Quality of life in patients with metastatic renal cell carcinoma participating in a phase I trial of an autologous tumor-derived vaccine

Psychosocial Aspects of Living Long Term with Advanced Cancer and Ongoing Systemic Treatment: A Scoping Review

(1) Background: Studies examining the psychosocial impact of living long term on systemic treatment in advanced cancer patients are scarce. This scoping review aimed to answer the research question “What has been reported about psychosocial factors among patients living with advanced cancer receiving life-long systemic treatment?”, by synthesizing psychosocial data, and evaluating the terminology used to address these patients; (2) Methods: This scoping review was conducted following the five stages of the framework of Arksey and O’Malley (2005); (3) Results: 141 articles published between 2000 and 2021 (69% after 2015) were included. A large variety of terms referring to the patient group was observed. Synthesizing qualitative studies identified ongoing uncertainty, anxiety and fear of disease progression or death, hope in treatment results and new treatment options, loss in several aspects of life, and worries about the impact of disease on loved ones and changes in social life to be prominent psychosocial themes. Of 82 quantitative studies included in the review, 76% examined quality of life, 46% fear of disease progression or death, 26% distress or depression, and 4% hope, while few studies reported on adaptation or cognitive aspects. No quantitative studies focused on uncertainty, loss, or social impact; (4) Conclusion and clinical implications: Prominent psychosocial themes reported in qualitative studies were not included in quantitative research using specific validated questionnaires. More robust studies using quantitative research designs should be conducted to further understand these psychological constructs. Furthermore, the diversity of terminology found in the literature calls for a uniform definition to better address this specific patient group in research and in practice.

Low MxA Expression Predicts Better Immunotherapeutic Outcomes in Glioblastoma Patients Receiving Heat Shock Protein Peptide Complex 96 Vaccination

Heat shock protein peptide complex 96 (HSPPC-96) has been proven to be a safe and preliminarily effective therapeutic vaccine in treating newly diagnosed glioblastoma multiforme (GBM) (NCT02122822). However, the clinical outcomes were highly variable, rendering the discovery of outcome-predictive biomarkers essential for this immunotherapy. We utilized multidimensional immunofluorescence staining to detect CD4+ CD8+ and PD-1+ immune cell infiltration levels, MxA and gp96 protein expression in pre-vaccination GBM tissues of 19 patients receiving HSPPC-96 vaccination. We observed low MxA expression was associated with longer OS than high MxA expression (48 months vs. 20 months, p=0.038). Long-term survivors (LTS) exhibited significantly lower MxA expression than short-term survivors (STS) (p= 0.0328), and ROC curve analysis indicated MxA expression as a good indicator in distinguishing LTS and STS (AUC=0.7955, p=0.0318). However, we did not observe any significant impact of immune cell densities or gp96 expression on patient outcomes. Finally, we revealed the association of MxA expression with prognosis linked to a preexisting TCR clone (CDR3-2) but was independent of the peripheral tumor-specific immune response. Taken together, low MxA expression correlated with better survival in GBM patients receiving HSPPC-96 vaccination, indicating MxA as a potential biomarker for early recognition of responsive patients to this immunotherapy.

Clinical Trial Registration: ClinicalTrials.gov (NCT02122822) http://www. chictr.org.cn/enindex.aspx (ChiCTR-ONC-13003309).

Global trends in the distribution of cancer types among patients in oncology phase I trials, 1991-2015

Background Systematic analyses regarding cancer types of patients enrolled in oncology phase I trials are scarce. The global distribution, time-dependent change, and regional differences were evaluated. Methods A systematic search of the PubMed database, in which all single-agent phase I trials permitting the enrollment of all-comer patients with any type of solid tumor published between January 1991 and December 2015 were specified, was performed. Trials expected to enroll specific patient populations were excluded according to predefined criteria. Results Eight hundred and sixty-six eligible trials, which had enrolled 29,112 advanced solid tumor patients, were identified. Colorectal (n = 7510; 25.8%) and lung cancer (n = 3212; 11.0%) were the most prevalent solid tumors, followed by sarcoma (n = 1756; 6.0%), breast cancer (n = 1623; 5.6%), and renal cancer (n = 1589; 5.5%). The proportion of patients with either colorectal or lung cancer tended to decrease over time. The proportion of trials, in which patients with either of these two cancers accounted for ≥50.0% of the total number of patients in each trial, also decreased: 33 of 67 trials (31/67) (46.3%) in 1991-1995, 58/142 (40.8%) in 1996-2000, 59/223 (26.5%) in 2001-2005, 38/189 (20.1%) in 2006-2010, and 41/245 (16.7%) in 2011-2015. Instead, the proportion of patients with various types of cancer increased, leading to diversification of enrolled patients. Conclusions The distribution of cancer types among patients in phase I trials has changed. The comprehensive review of the distribution of solid tumor types could contribute to flexible trial designs and optimal patient recruitment.

