Gene and Molecular Pathways of Ozone Treatment Response in Gynecological Tumor Patients with Chronic Pelvic Pain Secondary to Cancer Treatment (OzoGynEpigen)

Gene and Molecular Pathway Characterization of the Response to Ozone Treatment in Gynecological Tumor Patients with Chronic Pelvic Pain Secondary to Radio-chemotherapy

Gynecological cancers, including those affecting the ovaries, uterus, and cervix, represent a significant health burden for women. While survival rates have improved, many women experience chronic pelvic pain secondary to cancer treatment, especially radiotherapy and chemotherapy. This treatment-induced pelvic pain can be of difficult management and significantly affects patients' quality of life.

In our experience, ozone therapy has emerged as a promising complementary treatment for pain relief in patients with chronic diseases, including side effects of cancer treatment. However, the genetic and epigenetic mechanisms influencing its effectiveness have not yet been thoroughly studied.

The aim of this prospective study is to analyze how ozone therapy modulates the expression of certain genes and its impact on epigenetic clocks, which could help predict pain response.

Study Overview

• Status: Recruiting
• Conditions: Side Effect of Chemotherapy; Gynecological Cancers; Chronic Pelvic Pain Syndrome (CPPS); Radiotherapy Side Effects; Radiation-Induced Disorder

Detailed Description

While survival rates of gynecological cancers have improved, many women experience chronic pelvic pain as a consequence of cancer treatment, particularly radiotherapy and chemotherapy. This persistent pain often has neuropathic characteristics, and it can be challenging to manage, negatively impacting physical and emotional well-being and quality of life.

Conventional pain management strategies for these patients often provide limited relief. In our experience, ozone therapy has emerged as a promising option for managing chronic pain in various conditions, including side effects of cancer treatment.

While the clinical benefits of ozone therapy have been observed in preliminary studies, the underlying molecular mechanisms underlying its analgesic effect remain largely unknown. Understanding how ozone therapy influences gene expression and epigenetic modifications could facilitate the identification of genes involved in the differential response to ozone therapy and a potential way for personalized strategies for pain treatment.

The aim of this prospective study is to analyze how ozone therapy modulates the expression of certain genes and its impact on epigenetic clocks, which could help predict pain response.

Primary Objectives:

In patients with gynecological tumors treated by radiotherapy/chemotherapy, To evaluate

• among patients with or without chronic pelvic pain induced by treatment.
• before and after ozone treatment in those patients treated because of pelvic pain induced by radiotherapy/chemotherapy.

The potential differences in:

1. Gene expression.
2. Biological age based on epigenetic clocks:

Secondary Objectives:

Evaluate in those patients the potential relationship between gene expression and epigenetic clocks with:

1. Grade of toxicity
2. Pain score
3. Health-related quality of life,
4. Biochemical markers of oxidative stress and inflammation.

Trial Design:

This observational and prospective study will analyze data from two groups of patients with gynecological tumors treated with radiotherapy/chemotherapy:

• A group of patients with chronic pelvic pain secondary to radiotherapy-chemotherapy, submitted to our Chronic Pain Unit for compassionate/palliative ozone treatment.
• A group of patients without secondary chronic pelvic pain.

Trial Population:

Adult women (≥ 18 years old) with gynecological tumors treated with radiotherapy-chemotherapy. They will be analyzed into two different groups of patients:

• A group of patients with chronic pelvic pain secondary to radiotherapy-chemotherapy, submitted to our Chronic Pain Unit for compassionate/palliative ozone treatment.
• A group of patients without secondary chronic pelvic pain.

Intervention. No intervention. The management of patients will be the standard of care in our hospital.

