A realist evaluation of an enhanced court-based liaison and diversion service for defendants with neurodevelopmental disorders

BACKGROUND

In England, court-based mental health liaison and diversion (L&D) services work across courts and police stations to support those with severe mental illness and other vulnerabilities. However, the evidence around how such services support those with neurodevelopmental disorders (NDs) is limited.

AIMS

This study aimed to evaluate, through the lens of court and clinical staff, the introduction of a L&D service for defendants with NDs, designed to complement the existing L&D service.

METHODS

A realist evaluation was undertaken involving multiple agencies based within an inner-city Magistrates' Court in London, England. We developed a logic model based on the initial programme theory focusing on component parts of the new enhanced service, specifically training, screening, signposting and interventions. We conducted semi-structured interviews with the court staff, judiciary and clinicians from the L&D service.

RESULTS

The L&D service for defendants with NDs was successful in identifying and supporting the needs of those defendants. Benefits of this service included knowledge sharing, awareness raising and promoting good practice such as making reasonable adjustments. However, there were challenges for the court practitioners and clinicians in finding and accessing local specialist community services.

CONCLUSION

A L&D service developed for defendants with NDs is feasible and beneficial to staff and clinicians who worked in the court setting leading to good practice being in place for the defendants. Going forward, a local care pathway would need to be agreed between commissioners and stakeholders including the judiciary to ensure timely and equitable access to local services by both defendants and practitioners working across diversion services for individuals with NDs.

Severe mental illness, common mental disorders, and neurodevelopmental conditions amongst 9088 lower court attendees in London, UK

BACKGROUND

Court Mental Health Liaison and Diversion Services (CMHLDS) have developed in some countries as a response to the over-representation of mental illness and other vulnerabilities amongst defendants presenting to criminal justice (or correctional) systems. This study examined the characteristics and rates of mental disorder of 9088 defendants referred to CMHLDS.

METHOD

The study analysed service level data, obtained from the National Health Service's mental health data set, to examine characteristics relating to gender, ethnicity and comorbidity of common mental and neurodevelopmental disorders at five CMHLDS across London between September 2015 and April 2017.

RESULTS

The sample included 7186 males (79.1%) and 1719 females (18.9%), the gender of 183 (2%) were not recorded. Of those referred, 6616 (72.8%) presented with an identifiable mental disorder and 503 (5.5%) with a neurodevelopmental disorder (NDD). Significantly higher rates of schizophrenia were reported amongst Black defendants (n = 681; 37.2%) and Asian defendants (n = 315; 29%), while higher rates of depression were found amongst White defendants (n = 1007; 22.1%). Substance misuse was reported amongst 2813 defendants (31%), and alcohol misuse amongst 2111 (23.2%), with significantly high rates of substance and alcohol misuse amongst defendants presenting with schizophrenia or personality disorder.

CONCLUSIONS

This is one of the largest studies to examine mental health needs and vulnerabilities amongst defendants presenting to CMHLDS. It will enable an improved understanding of the required service designs and resources required to manage the healthcare pathways for people attending CMHLDS.

Evaluation of a liaison and diversion Court Mental Health Service for defendants with neurodevelopmental disorders

AIM

Neurodevelopmental disorders (NDD) may present as neuropsychiatric problems as well as impairments of motor, cognitive, social and communication functioning. This study describes the introduction of a specialist service with expertise in NDD into an existing court mental health liaison and diversion service to determine if the service would impact on the health needs or disposal outcomes of defendants.

METHODS

We examined referrals of defendants with NDD disorders over 30-months at a London Magistrates' Court. The pre-existing Court Mental Health (CMH) service was enhanced to provide additional expertise and hereafter referred to as the CMH + NDD Service. Baseline data including gender, ethnicity, remands and the rates of mental disorders was collected from the CMH Service using the existing minimum mental health service dataset. This was compared with data collected from the CMH + NDD Service.

RESULTS

We found the following rates of NDD 9.5 % (n = 43) for the CMH service, and 9.5 % (n = 79) for the CMH + NDD service. Although overall the rates were the same the number of defendants with a single NDD diagnosis was increased in the CMH + NDD service with ADHD 10 %, ASD and ID 4% higher, the rates of comorbid NDD decreased in the CMH + NDD service compared to baseline. Specific disorders such as depression were recorded at higher rates for NDD defendants in both phases, however, this did not reach significance. In contrast, schizophrenia and delusional disorders, alcohol and substance use were observed at much higher in the non-NDD defendants during both phases of the study. The rates of diagnosis of schizophrenia and delusional disorders increased for the NDD group within the CMH + NDD service. Following the first court appearance, there was a 10 % reduction in custodial remands for defendants with NDD who were seen by the CMH + NDD service (34.2 %, n = 25 in the CMH + NDD service vs 43.8 %, n = 14 in the CMH service).

CONCLUSION

The study found it is possible to successfully integrate practitioners with expertise of NDD into existing liaison and diversion services. This service enhancement demonstrated modest evidence of service effectiveness, including an increase in the detection of comorbid mental illness and a reduction in custodial remands for defendants with NDD. Further work needs to be completed to examine how this model can be rolled out across multiple courts and in particular, a cost-benefit analysis is required to understand whether an approach involving a cluster of Courts, as opposed to a single site is the most effective approach for this group of defendants.

Generation of a humanized Aβ expressing mouse demonstrating aspects of Alzheimer's disease-like pathology

The majority of Alzheimer's disease (AD) cases are late-onset and occur sporadically, however most mouse models of the disease harbor pathogenic mutations, rendering them better representations of familial autosomal-dominant forms of the disease. Here, we generated knock-in mice that express wildtype human Aβ under control of the mouse App locus. Remarkably, changing 3 amino acids in the mouse Aβ sequence to its wild-type human counterpart leads to age-dependent impairments in cognition and synaptic plasticity, brain volumetric changes, inflammatory alterations, the appearance of Periodic Acid-Schiff (PAS) granules and changes in gene expression. In addition, when exon 14 encoding the Aβ sequence was flanked by loxP sites we show that Cre-mediated excision of exon 14 ablates hAβ expression, rescues cognition and reduces the formation of PAS granules.

Changes in central motor conduction with physiotherapy in multiple sclerosis: a case report

Magnetic stimulation was used to assess central motor conduction times in a patient with multiple sclerosis before and after physiotherapy. A significant change in central motor conduction corresponding to clinical improvement was noted after physiotherapy.

