The MedXFit-study - CrossFit as a workplace health intervention: a one-year, prospective, controlled, longitudinal, intervention study

Introduction

Workplace health interventions aim to motivate employees toward healthy behaviors to improve fitness and health in the long-term. We investigated whether CrossFit® is an effective training concept to achieve these goals in inactive employees with sedentary occupations.

Methods

The study followed a prospective, controlled intervention design. Employees were invited to participate in intervention group (IG) or control group (CG) on their own preferences. Inclusion criteria were a predominantly sedentary occupation and execution of less than two muscle and/or mobility enhancing training sessions per week at the time of enrolling. The IG did at least two times a week a CrossFit training of 1 h. Mobility, strength, well-being, and back-issues were measured at the beginning, after 6, and 12 months. Participants in the CG were free to choose any other activities offered at the same time (e.g., circuit training, meditation, full body stability training). Adherence, respectively, behavioral change and maintenance qualities were evaluated based on the COM-B system and presence of behavior maintenance motives.

Results

89 employees were enrolled into the trial, from where 21 dropped out due to external factors (24%). From the remaining participants, 10 out of 39 (26%) in the IG and 1 out of 29 (4%) in the CG stopped for intrinsic reasons, leading to a non-adherence to the intervention of 22 percentage points. Motivation for behavioral change and maintenance in the IG was primarily driven by enhanced physical and psychological capability. Development of physical capability was evident by significant improvements (p < 0.001) in the IG compared to the CG for mobility (d = 3.3), maximal isometric strength (min. d = 1.7, max. d = 2.5), as well as reduction in pain intensity (p = 0.003, r = 0.4) and frequency (p = 0.009, r = 0.35) after 12 months. Significant improvements between the 6-month and the 12-month measurement in mobility and 6 out of 8 strength measures within the IG indicated the effectiveness of CrossFit beyond the beginner phase.

Conclusion

CrossFit is a motivating training concept that led to long-term health and fitness improvements in inactive employees doing sedentary work and should be given greater consideration in workplace health promotion.

Neratinib as Extended Adjuvant Treatment of HER2-Positive/HR-Positive Early Breast Cancer Patients in Germany, Austria, and Switzerland: Interim Results of the Prospective, Observational ELEANOR Study

Introduction

Prognosis of patients diagnosed with HER2+ early breast cancer (eBC) has substantially improved, but distant recurrences impacting quality of life and survival still occur. One treatment option for extended adjuvant treatment of patients with HER2+/HR+ eBC is neratinib, available in Europe for patients who completed adjuvant trastuzumab-based therapy within 1 year. The ELEANOR study is investigating the real-world use of neratinib in Germany, Austria, and Switzerland. Results from an interim analysis of the first 200 patients observed for ≥3 months are reported.

Methods

The primary objective of this prospective, multicenter, observational study is to assess patient adherence to neratinib (defined as the percentage of patients taking neratinib on ≥75% prescribed days). Secondary objectives are patient characteristics and treatment outcomes.

Results

At cut-off (May 2, 2022), a total of 202 patients had been observed for ≥3 months, with neratinib treatment documented for 187 patients (median age: 53.0 years; 67.9% at increased risk of disease recurrence). In total, 151 (80.7%) patients had received prior neoadjuvant treatment; of these, 82 (54.3%) patients achieved a pathologically complete response. Neratinib was initiated at a median 3.6 months after trastuzumab-based treatment, with 36.4% starting at a dose <240 mg/day. Treatment is ongoing for 46.0% of patients, with median treatment duration of 11.2 (interquartile range 0.9-12.0) months. Diarrhea was the most common adverse event (78.6% any grade, 20.3% grade ≥3); pharmacologic prophylaxis was used in 85.6% of patients.

Conclusions

The pattern of anti-HER2 pretreatment observed reflected the current treatment for HER2+/HR+ eBC in Germany, Austria, and Switzerland. These interim results suggest that neratinib as an extended adjuvant is a feasible option after various anti-HER2 pretreatments and that its tolerability can be managed and improved with proactive diarrhea management.

Favorable impact of therapy management by an interactive eHealth system on severe adverse events in patients with hormone receptor-positive, HER2-negative locally advanced or metastatic breast cancer treated by palbociclib and endocrine therapy

BACKGROUND

Oral cancer medications offer advantages but also pose challenges for therapy management and adherence. An eHealth-based platform such as CANKADO can help to support therapy management by probing the patient's quality of life (QoL) continuously throughout the course of treatment.

MATERIAL AND METHODS

AGO-B WSG PreCycle (NCT03220178) is a multicenter, randomized phase IV intergroup trial evaluating the impact of eHealth-based Patient-Reported Outcome (ePRO) assessment on QoL in patients with hormone receptor-positive (HR + )/HER2-negative (HER2-) advanced breast cancer treated with palbociclib and endocrine therapy. Patients were randomized (2:1) to CANKADO-active arm (supported by CANKADO PRO-React) or CANKADO-inform arm (drug intake documentation only) This exploratory analysis reports the impact of CANKADO PRO-React on safety. Time to first serious adverse event (SAE) was estimated taking competing risks into account.

RESULTS

While distributions of adverse events (AEs) were similar by arm overall, patients in the CANKADO-active arm had a favorable hazard ratio of 0.67 (95%CI 0.46-0.97; p = 0.04) for time to first SAE and were significantly less likely overall to suffer an SAE than patients in the inform arm. At 24 months, 22.9% [17.9%-27.8%] of patients in CANKADO-active had suffered an SAE vs. 30.3% [22.6%-38.0%] in CANKADO-inform. AE-related dose reductions affected approximately 20% of patients (CANKADO-active: 18.2%, CANKADO-inform: 21.1%).

CONCLUSION

Exploratory safety analysis of PreCycle demonstrates for the first time in a randomized prospective trial that interactive autonomous eHealth-based support has a substantial favorable impact on the risk of SAEs and mitigates their severity for patients with advanced HR+/HER2- breast cancer on oral tumor therapy.

Diagnostic Accuracy of Single-Lead Electrocardiograms Using the Kardia Mobile App and the Apple Watch 4: Validation Study

BACKGROUND

To date, the 12-lead electrocardiogram (ECG) is the gold standard for cardiological diagnosis in clinical settings. With the advancements in technology, a growing number of smartphone apps and gadgets for recording, visualizing, and evaluating physical performance as well as health data is available. Although this new smart technology is innovative and time- and cost-efficient, less is known about its diagnostic accuracy and reliability.

OBJECTIVE

This study aimed to examine the agreement between the mobile single-lead ECG measurements of the Kardia Mobile App and the Apple Watch 4 compared to the 12-lead gold standard ECG in healthy adults under laboratory conditions. Furthermore, it assessed whether the measurement error of the devices increases with an increasing heart rate.

METHODS

This study was designed as a prospective quasi-experimental 1-sample measurement, in which no randomization of the sampling was carried out. In total, ECGs at rest from 81 participants (average age 24.89, SD 8.58 years; n=58, 72% male) were recorded and statistically analyzed. Bland-Altman plots were created to graphically illustrate measurement differences. To analyze the agreement between the single-lead ECGs and the 12-lead ECG, Pearson correlation coefficient (r) and Lin concordance correlation coefficient (CCCLin) were calculated.

RESULTS

The results showed a higher agreement for the Apple Watch (mean deviation QT: 6.85%; QT interval corrected for heart rate using Fridericia formula [QTcF]: 7.43%) than Kardia Mobile (mean deviation QT: 9.53%; QTcF: 9.78%) even if both tend to underestimate QT and QTcF intervals. For Kardia Mobile, the QT and QTcF intervals correlated significantly with the gold standard (rQT=0.857 and rQTcF=0.727; P<.001). CCCLin corresponded to an almost complete heuristic agreement for the QT interval (0.835), whereas the QTcF interval was in the range of strong agreement (0.682). Further, for the Apple Watch, Pearson correlations were highly significant and in the range of a large effect (rQT=0.793 and rQTcF=0.649; P<.001). CCCLin corresponded to a strong heuristic agreement for both the QT (0.779) and QTcF (0.615) intervals. A small negative correlation between the measurement error and increasing heart rate could be found of each the devices and the reference.

CONCLUSIONS

Smart technology seems to be a promising and reliable approach for nonclinical health monitoring. Further research is needed to broaden the evidence regarding its validity and usability in different target groups.

Corrected QT Interval (QTc) Diagnostic App for the Oncological Routine: Development Study

BACKGROUND

Numerous antineoplastic drugs such as chemotherapeutics have cardiotoxic side effects and can lead to long QT syndrome (LQTS). When diagnosed and treated in time, the potentially fatal outcomes of LQTS can be prevented. Therefore, regular electrocardiogram (ECG) assessments are critical to ensure patient safety. However, these assessments are associated with patient discomfort and require timely support of the attending oncologist by a cardiologist.

