Health-related quality of life, fatigue, and depression under low-dose IFN-α therapy in melanoma patients

Reduced ex vivo TNFα synthesis upon whole blood stimulation with endotoxin predicts post-stroke fatigue

OBJECTIVE

Fatigue is a common, debilitating syndrome after stroke. Peripheral inflammation plays a role in the pathogenesis of fatigue of different origin, but its contribution to post-stroke fatigue (PSF) remains unclear. We aimed to determine if there is any association between ex vivo synthesized and circulating cytokines, and risk of PSF.

METHODS

We included 174 patients with ischemic stroke. We stimulated in vitro blood taken on day 3 after stroke with endotoxin. We measured ex vivo released (TNFα, IP-10, IL-1β, IL-6, IL-8, IL-10, IL-12p70) and plasma (TNFα, IL-6, sIL-6R, IL-1Ra) cytokines. We assessed fatigue at month 3 using Fatigue Severity Scale (FSS). We used logistic regression to assess the relationship between cytokines and fatigue scores.

RESULTS

Compared with patients with lower fatigue at month 3 (FSS < 36), patients with higher fatigue (FSS ≥ 36) had lower endotoxin-stimulated TNFα release after 24 h (median: 429 vs 581 pg/mL, P = 0.05). Plasma TNFα tended to be higher in patients who developed fatigue (median: 0.8 vs 0.6 pg/mL, P = 0.06). Other cytokines did not differ between groups. After adjusting for pre-stroke fatigue and depressive symptoms, TNFα release <559.7 pg/mL after 24 h was associated with an increased risk of PSF (OR: 2.61, 95%CI: 1.22-5.57, P = 0.01). Plasma TNFα >0.76 pg/mL was associated with higher risk of PSF in univariable (OR: 2.41, 95%CI: 1.13-5.15, P = 0.02), but not multivariable analysis (OR: 2.41, 95%CI: 0.96-6.00, P = 0.06).

CONCLUSION

Reduced ex vivo TNFα synthesis upon whole blood stimulation with endotoxin in the acute phase of stroke predicted PSF.

Teriflunomide in relapsing-remitting multiple sclerosis: outcomes by age and pre-treatment status

Background and aims:

To investigate effectiveness and safety of teriflunomide (14 mg once daily) in association with age and pre-treatment in unselected MS patients.

Methods:

Prespecified analysis of a non-interventional, prospective, real-world study in Germany.

Results:

A total of 558 (49.5%) patients were above 45 years old, and 593 patients (52.6%) had been pre-treated within 6 months prior to teriflunomide. Baseline Expanded Disability Status Scale (EDSS) was higher with older age, with lower number of relapses. Relapse rate decreased in all age groups, and in both treatment-naïve (0.82 ± 0.73 at baseline; 0.25 ± 0.55 under teriflunomide) and pre-treated (from 0.48 ± 0.76; 0.22 ± 0.50) patients after 12 months compared with the year before teriflunomide initiation. EDSS remained stable in patients of all age groups as well as in therapy-naïve and pre-treated patients over 24 months. The percentage of patients with adverse events (AEs) ranged between 29.2% (age group >25–35) and 38.9% (age group >55–65), with an increased discontinuation rate (most commonly due to diarrhoea, alopecia and nausea) in the higher age groups. AE rates were lower in pre-treated compared with treatment-naïve patients.

Conclusion:

Overall, patients of all age groups including older patients, and irrespective of pre-treatment, benefit from teriflunomide treatment in routine clinical practice.

Registration:

BfArM public study database number 2075.

Psychosocial distress in patients with cutaneous melanoma: validation of the Skin Cancer Index (SCI)

PURPOSE

The aim of this study is to examine the factor structure and psychometric properties of the Skin Cancer Index (SCI) in a sample of patients with melanoma.

METHODS

This study uses data from an observational study with longitudinal follow-up examining predictors of skin self-examination in melanoma patients from Montréal, Canada. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to investigate the factor structure of the 15-item SCI scale. Correlations with other psychosocial measures of anxiety and depression, fear of cancer recurrence, quality of life, and emotional well-being were computed to examine construct validity.

RESULTS

EFA results with 241 participants revealed a two-factor structure with acceptable fit and no significant cross-loadings. CFA results with a subsample of 173 participants examining the two-factor structure and second-order structure found equivalent fit for the two solutions. Cronbach's alpha for the total scale score and both subscales was high. Both factors showed positive associations with measures of anxiety and depression and fear of cancer and negative associations with quality of life and emotional well-being.

