Tisotumab Vedotin in Combination With Carboplatin, Pembrolizumab, or Bevacizumab in Recurrent or Metastatic Cervical Cancer: Results From the innovaTV 205/GOG-3024/ENGOT-cx8 Study

PURPOSE

Tissue factor is highly expressed in cervical carcinoma and can be targeted by tisotumab vedotin (TV), an antibody-drug conjugate. This phase Ib/II study evaluated TV in combination with bevacizumab, pembrolizumab, or carboplatin for recurrent or metastatic cervical cancer (r/mCC).

METHODS

This open-label, multicenter study (ClinicalTrials.gov identifier: NCT03786081) included dose-escalation arms that assessed dose-limiting toxicities (DLTs) and identified the recommended phase II dose (RP2D) of TV in combination with bevacizumab (arm A), pembrolizumab (arm B), or carboplatin (arm C). The dose-expansion arms evaluated TV antitumor activity and safety at RP2D in combination with carboplatin as first-line (1L) treatment (arm D) or with pembrolizumab as 1L (arm E) or second-/third-line (2L/3L) treatment (arm F). The primary end point of dose expansion was objective response rate (ORR).

RESULTS

A total of 142 patients were enrolled. In dose escalation (n = 41), no DLTs were observed; the RP2D was TV 2 mg/kg plus bevacizumab 15 mg/kg on day 1 once every 3 weeks, pembrolizumab 200 mg on day 1 once every 3 weeks, or carboplatin AUC 5 on day 1 once every 3 weeks. In dose expansion (n = 101), the ORR was 54.5% (n/N, 18/33; 95% CI, 36.4 to 71.9) with 1L TV + carboplatin (arm D), 40.6% (n/N, 13/32; 95% CI, 23.7 to 59.4) with 1L TV + pembrolizumab (arm E), and 35.3% (12/34; 19.7 to 53.5) with 2L/3L TV + pembrolizumab (arm F). The median duration of response was 8.6 months, not reached, and 14.1 months, in arms D, E, and F, respectively. Grade ≥3 adverse events (≥15%) were anemia, diarrhea, nausea, and thrombocytopenia in arm D and anemia in arm F (none ≥15%, arm E).

CONCLUSION

TV in combination with bevacizumab, carboplatin, or pembrolizumab demonstrated manageable safety and encouraging antitumor activity in treatment-naive and previously treated r/mCC.

Randomized Phase III Study Comparing Neoadjuvant Chemotherapy Followed by Surgery Versus Chemoradiation in Stage IB2-IIB Cervical Cancer: EORTC-55994

PURPOSE

This multicenter trial by the European Organisation for Research and Treatment of Cancer Gynecological Cancer Group was motivated by conflicting evidence on the value of neoadjuvant chemotherapy before surgery compared with concomitant chemoradiotherapy (CCRT) in stage IB2-IIB cervical carcinoma.

METHODS

Between May 2002 and January 2014, 626 patients with International Federation of Gynecology and Obstetrics stage IB2-IIb were randomly assigned between neoadjuvant chemotherapy followed by surgery (NACT-S; n = 314) and standard CCRT (n = 312). The primary end point was 5-year overall survival (OS) rate. Secondary end points were progression-free survival, OS, toxicity, and health-related quality of life (HRQOL).

RESULTS

After a median follow-up of 8.7 years, 198 patients (31.6%) died. Age, stage, and cell type were balanced in both arms. Protocol treatment was completed in 223 of 314 (71%) patients in NACT-S and 257 of 312(82%) in CCRT arms. Main reasons for incomplete protocol treatment were toxicity (30 of 314; 9.6%) and progressive disease (21 of 314; 6.7%) in the NACT-S arm and toxicity (23 of 312; 7.4%) and patient refusal (13 of 312; 4.2%) in the CCRT arm. Additional radiotherapy after completed NACT-S was given to 107 patients (48%), and additional surgery to 20 patients (8%) after completed CCRT. Short-term adverse events (AEs) ≥grade 3 occurred more frequently with NACT-S (41% v 23%), and long-term AEs ≥grade 3 more often with CCRT (21% v 15%). The 5-year OS was not significantly different between NACT-S (72%; 95% CI, 66 to 77) and CCRT (76%; 95% CI, 70 to 80).

