Family resilience of families with parental cancer and minor children: a qualitative analysis

Introduction

Estimated 50,000 minor children in Germany experience a newly diagnosed cancer in one of their parents every year. Family resilience has proven to be an important concept against life crises. However, little research exists regarding family resilience in the context of parental cancer with minor children. Based on the "Family Resilience Framework," the aim of the study is to investigate the processes of family resilience of affected families. In addition, we explore which combinations of promoting family resilience processes can be characterized.

Methods

As part of the mixed-method quasi-experimental interventional study "F-SCOUT," a qualitative content analysis was used to analyze the documentation of the "Family-Scouts" (a fixed contact person who advises, accompanies, and supports the families). Documentation was performed by families' study inclusion (T0), after 3 months (T1) and 9 months (T2) concerning current family situation, organization of everyday life, emotional coping, open communication within the family, and planned tasks.

Results

The N = 73 families had between one and six children. In 58 (79%) families, the mother had cancer. In the course of the analysis, a category system with 10 main categories and 36 subcategories emerged. Family resilience processes were described to different extents. Combinations of categories promoting family resilience were characterized by the use of social resources, flexibility, economic resources, and open communication.

Discussion

The findings are consistent with existing assumptions about family resilience in terms of the importance of social resources, family cohesion, mutual support, flexibility, open communication, and psychological well-being. In contrast to the findings of previous research, spirituality, and collaborative problem-solving indicate less centrality here. In turn, the findings on economic resources and information-seeking provide a valuable addition to the family resilience literature in the context of parental cancer with minor children.

Clinical trial registration

ClinicalTrials.gov, identifier NCT04186923.

Shared-Decision-Making Experiences in Breast Cancer Care with and without Patient Participation in Multidisciplinary Tumor Conferences: A Mixed-Methods-Study

Purpose

This study aimed (1) to analyze patients' perceived shared decision-making (SDM) experiences over 4 weeks between patients participating or not in multidisciplinary tumor conferences (MTCs) and (2) to analyze the association of patients' active participation in and organizational variables of MTCs with patients' perceived SDM experience directly after MTC.

Patients and Methods

From the N=317 patients, this observational study included patient surveys, observations, and audio transcripts from MTCs with (N=82) and without (N=145) patient participation in six breast and gynecologic cancer centers. We performed t tests for within- and between-group comparisons and linear regression with "patients' perceived SDM experiences in MTC" as the dependent variable.

Results

Patients' perceived SDM experiences increased at 4 weeks after MTC (p<0.001) with lower perceived SDM experiences for participating versus nonparticipating patients (p<0.001). Linear regression showed that the organizational variable "round table seating arrangement" was significantly associated with higher perceived SDM experiences compared with a theater or U-shape arrangement (beta=-0.38, p=0.043; beta=-0.69, p=0.010) directly after MTC.

Conclusion

Results provide first insights into patients' perceived SDM experiences in MTCs. SDM in MTCs is associated with organizational variables of MTCs. A round table seating arrangement in MTCs with patient participation seems important for patients' perceived SDM experiences. The relatively low perceived SDM experiences of participating patients directly after MTC indicates room for improvement, eg concerning patient-centered communication.

Effectiveness of interprofessional communication skills training for oncology teams: study protocol for a three-arm cluster randomised trial (KommRhein Interpro)

INTRODUCTION

Patient-provider communication is an important factor influencing the quality of care in oncology. The study examines the comparative effectiveness of a 10-hour interprofessional communication skills training (CST) programme for physicians and nurses in cancer centres.

METHODS AND ANALYSIS

KommRhein Interpro is a cluster-randomised trial sponsored by the German Cancer Aid (Deutsche Krebshilfe, DKH) and conducted at the cancer centres of the university hospitals of Aachen, Bonn, Cologne and Düsseldorf. Thirty oncology teams of four cancer centres are randomly assigned to three study arms, providing healthcare professionals with either (a) only written information on patient-centred communication or (b) written information plus CST for physicians or (c) written information plus interprofessional CST for physicians and nurses. For summative evaluation, standardised surveys from three measurement points for patients (T0pat: study enrollment; T1pat: after discharge; T2pat: 3 months' follow-up) and two measurement points for physicians and nurses (T0hcp: before the intervention; T1hcp: after the intervention) are used. N=1320 valid patient cases are needed for data evaluation. The primary endpoint is fear of progression in patients with cancer after discharge. Data will be analysed according to the intention-to-treat principle using a mixed model for repeated measurement. Secondary outcome is the providers' self-efficacy in patient centeredness. Individual confounders and possible moderating effects of organisational factors will be considered. Secondary analysis will be performed by means of multilevel analysis and structural equation modelling.

ETHICS AND DISSEMINATION

A vote of approval has been obtained from the ethics committees of the medical faculties of RWTH Aachen University (EK325/20), University of Bonn (391/20), University of Cologne (20-1332) and Heinrich Heine University Düsseldorf (2019-796). Data protection regulations are adhered to for all processed data. The conduct of the study will be monitored. Dissemination strategies include a transfer workshop with cancer teams and distribution of the final study report to participants.

TRIAL REGISTRATION NUMBER

DRKS00022563; DRKS (German Clinical Trials Register).

Patient participation in multidisciplinary tumor conferences in breast and gynecological cancer care: How patient-centered is the communication?

OBJECTIVE

Patients' participation is part of patient-centeredness, but it is so far unclear whether providers in multidisciplinary tumor conferences (MTCs) with patient participation communicate in a patient-centered way. Our aim is to explore (a) to what extent providers ask questions to breast and gynecological cancer patients during case discussion in MTCs, (b) how providers respond to patients' expressions of emotions during case discussions, and (c) which patient- and context-related characteristics and responses are associated with patients' trust in the treatment team after the case discussion.

METHODS

This observational study included survey data and audio recordings of MTCs with patient participation at three breast and gynecological cancer centers. Providers' questions to patients and responses to patients' emotional expressions were coded using the Verona Coding Definitions of Emotional Sequences. The response can be explicitly or non-explicitly related to the emotion and space-reducing or space-providing. Multiple linear regression analysis was used to determine associations between providers' responses, patient- and context-related characteristics, and patients' trust in the treatment team after the case discussion.

RESULTS

We analyzed 82 case discussions (77 breast, 5 breast and gynecological cancer patients). Providers asked a total of 646 questions, of which 86% were polar (yes/no). Providers gave 303 responses to a total of 230 emotional expressions by patients. Non-explicit responses were associated with more trust when they were space-providing, but with less trust when space-reducing.

CONCLUSIONS

The frequency of providers' closed questions and space-reducing responses to emotions shows that patient-centered communication rarely takes place in MTCs with patient participation.

Questions and emotional expressions from patients and companions while participating in multidisciplinary tumor conferences in breast and gynecological cancer centers

OBJECTIVE

To investigate (a) how many questions and negative emotions (cues/concerns) breast and/or gynecologic cancer patients and companions express during their case discussion in multidisciplinary tumor conferences (MTCs), (b) with which topics the emotions are linked, and (c) which patient- and context-related characteristics determine patients' communicative behavior.