Abstract P2-11-03: Phase I/II randomized study of combination immunotherapy with or without polysaccharide krestin (PSK) concurrently with a HER2 ICD peptide-based vaccine in patients with stage IV breast cancer receiving HER2-targeted monoclonal antibody therapy

Natural killer (NK) cell defects, commonly seen in metastatic breast cancer (MBC) lead to decrease in dendritic cell (DC) maturation, proinflammatory cytokine production, and tumor infiltrating T-cells (TILs). This results in a protumorigenic Th2 immune microenvironment with low response rates to immunotherapy (i.e., immune checkpoint blockade) and standard chemotherapy. PSK, a potent TLR-2 agonist, activates NK cells to produce IFN-γ and IL-12 and promote DC maturation/differentiation toward a Th1 profile in the tumor microenvironment which results in antigen specific TIL that can eradicate tumor. The combination immunotherapy of PSK and HER2 directed therapy described here, aims at inducing Th1 immunity and tumor specific T-cells. This proposed regimen could eradicate microscopic residual disease and prevent recurrence in optimally treated HER2+ MBC patients. Moreover, the regimen could result in enhanced trafficking of TILs to the site of tumor and improve the efficacy of checkpoint inhibitors and other therapies. A phase I/II randomized 2 arm study of combination immunotherapy with oral PSK (or placebo) given with a HER2 peptide vaccine and HER2 mAb therapy (trastuzumab (TZ) +/- pertuzumab (PZ)) was initiated to assess the safety of the approach and evaluate the effect of PSK on NK cell activity, pro-inflammatory cytokine/chemokine profile; and HER2 vaccine-induced T cell immunity.

Methods: Up to 30 patients with HER2+ MBC who are without evidence of disease after definitive therapy and currently on maintenance TZ +/- PZ are enrolled and randomly assigned in equal numbers to 1 of 2 arms (15 patients/arm): Arm 1: HER2 ICD vaccine + placebo or Arm 2: HER2 ICD vaccine + PSK. All patients receive concomitant treatment with 4 months of daily oral PSK or placebo, 3 monthly intradermal HER2 ICD vaccinations and continued TZ +/- PZ. Toxicity is evaluated per CTEP CTCAE 4.0, during and post vaccination. Serial blood draws for immunologic evaluation of NK cell activity and antigen-specific T cell immunity via flow cytometry and IFN-γ ELISPOT, respectively; and pro-inflammatory cytokines/chemokines.

Results: 24 subjects have been enrolled and 60 vaccines have been given. 16 subjects have completed all 3 vaccines and PSK/placebo; and 6 subjects are currently in progress. 2 subjects received < 3 vaccines and were taken off study. Of 144 reported adverse events (AEs), 97% were Grade 1-2; 66 (46%) were possibly, probably, or definitely related to study treatment. Most common AEs are injection site reaction and flu-like symptoms. There have been a total of four Grade 3 AEs, 1 episode of self-limited nausea/vomiting attributed to study treatment; and cognitive disturbance, fatigue, and lymphopenia all in 1 subject and attributed to disease progression. There have been no Grade 4 AEs. Immunologic analyses are ongoing and will be presented along with completed clinical data on all patients.

Conclusion: Combination immunotherapy with PSK/placebo and concurrent HER2 directed therapy is safe and well-tolerated. Further ongoing immunologic studies will help define the immunogenicity of the approach.

Citation Format: Salazar LG, Higgins D, Childs J, Coveler AL, Liao J, Stanton S, Gooley T, Standish LJ, Sasagawa M, DISIS ML. Phase I/II randomized study of combination immunotherapy with or without polysaccharide krestin (PSK) concurrently with a HER2 ICD peptide-based vaccine in patients with stage IV breast cancer receiving HER2-targeted monoclonal antibody therapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-11-03.

Abstract P2-11-05: Overall survival in inflammatory breast cancer patients receiving Her-2 Neu directed tumor vaccine therapy: Matched comparison with SEER registry patients

Background

Patients with inflammatory breast cancer (IBC) have a poor prognosis, primarily due to distant dissemination. Additionally, IBC patients have an increased rate of HER2 overexpression when compared to patients with non-inflammatory breast cancer. The forms the rationale for HER2 directed tumor vaccine therapy in these patients. The purpose of this study was to examine overall survival in IBC patients receiving HER2 directed tumor vaccine therapy when compared with matched control patients from the SEER Registry.

Methods

Patients with diagnosis of Stage III or IV HER2 positive IBC having completed standard initial therapy and without evidence of disease received HER2 vaccinations after being enrolled on 5 prospective clinical trials. Overall survival data were pooled and analyzed. A control group of matched IBC patients were identified by querying the SEER database from 1997-2011. The control group was identified as any individual in the database with a code for IBC. A secondary analysis comparing survival in HER2 positive IBC vs HER2 negative IBC patients was performed by querying the SEER database from 2010 onwards, the time point when the HER2 status was coded in the database. Propensity score adjustment were made to the control group to account for any imbalances between groups in measured covariates such as stage, race, age, sex, and era of enrollment and the time interval from diagnosis to enrollment on vaccine trial (median ∼2 years).

Results

A total of 37 IBC patients received HER2 directed vaccine therapy and 676 patients were identified for the SEER control group; Stage at enrollment: stage IIIB: 30 patients in the vaccine group and 639 patients in the control group; stage IIIC: 1 patient in the vaccine group and 15 patients in the control group; stage IV 6 patients in the vaccine group and 22 in the control group. The median survival of the overall population was 112 months for the vaccine group and 47 months for the control group (p=0.04). After using propensity scores to adjust the control for imbalances in measured covariates, the median survival for the overall population was 112 months for the vaccine group and 37 months for the control group (p=0.03). There was no difference in survival between HER2 positive and HER2 negative IBC patients in the control group (p=0.6).

Conclusion

These results demonstrate promising overall survival in HER2 positive IBC patients receiving HER2 directed vaccine therapy after initial therapy. Propensity matching was performed to adjust for imbalances in measured covariates and resulted in a modest decrease in survival of the control group after adjustment, suggesting that the vaccine trial group had relatively unfavorable pre-treatment characteristics. Despite these unfavorable characteristics, patients receiving vaccine had a median survival of 112 months. These results must be further confirmed in a prospective randomized trial.

Citation Format: Rengan R, Baker K, Salazar L, Childs J, Higgins D, Redman M, Reichow J, Disis ML. Overall survival in inflammatory breast cancer patients receiving Her-2 Neu directed tumor vaccine therapy: Matched comparison with SEER registry patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-11-05.

Inferior outcomes of total knee replacement in early radiological stages of osteoarthritis

BACKGROUND

Total knee replacement (TKR) for osteoarthritis (OA) is a common and successful operation; the severity of radiographic changes plays a key role as to when it should be performed. This study investigates whether an early radiological grade of OA has an adverse effect on the outcome of TKR in patients with arthroscopically confirmed OA.

METHODS

Between January 2006 and January 2011 data was collected prospectively on all patients undergoing a primary TKR for OA. We included all patients with a Kellgren-Lawrence score of two or less on their pre-operative radiograph who had had an arthroscopy to confirm significant OA. Our primary outcomes were the Oxford Knee Score (OKS) and a satisfaction rating.