CONCLUSION

This trial failed to demonstrate superiority in favor of the NACT-S arm but resulted in acceptable morbidity and HRQOL in both arms.

Abstract 4113: Classification of patient-specific sensitivity to immunotherapies by ex vivo tumor testing

Background: Immunotherapy has brought great progress with durable responses for cancers that were difficult to treat. However, it remains challenging to select sensitive patients upfront. PD-L1 expression, TMB and MSI/MSS status, do not optimally differentiate between the potential sensitivity to the individual immunotherapies.

Purpose: We aim to improve stratification of patients for immunotherapy through classification of patient-specific tumor sensitivity based on 3D ex vivo drug measurement.

Material: Our study includes 108 Patients with predominantly ovarian carcinoma (81/108). Tumor tissue was collected in ongoing clinical trials from biopsies, ascites or pleural fluid. Five immune checkpoint inhibitors and a STING pathway activator were tested.

Method: Fresh tumor clusters were seeded into 384 well plates and exposed to different immunotherapies, while preserving the TME. Tumor killing and immune cell proliferation were measured using 3D image analysis. Ex vivo tumor sensitivity was classified as no response (<10%), weak (10-20%), strong (20-50%), and very strong (>50%), based on percentage tumor killing and statistical significance (p-value: * < 0.05, ** < 3.33e-4).

Results: Differential patient response profiles were observed (Table 1). For the current cohort, we measured a highly significant immunotherapy response for ~30% of the samples. The assay has a technical success rate of 89%.

Conclusion: This study reports the development of a robust ex vivo tumor testing platform that classified patient-specific sensitivity to 6 immunotherapies for over 100 patients, demonstrating the potential of ex vivo tumor testing to optimize patient stratification for immunotherapy.

Discussion: The platform enables improved efficiency in clinical development of novel treatments and supports treatment decisions in the clinic. Clinical trials are ongoing to establish the correlation of our testing with patients' response to immunotherapy in lung cancer.

Overview of ex vivo immunotherapy response per category 1Therapy # Samples tested % Response No response Weak Strong Very strong SEA (control) 108 43% (30%**) 62 5 19 22 CD3/CD28 Dynabeads (control) 18 33% (17%**) 12 1 5 0 Pembrolizumab 89 16% (8%**) 75 6 5 3 Nivolumab 72 10% (4%**) 65 1 5 1 Ipilimumab 97 20% (11%**) 78 4 10 5 Atezolizumab 62 15% (11%**) 53 1 4 4 Durvalumab 52 2% (0%**) 51 1 0 0 ADU-S100 60 37% (27%**) 38 5 9 8

Citation Format: Lieke Johanna Ceton, Marta Garcia Montero, Fanny Grillet, Dieudonné J. van der Meer, Willemijn Vader, Anne van Altena, Cor D. de Kroon, Nelleke Ottevanger, Judith Kroep. Classification of patient-specific sensitivity to immunotherapies by ex vivo tumor testing. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4113.

Evaluation of a web-based intervention for patients with Gestational Trophoblastic Disease: a randomized controlled trial

Objective Gestational Trophoblastic Diseases (GTD) comprise a group of rare diseases originating from the trophoblast, affecting women of child-bearing age. Providing optimal information to patients with a rare disease is challenging, because of the small number of patients and limited clinical expertise of many healthcare professionals. Both knowledge and lack of knowledge in patients may influence illness perception. We investigated whether a web-based interactive intervention influences illness perception and knowledge in women with GTD. Design Multicenter randomized control trial. Setting General and academic hospitals in the Netherlands. Population Newly diagnosed GTD patients between 2017-2019. Methods Sixty-nine patients were randomized between direct access or postponed access to an online tool on GTD and received online questionnaires about illness perception, knowledge and anxiety. The main outcome measures were illness perception (primary outcome measure) and knowledge (secondary outcome measure) Results Patients using the online tool were satisfied with the information from the tool (92%). Although they had a higher level of knowledge compared to the control group (p = 0.006), illness perception did not change. Also, no differences in levels of anxiety, depression and distress were observed between the groups. Limitations: Participants had access to other information sources and many searched other websites. It is unknown what kind of websites were visited and when. It is unknown if the increased knowledge levels and low levels of distress will sustain over time as no long term follow-up took place. Healthcare professionals were not interviewed on how they experienced the consultation before and after using the tool by the patients. Conclusions The online tool did not change illness perception, but was shown to be valuable for newly-diagnosed GTD patients to gain knowledge. The improvement in knowledge after digital education, indicates that this tool can be used as an effective method of supporting GTD patients' informational needs without causing extra distress.