OBJECTIVE

This study aimed to examine whether this approach can be made more efficient and comfortable by a smartphone app (QTc Tracker), supporting single-lead ECG records on site and transferring to a tele-cardiologist for an immediate diagnosis.

METHODS

To evaluate the QTc Tracker, it was implemented in 54 cancer centers in Germany. In total, 266 corrected QT interval (QTc) diagnoses of 122 patients were recorded. Moreover, a questionnaire on routine ECG workflow, turnaround time, and satisfaction (1=best, 6=worst) was answered by the centers before and after the implementation of the QTc Tracker.

RESULTS

Compared to the routine ECG workflow, the QTc Tracker enabled a substantial turnaround time reduction of 98% (mean 2.67, 95% CI 1.72-2.67 h) and even further time efficiency in combination with a cardiologic on-call service (mean 12.10, 95% CI 5.67-18.67 min). Additionally, nurses and patients reported higher satisfaction when using the QTc Tracker. In particular, patients' satisfaction sharply improved from 2.59 (95% CI 2.41-2.88) for the routine ECG workflow to 1.25 (95% CI 0.99-1.51) for the QTc Tracker workflow.

CONCLUSIONS

These results reveal a significant improvement regarding reduced turnaround time and increased user satisfaction. Best patient care might be guaranteed as the exposure of patients with an uncontrolled risk of QTc prolongations can be avoided by using the fast and easy QTc Tracker. In particular, as regular side-effect monitoring, the QTc Tracker app promises more convenience for patients and their physicians. Finally, future studies are needed to empirically test the usability and validity of such mobile ECG assessment methods.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04055493; https://classic.clinicaltrials.gov/ct2/show/NCT04055493.

Evaluating the ability of an artificial-intelligence cloud-based platform designed to provide information prior to locoregional therapy for breast cancer in improving patient's satisfaction with therapy: The CINDERELLA trial

BACKGROUND

Breast cancer therapy improved significantly, allowing for different surgical approaches for the same disease stage, therefore offering patients different aesthetic outcomes with similar locoregional control. The purpose of the CINDERELLA trial is to evaluate an artificial-intelligence (AI) cloud-based platform (CINDERELLA platform) vs the standard approach for patient education prior to therapy.

METHODS

A prospective randomized international multicentre trial comparing two methods for patient education prior to therapy. After institutional ethics approval and a written informed consent, patients planned for locoregional treatment will be randomized to the intervention (CINDERELLA platform) or controls. The patients in the intervention arm will use the newly designed web-application (CINDERELLA platform, CINDERELLA APProach) to access the information related to surgery and/or radiotherapy. Using an AI system, the platform will provide the patient with a picture of her own aesthetic outcome resulting from the surgical procedure she chooses, and an objective evaluation of this aesthetic outcome (e.g., good/fair). The control group will have access to the standard approach. The primary objectives of the trial will be i) to examine the differences between the treatment arms with regards to patients' pre-treatment expectations and the final aesthetic outcomes and ii) in the experimental arm only, the agreement of the pre-treatment AI-evaluation (output) and patient's post-therapy self-evaluation.

DISCUSSION

The project aims to develop an easy-to-use cost-effective AI-powered tool that improves shared decision-making processes. We assume that the CINDERELLA APProach will lead to higher satisfaction, better psychosocial status, and wellbeing of breast cancer patients, and reduce the need for additional surgeries to improve aesthetic outcome.

PRECYCLE: multicenter, randomized phase IV intergroup trial to evaluate the impact of eHealth-based patient-reported outcome (PRO) assessment on quality of life in patients with hormone receptor positive, HER2 negative locally advanced or metastatic breast cancer treated with palbociclib and an aromatase inhibitor or palbociclib and fulvestrant

BACKGROUND

Efficacy and quality of life (QoL) are key criteria for therapy selection in metastatic breast cancer (MBC). In hormone receptor positive (HR +) human epidermal growth factor receptor 2 negative (HER2 -) MBC, addition of targeted oral agents such as everolimus or a cycline-dependent kinase 4/6 (CDK 4/6) inhibitor (e.g., palbociclib, ribociclib, abemaciclib) to endocrine therapy substantially prolongs progression-free survival and in the case of a CDK 4/6i also overall survival. However, the prerequisite is adherence to therapy over the entire course of treatment. However, particularly with new oral drugs, adherence presents a challenge to disease management. In this context, factors influencing adherence include maintaining patients' satisfaction and early detection/management of side effects. New strategies for continuous support of oncological patients are needed. An eHealth-based platform can help to support therapy management and physician-patient interaction.

METHODS

PreCycle is a multicenter, randomized, phase IV trial in HR + HER2 - MBC. All patients (n = 960) receive the CDK 4/6 inhibitor palbociclib either in first (62.5%) or later line (37.5%) together with endocrine therapy (AI, fulvestrant) according to national guidelines. PreCycle evaluates and compares the time to deterioration (TTD) of QoL in patients supported by eHealth systems with substantially different functionality: CANKADO active vs. inform. CANKADO active is the fully functional CANKADO-based eHealth treatment support system. CANKADO inform is a CANKADO-based eHealth service with a personal login, documentation of daily drug intake, but no further functions. To evaluate QoL, the FACT-B questionnaire is completed at every visit. As little is known about relationships between behavior (e.g., adherence), genetic background, and drug efficacy, the trial includes both patient-reported outcome and biomarker screening for discovery of forecast models for adherence, symptoms, QoL, progression free survival (PFS), and overall survival (OS).

DISCUSSION

The primary objective of PreCycle is to test the hypothesis of superiority for time to deterioration (TTD) in terms of DQoL = "Deterioration of quality of life" (FACT-G scale) in patients supported by an eHealth therapy management system (CANKADO active) versus in patients merely receiving eHealth-based information (CANKADO inform). EudraCT Number: 2016-004191-22.

Significantly longer time to deterioration of quality of life due to CANKADO PRO-React eHealth support in HR+ HER2- metastatic breast cancer patients receiving palbociclib and endocrine therapy: Primary outcome analysis of the multicenter randomized AGO-B WSG PreCycle trial

BACKGROUND

The multicenter, randomized phase IV intergroup AGO-B WSG PreCycle trial (NCT03220178) evaluated the impact of CANKADO-based ePRO (electronic patient-reported outcomes) assessment on quality of life (QoL) in HR+ HER2- locally advanced or metastatic breast cancer (MBC) patients receiving palbociclib (P) and an aromatase inhibitor or P+fulvestrant. CANKADO PRO-React, an EU-registered medical device, is an interactive autonomous application reacting to patient self-reported observations.

PATIENTS AND METHODS

Between 2017 and 2021, 499 patients (median age 59 years) from 71 centers were randomized (2:1, stratified by therapy line) between an active version of CANKADO PRO-React (CANKADO-active arm) or a version with limited functionality (CANKADO-inform arm). 412 patients (271 CANKADO-active; 141 CANKADO-inform) were available for analysis of the primary endpoint, time to deterioration (TTD) of QoL (10-point drop on FACT-G), using an Aalen-Johansen estimator for cumulative incidence function of TTD DQoL with 95% pointwise confidence intervals (CI). Secondary endpoints included PFS, OS, and DQoL (QoL deterioration).

RESULTS

In all pts (ITT-ePRO), cumulative incidence of DQoL was significantly more favorable (lower) in the CANKADO-active arm (HR=0.698, 95%CI [0.506 - 0.963]). Among 1^stL patients (n=295), the corresponding HR was 0.716 (0.484-1.060; p=0.09), and in 2^ndL patients (n=117) it was 0.661 (0.374-1.168; p=0.2). Absolute patient numbers declined in later visits; FACT-G completion rates were 80% and higher until about visit 30; mean FACT-G scores showed steady decline from baseline and an offset in favor of CANKADO-active. No significant differences in clinical outcome were observed between arms: Median PFS (ITT population) was 21.4 (95%CI 19.4-23.7) (CANKADO-active) and 18.7 (15.1-23.5) months (CANKADO-inform); median OS was not reached (CANKADO-active) and 42.6 months (CANKADO-inform).

CONCLUSIONS

PreCycle is the first multicenter randomized eHealth trial demonstrating a significant benefit for MBC patients receiving oral tumor therapy when using an interactive autonomous patient empowerment application.