Study Duration:

The primary completion date is planned for 14/February/2027. The study completion date is planned for 14/August/2027

• Study Type: Observational
• Enrollment (Estimated): 40

Contacts and Locations

• Study Contact: Name: Bernardino Clavo, MD, PhD; Phone Number: 34928449278; Email: bernardinoclavo@gmail.com
• Study Contact Backup: Name: Francisco Rodríguez-Esparragón, BSc, PhD; Phone Number: 34928449288; Email: afrodesp@gmail.com

Study Locations

• Spain
  • Las Palmas, Spain, 35019
    • Recruiting
    • Hospital Universitario de Gran Canaria Dr. Negrín, (FIISC)
    • Contact: Bernardino Clavo, MD, PhD; Phone Number: 34928449278; Email: bernardinoclavo@gmail.com
    • Contact: Francisco Rodríguez-Esparragón, BSc, PhD; Phone Number: 34928449288; Email: afrodesp@gmail.com
    • Contact: Sara Cazorla-Rivero, BSc, PhD
    • Contact: Mario Federico, MD, PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

Adult women (≥18 years) with gynecological tumors treated with radiotherapy-chemotherapy.

Description

Inclusion Criteria:

• Adult women (>=18 years old) with gynecological tumors treated with radiotherapy-chemotherapy.
• Cancer disease is stable or in remission.
• Life expectancy > = 6 months.
• Patients included in the group of patients with pelvic pain must have a clinical, radiological, endoscopic, or histopathological diagnosis that their pain is not secondary to the oncological process.
• Patients included in the group of patients with pelvic pain must have pain for >= 3 months duration, with an intensity >= 3 on the Visual Analog Scale (VAS), or classified as toxicity >= Grade-2 of the CTCAE v.5.0 of the National Cancer Institute of the USA.
• Signed and dated informed consent specific to this study.

Exclusion Criteria:

• Age < 18 years old.
• Severe psychiatric disorders.
• Inability to complete the quality of life questionnaires.
• Active neoplasia requiring recent initiation (< 3 months) of systemic or local treatment.
• Life expectancy (for any reason) < 6 months.
• Failure to meet all inclusion criteria

