Abstract NG12: Mechanisms governing efficacy of combination CD40 agonist and anti-PD-L1 in pancreatic ductal adenocarcinoma

Background: Pancreatic ductal adenocarcinoma (PDA) is a lethal malignancy that is resistant to conventional therapies including monotherapy using PD-1 or PD-L1 inhibition. Combination agonistic anti-CD40 and PD-1/PD-L1 blockade have clinical promise in advanced cancer patients including PDA. The underlying mechanism(s) driving the therapeutic effects of this combination are ill-defined. Here, we create a syngeneic PDA animal model and utilize various genetic tools to assess how CD40 agonist, PD-L1 blockade or the combination impact tumor antigen-specific T cells using fluorescently-labeled peptide:MHC tetramers and cells in the tumor microenvironment. Molecular analyses of tumor cell escape variants is also performed.

Methods: We recently developed a high-throughput orthotopic syngeneic KPC pancreatic cancer mouse model that expresses a novel model neoantigen in B6 mice described in Burrack et al., Cell Reports, 2019. We create fluorescently labeled peptide:H-2Db tetramers to track the fate of endogenous pancreatic tumor-antigen specific CD8+ T cells over time. Here, we use this model alone or mixed at a 1:1 ratio of KPC tumor cells that do not express the neoantigen to examine how agnostic anti-CD40 (a single dose, clone FGK145), anti-PDL1 (3 doses, clone 10F.932), or the combination impact tumor growth in the pancreas over time using bioluminescent imaging and high-resolution ultrasound. We use multiparameter flow cytometry to investigate how anti-CD40 +/- PD-L1 blockade impacts the phenotype, longevity and functionality of tetramer-binding T cells over time. We assess how other immune cell lineages are altered systemically and in the tumor microenvironment by quantifying myeloid subpopulations, B cells, NK cells and regulatory T cells following therapy. We use Batf3-/- mice and XCR1VenusDTR mice to assess the role of conventional type I dendritic cells (cDC1s) on therapeutic efficacy. We employ both cytokine and chemokine reporter strains to identify how anti-CD40 +/- PD-L1 blockade impacts inflammatory gene expression in immune cells enriched the tumor microenvironment. We examine the persistence and location of tetramer-binding T cells in the pancreas, lung and liver of mice following tumor eradication. Additionally, we re-derive resistant tumor cells from mice and evaluate the integrity of MHC class I antigen processing and presentation pathways. Finally, single cell sequencing is performed to assess the traits of subpopulations of tumor-antigen specific T cells that correlate with enhanced antitumor activity following therapy.

Results: We show that anti-CD40 or anti-PD-L1 monotherapy have significant yet transient antitumor effects in mice with neoantigen+ PDA with distinct effects on tumor specific T cells. Objective responses occur in 100% of the monotherapy treated mice and survival is significantly prolonged. However, tumors recur in 100% of these animals. Tumor escape variants defective in MHC class I protein and Tap1 gene expression following IFN-gamma treatment ultimately emerge. In contrast, combination agonistic anti-CD40 + PD-L1 blockade synergize therapeutically resulting in cures in 60% of the animals and formation of pancreas resident memory T cells that specifically bind tetramer and express CD49a and CD103 following tumor eradication. Mechanistically, the combination selectively expands conventional type 1 dendritic cells (cDC1s) in the spleens and tumors of tumor-bearing animals. cDC1s in PDA are CD11c+MHCII+ and express CD8, CD103 and Xcr1. Using Batf3-/- mice or an Xcr1venusDTR transient cDC1 depletion model, we demonstrate a striking dependency on cDC1s for therapeutic benefit with anti-CD40 or PD-L1 blockade. Unexpectedly, we find that the expansion of cDC1s in pancreatic tumor-bearing animals is partially dependent on Xcr1 expression by DCs. Anti-CD40+PD-L1 blockade significantly expand the number of tetramer-binding T cells that express KLRG1 in PDA. The tetramer-binding T cells remain PD-1+ yet have lower expression of Lag3 and have heightened polyfunctionality as measured by cytokine production. Further studies using chemokine and cytokine reporter models, we uncover key differences in how anti-CD40 and anti-PD-L1 impact inflammatory gene expression by antigen presenting cells in PDA. Finally, we demonstrate the requirement for tumor neoantigen expression for efficacy because in mice that have tumors containing a 50:50 mixture of neoantigen+ pancreatic tumor cells with neoantigen- pancreatic tumor cells, combination anti-CD40 + PD-L1 blockade results in elimination of predominantly those tumor cells that express the neoantigen. Further single cell sequencing data on how this combination impacts tumor-antigen specific T cell subpopulations as well as epitope spreading will be discussed.