Clinical research in ovarian cancer: consensus recommendations from the Gynecologic Cancer InterGroup

The Gynecologic Cancer InterGroup (GCIG) sixth Ovarian Cancer Conference on Clinical Research was held virtually in October, 2021, following published consensus guidelines. The goal of the consensus meeting was to achieve harmonisation on the design elements of upcoming trials in ovarian cancer, to select important questions for future study, and to identify unmet needs. All 33 GCIG member groups participated in the development, refinement, and adoption of 20 statements within four topic groups on clinical research in ovarian cancer including first line treatment, recurrent disease, disease subgroups, and future trials. Unanimous consensus was obtained for 14 of 20 statements, with greater than 90% concordance in the remaining six statements. The high acceptance rate following active deliberation among the GCIG groups confirmed that a consensus process could be applied in a virtual setting. Together with detailed categorisation of unmet needs, these consensus statements will promote the harmonisation of international clinical research in ovarian cancer.

Recurrent Endometrial Cancer: Local and Systemic Treatment Options

The treatment of recurrent endometrial cancer is a challenge. Because of earlier treatments and the site of locoregional recurrence, in the vaginal vault or pelvis, morbidity can be high. A total of about 4 to 20% of the patients with endometrial cancer develop a locoregional recurrence, mostly among patients with locally advanced disease. The treatment options are dependent on previous treatments and the site of recurrence. Local and locoregional recurrences can be treated curatively with surgery or (chemo)radiotherapy with acceptable toxicity and control rates. Distant recurrences can be treated with palliative systemic therapy, i.e., first-line chemotherapy or hormonal therapy. Based on the tumor characteristics and molecular profile, there can be a role for immunotherapy. The evidence on targeted therapy is limited, with no approved treatment in the current guidelines. In selected cases, there might be an indication for local treatment in oligometastatic disease. Because of the novel techniques in radiotherapy, disease control can often be achieved at limited toxicity. Further studies are warranted to analyze the survival outcome and toxicity of newer treatment strategies. Patient selection is very important in deciding which treatment is of most benefit, and better prediction models based on the patient- and tumor characteristics are necessary.

Harnessing natural killer cells for the treatment of ovarian cancer

INTRODUCTION

Adoptive cellular immunotherapy could be an interesting new treatment option for ovarian carcinoma (OC), as research has demonstrated that OC is an immunogenic disease. In particular, natural killer (NK) cells have attracted attention due to their ability to kill tumor cells without prior sensitization. The therapeutic value of allogeneic NK cells has been first observed in hematological cancers and is increasingly being explored in solid tumors.

METHODS

To substantiate the rationale for NK cell therapy in OC we performed a literature search in the Pubmed database and in the international trial register clinicaltrials.gov with attention for the effect of OC on NK cell function, the effect of current treatment on NK cell biology and the evidence on the therapeutic value of NK cell therapy against OC.

RESULTS

In six clinical trials only 31 OC patients have been reported that received NK cell adoptive transfer. The majority of patients reached stable disease after NK cell therapy, with a mild pattern of side effects. In patients who received repeated infusions, more complete responses are described. All reported studies investigated the intravenous infusion of NK cells. Whereas the studies that are currently recruiting, investigate intraperitoneal infusion of allogeneic NK cells.

CONCLUSION

In this review the pre-clinical evidence and current trials on NK cell immunotherapy in OC patients are summarized. Furthermore, challenges that have to be overcome for NK cell adoptive therapy to have a significant impact on disease outcome are discussed.

