We find that NRP1 expression is correlated with poor prognosis, glioma grade, and associates with the mesenchymal GB subtype. In human GB, NRP1 expression is highly correlated with markers of monocytes/macrophages, as well as genes that contribute to the pro-tumorigenic phenotype of these cells.High grade gliomas, including glioblastoma (GB), are devastating malignancies with very poor prognosis. Over the course of the last decade, there has been a failure to develop new treatments for GB. Reasons for this failure include the lack of validation of novel molecular targets, which are often characterized in animal models and directly transposed to human trials. Here we build on our previous findings, which describe how the multi-functional co-receptor Neuropilin-1 (NRP1) signals through glioma associated microglia/macrophages (GAMS) to promote murine glioma, and investigate NRP1 expression in human glioma. Clinical and gene expression data were obtained via The Cancer Genome Atlas (TCGA), and analyzed using R statistical software. Additionally, CIBERSORT  Gliomas account for 60% of all primary and other CNS tumor diagnoses, and make up ~80% of all malignant brain tumors . The WorNeuropilin-1 (NRP1) is a multi-functional co-receptor present in most tissues. It is expressed by a diverse range of cell types, such as neurons, glia, endothelial and immune cells. NRP1 was originally reported to associate with the cell surface receptor Plexin A1 and facilitate ligation with SEMA3A in neurons, which drives axonal pathfinding . NRP1 haThe complex tumor microenvironment (TME) of the brain is made up of non-cancerous stromal cells such as endothelial cells, cells of the immune system, astrocytes and microglia - all of which contribute to the maintenance and growth of malignant gliomas . Under h+ cells caused a shift in localization away from hypoxic areas, reduced neoangiogenic function, and reversed the immunosuppressed TME [NRP1 signaling in monocytic cells, such as GAMS, is not well characterized. In models of lung, breast and pancreatic cancers, macrophage-specific deletion of NRP1 shows profound effects on disease progression . Lack ofssed TME . Our labssed TME . Furtherssed TME . We havessed TME . Thus, met al. reported that patients overexpressing NRP1 have poor prognosis [The association between NRP1 expression and patient prognosis is not well studied in glioma. In 2004, Osada rognosis , howeverTo establish NRP1 as a therapeutic target in GB, this correlation must be corroborated. Whether NRP1 expression by GAMs drives their pro-tumorigenic phenotype and/or glioma disease progression in humans is unknown. We describe here our analysis of two questions: 1) Is NRP1 expression correlated with glioma prognosis and 2) Can NRP1 expression be linked to pro-tumorigenic GAMs of the TME.p = 0.036, HZ = 0.50; GBM log-rank p = 0.040, HZ = 0.57)  Figure . This re) Figure . The ana) Figure . It shouet al. [Given the differences in survival observed across the two cohorts, and within combined glioma, we next investigated the connection between NRP1 expression and glioma grade. Indeed, NRP1 expression increased significantly as glioma grade increased Figure . This reet al. . Thus, NNF1 gene distinguishes the mesenchymal subtype, and is functionally related to the recruitment of GAMs in human GB [Along with histological diagnosis, the WHO now recognizes four distinct molecular subtypes of GB: classical, mesenchymal, neural, and proneural –26. NRP1human GB , 26. We http://recur.bioinfo.cnio.es/) [p = 0.0886, HZ = 0.62), although, it is not significant in this sample size.NRP1 expression was also found to be significantly higher in grade III-IV patients with IDH wild type status Figure , furthernio.es/) , and theAIF1 and ITGAM  are pan markers of monocytes, macrophages, and microglia, and are highly upregulated across human GB subtypes . Using tin silico method to determine absolute immune cell fractions within the TME ((https://cibersort.stanford.edu/) [http://xcell.ucsf.edu/) (data not shown). In conjunction with the above functional gene analysis, there appears to be a strong connection between NRP1 expression and GAMs in human GB. These expression data suggest that the activity of this co-receptor may lead to pro-tumorigenic changes in this innate immune cell sub-population that drive disease progression.To further support the hypothesis that NRP1 is primarily expressed by pro-tumorigenic GAMs, and that this may drive disease progression, we used the CIBERSORT rd.edu/) . CIBERSOAccompanied by an extremely high mortality rate, GB is associated with histopathological variability and a median survival of approximately 14 months with standard therapy, marking it one of the most lethal cancers , 4, 39. indirectly support the hypothesis that GAM-specific NRP1 expression plays a major role in GB disease. Follow up studies should be conducted to directly detect the extent that GAM-specific NRP1 correlates with GB survival.With the explosive growth of immunotherapies, new tools are arising to treat glioma. Targeting GAMs via CSF1R inhibition is a novel suggested therapy, which has recently completed phase II clinical trials, however, results already exist detailing potential resistance mechanisms , 40, 41.We have shown in the GL261 model of murine GB that GAM-specific knockout of NRP1 slows disease progression by reducing tumor vascularization and inhibiting immunosuppressive TGFβ signaling . M2 pro-Our present comprehensive analysis of NRP1 expression in human GB, in combination with the conclusions from our murine glioma model , 21, 23,https://portal.gdc.cancer.gov/) by accessing TCGA datasets from the LGG and GBM studies [https://www.r-project.org/). For relative expression comparisons, NRP1 expression levels were distinguished into upper and lower quartiles. This resulted in 128 patients per group from the LGG cohort, and 39 patients per group from the GBM cohort.Patient and RNA-seq data were obtained through the NCI's Genomic Data Commons repository . This algorithm compares gene expression data sets to that of 22 immune cell subtype gene signature profiles to derive relative and absolute fractions of cell populations within the tumor sample. Two-way ANOVA with Bonferroni's correction was used for CIBERSORT comparisons.The Kaplan–Meier method and Cox regression analysis were used for survival comparisons. This statistically compares overall survival between groups and generates a hazard ratio which describes the likelihood of death occurring. For grade, subtype, IDH status, and gene comparisons, expression was taken across the entire patient sample set, as a less biased approach then segregating into quartiles. One-way ANOVA with Tukey's post hoc analysis was used for grade, subtype, and IDH comparisons. AIF1 and ITGAM expression were fitted with a linear regression model and compared for statistical significance. The R package


BACKGROUND. Liquid biopsies have demonstrated that the constitutively active androgen receptor splice variant-7 (AR-V7) associates with reduced response and overall survival from endocrine therapies in castration-resistant prostate cancer (CRPC). However, these studies provide little information pertaining to AR-V7 expression in prostate cancer (PC) tissue.METHODS. Following generation and validation of a potentially novel AR-V7 antibody for IHC, AR-V7 protein expression was determined for 358 primary prostate samples and 293 metastatic biopsies. Associations with disease progression, full-length androgen receptor (AR-FL) expression, response to therapy, and gene expression were determined.RESULTS. We demonstrated that AR-V7 protein is rarely expressed (<1%) in primary PC but is frequently detected (75% of cases) following androgen deprivation therapy, with further significant (P = 0.020) increase in expression following abiraterone acetate or enzalutamide therapy. In CRPC, AR-V7 expression is predominantly (94% of cases) nuclear and correlates with AR-FL expression (P ≤ 0.001) and AR copy number (P = 0.026). However, dissociation of expression was observed, suggesting that mRNA splicing remains crucial for AR-V7 generation. AR-V7 expression was heterogeneous between different metastases from a patient, although AR-V7 expression was similar within a metastasis. Moreover, AR-V7 expression correlated with a unique 59-gene signature in CRPC, including HOXB13, a critical coregulator of AR-V7 function. Finally, AR-V7–negative disease associated with better prostate-specific antigen (PSA) responses  and overall survival  from endocrine therapies (pre-chemotherapy).CONCLUSION. This study provides impetus to develop therapies that abrogate AR-V7 signaling to improve our understanding of AR-V7 biology and to confirm the clinical significance of AR-V7.FUNDING. Work at the University of Washington and in the Plymate and Nelson laboratories is supported by the Department of Defense Prostate Cancer Research Program , the Pacific Northwest Prostate Cancer SPORE (P50CA97186), the Institute for Prostate Cancer Research, the Veterans Affairs Research Program, the NIH/National Cancer Institute (P01CA163227), and the Prostate Cancer Foundation. Work in the de Bono laboratory was supported by funding from the Movember Foundation/Prostate Cancer UK (CEO13-2-002), the US Department of Defense (W81XWH-13-2-0093), the Prostate Cancer Foundation (20131017 and 20131017-1), Stand Up To Cancer (SU2C-AACR-DT0712), Cancer Research UK (CRM108X-A25144), and the UK Department of Health through an Experimental Cancer Medicine Centre grant (ECMC-CRM064X). Prostate cancer (PC) is the most commonly diagnosed noncutaneous cancer and the second leading cause of male cancer-related death in the Western world . AndrogeDespite this significant progress, resistance to AA and E is common and on average occurs within a year of starting therapy; this is due, at least in part, to the emergence of constitutively active AR splice variants, of