METHODS

This observational study included audio/video recordings of MTCs with patient participation in three breast and gynecological cancer centers. Using the Verona Coding Definitions of Emotional Sequences, patients' and companions' questions and negative emotions expressed were analyzed. Multiple regression analyses were used to determine associations between communicative behavior and patient- and context-related characteristics.

RESULTS

We identified 607 questions and 230 cues/concerns expressed by patients/companions in 82 case discussions in MTCs. The number of questions was significantly associated with the hospital. In case discussions with patients who had need for psychological support and who were accompanied, more questions were asked by patients/companions.

CONCLUSION

The results show that active patient participation does not depend only on patient characteristics, but also on the hospital setting.

PRACTICE IMPLICATIONS

If cancer centers want to enable patient participation in MTCs, they must define the role of the patient before. Subsequently, conditions must be created to enable this role expectation.

Is patient participation in multidisciplinary tumour conferences associated with their information needs? A multicentre prospective observational study

OBJECTIVES

To determine the association between participation of patients with breast cancer and patients with gynaecological cancer in their own multidisciplinary tumour conference (MTC) and their information needs with regard to their disease and treatment options.

METHODS

This is a prospective observational study that took place at six breast cancer and gynaecological cancer centres in North Rhine-Westphalia, Germany. Patient inclusion criteria included a minimum age of 18 years and at least one diagnosis of breast cancer or gynaecological cancer. Three surveys were administered. T0 (shortly before MTC), T1 (directly after MTC) and T2 (4 weeks after MTC). Patient information needs were measured using two three-item subscales of the Cancer Patients Information Needs scale. Analysis of change was done by one-way repeated measures analysis of variance (ANOVA). To control for sampling bias, a further one-way repeated measures analysis of covariance (ANCOVA) included a propensity score as a covariate.

RESULTS

Data from 81 patients in the participation group and 120 patients in the non-participation group were analysed. The patient groups did not differ in their levels of information needs at T0 or T2. From T0 to T2, information needs increased statistically significantly in both groups with regard to both disease-related information (η²=0.354) and treatment-related information (η²=0.250). The increase in both types of information needs lost its statistical significance when the propensity score was included as a covariate. Neither ANOVA nor ANCOVA revealed a statistically significant association between patients' participation in the MTC and their self-reported information needs.

CONCLUSION AND CLINICAL IMPLICATIONS

As concerns patients' information needs, findings do not support a general recommendation for or against the participation of patients in their MTCs. Future research should focus on the different ways of patients' participation in their MTCs facilitated at different cancer centres. Further research should also aim to establish which patient and disease characteristics predispose patients to benefit from participating in their MTCs.

Comprehensive support for families with parental cancer (Family-SCOUT), evaluation of a complex intervention: study protocol for a non-randomized controlled trial

Background

Families with minor children affected by parental cancer are at risk of considerable emotional and organizational stress that can severely burden all family members. So far, there has been a lack of comprehensive support services for affected families. The aim of this project is to implement and evaluate a complex psychosocial intervention for these families by providing advice, information, and care on an emotional, psycho-social, and communicative level during and after the cancer experience and across healthcare sectors.

Methods

Family-SCOUT is a project supported by the German Innovation Fund (https://innovationsfonds.g-ba.de/). The evaluation is based on a mixed-methods quasi-experimental design with the intervention and control groups. A standardized postal survey at three measurement points (T0: study enrollment; T1: 3 months of follow-up; T2: 9 months of follow-up), secondary data from the participating health insurance funds, and semi-structured qualitative interviews are used for summative and formative evaluation. The study aim is to include n=560 families. Data will be analyzed according to the intention-to-treat principle. The primary analysis is the comparison of the Hospital Anxiety and Depression Scale (HADS) response rates (minimal important difference (MID) ≥ 1.6 in at least one of the two parents) at T2 between the intervention and control group using Fisher’s exact test. The conduct of the study as well as the development and implementation of the intervention will be accompanied by comprehensive study monitoring following the principles of an effectiveness-implementation hybrid study.

Discussion

The results will allow to test the effectiveness and efficiency of the intervention for the target group. The first experience with the implementation of the intervention in model regions will be available. The evaluation results will serve as the basis to assess the need of including the intervention in the catalog of services of the statutory health insurance funds in Germany.

Trial registration

ClinicalTrials.gov, NCT04186923. Retrospectively registered on 4 December 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05577-y.

Patient participation in multidisciplinary tumor conferences: How is it implemented? What is the patients' role? What are patients' experiences?

Background

Prior research has shown that around 5%–7% of patients in breast cancer centers in Germany participate in the discussion of their own case within a multidisciplinary tumor conference (MTC). The PINTU study is one of the first to research this practice. The objective is to describe (a) how patient participation in MTCs is implemented, (b) what is the role of patients, and (c) how patients experience MTCs.

Methods

MTCs in six breast and gynecological cancer centers in North Rhine‐Westphalia, Germany, with and without patient participation, are studied prospectively by (non)participatory, structured observation. Breast and gynecological cancer patients completed surveys before, directly after, and 4 weeks after MTC participation. Data are analyzed descriptively.

Results

Case discussions of a sample of n = 317 patients (n = 95 with MTC participation and n = 222 without) were observed. Survey data were obtained from n = 242 patients (n = 87 and n = 155). Observational data showed heterogeneity in the ways MTC participation was practiced. Among participating patients, 89% had the opportunity to express their opinion and 61% were involved in decision‐making. Whereas most patients reported positive experiences and would recommend participation, some had negative experiences and regretted participating.

Conclusions

Due to a lack of recommendations, hospitals implement patient participation in MTCs in many different ways. So far, it is unknown which setting and procedures of MTC participation are beneficial for patients. However, existing evidence on communication in cancer care together with this exploratory study's findings can build the basis for developing recommendations for hospitals that invite their patients to MTCs.

Clinical trial registration number

German Clinical Trials Register Nr. DRKS00012552.

Decision-Making in Multidisciplinary Tumor Boards in Breast Cancer Care - An Observational Study

Purpose

Healthcare providers decide on recommendations for further treatment of patients with cancer in multidisciplinary tumor boards (MTBs). As such, communicative processes during MTBs are assumed to influence decision-making and, thereby, treatment planning. The aim of this exploratory study is to gain insights into decision-making during MTBs.

Methods

Case discussions from MTBs in breast cancer centers in North Rhine-Westphalia, Germany, were observed and audiotaped. The transcripts of the audio recordings were analyzed by procedures of conversation analysis.

Results

Based on 38 case discussions from 15 MTBs in four breast cancer centers, an action scheme for decision-making in MTBs in breast cancer care was developed. In addition, the conversational practices used by the participants during interactions were analyzed.

Conclusion

Analysis indicated that conventions in MTBs were observed during individual phases of decision-making but not for the entire process. Although exchanging multidisciplinary knowledge is an essential aspect of MTBs, this exchange does not always seem to occur in practice. The extent to which recommendations are derived from consensus during MTBs remains unclear. Thus, the study suggests developing standards for communication during MTBs to optimize decision-making and, thus, the quality of recommendation.

Is patient participation in multidisciplinary tumor conferences associated with their fear of progression?