Abstract CT002: A strong HPV-specific T-cell response after chemo-immunotherapy for advanced cervical cancer is associated with prolonged survival

The therapeutic synthetic long peptide (SLP) vaccine ISA101 selectively enlarges the pool of tumor-specific T cells recognizing the human papillomavirus type 16 (HPV16) antigens E6 and E7. Vaccine monotherapy for HPV16-induced pre-malignant anogenital lesions is effective, inducing durable complete regressions in approximately 50% of treated patients. However, cancer treatment requires appropriate countermeasures to overcome the suppression of T-cell activation, expansion and effector function imposed by suppressive myeloid cell populations, regulatory T cells and co-inhibitory molecule expression. We recently showed that carboplatin/paclitaxel chemotherapy can normalize the abnormally high levels of immune suppressive myeloid cells, allowing the development of much stronger therapeutic ISA101-induced tumor immunity1. Here we show the effects of ISA101 vaccination during chemotherapy in 77 patients with advanced, recurrent or metastatic cervical cancer in a dose assessment study. Study design involved a single arm dose escalation study with four different ISA101 doses (20, 40, 100 and 300 µg per peptide) with or without immunomodulator pegylated interferon alpha (Pegitron), given concomitantly with standard of care chemotherapy (carboplatin, AUC 6; paclitaxel, 175 mg/m2). Objective regressions were observed in 43% of 72 evaluable patients. The depletion of myeloid suppressive cells by carboplatin/paclitaxel was associated with detection of low level spontaneous HPV16-specific immunity in 26 of the 61 tested patients. Patients mounted type 1 T-cell responses to the vaccine across all doses. No significant differences were observed between the different doses and strength of vaccine-induced T cell responses; the results were therefore combined. Patients with an above median HPV16-specific T cell immune response to ISA101, measured by a validated IFNγ-Elispot, displayed a significantly prolonged median overall survival (OS) of 16.8 months compared to those with a lower HPV-specific immune response (OS 11.2 months, logrank p=0.012). Importantly, this effect was not due to differences in general immune status, as measured by T-cell reactivity to unrelated common microbial recall

antigens. In conclusion, our study demonstrates that chemo-immunotherapy can be exploited to the benefit of patients with cervical cancer and warrants confirmation of the benefit of this type of chemo-immunotherapy in a randomized controlled study in HPV16-induced cancer patients.

1Welters, M. J. et al. Vaccination during myeloid cell depletion by cancer chemotherapy fosters robust T cell responses. Sci Transl Med 8, 334ra352, doi:10.1126/scitranslmed.aad8307 (2016).

Citation Format: Cornelis J M Melief, Marij J. Welters, Ignace Vergote, Judith R. Kroep, Gemma G. Kenter, Nelleke Ottevanger, Wiebren A. Tjalma, Hannelore Denys, Mariette van Poelgeest, Hans W. Nijman, Anna K. Reyners, Thierry Velu, Frederic Goffin, Roy Lalisang, Willem-Jan Krebber, Leon Hooftman, Sonja Visscher, Brent A. Blumenstein, Richard B. Stead, Winald Gerritsen, Sjoerd van der Burg. A strong HPV-specific T-cell response after chemo-immunotherapy for advanced cervical cancer is associated with prolonged survival [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT002.

Intraperitoneal infusion of ex vivo-cultured allogeneic NK cells in recurrent ovarian carcinoma patients (a phase I study)

INTRODUCTION

Recurrent ovarian carcinoma has dismal prognosis, but control of disease and prolonged survival are possible in some patients. The estimated 5-year survival is 46% for all stages of ovarian cancer, and only 28% for metastasized disease. Notably, the majority of women with ovarian cancer are diagnosed with stage III or IV disease with a high recurrence rate. As most women with relapsed or metastatic cancer will die of progressive disease, there is an urgent need for novel therapeutic strategies. The primary aim of our study is to evaluate safety and toxicity of intraperitoneal infusion of ex vivo-expanded natural killer cells (NK), generated from CD34+ umbilical cord blood (UCB) progenitor cells, with and without a preceding non-myeloablative immunosuppressive conditioning regimen in patients suffering from recurrent ovarian cancer. The secondary objectives are to compare the in vivo lifespan, expansion, and biological activity of intraperitoneally infused NK cell products with or without preparative chemotherapy, as well as evaluate effects on disease load.