RESULTS

Over the study period 1708 primary TKRs were performed in 1381 patients. We identified 44 TKRs in 43 patients with a Kellgren-Lawrence score of two or less on their pre-operative radiograph. In this group the mean age was 63 years, 66% were female and the mean BMI was 31.7 kg/m(2). At a mean follow-up of 37 months the mean OKS was only 30 points compared to 36 in all TKRs performed over the same period (p=0.0004). Only 68% were either satisfied or very satisfied. Eight knees (18%) underwent further surgery, three (6.8%) of which were revision procedures, compared to a revision rate of 1.6% in all patients.

CONCLUSION

The outcomes of TKR in patients with early radiological changes of OA are inferior to those with significant radiological changes and should be performed with caution.

LEVEL OF EVIDENCE

Level IV case-series.

Abstract P2-15-02: The efficacy of recruitment and retention strategies for research subjects in an early phase investigator-initiated breast cancer trial

Background: One of the biggest challenges faced by investigators is the implementation of effective strategies to improve the recruitment and retention of research participants. This is especially true for investigator-initiated, federally funded (e.g. NIH and DOD), early phase clinical trials that involve the treatment of serious diseases such as metastatic breast cancer (MBC). These studies may face additional barriers to participation since patients have often already undergone maximal treatment and are usually not in a financial position that for allows the travel and lodging necessary to receive further investigative treatment. Moreover, efficacy and toxicology in early phase clinical trials are unknown. Thus, when study budget constraints do not allow monetary incentives to participation, it is difficult to provide motivation for patients to enroll and remain adherent to the protocol requirements. However, many MBC patients are motivated to join clinical trials for altruistic purposes alone, and evidence supports that the researcher-patient relationship may be the most important factor in clinical trial participation. Recognizing that many patients are willing to participate if provided the appropriate resources despite limited monetary incentives, we developed a system to improve patient recruitment and retention to our studies, which are primarily federally funded. We report here on the strategies developed and used by our group to recruit and retain patients in a federally-funded investigator-initiated phase I/II vaccine study in MBC patients.

Methods: This study was funded by the NIH/NCI and involved infusion of HER2 specific T cells in HER2+ MBC patients after completing in vivo priming with a HER2 vaccine. It required 11 visits to Seattle, Washington. Working with agencies that offer free services to patients enrolled in clinical trials, a list of available resources was compiled and a visit flowchart with specific information on travel and lodging resources (e.g. Angel Flights and ACS sponsorship), local transportation and entertainment was developed. During screening, patients were given the list of resources and trial information. An email system was used to quickly communicate and follow-up with patients. Eligible patients were given the visit flowchart to help with their planning of study visits. An enrollment packet was provided at the first visit with a calendar to keep track of the visit schedule. Coordination of care between the patient's primary oncologist and the research staff was maintained throughout the study.

Results: 17 of 19 patients enrolled were not from Washington State. Two out-of-state patients withdrew early from the trial for reasons unrelated to disease progression or toxicity; one subject completed 8 visits and enrolled in another study and the other completed 2 visits and discontinued the trial to resume chemotherapy.

Conclusion: We have developed a successful system to enroll and retain patients in a trial requiring multiple study visits. Development and implementation of site-specific standard procedures are critical to improve study participation and retention, especially when patients receive no financial benefit.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-15-02.

Abstract P5-16-04: A phase I study of a DNA plasmid based vaccine encoding the HER-2/neu intracellular domain in subjects with HER2+ breast cancer

HER2+ breast cancer (BC) is associated with early disease relapse, usually to distant sites. This would suggest relapse is due to residual microscopic disease. Generation of vaccine-induced HER2-specific CD4+ T helper immunity (Th1) may result in immunologic eradication of residual HER2+ tumor cells and subsequent development of immunologic memory and epitope spreading (ES), which has been associated with a survival benefit in vaccinated BC patients. We have shown HER2 peptide-based vaccines can generate immunity in BC however, more recently we developed a plasmid DNA based vaccine (pNGVL3-hICD) which may have additional advantages over synthetic peptides. DNA vaccines offer a strategy to immunize against multiple tumor antigens and are able to elicit both CTL and Th1 immunity. Plasmid DNA can also remain at the vaccine site, providing a constant source of antigen. Intradermal (i.d.) delivery of DNA vaccines with GM-CSF as adjuvant may enhance immunogenicity due to local influx of dermal Langerhans cells. We have recently completed a phase I trial utilizing pNGVL3-hICD in optimally treated stage III and IV HER2+ BC patients and have defined vaccine safety profile, optimal dose and schedule; and demonstrated vaccine biologic activity.

Methods: A total of 66 subjects with stage III and IV HER2+ BC in complete remission were enrolled sequentially into 1 of 3 pNGVL3-hICD dose arms (22 subjects/arm): Arm 1=10µg, Arm 2=100 µg, and Arm 3 = 500µg. All vaccines were admixed with 100µg GM-CSF and given i.d. monthly for a total of 3 vaccines. Toxicity was assessed at baseline, during vaccination and at follow-up. Immune responses to HER ICD and ECD were assessed with IFN-γ ELISPOT at baseline and serially through week 60 post-vaccination. Linear regression analysis was used to compare differences in immune responses from baseline over the whole study period between dose arms. Vaccine site skin biopsies and peripheral lymphocytes were serially analyzed for plasmid persistence via RT-PCR.

Results: 64 subjects (20 in Arm 1; 22 in Arm 2; 22 in Arm 3) completed 3 vaccines. Age, stage/status, number of previous chemotherapy regimens, and use of bisphosphonate and trastuzumab therapies was similar across dose arms. Vaccine-related toxicity was primarily Grade 1/2 injection site reactions, myalgias, arthralgias and not significantly different between arms; no cardiac or grade IV toxicity was observed. Immune responses to HER2 ICD were significantly better in Arms 2 and 3 vs Arm 1 (p = 0.001 and 0.002, respectively) but not statistically different between Arms 2 and 3. 38 patients had DNA plasmid persistence at the vaccination site with no difference between arms. There has been no detection of DNA plasmid in lymphocytes from patients in all arms. Analyses of survival and ES (HER ECD immune responses) are on-going and will be presented.

Conclusions: pNGVL3-hICD was safe and effectively induced persistent HER2 ICD specific Th1 immunity without increased cardiac toxicity. Moreover, immunity was present more than 1 year after end of vaccination, indicative of vaccine-induced immunologic memory.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-16-04.