PURPOSE

Previous studies found that some breast cancer patients in Germany are invited to participate in a multidisciplinary tumor conference (MTC) during the discussion of their own case. MTCs are regular meetings of a treatment team in which the diagnosis and treatment plan of cancer patients are discussed. Psychological consequences concerning the patients' participation in an MTC have not been examined yet. This study examines the association between patients' participation in MTC and patients' fear of progression (FoP).

METHODS

This analysis is part of a larger project named "Patient participation in multidisciplinary tumor conferences in Breast Cancer Care" (PINTU) which is a multicenter observational mixed-methods study. The study was conducted in six breast and gynecological cancer centers in North Rhine-Westphalia, Germany. Data were collected from 2018 to 2020 by patient survey at three time points. Patients with (n = 81) and without (n = 120) MTC participation were compared. FoP was measured with a 12-item short form of the FoP Questionnaire (FoP-Q-SF) at all three measurement time points. Data analysis included descriptive statistics, a one-way repeated variance analysis (ANOVA), and a one-way repeated ANCOVA using the propensity score as a covariate.

RESULTS

Data of n = 201 patients were included in the analysis. In general, FoP scores decreased in both groups from T0 to T2 (F = 36.539, p < 0.001, η²  = 0.155). Non-participating patients did not differ with regard to their FoP from patients who participated in an MTC before and after participation. The results of AN(C)OVA revealed no significant effects concerning the influence of patient participation in an MTC on FoP (F = 0.014, p = 0.907, η² = <0.001 and (F = 0.013, p = 0.909, η² = <0.001).

CONCLUSION

Since the FoP is not influenced by participation, the findings do not support recommendations for or against patient participation in an MTC. Further research should focus on the question of which patient groups might benefit from participation in an MTC with regard to which outcome variables.

Opportunities and limitations of shared decision making in multidisciplinary tumor conferences with patient participation - A qualitative interview study with providers

OBJECTIVE

The aim of this study was to examine opportunities and limitations of shared decision making in multidisciplinary tumor conferences with patient participation from the providers' perspective in breast and gynecological cancer centers.

METHODS

Semi-structured guideline-based expert interviews were conducted with providers from breast and gynecological cancer centers with and without patient participation in multidisciplinary tumor conferences. Interviews were transcribed, anonymized and analyzed using qualitative content analysis.

RESULTS

The providers (n = 30) reported that some process steps of shared decision making can be implemented in limited form and under certain conditions in multidisciplinary tumor conferences with patient participation. Above all, patients can potentially ask questions and contribute individual additional information and their preferences.

CONCLUSION

This study contributes first insights into the implementation of shared decision making in multidisciplinary tumor conferences with patient participation. From the providers' perspective, the implementation of shared decision making seems difficult under the current circumstances. Further studies, using patient experiences, participative observations or interventional designs, are required.

PRACTICE IMPLICATIONS

Despite the limited implementation of shared decision making in tumor conferences, patient participation can be advantageous as it can allow patients to ask questions and contribute individual additional information as well as their preferences.

Patient Participation in Multidisciplinary Tumor Conferences from the Providers' Perspective: Is It Feasible in Routine Cancer Care?

Objective

Recent studies from Germany show that a small amount of breast and gynecological cancer patients participate in multidisciplinary tumor conferences (MTCs) at some cancer centers. One reason for the variation by center might be the providers’ attitudes about and experiences with MTC patient participation (MTCpp), which has not been analyzed before. Therefore, it is the aim of this study to analyze the providers’ expected or experienced feasibility concerning MTCpp at breast and gynecological cancer centers in Germany.

Methods

This paper presents cross-sectional qualitative interview data from the PINTU study. From April to December 2018, n=30 health-care providers from n=6 breast and gynecological cancer centers in North-Rhine-Westphalia, Germany, were interviewed. One-half of the providers had no experience and the other half had experience with MTCpp. Inductive and deductive coding was performed in order to capture the feasibility aspects of participation.

Results

MTCpp seems not to be feasible in routine cancer care following providers’ expected barriers and negative experiences. However, MTCpp seems to be feasible for selected cancer patients following providers’ expected opportunities and positive experiences. Our results show that both provider groups report positive and negative experiences or expectations.

Conclusion

The mixed findings regarding expected or experienced feasibility of MTCpp provide first insights into differences concerning MTCpp between organizations. Our results suggest that the providers’ perceptions (expectations and experiences) influence the possibility for patients to participate in an MTC in a cancer center.

Interaktive Gesundheitskompetenz, soziodemografische Faktoren und der Zeitraum bis zur Inanspruchnahme psychotherapeutischer oder medikamentöser Behandlung – gibt es Hinweise auf soziale Ungleichheiten in der Therapie der Sozialen Angststörung?

Ziel Ziel ist die Untersuchung des Zusammenhangs zwischen soziodemografischen Merkmalen sowie der interaktiven Gesundheitskompetenz und dem Zeitraum zwischen der Behandlungsentscheidung und der Inanspruchnahme einer Therapie der Sozialen Angststörung.

Methodik Hierzu wurde eine Online-Befragung von N = 311 Personen mit Sozialer Angststörung durchgeführt (Responserate 54,1 %). Neben deskriptiven statistischen Verfahren wurde eine logistische Regressionsanalyse durchgeführt.

Ergebnisse Die Befragten sind durchschnittlich 46 Jahre alt (20–81), 59 % sind Frauen. Höheres Alter (OR 2,579), nicht in Partnerschaft lebend (OR 1,963), Angst vor persönlichen Kontakten (OR 5,716) und geringe (OR 3,585) bzw. mäßige (OR 3,144) interaktive Gesundheitskompetenz sind signifikant mit der Wartezeit auf eine Behandlung assoziiert.

Schlussfolgerung Die Ergebnisse können als Hinweise auf soziale Ungleichheiten in Bezug auf die Inanspruchnahme einer Therapie bei Personen mit sozialer Angststörung gedeutet werden.

[DNVF Memorandum Health Services Research in Oncology]

Health services research in oncology deals with all situations which cancer patients face. It looks at the different phases of care, i. e. prevention / early detection, prehabilitation, diagnostics, therapy, rehabilitation and palliative care as well as the various actors, including those affected, the carers and self-help. It deals with healthy people (e. g. in the context of prevention / early detection), patients and cancer survivors. Due to the nature of cancer and the existing care structures, there are a number of specific contents for health services research in oncology compared to general health services research while the methods remain essentially identical. This memorandum describes the subject, illustrates the care structures and identifies areas of health services research in oncology. This memorandum has been prepared by the Oncology Section of the German Network for Health Services Research and is the result of intensive discussions.

Patient participation in multidisciplinary tumor conferences: Providers' perceptions of patients' need satisfaction and emotional experiences

OBJECTIVE

In some breast and gynecological cancer centers in Germany, patients participate in multidisciplinary tumor conferences (MTCs) during the discussion of their own case. The aim of this study was to explore providers' perceptions concerning patients' emotional experiences during participation in an MTC by comparing the perspectives of providers with and without experience with patient participation.