METHODS

In this phase I safety trial, 12 patients who are suffering from recurrent ovarian cancer, detected by a significant rise in serum level of CA-125 on two successive time points, will be included. Prior to UCB-NK cell infusion, a laparoscopy is performed to place a catheter in the peritoneal cavity. The first cohort of three patients will receive a single intraperitoneal infusion of 1.5-3×10 UCB-NK cells, generated ex vivo from CD34+ hematopoietic progenitor cells obtained from an allogeneic UCB unit, without a preparative chemotherapy regimen. The second group of three patients will be treated with a similar dose of UCB-NK cells following a preparative four days non-myeloablative immunosuppressive conditioning regimen with cyclophosphamide and fludarabine (Cy/Flu). If no severe toxicity is seen in these 6 patients, an extension cohort of 6 patients will be included to answer the secondary objectives.

DISCUSSION

This study investigates the safety of a promising new cellular therapy in a group of patients with a poor prognosis. Demonstration of safety and in vivo expansion capacity of allogeneic UCB-NK cells in the absence of Cy/Flu pretreatment will provide rationale for UCB-NK cell infusion after regular second-line chemotherapy.

Association of T cell responses after vaccination with HPV16 long peptides for late stage cervical cancer with prolonged survival

5525

Background: Therapeutic vaccination with HPV type 16 synthetic long peptides (HPV16-SLP) results in T cell–mediated regression of HPV16-induced premalignant lesions but fails to install effective immunity in patients with advanced HPV16-positive cervical cancer. We showed that HPV16-SLP vaccination in mice and in patients with advanced cervical cancer patients fosters robust HPV16-specific T cell responses, when combined with chemotherapy (Welters et al. Sci. Transl. Med., 2016). Methods: We have now completed a chemo-immunotherapy study in 70 patients with late stage HPV16+ cervical cancer (clinical trials.gov NCT02128126). Three HPV16-SLP vaccine doses were given 2 weeks after the second, third and fourth cycle of standard chemotherapy (carboplatin, AUC 6; paclitaxel 175 mg/ m2). Cohorts of 12 patients each were vaccinated with each of 4 dose levels (20, 40, 100 and 300 µg/ per peptide) of 13 overlapping HPV16 synthetic long peptides (HPV16-SLP) together covering the length of the 2 E6 and E7 proteins. Two additional cohorts of 6 patients each were vaccinated with the most promising doses of 40 and 100 µg/ peptide. Results: Robust vaccine-induced HPV16-specific T cell responses as assessed by interferon-γ Elispot were observed and were sustained until at least 30 days after the 6th cycle of chemotherapy. In addition the chemotherapy augmented recall responses to microbial antigens. Such robust T cell responses were not noted in previous trials when similar patients were vaccinated without timing of vaccination during chemotherapy. A marked and significant positive correlation was observed between the strength of the vaccine-induced immune response and overall survival. No such correlation was observed between the strength of the T cell response against common recall antigens and survival. In addition a remarkably high proportion of patients survived beyond 2 years after the start of therapy. Conclusions: The results suggest that survival duration is directly related to the strength of the vaccine-induced HPV16-specific T cell response and is not due to generally better immuno-competence. Clinical trial information: NCT 02128126.

Oncologic multidisciplinary team meetings: evaluation of quality criteria

RATIONALE, AIMS AND OBJECTIVES

To develop a guideline with quality criteria for an optimal structure and functioning of a multidisciplinary team meeting (MTM), and to assess to what extent the Dutch MTMs complied with these criteria.

METHOD

A literature search and expert opinions were used to develop a guideline for optimal MTMs. In order to assess adherence to the guideline, we conducted interviews with MTM chairs and observed general and tumour-specific MTMs in seven hospitals.

RESULTS

The new guideline included the following domains: (i) organization of the MTMs; (ii) membership of the MTM and roles and responsibilities of the members; (iii) the meeting itself; and (iv) documentation of meeting-recommendations. We observed good adherence to the quality criteria on the organization of the MTMs. Only the required coordinator/administrative support was often absent, particularly during general MTMs. Regarding membership of MTMs and roles, the recommended average attendance of 100% of the core disciplines was never reached and particularly the role of the chair needs improvement. Regarding the meeting itself, many interruptions took place and relevant information about the diagnoses of the cases was not available in 4-5% of the cases. Concerning the documentation of meeting-recommendations, only in a quarter of the meetings a specific form was used for the documentation.

CONCLUSIONS

We found a lot of diversity in the organization of MTMs. The variation in compliance with the quality criteria may decrease with better knowledge about the quality criteria around MTMs and by overcoming practical barriers for the effective organization of MTMs.