Timing and magnitude of C partitioning through a young loblolly pine (Pinus taeda L.) stand using 13C labeling and shade treatments

The dynamics of rapid changes in carbon (C) partitioning within forest ecosystems are not well understood, which limits improvement of mechanistic models of C cycling. Our objective was to inform model processes by describing relationships between C partitioning and accessible environmental or physiological measurements, with a special emphasis on short-term C flux through a forest ecosystem. We exposed eight 7-year-old loblolly pine (Pinus taeda L.) trees to air enriched with (13)CO(2) and then implemented adjacent light shade (LS) and heavy shade (HS) treatments in order to manipulate C uptake and flux. The impacts of shading on photosynthesis, plant water potential, sap flow, basal area growth, root growth and soil CO(2) efflux rate (CER) were assessed for each tree over a 3-week period. The progression of the (13)C label was concurrently tracked from the atmosphere through foliage, phloem, roots and surface soil CO(2) efflux. The HS treatment significantly reduced C uptake, sap flow, stem growth and fine root standing crop, and resulted in greater residual soil water content to 1 m depth. Soil CER was strongly correlated with sap flow on the previous day, but not the current day, with no apparent treatment effect on the relationship. Although there were apparent reductions in new C flux belowground, the HS treatment did not noticeably reduce the magnitude of belowground autotrophic and heterotrophic respiration based on surface soil CER, which was overwhelmingly driven by soil temperature and moisture. The (13)C label was immediately detected in foliage on label day (half-life = 0.5 day), progressed through phloem by Day 2 (half-life = 4.7 days), roots by Days 2-4, and subsequently was evident as respiratory release from soil which peaked between Days 3 and 6. The δ(13)C of soil CO(2) efflux was strongly correlated with phloem δ(13)C on the previous day, or 2 days earlier. While the (13)C label was readily tracked through the ecosystem, the fate of root C through respiratory, mycorrhizal or exudative release pathways was not assessed. These data detail the timing and relative magnitude of C flux through various components of a young pine stand in relation to environmental conditions.

P1-13-04: Phase II Study of Topical Imiquimod and Abraxane for Treatment of Breast Cancer Cutaneous Metastases

Background: Breast cancer (BC) cutaneous lesions can present as local chest wall recurrence or isolated sites of metastatic disease. Current treatments with full thickness chest wall resection, radiation therapy and chemotherapy are not curative; and have significant morbidity and poor overall response rates. Combining local immunomodulation and systemic chemotherapy may be more effective in treating cutaneous disease. Topical imiquimod (IMQ), a TLR-7 agonist, has shown clinical activity against cutaneous metastasis. Pre-clinical studies have shown IMQ to stimulate Th1 cytokine secretion and up-regulate immune co-stimulatory molecules at the tumor site; resulting in augmented tumor specific T cell immunity and tumor growth inhibition. Use of paclitaxel in BC, has demonstrated immunostimulatory effects of increased serum IFN-γ and enhanced NK/LAK cell activity. Abraxane (albumin-bound paclitaxel) may be used in conjunction with IMQ as steroid pre-treatment is not required. We hypothesize the immune effects of Abraxane may synergize and augment the IMQ anti-tumor effects, resulting in greater clinical response. A phase II single-arm study of chemoimmunotherapy with topical IMQ and Abraxane was initiated to determine its safety and therapeutic efficacy; and examine its effect on augmenting endogenous tumor specific immunity and inducing tumor molecular alterations associated with inhibition of tumor growth and/or common pathways of BC immune escape.

Materials and Methods: Up to 15 BC patients with cutaneous lesions no longer amenable to standard therapy are enrolled and receive 3 treatment cycles. A treatment cycle consist of topical 5% IMQ to target lesions 4 days/week (wk.) and Abraxane 100 mg/m2 on Days 1, 8, 15 every 28 Days. Toxicity is evaluated per CTCAE v3.0 on Days 1, 8, 15 of each cycle and wks. 13, 16, 20, 24. Target lesion antitumor activity is assessed per modified WHO criteria (Complete response (CR); Partial response (PR); Stable disease (SD); Progressive disease (PD)) at baseline, wks. 4, 8, 12, 16, 20, 24. 2-mm target lesion skin biopsies are obtained pre-and post-treatment for histologic analysis and RT-PCR analysis of a 7 IFN-related gene signature associated with tumor inhibition. Immunity to HER2, IGFBP-2, TOPO-IIα, p53 and serum TGF-β levels are evaluated at baseline and wks. 12, 24 with IFN-γ ELISPOT and ELISA, respectively.

Results: 10 patients have been enrolled. Median (range) values include: age, 54 years (48-92), time from metastatic diagnosis, 134 months (58-728), prior chemotherapy regimens, 5 (2-10). 5/10 patients had received prior local therapy, e.g., radiation. 5/10, 4/10, and 2/10 patients had triple negative, HER2+ and ER+/PR+ tumors, respectively. In 5 patients completing 3 treatment cycles, overall response rate (ORR) = 100% (3 CR, 2 PR). In the 5 patients who completed 1–2 treatment cycles, ORR = 80% (2 PR, 2 SD, 1 PD). Treatment related toxicity is primarily grade I/II neutropenia, anemia; grade I skin toxicity. Immunologic analyses are ongoing and will be presented with completed clinical data on all patients.

Conclusions: Chemoimmunotherapy with topical IMQ and Abraxane is well-tolerated and shows excellent clinical efficacy in treating metastatic cutaneous lesions in heavily pretreated BC patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-13-04.

OT3-01-19: Phase II Study of Topical Imiquimod and Weekly Abraxane for the Treatment of Breast Cancer Cutaneous Metastases

Background

Breast cancer (BC) cutaneous lesions present as local chest wall recurrence or as isolated sites of metastatic disease. The treatment of cutaneous lesions is challenging and includes chest wall resection, local radiation therapy, and/or salvage chemotherapy which is not curative, associated with significant morbidity, and results in overall response rates of 20–30%. Thus, investigation of novel treatment strategies is warranted. This study incorporates multimodality treatment with topical imiquimod, a TLR-7agonist which generates an immune signal similar to that of pathogenic bacteria and Abraxane, a conventional systemic chemotherapy with potential immunostimulatory effects. Combined, these two agents provide local and systemic strategies which are potentially synergistic; and more effective than as single-agents in treating and controlling cutaneous disease.

Trial design: A Phase II single arm, non-randomized study. Patients will be sequentially enrolled and receive a maximum of 3 treatment cycles. A treatment cycle consists of topical imiquimod daily to target lesions for 4 days/week for 4 weeks in addition to Abraxane on Days 1, 8, and 15 every 28 days. Toxicity will be evaluated weekly during treatment then monthly for four months. Defined lesions are assessed at baseline and monthly. Skin biopsies are obtained pre and post treatment for histologic analysis and RT-PCR analysis of a 7 IFN-related gene signature previously associated with tumor inhibition. Immunity to BC antigens and serum TGF-β levels are also evaluated.

Aims: To evaluate the safety and anti-tumor effects of chemoimmunotherapy with topical imiquimod and Abraxane.

Eligibility criteria: Patients with progressive or relapsed BC after standard therapy who 1) have measurable cutaneous metastatic lesions, 2) are at least 7 days from last chemotherapy, 30 days from local radiotherapy and/or systemic steroids, 3) have adequate blood counts and 4) no history of active autoimmune disease. Bisphosphonates, trastuzumab, and/or hormonal therapy is allowed.