METHODS

In this study, semi-structured interviews with n = 30 providers in n = 6 breast and gynecological cancer centers in North Rhine-Westphalia, Germany, were conducted. One half of the providers had no experience and the other half had experience with patient participation in MTCs. The interviews were audiotaped and transcribed, and content analysis was performed.

RESULTS

The results of this study show a mixed picture of met, unmet and disappointed needs of patients and their emotional reactions, which mainly overlap between both provider groups. Our results show that both provider groups report positive and negative experiences or expectations.

CONCLUSION

The mixed results regarding expected and perceived patient experiences from the providers' perspective suggest that patient participation in MTCs may not be exclusively of benefit. Further research on advantages and disadvantages for patients and on feasibility from the providers' perspective is necessary and will be conducted within the PINTU project.

[HIS bundle pacing : Far more than an ECG cosmetic effect]

The therapy for heart failure in patients with uncompromised systolic ventricular function (HfpEF) is still challenging because there is an obvious lack of effective therapy options. Several of these particular patients are additionally presenting atrioventricular (AV) block. In these patients HIS bundle pacing could be a hopeful therapy strategy due to the option of an AV resynchronisation as illustrated in the following case.

Patient participation in multidisciplinary tumour conferences in breast cancer care (PINTU): a mixed-methods study protocol

INTRODUCTION

A central instrument of multidisciplinary care is the multidisciplinary tumour conference (MTC). In MTCs, diagnosis and treatment of cancer patients are discussed, and therapy recommendations are worked out. As we found previously, patients participate in MTCs in some breast cancer centres in the state of North Rhine-Westphalia, Germany. However, studies on risks and benefits of patient participation have not provided substantiated findings. Therefore, the study's objective is to analyse differences between MTCs with and without patient participation.

METHODS AND ANALYSIS

This is an exploratory mixed-methods study. MTCs in six breast and gynaecological cancer centres in North Rhine-Westphalia, Germany, are examined. MTCs will be conducted with and without patient participation. First, interviews with providers concentrating on the feasibility of patient participation and quality of decision-making will be carried out, transcribed and analysed by means of content analysis. Second, videotaped or audiotaped participatory observations in MTCs will be executed. Video data or transcribed audio data from video and audio recordings will be coded using the established "Observational Assessment Rating Scale" for MTCs and analysed by comparing centres with and without patient participation. Third, all patients will fill out a questionnaire before and after MTC, including questions on psychosocial situation, decision-making and expectations before and experiences after MTC. The questionnaire data will be analysed by means of descriptive and multivariate statistics and pre-post-differences within and between groups.

ETHICS AND DISSEMINATION

Consultation and a positive vote from the ethics committee of the Medical Faculty of the University of Cologne have been obtained. For all collected data, relevant data protection regulations will be adhered to. All personal identifiers from patients and providers will be pseudonymised, except video recordings. Dissemination strategies include a discussion with patients and providers in workshops about topics such as feasibility, risks and benefits of patient participation in MTCs.

TRIAL REGISTRATION NUMBER

DRKS00012552.

Health literacy and patient participation in multidisciplinary tumor conferences in breast cancer care: a multilevel modeling approach

Background

Decisions made in multidisciplinary tumor conferences (MTC) that consider patient preferences result in better patient outcomes. Furthermore, it has been shown that in some breast cancer centers in Germany, patients participate in MTCs and that participation is associated with sociodemographic and breast cancer center-related factors. Health literacy (HL) has been shown to be predictive for individual health behavior and is an important prerequisite for patient participation in healthcare. However, so far nothing is known about the association between HL and MTC patient participation. To close this gap in research, we analyzed which patient characteristics affect participation in MTCs and whether participation varies between breast cancer centers.

Methods

In a prospective, multicenter cohort study, newly diagnosed breast cancer patients were surveyed directly after surgery (T1) as well as 10 weeks (T2) and 40 weeks (T3) after surgery. After descriptive analysis, t-tests were conducted, correlations for independent variables were run, and logistic multilevel regression analysis was applied to estimate the association between patient participation in MTCs at T1 and HL (HLS-EU-Q16 [1]), sociodemographic and disease-related characteristics (n = 863 patients) and the variation between breast cancer centers (n = 43 centers).

Results

Descriptive results show that 6.8% of breast cancer patients took part in a MTC. The logistic multilevel regression model revealed that patients with an inadequately HL are less likely to participate in MTCs (OR = 0.31, 95%-CI = 0.1–0.9, Pseudo-R² = 0.06), and participation is dependent on the breast cancer center (ICC = 0.161).

Conclusions

These findings are the first to show significant differences in HL and patient participation in MTCs in a large sample of breast cancer patients. In future research on patient participation in MTCs and HL, questions concerning the organization, communication and decision-making in MTCs with and without patient participation have to be addressed, and patient and provider perspectives must be equally considered.

Trial registration

Database Health Services Research, VfD_PIAT_12_001630, registered prospectively on 01.03.2012.

Sociodemographic and disease-related determinants of return to work among women with breast cancer: a German longitudinal cohort study

Background

Return to work (RTW) is a key parameter of outcome quality that ensures social participation. Therefore, this study analyses the sociodemographic and disease-related determinants of RTW among newly diagnosed breast cancer patients.

Methods

In a prospective, multicentre cohort study, breast cancer patients were surveyed three times: directly after surgery, after 10 weeks, and after 40 weeks. Logistic regression analysis was applied to estimate the association of RTW at 40 weeks following discharge with sociodemographic and disease-related characteristics (n = 577).

Results

The sociodemographic variables “entrance certificate at a university of applied science” compared to “university entrance certificate” (OR = 3.1, 95%-CI = 1.2–8.1), age group “55–59 years” compared to “18–44 years” (OR = 3.2, 95%-CI = 1.2–8.4) and “having children” (OR = 2.8, 95%-CI = 1.2–6.2) as well as the disease-related variables “rehabilitation” (OR = 0.5, 95%-CI = 0.3–0.9), self-rated health “good” and “excellent” compared to “bad” (OR = 2.7, 95%-CI = 1.4–5.5; OR = 11.6, 95%-CI = 4.2–31.8) and the UICC-classification “stage II” and “stage III/IV” in comparison to “stage 0/I” (OR = 0.5, 95%-CI = 0.3–0.8; OR = 0.2, 95%-CI = 0.1–0.5) significantly affect RTW among breast cancer patients (Nagelkerke’s Pseudo-R² = 0.275).

Conclusions

The findings show that significant differences in RTW exist between patient groups and suggest that RTW issues must be addressed more effectively before, during and after treatment. For future research on RTW in Germany, longitudinal studies with a follow-up of several years are necessary. Information and support deficits should be tackled by social services or breast care nurses.

Trial registration

Database Health Services Research, VfD_PIAT_12_001630, registered 01.03.2012

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3768-4) contains supplementary material, which is available to authorized users.

[Health Services Research Facilities at German Universities]

OBJECTIVES

So far, there is a lack of knowledge about the situation of health services research at German universities. The aim of the present study is to provide data about health services research facilities and teaching activity in German universities.

METHODS

An online survey of German university lecturers in the field of health services research was conducted in 2017. The semi-standardized survey contained 25 factual questions. The quantitative responses were analyzed descriptively using IBM SPSS Statistics 24. The open questions were analyzed by content analysis.