which AR splice variant-7 (AR-V7) is regarded as the most significant and most extensively characterized –31. AR-VInsufficient data have been available on AR-V7 mRNA and protein expression in primary PC, although some studies suggest expression –38. AR-VIn this work, we have performed an extensive cross-institutional study to determine nuclear AR-V7 protein expression in tissue biopsies and autopsies from primary and metastatic PC tumors using a potentially novel AR-V7 antibody. We establish that expression of AR-V7 protein is rare in primary PC. In addition, nuclear AR-V7 expression emerges in response to primary ADT alone in most patients, and further increases in response to AA or E therapy, with nuclear AR-V7 being an important marker of response to these endocrine therapies in CRPC. Furthermore, AR-V7 expression associates with AR-FL expression and AR copy number in CRPC, although many cases with high AR-FL protein expression have undetectable/low AR-V7 protein expression. Moreover, nuclear AR-V7 expression is heterogeneous in different CRPC metastases in the same patient. Finally, nuclear AR-V7 expression is associated with a unique gene signature in CRPC patients. These data support a critical role for AR-V7 in CRPC biology and resistance to established endocrine therapies, providing further impetus for the development of therapeutic strategies that overcome AR-V7–mediated signaling to improve the outcome for patients with this lethal disease.https://doi.org/10.1172/JCI122819DS1). In contrast, no band was seen in AR-V7–negative cell lines  at 80 kDa  was developed, in collaboration with RevMAb Biosciences, against CE3 of AR-V7. Antibody validation was performed at The Institute of Cancer Research/Royal Marsden Hospital (ICR/RMH) and the University of Washington (UW). Western blot analysis of AR-V7–positive cell lines  demonstrated a strong AR-V7 band at 80 kDa  increased from CSPC  to CRPC  (P = 0.020) in 40 biopsies prior to AA or E therapy  than in 120 biopsies after AA or E therapy   (P = 0.013) in lymph node metastases  compared with bone , liver , prostate , and other  sites of metastases  . Next, w, 5–130) . Median , 5–130) ; three  . Interes, 5–130) . Further 20–150) . There w = 0.27) . Next wetastases . Finallytastases . AlthougP = 0.04) at the time of starting AR-targeting therapy before chemotherapy, but no other differences in baseline characteristics were observed (n = 8) had a greater prostate-specific antigen (PSA) 50% nadir  and PSA 50% response rate  than AR-V7–positive patients (n = 28) (P = 0.012) nuclear AR-V7 expression  than those who did not  (P = 0.02), longer time to clinical/radiological progression , and improved overall survival  (n = 17) had a significantly greater PSA 50% nadir  and PSA 50% response rate  than those positive for AR-V7 (n = 37) (P = 0.011) nuclear AR-V7 expression  than those who did not  (P = 0.90), time to clinical/radiological progression , or overall survival  (P = 0.57) and PSA 50% response rate  between AR-V7–negative (n = 18) and –positive patients (n = 37) (P = 0.14) different in patients achieving a 50% PSA fall with docetaxel  compared with those who did not  (P = 0.90) and time to clinical/radiological progression  (P = 0.03) compared with AR-V7–positive patients (Studies have shown AR-V7 protein and mRNA to be a marker of next-generation AR-targeted therapy (AA and E) resistance , 26–30. observed . Patient(n = 28) . Patient 55–180) . Further = 0.02) . Fifty-f = 0.02) . There w = 0.02) . Patient(n = 37) . Patient 25–125) . Interes = 0.98) . Having  = 0.98) . There w = 0.98) . In cont(n = 37) . Nuclear5–132.5) . Consist = 0.36) . Howeverpatients . Taken tr = 0.69 [0.58–0.77], P ≤ 0.001)   and total AR-V7  protein significantly correlated with AR copy number in 95 CRPC biopsies from the ICR/RMH CRPC cohort   . In ligh≤ 0.001) . Unlike ≤ 0.001) . There w≤ 0.001) . HoweverC cohort . Finally = 0.20) . These dv567es variant, each of 5 metastases expressed the variant AR in a homogenous fashion  with manual scoring and was used to determine nuclear AR-V7 expression in the UW CRPC cohort   (We have previously shown that in a patient with a genomic rearrangement resulting in the constitutively active AR fashion . Since A fashion . AutomatC cohort . Three t 0.9972) . However× 10–07) . These d2 counts per million) was determined and corrected for multiple testing. We identified 487 genes that correlated (q < 0.05) with AR-V7 protein expression; of these, 407 positively correlated and 80 negatively correlated (P < 0.001) and 21 ICR/RMH (P = 0.004) CRPC biopsies (data not shown). Next we independently tested the positively correlated 407-gene signature in 21 CRPC metastases from an ICR/RMH CRPC cohort and 122 CRPC tumor transcriptomes   and AR-V7 protein expression (IHC) available. The correlation between AR-V7 protein expression (OD) and gene mRNA expression  . Of the  cohort) . Followi cohort) . Consist cohort) –64. In a cohort) . Althoug cohort) . These dSince the pioneering studies of Huggins and Hodges in 1941, the androgen receptor has remained the focus of therapeutic targeting in CRPC. Inhibition of the AR axis with AA and E has improved both overall survival and quality of life for patients with CRPC –17, 65. In contrast to primary PC, 75% of CRPC patients who had progressed on primary ADT alone  expressed nuclear AR-V7 before receiving AA or E. Despite AR-V7 expression after primary ADT, subsequent AA or E treatment has significant antitumor activity with response rates ranging from 57% to 78% , 14, 66.Critically, we found that AR-V7 protein expression is more prevalent in CRPC biopsies than previously reported from AR-V7 mRNA and protein expression studies in liquid biopsies (11%–46%) , 27–29. The majority of clinical studies have demonstrated that AR-V7 positivity confers resistance and poorer outcome to AR-targeting therapies in patients with CRPC , 26–31. The mechanisms by which AR splice variants are generated include genomic rearrangements and/or aberrant alternative mRNA splicing , 68–71. Previous studies examining AR-V7 cistromes and transcriptomes demonstrated proliferative cistomes/transcriptomes that are likely not specific to AR-V7 but a marker of rapidly progressive disease , 78–80. In conclusion, our results show that AR-V7 protein expression, using a validated, highly specific antibody, is not seen in primary CSPC and does not appear until initial resistance to standard ADT occurs, and increases further with AA and E therapy. In addition, AR-V7 protein expression associates with resistance to AR-targeted therapies but not taxane treatment in patients with CRPC. Furthermore, although AR-V7 and AR-FL expression levels associate in CRPC, there are many cases in which expression levels are uncoupled, suggesting that AR-V7 protein expression is not simply a function of AR-FL protein expression. Moreover, AR-V7 protein is heterogeneously expressed, especially between metastases from the same patient, indicating multiple resistance mechanisms in the same subject. These data suggest that multiple therapeutic modalities may be needed simultaneously to adequately reverse endocrine resistance in AR-V7–positive PC. Finally, AR-V7 protein expression associates with a unique gene signature that may drive transcriptional activity and PC progression. These results further confirm the importance of AR-V7 in CRPC biology and provide impetus for the development of novel therapeutic strategies that abrogate AR-V7 expression at the time of initial ADT in CSPC in order to prevent or delay development of CRPC and improve the outcome for patients with lethal PC.2. Cell lines were tested for mycoplasma using the VenorGem One Step PCR Kit (Cambio) and short tandem repeat (STR) profiled.LNCaP95 cells were provided by Alan K. Meeker and Jun Luo . 22Rv1 (CRL-2505), VCaP (CRL-2876), DU145 HTB-81), M12 , and PC3 (CRL-1345) cells were obtained from American Type Culture Collection. Doxycycline-inducible cell lines were created using lentiviral vectors in pLKO-Tet-On backbones targeting either GFP , AR-FL exon 8 , or AR-V7 cryptic exon 3 , and lentiviral particles were produced as previously described  supplemented with protease inhibitor cocktail (Roche). Protein extracts (20 μg) were separated on 7% NuPAGE Tris-Acetate gel (Invitrogen) by electrophoresis and subsequently transferred onto Immobilon-P PVDF membranes of 0.45 μm pore size (Millipore). Primary antibodies used were rabbit monoclonal anti–AR-V7 , rabbit monoclonal anti–AR-V7 , and mouse monoclonal anti-vinculin  with species-specific secondary antibodies conjugated to horseradish peroxidase. Chemiluminescence was detected on the Chemidoc Touch imaging system (Bio-Rad).Cells were lysed with M-PER Mammalian Protein Extraction Reagent (Thermo Fisher Scientific) supplemented with Halt Protease Inhibitor and Halt Phosphatase Inhibitor Cocktail. Protein extracts (30 μg) were separated on 4%–15% Mini-PROTEAN TGX Precast Protein Gel (Bio-Rad) by electrophoresis and subsequently transferred to a nitrocellulose membrane with an iBlot system. Primary antibodies used were rabbit monoclonal anti–AR-V7 , mouse monoclonal anti–AR N-terminus , and rabbit monoclonal anti-GAPDH . The specific signals were visualized on Blue Ultra Autorad Film (GeneMate) with species-specific secondary antibodies conjugated to horseradish peroxidase by chemiluminescence.Cellular extracts were prepared from cumate-treated M12 cells expressing cumate-inducible AR-V7 lentivirus using the SparQcumate switch lentivector system (Systems Bioscience) as previously described . Preclea3; then mice were castrated. For AA- and E-resistant xenograft model, when castrated tumors exceeded 150% nadir volume, they were treated with AA (30 mg/kg) and E (50 mg/kg). Tumors were biopsied before castration resistance, at castration resistance, and when resistant to AA and E therapy.All animal studies were performed in accordance with Beth Israel Deaconess