Conclusions: These findings reveal for the first time to our knowledge that anti-CD40 + PD-L1 blockade synergize via the expansion of cDC1s in pancreatic tumor-bearing animals. Instead of anti-CD40 promoting priming of neoantigen-specific T cells, we find that this combination promotes the systemic expansion and intratumoral accumulation of KLRG1+ tumor-specific T cells that eradicate PDA and form pancreas resident CD49a+CD103+ memory T cells.

Citation Format: Adam L. Burrack, Meagan R. Rollins, Ellen J. Spartz, Jackson F. Raynor, Iris Wang, Jason Mitchell, Tsuneyasu Kaisho, Brian Fife, Ross Kedl, Stephen Shen, Ingunn M. Stromnes. Mechanisms governing efficacy of combination CD40 agonist and anti-PD-L1 in pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr NG12.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Eradication of Established Tumors by Chemically Self-Assembled Nanoring Labeled T Cells

Our laboratory has developed chemically self-assembled nanorings (CSANs) as prosthetic antigen receptors (PARs) for the nongenetic modification of T cell surfaces. PARs have been successfully employed in vitro to activate T cells for the selective killing of leukemia cells. However, PAR efficacy has yet to be evaluated in vivo or against solid tumors. Therefore, we developed bispecific PARs that selectively target the human CD3 receptor and human epithelial cell adhesion molecule (EpCAM), which is overexpressed on multiple carcinomas and cancer stem cells. The αEpCAM/αCD3 PARs were found to stably bind T cells for >4 days, and treating EpCAM⁺ MCF-7 breast cancer cells with αEpCAM/αCD3 PAR-functionalized T cells resulted in the induction of IL-2, IFN-γ, and MCF-7 cytotoxicity. Furthermore, an orthotopic breast cancer model validated the ability of αEpCAM/αCD3 PAR therapy to direct T cell lytic activity toward EpCAM⁺ breast cancer cells in vivo, leading to tumor eradication. In vivo biodistribution studies demonstrated that PAR-T cells were formed in vivo and persist for over 48 h with rapid accumulation in tumor tissue. Following PAR treatment, the production of IL-2, IFN-γ, IL-6, and TNF-α could be significantly reduced by an infusion of clinically relevant concentrations of the FDA-approved antibiotic, trimethoprim, signaling pharmacologic PAR deactivation. Importantly, CSANs did not induce naïve T cell activation and thus exhibit a limited potential to induce naïve T cell anergy. In addition, murine immunogenicity studies demonstrated that CSANs do not induce a significant antibody response nor do they activate splenic cells. Collectively, our results demonstrate that bispecific CSANs are able to nongenetically generate reversibly modified T cells that are capable of eradicating targeted solid tumors.

Exploiting T cell co-inhibition to delay autoimmune disease recurrence

Type 1 diabetes (T1D) results from T cell-mediated destruction of insulin-producing pancreatic β cells. Individuals with long-term disease are at risk of developing life-threatening complications. β cell replacement is a therapy for T1D but is limited by recurrent autoreactive T cell targeted β cell death. Thus, β cells better equipped to inhibit local T cell responses may survive longer in autoimmune recipients. Programmed-death 1 (PD-1) signaling through its ligand PD-L1 inhibits T cells, and may serve as a prominent defense in T1D. Using flow cytometric analysis, in the absence of T cells in NOD.RAG−/− mice we do not detect β cell PD-L1 expression. However, with T cells, we observed an increased proportion of β cells expressing PD-L1 in female non-obese diabetic (NOD) mice which had not developed diabetes. In addition, the majority of remaining live β cells at diabetes onset in NOD mice continue to express high levels of PD-L1. These three situations suggest that islet β cells may increase PD-L1 expression as a last line of defense to limit infiltrating T cell mediated destruction. To manipulate β cell PD-L1 expression prior to transplantation, we screened a panel of diabetes-related cytokines and found that IFN-γ enhances β cell PD-L1 expression. Unfortunately, islet transplant survival was not prolonged, which we hypothesized was due to enhanced MHC class I expression, facilitating CD8+ T cell-mediated killing. We therefore de-coupled PD-L1 from enhanced MHC I expression. Using this approach, enforced β cell PD-L1 expression delays disease recurrence. These data support our hypothesis that β cells expressing T cell co-inhibitory molecules, like PD-L1, can locally inhibit autoreactive T cells which may prevent transplant destruction.