Statistical methods: Antitumor activity of target lesions will be assessed per modified WHO criteria. Complete response (CR)-complete clearance of lesions; Partial response (PR) ≥ 50% decrease in lesion size; Stable disease (SD) < 50% decrease in lesion size; Progressive disease (PD) increase in ≥ 25% lesion size). Historical overall response rates (ORR) with second and third line salvage chemotherapy range from 20–30%, with CR rates less than 2%. Based on these numbers, an ORR of 50% or a CR rate of 10% will be used as benchmarks for success (i.e., ≥8 responses or ≥2 CRs among 15 patients (observed ORR of ≥ 53% or observed CR rate of ≥ 13%) to consider the treatment worthy of further study. As a measure of the precision of the estimate of ORR achievable with 15 patients, if the response rate is 60%, we will be 80% confident that the observed RR is within 0.16 of the true RR with 15 patients treated. Toxicity will be evaluated by CTCAE v. 3.0 and descriptive statistics will be used to summarize changes from baseline and for reporting of immunological parameters.

Accrual: 10 patients received treatment with a target accrual of 15.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT3-01-19.

OT1-02-10: Phase I-II Study of HER2 Vaccination with Poly(I) • Poly(C12U) (Ampligen®) as an Adjuvant in Optimally Treated Breast Cancer Patients

Background

Despite improved response rates and overall survival, many HER2+ breast cancer (BC) patients have disease relapse suggesting residual microscopic disease. HER2 vaccines given with adjuvants that can enhance, sustain, and skew antigen immunogenicity toward a Th1 phenotype could induce robust tumor-specific Th1 immunity resulting in immunologic eradication of residual tumor cells and potentially prevent relapse. One such adjuvant is Ampligen which is highly selective as a TLR-3 agonist. Our pre-clinical studies show a dose effect in the tumor prevention efficacy of Ampligen when given as an adjuvant with vaccines. We hypothesize HER2 peptide vaccination given with standard adjuvant 100mcg GMCSF and Ampligen can induce a higher incidence and magnitude of protective HER2−specific Th1 immunity than with GMCSF alone.

Trial design: Phase I-II randomized 2-stage HER2 vaccine study. Stage I will enroll 40 patients (10/arm) into one of 4 Ampligen dose arms (4, 20, 79, or 495 mcg + HER2 vaccine). The Ampligen “maximum biologic dose” (MBD), the dose with the highest incidence/magnitude of immune response and lowest incidence of toxicity will be defined. Stage II will enroll 48 patients (24/arm) receiving Ampligen MBD + HER2 vaccine + GMCSF or HER2 vaccine + GMCSF to evaluate if Ampligen MBD increases the incidence and magnitude of immunity vs HER2 vaccine + GMCSF alone. Patients will be enrolled sequentially and randomized equally into all arms via a permuted block design. Patients will receive 3 monthly vaccines. Toxicity and immune response will be assessed.

Aims: 1) To evaluate toxicity and define the MBD of Ampligen as an adjuvant with HER2 vaccination 2) determine if Ampligen MBD when combined with GMCSF as adjuvant and HER2 vaccination increases incidence/magnitude of HER2 Th1 immunity compared to standard GMCSF alone.

Eligibility criteria: Stage II–IV HER2+ BC patients who: 1) have completed definitive standard treatment, and in clinical remission 2) 14 days post chemotherapy and steroids 3) have adequate blood counts 4) are off trastuzumab 5) have no active autoimmune disease.

Statistical methods: In aim 1, we expect mild toxicity between the 4 dose arms, thus lack of efficacy based on incidence of immune response will be evaluated. Six responses must be observed within a dose arm to move forward based on historical 60% response rate (RR) with standard GMCSF (probability of continuing if true RR is 40% and 70% is 0.17, 0.85, respectively). In aim 2, 24 patients/arm provides 80% power to detect 40% difference in incidence of immune response between the 2 groups (Pearson chi-square test, two-sided alpha of 0.05) and 82% power to assess a 0.85 SD unit difference in change between control and MBD, based on a 2-sample t-test (p=0.05) and effect size defined as the difference in the means divided by the common SD. Incidences of HER2 Th1 immunity will be compared across treatment arms via Pearson chi-square test; magnitude of immune response will be compared across groups via linear regression model.

Study Accrual: Target accrual is 88 patients: Stage 1 (n=40) and Stage II (n=48). There has been no accrual at this time.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-02-10.

A comparison of mental health assessment of mentally ill offenders by mental health professionals

Background

Criminal justice mental health teams were established in The United kingdom in the late nineties of the last century following the publication of the Reed Report 1991.

Two teams were established in South Essex following the geographical locality of each team. Basildon and Thurrock and Southend.

Methods

An evaluation form was devised to record all essential areas of assessment.

Twenty five assessment of each team were picked and evaluated randomly over a period of a three months. A comparison was done between the assessment of the two teams.

Results

Referring agency one from the west didn’t mention it

Three of the west didn’t have the index offence;

One of the east and two of the west didn’t have past forensic history.

Three of the west and one of the east didn’t have risk assessment.

One of the west didn’t have summary of concerns

Three of both didn’t mention whether other professionals involved or not.

Discussion

Comparison between different teams is important to make sure that there is a standard format for assessment and whether it is used in all assessments.

It has been shown that assessments are very good in general in both teams. There are some areas which need to be addressed and managed.

12% of patients on the west didn’t have risk assessment which is very risky.

Conclusion

This comparison has highlighted areas we need to take care off especially risk assessment and liaising with other agencies in managing theses very special group of patients.

Phase I-II Study of Denileukin Diftitox (ONTAK®) in Patients with Advanced Refractory Breast Cancer