Efficacy of Endocrine Therapy Plus Trastuzumab and Pertuzumab vs De-escalated Chemotherapy in Patients with Hormone Receptor-Positive/ERBB2-Positive Early Breast Cancer: The Neoadjuvant WSG-TP-II Randomized Clinical Trial

Importance

Combination of chemotherapy with (dual) ERBB2 blockade is considered standard in hormone receptor (HR)-positive/ERBB2-positive early breast cancer (EBC). Despite some promising data on endocrine therapy (ET) combination with dual ERBB2 blockade in HR-positive/ERBB2-positive BC, to our knowledge, no prospective comparison of neoadjuvant chemotherapy vs ET plus ERBB2 blockade in particular with focus on molecular markers has yet been performed.

Objective

To determine whether neoadjuvant de-escalated chemotherapy is superior to endocrine therapy, both in combination with pertuzumab and trastuzumab, in a highly heterogeneous HR-positive/ERBB2-positive EBC.

Design, Setting, and Participants

This prospective, multicenter, neoadjuvant randomized clinical trial allocated 207 patients with centrally confirmed estrogen receptor-positive and/or progesterone receptor-positive (>1%) HR-positive/ERBB2-positive EBC to 12 weeks of standard ET (n = 100) vs paclitaxel (n = 107) plus trastuzumab and pertuzumab. A total of 186 patients were required to detect a statistically significant difference in pathological complete response (pCR) (assumptions: 19% absolute difference in pCR; power, ≥80%; 1-sided Fisher exact test, 2.5% significance level).

Interventions

Standard ET (aromatase inhibitor or tamoxifen) or paclitaxel, 80 mg/m2, weekly plus trastuzumab and pertuzumab every 21 days.

Main Outcomes and Measures

The primary end point was pCR (ypT0/is, ypN0). Secondary end points included safety, translational research, and health-related quality of life. Omission of further chemotherapy was allowed in patients with pCR. PAM50 analysis was performed on baseline tumor biopsies.

Results

Of the 207 patients included (median [range] age, 53 [25-83] years), 121 (58%) had cT2 to cT4 tumors, and 58 (28%) had clinically node-positive EBC. The pCR rate in the ET plus trastuzumab and pertuzumab arm was 23.7% (95% CI, 15.7%-33.4%) vs 56.4% (95% CI, 46.2%-66.3%) in the paclitaxel plus trastuzumab and pertuzumab arm (odds ratio, 0.24; 95% CI, 0.12-0.46; P < .001). Both immunohistochemical ERBB2 score of 3 or higher and ERBB2-enriched subtype were independent predictors for pCR in both arms. Paclitaxel was superior to ET only in the first through third quartiles but not in the highest ERBB2 quartile by messenger RNA. In contrast with the paclitaxel plus trastuzumab and pertuzumab arm, no decrease in health-related quality of life after 12 weeks was observed in the ET plus trastuzumab and pertuzumab arm.

Conclusions and Relevance

The WSG-TP-II randomized clinical trial is, to our knowledge, the first prospective trial comparing 2 neoadjuvant de-escalation treatments in HR-positive/ERBB2-positive EBC and demonstrated an excellent pCR rate after 12 weeks of paclitaxel plus trastuzumab and pertuzumab that was clearly superior to the pCR rate after ET plus trastuzumab and pertuzumab.

Trial Registration

ClinicalTrials.gov Identifier: NCT03272477.

CrossFit Motivates a 41-Year-Old Obese Man to Change His Lifestyle and Achieve Long-Term Health Improvements: A Case Report

The purpose of this case report was to demonstrate how CrossFit (CF) as a workplace health intervention (WHI) led to long-term lifestyle changes and health improvements in an inactive, sedentary individual. Therefore, we analysed the case of a 41-year-old obese man (BMI: 41.3 kg/m²) with elevated blood pressure and poor fitness. To evaluate the factors that facilitated his behavioural change, we collected quantitative and qualitative data (from 2015 to 2022) and analysed it based on the COM-B framework. Given the already great training opportunities at his workplace, we assumed that improvements in capability and motivation led to behavioural change and maintenance. Essential for this behavioural change was the fact that CF combined health-promoting training with intrinsically motivating aspects which are typical for classic sports such as challenge, a feeling of competence, and social interaction. In conjunction with rapid fitness improvements (capability), a positive feedback cycle between capability, motivation, and behaviour developed which enabled physical activity to become habitual. As a result, blood pressure was normalized, BMI (32.9 kg/m²) and resting heart rate decreased (-20 bpm), and mobility (FMS score: +89%), strength (+14 to 71%), and well-being (WHO-5 score: +12%) increased. In conclusion, CF should be considered an effective, efficient, and safe WHI with great potential for behavioural changes and maintenance.

Abstract P6-03-08: Trained Artificial Intelligence (AI) for Predicting Treatment Termination Based on Patient Observations in Advanced Breast Cancer

Background: In various fields outside of medicine, AI-supported systems have been established that can predict an undesirable event. The purpose of such systems is to detect events earlier and, if necessary, to be able to prevent them. In medicine, it would be particularly interesting to be able to make such predictions based solely on patient observations. Methods: The usage from 323 patients with advanced breast cancer with a total of 78542 documentation days was used. In addition, the premature termination of use was defined as an undesirable event. The data was then processed and annotated. A deep-learning neural network (NN) classifier was trained on this dataset independently on all documented days to predict this target endpoint. The patient classifier score was computed by averaging over daily scores. Overall classifier accuracy and binary cross entropy loss were computed as performance indicators on training and test data sets (2:1 split). Results: After tuning the hyperparameters, the best-performing NN comprised three hidden layers, each with 88 neurons, using ReLU (linear ramp) activation, and an output layer using sigmoid activation. In the test collective, this model achieved a prediction accuracy of 87%. Discussion: The present application shows for the first time that treatment discontinuation can be predicted with a very high degree of accuracy using patient data alone. This opens up new possibilities in the early detection of possible therapy failures and can represent an essential auxiliary tool in medical care in the future.

Citation Format: Timo Schinköthe, Ronald Kates, Benedikt Sprecher, Silja Meyer, Christian Horst Tonk, Nadia Harbeck, Annette Schmidt. Trained Artificial Intelligence (AI) for Predicting Treatment Termination Based on Patient Observations in Advanced Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-03-08.

Abstract OT3-33-01: Prospective, Multi-Center, Artificial Intelligence Study for Early Prediction of Serious Events under Treatment Is Now Open for Recruitment in Breast Cancer - OMCAT Trial in Progress

Background: Aim of the OMCAT trial (‘One Million CAncer Treatment months’, NCT04531995) is improvement of cancer patient care and safety by developing artificial intelligence (AI)-based, incident prediction algorithms. Incident detection allows early notification of treatment teams, enabling timely management changes or interventions. Ultimately the algorithms can also support improved health resource allocation. This trial in progress aims to provide learning databases in breast cancer comprising both electronic patient reported outcome (ePRO) data using the mobile medical device ‘CANKADO PRO-React’ and ground truth outcome data, which provide disease-specific events of interest (“incidents”) verified by the physician (e.g., during patient examinations). Methods: Incident prediction is posed as an application of stochastic time series analysis using AI and knowledge engineering technology. The learning process begins by fitting individualized and disease-specific stochastic process models to “incident-free” intervals extracted from the ePRO data series. Incidents produce detectable deviations from “ordinary” ePRO fluctuations. The algorithms are trained on CANKADO PRO-React data to produce real-time risk functions for predicting incidents on a clinically specified time horizon. Results: Considering the heterogeneity and combinatorics of diseases, stages, therapies, and types of events considered in this study, ultimately the AI algorithms aim to discover about 360 distinct predictive relationships. The estimate of one million treatment months is derived from statistical power analysis of this target, considering estimated median documentation time of six months per patient and estimated 400-500 patients per predictive relationship. To date, 45 centers in Germany have expressed interest in participating. This participation level will enable proof of principle. Ethics votes are already available in most regions. Other centers are invited to participate in this trial. Conclusions: OMCAT opens a whole new path towards evidence-trained AI and a novel combination of patient observation and predictive care. The goals of OMCAT are ambitious and will therefore require many more supporters.

Citation Format: Timo Schinköthe, Christian Horst Tonk, Ronald Kates, Sherko Küemmel, Fatima Cardoso, Nadia Harbeck, Peter Staib, Annette Schmidt. Prospective, Multi-Center, Artificial Intelligence Study for Early Prediction of Serious Events under Treatment Is Now Open for Recruitment in Breast Cancer - OMCAT Trial in Progress [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT3-33-01.