CONCLUSION

Our study suggests that the SCI functions as a reliable two-factor scale assessing emotional and social distress in patients with melanoma, with the total SCI score assessing overall psychosocial distress.

The Impact of Cytokines on the Health-Related Quality of Life in Patients with Systemic Lupus Erythematosus

Introduction: Systemic lupus erythematosus (SLE) reduces the health-related quality of life (HRQoL), even during periods of disease quiescence. We investigated whether subclinical inflammation as reflected by cytokine levels is linked with reduced HRQoL. Methods: A cross-sectional study of SLE patients (n = 52, mean age 47.3, 86.5% female) who completed a Short Form Health Survey-36 (SF-36) questionnaire. The clinical and demographic data, scores for the disease activity (SLEDAI-2K), organ damage (SDI), and laboratory data were collected simultaneously. The autoantibody and cytokine levels (IFN-γ, IL-1β, IL-4, IL-6, IL-10, IL-12, IL-17, BAFF, TNF-α, TGF-β1, MIP-1α, MIP-1β and MCP-1 (levels in pg/mL) were quantified by sandwich ELISA. The comparisons and associations were assessed non-parametrically, and a multiple regression determined the effect sizes (ES) of the variables on the SF-36 domain and summary scores. Results: The SF-36 summary and domain scores for SLE patients were significantly (20–40%) lower than in a comparable control group, with the exception of the Mental Health scores (p = 0.06). SLE patients had a normal body mass index (BMI) (median, 24.2 kg/m²), a high rate of smoking (69.2%), and usage of social security benefits (90.4%). TGF-β1 (ES 0.06), IL-12 (ES −0.11), IFN-γ (ES 0.07) and MCP-1 (ES 0.06) influenced the SF-36 domain scores; and MCP-1 (ES 0.04) influenced the Mental Health Summary Score (MCS). Obvious manifestations, including patient visual analogue scale (VAS) (ES −2.84 to −6.29), alopecia (ES −14.89), malar rash (ES −14.26), and analgesic requirement (ES −19.38), independently influenced the SF-36 items; however, the SF-36 scores were not reflected by the physician VAS or disease activity (SLEDAI-2K). Conclusions: Cytokines had a minimal impact on HRQoL in SLE patients, especially compared to visible skin manifestations, central nervous system (CNS) damage, and pain. Better tools are needed to capture HRQoL in measures of disease activity.

Quality of life measurement in skin cancer patients: literature review and position paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer

The European Academy of Dermatology and Venereology (EADV) Task Forces (TFs) on Quality of Life (QoL) and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer (NMSC) present a review of the literature and position statement on health-related (HR) QoL assessment in skin cancer patients. A literature search was carried out to identify publications since 1980 that included information about the impact of SC on QoL. Generic, dermatology-specific, cancer-specific, SC-specific, facial SC-specific, NMSC-specific, basal cell carcinoma-specific and melanoma-specific QoL questionnaires have been used to assess HRQoL in SC patients. HRQoL was assessed in the context of creation and validation of the HRQoL instruments, clinical trials, comparison of QoL in SC and other cancers, other diseases or controls, HRQoL assessment after treatment, comorbidities, behaviour modification, predictors of QoL and survival, supportive care needs, coping strategies and fear of cancer recurrence. The most widely used instruments for HRQoL assessment in SC patients are the European Organisation for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30), the Functional Assessment of Cancer Therapy-Melanoma (FACT-M), Skin Cancer Index (SCI), Short Form 36 Item Health Survey (SF-36) and the Dermatology Life Quality Index (DLQI). The TFs recommend the use of the cancer-specific EORTC QLQ-C30, especially in late stages of disease, and the melanoma-specific FACT-M and SC-specific SCI questionnaires. These instruments have been well validated and used in several studies. Other HRQoL instruments, also with good basic validation, are not currently recommended because the experience of their use is too limited. Dermatology-specific HRQoL instruments can be used to assess the impact of skin-related problems in SC. The TFs encourage further studies to validate HRQoL instruments for use in different stages of SC, in order to allow more detailed practical recommendations on HRQoL assessment in SC.

Development and initial validation of the Self-Efficacy for Skin Self-Examination Scale in a Canadian sample of patients with melanoma

PURPOSE

Melanoma is the deadliest type of skin cancer, although survival rates are high if detected early. Skin self-examination (SSE) is a health behaviour that can lead to early detection of melanoma and more positive health outcomes. Self-efficacy for SSE is a potential predictor of engaging in skin self-exams. However, no standardized measures of self-efficacy for SSE are currently available. The present study reports on the development and initial validation of a measure assessing self-efficacy for SSE.