Ethical considerations and challenges in first-in-human research

First-in-human (FIH) research is a translational process to move a new potential therapy from bench to bedside. Major ethical challenges of an FIH trial arise because of the indeterminate nature of the risks involved and the controversial risk-benefit justification. Severe adverse events and death of subjects who participated in FIH research in the past have led to an increased attention on ethical considerations in the design and conduct of such research. Furthermore, novel therapies in the current decade, such as molecular-targeted, gene transfer, and pluripotent stem cells therapies, have led to numerous emerging ethical challenges or different ethical assessment and justification frameworks for FIH research. This article presents, discusses, and interlinks ethical considerations and challenges in FIH research through a review of related ethical principles and their application to each ethical issue with given examples. Possible solutions to address each ethical challenge are presented. The scope of this article focuses on 4 major ethical issues in FIH research: risk-benefit assessment and justification for the conduct of research, selection of a suitable target population, informed consent, and conflict of interest.

Immunomodulatory and antitumor effects of interleukin-21 in patients with renal cell carcinoma

Interleukin (IL)-21 is a class I cytokine with sequence homology to the IL-2 cytokine superfamily. IL-21 signals through a heterodimer of a unique IL-21 receptor and the common gamma-chain cytokine receptor. Preclinical murine models suggested strong antitumor activity of IL-21 in renal cell carcinoma, melanoma and other tumor models. IL-21 antitumor activity was superior to IL-2 in these tumor models. A Phase I clinical trial of IL-21 in humans with metastatic renal cell carcinoma or melanoma began in May 2004. Clinical regressions were observed in renal cell carcinoma. Preliminary immunological and clinical findings of patients receiving IL-21 will be reviewed.

Cytokine and vaccine therapy of kidney cancer

In this paper, results from current randomized and other relevant studies on cytokine and vaccine therapy of kidney cancer in the adjuvant setting and in metastatic disease are reviewed. Improvement of medical therapy of kidney cancer is required since the relative 5-year survival of kidney cancer is only 62%. In the adjuvant setting, cytokine monotherapy (interferon [IFN]-alpha or interleukin [IL]-2) is not effective in improving progression-free or overall survival. Recently, an autologous kidney cancer cell vaccine has been shown to reduce the risk of tumor progression following radical nephrectomy for organ-confined or locally advanced kidney cancer in a randomized Phase III study. There were only a few vaccine-related side effects. Presently, this is the only promising approach for the adjuvant treatment of kidney cancer following nephrectomy. In metastatic kidney cancer patients with the tumor-bearing kidney in situ, a combination of radical nephrectomy plus IFN-alpha is more effective than IFN-alpha alone. In metastatic kidney cancer without the option of operative removal of the primary tumor and/or metastases, cytokines such as IFN-alpha, IL-2 and IL-12 and their combinations result in response rates of 10-30%, but the 5-year overall survival is less than 10%. Furthermore, the ideal dose, administration and combination of different agents are yet to be defined. Vaccine therapy of metastatic kidney cancer has been investigated only in Phase I and II studies with limited clinical benefit. Based on the current literature there is a clear need for new approaches in metastatic kidney cancer.

Identification of peptide mimotopes of gp96 using single-chain antibody library

Heat shock proteins such as gp96 are immunogenic and are widely used as vaccines in immunotherapy of cancers. The present study focuses on the use of peptide mimotopes as immunotherapeutic vaccines for prostate cancer. To this end, we developed a 15-mer gp96 peptide mimotope specifically reactive to MAT-LyLu gp96-peptide complex using combinatorial single-chain antibody and peptide phage display library. The immunogenicity of the synthesized gp96 mimotope was analyzed initially in normal BALB/c mice in combination with various adjuvants such as complete Freund's adjuvant (CFA), aluminum salts (ALUM), granulocyte-macrophage colony-stimulating factor (GM-CSF), and liposome, of which CFA served as a positive control. The antibody response was determined and found that the gp96 mimotope with ALUM showed a significant increase in antibody titer, followed by GM-CSF and liposomes. Further, the T cell (CD4(+) and CD8(+)) populations from splenocytes, as well as IgG isotypes, interleukin-4, and interleukin-5 of gp96 mimotope with ALUM-immunized animals, were analyzed. The results suggest that the gp96 mimotope may elicit a potent and effective antitumor antibody response. Further, the study identifies ALUM and GM-CSF as adjuvant options to drive an appropriate protective immune response as these adjuvants have prior use in humans.