Abstract P2-01-01: Interim analysis (n=200) from ELEANOR: a multi-national, prospective, non-interventional study among patients with HER2+ and HR+ early breast cancer treated with extended adjuvant neratinib in the clinical routine

Background Recent advances in the treatment of human epidermal growth factor receptor positive (HER2+) early breast cancer (eBC) have led to a reduction in recurrence risk; still a relevant percentage of patients relapses over time, predominantly presenting with distant recurrence. Neratinib is registered in Europe as extended adjuvant treatment for adult patients with HER2+, hormone receptor positive (HR+) eBC, who completed adjuvant trastuzumab-based therapy within one year prior to start of neratinib. In the ExteNET study, neratinib improved the absolute 5-year invasive disease-free survival (iDFS) rate by 5.1% versus placebo in this population (90.8% vs. 85.7%; HR 0.58 [95% CI 0.41-0.82]), mainly by reducing the rate of distant metastases. According to explorative analyses from ExteNET, the effect may be even more pronounced in patients with non-pCR after neoadjuvant trastuzumab treatment and/or in patients completing the full duration of neratinib therapy (i.e. ≥11 months of neratinib treatment). Diarrhea, the most common grade 3 adverse event (neratinib: 39% without primary diarrhea prophylaxis, median cumulative duration 5 days; placebo: 1%; no grade 4 events) can generally be managed through adequate prophylaxis and treatment management. ELEANOR is the first non-interventional study (NIS) of real-world use of neratinib and its management in eBC patients in Germany, Austria and Switzerland. Methods Enrollment of 300 adult female patients with HER2+/HR+ eBC is planned in accordance with the SmPC specifications. Primary endpoint is the rate of patients adherent to neratinib treatment (i.e. neratinib use for ≥75% of treatment days). Secondary objectives include characterization of patients scheduled to receive neratinib, details on neratinib treatment, recurrences, safety/tolerability, and health-related quality of life (HRQoL). CANKADO, an eHealth application developed to support patient/physician communication, is an integral part of the NIS. Here, we report results of the preplanned interim analysis based on 200 enrolled patients. Results At data cut-off (May 2022), 202 patients had been observed for 3 months; patient enrollment is ongoing. Median age was 53.0 years and 66.3% of patients were at increased risk of disease recurrence (defined as non-pCR or AJCC stage &gt; I). Most patients had received prior neoadjuvant treatment (79.7%). Post-neoadjuvant treatment included dual HER2 blockade with trastuzumab and pertuzumab (38.8%/23.9% of pCR/non-pCR patients) and trastuzumab-emtansine (T-DM1, 53.5% of non-pCR patients). Neratinib treatment had been documented for 187 patients, treatment was ongoing for 46.0% of patients. Diarrhea was the most common adverse event (78.6% any grade, 19.3% grade 3, 2 patients grade 4), but was markedly lower when indirectly compared to ExteNET (39% grade 3). The neratinib dose escalation schedule was chosen for 36.4% of patients and led to a decreased incidence of severe diarrhea (16.2% grade 3, no grade 4 events). 93.9% (95% CI: 87.9-97.5%) of 115 evaluable patients adhered to neratinib treatment. Conclusion The results of this preplanned interim analysis reflect the current treatment landscape in Germany, Austria and Switzerland. These results confirm, in line with the observed adherence data, that extended adjuvant neratinib use is feasible in typical clinical practice settings. Furthermore, treatment management strategies such as diarrhea prophylaxis or neratinib dose escalation are routinely used and can increase treatment tolerability markedly. The study is funded by Pierre Fabre Pharma GmbH (Freiburg, Germany), Pierre Fabre Pharma Austria (Wels, Austria) and Pierre Fabre Pharma AG (Allschwil, Switzerland).

Citation Format: Rupert Bartsch, Nadia Harbeck, Denise Wrobel, Matthias Zaiss, Jürgen Terhaag, Dagmar Guth, Andrea Distelrath, Rachel Wuerstlein, Mark-Oliver Zahn, Diana Lüftner, Michael Schwitter, Marija Balic, Christian Jackisch, Volkmar Müller, Gabriel Rinnerthaler, Marcus Schmidt, Khalil Zaman, Timo Schinköthe, Anna Resch, Urs Breitenstein. Interim analysis (n=200) from ELEANOR: a multi-national, prospective, non-interventional study among patients with HER2+ and HR+ early breast cancer treated with extended adjuvant neratinib in the clinical routine [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-01-01.

Abstract P1-05-36: AI-Based Smartphone App Using a Single-Lead ECG for Automated QTc Diagnostics in Oncology

Introduction: Long QT syndrome is a common cardiotoxic side effect of various anti-tumor drugs. Previous cardiological monitoring of oncological patients is primarily complex and requires for non-internal oncologists a consultation. Therefore, the QTc-Tracker smartphone APP was developed, which enabled a tele-cardiological diagnosis of the QTc time with standard single-lead ECG devices. As a result, diagnosis times could already be reduced by 99%. The further development examined an automatic determination of the QT time using the smartphone APP. However, since single-lead ECG devices are significantly more susceptible to interference, the determination of the QT time is more complex than with 12-lead ECGs. Methods: The QTc-Tracker smartphone APP was developed to determine the QT time. Self-tracker single-lead ECG devices were used to record the lead I signal. The ECG recordings were analyzed in the APP and passed on to an external cardiologist as reference. The APP used artificial intelligence and was trained in the first phase and validated in the second phase. The first phase aimed to improve QT time detection. The results of the APP were compared with the findings of the external cardiologist. In both phases, ECGs from breast cancer patients receiving ribociclib were used. Results: A total of 1889 single-lead ECGs were carried out. 248 of these could not be evaluated (13%). QTc prolongation, according to CTCAE, was diagnosed in 41 cases (2.5%). 878 of the evaluable ECGs were used for the training phase and 763 for the evaluation phase. In the first group (before the improvement), the sensitivity to automatically detect a prolongation of the QT time was 36%, and the specificity was 96%. In the evaluation collective (after the training), the sensitivity went up to 85%, and the specificity was unchanged at 96%. Conclusions: The trained method of the QTc tracker is able to reliably detect a QT time lengthening even without a cardiological diagnosis only by using single-lead self-tracker ECG’s. In the rare cases in which an elongation was not detected, the cardiac diagnosis was only a few milliseconds above the threshold value. This artificial intelligence-based smartphone APP is not intended to replace the cardiological diagnosis, but it can simplify routine processes and help to decide which patients need a cardiological examination more urgently.

Citation Format: Timo Schinköthe, Christian Horst Tonk, Nadia Harbeck, Vanda Carmelo, Joana Gomes Feliciano, Rachel Wuerstlein, Sherko Küemmel, Annette Schmidt. AI-Based Smartphone App Using a Single-Lead ECG for Automated QTc Diagnostics in Oncology [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-05-36.

MedXFit—Effects of 6 months CrossFit® in sedentary and inactive employees: A prospective, controlled, longitudinal, intervention study

Background and Aims

Sedentary behavior and physical inactivity are associated with musculoskeletal disorders (MSD). Muscle and mobility enhancing training is recommended to promote musculoskeletal fitness and prevent MSD. A functional fitness program emphasizing the importance of musculoskeletal fitness is provided by CrossFit®. However, data from long‐term CrossFit® interventions assessing measures of musculoskeletal fitness in sedentary and inactive individuals does not exist.

Methods

This prospective, controlled study investigates the effects of 6 months CrossFit® training (2×60 min/week) in inactive adults (in terms of <2 muscle or mobility enhancing training sessions per week) with predominantly sitting or standing occupations. 91 participants were initially assessed, 2 were excluded, 55 self‐selected for intervention (IG), and 34 for the control group (CG). Primary endpoint was a change in mobility (Functional Movement Screen score). Secondary endpoints were changed in strength (maximum isometric strength in kg; Dr. Wolff BackCheck®), and well‐being (WHO‐5 score). Key exploratory endpoints were changes in back‐issue measures (pain intensity, limitation, and frequency).

Results

39 participants of IG and 31 of CG completed the evaluation after 6 months. The IG improved significantly more (p < 0.001) compared with the CG in the FMS (η² = 0.58), trunk extension (η² = 0.46), trunk flexion (η² = 0.47), trunk lateral flexion left (η² = 0.41), trunk lateral flexion right (η² = 0.42), upper body push (η² = 0.4), upper body pull (η² = 0.25), hip extension left (η² = 0.18), and hip extension right (η² = 0.4). Change of WHO‐5 scores did not significantly differ between groups (p = 0.55; η² = 0.01). Exploratory analysis of back‐issue data showed a higher decrease for pain intensity, limitation, and frequency in the IG compared with the CG.

Conclusion

This study proves for the first time within the scope of a prospective, controlled study the broad benefits of CrossFit® in inactive adults doing predominantly sedentary work.