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Treated patients, without secondary pain; Patients with gynecological tumors, treated with radiotherapy/chemotherapy, without chronic pelvic pain.
Treated patients, with chronic pelvic pain; Patients with gynecological tumors, treated with radiotherapy/chemotherapy, with chronic pelvic pain, submitted to our Chronic Pain Unit for compassionate/palliative ozone treatment.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Differences in gene expression among patients with or without chronic pelvic pain induced by radiotherapy/chemotherapy.	Differences (among patients with or without chronic pelvic pain induced by radiotherapy/chemotherapy) in gene expression profile.	At 0 week
Changes (from baseline) in gene expression at the end of ozone treatment.	Changes (from baseline) in gene expression profile, after ozone treatment.	At 16 weeks
Differences in biological age based on epigenetic clocks among patients with or without chronic pelvic pain induced by radiotherapy/chemotherapy	Differences (among patients with or without chronic pain induced by radiotherapy/chemotherapy) in the biological age based on epigenetic clocks.	At 0 week.
Changes (from baseline) in the biological age based on epigenetic clocks, after ozone treatment	Changes (from baseline) in the biological age based on epigenetic clocks, after ozone treatment	At 16 weeks.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Differences in the grade of toxicity according to the Common Terminology Criteria for Adverse Events (CTCAE) v.5.0 scale among patients with or without chronic pain induced by radiotherapy/chemotherapy	Differences (among patients with or without chronic pain induced by radiotherapy/chemotherapy) in the grade of toxicity according to the Common Terminology Criteria for Adverse Events (CTCAE) v.5.0 scale (from the National Cancer Institute of EEUU). Range from: Grade = (asymptomatic or mild symptoms) to Grade 3 (severe symptoms, limiting self-care activities in daily life).	At 0 week.
Changes (from baseline) in the grade of toxicity according to the Common Terminology Criteria for Adverse Events (CTCAE) v.5.0 scale, after ozone treatment.	Changes (from baseline) in the grade of toxicity according to the Common Terminology Criteria for Adverse Events (CTCAE) v.5.0 scale (from the National Cancer Institute of EEUU). Range from: Grade = (asymptomatic or mild symptoms) to Grade 3 (severe symptoms, limiting self-care activities in daily life).	At 16 weeks.
Differences in pain score according to the visual analog scale (VAS) among patients with or without chronic pain induced by radiotherapy/chemotherapy	Self-reported evaluation of the severity of pain according to the VAS, scored from 0 ("No pain") to 10 ("Pain as bad as you can imagine").	At 0 week.
Change (from baseline) in pain score according to the visual analog scale (VAS), after ozone treatment.	Self-reported evaluation of the severity of pain according to the VAS, scored from 0 ("No pain") to 10 ("Pain as bad as you can imagine").	At 16 weeks.
Differences in "Quality of Life" (using the EQ-5D-5L questionnaire) self-perceived by patients among patients with or without chronic pain induced by radiotherapy/chemotherapy.	Self-reported evaluation of: a) 5 physical and emotional items scored in five levels, from 1 (Best: I have no problem) to 5 (worst: I have an extreme problem or I am unable to…) and b) additional self-assessment of health by a visual analog scale (0 = worst health patient can imagine, 100 = best health patient can imagine).	At 0 week.
Changes (from baseline) in "Quality of Life" (using the EQ-5D-5L questionnaire) self-perceived by patients, after ozone treatment.	Self-reported evaluation of: a) 5 physical and emotional items scored in five levels, from 1 (Best: I have no problem) to 5 (worst: I have an extreme problem or I am unable to…) and b) additional self-assessment of health by a visual analog scale (0 = worst health patient can imagine, 100 = best health patient can imagine).	At 16 weeks.
Differences in biochemical parameters of oxidative stress among patients with or without chronic pain induced by radiotherapy/chemotherapy.	Differences in serum levels of antioxidants and free radicals.	At 0 week.
Changes (from baseline) in biochemical parameters of oxidative stress, after ozone treatment.	Changes in serum levels of antioxidants and free radicals.	At 16 weeks.
Differences in biochemical parameters of inflammation among patients with or without chronic pain induced by radiotherapy/chemotherapy.	Differences in serum levels of pro-inflammatory cytokines.	At 0 week.
Changes (from baseline) in biochemical parameters of inflammation, after ozone treatment.	Changes in serum levels of pro-inflammatory cytokines.	At 16 weeks.

Collaborators and Investigators

• Sponsor: Bernardino Clavo, MD, PhD
• Collaborators: Fundación DISA, Canary Islands, Spain; Fundacion Canaria Instituto de Investigacion Sanitaria de Canarias (FIISC); Council of Gran Canaria
• Investigators: Study Chair: Bernardino Clavo, MD, PhD, Hospital Universitario de Gran Canaria Dr. Negrín, (FIISC), Las Palmas, Spain.; Study Director: Francisco Rodríguez-Esparragón, BSc, PhD, Hospital Universitario de Gran Canaria Dr. Negrín, (FIISC), Las Palmas, Spain.; Principal Investigator: Sara Cazorla-Rivero, BSc, PhD, Hospital Universitario de Gran Canaria Dr. Negrín, (FIISC), Las Palmas, Spain.; Principal Investigator: Mario Federico, MD, PhD, Hospital Universitario de Gran Canaria Dr. Negrín, (FIISC), Las Palmas, Spain.