Medical Center IACUC regulations (protocol 086-2016). VCaP mouse xenograft models have been previously described . BrieflyThe Institute of Cancer Research and Royal Marsden Hospital (ICR/RMH) CSPC and CRPC cohort was identified from men with CRPC treated at the Royal Marsden NHS Foundation Trust. The ICR/RMH CSPC cohort contained 63 patients with sufficient formalin-fixed, paraffin-embedded (FFPE) diagnostic  CSPC biopsies; all biopsies demonstrated adenocarcinoma and were from either prostate needle biopsies (47 patients), transurethral resection of the prostate , transurethral resection of bladder tumor , prostatectomy (8 patients), bone (1 patient), or rectal biopsy (1 patient). The ICR/RMH CRPC cohort contained 160 patients  with sufficient FFPE CRPC biopsies from metastatic biopsies of bone (81 patients), lymph node (51 patients), soft tissue (8 patients), liver (10 patients), TURP (7 patients), TURBT (1 patient), or prostate (2 patients). All tissue blocks were freshly sectioned and were only considered for IHC analyses if adequate material was present. Demographic and clinical data for each patient were retrospectively collected from the hospital electronic patient record system.The University of Washington (UW) CSPC cohort was identified from men who received radical prostatectomy without neoadjuvant therapy. Tissue microarrays (TMAs) of FFPE tissue from primary prostate acinar adenocarcinomas were generated. The tissue came from the radical prostatectomy samples of 295 patients, none of whom had received neoadjuvant therapy. The TMAs consisted of single cores of 12 carcinomas, duplicate cores of 167 carcinomas, triplicate cores of 44 carcinomas, and quadruplicate cores of 72 carcinomas. The UW CRPC cohort was identified from men who died of their prostate cancer and were part of the University of Washington Medical Center Prostate Cancer Rapid Autopsy Program . Deparaffinization, antigen retrieval , and immunostaining were performed on the Ventana Benchmark automated stainer . Sections were incubated for 2 hours at 37°C with anti–AR-V7 antibody . After washes, bound antibody was visualized using Ventana Optiview DAB detection kit . Sections were counterstained with hematoxylin. Controls were sections of a TMA made of cell lines known to express AR-FL and/or AR-V7  or known not to express AR-FL or AR-V7  and cells engineered to stably express both AR-FL (M12 AR-FL) and AR-V7 (M12 AR-V7) by transfection.AR-V7 and AR-FL protein expression was determined for each case by a pathologist (D.N. Rodrigues) blinded to clinical data using the modified H score (HS) method, a semiquantitative assessment of staining intensity that reflects antigen concentration. HS was determined according to the formula: ([% of weak staining] × 1) + ([% of moderate staining] × 2) + ([% of strong staining] × 3), yielding a range from 0 to 300 .AR-V7 protein expression in the UW CSPC cohort was determined for each case by a pathologist (L.D. True) as described above. AR-V7 protein expression in the UW CRPC cohort was determined using automated digital scoring as follows: TMA slides were scanned with an Aperio ScanScope (Leica Biosystems) at ×40 (0.25 μm/pixel). Using Aperio ImageScope software, the AR-V7–stained TMA slides were annotated to create regions of interest (ROIs) for analysis. Quantitative image analysis of the annotated ROIs was performed using Aperio Brightfield Image Analysis Toolbox software (Leica Biosystems). The analysis data for each TMA spot were extracted into Microsoft Excel for further analysis. The quantitative analysis data for each TMA spot included total numbers and percentages of nuclei (positive and negative), average positive intensity, average positive OD, and area of analysis. The intensity is a measurement of the light transmission, or brightness, of the positive staining in the nuclei and is logarithmically related to the OD. The OD is a measurement of absorbance and is linearly related to the amount of staining present. Automated scores for AR-V7 protein expression were reviewed and confirmed by a pathologist (L.D. True), and have been shown to correlate highly with manual scoring –86.AR mutations and AR copy number were determined for CRPC patient biopsies as previously described .2 counts per million), controlling for multiple testing using the cor.test and qvalue functions in R. There were 487 genes with q value less than 0.05, 407 of which correlated with higher expression in AR-V7–expressing tumors. This 407-gene signature was independently tested in a set of 21 CRPC biopsies  and 122 CRPC transcriptomes . AR-FL and AR-V7 mRNA expression in spliced reads per million mapped reads for 41 CRPC transcriptomes from the UW cohort were calculated as previously described  with AR-V7 protein expression by IHC and RNA-Seq analysis from the same biopsy were used. Data from 21 transcriptomes generated by the International Stand Up To Cancer/Prostate Cancer Foundation (SU2C/PCF) Prostate Cancer Dream Team were downloaded and reanalyzed . Paired-Data from 122 CRPC transcriptomes generated by the International Stand Up To Cancer/Prostate Cancer Foundation (SU2C/PCF) Prostate Cancer Dream Team were downloaded and reanalyzed as described above. For those genes identified in the UW CRPC cohort, association between AR-V7 mRNA expression and each gene mRNA expression was determined using Pearson correlation coefficient.q value less than 0.05 in the UW CRPC cohort (described above), 59 were found to be positively associated and significant with P less than 0.05 in either the ICR/RMH cohort or the SU2C/PCF cohort. The UpSetR R package was used to plot overlap between cohorts. Pathway overrepresentation analysis of the 407- and 59-gene sets was conducted using the Compute Overlaps tool with MSigDB v6.2  (Of the 407 genes positively associated with higher AR-V7 levels with a athways) , 50, 91.t tests (2-tailed), and Wilcoxon rank-sum test as indicated. The 50% PSA nadir and 12-week 50% PSA response rates were compared using Fisher’s exact test. Nuclear AR-V7 expression by 50% PSA response rate was compared using Mann-Whitney U test. Median time to PSA progression, time to clinical/radiological progression, and overall survival were estimated using the Kaplan-Meier method. Association with AR-V7 status (positive vs. negative) was tested using univariable Cox proportional hazards models. For all statistical analysis, a P value less than 0.05 was considered to be statistically significant.All statistical analyses were conducted using Stata v13.1 or GraphPad Prism v6 and are indicated within all figures and tables. H scores (HSs) were reported as median values with interquartile range. For the ICR/RMH CSPC and CRPC cohort, Mann-Whitney test was used to compare differences in nuclear AR-V7 protein expression levels. Spearman’s rank correlation coefficient was used to determine the association between nuclear AR-V7 protein expression and timing of CRPC biopsy after the starting of AA or E therapy. Nonparametric equality-of-medians test was used to determine the difference in nuclear AR-V7 protein expression between metastatic sites. Wilcoxon matched-pairs signed-rank test was used to determine the difference in nuclear AR-V7 protein expression as VCaP mouse xenografts progressed from castration sensitive through castration resistant to AA/E resistant. Spearman’s rank correlation coefficient was used to determine associations between AR-FL and AR-V7 mRNA expression, total AR-V7 and total AR-FL protein expression, total AR-V7 protein expression and AR copy number, total AR-FL protein expression and AR copy number, nuclear AR-V7 and nuclear AR-FL protein expression, and OD and HS quantification for nuclear AR-V7 expression. Fligner-Killeen’s and Levene’s tests for homogeneity of variances between tumors and within tumors were performed in R using the fligner.test and leveneTest functions. Patients’ responses to AR-targeted therapy (AA or E) before and after chemotherapy and docetaxel were determined. For each therapy, PSA nadir was calculated as the lowest PSA level on therapy, and 12-week PSA response was calculated as the percentage change in PSA between the start of therapy (baseline) and 12 weeks of treatment (or closest available PSA reading). Time to PSA progression was defined as time from start of therapy to first PSA increase that is at least 25% and at least 2 μg/l above the PSA nadir. Time to clinical/radiological progression was defined as time from start of therapy to documented radiological progression or clinical progression . Overall survival was defined as time from start of therapy to date of death or last follow-up/contact. Patients’ baseline characteristics and clinical outcomes were compared by positive (nuclear AR-V7 HS >10) or negative (nuclear AR-V7 HS ≤10) AR-V7 status. Patients’ baseline characteristics were compared using Fisher’s exact test, Student’s All animal studies were performed in accordance with Beth Israel Deaconess Medical Center  IACUC regulations (protocol 086-2016). All patients treated at the Royal Marsden NHS Foundation Trust had provided written informed consent and were enrolled in institutional protocols approved by the Royal Marsden NHS Foundation Trust Hospital  ethics review committee (reference 04/Q0801/60). All procedures involving human subjects at the University of Washington  and Fred Hutchinson Cancer Research Center  were approved by the Institutional Review Board at those institutions.AS, IC, WY, CS, DNR, JWR, IF, CB, DD, GS, RR, TU, AN, JW, CM, SC, PSN, SPB, LDT, JSDB, and SRP designed the research studies. AS, IC, WY, CS, DNR, JWR, IF, CB, RR, TU, AN, JW, SC, and LDT conducted experiments and acquired data. AS, IC, WY, CS, DD, DNR, JWR, IF, CB, GS, TU, AN, JW, SC, PSN, SPB, LDT, JSDB, and SRP analyzed the data. AS, IC, WY, CS, DD, DNR, JWR, IF, CB, GS, RR, TU, AN, JW, CM, SC, JL, PSN, SPB, LDT, JSDB, and SRP wrote and critically reviewed the manuscript.