RESULTS

N=42 lecturers took part in the survey (response rate 97.6%). Health services research methods are subject to human medicine as well as health science programs. Specific programs in health services research were identified at 3 locations. The doctoral and postdoctoral opportunities in the field of health services research are heterogeneous. In the field of research methods, quantitative methods dominate, in particular patient-reported outcome research with primary data. The most frequently mentioned interdisciplinary cooperation is with biometry/epidemiology and health economics.

CONCLUSION

There is a need for further training for health services researchers in terms of specific terminology, framework models, data sources, evaluation methods, data protection aspects, and health policy aspects. In addition to the training of the health services researchers, it is important to improve the doctoral and habilitation opportunities in the field of health services research in order to encourage and support young scientists in health services research.

Bait acceptability for delivery of oral rabies vaccine to free-ranging dogs on the Navajo and Hopi Nations

In many areas of the world, only 30 to 50% of dogs are vaccinated against rabies. On some US Indian Reservations, vaccination rates may be as low as 5 to 20%. In 2003 and 2004, we evaluated the effectiveness of commercially available baits to deliver oral rabies vaccine to feral and free-ranging dogs on the Navajo and Hopi Nations. Dogs were offered one of the following baits containing a plastic packet filled with placebo vaccine: vegetable shortening-based Ontario slim baits (Artemis Technologies, Inc.), fish-meal-crumble coated sachets (Merial, Ltd.), dog food polymer baits (Bait-Tek, Inc.), or fish meal polymer baits (Bait-Tek, Inc.). One bait was offered to each animal and its behaviour toward the bait was recorded. Behaviours included: bait ignored, bait swallowed whole, bait chewed and discarded (sachet intact), bait chewed and discarded (sachet punctured), or bait chewed and consumed (sachet punctured). Bait acceptance ranged from 30.7% to 77.8% with the fish-meal-crumble coated sachets having the highest acceptance rate of the tested baits.

An anti-MUC1-antibody-interleukin-2 fusion protein that activates resting NK cells to lysis of MUC1-positive tumour cells

MUC1 mucin is aberrantly glycosylated and overexpressed in a number of epithelial malignancies and is therefore a promising tumour-associated antigen for target-directed immunotherapy of a panel of malignant diseases. In MUC1-positive tumours, MHC class I expression is frequently downregulated and MUC1-specific cytotoxic T cells (CTLs) are either not available or in a state of anergy allowing tumour growth without limitation by CTL control. To activate lymphocytes and natural killer (NK) cells, we here generated an anti-MUC1-scFv-IL2 fusion protein (C595scFv-Fc-IL2) that contains the C595 single-chain antibody for MUC1 binding, the human IgG1 CH2CH3 domain for protein dimerisation, and interleukin-2 (IL2) for activation of immunological effector cells. The fusion protein binds to MUC1-derived peptides and to MUC1-positive tumour cells with the same specificity as does the C595 monoclonal antibody. Bound to MUC1, the C595scFv-Fc-IL2 fusion protein stimulates proliferation of human activated lymphocytes in vitro. Upon binding to MUC1-positive MCF7 breast carcinoma cells, moreover, the fusion protein activates resting NK cells to tumour cell lysis. These properties make the C595scFv-Fc-IL2 fusion protein a suitable candidate for the immunotherapy of MUC1-positive tumours.

T-cell activation by recombinant immunoreceptors: impact of the intracellular signalling domain on the stability of receptor expression and antigen-specific activation of grafted T cells

Recombinant immunoreceptors are modularily composed of extracellular antigen binding and intracellular signalling domains that are preferentially derived from CD3zeta or Fc epsilon RIgamma. The impact of the signalling domain on the stability of immunoreceptor expression and function is not completely understood. To address this issue, we generated and expressed a panel of recombinant zeta- and gamma-chain immunoreceptors, respectively, in human peripheral blood T cells. The expression level of zeta-chain immunoreceptors in human T cells is significantly lower than those of the homologous gamma-chain receptors. Low zeta-chain receptor expression in peripheral T cells is because of the intracellular signalling domain and independent of the Fc epsilon RIgamma or CD3zeta transmembrane region. Expression of both receptors decreases upon prolonged cultivation. Shortly after receptor engraftment, target cell lysis and induction of IFN-gamma secretion are mediated with similar efficiency by zeta- and gamma-chain immunoreceptors. Upon prolonged propagation, however, T-cell activation mediated by zeta-chain immunoreceptors is more efficient than by gamma-chain receptors, indicating that the initial high expression level of gamma-chain immunoreceptors compensates its lower activation capacity. Consequently, gamma-chain immunoreceptors exhibit a higher threshold value for specific activation and are more pronouncedly inhibited by soluble ligand antigen compared to the homologous zeta-chain receptor. These findings have substantial consequences for the design of recombinant immunoreceptors for use in adoptive immunotherapy.

Tumor-specific T cell activation by recombinant immunoreceptors: CD3 zeta signaling and CD28 costimulation are simultaneously required for efficient IL-2 secretion and can be integrated into one combined CD28/CD3 zeta signaling receptor molecule

Recombinant immunoreceptors with specificity for the carcinoembryonic Ag (CEA) can redirect grafted T cells to a MHC/Ag-independent antitumor response. To analyze receptor-mediated cellular activation in the context of CD28 costimulation, we generated: 1) CEA+ colorectal tumor cells that express simultaneously B7-1 and B7-2, and 2) CEA-specific immunoreceptors that harbor intracellularly the signaling moities either of CD28 (BW431/26-scFv-Fc-CD28), CD3zeta (BW431/26-scFv-Fc-CD3zeta), or FcepsilonRIgamma (BW431/26-scFv-Fc-gamma). By retroviral gene transfer, we grafted activated T cells from the peripheral blood with these immunoreceptors. T cells that express the FcepsilonRIgamma or CD3zeta signaling receptor lysed specifically CEA+ tumor cells and secreted high amounts of IFN-gamma upon receptor cross-linking, whereas anti-CEA-CD28 receptor-grafted T cells did not, indicating that CD28 signaling alone is not sufficient for efficient T cell activation. CD28 costimulation did not affect cytolysis by T cells equipped with gamma- or zeta-signaling receptors, but enhanced both IFN-gamma secretion and proliferation. CD28 costimulation, however, was required for efficient IL-2 secretion of anti-CEA-gamma receptor-grafted T cells. Both purified CD4+ and CD8+ T cells grafted with immunoreceptors required CD28 costimulation for complete T cell activation. We integrated both CD28 and CD3zeta signaling domains into one combined immunoreceptor molecule (BW431/26-scFv-Fc-CD28/CD3zeta) with dual signaling properties. T cells grafted with the combined CD28/CD3zeta signaling receptor secreted high amounts of IL-2 upon Ag binding without exogenous B7/CD28 costimulation, demonstrating that both MHC-independent cellular activation and CD28 costimulation for complete T cell activation can be delivered by one recombinant receptor molecule.