Identification of self-specific CD4+ T cell subsets resistant to PD-1 blockade (BA11P.130)

The inhibitory receptor programmed death (PD)-1 and its ligand PD-L1 regulate T cell function to limit autoimmunity. PD-1 is highly expressed on exhausted T cells, limiting their antiviral or antitumor activity. Even though PD-1 pathway blockade has gained momentum in cancer treatment, it is unclear how PD-1/PD-L1 blockade impacts different T cell subsets. We examined the effects of PD-1 blockade on self-reactive CD4+ T cells in mouse models of varying autoimmune susceptibilities. We used insulin-peptide/MHC Class II tetramers to track endogenous insulin-specific CD4+ T cells in diabetes-prone (NOD), and diabetes-resistant (NOR and B6.g7) mice. PD-1 was expressed at lower levels on insulin-specific cells in diabetes-resistant mice compared to cells from NOD mice. Moreover, PD-1 pathway blockade accelerated autoimmunity in all NOD mice and 30% of NOR mice, but B6.g7 mice remained protected from disease. By transferring congenically marked islet-specific CD4+ T cells into pre-diabetic NOD mice, we asked whether anti-PD-L1 reinvigorates anergic cells. Surprisingly, anergic cells remained functionally blunted compared to effector cells after anti-PD-L1, suggesting that established anergic cells were not dependent on PD-1 signaling to maintain their unresponsive state. This work highlights how the differentiation status of a T cell may predetermine its susceptibility to PD-1 blockade, and influence autoimmunity or antitumor responses that ensue.

Antigen specific tolerance and the prevention of autoimmune type 1 diabetes occurs through indirect antigen presentation and requires programmed death ligand 1 (THER5P.918)

Antigen-coupled ethylene carbodiimide-fixed cells is an attractive therapeutic platform for treating human patients with type 1 diabetes since these cells can prevent and reverse diabetes in the non-obese diabetic mouse model of diabetes. However, the mechanisms contributing to the induction of T cell tolerance in vivo following treatment are unclear. Therefore, we used the BDC2.5 T cell transfer model to study how p31-coupled cells inhibit T cell function in vivo. Our results demonstrate that indirect antigen presentation was critical for tolerance induction in vivo. We further demonstrate that PD-L1 on the host antigen presenting cells is required for tolerance induction. Importantly, using two-photon microscopy we show that BDC2.5 T cells arrest on CD11c+ dendritic cells during the induction of tolerance, suggesting that these cells are responsible for presenting coupled cell antigen and tolerance induction. To increase the feasibility of translating antigen coupled cells to the clinic, we demonstrate that whole blood preparations and frozen cells are sufficient for tolerance induction, a significant concern for donor coupled cell sources when considering translation to human patients. These data further our understanding of how antigen-coupled cells induce tolerance and how this tolerance protocol could be altered to increase clinical feasibility.

Indirect presentation of antigen-coupled cells mediates specific CD4+ T cell tolerance by PD-L1 for the prevention of type 1 diabetes (BA14P.207)

Antigen coupled to the surface of cells using ethylene carbodiimide is a potent inducer of tolerance in multiple models of autoimmunity including Type 1 Diabetes (T1D). Yet, the mechanisms contributing to the induction of T cell tolerance in vivo during T1D are unclear. We used the BDC2.5 T cell receptor transgenic T cell transfer model to study how p31-coupled cells inhibit T cell function in vivo. Antigen-coupled cells that were either deficient in MHC class II or MHC-mismatched induced tolerance similarly to MHC class II-sufficient matched cells, suggesting that indirect presentation of coupled cell antigens is required for tolerance induction in vivo. We also show that BDC2.5 T cells predominantly encounter coupled cell antigen that has been ingested by host antigen presenting cells, and that the inhibitory receptor PD-L1 is required on the host but not the coupled cells to induce tolerance, further highlighting an indirect mechanism of tolerance induction. These data add to our current understanding of how antigen-coupled cells induce tolerance and aid in the translation of this therapeutic into the clinic.