Despite the key role played by androgen receptor (AR) in tumor cell aggressiveness and prostate cancer (PCa) progression, its function in the tumor microenvironment (TME) is still controversial. Increasing studies highlight the crucial role played by TME modulation in treatment outcome and tumor cell spreading. In this context, targeting specific constituents of the TME could be considered an alternative approach to classic treatments directed against cancer cells. Currently, androgen deprivation therapy (ADT) is a routinely adopted strategy in the management of PCa, with initial success, and consecutive fail. A possible justification to this is the fact that ADT aims to target all the transcription/translation-related activities of AR, which are typical of tumor epithelial cells. Less is still known about side effects of ADT on TME. Cancer Associated Fibroblasts (CAFs), for example, express a classic AR, mostly confined in the extra-nuclear portion of the cell. In CAFs ADT exerts a plethora of non-transcriptional effects, depending by the protein partner linked to AR, leading to cell migration, proliferation, and differentiation. In recent years, substantial progress in the structure-function relationships of AR, identification of its binding partners and function of protein complexes including AR have improved our knowledge of its signaling axis. Important AR non-genomic effects and lots of its cytoplasmatic binding partners have been described, pointing out a fine control of AR non-genomic pathways. Accordingly, new AR inhibitors have been designed and are currently under investigation. Prompt development of new approaches to target AR or block recruitment of its signaling effectors, or co-activators, is urgently needed. The present review takes an in-depth look at current literature, furnishing an exhaustive state-of-the-art overview of the non-genomic role of AR in PCa, with particular emphasis on its involvement in TME biology. Prostate cancer (PCa) is one of the leading causes of cancer death in men, with ~307,000 deaths representing 6.6% of male cancer mortality worldwide Taitt, . The rolNotably, although the genomic function of AR is considered to be the main role of this nuclear receptor, lots of binding partners of AR have been described in the cytoplasm highlighting a fine tuning of AR non-genomic pathways whose involvement in prostate cancer disease and progression is currently subject to debate.The present review aims to provide state-of-the-art knowledge on the most important non-genomic effects of AR receptor and the compelling evidence underlying their potential involvement in prostate cancer are here discussed.The AR gene, located on the long arm of the X-chromosome (locus: Xq11-q12), comprises eight exons interrupted by introns of different lengths (0.7–2.6 kb) and encodes a 110-kDa protein made up of 919 amino acids . AR sharThe LBD is the most widely studied and exploited AR domain by Big Pharma due to its crucial role in ligand binding and consequent AR activation. It is constituted by 11 α-helices (α-helix 2 is lacking) and two short β-turn strands arranged in three layers to form an antiparallel “α-helical sandwich.” In particular, upon agonist binding, α-helix 12 (H12) is repositioned and serves as the “lid.” LBD forms the second β-turn that serves as a “lock” to better stabilize the “lid.” A plethora of molecules have been designed taking into account H12, because of its crucial position and pivotal role in AR action mechanism  and ligand-binding dependent activation function 2 (AF2). Both domains bind specific co-regulatory proteins and are crucial for the activity of the full-length receptor, as they are also used for drug development and therapeutic targeting of PCa . It is not weakened by transcription inhibitors and does not require functional nucleus or transcription/translation machinery activation  in proliferation, angiogenesis, invasion and bone metabolism  and downstream phosphorylation of Akt and its targets Bad and FKHR-L1 (Forkhead in rhabdomyosarcoma-L1). As a result, survival pathways are activated with a clear protection against apoptosis by androgens  are still poorly defined as well as the mechanisms triggered by AR.In CAFs, androgens would seem to stimulate DNA synthesis at low picomolar concentrations, enhancing cell motility at high nanomolar concentrations. CAFs may thus shift from a proliferative to a migratory phenotype, depending on the androgen concentration present in the medium  concentration of androgens is present in the medium, stromal AR associates to Src and p85α  representing the main components of the host leukocytic infiltrate  ends up complete blocking the mobilization of intracellular [Ca++]. Such findings suggest the involvement of mAR in androgen-dependent [Ca++] response, involved in the regulation of many cellular mechanisms, including phagocytosis  with a rapid rise of [Camediated . Few datEndothelial cells, a key component of blood vessels, express AR, but little is known about the function and impact of androgens on these cells  to the recruitment of cytoplasmic binding partners, which are the topic of the present review. In great contrast with AR LBD, AR NTD is an intrinsically disordered protein domain which lacks of a stable secondary structure; for this reason, it is not easy to target using structure-based drug design. It is characterized by the presence of two large polymorphic glutamine (20–23 residues) and glycine (16–23 residues) stretches, two glutamine repeats (5 and 6 aminoacids), shorts repeats of 5 alanine and 8 proline residues and a repeat of the sequence PSTLTL . BADGE derivatives from contaminated water were likely bioaccumulated in the collected sponge and cell-based assays were used to test 20 BADGE analogs in order to collect additional structure activity relationship for the pharmacophore. In particular, BADGE.HCl.H2O  initiated in 2016 (NCT02606123). Unfortunately the trial, terminated in 2018, reported an excessive high pill burden (18 capsules/day) at the end of phase 1 and no other results are available, so further studies and ameliorations need to be undertaken.Niphates digitalis  stage. CRPC patients, despite androgen deprivation, still have low levels of testosterone in serum  isolated from PCa cell lines contains AR, and that it can be vehiculated to the nucleus of AR-null cells. In this “receiving”/“target” cells, then, it can bind the PSA promoter and form a classic transcription complex involving DNA pol II, resulting in enhanced proliferation (Read et al., In conclusion, targeting both genomic and non-genomic activity of AR could lead to the eradication of AR tumor dependency in PCa patients. Providing new combinatorial microenvironment-targeting strategies is urgently needed, focusing on the early stages of disease. Particularly challenging but fascinating is the idea to target specific activated stromal pathways to offer a personalized TME-based anticancer therapy in the next future.AT and AZ conceived the idea for the research project, designed the review, and wrote the first draft of the manuscript. MC and MZ critically contributed to the work by describing the genomic role of AR in prostate cancer and provided valuable feedback on the first draft. All authors performed the literature review and all read and approved the final version of the work for submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Bin-CE, a free tool to assist clinicians for computing the SSR for binary composite endpoints. In a first step, the user enters a set of candidate outcomes, the assumed rate of events for each outcome and the assumed effect of therapy on each outcome. Since the strength of the association between outcomes is usually unknown, a semi-parametric approach linking the a priori clinical knowledge of the potential degree of association between outcomes with the exact values of these parameters was programmed with Bin-CE. Bin-CE works with a recursive algorithm to choose the best combination of outcomes that minimizes the SSR. In addition, Bin-CE computes the sample size using different algorithms and shows different figures plotting the magnitude of the sample size reduction, and the effect of different combinations of outcomes on the rate of the primary endpoint. Finally, Bin-CE is programmed to perform sensitivity analyses. This manuscript presents the mathematic bases and introduces the reader to the use of Bin-CE using a real example.The estimation of the Sample Size Requirement (SSR) when using a binary composite endpoint (i.e. two or more outcomes combined in a unique primary endpoint) is not trivial. Besides information about the rate of events for each outcome, information about the strength of association between the outcomes is crucial, since it can determine an increase or decrease of the SSR. Specifically, the greater the strength of association between outcomes the higher the SSR. We present  The use of a binary Composite Endpoint (CE) in clinical trials, defined as the combination of two or more dichotomous variables in a unique endpoint, is common,2. PartiThe potential of a binary CE to reduce the SSR is closely related to the magnitude of association between components. In thisk possible candidate outcomes, finds the best combination which minimizes the SSR, using or not all k components. This tool named Bin-CE is available as a beta version in https://uesca-apps.shinyapps.io/bincep/. We also present a numeric example to illustrate the inputs and outputs of Bin-CE.In the present work, our previous findings with a binary CE with only two dichotomous components are generalized to a binary CE with k dichotomous components. Specifically, we present an Internet accessible computational tool that incorporates a simple method to assess the SSR and helps a trialist to decide upon combining a set of candidate outcomes in a unique CE. The algorithm has been programmed in a free tool that, starting from Relevant Endpoint (RE) as the outcome that is assumed to drive the main effect of the therapy. An Additional Endpoint (AE) is another outcome that the researcher considers to combine with the RE in a binary CE to reduce the SSR. A CE could be built up from one RE and k additional endpoints. For simplicity, the statistical test applied by default is the asymptotic approximation to the Normal distribution of the difference in the proportion of events between groups[CE) and the RE (SSRRE). If the SSR of the CE is smaller than the SSR of the single RE then researcher would prefer the use of the CE [CE < SSRRE).We define a en groups,13,14. Hf the CE  instead Xijk be the binary response of the j-th patient  in the i-th group  for the k-th outcome . The algorithm assumes the same number of patients in each group (n1 = n2) and that at least two outcomes are considered to be combined (K>1). The Relevant Endpoint is codified with k = 1 and the Additional Endpoint uses the remaining subscripts (k>1). E(Xijk) = πik and V(Xijk) = πik(1−πik). Imagine a specific two-component binary CE that combines two outcomes, the RE (Xijk = 1) and the k’-th AE (Xijk = k′), we denote this as Xijk = 1or Xijk = k′ are equal to 1 and 0 otherwise. πi,1k′ corresponds to the probability of both outcomes (i.e. RE and the k’-th AE) happening together. Note that with these six parameters  the SSR of the RE and the CE can be determined[πi1,πik, are known, but πi,1k′ is sometimes unknown[Let etermined,16 and ts unknown.