CD4+ T cells engrafted with a recombinant immunoreceptor efficiently lyse target cells in a MHC antigen- and Fas-independent fashion

T cells engrafted by a recombinant immunoreceptor with predefined Ag specificity can efficiently lyse Ag-positive target cells in a MHC Ag-independent manner. It is yet unresolved how receptor-grafted CD4+ T cells contribute to MHC Ag-independent target cell lysis. To address this issue, we grafted isolated CD8+ and CD4+ T cells from the peripheral blood with recombinant anti-carcinoembryonic Ag and anti-CD30 receptors, respectively. Cytotoxicity analyses revealed that grafted CD4+ T cells exert cytolysis of Ag-positive target cells with an efficiency similar to that of grafted CD8+ T cells. Lysis by receptor-grafted CD4+ T cells is Ag specific and is inhibited by blocking the target Ag or the Ag binding site of the recombinant receptor. Both Fas-sensitive and Fas-resistant target cells are lysed with equal efficiency, and lysis of Fas-sensitive target cells is not blocked by an anti-Fas ligand Ab, indicating that cytolysis by receptor-grafted CD4+ T cells is independent of the Fas pathway. We conclude that cytolysis by CD4+ T cells equipped with a recombinant immunoreceptor is MHC Ag and Fas independent and likely to be mediated by perforin present in receptor-grafted CD4+ T cells.

T cells engrafted with a recombinant anti-CD30 receptor target autologous CD30(+) cutaneous lymphoma cells

T cells can be directed to antigen-specific, MHC-independent target cell lysis by grafting with a recombinant receptor with antibody-like specificity. Here, we asked whether T cells from the peripheral blood of a patient with cutaneous T cell lymphoma can be recruited for an immune response against autologous tumor cells. Lymphoma cells with a CD3(-) CD4(+) CD30(+) phenotype and clonal TCR-Vbeta7 rearrangement were isolated from a cutaneous lesion. The lymphoma lesion additionally harbored CD3(+) CD25(+) activated normal T cells despite ongoing tumor progression. Peripheral blood-derived T cells from the lymphoma patient were retrovirally engrafted with a recombinant anti-CD30-scFv-gamma receptor. Upon cocultivation with autologous CD30(+)lymphoma cells, grafted T cells increase IFN-gamma secretion and lyse specifically lymphoma cells with high efficiency, even at an effector to target cell ratio of as low as 1:20. Our data demonstrate that the recombinant anti-CD30-gamma receptor overcomes T cell tolerance for tumor cells and directs T cells specifically against autologous lymphoma cells.

A novel strategy in the elimination of disseminated melanoma cells: chimeric receptors endow T cells with tumor specificity

The application of immunotherapy to the treatment of micrometastases of melanoma has attracted growing interest in recent years. This trend reflects, at least in part, the disappointing results of conventional chemotherapy, the identification of melanoma-associated antigens suitable to be used as targets for immunotherapy, and the significant progress in our understanding of molecular processes involved in the development of an immune response. Because of the general belief that T cell immunity plays a major part in the control of tumor growth, we have recently applied a novel strategy to target cytolytic T cells to melanoma cells. The strategy bypasses the requirement of presentation of melanoma-associated-antigen-derived peptides by the major histocompatibility complex to the T cell receptor complex by permanent grafting of T cells with a recombinant, chimeric T cell receptor. The extracellular moiety of the grafted receptor contains the antigen-binding domain, consisting of a single-chain antibody fragment (scFv) derived from a monoclonal antibody specific for the high-molecular-weight melanoma-associated antigen (HMW-MAA). The intracellular receptor moiety contains the cellular activation domain, consisting of the gamma-signaling chain derived from the Fc epsilon RI receptor. Cytotoxic T cells grafted with the chimeric anti-HMW-MAA scFv-gamma signaling receptor specifically lyse HMW-MAA-positive melanoma cells in a human leukocyte antigen class I-independent fashion. The chimeric T cell receptor strategy is designed to eliminate disseminated tumor cells by the power of cytolytic T cells that physiologically penetrate tissues and that are specifically activated by the grafted receptor after binding to antigen-positive melanoma cells.

T-cell activation by recombinant receptors: CD28 costimulation is required for interleukin 2 secretion and receptor-mediated T-cell proliferation but does not affect receptor-mediated target cell lysis

Recombinant T-cell receptors with antibody-like specificity are successfully used to direct CTLs toward a MHC-independent immune response against target cells. Here we monitored the specific activation of receptor grafted CTLs in the context of CD28 costimulation. Peripheral blood T cells were retrovirally engrafted with recombinant anti-CD30 and anti-carcinoembryonic antigen receptors, respectively, that harbor either the Fc epsilonRI-gamma or the CD3-zeta intracellular signaling domain. Cross-linking of recombinant receptors by solid-phase bound ligand, i.e., CD30 and a carcinoembryonic antigen receptor-specific anti-idiotypic antibody, respectively, induces IFN-gamma secretion that is further enhanced by CD28 costimulation of grafted T cells. Induction of interleukin (IL)-2 secretion, in contrast, requires CD28 costimulation in addition to receptor cross-linking, irrespective of T-cell preactivation by anti-CD3 monoclonal antibody plus IL-2 or by anti-CD3 monoclonal antibody plus anti-CD28 monoclonal antibody. Accordingly, induction of IL-2 secretion upon receptor cross-linking by membrane-bound antigen requires CD28/B7 costimulation whereas IFN-gamma secretion and cell proliferation does not. The efficiency of cytolysis by receptor-grafted CTLs does not depend on and is not affected by CD28 costimulation. The data demonstrate that CTL proliferation, cytokine secretion, and cytolysis upon receptor cross-linking are differentially modulated by CD28 costimulation and that cytolysis does not require B7 expression on target cells.

Dermal fibroblasts sustain proliferation of activated T cells via membrane-bound interleukin-15 upon long-term stimulation with tumor necrosis factor-alpha

In chronic inflammatory conditions, mononuclear cells infiltrate the connective tissue attracted by fibroblast-secreted chemokines. The role of fibroblasts in sustaining the lymphocyte immune response upon cellular infiltration is so far unresolved. We here report that, upon prolonged stimulation with tumor necrosis factor-alpha, dermal fibroblasts enhance proliferation of activated T cells whereas unstimulated fibroblasts do not. T cell growth stimulation requires cell contact of tumor necrosis factor-alpha stimulated fibroblasts to T cells and is not due to soluble factors. Growth stimulation is substantially blocked by neutralizing antibodies to interleukin-15. Fluorescence-activated cell sorter analyses revealed that tumor necrosis factor alpha stimulated fibroblasts expose interleukin-15 in a membrane-bound form on the cell surface whereas nonstimulated fibroblasts and interferon-gamma treated fibroblasts do not. The amount of membrane interleukin-15 increases with the duration of tumor necrosis factor-alpha stimulation for at least 3 d. Unstimulated fibroblasts, however, accumulate interleukin-15 in the cytoplasm. No interleukin-15 could be detected in the culture supernatant. Immunohistochemical analyses confirmed membrane interleukin-15 on dermal fibroblasts in discoid lupus erythematosus skin lesions whereas no membrane interleukin-15 was found on the surface of fibroblasts in healthy skin. We conclude that dermal fibroblasts upon long-term tumor necrosis factor-alpha stimulation during chronic inflammation are involved via membrane-bound interleukin-15 in stimulating proliferation of accumulated, activated T cells.