Background: CD4+CD25+Foxp3+ regulatory T cells (Tregs) are potent suppressors of CD4+ and CD8+ T cells, produce the immunosuppressive cytokine TGF-β; and as such, may down-regulate immune responses to tumor antigens. Additionally, Tregs are increased in the peripheral blood (PB) and tumors of breast cancer patients; and are associated with poor prognosis. Depletion of PB and tumor-associated Tregs may induce anti-tumor immunity by augmenting anti-tumor effector T cells and enhancing endogenous tumor specific immunity. ONTAK®, a diphtheria/IL-2R fusion protein depletes PB Tregs when given intravenously (IV) and selectively targets tumor cells that overexpress IL-2R. Breast tumors have been shown to overexpress IL-2R which is associated with their malignant potential. We hypothesized that ONTAK® could (1) have direct anti-tumor activity in breast cancers that overexpress IL-2R, and (2) deplete Tregs resulting in generation of functional immune effector cells and enhanced anti-tumor immunity. A phase I-II study was conducted to evaluate the safety of IV ONTAK® and assess its effect on Tregs and endogenous immunity in patients with advanced refractory breast cancer.Materials and Methods: 15 patients with progressive stage IV breast cancer following standard therapy were sequentially enrolled and received IV ONTAK® 18 mcg/kg/day on Days1-5 every 21 days for a total of 6 cycles and/or maximal tumor response. Toxicity was evaluated on Days 1 8, and 14 of each cycle per CTEP CTCAE v3.0. Tumor response was evaluated per RECIST at baseline, and after cycles 3 and 6. PB was collected at baseline and after cycles 2, 4, and 6 for evaluation of Tregs, sIL-2R, and endogenous tumor-antigen specific T cell immunity to HER-2/neu (HER2), CEA, and MAGE-3 via RT-PCR, LUMINEX and IFN-γ ELISPOT assay, respectively. Expression of IL-2R in patient paraffin embedded tumor samples was analyzed by IHC analysis.Results: 15 subjects have been enrolled and 14/15 have completed treatment; median age is 58 years (range, 32-69) and median salvage regimens is 3 (range, 2-8). 7/14 subjects had triple negative tumors. 7 subjects completed 1-2 and 7 completed 3-6 ONTAK® cycles, respectively. 4 subjects who completed 6 cycles of ONTAK® had SD or PR per RECIST. ONTAK®-related toxicities have been primarily grade I and II fatigue, nausea, and headache; and transient grade 3 hypoalbuminemia and lymphopenia. Preliminary data in 2 subjects shows enhanced tumor-antigen specific T cell immunity defined as mean tumor antigen-specific T cell precursors:PBMC to CEA (pre- ONTAK® 1:250,000; post- ONTAK® 1:15,000) and HER2 (pre- ONTAK® 1:63,000; post- ONTAK® 1:6,312). Immunologic analyses are ongoing and will be presented along with clinical data on all patients.Conclusions: ONTAK® is well-tolerated when used as a salvage regimen in heavily pretreated breast cancer patients. Additionally, ONTAK® treatment can enhance endogenous immunity to known breast cancer antigens and potentially lead to more effective eradication of tumor.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4130.

Phase II Study of a HER-2/Neu (HER2) Intracellular Domain (ICD) Vaccine Given Concurrently with Trastuzumab in Patients with Newly Diagnosed Advanced Stage Breast Cancer

HER2 is a tumor antigen in breast cancer and several trials have demonstrated that breast cancer patients can be immunized against this protein. We have developed HER2 peptide based vaccines that are aimed at eliciting CD4+ Th1 tumor antigen specific T cell responses. Th1 effectors provide immunologic memory, enhance cross priming which will allow the elaboration of tumor specific CD8+ T cells, and stimulate epitope spreading which we have shown to be a potential biomarker of clinical response. 52 patients will be enrolled with the primary objective to determine relapse free survival after active immunization. Eligible patients are newly diagnosed with Stage III (B or C) or Stage IV breast cancer and begin vaccination within 6 months of starting maintenance trastuzumab. This interim report will present data on the first 25 patients enrolled; 21 stage IV and 4 locally advanced patients. The vaccine is well tolerated with all adverse events (AE) being Grade I or 2. The most common AE is injection site reaction. Moreover, the combination of HER2 vaccination with trastuzumab did not result in additive cardiac toxicity in these patients. Immune responses were evaluated by IFN-gamma ELISPOT. To date, 88% of patients immunized developed significant immunity to the components of the ICD vaccine. The majority, 75%, developed robust immunity to the HER2 protein. Our group has recently demonstrated that a broadening of immunity throughout the HER2 protein, to components of the protein that weren't in the vaccine, i.e. epitope spreading, may be associated with improved survival in vaccinated patients. 63% of immunized patients demonstrated evidence of intramolecular epitope spreading. We questioned whether such high frequencies of homing Type 1 T cells might modulate the immunosuppressive tumor microenvironment, so we evaluated whether circulating serum immunosuppressive cytokines were impacted by immunization. TGF-beta is an immunosuppressive cytokine secreted by tumor stroma and regulatory T cells. We found that the levels of serum TGF-beta decreased significantly in the majority of patients after vaccination. We further analyzed the correlation between the change of serum levels of TGF-beta post vaccination and HER2 ICD vaccine-induced T cell responses. We found that the greater the magnitude of the HER2 specific T cell response, as demonstrated by IFN-gamma secretion, the greater the decrease in serum TGF-beta (p=0.0045, r=0.742). The correlation between the increased epitope spreading T cell response and decreased levels of TGF-beta was even more significant (p=0.0003). The median overall survival has not been reached with 100% of patients alive at this time. Relapse free survival data will be presented.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5102.

The Impact of National Press Coverage on Early Phase Clinical Trial Recruitment and Enrollment

The American Society of Clinical Oncologists reports that only 5% of cancer patients ultimately enroll in a clinical trial. According to the National Cancer Institute, one key barrier to participation is a lack of knowledge about clinical trials, both on behalf of oncologists and the patients themselves. Unfortunately, many investigator-initiated and academic clinical trials simply do not have budgets that permit implementation of large-scale recruitment efforts. Recent experience by our group demonstrates that press coverage by national media is a particularly effective tool for generating public interest in clinical research, as well as increasing trial enrollment.In the third quarter of 2008, our academic translational research group was featured on a national news program. In the week following the broadcast, our group's website, which had been listed in the broadcast and accompanying web story, received an unprecedented number of hits. Not only did the broadcast generate interest in our group's research; more specifically, it translated to substantial increases in potential clinical trial candidates, and subsequently, increased trial enrollment. In the month following the broadcast, our group received 125 new clinical trial inquiries as a result of the feature. That number represented a seven-fold increase in new inquiries during the same period in 2007. Of those 125 contacts, more than half of patients were potentially eligible for one of our clinical trials based on an initial screening. From November 2008 to the present, nearly one-third of all clinical trial enrollments can be attributed to the news story. Enrollment to the vaccine trial specifically described in the news feature increased four fold in comparison to the same 6-month period in 2008-2009, with half of all new enrollments attributable to the news feature.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6078.

HER2/neu (HER2) specific T-cell immunity in patients with HER2+ inflammatory breast cancer (IBC) and prognosis