πi,1k′ equals the joint probability between the RE and the k’-th AE and it measures the strength of association between them. We assume that the association between outcomes is the same in both study groups. The probability of both outcomes occurring together is the same in the two arms. Henceforth πi,1k′ it will be referred as πk′1.It should be noted that the parameter Although there are many different coefficients to quantify the strength of association between components of a binary CE . It was shown that the distribution is bounded between a lower and an upper limit and that not all values between 0 and 1 are possible. These bounds, known as Fréchet bounds, depend on the marginal prevalence of each outcome as follows:On the early sixties, the work by Fréchet on the cπk′1 = πi1πik′ both outcomes are considered as not being associated or as independent events. For instance, imagine a CE including the outcomes “ACS or stroke”, these are considered independent if the probability of a patient experiencing an ‘ACS’ is the same regardless the patient had a ‘stroke’ previously and vice versa.When https://uesca-apps.shinyapps.io/bincep/). Bin-CE has been programmed using the Shiny library on R Studio. The R statistical language[https://www.shinyapps.io/) without need to install neither R Studio or Shiny package. Nevertheless, users with programming notions of R language can download the source code at Supplementary Material, S2. File All necessary functions to implement Bin-CE can be found in Bin-CE is a free available web application that can be accessed using a web browser , the combination that minimizes the SSR. The four-screens that conform Bin-CE are automatically refreshed when any input data changes . The firπi = 1,k) in the control group, and the assumed effect of the therapy for each outcome. In addition, the user can choose the Type I and Type II errors. The effect can be assessed using different parameters . For the following discussion we will assume that the effect is estimated by the Relative Risk (RR)  because it is better suited as a measure of intervention effect in clinical trials[Bin-CE allows up to nine outcomes that may be combined with the RE. Bin-CE permits allows uploading the label, the rate of events . Additionally, there are two specific scenarios, one for the maximum and another for the minimum possible association (i.e. minimum and maximum Fréchet bound). For instance, the association between the outcomes “CV death” and “Death from any cause” is the maximum possible association  whereas the association between “ischemic stroke” and “hemorrhagic stroke” is the minimum possible association . There are also three scenarios indicating negative association: strong, moderate, and low negative association, and three scenarios indicating positive association .Bin-CE uses the joint probability as a parameter to quantify the degree of association between outcomes (i.e. second-order association). If values of joint probabilities between outcomes were known by the user they can be assigned manually. However, as usually their exact values are unknown, Bin-CE permits to enter semi-parametric approximations based on the Fréchet bounds . In thisπik,πik′); b) the range between minimum and maximum of the Fréchet bound −Low); and finally, c) the non-association scenario (πkk′ = πikπik′). In (4) it is shown the mathematical expression applied when the user considers that outcomes are not associated, whereas in (5) and (6) the expressions for the negative and positive association are displayed.Bin-CE imputes the joint probability using: a) the marginal prevalence of each outcome  and the (k-1) possible SSRs of the hypothetical two-components CEs when combining the RE and the other AE (SSRk = 2 … K). From all possible additional outcomes Bin-CE selects the one that combined with the RE leads to the largest decrease in the SSRRE. Then, this combination of the RE and the AE with the lowest SSR is considered as the new RE and the algorithm starts again seeking among the k-2 remaining outcomes. Bin-CE additionally estimates the rate of the CE (1) and the effect of the CE on the treatment group .AB) can decrease the SSR of the initial RE (i.e. A outcome). Then the joint probability between the CEAB and the outcome C (i.e. a second order association) is red-colored. The joint probability between AC and BC is known or have been estimated using the semi-parametric approach, but the joint probability between the three outcomes (i.e. the third-order association: πABC) is unknown. To solve this issue, it is assumed a non-associated scenario as a good approximation of the third-order association, πABC = πAC*πAB.The joint probability between the new RE and all other AE candidates has now to be recalculated. If a new CE of three components with lower SSR that the CE of two components exists, this new three-components-CE is in turn considered as the new provisional RE, and the algorithm starts the process again until either all k-1 AE are included in the CE or there is no additional gain in the SSR.Bin-CE shows a table that includes the best combination of outcomes, the rate of events, the effect of the therapy on the CE, the SSR estimated and the percentage of SSR reduction achieved in each step . It alsoThe STEMI-RADIAL study  is a ranThe primary endpoint was the cumulative incidence of major bleeding and vascular access site complications requiring intervention at 30 days. The components of the CE were: gastrointestinal bleeding, hemoglobin drop ≥ 4g/dl without overt bleeding, hemoglobin ≥ 3g/dl with overt bleeding, hematoma > 15 cm, transfusion (non-coronary artery bypass graft), and vascular access complication. Secondary outcomes at 30 days include Major Adverse Cardiovascular Event, defined as combinations of death, myocardial infarction, stroke and coronary artery bypass graft. Since STEMI-RADIAL study included both ischemic and bleeding outcomes we illustrate the performance of Bin-CE using separately both set of outcomes . Figs 2,Using data from STEMI-RADIAL trial, we illustrate the selection of the most efficient combination among the five bleeding outcomes (i.e. 31 possible combinations) and the 4 ischemic outcomes (i.e. 15 possible combinations) in two CEs, one for the bleeding outcomes and the ischemic outcomes, employing Bin-CE.The association between each pair of components is not available in the STEMI-RADIAL publication. Although it is highly recommended, the report of the association between individual components is generally inadequate ,24,25. SIn a first step , the useBin-CE plots the potential SSR using the different combinations between the RE and each AE . A small number of patients had the event, and in this situation the variability of the effect can be high. Thus, simulating different scenarios with different effects as a sensitivity analyses is advisable because it will provide robustness.et al.[et al. have reported several findings concerning the SSR when using CE in the time-to-event setting [Bin-CE, a free intuitive Shiny App available at https://uesca-apps.shinyapps.io/bincep/ with the objective of computing the SSR of a binary CE with more than two potentially candidate endpoints. It has to be noted that the iterative algorithm developed to compute the SSR is not an exact method. Thus, some degree of error is assumed because of the categorical approximation of the second-order associations and the imputation of the third-order association using the mathematical expectation. However, the exact solution would imply the estimation of 2k−1 coefficients  if it is known, which in most cases will not be the case, or to use a semi-parametric approximation based on the Fréchet bounds otherwise. The semi-parametric approximation is, in our view, a pragmatic solution, since for clinicians it is usually easy to intuitively know whether components are correlated or not and, in the case of correlation, if it is positive or negative and the rough strength of the association.As a limitation, the reliability of Bin-CE lies on the validity of the assumption that the mathematical expectation (product of probabilities) is a good approximation of the third-order associations between outcomes. However, as it is shown in the sensitivity analysis, the potential error considering different levels of associations is unlikely to be clinically relevant.Bin-CE uses a greedy step-wise forward iterative algorithm to find the optimal combination. So, Bin-CE solves locally the problem (i.e. to combine the RE with the AE whom establish the lowest SSR) in each step. However, although we assume that the final combination of outcomes in a CE selected by Bin-CE is the most efficient, it cannot be demonstrated. Such demonstration would require simulating all possible combinations from all available outcomes, which would overcharge the programme.In this article, we have focused on the issue of improving efficiency in clinical trials through the minimization of SSR, provided there are a set of potential candidate outcomes available. However, the importance of other critical considerations in the decision to use a CE  should not be underemphasized–5.There are several types of CE depending on the type of outcomes to be combined. Time-to-event CE are by far the most used CE in clinical trials, although there are many other possibilities . In this sense, binary outcomes are used when the outcomes occur in a short-fixed follow-up period or when the outcome has to be dichotomized. Although binary CE are much less used in clinical trials, they are very useful to implement new knowledge on this topic because their mathematic properties are well-stablished. Other authors ,28,33–35In spite of that, we believe that our work is conceptually valid also in survival analysis in the sense that an influence of the outcomes association and of the prevalence on the sample size requirement is also required ,29,36.Bin-CE selects the best set of outcomes comparing the SSR for the RE versus the combination of RE with one of the AE remaining. The SSR is computed considering the simplest hypothesis testing case of equality of probabilities. This approximation is simpler enough when the number of outcomes to be combined is either large (i.e. multiplicity testing problem) or other type of hypotheses testing is desired (e.g. at least one of the components is significant). Some authors have studied in depth,37–39, tAn essential difference between Bin-CE and other tools to compute SSR is that Bin-CE calculates the SSR for the most efficient CE and not for other prespecified CEs. Thus, the clinical trialists have to be aware that bin-CE does not take into account the clinical relevance of the outcomes combinates, which must always be assessed by the researcher. In this paper, we describe a new tool that could be useful to reduce the SSR when one is considering a CE as a primary endpoint. However, not only the SSR but other issues must also be taken into consideration when using a CE in order to correctly interpret the final CE. We and other authors have address these issues previously ,25,39–44So, although Bin-CE does not solve completely the SSR in CE issue, it can be considerate a first step. In this sense, we encourage other researchers to improve the utility of this tool.https://uesca-apps.shinyapps.io/bincep/.To summarize, in this manuscript a free tool to estimate the SSR in a two-arms randomized clinical trial using a binary CE with more than two-components is presented. When a set of possible candidate outcomes is to be combined in a CE and the decision to combine them or not depends on the SSR Bin-CE can be a good tool to consider. Accessible at: S1 File(DOCX)Click here for additional data file.S2 FileThis file includes all functions used in Bin-CE but it not includes the appearance of the tool.(R)Click here for additional data file.S3 File(DOCX)Click here for additional data file.


