Limited nutrient availability in the tumor microenvironment renders pancreatic tumors sensitive to allosteric IDH1 inhibitors.


Journal

Nature cancer
ISSN: 2662-1347
Titre abrégé: Nat Cancer
Pays: England
ID NLM: 101761119

Informations de publication

Date de publication:
07 2022
Historique:
received: 19 03 2021
accepted: 02 05 2022
pubmed: 11 6 2022
medline: 29 7 2022
entrez: 10 6 2022
Statut: ppublish

Résumé

Nutrient-deprived conditions in the tumor microenvironment (TME) restrain cancer cell viability due to increased free radicals and reduced energy production. In pancreatic cancer cells a cytosolic metabolic enzyme, wild-type isocitrate dehydrogenase 1 (wtIDH1), enables adaptation to these conditions. Under nutrient starvation, wtIDH1 oxidizes isocitrate to generate α-ketoglutarate (αKG) for anaplerosis and NADPH to support antioxidant defense. In this study, we show that allosteric inhibitors of mutant IDH1 (mIDH1) are potent wtIDH1 inhibitors under conditions present in the TME. We demonstrate that low magnesium levels facilitate allosteric inhibition of wtIDH1, which is lethal to cancer cells when nutrients are limited. Furthermore, the Food & Drug Administration (FDA)-approved mIDH1 inhibitor ivosidenib (AG-120) dramatically inhibited tumor growth in preclinical models of pancreatic cancer, highlighting this approach as a potential therapeutic strategy against wild-type IDH1 cancers.

Identifiants

pubmed: 35681100
doi: 10.1038/s43018-022-00393-y
pii: 10.1038/s43018-022-00393-y
pmc: PMC9325670
doi:

Substances chimiques

Enzyme Inhibitors 0
Isocitrate Dehydrogenase EC 1.1.1.41
IDH1 protein, human EC 1.1.1.42.

Types de publication

Journal Article Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

IM

Pagination

852-865

Subventions

Organisme : NIH HHS
ID : S10 OD030245
Pays : United States
Organisme : NCI NIH HHS
ID : R01 CA196643
Pays : United States
Organisme : NCI NIH HHS
ID : P30 CA010815
Pays : United States
Organisme : NCI NIH HHS
ID : F32 CA247466
Pays : United States
Organisme : NCI NIH HHS
ID : P50 CA150964
Pays : United States
Organisme : NCI NIH HHS
ID : R01 CA244931
Pays : United States
Organisme : NCI NIH HHS
ID : R37 CA227865
Pays : United States
Organisme : NIDDK NIH HHS
ID : R33 DK070291
Pays : United States
Organisme : NCI NIH HHS
ID : P30 CA043703
Pays : United States
Organisme : NCI NIH HHS
ID : P30 CA046592
Pays : United States
Organisme : NCI NIH HHS
ID : R01 CA248160
Pays : United States
Organisme : NCI NIH HHS
ID : R37 CA237421
Pays : United States
Organisme : NCI NIH HHS
ID : R01 CA212600
Pays : United States