Challenges in clinical design of immunotherapy trials for malignant glioma

Glioblastoma multiforme (GBM) is the most common and lethal primary malignant brain tumor. The traditional treatments for GBM, including surgery, radiation, and chemotherapy, only modestly improve patient survival. Therefore, immunotherapy has emerged as a novel therapeutic modality. Immunotherapeutic strategies exploit the immune system's ability to recognize and mount a specific response against tumor cells, but not normal cells. Current immunotherapeutic approaches for glioma can be divided into 3 categories: immune priming (active immunotherapy), immunomodulation (passive immunotherapy), and adoptive immunotherapy. Immune priming sensitizes the patient's immune cells to tumor antigens using various vaccination protocols. In the case of immunomodulation, strategies are aimed at reducing suppressive cytokines in the tumor microenvironment or using immune molecules to specifically target tumor cells. Adoptive immunotherapy involves harvesting the patient's immune cells, followed by ex vivo activation and expansion before reinfusion. This article provides an overview of the interactions between the central nervous system and the immune system, and discusses the challenges facing current immunotherapeutic strategies.

A review of the literature on the impact of renal cancer therapy on quality of life

AIM

To explore the impact of renal cancer treatment on patients' quality of life.

BACKGROUND

Renal cancer accounts for 95,000 deaths worldwide and its incidence rate is rising. At present there are several therapeutic approaches to the treatment of renal cancer, ranging through surgery, immunological therapies and vaccine treatment. Each of these therapies may have a substantial effect upon patients' quality of life. However, a systematic appraisal of the empirical evidence about treatment impact is lacking.

DESIGN

Literature review.

METHODS

A structured review of the empirical literature on the impact of renal cancer treatment upon quality of life was undertaken. Literature was appraised and themed according to the treatment modalities included in the study.

RESULTS

From 873 papers initially identified 52 were retrieved for detailed scrutiny resulting in a final 16 papers being included in the review.

CONCLUSIONS

This review discusses the complex effect of renal cancer upon a patient's quality of life as treatment modalities change. The need for nursing education and awareness of these issues is therefore highlighted to maximise patient care.

RELEVANCE TO CLINICAL PRACTICE

Understanding the impact of treatment for renal cancer enables nurses to empathise more significantly with patients and also act as mediators in regard to treatment choice and treatment cessation. It also enables nurses to inform and educate renal cancer patients prior to making treatment choices.

The ethics of phase 0 oncology trials

Recent guidance from the Food and Drug Administration supports the conduct of a new type of exploratory clinical trial, commonly called phase 0 clinical trials. Proponents argue that phase 0 clinical trials have the potential to expedite the development of new oncology drugs while exposing fewer research subjects to the risks of experimental treatments. At the same time, phase 0 oncology trials raise important ethical concerns that have received little attention. In particular, there is a question of whether it is ethical to enroll individuals in research that offers them no potential for clinical benefit. Further concern focuses on the inclusion of terminally ill and consequently vulnerable cancer patients in these trials. To evaluate these concerns, this article considers relevant empirical data from phase 1 oncology trials and develops several recommendations regarding the conduct of phase 0 clinical trials in oncology.

Epidemiologic and socioeconomic burden of metastatic renal cell carcinoma (mRCC): a literature review

Renal cell carcinoma (RCC), the most common form of kidney cancer, initially has an asymptomatic clinical course; 25-30% of patients present with metastatic disease at time of diagnosis. Worldwide incidence and mortality rates are rising at a rate of approximately 2-3% per decade. Metastatic RCC (mRCC) is one of the most treatment-resistant malignancies; outcomes are generally poor and median survival after diagnosis is less than one year. Surgery and chemotherapy have limited or no effect, leaving mRCC patients underserved in the realm of cancer treatment. As the world's population ages and the prevalence of risk factors (obesity, hypertension) increases, the burden of mRCC is predicted to increase significantly. With a shift in treatment of mRCC to novel therapies, such as molecularly targeted therapies (MTTs) (e.g., sorafenib and sunitinib), clinicians, payers, and other healthcare decision-makers must re-evaluate the optimal role for new treatments. Timely understanding of the burden of mRCC on individuals and society clearly is needed at this juncture. Using a comprehensive literature review, we assessed the epidemiologic, economic, and health-related quality of life (HRQOL) burdens of mRCC. The annual incidence of mRCC in major European countries, the US, and Japan ranges from 1500 to 8600 cases. However, prevalence data were lacking. The estimated economic burden of mRCC is large; $107-$556 million (2006 USD) in the US and $446 million-$1.6 billion (2006 USD) collectively in select countries worldwide. MTTs have potential to reduce the burden of mRCC and provide substantial value beyond their clinical effectiveness.