3057

Background: IBC is rare, highly aggressive, and associated with worse prognosis when compared to non-IBC tumors. Moreover, multimodality treatment has had little impact on overall prognosis. HER2 is overexpressed in about 40% of IBC tumors and is associated with worse overall survival (OS). We have developed vaccines that elicit both HER2-specific CD4+ and CD8+ T-cell immunity in HER2+ cancer patients. Generation of HER2-specific T-cell immunity could (1) target immunogenic and biologically relevant proteins such as HER2 in IBC, (2) result in immunogenic eradication of HER2+ tumor cells, and (3) potentially prevent disease relapse when used in the adjuvant setting after standard therapy. A retrospective analysis of IBC patients immunized with HER2 vaccines was conducted to better understand the development of HER2-specific T-cell immunity and its possible impact on overall prognosis in IBC. Methods: Clinical and immunological data of IBC patients enrolled in University of Washington IRB approved HER2 vaccine trials was collected and reviewed. 27 patients immunized between 1996–2008 were identified; and 24/27 subjects who received vaccines designed to elicit both CD4+/CD8+ immunity were included in immunologic and survival analysis. The 24 subjects received either a HER2 DNA or HER2 peptide-based vaccine that were admixed with GM-CSF and given intradermally monthly for a total of 3 DNA or 6 peptide vaccines. Immune responses were assessed via IFN-γ ELISPOT at baseline and post-vaccination. Results: All 24 subjects had stage III IBC and median age was 48 (range 34–77). 10/24 (42%) patients had ER/PR+ tumors, 9/24 (37%) had received trastuzumab, and 15/24 (62%) had received multimodality treatment (chemotherapy, mastectomy, radiotherapy). 12/18 subjects (66%) evaluable for immunologic response developed HER2-specific T-cell immunity post-vaccination. Median OS for patients (n=6) not generating HER2-specific immunity was 31 months and median OS for the 12 patients who developed HER2-specific immunity has not been reached at median follow-up of 46 months, (p=0.026). Conclusions: Patients with IBC are able to generate HER2-specific T-cell immunity after HER2 vaccination, and development of HER2-specific immunity may impact survival.

No significant financial relationships to disclose.

A phase I study of a DNA plasmid based vaccine encoding the HER2/neu (HER2) intracellular domain (ICD) in subjects with HER2+ breast cancer

3054

Background: HER2 is overexpressed in 25% of breast cancers and plays a role in the malignant transformation of cells. Vaccine-induced immunity against the HER2 ICD correlates with antitumor responses in animal models. DNA-based vaccines offer a strategy to immunize against multiple tumor antigens and are able to elicit both CTL and T helper immune responses. Plasmid DNA can also remain at the vaccine site, providing a constant source of antigen. However, DNA vaccines have been poorly immunogenic due in part to inefficient APC transfection. Intradermal (i.d.) delivery of DNA vaccines with GM-CSF as adjuvant may enhance immunogenicity due to local influx of dermal Langerhans cells. A phase I study was conducted to evaluate the safety and immunogenicity of a DNA-based vaccine encoding the HER2 ICD. Methods: 44 subjects with stage III and IV HER2+ breast cancer in complete remission were enrolled sequentially into 2 vaccine arms (22 subjects/arm) and received 10μg pNGVL3-hICD (Arm 1) or 100μg pNGVL3-hICD (Arm 2). All vaccines were admixed with 100μg GM-CSF and given i.d. monthly for a total of 3 vaccines. Toxicity was assessed at baseline, during vaccination, and at follow-up. Immune responses were assessed with IFN-γ ELISPOT at baseline and post-vaccination. Vaccine site biopsies were analyzed for plasmid persistence via RT-PCR, 1 and 6 months after vaccination. Results: 43 subjects (21 in Arm 1; 22 in Arm 2) completed 3 vaccines. Vaccine-related toxicity in both arms was primarily grade I/II; no cardiac or grade IV toxicity was observed. 13/21 (62%) subjects in Arm 1 developed T-cell immunity, defined as HER2-specific T cell precursors:PBMC, to the HER2 protein (median 1:5,972, range 1:717–1:3,000,000) and to p776, a HER2 pan DR binding epitope (median 1:3,150, range 1:543–1:108,696). 13/19 (68%) subjects in Arm 1 had persistent plasmid DNA at the vaccine site. ELISPOT and RT-PCR analysis for Arm 2 are on-going. Conclusions: Immunization with a DNA plasmid-based HER2 vaccine is safe and immunogenic. Moreover, plasmid DNA persists at the vaccine site post-immunization and HER2+ cancer patients are able to develop immunity to the HER2 ICD.

No significant financial relationships to disclose.

Phase I study of infusion of HER2/neu (HER2) specific T cells in patients with advanced-stage HER2 overexpressing cancers who have received a HER2 vaccine

3000

Background: Adoptive T-cell therapy has shown promise in the treatment of advanced-stage melanoma. We have previously reported that expansion of HER2-specific T cells from peripheral blood mononuclear cells (PBMC) can be greatly facilitated by vaccine-priming. In this study, we evaluated the safety and clinical efficacy of infusion of HER2-specific T cells in patients with advanced HER2 overexpressing cancers. Methods: 10 patients with progressive HER2+ metastatic breast and ovarian cancer, not considered curable by conventional therapies, will be enrolled in this study. The patients must have been pre-immunized with a HER2-specific vaccine. Three escalating doses of T cells are given at 10-day intervals. Cyclophosphamide or denileukin diftitox is administrated before the first dose of T cells. Results: To date, 5 of 10 subjects have been enrolled. T cells were expanded with HER2-specific class II restricted peptides. After in vitro expansion cell products were >95% CD3+ with an average of 35% CD4+ and 60% CD8+ T cells. The maximal doses infused were 1x109-41x109 cells (median 10x109). Subjects tolerated the infusions well with the primary toxicity being related to the conditioning agent. Objective tumor regression has been observed in 2 of the 5 treated patients. One other patient has had stable disease after treatment. In patients with tumor regression, the magnitude of HER2-specific T cells in the infused product was 8-fold higher than that in patients without clinical responses. The total number of HER2-specific T cells infused was 43-fold higher in responding patients than in nonresponding patients. Moreover, HER2-specific CD4+ and CD8+ T cells persisted over a year and even augmented in magnitude post-infusion in responding patients. Conclusions: Adoptive transfer of autologous HER2 specific polyclonal T cells generated from PBMC after vaccine-priming is well tolerated and has shown evidence of some clinical efficacy in patients with advanced-stage HER2+ cancers.

No significant financial relationships to disclose.

Association of the level of HER2/neu (HER2) gene amplification in breast cancer and the magnitude of antigen specific T-cell immunity achieved after HER2 vaccination

3059

Background: Studies have demonstrated that the level of HER2 gene amplification in breast cancer, assessed by fluorescence in situ hybridization (FISH), correlates with favorable clinical response after treatment with trastuzumab. We questioned whether HER2 gene amplification impacted the development of HER2-specific T-cell immunity following immunization with a HER2 vaccine. Methods: Patients with HER2+ stage III or IV breast cancer, treated to complete remission or stable bone only disease, were enrolled in one of two concurrent clinical trials of HER2-specific vaccines. Eligibility criteria between the two studies were similar. Patients received either a plasmid DNA-based vaccine encoding the HER2 intracellular domain or a peptide-based vaccine composed of 3 HER2 class II epitopes. Peripheral blood was assessed for HER2-specific T-cell responses by interferon gamma (IFN-g) ELISPOT prior to, immediately after, and 6 months to 1 year after the end of vaccinations. Both immune response and FISH data were available on 31 patients. Results: Correlation of FISH levels to IFN-g spots/well in evaluable patients revealed the level of HER2 gene amplification was not related to the presence of pre-existent HER2-specific T-cell immunity prior to vaccination (p=0.43), the generation of a HER2-specific immune response after vaccination (p=0.35), or the persistence of the HER2-specific T-cell response (p=0.33). However, the magnitude of the T-cell response achieved was less as HER2 gene amplification increased (p=0.05). Conclusions: The level of HER2 gene amplification in the primary tumor can adversely impact the magnitude of HER2-specific T-cell immunity achieved after vaccination.