Informations de copyright

© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

Références

Vaziri-Gohar, A., Zarei, M., Brody, J. R. & Winter, J. M. Metabolic dependencies in pancreatic cancer. Front. Oncol. 8, 617 (2018).
pubmed: 30631752 pmcid: 6315177 doi: 10.3389/fonc.2018.00617
Whatcott, C. J. et al. Desmoplasia in primary tumors and metastatic lesions of pancreatic cancer. Clin. Cancer Res. 21, 3561–3568 (2015).
pubmed: 25695692 pmcid: 4526394 doi: 10.1158/1078-0432.CCR-14-1051
Kamphorst, J. J. et al. Human pancreatic cancer tumors are nutrient poor and tumor cells actively scavenge extracellular protein. Cancer Res. 75, 544–553 (2015).
pubmed: 25644265 pmcid: 4316379 doi: 10.1158/0008-5472.CAN-14-2211
Olive, K. P. et al. Inhibition of Hedgehog signaling enhances delivery of chemotherapy in a mouse model of pancreatic cancer. Science 324, 1457–1461 (2009).
pubmed: 19460966 pmcid: 2998180 doi: 10.1126/science.1171362
Badgley, M. A. et al. Cysteine depletion induces pancreatic tumor ferroptosis in mice. Science 368, 85–89 (2020).
pubmed: 32241947 pmcid: 7681911 doi: 10.1126/science.aaw9872
Halbrook, C. J. & Lyssiotis, C. A. Employing metabolism to improve the diagnosis and treatment of pancreatic cancer. Cancer Cell 31, 5–19 (2017).
pubmed: 28073003 doi: 10.1016/j.ccell.2016.12.006
Zarei, M. et al. Posttranscriptional upregulation of IDH1 by HuR establishes a powerful survival phenotype in pancreatic cancer cells. Cancer Res. 77, 4460–4471 (2017).
pubmed: 28652247 pmcid: 5922269 doi: 10.1158/0008-5472.CAN-17-0015
Biancur, D. E. & Kimmelman, A. C. The plasticity of pancreatic cancer metabolism in tumor progression and therapeutic resistance. Biochim. Biophys. Acta Rev. Cancer 1870, 67–75 (2018).
Lyssiotis, C. A. & Cantley, L. C. Targeting metabolic scavenging in pancreatic cancer. Clin. Cancer Res. 20, 6–8 (2014).
pubmed: 24166909 doi: 10.1158/1078-0432.CCR-13-2570
Sousa, C. M. & Kimmelman, A. C. The complex landscape of pancreatic cancer metabolism. Carcinogenesis 35, 1441–1450 (2014).
pubmed: 24743516 pmcid: 4076815 doi: 10.1093/carcin/bgu097
Kimmelman, A. C. Metabolic dependencies in RAS-driven cancers. Clin. Cancer Res. 21, 1828–1834 (2015).
pubmed: 25878364 pmcid: 4400826 doi: 10.1158/1078-0432.CCR-14-2425
Biancur, D. E. et al. Functional genomics identifies metabolic vulnerabilities in pancreatic cancer. Cell Metab. 33, 199–210 (2021).
pubmed: 33152323 doi: 10.1016/j.cmet.2020.10.018
Mukhopadhyay, S., Vander Heiden, M. G. & McCormick, F. The metabolic landscape of RAS-driven cancers from biology to therapy. Nat. Cancer 2, 271–283 (2021).
pubmed: 33870211 pmcid: 8045781 doi: 10.1038/s43018-021-00184-x
Esposito, M., Ganesan, S. & Kang, Y. Emerging strategies for treating metastasis. Nat. Cancer 2, 258–270 (2021).
Kim, P. K. et al. Hyaluronic acid fuels pancreatic cancer cell growth. eLife 10, e62645 (2021).
Yang, S. et al. Pancreatic cancers require autophagy for tumor growth. Genes Dev. 25, 717–729 (2011).
pubmed: 21406549 pmcid: 3070934 doi: 10.1101/gad.2016111
Commisso, C. et al. Macropinocytosis of protein is an amino acid supply route in Ras-transformed cells. Nature 497, 633–637 (2013).
pubmed: 23665962 pmcid: 3810415 doi: 10.1038/nature12138