T cell activation by recombinant FcepsilonRI gamma-chain immune receptors: an extracellular spacer domain impairs antigen-dependent T cell activation but not antigen recognition

T cells can be endowed with antigen specificity by grafting with a chimeric receptor consisting of an extracellular antigen binding moiety (scFv) derived from an antibody and an intracellular signaling domain. Conflicting data exist on the impact of an extracellular spacer domain between the antigen binding and the signaling domain with respect to cellular activation. Here, we recorded conjugate formation and antigen-driven cellular activation of T cells grafted with receptor molecules that contain the same antigen binding site (anti-CD30 HRS3-scFv) and signaling domain (FcepsilonRI gamma-chain), however, with and without an IgG1 CH2CH3 (Fc) spacer domain between the scFv and transmembrane moiety. Receptors of both configurations mediate equally efficient conjugate formation between receptor grafted T cells and antigen-positive target cells. Specific signaling by the spacer containing receptor, however, is blocked by five- to 10-fold lower concentrations of soluble antigen than by the spacer-less receptor indicating a higher avidity of the spacer containing receptor to soluble antigen. In contrast, cellular activation upon binding to antigen-positive cells is mediated more efficiently by the spacer-less receptor. This demonstrates that the extracellular spacer domain impairs antigen-dependent cellular activation by the chimeric immune receptor, but not intercellular conjugate formation.

Enhanced green fluorescent protein fusion proteins of herpes simplex virus type 1 thymidine kinase and cytochrome P450 4B1: applications for prodrug-activating gene therapy

To monitor therapeutic transgene expression, we developed fusion genes of enhanced green fluorescent protein (EGFP) with two different prodrug-activating enzyme genes: herpes simplex virus type 1 thymidine kinase (HSV-tk) and rabbit cytochrome P450 4B1 (cyp4b1). Expression of the resulting fusion proteins, TK-EGFP and 4B1-EGFP, rendered transduced human and rodent glioma cells sensitive to cytotoxic treatment with the corresponding prodrugs ganciclovir and 4-ipomeanol. Ganciclovir and 4-ipomeanol sensitivity was comparable with that achieved with the native HSV-TK and CYP4B1 proteins. As shown by fluorescence microscopy, TK-EGFP was expressed predominantly intranuclearly, whereas 4B1-EGFP was detectable in the cytoplasm, thereby displaying the orthotopic subcellular distribution of the corresponding native enzymes. The fluorescence intensity correlated well with the corresponding prodrug sensitivity, as shown by fluorescence-activated cell sorter analysis. EGFP expression was also used for the selection of stably HSV-tk-transduced cells by flow cytometric cell sorting. Resulting cell populations showed a homogeneity of fluorescence intensity similar to single-cell clones after antibiotic selection. In conclusion, tk-egfp and 4b1-egfp fusion genes are valuable tools for monitoring prodrug-activating gene therapy in living cells. EGFP fusion genes/proteins provide a simple and reproducible means for the detection, selection, and characterization of cells expressing enzyme genes for prodrug activation.

Characterization of a chimeric T-cell receptor with specificity for the Hodgkin's lymphoma-associated CD30 antigen

Recombinant receptors with antibody-like specificity for tumor-associated antigens were shown to direct specifically T cells to target tumor cells. Hodgkin and Reed-Sternberg cells, the malignant cell population in Hodgkin's lymphoma, express high amounts of the cell surface antigen CD30. An anti-CD30 T-cell receptor with cellular activation properties is expected to graft T cells with specificity to Hodgkin cells. Here, the authors characterize a chimeric T-cell receptor with an extracellular domain consisting of the single-chain antibody fragment HRS3-scFv with specificity for the CD30 antigen and intracellular domain of the signal transducing part of the Fc-epsilon-I-gamma receptor. The HRS3-scFv was derived from the monoclonal anti-CD30 antibody HRS3 and retained specificity for the CD30 antigen. The recombinant HRS3-scFv-gamma receptor was expressed under control of the RSV-LTR after transfection into MD45 T-cells. The chimeric receptor protein is detected and analyzed by enzyme-linked immunosorbent assay (ELISA) and immunoprecipitation. Expression of the chimeric receptor converts MD45 T cells to specificity for CD30+ lymphoma cells. Specific cross-linking of the chimeric receptor with antigen resulted in cytolytic reactivity against CD30+ tumor cells in vitro. The results demonstrate that the chimeric receptor HRS3-scFv-gamma converts T cells to a specific MHC-unrestricted cytolytic response against CD30+ tumor cells offering an alternative strategy in cellular immunotherapy of Hodgkin's disease.

Specific lysis of melanoma cells by receptor grafted T cells is enhanced by anti-idiotypic monoclonal antibodies directed to the scFv domain of the receptor

Malignant transformation of melanocytes is frequently associated with abnormalities in antigen processing and in human leukocyte antigen class I antigen expression. Here, we evaluated a human leukocyte antigen class I antigen-independent approach to target cytotoxic T lymphocytes to melanoma cells by grafting cytotoxic T lymphocytes with a chimeric receptor that consists of both a domain binding to high molecular weight-melanoma associated antigen and a cellular activation domain. The binding domain is a single-chain antibody fragment (scFv) derived from the monoclonal anti-high molecular weight-melanoma associated antigen antibody 763.74 by phage display techniques. The cellular activation domain is the signaling unit of the FcepsilonRI receptor gamma chain. Both domains constitute the chimeric receptor scFv763.74-gammaR. Cytotoxic MD45 T cells grafted with the scFv763.74-gammaR receptor bind specifically to high molecular weight-melanoma associated antigen-positive melanoma cells and lyse melanoma cells in a human leukocyte antigen class I independent fashion. Pre-incubation of receptor grafted T cells with immobilized anti-idiotypic (id) monoclonal antibody MK2-23 binding to the scFv domain of the receptor enhanced the lysis of melanoma cells indicating that the specific cytolytic activity of receptor grafted T cells can be increased by costimulation with cross-linked anti-idiotypic monoclonal antibodies that recognize the antigen binding domain of the chimeric receptor.

A chimeric receptor that selectively targets membrane-bound carcinoembryonic antigen (mCEA) in the presence of soluble CEA

Chimeric T cell receptors with specificity for tumor-associated antigens are successfully used to target T cells to tumor cells. The efficacy of this approach, however, is reduced by soluble antigen that is frequently present in high serum concentrations. To overcome this situation, we constructed an anti-CEA chimeric receptor whose extracellular moiety is composed of a humanized single chain antibody fragment (scFv) derived from the anti-CEA mAb BW431/26 and the CH2/CH3 constant domains of human IgG. The intracellular moiety consists of the gamma-signaling chain of the human Fc epsilon RI receptor constituting a completely humanized chimeric receptor. After transfection, the humBW431/26 scFv-CH2CH3-gamma receptor is expressed as a homodimer on the surface of MD45 T cells. Co-incubation with CEA+ tumor cells specifically activates grafted MD45 T cells indicated by IL-2 secretion and cytolytic activity against CEA+ tumor cells. Notably, the efficacy of receptor-mediated activation is not affected by soluble CEA up to 25 micrograms/ml demonstrating the usefulness of this chimeric receptor for specific cellular activation by membrane-bound CEA even in the presence of high concentrations of CEA, as found in patients during progression of the disease.