Phase I participants' views of quality of life and trial participation burdens

PURPOSE

Participants' perception of quality of life (QOL) and respondent burden have significant implications for investigators' ethical responsibilities to their subjects in phase I cancer trials. To address these responsibilities, analysis was conducted on participants' views of their experiences of a phase I trial, including the associated burdens and what constitutes QOL.

PATIENTS AND METHODS

One hundred potential participants of the endostatin trial were surveyed. Sixteen of the 18 trial participants were interviewed extensively about their experiences on the trial.

RESULTS

Participants described 'normality' as a baseline ability to function, be productive, and be free from symptoms of disease and side effects of treatment. Reflecting the relative nontoxicity of the study drug, participants contrasted their current QOL with their negative experience of previous cancer treatments and viewed their QOL as fairly good. However, participants emphasized that indirect and procedural burdens of trial participation had a significant impact on their current QOL.

CONCLUSIONS

Candid descriptions of a trial's practical demands, in addition to potential physical complications in a trial, could improve the quality of informed consent.

Symptom burden among patients with renal cell carcinoma (RCC): content for a symptom index

BACKGROUND

Renal cell carcinoma (RCC) has multiple symptoms stemming from disease and treatments. There are few validated scales for evaluating RCC symptoms.

METHODS

A national cross-sectional study of adult RCC patients was conducted from October to December 2003 to define patient-reported RCC symptomology. Participants were asked open-ended questions regarding their signs and symptoms and completed an 86-item pilot questionnaire of physical and psychological symptoms. Patients were asked to rate the relevancy and clarity of each pilot question using a 5-point Likert scale. Subsequent open-ended caregiver interviews and a provider panel relevance ranking contributed additional information.

RESULTS

The average age of the participants (n = 31) was 55 years; 55% of patients were male, 74% had attended college, and 97% were Caucasian. The five most frequent symptoms among localized-stage patients (n = 14) were irritability (79%), pain (71%), fatigue (71%), worry (71%), and sleep disturbance (64%). Among metastatic patients (n = 17), the five most frequent symptoms were fatigue (82%), weakness (65%), worry (65%), shortness of breath (53%), and irritability (53%). More than 50% of localized and metastatic-stage patients reported pain, weakness, fatigue, sleep disturbance, urinary frequency, worry, and mood disorders as being moderately to highly relevant.

CONCLUSION

A brief, self-administered RCC Symptom Index was created that captures the relevant signs and symptoms of both localized and metastatic patients. Pending additional content validation, the Index can be used to assess the signs and symptoms of RCC and the clinical benefit resulting from RCC treatment.

Molecular chaperones and cancer immunotherapy

As one of the most abundant and evolutionally conserved intracellular proteins, heat shock proteins, also known as stress proteins or molecular chaperones, perform critical functions in maintaining cell homeostasis under physiological as well as stress conditions. Certain chaperones in extracellular milieu are also capable of modulating innate and adaptive immunity due to their ability to chaperone polypeptides and to interact with the host's immune system, particularly professional antigen-presenting cells. The immunomodulating properties of chaperones have been exploited for cancer immunotherapy. Clinical trials using chaperone-based vaccines to treat various malignancies are ongoing.

Antigenic targets for renal cell carcinoma immunotherapy

Renal cell carcinoma (RCC) has been shown to respond to immunotherapeutic intervention, thus fostering continued interest in exploiting the ability of the immune system to recognise and eradicate renal malignancy. Considerable progress in the characterisation of tumour-associated antigens, coupled with the appreciation that dendritic cells act as master regulators of immunity and tolerance, has opened new possibilities for immunotherapeutic intervention against human cancer. However, in contrast to other tumour systems, clinically relevant antigens expressed by RCC have not yet been identified. Therefore, most RCC vaccine trials have employed unfractionated antigens derived from tumour cells, with the goal of eliciting T cell responses against many unknown antigens expressed by the tumour. The recent discovery of genes with critical roles in oncogenesis has facilitated the identification of novel, more universal targets that may make cancer vaccines more practical, applicable and, potentially, more effective. In addition, immunisation against tumour antigens can be combined with tumour stroma-associated targets, thereby exerting a synergistic antitumour effect. Continued identification of molecular targets, in concert with more effective vaccination protocols, is likely to produce vaccination strategies with clinical impact.