Sousa, C. M. et al. Pancreatic stellate cells support tumour metabolism through autophagic alanine secretion. Nature 536, 479–483 (2016).
pubmed: 27509858 pmcid: 5228623 doi: 10.1038/nature19084
Rossignol, R. et al. Energy substrate modulates mitochondrial structure and oxidative capacity in cancer cells. Cancer Res. 64, 985–993 (2004).
pubmed: 14871829 doi: 10.1158/0008-5472.CAN-03-1101
Birsoy, K. et al. Metabolic determinants of cancer cell sensitivity to glucose limitation and biguanides. Nature 508, 108–112 (2014).
pubmed: 24670634 pmcid: 4012432 doi: 10.1038/nature13110
Ahmad, I. M. et al. Mitochondrial O
pubmed: 15561720 doi: 10.1074/jbc.M411662200
DeNicola, G. M. et al. Oncogene-induced Nrf2 transcription promotes ROS detoxification and tumorigenesis. Nature 475, 106–109 (2011).
pubmed: 21734707 pmcid: 3404470 doi: 10.1038/nature10189
Vander Heiden, M. G., Cantley, L. C. & Thompson, C. B. Understanding the Warburg effect: the metabolic requirements of cell proliferation. Science 324, 1029–1033 (2009).
doi: 10.1126/science.1160809
Feig, C. et al. The pancreas cancer microenvironment. Clin. Cancer Res. 18, 4266–4276 (2012).
pubmed: 22896693 pmcid: 3442232 doi: 10.1158/1078-0432.CCR-11-3114
Jiang, L. et al. Reductive carboxylation supports redox homeostasis during anchorage-independent growth. Nature 532, 255–258 (2016).
pubmed: 27049945 pmcid: 4860952 doi: 10.1038/nature17393
Mullen, A. R. et al. Reductive carboxylation supports growth in tumour cells with defective mitochondria. Nature 481, 385–388 (2011).
pubmed: 22101431 pmcid: 3262117 doi: 10.1038/nature10642
Metallo, C. M. et al. Reductive glutamine metabolism by IDH1 mediates lipogenesis under hypoxia. Nature 481, 380–384 (2011).
pubmed: 22101433 pmcid: 3710581 doi: 10.1038/nature10602
Calvert, A. E. et al. Cancer-associated IDH1 promotes growth and resistance to targeted therapies in the absence of mutation. Cell Rep. 19, 1858–1873 (2017).
pubmed: 28564604 pmcid: 5564207 doi: 10.1016/j.celrep.2017.05.014
Wise, D. R. et al. Hypoxia promotes isocitrate dehydrogenase-dependent carboxylation of α-ketoglutarate to citrate to support cell growth and viability. Proc. Natl Acad. Sci. USA 108, 19611–19616 (2011).
pubmed: 22106302 pmcid: 3241793 doi: 10.1073/pnas.1117773108
Zarei, M. et al. RNA-binding protein HuR regulates both mutant and wild-type IDH1 in IDH1-mutated cancer. Mol. Cancer Res. 17, 508–520 (2019).
pubmed: 30266754 doi: 10.1158/1541-7786.MCR-18-0557
Wahl, D. R. et al. Glioblastoma therapy can be augmented by targeting IDH1-mediated NADPH biosynthesis. Cancer Res. 77, 960–970 (2017).
pubmed: 27923831 doi: 10.1158/0008-5472.CAN-16-2008
Weinberg, S. E. & Chandel, N. S. Targeting mitochondria metabolism for cancer therapy. Nat. Chem. Biol. 11, 9–15 (2015).
pubmed: 25517383 pmcid: 4340667 doi: 10.1038/nchembio.1712
Balaban, R. S., Nemoto, S. & Finkel, T. Mitochondria, oxidants, and aging. Cell 120, 483–495 (2005).
pubmed: 15734681 doi: 10.1016/j.cell.2005.02.001
Schieber, M. & Chandel, N. S. ROS function in redox signaling and oxidative stress. Curr. Biol. 24, R453–462 (2014).
pubmed: 24845678 pmcid: 4055301 doi: 10.1016/j.cub.2014.03.034
Vyas, S., Zaganjor, E. & Haigis, M. C. Mitochondria and cancer. Cell 166, 555–566 (2016).