Requirement for PD-1 in the induction and maintenance of tolerance differs depending on tolerogenic stimulus (BA8P.118)

The inhibitory receptor Programed Death (PD)-1 interacting with PD-L1 is important for tolerance since blocking this pathway accelerates autoimmunity. However, the mechanisms by which PD-1/PD-L1 contribute to tolerance remain unclear. In this study we tracked endogenous insulin-specific CD4 T cells in mice that are susceptible (NOD) or resistant (B6.g7) to Type 1 Diabetes (T1D). Despite the presence of insulin-reactive CD4 T cells in both strains, anti-PD-L1 precipitated T1D in NOD but not B6.g7 mice. Accelerated T1D in NOD mice correlated with increased numbers of insulin-specific CD4 T cells in the spleen, pancreatic LN, and pancreas. The number of cells increased in the pancreatic LN of B6.g7, but not the spleen or pancreas, suggesting that loss of PD-1 signaling was insufficient to promote trafficking to the pancreas in these mice. Unexpectedly, the breakdown of self tolerance in NOD mice did not rely on PD-1 signals as anergic cells did not change with PD-1 blockade. Rather, PD-1 was more important for regulating effector T cells. This contrasts data using antigen-coupled ECDI-fixed cells to induce anergy in potently activated effector cells during T1D in NOD, where PD-1/PD-L1 ligation is required for both the induction and maintenance of tolerance. This work reveals the role PD-1 signaling has for different contexts of tolerance, and has important therapeutic implications for use of PD-1 inhibitors in patients.

Analysis of the formation of antigen-specific memory CD4+ T cell populations derived from single naïve precursors (LYM3P.731)

Following infection, a naive antigen-specific CD4+ T cell population proliferates and differentiates into to effector cell progeny that are either Th1 cells, which activate the microbicidal functions of macrophages, or T follicular helper cells, which help B cells make antibodies. After the resolution of infection, most antigen-specific cells die, while a small number of cells survive to form long-lived memory cells. The origins of these memory cells remain unclear. In this study, we tracked the differentiation clonal populations of CD4+ T cells, from single naïve cells into effector cells, and subsequently memory cells. We find that not all naïve CD4+ T cells that produce effector cell populations give rise to memory populations. However, when memory populations are formed, they are phenotypically similar to the effector populations in terms of Th1 and T follicular helper cell differentiation, suggesting that effector cell phenotype is maintained into memory, and that memory cells are derived from effector cells. Ongoing work is focused on determining the contributions of TCR signal strength and effector population burst size has in memory cell differentiation.

PD-1 and CTLA-4 signals are not important for the maintenance of tolerant self-reactive CD8 T cells in the small intestine (MUC8P.808)

Tolerance is an important mechanism by which the immune system distinguishes between self and non-self. Peripheral T cell tolerance is critical for the control of self-reactive cells that escape negative selection. Anergy is one mechanism that controls self-reactive cells in the periphery and prevents autoimmunity. Using a system that allows for the study self-specific CD8 T cell responses to a known intestinal auto-antigen, we determined that mucosal antigen signaling can lead to a long-term, stable population of cells in the intestine that have a classic anergic phenotype. These cells do not produce effector cytokines or induce intestinal damage. Inhibitory molecules, like PD-1 and CTLA-4, are believed to be important for both the induction and maintenance of T cell tolerance. We show that the induction phase of CD8 T cell tolerance to self was highly sensitive to control through both PD-1 and CTLA-4. However, once tolerance was established, the maintenance of tolerant CD8 T cells was independent of PD-1 or CTLA-4 signaling. Overall, this indicates that distinct mechanisms are responsible for the induction and maintenance of tolerant T cells. In addition, there may be many tolerant T cells resistant to immunotherapeutics targeting these pathways. Determining which subsets of self-reactive cells are susceptible to modulation through these pathways is important for understanding basic mechanisms tolerance and autoimmunity and for improving cancer therapeutics.