Abstract P2-13-30: First interim analysis from ELEANOR: A multi-national, prospective, non-interventional study (NIS) in patients with human epidermal growth factor receptor positive (HER2+) early breast cancer observing real-life extended adjuvant treatment with neratinib

Background: Recent advances in (post-)/(neo)adjuvant treatment for HER2+ breast cancer have led to a major reduction in recurrence risk; still a relevant percentage of patients relapses over time, predominantly presenting with distant recurrence. Neratinib is registered in Europe as extended adjuvant treatment for adult patients with HER2+, HR+ early-stage breast cancer (eBC), who completed adjuvant trastuzumab-based therapy less than one year ago. In the ExteNET study, neratinib improved the 5-year iDFS absolute-rate by 5.1% versus placebo in this population (90.8% vs. 85.7%; HR 0.58 [95% CI 0.41-0.82]), mainly by prolonging time to development of distant metastases. According to explorative (post-hoc) analyses from ExteNET, the effect might be even more pronounced in patients with non-pCR after neoadjuvant trastuzumab treatment and/or in patients with completion of neratinib therapy (i.e. ≥11 months of neratinib treatment). Diarrhea, the most common grade 3 adverse event (neratinib: 39% without primary diarrhea prophylaxis, median cumulative duration 5 days; placebo: 1%; no grade 4 events) can generally be managed through adequate prophylaxis and treatment management. ELEANOR is the first international NIS to investigate real-world use of neratinib and its treatment management in eBC patients in Germany, Austria and Switzerland. Methods: The primary objective of this ongoing NIS is to investigate the rate of patients being adherent to neratinib treatment (i.e. neratinib intake for ≥75% of treatment days). Secondary objectives include detailed patient and disease characteristics, details on prior trastuzumab-based therapies (including pertuzumab and T-DM1), neratinib doses, dose modifications and neratinib treatment management, relapses, safety/tolerability, and quality of life (QoL), among others. 300 adult female patients with HER2+/HR+ eBC are planned in accordance with the SmPC specifications (planned end of documentation: 2023). CANKADO, an application developed to support patient/physician communication, is an integral part of the NIS. Different CANKADO modules can be used optionally, including QoL documentation (EQ-5D-5L- and diarrhea-specific questionnaires) and continuous documentation of health status and symptoms. Results: Between July 2020 and July 2021, 141 patients have been enrolled; patient enrollment is ongoing. The first pre-planned interim analysis will be performed after the 100th patient has been observed for 3 months (data cut July 2021). Here, we will present baseline demographic and tumor characteristics for the first 100 patients, as well as prior trastuzumab-based treatments and first safety and tolerability data of real-world neratinib use. Conclusion: The results of the first interim analysis present a preliminary snapshot of the current treatment landscape and real-life neratinib use in Germany and Austria. The ELEANOR NIS should help to understand adherence to neratinib treatment and use of extended adjuvant HER2-targeted therapy in the current treatment landscape focussing on treatment management after different pre-therapies. The study is funded by Pierre Fabre Pharma GmbH (Freiburg, Germany), Pierre Fabre Pharma Austria (Wels, Austria) and Pierre Fabre Pharma AG (Allschwil, Switzerland).

Citation Format: Diana Lüftner, Rupert Bartsch, Urs Breitenstein, Marija Balic, Christian Jackisch, Volkmar Müller, Gabriel Rinnerthaler, Marcus Schmidt, Michael Schwitter, Khalil Zaman, Denise Wrobel, Dagmar Guth, Jürgen Terhaag, Matthias Zaiss, Timo Schinköthe, Nadia Harbeck. First interim analysis from ELEANOR: A multi-national, prospective, non-interventional study (NIS) in patients with human epidermal growth factor receptor positive (HER2+) early breast cancer observing real-life extended adjuvant treatment with neratinib [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-13-30.

A Web- and App-Based Connected Care Solution for COVID-19 In- and Outpatient Care: Qualitative Study and Application Development

Background

From the perspective of health care professionals, coronavirus disease (COVID-19) brings many challenges as well as opportunities for digital health care. One challenge is that health care professionals are at high risk of infection themselves. Therefore, in-person visits need to be reduced to an absolute minimum. Connected care solutions, including telehealth, remote patient monitoring, and secure communications between clinicians and their patients, may rapidly become the first choice in such public health emergencies.

Objective

The aim of the COVID-19 Caregiver Cockpit (C19CC) was to implement a free-of-charge, web- and app-based tool for patient assessment to assist health care professionals working in the COVID-19 environment.

Methods

Physicians in Argentina, Germany, Iran, Italy, Portugal, Switzerland, and the United States explained their challenges with COVID-19 patient care through unstructured interviews. Based on the collected feedback, the first version of the C19CC was built. In the second round of interviews, the application was presented to physicians, and more feedback was obtained.

Results

Physicians identified a number of different scenarios where telemedicine or connected care solutions could rapidly improve patient care. These scenarios included outpatient care, discharge management, remote tracking of patients with chronic diseases, as well as incorporating infected physicians under quarantine into telehealth services.

Conclusions

The C19CC is the result of an agile and iterative development process that complements the work of physicians. It aims to improve the care and safety of people who are infected by COVID-19.

Abstract OT3-14-02: Impact of CANKADO-based eHealth-support on quality of life in metastatic breast cancer patients treated with palbociclib and endocrine therapy - Precycle

Background: Efficacy and quality of life (QoL) are key factors when selecting therapies for metastatic breast cancer (MBC) patients. The addition of targeted oral agents such as CDK4/6 inhibitors to endocrine therapy is the new standard for hormone receptor (HR)+ HER2- MBC and substantially prolongs progression-free survival. However more complex oral medication in oncology might require substantial improvement of patient management. Despite several advantages of an oral treatment, patients become increasingly self-responsible and physician/patient contact is reduced. Adherence, maintaining patients’ satisfaction, and early detection and management of side effects become important challenges and new ways of continuous support for oncological patients are needed. An eHealth-based platform could help to support therapy management and physician-patient interaction. Methods: PRECYCLE is a multicenter, randomized, phase IV trial in HR+ HER2- MBC. All patients (n = 960) receive the CDK4/6 inhibitor palbociclib either in first (62.5%) or later line (37.5%) together with endocrine therapy (AI, fulvestrant) according to national guidelines. Primary study aim is the time to deterioration (TTD) of QoL in patients supported by two eHealth systems with substantially different functionality. To date (05/07/2019), 250 patients have been registered in all 72 participating centers and 230 randomized to the different study arms: - CANKADO inform with only a CANKADO-based eHealth service with a personal login, documentation of daily drug intake and passive text information (disease, treatment), but no further functions. vs. - CANKADO active with the fully functional CANKADO-based eHealth treatment support system (+ drug diary, QoL, AEs, automated recommendations, etc.) To evaluate QoL, the FACT-B questionnaire is completed at every visit. Primary objective is to test the hypothesis of superiority for TTD with regards to QoL (FACT-G scale) in patients supported by an eHealth therapy management system (CANKADO active) versus in those merely receiving eHealth-based information (CANKADO inform). As little is known about relationships between behavioral patterns (e.g. adherence), genetic background, and drug efficacy. The trial also includes a large translational program that aims at the discovery and validation of biomarkers concerning efficacy, toxicity, adherence and QoL. Recruitment is ongoing.

Citation Format: Tom Degenhardt, Peter Fasching, Diana Luftner, Volkmar Mueller, Christoph Thomssen, Christian Schem, Isabel Witzel, Thomas Decker, Hans Tesch, Sherko Kuemmel, Christoph Uleer, Rachel Wuerstlein, Christoph Riese, Timo Schinköthe, Ronald Kates, Johannes Schumacher, Nadia Harbeck, Marcus Schmidt. Impact of CANKADO-based eHealth-support on quality of life in metastatic breast cancer patients treated with palbociclib and endocrine therapy - Precycle [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT3-14-02.

EVA-Scalp: Evaluation of Patient Satisfaction with a Scalp Cooling Device to Prevent Chemotherapy-Induced Alopecia in Breast Cancer Patients

Purpose

Scalp cooling (SC) offers a chance to reduce hair loss (HL), but patient satisfaction, the effect on well-being, as well as patient selection criteria have not been sufficiently assessed yet.

Methods

In the EVAScalp trial, SC was offered to 70 breast cancer patients who received chemotherapy between November 2015 and September 2018. For SC, the Paxman-Orbis-II System was used. Satisfaction was measured by a questionnaire evaluating the level of depression with the WHO-5 well-being index (WHO-5) plus questions addressing the patient's experiences and side effects using the SC device. To evaluate efficacy, documentation by photo, by a physician, and by an HL-diary was conducted.