pubmed: 27471965 pmcid: 5036969 doi: 10.1016/j.cell.2016.07.002
Sullivan, L. B. & Chandel, N. S. Mitochondrial reactive oxygen species and cancer. Cancer Metab. 2, 17 (2014).
pubmed: 25671107 pmcid: 4323058 doi: 10.1186/2049-3002-2-17
Wise, D. R. & Thompson, C. B. Glutamine addiction: a new therapeutic target in cancer. Trends Biochem. Sci. 35, 427–433 (2010).
pubmed: 20570523 pmcid: 2917518 doi: 10.1016/j.tibs.2010.05.003
Bott, A. J. et al. Glutamine anabolism plays a critical role in pancreatic cancer by coupling carbon and nitrogen metabolism. Cell Rep. 29, 1287–1298 (2019).
pubmed: 31665640 pmcid: 6886125 doi: 10.1016/j.celrep.2019.09.056
DeBerardinis, R. J. & Cheng, T. Q’s next: the diverse functions of glutamine in metabolism, cell biology and cancer. Oncogene 29, 313–324 (2010).
pubmed: 19881548 doi: 10.1038/onc.2009.358
Hensley, C. T., Wasti, A. T. & DeBerardinis, R. J. Glutamine and cancer: cell biology, physiology, and clinical opportunities. J. Clin. Invest. 123, 3678–3684 (2013).
pubmed: 23999442 pmcid: 3754270 doi: 10.1172/JCI69600
Sutherland, R. M. Cell and environment interactions in tumor microregions: the multicell spheroid model. Science 240, 177–184 (1988).
pubmed: 2451290 doi: 10.1126/science.2451290
Provenzano, P. P. et al. Enzymatic targeting of the stroma ablates physical barriers to treatment of pancreatic ductal adenocarcinoma. Cancer Cell 21, 418–429 (2012).
pubmed: 22439937 pmcid: 3371414 doi: 10.1016/j.ccr.2012.01.007
Huang, Y. H. et al. Delivery of therapeutics targeting the mRNA-binding protein HuR using 3DNA nanocarriers suppresses ovarian tumor growth. Cancer Res. 76, 1549–1559 (2016).
pubmed: 26921342 doi: 10.1158/0008-5472.CAN-15-2073
Itsumi, M. et al. Idh1 protects murine hepatocytes from endotoxin-induced oxidative stress by regulating the intracellular NADP(
pubmed: 25882048 pmcid: 4648331 doi: 10.1038/cdd.2015.38
Ye, J. et al. IDH1 deficiency attenuates gluconeogenesis in mouse liver by impairing amino acid utilization. Proc. Natl Acad. Sci. USA 114, 292–297 (2017).
pubmed: 28011762 doi: 10.1073/pnas.1618605114
Deng, G. et al. Selective inhibition of mutant isocitrate dehydrogenase 1 (IDH1) via disruption of a metal binding network by an allosteric small molecule. J. Biol. Chem. 290, 762–774 (2015).
pubmed: 25391653 doi: 10.1074/jbc.M114.608497
Xie, X. et al. Allosteric mutant IDH1 inhibitors reveal mechanisms for IDH1 mutant and isoform selectivity. Structure 25, 506–513 (2017).
pubmed: 28132785 doi: 10.1016/j.str.2016.12.017
Urban, D. J. et al. Assessing inhibitors of mutant isocitrate dehydrogenase using a suite of pre-clinical discovery assays. Sci. Rep. 7, 12758 (2017).
pubmed: 28986582 pmcid: 5630632 doi: 10.1038/s41598-017-12630-x
DiNardo, C. D. et al. Durable remissions with ivosidenib in IDH1-mutated relapsed or refractory AML. N. Engl. J. Med. 378, 2386–2398 (2018).
pubmed: 29860938 doi: 10.1056/NEJMoa1716984
Abou-Alfa, G. K. et al. Ivosidenib in IDH1-mutant, chemotherapy-refractory cholangiocarcinoma (ClarIDHy): a multicentre, randomised, double-blind, placebo-controlled, phase 3 study. Lancet Oncol. 21, 796–807 (2020).
pubmed: 32416072 pmcid: 7523268 doi: 10.1016/S1470-2045(20)30157-1