Therapeutic cancer vaccines: using unique antigens

A decade ago, it seemed rational that our rapidly increasing knowledge of the molecular identities of tumor antigens and a deeper understanding of basic immunology would point the way to an effective therapeutic cancer vaccine. Significant progress has been made, but we do not yet have a cancer vaccine that can reliably and consistently induce tumor destruction or improve patient survival. Random mutations in cancer cells generate unique antigens in each individual, and this may be important in terms of generating a therapeutic immune response. Autologous heat shock protein-peptide complexes produced from each patient's tumor is a logical personalized approach that may obviate the need to identify the unique antigens contained in the individual vaccine. Heat shock proteins elicit adaptive and innate immune responses and have been tested in a variety of animal models and different human cancers. Activity has been seen in several animal studies. Early-phase human studies have also suggested some activity in certain cancers. Large, randomized phase 3 studies are ongoing, and these will effectively answer the question of efficacy regarding this approach to therapeutic vaccination. There are sufficient data to support the notion that cancer vaccines can induce anti-tumor immune responses in humans with cancer. How best to translate this increase in immune responsiveness to consistently and reproducibly induce objective cancer regression or increased survival remains unclear at this time.

Melacine: an allogeneic melanoma tumor cell lysate vaccine

Cancer vaccines have represented the holy grail of tumor immunology to many. In 2003, there are innumerable approaches to active specific immunotherapy for cancer. The identification of tumor antigens recognized by and able to activate human T-lymphocytes has heightened the enthusiasm for this approach. Melanoma is one of the diseases that has been primarily targeted by vaccine approaches. The identification of peptides and proteins associated with cancer has provided strategies to target specific components of the cancer cell. However, older vaccines utilizing products from whole cells may have a number of advantages. Melacine (Corixa Corp.) is an allogeneic melanoma tumor cell lysate combined with the adjuvant DETOX. Pioneered by Malcolm Mitchell, it has rare but confirmed antitumor activity in metastatic melanoma (5-10%). However, previous analysis of responses in advanced disease and a recent analysis in early-stage adjuvant trials suggest that Melacine may have its greatest benefit in a large subset of melanoma patients who express either the human leukocyte antigen (HLA) class I antigens A2 and/or HLA-C3. This finding must now be confirmed in a large perspective observation-controlled clinical trial to solidify the role of Melacine as an effective cancer vaccine in melanoma.

Recent progress in tumour vaccine development

Immunotherapy offers an exciting opportunity to treat human cancer. Analysis of tumour-associated antigens is progressing. Assisted by animal models, such knowledge can be used to design tumour vaccines. By including adjuvants to increase immunogenicity, several tumours previously thought to be non-immunogenic are now considered targets for tumour vaccines. Newly acquired knowledge regarding dendritic cell physiology is incorporated in newly designed vaccines that are currently in Phase I and II trials. Such assessment provides the overall conclusion that tumour vaccines are safe and deserve a more prominent place in the sequel of treatments for human cancer.

Quality of life in patients with malignant melanoma participating in a phase I trial of an autologous tumour-derived vaccine

Quality of life (QOL) plays an increasingly important role in the decision-making process and the ultimate acceptability of particular treatments for patients. We prospectively examined QOL in patients with advanced melanoma treated with surgery followed by heat-shock protein peptide complex 96 (HSPPC-96) vaccine, an active, patient-specific immunotherapy. QOL (the RAND 36-Item Health Survey; SF-36) and cancer-related intrusive thoughts (Impact of Event Scale; IES) were measured at the start of treatment, 3 weeks later on the final day of treatment, and at follow-up 1 month later in 30 patients with stage III or IV malignant melanoma. Mixed model analyses revealed no significant change over time in the SF-36 Physical or Mental Component Summary scores, or the IES scores. In comparisons with other populations, at the 1 month follow-up assessment, melanoma patients reported similar QOL to patients with metastatic renal cell carcinoma who received the same treatment, significantly worse QOL on the physical dimensions and similar QOL on the psychosocial and emotional dimensions compared with the general population, similar QOL to patients with type II diabetes, and significantly better QOL on all three dimensions than patients with congestive heart failure. There was also a significant negative association between IES scores at baseline and mental health scores at each time point ( < 0.002 for all). QOL remained stable during treatment with the HSPPC-96 vaccine. In addition, patients who reported high levels of cancer-related intrusive thoughts at the start of treatment reported worse mental health at the end of the treatment.