Systems for monitoring effectiveness and quality of rehabilitation services across health care levels are needed. The purpose of this study was to develop and pilot test a quality indicator set for rehabilitation of rheumatic and musculoskeletal diseases.The set was developed according to the Rand/UCLA Appropriateness Method, which integrates evidence review, in-person multidisciplinary expert panel meetings and repeated anonymous ratings for consensus building. The quality indicators were pilot-tested for overall face validity and feasibility in 15 specialist and 14 primary care rehabilitation units. Pass rates (percentages of “yes”) of the indicators were recorded in telephone interviews with 29 unit managers (structure indicators), and 164 patients (process and outcome indicators). Time use and participants’ numeric rating of face validity  were recorded.Nineteen structure, 12 process and five outcome indicators were developed and piloted. Mean (range) sum pass rates for the structure, process and outcome indicators were 59%(84%), 66%(100%) and 84%(100%), respectively. Mean (range) face validity score for managers/patients was 8.3 (8)/7.9 (9), and mean answering time was 6.0/5.5 min. The final indicator set consists of 19 structure, 11 process and three outcome indicators.To our knowledge this is the first quality indicator set developed for rehabilitation of rheumatic and musculoskeletal diseases. Good overall face validity and a feasible format indicate a set suitable for monitoring quality in rehabilitation. The variation in pass rates between centers indicates a potential for quality improvement in rheumatic and musculoskeletal rehabilitation in Norway.The online version of this article (10.1186/s12913-019-4091-4) contains supplementary material, which is available to authorized users. Rheumatic and musculoskeletal diseases (RMDs) are among the most regular disorders in the general population and have a large economic and social impact on societies . Due to When it comes to the organization of rehabilitation in Norway, healthcare statutes push for a shift in the direction of shorter in-patient stays or day programmes in specialized care, and more rehabilitation and better follow-up in primary care. However, several recent reports conclude that the quality of rehabilitation services in general is low, characterized by a lack of coordination across levels of care, and with divergences in content and quality, especially in primary care. Furthermore, the same reports underline that systems for monitoring effectiveness and quality across health care levels are needed , 9. One QI sets to manage different rheumatic diseases have been developed –18. SomeThe purpose of this project was to develop and pilot test a set of QIs for use in rehabilitation team care of people with RMDs.We used a design based on the Rand/UCLA Appropriateness Method, which has been widely used to develop healthcare QIs . The metA broad national working group of nine members was established, approved by The Norwegian Health Directorate. The sampling strategy was non-random, aiming for a broad and relevant composition for the project. Both genders  and different geographic areas of Norway were represented. The professions were physician, nurse, physical- and occupational therapist (two of each), representing clinicians, researchers and administrators. The Norwegian Rheumatism Association nominated a patient representative. Four of the working group members later became participants of the broader expert panel.The working group prepared the consensus process in an initial meeting. Rehabilitation was defined according to the definition provided by the Norwegian Ministry of Health and Social Affairs as “… a process, or set of processes, which is (are) planned and limited in time, where several professions or services cooperate in assisting the individual user in his or her own efforts to achieve best possible functioning and coping capabilities, and promoting independence and participation in society” . Furthern = 4), rheumatoid arthritis or osteoarthritis (n = 5), and low back pain, osteoporosis or older people (1 publication each). We found no publications describing a QI set for rehabilitation of RMDs. However, several main themes for quality measurement were identified. This informed the process of generating a set of proposed quality domains, which later in the process were operationalized into specific QIs. The literature search was updated in March 2019. Eighty-one new publications were identified, of which three described QIs or quality measures for different managements of rheumatoid arthritis and osteoarthritis [We conducted a systematic literature search in Medline, Embase, Amed, PsycINFO, PubMed and Cochrane from January 1980 to October 2014 for existing QIs in rehabilitation. Search terms were Quality Indicators, Health Care, Structure or Process or Outcome, Quality and Rehabilitation. The search was not limited to diagnostic groups or study design. We included only publications available in English, German, or Scandinavian languages. A total of 660 publications were identified, of which 12 described QIs for rehabilitation. These concerned rehabilitation in general , and feasibility. Each criterion was scored on a Likert scale from 1 to 9 (9 = high degree of agreement).The fact sheets describing each quality domain and the reference list were distributed to all panel members by e-mail. Members anonymously rated each domain according to the following OECD criteria in the Health Care Quality Project : ImportaFor each quality domain, medians of the nine point Likert scores were calculated and the domains were classified into three levels of appropriateness: 1) “appropriate” was defined as a panel median of 7–9 for all criteria. 2) “uncertain” (and included in the next voting round) was defined as a panel median of ≥6 in up to two criteria and a median of ≥7 in the rest, and 3) “inappropriate” (and excluded from further voting rounds) was defined as a panel median lower than the minimum scores for “uncertain”.The expert panel met for a second one-day, in-person meeting. The results from round 1 were discussed, and the panel decided to revise the wording and elements of some of the domains. Following this, the domains were assessed a second time, during which the panel members voted on the domains that had been rated “uncertain” in round 1.After round 2, the results from the consensus process were presented to the expert group and discussed in a third one-day, in-person meeting. Each appropriate and uncertain quality domain was formulated as one or more specific QIs, and the panel reached consensus on a set of QIs to be pilot tested.The purpose of the pilot testing was to test the face validity (the degree to which the instrument appears to be an adequate reflection of the construct to be measured ) and theRehabilitation units from both specialist and primary care were invited to participate in the pilot testing, using a snowball method whereby expert panellists suggested units to be invited. Both oral and written information about the study was provided. The managers of the rehabilitation units answered the structure QIs in the beginning of the test period, whereas patients answered the process and outcome QIs one to two months after completion of a rehabilitation programme. The questionnaire was first sent by e-mail to the participants, who thereafter gave their answers in a telephone interview conducted by the first author (IJ) or a study secretary.The time spent answering the questionnaire in the interview was recorded in minutes, and participants’ ratings of face validity were recorded on a numeric rating scale  according to the question: To what degree do you think the questions capture important elements in rehabilitation? The participants were also asked to comment on the content and comprehensibility of the questionnaire.The study was approved by the Data Inspectorate/Data Protection Official (ref.no: 2015/16099). All participants provided written consent.yes or no for approval/disapproval of each QI in a final anonymous consensus round. The previously uncertain QI was included if 75% or more of the panel had approved it.Results from the pilot test were used as a basis for the discussion in the expert panel in a fourth meeting. Thereafter, the uncertain QIs were rated by the options p-value was set at = < 0.05.Data were analysed in the statistical software SPSS version 21. Descriptive data were given in means and medians. QI pass rates (PRs) were calculated in percent. Separate PRs for each QI were calculated by dividing the number of participants passing the QI (reporting “yes”) by the total number of participants answering “yes” or “no” for the same QI. Correspondingly, summary PRs were calculated by dividing the total number of QIs passed by each participant by the total number of eligible QIs. Correlations between PRs were analysed by Pearson’s r and comparisons of PRs between specialist and primary care by Independent Samples T-test or Mann-Whitney U Test. The statistical significant Based on assessment by experts, the initial literature review and relevant reports and recommendations, a first set of 35 quality domains was proposed Table . Of thesn = 1306), “discharge criteria” and “length of stay” (n = 900), “bio-psycho-social assessment” (n = 1482), “patient participation” and “patient-centred” (n = 979), “arena”, “facilities” and “equipment” (n = 823), “systematic and targeted rehabilitation” (n = 782), “staffing”, “multidisciplinary competence” (n = 974), and “outcome” (n = 620). The first author screened the titles and abstracts. A total of 38 articles were deemed relevant according to the quality domains and were included in the reference list, which served as background material for the consensus process.The literature searches related to the proposed quality domains identified 7866 publications related to “population selection criteria” (Fourteen expert panel members (78%) voted in round 1, and 17 (94%) in round 2. The rating rounds resulted in 19 quality domains to be included for pilot testing, seven structure, seven process and five outcome domains  and 14 from primary care .A total of 207 patients received the patient questionnaire, of whom 164 (79%) completed it. Forty-one did not answer repeated phone calls, and two were excluded due to cognitive impairment. In five of the units, no patients answered the questionnaire.n = 115), osteoarthritis (n = 75), neck-, shoulder- and/or back-pain (n = 86), generalized musculoskeletal pain (N = 44), fractures (N = 36), and osteoporosis (n = 24). More than half were employed and had previously undergone rehabilitation. Compared to the participants in specialist care, participants in primary care were older and more predominantly lived alone. Other patient characteristics are shown in Table The majority of participants were female and admitted to rehabilitation at a specialist rehabilitation institution. They had one or several of the following diagnoses: inflammatory rheumatic disease  face validity scores were 8.3 (8) and 7.9 (9), respectively.Figure Assessment of HRQoL 3–6 months after discharge to highest 96% for the QIs Defined patient target group and Assessment of adverse events.The PRs for structure QIs ranged from lowest 17% for the QI Access to meetings for next of kin and external personnel and External personnel were involved in planning follow-up, to highest 93% for the QI Initial health assessment and 91% for the QI Participated in setting goals.The PRs for process QIs ranged from lowest 19 and 22% for the QIs The PRs for the five outcome QIs ranged from 77 to 89%.Improvement in quality of life, Important improvement in physical, psychological or social function and Reached important goals. 13.8% passed one or no outcome indicator.Figure Results for rehabilitation unit number 11, 19, 22, 26 and 27 Fig.  are not The mean (range) sum PRs for the structure, process and outcome QIs were 59%(84%), 66%(100%) and 84%(100%), respectively.p = 0.3), and for process QIs 70.0 and 50.0%, (p = 0.001), respectively. Regarding outcome QIs the mean sum score was 83.3% in specialist care and 80.0% in primary care (p = 0.5).In general, the mean sum PRs were higher in specialist compared to primary care; for structure QIs 64.2 and 58.4% (Satisfied or very satisfied with the rehabilitation (r = 0.56 p < 0.001). 