Generation of the single chain antibody fragment conserves the idiotypic profile of the anti-CD30 monoclonal antibody HRS3

Recombinant single chain antibody fragments (scFv) derived by combining immunoglobulin VL and VH regions provide valuable antibody-like reagents. A number of them are shown to have retained the antigen specificity of the parental monoclonal antibody (MoAb). Little is known about the idiotypic profile of scFv fragments compared with that of the parental MoAb. To address this question we analysed the idiotypic profile of a scFv that was derived by phage-display techniques from the anti-CD30 MoAb HRS3. We assayed (i) binding of HRS3-scFv to recombinant CD30-Fc antigen and to four different anti-idiotypic MoAbs defining at least three different idiotopes on HRS3, and (ii) cross-competition with the parental MoAb HRS3 and the closely related anti-CD30 MoAb HRS4. The assays revealed that the HRS3-scFv fragment exhibits the same specificity for both CD30 antigen and the tested anti-idiotypic MoAbs compared with the parental MoAb demonstrating that the recombinant scFv fragment has retained the complete idiotope of the parental MoAb.

Isolation of single chain antibody fragments with specificity for cell surface antigens by phage display utilizing internal image anti-idiotypic antibodies

Recombinant single chain antibody fragments (scFv) with specificity for membrane-bound antigens can be isolated by phage display techniques. The strategy involves selection of recombinant phage antibodies by binding to cells expressing the respective antigen. This results frequently in high nonspecific adherence of phages to cellular membranes. To resolve the problem we have made use of an internal image anti-idiotypic antibody mimicking the membrane-bound CD30 antigen and successfully isolated scFv fragments with specificity for CD30. The cDNA coding for the immunoglobulin heavy and light chain variable regions of the anti-CD30 monoclonal antibody (mAb) HRS3 was expressed by phage display techniques. Recombinant HRS3-scFv phages were efficiently enriched by one cycle of panning on the internal image anti-idiotypic mAb 9G10. The isolated HRS3-scFv clone retained the binding specificity of the parental mAb HRS3 to the internal image anti-idiotypic mAb 9G10 as well as to an anti-idiotypic mAb without the internal image. Furthermore HRS3-scFv reacted with recombinant and cell-bound CD30 antigen, respectively. Binding of scFv fragments to anti-idiotypic mAbs will provide a versatile strategy for the efficient isolation of recombinant antibody fragments.

Chimeric anti-TAG72 receptors with immunoglobulin constant Fc domains and gamma or zeta signalling chains

We recently described the generation and expression of a chimeric T cell receptor with specificity for the tumor antigen TAG72 consisting of the single chain antibody (scFv) B72.3-scFv and the gamma chain of the FcepsilonRI receptor. The corresponding chimeric receptor containing the zeta chain of the TCR as signalling unit is not functionally expressed reflecting that the requirements for functional expression of chimeric receptors containing the gamma signalling chain are apparently different compared to those containing the CD3zeta signalling chain of the TCR. We describe a novel set of chimeric anti-TAG72 receptors including in their extracellular moiety the constant immunoglobulin CH2/3 domains that allow stable expression of chimeric gamma as well as zeta receptors. We designed anti-TAG72 receptors that consist of a scFv fragment derived from an anti-TAG72 second generation antibody (CC49) and of the CH2/3 domains of the human IgG and intracellularily either of the zeta or gamma signalling chain. The recombinant CC49-CH2/3-zeta and CC49-CH2/3-gamma DNA, respectively, was transfected into MD45 T cells and expressed under control of the RSV LTR. Both receptors were found on the cell membrane of transfected cells as demonstrated by flow cytometry analysis using an anti-human IgG Fc antibody directed to the CH2/3 immunoglobulin domains of the chimeric receptor. Specific cross-linking of the chimeric zeta as well as the gamma receptor by antigen or anti-human Ig antibodies resulted in specific activation of transfected cells. Our results demonstrate that both the gamma chain and the zeta chain++ containing receptor are stably expressed and convert T cells to specificity for the TAG72 antigen. This receptor design will facilitate efficient generation of genetically modified peripheral T cells and may provide valuable tools for the cellular immunotherapy of TAG72+ tumors.

An anti-CD30 chimeric receptor that mediates CD3-zeta-independent T-cell activation against Hodgkin's lymphoma cells in the presence of soluble CD30

Hodgkin's lymphoma patients fail to establish an efficient cellular response against CD30+ Hodgkin/Reed-Sternberg cells. An impaired T-cell receptor/CD3-zeta-mediated activation of T cells is thought to be involved in this situation. We here present a chimeric anti-CD30 receptor that mediates MHC and T-cell receptor/CD3-zeta-independent T-cell activation against CD30+ lymphoma cells even in the presence of soluble CD30. The receptor consists of the binding domain of the monoclonal antibody HRS3 and the signaling unit of the Fc epsilonRI-receptor gamma-chain. After expression in MD45 T cells, receptor cross-linking with immobilized anti-idiotypic monoclonal antibody and CD30+ cells, respectively, results in increased interleukin 2 secretion and specific cytolysis of CD30+ Hodgkin's lymphoma cells. Soluble CD30 in concentrations up to 6000 units/ml did not interfere with cellular activation induced by membrane-bound antigen. This demonstrates the feasibility of the chimeric anti-CD30-scFv-gamma receptor in CD30+ lymphoma cell targeting, even in the presence of as high concentrations of soluble CD30 as are found in patients during progression of the disease.

T cell targeting of TAG72+ tumor cells by a chimeric receptor with antibody-like specificity for a carbohydrate epitope

BACKGROUND & AIMS

Chimeric receptors with specificity for defined tumor antigens are valuable tools for targeting cytolytic T cells specifically to tumor cells. The aim of this study, for the situation of gastrointestinal cancer, was to investigate the generation of a chimeric T cell receptor that specifically binds the tumor antigen TAG72 (CA72-4) and transmits a signal for cellular activation.

METHODS

A single-chain antibody (scFv) was derived from the monoclonal anti-TAG72 antibody B72.3 by phage display techniques (B72.3-scFv) and fused to the signaling unit of the Fc epsilon-RI receptor gamma chain, resulting in a chimeric signaling receptor, B72.3-scFv-gamma.

RESULTS

The B72.3-scFv and the chimeric B72.3-scFv-gamma receptor bound specifically to the TAG72 antigen. After transfection, T cells expressing the chimeric B72.3-scFv-gamma specifically recognized TAG72 positive cells. Cross-linking of the chimeric receptor with antigen resulted in interleukin 2 release and cytolytic activity against TAG72 positive tumor cells in vitro.

CONCLUSIONS

T cells equipped with the chimeric anti-TAG72 receptor can be specifically activated to target and lyse TAG72 positive gastrointestinal tumor cells.