Publications and helpful links

General Publications

• Clavo B, Martinez-Sanchez G, Rodriguez-Esparragon F, Rodriguez-Abreu D, Galvan S, Aguiar-Bujanda D, Diaz-Garrido JA, Canas S, Torres-Mata LB, Fabelo H, Tellez T, Santana-Rodriguez N, Fernandez-Perez L, Marrero-Callico G. Modulation by Ozone Therapy of Oxidative Stress in Chemotherapy-Induced Peripheral Neuropathy: The Background for a Randomized Clinical Trial. Int J Mol Sci. 2021 Mar 10;22(6):2802. doi: 10.3390/ijms22062802.
• Clavo B, Rodriguez-Abreu D, Galvan S, Federico M, Martinez-Sanchez G, Ramallo-Farina Y, Antonelli C, Benitez G, Rey-Baltar D, Jorge IJ, Rodriguez-Esparragon F, Serrano-Aguilar P. Long-term improvement by ozone treatment in chronic pain secondary to chemotherapy-induced peripheral neuropathy: A preliminary report. Front Physiol. 2022 Aug 30;13:935269. doi: 10.3389/fphys.2022.935269. eCollection 2022.
• Bocci V, Valacchi G. Nrf2 activation as target to implement therapeutic treatments. Front Chem. 2015 Feb 2;3:4. doi: 10.3389/fchem.2015.00004. eCollection 2015.
• Bocci VA, Zanardi I, Travagli V. Ozone acting on human blood yields a hormetic dose-response relationship. J Transl Med. 2011 May 17;9:66. doi: 10.1186/1479-5876-9-66.
• Bocci V, Borrelli E, Travagli V, Zanardi I. The ozone paradox: ozone is a strong oxidant as well as a medical drug. Med Res Rev. 2009 Jul;29(4):646-82. doi: 10.1002/med.20150.
• Clavo B, Rodriguez-Esparragon F, Rodriguez-Abreu D, Martinez-Sanchez G, Llontop P, Aguiar-Bujanda D, Fernandez-Perez L, Santana-Rodriguez N. Modulation of Oxidative Stress by Ozone Therapy in the Prevention and Treatment of Chemotherapy-Induced Toxicity: Review and Prospects. Antioxidants (Basel). 2019 Nov 26;8(12):588. doi: 10.3390/antiox8120588.
• Tricarico G, Travagli V. The Relationship between Ozone and Human Blood in the Course of a Well-Controlled, Mild, and Transitory Oxidative Eustress. Antioxidants (Basel). 2021 Dec 4;10(12):1946. doi: 10.3390/antiox10121946.
• Hidalgo-Tallon FJ, Torres-Morera LM, Baeza-Noci J, Carrillo-Izquierdo MD, Pinto-Bonilla R. Updated Review on Ozone Therapy in Pain Medicine. Front Physiol. 2022 Feb 23;13:840623. doi: 10.3389/fphys.2022.840623. eCollection 2022.
• Galie M, Covi V, Tabaracci G, Malatesta M. The Role of Nrf2 in the Antioxidant Cellular Response to Medical Ozone Exposure. Int J Mol Sci. 2019 Aug 17;20(16):4009. doi: 10.3390/ijms20164009.
• Clavo B, Navarro M, Federico M, Borrelli E, Jorge IJ, Ribeiro I, Rodriguez-Melcon JI, Carames MA, Santana-Rodriguez N, Rodriguez-Esparragon F. Long-Term Results with Adjuvant Ozone Therapy in the Management of Chronic Pelvic Pain Secondary to Cancer Treatment. Pain Med. 2021 Sep 8;22(9):2138-2141. doi: 10.1093/pm/pnaa459. No abstract available.
• Clavo B, Navarro M, Federico M, Borrelli E, Jorge IJ, Ribeiro I, Rodriguez-Melcon JI, Carames MA, Santana-Rodriguez N, Rodriguez-Esparragon F. Ozone Therapy in Refractory Pelvic Pain Syndromes Secondary to Cancer Treatment: A New Approach Warranting Exploration. J Palliat Med. 2021 Jan;24(1):97-102. doi: 10.1089/jpm.2019.0597. Epub 2020 May 5.
• Clavo B, Canovas-Molina A, Ramallo-Farina Y, Federico M, Rodriguez-Abreu D, Galvan S, Ribeiro I, Marques da Silva SC, Navarro M, Gonzalez-Beltran D, Diaz-Garrido JA, Cazorla-Rivero S, Rodriguez-Esparragon F, Serrano-Aguilar P. Effects of Ozone Treatment on Health-Related Quality of Life and Toxicity Induced by Radiotherapy and Chemotherapy in Symptomatic Cancer Survivors. Int J Environ Res Public Health. 2023 Jan 13;20(2):1479. doi: 10.3390/ijerph20021479.
• Clavo B, Canovas-Molina A, Diaz-Garrido JA, Canas S, Ramallo-Farina Y, Laffite H, Federico M, Rodriguez-Abreu D, Galvan S, Garcia-Lourve C, Gonzalez-Beltran D, Carames MA, Hernandez-Fleta JL, Serrano-Aguilar P, Rodriguez-Esparragon F. Effects of ozone therapy on anxiety and depression in patients with refractory symptoms of severe diseases: a pilot study. Front Psychol. 2023 Aug 4;14:1176204. doi: 10.3389/fpsyg.2023.1176204. eCollection 2023.
• Clavo B, Rodriguez-Abreu D, Galvan-Ruiz S, Federico M, Canovas-Molina A, Ramallo-Farina Y, Antonilli C, Benitez G, Fabelo H, Garcia-Lourve C, Gonzalez-Beltran D, Jorge IJ, Rodriguez-Esparragon F, Callico GM. Long-Term Effects of Ozone Treatment in Patients with Persistent Numbness and Tingling Secondary to Chemotherapy-Induced Peripheral Neuropathy. A Retrospective Study. Integr Cancer Ther. 2025 Jan-Dec;24:15347354241307038. doi: 10.1177/15347354241307038.
• Clavo B, Santana-Rodriguez N, Llontop P, Gutierrez D, Ceballos D, Mendez C, Rovira G, Suarez G, Rey-Baltar D, Garcia-Cabrera L, Martinez-Sanchez G, Fiuza D. Ozone Therapy in the Management of Persistent Radiation-Induced Rectal Bleeding in Prostate Cancer Patients. Evid Based Complement Alternat Med. 2015;2015:480369. doi: 10.1155/2015/480369. Epub 2015 Aug 18.