Breast cancer in pregnancy: recommendations of an international consensus meeting

PURPOSE

To provide guidance for clinicians about the diagnosis, staging and treatment of breast cancer occurring during an otherwise uncomplicated pregnancy.

METHODS

An international expert Panel convened to address a series of questions identified by a literature review and personal experience. Issues relating to the diagnosis and management of breast cancer after delivery were outside the scope.

RESULTS

There is a paucity of large and/or randomized studies. Based on cohort studies, case series and case reports, the recommendations represent the best available evidence, albeit of a lower grade than is optimal.

RECOMMENDATIONS

In most circumstances, serious consideration should be given to the option of treating breast cancer whilst continuing with the pregnancy. Each woman should ideally be referred to a centre with sufficient expertise, given a clear explanation of treatment options. Most diagnostic and staging examinations can be performed adequately and safely during pregnancy. Treatment should however be adapted to the clinical presentation and the trimester of the pregnancy: surgery can be performed during all trimesters of pregnancy; radiotherapy can be considered during the first and second trimester but should be postponed during the third trimester; and standard chemotherapies can be used during the second and third trimester. Since neonatal morbidity mainly appears to be related to prematurity, delivery should not be induced before 37 weeks, if at all possible.

CONCLUSIONS

The treatment of breast cancer in pregnancy should be executed by experienced specialists in a multidisciplinary setting and should adhere as closely as possible to standard protocols.

Cancer during pregnancy: an analysis of 215 patients emphasizing the obstetrical and the neonatal outcomes

PURPOSE

The aim of this study was to assess the management and the obstetrical and neonatal outcomes of pregnancies complicated by cancer.

PATIENTS AND METHODS

In an international collaborative setting, patients with invasive cancer diagnosed during pregnancy between 1998 and 2008 were identified. Clinical data regarding the cancer diagnosis and treatment and the obstetric and neonatal outcomes were collected and analyzed.

RESULTS

Of 215 patients, five (2.3%) had a pregnancy that ended in a spontaneous miscarriage and 30 (14.0%) pregnancies were interrupted. Treatment was initiated during pregnancy in 122 (56.7%) patients and postpartum in 58 (27.0%) patients. The most frequently encountered cancer types were breast cancer (46%), hematologic malignancies (18%), and dermatologic malignancies (10%). The mean gestational age at delivery was 36.3 +/- 2.9 weeks. Delivery was induced in 71.7% of pregnancies, and 54.2% of children were born preterm. In the group of patients prenatally exposed to cytotoxic treatment, the prevalence of preterm labor was increased (11.8%; P = .012). Furthermore, in this group a higher proportion of small-for-gestational-age children (birth weight below 10th percentile) was observed (24.2%; P = .001). Of all neonates, 51.2% were admitted to a neonatal intensive care unit, mainly (85.2%) because of prematurity. There was no increased incidence of congenital malformations.

CONCLUSION

Pregnant cancer patients should be treated in a multidisciplinary setting with access to maternal and neonatal intensive care units. Prevention of iatrogenic prematurity appears to be an important part of the treatment strategy.

Controlled release carbamazepine: cognitive side effects in patients with epilepsy

The treatment of epilepsy with carbamazepine (CBZ) may be hampered by cognitive side effects. These side effects are thought to be related to pharmacokinetic properties of the drug. The serum concentration of CBZ is characterized by rapid absorption and a short half-life, which may lead to a considerable fluctuation of the level between doses. Cognitive defects may result from peak levels: short periods with high serum concentration. In a single-blind crossover design, cognitive performance was compared in three conditions. All patients were first tested in the steady state of conventional CBZ. The patients were then assigned randomly to either CBZ-controlled release (CR) or a condition in which conventional CBZ was administered in the same tablet form and dose frequency as CR. Psychological tests were administered four times daily, immediately after the serum samples were taken. A nonmedication control group was tested following the same test scheme to obtain standards for the evaluation of changes in performance during the day. A systematic tendency was found toward higher test performance in the CR condition. This is especially evident for tests of memory and accuracy of visual information processing. The results of the repeated test procedure show that the smoothing effect of the CR condition on serum concentration fluctuations results in a more stable pattern of cognitive functioning during the day.