Role of the PD-1 pathway in regulating islet-reactive CD4 T cells during autoimmune diabetes (123.39)

Engagement of the inhibitory receptor PD-1 with its ligand PD-L1 is critical for preventing Type 1 diabetes in non-obese diabetic (NOD) mice. The mechanism by which PD-1 signaling limits self-reactive CD4 T cells is not well understood. To investigate this we transferred a low number of self-reactive BDC2.5 T cell receptor transgenic CD4+ T cells into prediabetic NOD mice. These cells became activated due to the presence of endogenous antigen. Following activation we administered anti-PD-L1 antibody to block PD-1 signaling and determined the affect on the BDC2.5 cells. PD-1 blockade resulted in an increase in BDC2.5 T cells in the spleen, pancreatic lymph node, and pancreas. This increase correlated with an increase in proliferation in the secondary lymphoid organs measured by CFSE dye dilution. However, it is unclear whether the increase in the pancreas was due to increased proliferation or enhanced recruitment. To investigate the requirement for PD-1 and/or PD-L1 on effector CD4+ T cells, we utilized genetically deficient BDC2.5 T cells. We determined that PD-1 on the BDC2.5 T cell was required to suppress proliferation and recruitment to the pancreas, whereas PD-L1 on the BDC2.5 T cell was dispensable. These data suggest that PD-1 is required on the autoreactive CD4+ T cells and under normal conditions will suppress proliferation in the secondary lymphoid organs and limit recruitment to the pancreas in a cell intrinsic manner.

Programmed death-1 promotes tolerance by blocking the T cell receptor-induced stop signal. (167.26)

Programmed death-1 (PD-1) and CTLA-4 are inhibitory receptors expressed on activated T cells that are critical for preventing autoimmunity. However, the biological context in which PD-1 and CTLA-4 control T cell tolerance is not fully understood. In this study we used an antigen specific diabetes model and T cell dynamic motility during the induction and maintenance of tolerance in vivo by two-photon imaging. Using this system we demonstrate that unlike naive or activated islet antigen-specific T cells, tolerized islet antigen-specific T cells moved freely and did not swarm around antigen-bearing dendritic cells (DCs) in pancreatic lymph nodes. However, blocking interactions between PD-1 and PD-L1 altered the dynamic T cell motility and caused the breakdown in peripheral tolerance resulting in autoimmune diabetes. Neutralizing CTLA-4, on the other hand, did not impact tolerized T cell motility in vivo or clinical disease. The ability of PD-1 to influence the T-cell stop signal was antigen dependent, since T cell motility and T cell-DC contact times were unaffected by PD-L1 neutralization in non-draining (inguinal) LNs. These data provide in vivo evidence that PD-1 -PD-L1 interactions are critical for the maintenance of peripheral tolerance and prevention of autoimmunity. Further, the effects of PD-1 are fundamentally distinct from those of CTLA-4 and suggest unique mechanisms of action for these two inhibitory receptors.

Mechanisms of PDL1-mediated regulation of autoimmune diabetes

The PD-1-PDL1 pathway plays a critical role in regulating autoimmune diabetes as blockade or deficiency of PD-1 or PDL1 results in accelerated disease in NOD mice. We explored the cellular mechanisms involved in the regulation of these autoimmune responses by investigations involving various gene-deficient mice on the NOD background. Administration of blocking anti-PDL1 antibody to CD4+ T cell-deficient, CD8+ T cell-deficient and B cell-deficient mice demonstrated that PDL1-mediated regulation of autoreactive CD4+ and CD8+ T cells is critical for diabetes development. This concept was confirmed by adoptive transfer studies utilizing lymphocytes from BDC2.5 and 4.1 (CD4+) TCR transgenic mice and 8.3 (CD8+) TCR transgenic mice; efforts showing increased proliferation of both CD4+ and CD8+ T cells following PDL1 blockade in vivo. Furthermore, we observed that anti-PDL1-mediated acceleration is dependent upon events occurring in the pancreatic lymph nodes during early disease stages, but becomes independent of the pancreatic lymph nodes during later disease stages. These data provide strong evidence that PDL1 regulates autoimmune diabetes by limiting the expansion of CD4+ and CD8+ autoreactive T cells, and define the timing and locale of PDL1-mediated regulation of type 1 diabetes.