75% of the patients who passed the outcome QI Important improvement in function also passed the outcome QI Improvement in quality of life.The total mean sum PRs of the process and outcome QIs correlated strongly and positively to the PR of the outcome indicator Regarding comments to the questionnaires, three patients and two managers commented on comprehensibility of some of the QIs, and four patients said it was difficult to answer only “yes” or “no”.Access to meetings for next of kin and external personnel and the structure indicator Procedures for an individual plan for follow-up.Evaluation of the QIs after the pilot test resulted in dividing three of the QIs to ensure accurate answers to each question Fig. . This coDefined patient target group and Assessment of adverse events, the process indicators Validated tests at admission and at discharge, and the outcome indicators Satisfied or very satisfied with the rehabilitation and No adverse events, all marked with # in Fig. The third round (voter participation 72%) resulted in exclusion of the structure indicators An additional file shows the final approved QI set , and process indicators (mean sum PR from 18 to 70%). The domain represents a basic principle in rehabilitation [The pilot revealed substantial potential for improvement in several important quality domains for many participating units. Three domains stood out. The first was litation . Patientlitation . Howeverlitation . The implitation . Both thUse of validated assessment instruments at admission, discharge and 3–6 months after rehabilitation. This domain was developed into ten structure indicators (mean sum PRs from 17 to 69%). Standardized assessment is the first step in, and a fundamental part of, a rehabilitation process [The second domain was  process , 43. At  process . Again tIndividual planning of follow-up, involving the patient and external personnel. This domain was developed into both a structure indicator (mean sum PR 52%), and process indicators (mean sum PRs from 25 to 65%). The lack of coordination and cooperation between rehabilitation programmes and levels of care has been documented for years as one of the weakest elements in rehabilitation [, and there are unfortunately few signs of improvement. When discharged from rehabilitation, patients too often feel isolated and poorly prepared for living with disability in the municipality and know too little about where to turn to access the appropriate further health care [The third domain with a notable potential for improvement was litation , 45, andOverall face validity of the QI set was tested with one question in the pilot study. However, during the anonymous ratings, panel members scored proposed items according to whether it was an obvious measure of quality, if it measured the intended item, and if it captured significant aspects of health and disease or important not medical conditions valued by the patients . Thus, vA limitation of the proposed QI set is that it is based on self-reports from rehabilitation unit leaders and users/patients and lacks data traditionally perceived as structural indicators. For practical application and information about the resource use of the health care, the proposed QIs should be linked to such data, i.e. national registers on work participation or medication, in future studies.Regarding the feasibility of the QI set, the simple yes/no questions and the short time both managers and patients spent on answering them are in congruence with claims that data collection for quality measurement must be simple and not resource demanding . HoweverRecall bias may also have influenced the results, since the questions were answered one to two months after the rehabilitation period. On the other hand, these answers may be more reliable, as the first emotional reaction after the rehabilitation has come to some distance, and patients have got time to test their goals and self-management strategies in their home environment.While the objective of the project was to develop a QI set for use in rehabilitation of patients with RMDs, the QI set appears generic and overriding and not limited to specific disease groups. This can be explained by the fact that good quality in rehabilitation encompasses change processes aimed at enhancing activity, participation and quality of life, which to a large extent are generic and independent of diagnostic group , 47. Theeumusc.net sets for rheumatoid arthritis and osteoarthritis [Since the basic principles of rehabilitation to a large degree are the same across Europe and often independent of diagnostic group, it would be useful to try to reach international consensus for a generic QI set, which could be used to compare the quality of rehabilitation across countries. Further, diagnosis specific health care quality indicators, such as the rthritis , 14, mayThe healthcare level at which rehabilitation takes place varies between countries. A contemporary policy in many countries is to move responsibility for rehabilitation from specialist to primary care. To be able to monitor the quality of patient rehabilitation trajectories over time and compare the quality at different care levels, we aimed at developing a QI set that is valid and feasible both in a specialist and primary health care context. One potential risk of this strategy may be a ceiling effect in specialist care, since higher quality is expected at this level. Still, the results from the pilot test indicate considerable potentials for improvement at both levels.The development of two separate questionnaires answered by rehabilitation managers and patients, respectively, may help to shed light on the black box of rehabilitation . AnalysiA limitation in the pilot test was that the participating rehabilitation units were not randomly selected and were predominantly expected to give rehabilitation of high quality. This selection bias may have resulted in higher PRs than are representative for the average Norwegian rehabilitation unit. Furthermore, the present QI set was developed and pilot tested in a Norwegian context. As far as we know, the content of Norwegian rehabilitation of RMDs is largely comparable to other Northern European countries . NeverthA QI set for the rehabilitation of RMDs has been developed and pilot tested according to the Rand/UCLA Appropriateness Method. The results from the pilot test indicate that the QI set has good overall face validity and is feasible for monitoring quality in rehabilitation. The large variation in PRs suggests a potential for quality improvement in rehabilitation.Additional file 1:The final approved QI set. (DOCX 25 kb)


Given its role in treating musculoskeletal conditions, rehabilitation medicine may be an important factor in decreasing the use of opioids among injured workers. The primary objective was to determine if increased utilization of rehabilitation services was associated with decreased persistent opioid use among workers’ compensation claimants. The secondary objective was to determine the combined association of rehabilitation service utilization and persistent opioid use with days of work lost due to injury.Using Chesapeake Employers’ Insurance Company claims data from 2008 to 2016, claimants with at least one filled opioid prescription within 90 days of injury were eligible for inclusion. The primary outcome was persistent opioid use, defined as at least one filled opioid prescription more than 90 days from injury. The secondary outcome was days lost due to injury. The primary variable of interest, rehabilitation service utilization, was quantified based on the number of rehabilitation service claims and grouped into five levels .p < 0.001) to be persistent opioid users and claimants with low and medium levels of rehabilitation utilization were less likely to be persistent opioid users  . Compared to claimants that did not utilize rehabilitation services, very high rehabilitation utilization was associated with a 27% increase in days lost due to the injury , while low  and medium  levels of rehabilitation utilization were associated with a decrease in days lost due to injury, adjusting for persistent opioid use.Of the 9596 claimants included, 29% were persistent opioid users. Compared to claimants that did not utilize rehabilitation services, patients with very high rehabilitation utilization were nearly three times more likely (OR: 2.71, 95% CI: 2.28–3.23, Our analysis of insurance claims data revealed that low to moderate levels of rehabilitation was associated with reduced persistent opioid use and days lost to injury. Very high rehabilitation utilization was associated with increased persistent opioid use and increased time from work. Opioid drug use in the United States is alarmingly high, with at least 214 million prescriptions dispensed every year since 2006 . The UniAccording to the United States Bureau of Labor Statistics, there were approximately 2.9 million nonfatal workplace injuries and illnesses in private industry in 2016, which occurred at a rate of 2.9 cases per 100 full-time equivalents , 8, and Opioid therapy for the treatment of a workplace injury has been estimated to more than double the likelihood of the claim exceeding $100,000 . SeveralThe primary objective of this study was to determine if an increased utilization of rehabilitation services was associated with decreased persistent opioid use in workers’ compensation claimants. The secondary objective of the study was to determine the combined association of rehabilitation service utilization and persistent opioid use with days of work lost due to injury. We hypothesized that higher rehabilitation service utilization would be associated with lower persistent opioid use . Our secWe examined insurance claims data from Chesapeake Employers Insurance Company (CEIC) from January 1, 2008 to December 31, 2016. CEIC is the largest writer of workers’ compensation insurance in the State of Maryland, providing coverage to approximately 266,000 workers in 2016. This study was approved by the University of Maryland Institutional Review Board. Informed consent was waived for the study as the dataset was de-identified. Data were extracted for each year of the study. During the study period, there were 100,357 unique claims included in the dataset. For patients with unique injury claims in multiple years of the study, only the first claimed injury was included in our analysis. Patients that died as a result of the claimed injury were excluded. All included patients claimed at least one opioid prescription.The primary outcome for this study was persistent opioid use, defined as at least one filled opioid prescription paid for by the workers’ compensation claim more than 90-days from the date of injury. To be categorized as a persistent opioid user, the participant must have also filled at least one opioid prescription in the first 90-days post-injury. The 90-days from injury time frame is consistent with recent publications on persistent opioid use , 21. TheCurrent Procedural Terminology (CPT) codes 97001–97799) included for a single individual in a workplace injury claim. The most common rehabilitation codes used in the claims data were 97110 – therapeutic procedure (36% of rehab claims), 97010 – application of a modality (19% of rehab claims), 97140 – rehabilitation therapeutic procedure (11% of rehab claims), and 97112 – therapeutic procedure (5% of rehab claims). Claimants were categorized by their level of rehabilitation service utilization. The categories for this variable included “no utilization”, plus the four quartile ranges. “Low utilization” ranging from 1 to 7 claims, “medium utilization” ranging from 8 to 37 claims, “high utilization” ranging from 38 to 147 claims, and “very high utilization” for those with more than 147 claims. The categorization of rehabilitation utilization in the sensitivity analyses was similarly based on the distribution quartiles.Rehabilitation service utilization was the primary variable of interest and was quantified based on the number of rehabilitation procedures  codes were used to define the mechanism of injury and categorized into high energy, low energy, or other/unspecified. The claimant’s disability status associated with the injury was categorized based on the most severe level of the claim as adjudicated by the Maryland Workers’ Compensation Commission and included five levels; medical-only claims, permanent total disability, permanent partial disability, total compensation, and temporary partial compensation. Surgical procedures were determined based on claimed CPT codes. Additional joint pain diagnoses were also recorded based on ICD-9 and International Classification of Diseases, 10th Revision (ICD-10) codes. The employment type was categorized using Standard Occupational Classifications and the employer was coded as the State or a private company [Sociodemographic, clinical, and employment variables were extracted from the insurance claims data. Demographic characteristics included age and sex.  company . The numCharacteristics of the study population were summarized with counts and proportions and compared across the five levels of rehabilitation utilization using Chi-squared tests. Logistic regression was used for our primary analysis to test the association between rehabilitation utilization and persistent opioid use. The model was adjusted for age, mechanism of injury, disability status, type of occupation, years with current employer, receiving surgical treatment for the injury, and a concomitant diagnosis of chronic joint pain. For the secondary analysis, the outcome variable (days lost due to injury) was generalized logarithm transformed due to a highly skewed distribution. Multivariable linear regression was used to model the association between days lost due to injury and level of rehabilitation utilization, controlling for persistent opioid use, the interaction between rehabilitation utilization and persistent opioid use, and adjusting for patient age, sex, mechanism of injury, disability status, type of occupation, employer type, years with current employer, receiving surgical treatment for the injury, and a concomitant diagnosis of chronic joint pain.An additional set of sensitivity analyses were performed to assess the effect of rehabilitation utilization within 90 days of injury and, specifically, active rehabilitation procedures within 90 days of injury. CPT codes were classified as either active or passive procedures based on the methods described by Fritz et al. . The priAll statistical analyses were performed using JMP Pro Version 13 .Between January 1, 2008 and December 31, 2016, 100,357 unique claims were registered. Claims pertaining to a second injury during the study period led to the exclusion of 16,477 claimed injuries. Two subjects died as a result of their workplace injury and were excluded. An additional 74,266 individuals were excluded from the data for not having a single opioid prescription filled as part of their insurance claim. Nine thousand five hundred ninety-six employees were included for analysis  and male . Over 60% sustained a high energy injury (n = 5827). Operators and technicians were the most common occupation , followed by service