Zarei, M. et al. Clinical development of IDH1 inhibitors for cancer therapy. Cancer Treat. Rev. 103, 102334 (2022).
pubmed: 34974243 doi: 10.1016/j.ctrv.2021.102334
Okoye-Okafor, U. C. et al. New IDH1 mutant inhibitors for treatment of acute myeloid leukemia. Nat. Chem. Biol. 11, 878–886 (2015).
pubmed: 26436839 pmcid: 5155016 doi: 10.1038/nchembio.1930
Seltzer, M. H., Rosato, F. E. & Fletcher, M. J. Serum and tissue magnesium levels in human breast carcinoma. J. Surg. Res. 10, 159–162 (1970).
pubmed: 5437734 doi: 10.1016/0022-4804(70)90026-0
Liu, Q., Yin, X., Languino, L. R. & Altieri, D. C. Evaluation of drug combination effect using a Bliss independence dose-response surface model. Stat. Biopharm. Res. 10, 112–122 (2018).
pubmed: 30881603 pmcid: 6415926 doi: 10.1080/19466315.2018.1437071
Di Veroli, G. Y. et al. Combenefit: an interactive platform for the analysis and visualization of drug combinations. Bioinformatics 32, 2866–2868 (2016).
pubmed: 27153664 pmcid: 5018366 doi: 10.1093/bioinformatics/btw230
Popovici-Muller, J. et al. Discovery of AG-120 (ivosidenib): a first-in-class mutant IDH1 inhibitor for the treatment of IDH1 mutant cancers. ACS Med. Chem. Lett. 9, 300–305 (2018).
pubmed: 29670690 pmcid: 5900343 doi: 10.1021/acsmedchemlett.7b00421
Nicolay, B. et al. The IDH1 mutant inhibitor AG-120 shows strong inhibition of 2-HG production in an orthotopic IDH1 mutant glioma model in vivo. In Proc. 22nd Annual Scientific Meeting and Education Day of the Society for Neuro-oncology (SNO, 2017).
Mullen, A. R. et al. Oxidation of alpha-ketoglutarate is required for reductive carboxylation in cancer cells with mitochondrial defects. Cell Rep. 7, 1679–1690 (2014).
pubmed: 24857658 pmcid: 4057960 doi: 10.1016/j.celrep.2014.04.037
Sangeetha, P., Das, U. N., Koratkar, R. & Suryaprabha, P. Increase in free radical generation and lipid peroxidation following chemotherapy in patients with cancer. Free Radic. Biol. Med. 8, 15–19 (1990).
pubmed: 2157633 doi: 10.1016/0891-5849(90)90139-A
Yu, X. et al. Zinc metallochaperones reactivate mutant p53 using an ON/OFF switch mechanism: a new paradigm in cancer therapeutics. Clin. Cancer Res. 24, 4505–4517 (2018).
pubmed: 29914895 pmcid: 6139040 doi: 10.1158/1078-0432.CCR-18-0822
Molina, D. M. et al. Monitoring drug target engagement in cells and tissues using the cellular thermal shift assay. Science 341, 84–87 (2013).
doi: 10.1126/science.1233606
Hingorani, S. R. et al. Trp53R172H and KrasG12D cooperate to promote chromosomal instability and widely metastatic pancreatic ductal adenocarcinoma in mice. Cancer Cell 7, 469–483 (2005).
pubmed: 15894267 doi: 10.1016/j.ccr.2005.04.023
Merlo, L. M., Bowers, J., Stefanoni, T., Getts, R. & Mandik-Nayak, L. B-cell-targeted 3DNA nanotherapy against indoleamine 2,3-dioxygenase 2 (IDO2) ameliorates autoimmune arthritis in a preclinical model. Clin. Pathol. 13, 2632010X20951812 (2020).
pubmed: 32924009 pmcid: 7457693 doi: 10.1177/2632010X20951812
Leone, R. D. et al. Glutamine blockade induces divergent metabolic programs to overcome tumor immune evasion. Science 366, 1013–1021 (2019).
pubmed: 31699883 pmcid: 7023461 doi: 10.1126/science.aav2588
Fleming, T. R. & Harrington, D. P. Counting Processes and Survival Analysis (John Wiley & Sons, 1991).