Coping with a partner's cancer: adjustment at four stages of the illness trajectory

PURPOSE/OBJECTIVES

To study the psychosocial adjustment of partners/spouses of patients with cancer at four specific stages of the illness trajectory time of diagnosis, period of first remission, first recurrence, and period of metastatic disease.

DESIGN

A cross-sectional, descriptive survey.

SETTINGS

A university cancer center, a private cancer clinic, and a clinic in a large city serving people who are uninsured and unable to pay for their treatment.

SAMPLE

175 partners of patients who were in one of four specific stages of the illness trajectory participated in this study, Various types of cancer were represented. Seventy-seven participants were men, and 98 were women; their mean age was 49 years.

METHODS

A survey questionnaire was used to collect data on psychosocial adjustment, specific sources of social support, dyadic adjustment, coping strategies, emotional response, cognitive response, and personal control.

FINDINGS

Results indicate that partners of patients who were experiencing a recurrence of their illness or who were in the metastatic stage of the disease were more vulnerable to increased distress and problems of adjustment. Women also reported higher levels of distress than men. Variables that had the most significant direct affect on adjustment were emotional response, cognitive response, family support, and partner cohesion. Coping strategies influenced emotion and cognition.

CONCLUSIONS

Caring for partners is essential to promoting quality of life for the patient and the family.

IMPLICATIONS FOR NURSING PRACTICE

Assessment, providing an opportunity to express concerns, and referral for psychosocial intervention as necessary are important to promote the highest possible quality of life for partners and patients.

The family's adaptation to childhood leukemia

This baseline study obtained data measuring the specific effects of the stress of childhood leukemia on family life and on the lives of individual family members. Mothers, fathers, siblings, and patients were included in the data collection. Specific variables measured were marital adjustment, anxiety level, dynamics of family interaction, and the school behavior of patients and siblings. The data were collected at designated intervals over a one year period beginning at the time of diagnosis. In addition, the data were utilized to speculate on those families that appeared to be at risk for the development of long-term psychosocial problems secondary to, or aggravated by the illness. Results indicated that patterns of coping for families, as well as for individual family members, were relatively constant over time. Families with predominantly stable relationships and adequate support within the family unit were able to maintain their usual quality of life over an extended period of time despite the onset of acute stress. However, families with pre-existing problems prior to diagnosis for the most part experienced increased deterioration in family life and had difficulty coping. Results of the Spielberger State-Trait Anxiety Scale, the Locke-Wallace Marital Adjustment Test, the Moos Family Environment Scale, the MMPI, and school data supporting these conclusions are given.

The psychiatric nurse specialist: a valuable asset in the general hospital

In summary, what are the ways in which the psychiatric/mental clinical specialist contributes to cost-effectiveness, the professional growth of nursing staff, and quality patient care in the general hospital setting? All services of the psychiatric/mental health clinical specialist are ultimately directed toward increasing the effectiveness with which staff can deliver care. This goal is accomplished by helping staff nurses maximize their knowledge, by providing needed educational opportunities, by promoting the use of a holistic model of care, and by helping staff cope with their own stress. In our experience, high quality care that meets the physiological, psychological, and sociological needs of patients decreases the length of the hospital stay, prevents repeated hospitalizations, and minimizes the development of psychosocial problems secondary to the illness. With the necessary support and cooperation from administration, this clinical specialist role reduces health care costs, promotes a higher level of functioning in patients and their families, and increases the level of job satisfaction for the staff who provide direct bedside care.

The Challenge of the Medical Setting for the Clinical Specialist in Psychiatric Nursing

The purpose of sharing these ideas about the role of the psychiatric clinical specialist in the medical setting has been threefold: first, to stimulate the interest of others by communicating the needs for and the value of such a role in improving health care; secondly, to convey the variety of potential opportunities available in the role; and third, to share some ideas about specific activities which can be pursued in such a role. The clinical specialist who chooses to work in the medical setting will discover opportunities to develop creativeness, to explore innovative ideas, and to utilize the variety of one's personal resources and past learning experiences. It affords one with opportunities to serve as a change agent, to influence the quality of patient care, and to stimulate the growth of other nurses. It allows for on-going contact and exchange with other professional groups comprising the health care team, and finally, it provides the nurses with a high level of autonomy and challenge in defining their own roles.