workers . Most were employed by private companies . Fourteen-percent of the sample received surgical treatment for their injury (n = 1325) and 37.7% had a concomitant diagnosis of chronic joint pain (n = 3616).The injured patient characteristics are described in Table p < 0.001) more likely to fill a subsequent opioid prescription more than 90 days from injury than patients with no rehabilitation service claims, in our adjusted analysis (Table p < 0.001) when compared to injured workers that did not have a single rehabilitation service claim. High levels of rehabilitation utilization (range: 38–147) were found to be moderately protective against persistent opioid use, in our adjusted analysis .Two thousand seven hundred fifty-one 28.6%) claimants filled an opioid prescription more than 90 days from their date of injury. Patients with very high rehabilitation utilization (more than 147 claims) were nearly three times  did not lose any work days due to their injury. The median days of work missed due to injury was 17 days (IQR: 0–136). Very high rehabilitation utilization was associated with a 27.1% increase in days lost due to the injury  compared to patients that did not use rehabilitation services (Table p < 0.001) and medium , levels of rehabilitation utilization were associated with a decrease in days lost due to injury compared to patients who did not use rehabilitation services. There was no difference in days lost due to injury between patients with high levels of rehabilitation utilization and patients who did not use any rehabilitation services. Persistent opioid use was associated with increased days lost due to injury by 17.3% , in the adjusted analysis.Over 40% of the cohort ( IQR: 0–16. Very hp < 0.01) compared to study participants with no rehabilitation claims (Table p < 0.001) [In the first sensitivity analysis, very high rehabilitation utilization within 90 days of injury was associated with a 21% increase in the odds of persistent opioid use  .Table 4TThe second sensitivity analysis observed a similar association between very high rehabilitation utilization  with an increase in the days lost due to injury Table . Less reAmong workers’ compensation claimants in the State of Maryland, we observed a strong association between rehabilitation utilization and persistent opioid use even when adjusted for age, mechanism of injury, disability status, type of occupation, years with current employer, receipt of surgical treatment for the injury, and a concomitant diagnosis of chronic joint pain. Low and medium levels of rehabilitation utilization, in particular, were associated with reduced persistent opioid use compared to claimants who did not utilize rehabilitation services. Similarly, 1 to 37 rehabilitation service claims were associated with fewer days lost due to injury compared to claimants who did not utilize rehabilitation services, in the adjusted analysis. The protective effects of rehabilitation against persistent opioid use and days lost due to injury did not extend to claimants with high and very high levels of rehabilitation utilization, which was counter to our hypothesis. Claimants with very high levels of rehabilitation utilization (more than 147 service claims) were more likely to be persistent opioids users and to have more work days lost due to injury.The sensitivity analyses suggest that the level of early rehabilitation utilization had less of an effect on persistent than the overall level of rehabilitation utilization. In contrast to the main secondary analysis, low and medium levels of rehabilitation utilization within 90 days of injury did not reduce the number of days lost due to injury when compared to study participants that did not attend a single rehabilitation session. However, this result may be confounded by nuances to the types and severity of injury that was not available in the data. The findings also suggest a modest benefit from active rehabilitation compared to passive rehabilitation within 90 days of injury in reducing the likelihood of persistent opioid use and reducing the number of days lost due to injury.Our findings suggest that there may be an optimum level of rehabilitation utilization, a concept supported by prior work-disability duration research. Wasiak et al. found that shorter chiropractic care duration was associated with shorter work-disability duration . AdditioPersistent opioid use was associated with very high rehabilitation utilization (147 or more rehabilitation service claims), as well as increased days lost to injury. It is possible that persistent opioid use may impact the recovery process, however, causation cannot be established in this study design. Previous studies have observed an association between early opioid prescription and delayed recovery , and earWe utilized a workers’ compensation claims database with a robust capture of baseline characteristics, injury, and treatment details spanning 9 years. Despite these strengths, some limitations must be considered in the interpretation of the findings. The definition of persistent opioid use is based on prescriptions filled, however, we are unable to determine if the medication was actually consumed by the study participant. The categorization of rehabilitation use was based on the quartiles observed in the data and may not be consistent with the frequency of rehabilitation use in other workers’ compensation populations. A precise measure of injury severity was not available in the data, and while the adjusted models included the adjudicated disability status of the claim, this may not be correlated with the severity of injury. A concomitant diagnosis of previous alcohol or substance abuse as well as anxiety and mood disorders have been previously associated with persistent opioid use but were infrequently reported in the claims data and therefore not included in our analysis . UnderlyFurther studies, in the form of well-designed randomized controlled trials, are needed to determine the effect of the number of physical therapy sessions on days lost due to injury and persistent opioid use. The findings of this study support a hypothesis of diminishing marginal gains from more than 40 rehabilitation service claims and negative implications for days lost due to injury and persistent opioid use at levels of rehabilitation service utilization exceeding 147 claims. It is possible that capping the number of rehabilitation sessions available to injured workers may improve the patient’s activation during the rehabilitation stage of recovery. This policy may also encourage the utilization of other therapeutic modalities in combination or as a substitute for physical therapy. Absent of strong evidence to support an upper limit to effective rehabilitation utilization, many healthcare providers and payers are impugned to discontinue physical therapy treatment. However, if supported, this simple policy change may lead to significant benefit and reduced cost for the rehabilitation of injured workers.Our analysis of insurance claims data revealed that low to moderate levels of rehabilitation was associated with reduced persistent opioid use and days lost to injury compared to no rehabilitation. Very high rehabilitation utilization was associated with increased persistent opioid use and increased time away from work.


The incidence of cancer-associated non-traumatic spinal cord dysfunction is rising due to population aging and better cancer treatment. The overall benefit of rehabilitation in specialized facilities for traumatic spinal cord dysfunction has been confirmed many times. Because of their fragility and multiple comorbidities cancer patients still face challenges to complete rehabilitation in the spinal rehabilitation facilities. In this narrative review we describe specific aspects, challenges in rehabilitation and opportunities to improve care. A literature search was performed in the PubMed database from 1 January 1978 to 30 November 2018. The focus was to find publications that discuss challenges and opportunities for rehabilitation of patients with non-traumatic spinal cord dysfunction due to a tumor. Most publications described the benefits of rehabilitation in specialized facilities. There were only few publications about survival and functional outcomes after rehabilitation for this patient population. Overall benefits including fewer complications associated with spinal cord dysfunction, less pain and depression, and better quality of life were shown. Within the past decades increasing number of publications revealed a growing interest for this group of patients. Despite major progress in cancer treatment, patients still have a limited vital prognosis and access to specialized rehabilitation units because of the concerns about the medical complexity. Patients with spinal cord tumors can benefit in areas of functionality, mood, quality of life, and survival from inpatient rehabilitation programs, in spite of the increased medical comorbidities. Spinal cord injury (SCI) is a debilitating condition resulting in paralysis with associated severe consequences. Non-traumatic spinal cord dysfunction (NTSCD) is suspected to be more common than a traumatic SCI in many developed countries, with best evidence shown in publications from Canada, Australia and Norway –3. A widThe early recognition of NTSCD with its associated neurological complications and timely submission to rehabilitation would result in better functional independence of the patients but the long-term results of rehabilitation are not depicted in newer studies. This primarily resulted from the poor survival time , 18. DesThe narrative review includes most relevant studies regarding the rehabilitation of patients with NTSCD due to tumors , which were published in the PubMed database. The search was conducted in November 2018, the search period was restricted to 1 January 1978 to 30 November 2018 and included the following keywords: spinal cord injury, spinal cord dysfunction, tumor and rehabilitation. After assessing the most relevant studies a search of secondary sources was performed, which also included the references of initially identified articles. Only literature published in the English language and involving humans was included. The focus of this search was to identify publications that discuss challenges and possibilities for rehabilitation of patients with NTSCD due to tumors.There are numerous publications about the benefits of inpatient rehabilitation in SRU compared to general rehabilitation facilities , 20. DesThe primary goal of cancer therapy is to maintain the neurological status, reduce pain and avoid further complications . ManagemPatients with NTSCD due to tumors experience neurological complications, such as pain, bowel and bladder dysfunction, pressure ulcers, increased skin fragility and sexual dysfunction. Some of these conditions may be further complicated due to the tumor and consequently have an influence on the rehabilitation process . The mosThe skin of patients with NTSCD can be affected by developing pressure ulcers, which can be worsened due to immobility, bladder and bowel incontinence, and malnutrition. A large proportion of this complication is preventable using appropriate techniques and education of the patient and caregivers . PatientRehabilitation of patients with NTSCD due to tumors is compounded by several factors, including overall tumor burden with associated secondary depression, adverse reaction of different anti-tumor medications, sedative effect of pain relief medication, effect of radiation, and tumor-related fatigue. Some of these factors can be influenced by correction of the causes. For example, fatigue could be a result of anemia or hypothyroidism secondary to radiation. Thus, supportive care is essential and will help in optimization and improvement of the rehabilitation course . AdequatWhen diagnosed with cancer and spinal cord dysfunction, patients have to undergo difficult adjustments, from denial of their disability to acceptance and learning to live with a new situation . PatientMain attention should be paid to the neurological status and to the degree of spinal cord damage. With increased severity of spinal cord damage, the changes of improvements in neurological function are decreased.The next important step in choosing the rehabilitation unit is the determination of oncological status. Prognosis varies considerably for tumors of different types.Secondary medical health conditions can influence patient’s ability to participate in rehabilitation and need to be optimally managed. Primarily a comprehensive evaluation and management of pain should be done.The patients’ social support has a major influence on planning discharge to home and should be discussed from the very beginning of the rehabilitation.Authors of several studies have shown that patients with functional loss from spinal cord compression can make significant functional gains from inpatient rehabilitation from admission to discharge based on total functional independence measure scores –21, 60. These criteria are vital to guide the decision of admitting patients with NTSCD due to tumors into SRU , 65, 66.In the past decades, a growing interest for NTSCD is reflected in increased publication numbers for this group of patients. Despite major progress in cancer treatment, patients with NTSCD due to a tumor still have a limited vital prognosis and access to specialized rehabilitation units. Full access to treatment in SRUs is still limited due to concerns about fragility and medical complexity associated with this diagnosis. Patients with spinal cord tumors can benefit in areas of functionality, mood, quality of life, and survival from inpatient rehabilitation programs, in spite of increased medical comorbidity from the disease process itself.