Results

Regarding efficacy, a significant difference between chemotherapy regimens is seen. Anthracycline-based therapies led to a stop of SC in 71% of the patients, whereas taxane-based therapies without anthracyclines were associated with a high acceptance of SC, and 88% of patients with paclitaxel-based therapies continued SC throughout their chemotherapy. Overall, only 7.69% of the patients stopped because of side effects. As an indicator for quality of life, WHO-5 was higher (65.8%) in patients with successful SC compared to in patients who stopped SC because of HL or side effects (only 53.0%). The majority of patients (82.22%) with successful SC would recommend SC to other patients.

Conclusions

Patients tolerated SC as long as HL was successfully prevented. The well-being of patients with successful SC was significantly higher than that of patients who stopped SC prematurely. In general, SC is a promising approach and improves patient well-being, but there are still limitations to its utility depending on the chemotherapy regimen used.

Individualized eHealth Support for Oncological Therapy Management

eHealth support for oncological therapy management has different faces. In addition to the direct support of therapy-supportive measures such as the promotion of physical activities, monitoring of the diet and observation of the quality of life through eHealth approaches are possible. Many solutions are now in transition between research and routine use. The most substantial evidence today is in the area of symptom monitoring. Independent studies have shown a significant survival benefit among other advantages as well. There is also a good overlap in eHealth and physical activity. More and more solutions are coming onto the market, which also has an impact for cancer patients. In the field of nutrition, there are only a few successful approaches both within and outside oncology. In contrast, the application of eHealth for the detection of disease-related malnutrition seems promising. Innovative approaches involving "artificial intelligence" or "Internet of Things" are slowly finding their place in both research and routine. For routine care, it will be necessary for doctors, nurses, and patients to know what a real medical eHealth application is and which are just lifestyle products without the needed quality for professional medical usage.

The AutoDiSC: development and validation of a novel chemotherapy sensitivity and resistance assay

BACKGROUND

Measurement of cell survival as performed by the differential staining cytotoxicity (DiSC) assay allows for a comprehensive prediction of individual chemotherapy response. This assay has not reached routine clinical application because of its several limitations. In order to improve the DiSC assay, we developed a new type of chemotherapy sensitivity and resistance assay (CSRA) by combining a novel evaluation methodology with automated measurement of cell survival based on flow cytometry, termed AutoDiSC.

MATERIALS AND METHODS

Tumour cell lines were treated with cytostatic drugs and cultured in 96-well plates for four days at 37 °C. Subsequently, propidium iodide was added and 96-well plates were analyzed using flow cytometry in order to determine the number of living cells in each well. Each component was evaluated for reproducibility and impact on assay read-out.

RESULTS

The evaluation process allowed for specification of all relevant parameters that determine assay performance.

CONCLUSION

AutoDiSC is a new fully-automated CSRA which meets all criteria required for routine clinical use.

Elevated pretreatment interleukin-10 serum level is an International Prognostic Score (IPS)-independent risk factor for early treatment failure in advanced stage Hodgkin lymphoma

Early treatment failure is still a clinical challenge despite high cure rates in Hodgkin lymphoma (HL) patients. To identify the biological risk factors predicting early treatment failure, we performed a retrospective case-control study. Forty-seven pretherapeutic serum samples were available from 47 advanced stage HL patients with early treatment failure and from 47 matched controls in complete remission. All patients were treated within German Hodgkin Study Group phase 3 trials. Matching was done according to treatment, stage, age, gender, International Prognostic Score (IPS) and histological subtype. Pretreatment serum levels of 30 cytokines, chemokines and soluble receptors were determined using immunoassays and flow cytometer based cytometric bead arrays. Only interleukin-10 serum levels were significantly associated with early treatment failure after statistical correction for multitesting (paired-sign test, p = 0.0008). In summary, pretherapeutic interleukin-10 levels are associated with early treatment failure within 12 months after the end of treatment in advanced stage HL independently from known clinical factors such as age or IPS.

In vitro secreting profile of human mesenchymal stem cells

In addition to their multilineage potential, mesenchymal stem cells (MSCs) also have a wide range of functionality. Not only can MSCs reconstruct a tissue, but they also have the ability to control or cure other cells and can reconstruct a coordinating function. The opportunity to control other cells depends on MSCs being able to secrete factors like cytokines and chemokines. Therefore, we focused on asking, Which factors can be secreted by human MSCs? To answer this question, we analyzed the secreting profile of in vitro-expanded MSCs by using cytokine arrays. The media concentrations of 44 of the 120 analyzed cytokines were significantly increased by MSCs. Conversely, concentrations of 40 cytokines given with the sera were significantly decreased. The data presented here provide an overview about a large range of factors that were secreted by MSCs under cell culture conditions. These data indicate that MSCs demonstrate all previously described functions in cellular interactions without an external stimulus. The MSCs secreted angiogenic, immunosuppressive, anti-apoptotic, and proliferation-stimulating factors.

Practical guidelines for diagnostic use of in vitro chemosensitivity tests

To date, a multitude of chemotherapy sensitivity and resistance assays (CSRAs) have been developed to examine the efficiency of diverse cytostatic drugs on a patient's tumour material in vitro, and therefore provide the opportunity of customizing the particular treatment strategy in vivo. In an attempt to assess the impact of the hitherto developed CSRAs on routine clinical practice, in 2004, the American Society of Clinical Oncology (ASCO) performed a comparative analysis of previously published studies (1966 until January 2004) referring to the diverse assays and came to the conclusion that none of these assays was suitable for routine clinical practice. As the CSRAs aim to support the clinician in selecting the most efficient regimen to be applied to the individual patient, they must comply with several technical requirements. In this report, we examined the indispensable criteria for a CSRA to be broadly applicable to clinical routine use and to be meaningful for treatment recommendations not only at present but also with respect to newer cytostatic drugs in the future.

Modification of surface antigens in blood CD8+ T-lymphocytes in COPD: effects of smoking

In contrast to the effects of cigarette smoke on T-lymphocyte subsets in the airways, it has not yet been determined whether smoking has immunomodulatory effects on surface antigens of peripheral blood T-lymphocytes and, if that is the case, whether these effects differ in smokers with and without chronic obstructive pulmonary disease (COPD). The present authors have, therefore, examined the expression of the surface activation marker CD28, the levels of cytotoxic effector lymphocytes (CD27-/CD45RA+) and the expression of the lung type (Tc)1-specific chemokine receptor CXCR(3)+ on peripheral blood CD8+ T-lymphocytes. The present authors have also studied the chemotactic activity of CD8+ T-lymphocytes on monocyte chemotactic protein (MCP)-1 and compared 13 nonsmoking controls, 12 smokers with COPD and 14 smokers without airflow limitation. There was a decrease in the total count of CD8+ T-cells and an increase in the CD4+/CD8+ ratio in smokers with COPD compared with smokers without COPD and controls. Expression of the Tc1-specific chemokine receptor CXCR(3)+ by CD8+ T-cells was increased in smokers with COPD compared with smokers without COPD and controls. The expression of activated and of cytotoxic effector CD8+ T-cells in smokers with and without COPD showed an increase compared with controls. CD8+ T-cells from smokers with and without COPD showed a decrease in chemotactic activity to MCP-1 compared with controls. In conclusion, chronic obstructive pulmonary disease may be a systemic immunomodulatory disease associated with the modification of surface antigens in blood CD8+ T-lymphocytes.

Basic fibroblast growth factor controls migration in human mesenchymal stem cells

Little is known about the migration of mesenchymal stem cells (MSCs). Some therapeutic approaches had demonstrated that MSCs were able to regenerate injured tissues when applied from different sites of application. This implies that MSCs are not only able to migrate but also that the direction of migration is controlled. Factors that are involved in the control of the migration of MSCs are widely unknown. The migratory ability of isolated MSCs was tested in different conditions. The migratory capability was examined using Boyden chamber assay in the presence or absence of basic fibroblast growth factor (bFGF), erythropoietin, interleukin-6, stromal cell-derived factor-beta, and vascular endothelial growth factor. bFGF in particular was able to increase the migratory activity of MSCs through activation of the Akt/protein kinase B (PKB) pathway. The results were supported by analyzing the orientation of the cytoskeleton. In the presence of a bFGF gradient, the actin filaments developed a parallelized pattern that was strongly related to the gradient. Surprisingly, the influence of bFGF was not only an attraction but also routing of MSCs. The bFGF gradient experiment showed that low concentrations of bFGF lead to an attraction of the cells, whereas higher concentrations resulted in repulsion. This ambivalent effect of bFGF provides the possibility to a purposeful routing of MSCs.