Auteurs

Ali Vaziri-Gohar (A)

Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.

Joel Cassel (J)

Molecular and Cellular Oncogenesis Program, The Wistar Institute, Philadelphia, PA, USA.

Farheen S Mohammed (FS)

Molecular and Cellular Oncogenesis Program, The Wistar Institute, Philadelphia, PA, USA.

Mehrdad Zarei (M)

Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.
Department of Surgery, Division of Surgical Oncology, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA.

Jonathan J Hue (JJ)

Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.
Department of Surgery, Division of Surgical Oncology, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA.

Omid Hajihassani (O)

Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.

Hallie J Graor (HJ)

Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.

Yellamelli V V Srikanth (YVV)

Molecular and Cellular Oncogenesis Program, The Wistar Institute, Philadelphia, PA, USA.

Saadia A Karim (SA)

Cancer Research UK Beatson Institute, Glasgow, UK.

Ata Abbas (A)

Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.

Erin Prendergast (E)

Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, USA.

Vanessa Chen (V)

Department of Nutrition, Case Western Reserve University, Cleveland, OH, USA.

Erryk S Katayama (ES)

Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.

Katerina Dukleska (K)

Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA.

Imran Khokhar (I)

Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA.

Anthony Andren (A)

Department of Molecular and Integrative Physiology, University of Michigan School of Medicine, Ann Arbor, MI, USA.

Li Zhang (L)

Department of Molecular and Integrative Physiology, University of Michigan School of Medicine, Ann Arbor, MI, USA.

Chunying Wu (C)

Department of Radiology, Case Western Reserve University, Cleveland, OH, USA.

Bernadette Erokwu (B)

Department of Radiology, Case Western Reserve University, Cleveland, OH, USA.

Chris A Flask (CA)

Deptartments of Radiology, Biomedical Engineering, and Pediatrics, Case Western Reserve University, Cleveland, OH, USA.

Mahsa Zarei (M)

Department of Veterinary Physiology and Pharmacology, Texas A&M University, College Station, TX, USA.

Rui Wang (R)

Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.

Luke D Rothermel (LD)

Department of Surgery, Division of Surgical Oncology, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA.

Andrea M P Romani (AMP)

Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, OH, USA.

Jessica Bowers (J)

Code Biotherapeutics Inc, Hatfield, PA, USA.

Robert Getts (R)

Code Biotherapeutics Inc, Hatfield, PA, USA.

Curtis Tatsuoka (C)

Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA.

Jennifer P Morton (JP)

Cancer Research UK Beatson Institute, Glasgow, UK.
Institute of Cancer Sciences, University of Glasgow, Glasgow, UK.

Ilya Bederman (I)

Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, USA.

Henri Brunengraber (H)

Department of Nutrition and Biochemistry, Case Western Reserve University, Cleveland, OH, USA.

Costas A Lyssiotis (CA)

Department of Molecular and Integrative Physiology, University of Michigan School of Medicine, Ann Arbor, MI, USA.

Joseph M Salvino (JM)

Molecular and Cellular Oncogenesis Program, The Wistar Institute, Philadelphia, PA, USA.

Jonathan R Brody (JR)

Brenden Colson Center for Pancreatic Care; Departments of Surgery and Cell, Developmental & Cancer Biology; Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA.

Jordan M Winter (JM)

Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA. jordan.winter@UHhospitals.org.
Department of Surgery, Division of Surgical Oncology, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA. jordan.winter@UHhospitals.org.

Articles similaires

[Redispensing of expensive oral anticancer medicines: a practical application].

Lisanne N van Merendonk, Kübra Akgöl, Bastiaan Nuijen
1.00
Humans Antineoplastic Agents Administration, Oral Drug Costs Counterfeit Drugs

Smoking Cessation and Incident Cardiovascular Disease.

Jun Hwan Cho, Seung Yong Shin, Hoseob Kim et al.
1.00
Humans Male Smoking Cessation Cardiovascular Diseases Female
Humans United States Aged Cross-Sectional Studies Medicare Part C
1.00
Humans Yoga Low Back Pain Female Male

Classifications MeSH