Study record dates

Study Major Dates

• Study Start (Actual): February 10, 2025
• Primary Completion (Estimated): February 14, 2027
• Study Completion (Estimated): August 14, 2027

Study Registration Dates

• First Submitted: February 4, 2025
• First Submitted That Met QC Criteria: February 4, 2025
• First Posted (Actual): March 25, 2025

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: February 10, 2025
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Keywords: Quality of Life; oxidative stress; gene expression; Cancer survivors; Ozone therapy; Gynecological Cancers; Radiation-Induced Disorder; Radiotherapy Side Effects; Chronic Pelvic Pain Syndrome (CPPS); epigenetic clocks; side effects of cancer treatment; Toxicity of chemotherapy
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Pelvic Pain
• Other Study ID Numbers: 2024-192-1; CIGC'23/24 (Other Grant/Funding Number: Cabildo de Gran Canaria); DISA'24: OA24/104 (Other Grant/Funding Number: Fundación DISA)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES

IPD Plan Description

It will be available (after request):

• Individual participant data (IPD) that underlie the results reported in further articles, after deidentification
• Data will be available after publication, ending 36 months following article publication.
• They will be available for investigators whose proposed use of the data has been approved by an independent review committee identified for this purpose.
• Study protocol

Proposals should be directed to: bernardinoclavo@gmail.com To gain access, data requestors will need to sign a data access agreement.

• IPD Sharing Time Frame: Data will be available after publication, ending 36 months following article publication.

IPD Sharing Access Criteria

Data will be available for investigators whose proposed use of the data has been approved by an independent review committee identified for this purpose.

- Study protocol

Proposals should be directed to: bernardinoclavo@gmail.com To gain access, data requestors will need to sign a data access agreement.

• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No