Mesenchymal stem cells transmigrate over the endothelial barrier

Mesenchymal stem cells (MSCs) seem to be a useful tool for cellular therapy in injured tissues, e.g. myocardial infarction or cardiomyopathies resulting in heart failure. For therapeutic approaches it is crucial that MSCs cross the endothelial barrier especially in intravascular or rather intracoronary application. Until today little is known about MSCs transmigrating across the endothelium. We performed co-culture experiments of MSCs on an endothelial monolayer to analyse direct interactions. An increasing flattened morphology of the MSCs was followed by a total integration into the monolayer after 2h. We repeated these experiments in isolated heart perfusions with gold-labelled MSCs. Using electron microscopy we detected MSCs exhibited direct cell-cell contacts. Tight junctions between the endothelial cells became abolished resulting in a distinct split between the cells. MSCs developed tight cell-cell contacts and became integrated into the endothelial wall of the capillary vessel. Finally, using confocal laser scanning microscopy, we assessed the ability of the MSCs to fully pass the endothelial barrier. Within the first 30 min, 30+/-8% of MSCs transmigrated, increasing to about half at 60 min (50+/-8%), whereas after 120 min the rate remained nearly unchanged (53+/-10%). This work demonstrates the capability of MSCs for transendothelial migration. Moreover we showed that the vast majority of MSCs migrated within 30 min, an important finding for the exposure times in clinical settings.

Human bone marrow stroma cells display certain neural characteristics and integrate in the subventricular compartment after injection into the liquor system

Because the neural differentiation capacity of bone marrow stromal cells (BMSCs) is still a matter of controversial debate, we performed a thorough investigation into the differentiation capacity of human BMSCs and examined their therapeutic potency. BMSCs were isolated from the femur and kept in cell cultures with various cultivation protocols being applied. In standard culture conditions using a fetal calf serum-enriched medium, while not exhibiting a neural phenotype, the majority of cells expressed a variety of neuronal marker proteins as well as the astrocyte marker GFAP. Only a minority of stem cells expressed nestin, a marker for neural precursor cells. Cultivation in serum-free medium supplemented with specific growth factors resulted in a markedly higher percentage of nestin-positive cells. To establish the therapeutic potency of bone marrow-derived cells, the synthesis of neurotrophic factors such as NGF, BDNF and GDNF was analyzed under non-stimulating standard culture conditions as well as after a neural selection procedure. The therapeutic potency of BMSCs was further examined with regard to their migratory potential in vitro and after transplantation in vivo. After stereotactic engraftment into the lateral ventricle of adult rats, mesenchymal stem cells were seen to adhere to the ependymocytes and cells of the choroids plexus. Afterwards grafted cells passed through the ependymal barrier, locating in the subventricular space. Their BMSCs took up a close host graft interaction without any degenerative influence on the host cells. Furthermore, there was morphological as well as immunohistochemical evidence for a transdifferentiation within the host tissue. In addition, BMSCs could be efficiently transduced using a third-generation adenoviral vector, indicating their potential feasibility for a gene-therapeutic option.

Plasma levels of tumor M2-pyruvate kinase should not be used as a tumor marker for hematological malignancies and solid tumors

It has been reported that the dimeric isoform of the enzyme pyruvate kinase M2 was overexpressed in various solid tumor cells. Hence, it was suggested that circulating levels of the so-called tumor M2-pyruvate kinase (Tu M2-PK) could be used as a tumor marker for monitoring systemic therapies of various solid tumors. We analyzed its validity as a tumor marker by comparing plasma levels of Tu M2-PK in patients with different non-malignant diseases to levels in healthy individuals and in patients with hematological diseases. Plasma levels of Tu M2-PK were measured using an ELISA assay in a total of 284 patients. The mean Tu M2-PK concentration of 32 U/mL was significantly higher in the group of patients with hematological malignancies (n = 121) (p < 0.001). However, 37% of healthy individuals (n = 63) and 44% of patients with non-malignant diseases (n = 100), especially patients with an acute inflammatory reaction (67%), were found to have elevated levels of Tu M2-PK using a cutoff level of 15 U/mL. The specificity was 59% and the sensitivity was 51%. There was no significant correlation between the prevalence of a hematological malignancy and positive Tu M2-PK result. Thus, our data imply that Tu M2-PK is not a useful tumor marker for hematological malignancies and solid tumors, as a significant number of false positive results were detected in healthy individuals and patients with non-malignant diseases.

Phospho-eNOS Ser-114 in human mesenchymal stem cells: Constitutive phosphorylation, nuclear localization and upregulation during mitosis

Activity of endothelial nitric oxide synthase (eNOS) is modulated by protein-protein interaction and phosphorylation at specific serine or threonine residues. Using immunofluorescence analysis we show here that proliferating mesenchymal stem cells (MSCs) derived from human bone marrow exhibit cytosolic and pronounced nuclear localization of eNOS. Examination of phosphorylated eNOS subspecies revealed that eNOS phosphorylated at Ser-114 is heavily enriched in the nucleus, whereas eNOS phosphorylated at Ser-1177 is localized at filamentous structures in the cytosol that are abundant in the perinuclear region. Phosphorylation of eNOS at Ser-114 but not at Ser-1177 was strongly increased in cells shortly before mitosis and decreased to normal level after completed cell division. Double immunofluorescence analysis revealed that subcellular localization of 8-hydroxyguanosine immunoreactivity was overlapping with eNOS phosphorylated at Ser-114 in human MSCs providing evidence that phosphorylation at this residue is linked to the generation of superoxide anions. As expected there was only a weak colocalization between eNOS phosphorylated at Ser-1177 and caveolin-1. Different from many other cell systems, human MSCs accumulate eNOS in the nucleus without an acute stimulus. eNOS constitutively phosphorylated at distinct amino acid residues is targeted to different subcellular compartments pointing to an important role of specific phosphorylation events in the life cycle of proliferating human MSCs.

Fludarabine in Combination With Alemtuzumab Is Effective and Feasible in Patients With Relapsed or Refractory B-Cell Chronic Lymphocytic Leukemia: Results of a Phase II Trial

Purpose

To determine the efficacy and safety of a newly developed concomitant administration of fludarabine and alemtuzumab (FluCam) in patients with relapsed or refractory B-cell chronic lymphocytic leukemia (B-CLL).

Patients and Methods

A total of 36 patients were treated in this phase II study (median age, 61.47 years; mean number of prior chemotherapies, 2.6; Binet stage C, n = 28). After an initial dose escalation of alemtuzumab over 3 days, alemtuzumab 30 mg and fludarabine 30 mg/m2 were administered on 3 consecutive days. Treatment was repeated after 28 days for up to six cycles. Restaging (following National Cancer Institute criteria) was carried out after cycles 2 and 4 and 1 month after the end of treatment.

Results

The overall response rate was 83% (11 complete responses, 19 partial responses, one stable disease, and five progressive diseases). Two patients with progressive disease developed fungal pneumonias, and one patient died as a result of Escherichia coli sepsis. Two subclinical cytomegalovirus reactivations occurred.

Conclusion

The new FluCam regimen is effective and feasible in patients with relapsed and refractory B-CLL.

Determination of caspase-3 activation fails to predict chemosensitivity in primary acute myeloid leukemia blasts

Background

Ex-vivo chemosensitivity tests that measure cell death induction may predict treatment outcome and, therefore, represent a powerful instrument for clinical decision making in cancer therapy. Such tests are, however, work intensive and, in the case of the DiSC-assay, require at least four days. Induction of apoptosis is the mode of action of anticancer drugs and should, therefore, result in the induction of caspase activation in cells targeted by anticancer therapy.

Methods

To determine, whether caspase activation can predict the chemosensitivity, we investigated enzyme activation of caspase-3, a key executioner caspase and correlated these data with chemosensitivity profiles of acute myeloid leukemia (AML) blasts.

Results

There was, however, no correlation between the ex-vivo chemosensitivity assessed by measuring the overall rates of cell death by use of the DiSC-assay and caspase-3 activation.

Conclusion

Thus, despite a significant reduction of duration of the assay from four to one day, induction of apoptosis evaluated by capase-3 activity does not seem to be a valid surrogate marker for chemosensitivity.