METHOD

Based on a literature review, including previous studies assessing this construct, the research team developed 9 items capturing confidence in one's ability to conduct SSE. Items were subsequently revised by the research team and two dermatologists, resulting in the elimination of 4 items and modifications to the response options. The final 5-item Self-Efficacy for SSE scale was administered to a sample of 242 melanoma patients recruited from local hospitals. We assessed the scale's factor structure through exploratory factor analysis and the internal consistency with Cronbach's alpha. Scale scores were correlated with intentions to perform SSE, physician support for SSE, skin cancer-specific distress, general distress, and sociodemographic variables to assess convergent and divergent validity.

RESULTS

The scale was found to be unifactorial with adequate model fit, have acceptable internal consistency (Cronbach alpha = 0.74), and initial evidence of convergent and divergent validity, as indicated by the scale correlating with physicians' support for SSE (r = 0.30, p < 0.01), intention to perform SSE (r_s = 0.21, p < 0.01) and a weak correlation with general distress (r = 0.15, p < 0.05).

CONCLUSIONS

Pending future research corroborating these findings, this measure has potential for use by nurses and other health professionals in follow-up care to identify individuals at risk for low self-efficacy for SSE requiring more targeted educational SSE interventions.

Health-related quality of life with adjuvant ipilimumab versus placebo after complete resection of high-risk stage III melanoma (EORTC 18071): secondary outcomes of a multinational, randomised, double-blind, phase 3 trial

BACKGROUND

The EORTC 18071 phase 3 trial compared adjuvant ipilimumab with placebo in patients with stage III melanoma. The primary endpoint, recurrence-free survival, was significantly longer in the ipilimumab group than in the placebo group. Investigator-reported toxic effects of ipilimumab consisted mainly of skin, gastrointestinal, endocrine, and hepatic immune-related adverse events. Adjuvant treatment with ipilimumab in this setting was approved in October, 2014, by the US Food and Drug Administration based on the results of the primary outcome of this trial. Here, we report the results of the secondary endpoint, health-related quality of life (HRQoL), of this trial.

METHODS

EORTC 18071 was a multinational, double-blind, randomised, phase 3 trial in patients with stage III cutaneous melanoma (excluding lymph node metastasis ≤1 mm or in-transit metastasis) in 19 countries worldwide. Participants were randomly assigned (1:1) centrally by an interactive voice response system, to receive either ipilimumab 10 mg/kg or placebo every 3 weeks for four doses, then every 3 months for up to 3 years. Using a minimisation technique, randomisation was stratified by disease stage and geographical region. HRQoL was assessed with the EORTC QLQ-C30 quality-of-life instrument at baseline, weeks 4, 7, 10, and 24, and every 12 weeks thereafter up to 2 years, irrespective of disease progression. Results were summarised by timepoint and in a longitudinal manner in the intention-to-treat population. Two summary scores were calculated for each HRQoL scale: the average score reported during induction (ipilimumab or placebo at a dose of 10 mg/kg, administered as one single dose at the start of days 1, 22, 43, and 64-ie, four doses in 3 weeks), and the average score reported after induction. A predefined threshold of a 10 point difference between arms was considered clinically relevant. The primary HRQoL endpoint was the global health scale, with the predefined hypothesis of no clinically relevant differences after induction between groups. This trial is registered with EudraCT, number 2007-001974-10, and ClinicalTrials.gov, number NCT00636168.

FINDINGS

Between July 10, 2008, and Aug 1, 2011, 951 patients were randomly assigned to treatment: 475 in the ipilimumab group and 476 in the placebo group. Compliance with completing the HRQoL questionnaire was 893 (94%) of 951 patients at baseline, 693 (75%) of 924 at week 24, and 354 (51%) of 697 at week 108. Patient mean global health scores during (77·32 [SD 17·36] vs 72·96 [17·82]; p=0·00011) and after induction (76·48 [17·52] vs 72·32 [18·60]; p=0·00067) were statistically significantly different between groups but were not clinically relevant. Mean global health scores differed most between the groups at week 7 (77 [SD 19] in the placebo group vs 72 [22] in the ipilimumab group) and week 10 (77 [20] vs 70 [23]). Mean HRQoL scores differed by more than 10 points at week 10 between treatment groups for diarrhoea (7·67 [SD 17·05] for placebo vs 18·17 [28·35] for ipilimumab) and insomnia (15·17 [22·53] vs 25·60 [29·19]).

