was not observed to initiate tumorigenesis. Total B-vitamin status can be estimated by three different recently introduced homocysteine ratios. We used the full study cohort to relate the ratios as determinants of the total B-vitamin score in case and control participants and estimated the CRC risk for each marker. Sufficient B-vitamin status as estimated with homocysteine ratios was associated with a lower CRC risk. These studies provide a deeper biochemical knowledge of the complexities inherent in the relationship between one-carbon metabolism and colorectal tumorigenesis.

Glioblastoma is the most common primary brain tumor in humans and has a poor prognosis. Current therapies are not curative. Oncolytic viruses (OVs) are being investigated as tools to induce immunogenic cell death (ICD), cell death capable of activating the immune system. Semliki Forest Virus (SFV) strain 4 is an OV being investigated to treat glioblastoma. Previous studies in our lab have shown that SFV4 can induce ICD in human osteosarcoma (HOS) cells and ongoing in vivo studies show that SFV4 infected GL261 cell vaccination providesprotective immunity in mouse models. This study aimed to characterize the ICD induced by SFV4in glioblastoma cell lines, namely GL261, SB28 and CT2A, and to explain some of our in vivoobservations, namely why vaccination with SFV infected GL261 provides protective immunity but vaccination with infected CT2A and SB28 does not. Our in vitro studies found that GL261 is resistant to SFV4 while SB28 and CT2A are susceptible. We show that the virus can replicate in all three cell lines as seen by the presence of dsRNA, but that viral translation is delayed or inhibited in GL261 cells as not all cells positive for dsRNA were positive for SFV4 protein. Additionally, the type I interferon (IFN) pathway, responsible for antiviral defense, was highly upregulated in CT2A and SB28 but not as much in GL261 after infectionas seen by surveying IFIT1, IFITM3 and IFN-beta genes. Interferon stimulated genes (ISG) like CXCL10, a chemoattractant, was highly upregulated in GL261 after infection and might account for the protective immunity seen in vivo after vaccination. PDL1, an interferon stimulated gene responsible for self-tolerance, was highly upregulated in CT2A after infection. The IFN-beta ELISA revealed that both infected and uninfected GL261 cells produce IFN-beta suggesting a constitutively active pathway. Our DC phagocytosis assay showed that SFV4 infection of CT2A and SB28 cells induced a significant increase in DC phagocytosis and SFV4 infection of all three cell lines significantly increased DC maturation. We conclude that SFV4 infection of GL261 cells may induce ICD in vivo through a persistent viral infection and increased expression of CXCL10.