Prediction of individual response to chemotherapy in patients with acute myeloid leukaemia using the chemosensitivity index Ci

As the response to chemotherapy in patients with acute myeloid leukaemia (AML) may still not be accurately determined by known prognostic factors, such as karyotype, the ex vivo chemosensitivity profile may help to predict the individual response. The predictive accuracy of an ex vivo assay should be assessed by correlation of assay results with both response rate and survival. We prospectively investigated the prognostic relevance of pre-therapeutic ex vivo chemosensitivity testing in primary cell cultures from adult AML patients by applying a new evaluation methodology, designated the chemosensitivity index, C(i). This C(i) was designed as a prognostic index by taking the area under the curve as an exact measure of the total dose-response relationship. We found an overall predictive accuracy of 98.2% concerning treatment response, which compares favourably with previously published data ranging from 75% to 92%. Moreover, the C(i) proved to be the strongest prognostic factor for overall survival in a multivariate Cox regression analysis including karyotype grouping and age (P < 0.001), and enabled the evaluation of response to combination therapies and selection of possible treatment alternatives. Our data suggest that ex vivo chemosensitivity testing evaluated by the C(i) could serve as a powerful tool for assay-directed therapy strategies in AML.

The bi-specific CD3 x NCAM antibody: a model to preactivate T cells prior to tumour cell lysis

To target the neural cell adhesion molecule (NCAM, CD56) on neuroblastoma by T cell-based immunotherapy we have generated a bi-specific CD3 x NCAM antibody (OE-1). This antibody can be used to redirect T cells to NCAM+ cells. Expectedly, the antibody binds specifically to NCAM+ neuroblastoma cells and CD3+ T cells. OE-1 induces T cell activation, expansion and effector function in peripheral blood mononuclear cell (PBMC)-derived CD4+ and CD8+ T cells. T cell activation was shown to depend on the presence of normal natural killer (NK) cells in the culture. Interestingly, while PBMC- derived T cells were activated by OE-1, NK cells were almost completely depleted, suggesting that T cells activated by OE-1 deleted the NK cells. Activated CD4+ and CD8+ T cells differentiate into a larger CCR7+ central memory and a smaller CCR7- effector memory cell population. Most importantly, preactivated T cells were highly cytotoxic for neuroblastoma cells. In eight of 11 experiments tumour-directed cytotoxicity was enhanced when NK cells were present during preactivation with OE-1. These data strongly support a bi-phasic therapeutic concept of primarily stimulating T cells with the bi-specific antibody in the presence of normal NCAM+ cells to induce T cell activation, migratory capacity and finally tumour cell lysis.

Quantitative molecular monitoring of residual tumor cells in chronic lymphocytic leukemia

New therapeutic approaches for the treatment of B-cell chronic lymphocytic leukemia (B-CLL) can induce remarkable responses. Molecular remissions have been observed occasionally after high-dose chemotherapy. Thus, new improved techniques to monitor residual tumor cells on a molecular basis in CLL are warranted. For this purpose, a real-time quantitative allele-specific oligonucleotide polymerase chain reaction (ASO-PCR) for patients with B-CLL was designed. In the present study, the PCR assay was standardized with identical cycling parameters as well as primer, probe, and MgCl(2) concentration for each patient. Ten patients were monitored with DNA samples obtained at 52 time points (median: 5.2 per patient). The median follow-up per patient was 11.4 months. Nine of ten patients had PCR-detectable residual tumor cells in the peripheral blood after therapy. One patient became PCR negative with a combination of fludarabine and rituximab after the end of treatment. The MRD levels in patients with detectable disease ranged from 0.002% to 10.1% after therapy. We conclude that real-time quantitative ASO-PCR can be utilized for quantitative molecular monitoring of minimal residual disease (MRD) in B-CLL patients in complete remission (CR), that new effective treatment approaches such as combined chemo/immunotherapy can render CLL patients PCR negative, and that different MRD levels in PCR-positive patients were observed warranting further investigation into possible correlation with clinical outcome.

Human angiogenin fused to human CD30 ligand (Ang-CD30L) exhibits specific cytotoxicity against CD30-positive lymphoma

A number of different immunotoxins composed of cell-specific targeting structures coupled to plant or bacterial toxins have increasingly been evaluated for immunotherapy. Because these foreign proteins are highly immunogenic in humans, we have developed a new CD30 ligand-based fusion toxin (Ang-CD30L) using the human RNase angiogenin. The completely human fusion gene was inserted into a pET-based expression plasmid. Transformed Escherichia coli BL21(DE3) were grown under osmotic stress conditions in the presence of compatible solutes. After isopropyl beta-D-thiogalactoside induction, the M(r) 37,000 His(10)-tagged Ang-CD30L was directed into the periplasmic space and functionally purified by a combination of metal ion affinity followed by enterokinase cleavage of the His(10)-Tag and molecular size chromatography. The characteristics of the recombinant protein were assessed by ELISA, flow cytometry, and toxicity assays showing specific activity against CD30(+) Hodgkin-derived cells. Specific binding activity of Ang-CD30L was verified by competition with anti-CD30 monoclonal antibody Ki-4 and commercially available CD30L-CD8 chimeric protein. Ang-CD30L showed RNase activity in vitro. The human recombinant immunotoxin showed significant toxicity toward several CD30-positive cell lines (HDLM-2, L1236, KM-H2, and L540Cy) and exhibited highest cytotoxicity against L540 cells (IC(50) = 8 ng/ml) as determined by cell proliferation assays. CD30 specificity was confirmed by competitive toxicity assays. This is the first report on the specific cytotoxicity of a recombinant completely human fusion toxin with possibly largely reduced immunogenicity for the treatment of CD30-positive malignancies.

Ki-4(scFv)-ETA', a new recombinant anti-CD30 immunotoxin with highly specific cytotoxic activity against disseminated Hodgkin tumors in SCID mice

The human lymphocyte activation marker CD30 is highly overexpressed on Hodgkin/Reed-Sternberg cells and represents an ideal target for selective immunotherapy. We used the murine anti-CD30 hybridoma Ki-4 to construct a new recombinant immunotoxin (rIT) for possible clinical use in patients with CD30(+) lymphoma. Hybridoma V genes were polymerase chain reaction-amplified, assembled, cloned, and expressed as a mini-library for display on filamentous phage. Functional Ki-4 scFv obtained by selection of binding phage on the CD30-expressing Hodgkin lymphoma cell line L540cy was inserted into the bacterial expression vector pBM1.1 and fused to a deletion mutant of Pseudomonas exotoxin A (ETA'). Periplasmically expressed Ki-4(scFv)-ETA' demonstrated specific activity against a variety of CD30(+) lymphoma cells as assessed by different in vitro assays. To evaluate in vivo antitumor activity, severe combined immunodeficient mice challenged with human lymphoma cell lines were treated with the immunotoxin. The blood distribution time t(1/2)alpha of Ki-4(scFv)-ETA' was 19 minutes, and its serum elimination time t(1/2)alpha was 193 minutes. A single intravenous injection of 40 microg rIT 1 day after tumor inoculation rendered 90% of the mice tumor free, extending the mean survival time to more than 200 days compared with 38.1 days in the phosphate-buffered saline control group (P <.001). This new rIT is a promising candidate for further clinical evaluation in patients with Hodgkin lymphoma or other CD30(+) malignancies. (Blood. 2000;95:3909-3914)

Recombinant anti-CD25 immunotoxin RFT5(SCFV)-ETA' demonstrates successful elimination of disseminated human Hodgkin lymphoma in SCID mice

Since clinical phase-I/II trials in patients with resistant Hodgkin's lymphoma treated with the chemically linked anti-CD25 ricin-A-chain immunotoxin RFT5-SMPT-dgA indicate promising results for patients with minimal residual disease, we constructed a new immunotoxin by fusing the RFT5 single-chain variable fragment to a deletion mutant of Pseudomonas exotoxin A (ETA'). The recombinant protein was directed into the periplasmic space of E. coli by means of the pET-derived expression vector pBM1.1 and our newly developed expression/purification method. Biologically active RFT5(scFv)-ETA' was isolated by freezing/thawing and purified by immobilized metal-ion affinity and molecular-size-chromatography. RFT5(scFv)-ETA' was subsequently used for the treatment of disseminated human Hodgkin's lymphoma in a SCID-mouse model. The mean survival time (MST) of L540rec-challenged SCID mice was 38.1 days. A single i.v. injection of 40 microg recombinant immunotoxin (rIT) 1 day after tumor inoculation resulted in 100% tumor-free mice, extending the MST to more than 220 days (p < 0.0001). The blood-distribution time T(1/2)alpha was 39.65 min, the serum elimination time T(1/2)alpha, 756.6 min. All animals were assessed for soluble interleukin-2 receptor alpha, which is directly correlated to tumor burden. Soluble CD25 was not detectable in mice treated with the rIT. Our findings, concerning potent anti-tumor effects of a recombinant anti-CD25 immunotoxin against disseminated Hodgkin's lymphoma in SCID mice reported here demonstrate that RFT5(scFv)-ETA' might be suitable for further evaluation against Hodgkin's lymphoma in humans.