INTERPRETATION

Despite increased toxicity, which led to treatment discontinuation for most patients during the induction phase of ipilimumab administration, overall HRQoL, as measured by the EORTC QLQ-C30, was similar between groups, as no clinically relevant differences (10 points or more) in global health status scores were observed during or after induction. Clinically relevant deterioration for some symptoms was observed at week 10, but after induction, no clinically relevant differences remained. Together with the primary analysis, results from this trial show that treatment with ipilimumab results in longer recurrence-free survival compared with that for treatment with placebo, with little impairment in HRQoL despite grade 3-4 investigator-reported adverse events.

FUNDING

Bristol-Myers Squibb.

Parallel Effects of Methamphetamine on Anxiety and CCL3 in Humans and a Genetic Mouse Model of High Methamphetamine Intake

BACKGROUND

Methamphetamine (MA) abuse causes immune dysfunction and neuropsychiatric impairment. The mechanisms underlying these deficits remain unidentified.

METHODS

The effects of MA on anxiety-like behavior and immune function were investigated in mice selectively bred to voluntarily consume high amounts of MA [i.e., MA high drinking (MAHDR) mice]. MA (or saline) was administered to mice using a chronic (14-day), binge-like model. Performance in the elevated zero maze (EZM) was determined 5 days after the last MA dose to examine anxiety-like behavior. Cytokine and chemokine expressions were measured in the hippocampus using quantitative polymerase chain reaction (qPCR). Human studies were also conducted to evaluate symptoms of anxiety using the General Anxiety Disorder-7 Scale in adults with and without a history of MA dependence. Plasma samples collected from human research participants were used for confirmatory analysis of murine qPCR results using an enzyme-linked immunosorbent assay.

RESULTS

During early remission from MA, MAHDR mice exhibited increased anxiety-like behavior on the EZM and reduced expression of chemokine (C-C motif) ligand 3 (ccl3) in the hippocampus relative to saline-treated mice. Human adults actively dependent on MA and those in early remission had elevated symptoms of anxiety as well as reductions in plasma levels of CCL3, relative to adults with no history of MA abuse.

CONCLUSIONS

The results highlight the complex effects of MA on immune and behavioral function and suggest that alterations in CCL3 signaling may contribute to the mood impairments observed during remission from MA addiction.

Adjuvant treatment with pegylated interferon α-2a versus low-dose interferon α-2a in patients with high-risk melanoma: a randomized phase III DeCOG trial

BACKGROUND

Adjuvant treatment with interferon (IFN)-α-2a improved disease-free survival (DFS) and showed a trend for improving overall survival (OS) in melanoma. This trial was designed to examine whether PEG-IFN is superior to IFN with regard to distant metastasis-free survival (DMFS), DFS and OS.

PATIENTS AND METHODS

In this multicenter, open-label, prospective randomized phase III trial, patients with resected cutaneous melanoma stage IIA(T3a)-IIIB (AJCC 2002) were randomized to receive PEG-IFN (180 μg subcutaneously 1×/week; 24 months) or IFN α-2a (3MIU subcutaneously 3×/week; 24 months). Randomization was stratified for stage, number of metastatic nodes, age and previous IFN treatment. The primary end point was DMFS; secondary end points were OS, DFS, quality of life (QoL) and tolerability.

RESULTS

A total of 909 patients were enrolled (451 PEG-IFN versus 458 IFN). Neither 5-year DMFS [PEG-IFN 61.0% versus IFN 67.3%; hazard ratio (HR) 1.16, P = 0.21] nor 5-year OS (PEG-IFN 73.2% versus IFN 75.2%; HR 1.05, P = 0.70) nor 5-year DFS (PEG-IFN 57.3% versus IFN 60.9%; HR 1.09, P = 0.40) showed significant differences. Subgroup analyses in patients ± ulcerated primaries and of different tumor stages did not find differences in DMFS, OS or DFS between the treatment groups. One hundred and eighteen patients (26.2%) in the PEG-IFN and 61 patients (13.3%) in the IFN population did not receive the full dosage and length of treatment due to adverse events (P < 0.001). Leukopenia and elevation of liver enzymes were more common in the PEG-IFN arm (56% versus 23.5% LCP; 19.1% versus 9.4% AST; 33.0% versus 16.5% ALT). QoL was identical for nearly all domains.

CONCLUSION

PEG-IFN did not improve the outcome over IFN. A higher percentage of patients under PEG-IFN discontinued treatment due to toxicity.

CLINICAL TRIALSGOV IDENTIFIER

NCT00204529.