No significant financial relationships to disclose.

Sources of referral to early phase clinical trials: a case for putting all your eggs in one basket

Abstract #3116

Background: Studies suggest that only 2% to 3% of all adult cancer patients and approximately 5% of breast cancer patients enroll in clinical trials. To better understand the factors that contribute to enrollment we collected data from patients on sources that prompted them to contact us.
 Methods: From Jan 2005 to Apr 2008 we screened nearly 400 patients for 8 Phase I/II clinical trials focused on immunotherapy of breast and ovarian cancer. We queried subjects about informational sources that led them to consider our clinical studies. Patients learned about our trials from sources including: Clinicians, the Internet (advocacy group websites, search engines, government/university sites), Other patients, Family/friends, Media, Community events and Postings seeking research participants. Many patients who cited a clinician as their referral source specifically referenced a private, multi-site breast cancer clinic in Southern California with which our clinical group has formed a partnership, or consortium. To ensure that this was represented in the data and because the clinician category comprised a large percentage of the referral sources we split the category into 2 groups-one being the private practice in California (to be referred to as “consortium”) and the other being all other clinicians.
 Results: Of the 399 patients screened, 336 (84%) were considered potentially eligible for study. A total of 72 patients, or 18% of those screened have enrolled in one of our trials to date.
 Among patients screened, most learned about our trials from clinicians outside the consortium (34%), the Internet (27%), and consortium clinicians (15%). Patients most often named her2support.org (35%) and clinicaltrials.gov (23%) as their specific Internet sources. The remaining sources, family/friends, patients, media sources, community events and postings in medical facilities, were each cited by <5% of patients.
 Although consortium clinicians were responsible for only 15% of referrals, 50% of their referrals enrolled in a study. Only 16% of patients referred by other clinicians and 9% referred via the Internet were enrolled. Though other clinicians and the Internet are the most common referral sources, referrals from our consortium were significantly more likely to enroll than any other source (p<0.001).
 This may be due to the fact that patients referred by the consortium were more likely to meet eligibility criteria. Relative to 93% of consortium referrals, 87% of other clinician and 79% of Internet referrals were potentially eligible for trial (p<0.05). Patients referred by our consortium were significantly more likely to meet study criteria relative to those referred by other sources.
 Discussion: Physician referrals often lead to higher accrual to clinical trials relative to other referral sources. Our data reveal that accrual can be further improved by forming a close collaborative relationship with a single select practice of clinicians.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3116.

A phase I/II study of a HER2/neu (HER2) peptide vaccine plus concurrent trastuzumab

2528

Background: HER2 is a tumor antigen in breast and ovarian cancer. Vaccines targeting both Class I and II epitopes of HER2 can elicit long-lived cellular immunity. Trastuzumab increases the activity of HER2-specific T cells in vitro. This study examines the safety and immunogenicity of a HER2 peptide vaccine given with trastuzumab to augment HER2-specific immune responses in vivo. Methods: 20 HLA-A2+ subjects will be enrolled on this Phase I/II single institution trial. Eligible subjects must have stage IV HER2 overexpressing breast or ovarian cancer, stable or no evident disease on maintenance trastuzumab and a normal baseline MUGA. Subjects must have ECOG performance status 0–1, creat ≤ 2.0, bili < 1.5 × ULN, SGOT < 2 × ULN. The HER2 vaccine used in this study has been previously reported and is composed of 3 HER2 Class II epitopes encompassing Class I epitopes in their natural sequence. (Knutson et al, J Clin Investigation 107:477–484, 2001). Subjects receive 6 vaccinations + GM-CSF at monthly intervals. Primary endpoints are safety and immunogenicity. Results: To date, 14 of 20 subjects have been enrolled. A total of 77 vaccinations have been given. Of 276 reported toxicities, 88% were Grade 1; most common were constitutional symptoms (25%), injection site reactions (14%), and cytopenias (14%). 11% of toxicities were Grade 2; most common were lymphopenia (34%) and headache (19%). There was one Grade 3 toxicity (syncope 5 hours after vaccination) and one Grade 4 toxicity (stroke secondary to brain metastases in long-term follow up). Cardiac toxicity included two Grade 2 asymptomatic decreases in LVEF (54 to 49% and 64 to 45%.) The average decrease in LVEF between baseline and 9 month post-vaccine follow up was 5% ± 5.85 (n = 10). Of the 10 patients who have had immunologic analysis performed at multiple time points, 5 have developed significant T cell immunity to either HER2 overlapping peptide pools and/or HER2 peptides. Complete immunologic analysis will be presented. Conclusions: Subjects with HER2 overexpressing Stage IV cancer can be safely immunized with a HER2 peptide vaccine while receiving concurrent trastuzumab without additional cardiac toxicity. In addition, the approach is immunogenic, generating significant levels of HER2-specific T cells in the peripheral blood.

No significant financial relationships to disclose.

Optical clearing of skin using flashlamp-induced enhancement of epidermal permeability

BACKGROUND AND OBJECTIVES

Strong light scattering in skin prevents precise targeting of optical energy in therapeutic and diagnostic applications. Optical immersion based on matching refractive index of scattering centers with that of surrounding matter through introduction of an exogenous index-matching agent can alleviate the problem. However, slow diffusion of the index-matching agent through skin barrier makes practical implementation of this approach difficult. We propose a method of accelerating penetration of the index-matching compounds by enhancing skin permeability through creating a lattice of micro-zones (islets) of limited thermal damage in the stratum corneum (SC).

STUDY DESIGN/MATERIALS AND METHODS

A flash lamp (intense pulsed light) system and an island mask with a pattern of absorbing centers (center size approximately 75-120 microm, lattice pitch approximately 450-500 microm) were used to create the lattice of islets of damage (LID). Index-matching agents, such as glucose solution, propylene glycol solution, and glycerol solution, were applied.

RESULTS

Experimental results of optical clearing ex vivo rat and pig skin, and ex vivo and in vivo human skin are presented. Optical transmission spectra of the skin samples with LID were measured during some 2 hours after application of index-matching chemical agents. In order to assess and compare the clearing rate under different treatment and clearing agents we calculated the quantity that we call "relative transmittance": T(rel) = I(t)(lambda)/I(0)(lambda), were I(t)(lambda) is the intensity measured at elapsed time t. The dynamics of relative transmittance of skin samples at 470 and 650 nm shows that the implementation of limited thermal damage technique leads to a 3-10-fold increase of optical clearing (rise of transmittance) rate compared to the results obtained when the samples were treated with high-intensity light pulses but without the use of island damage mask (IDM). It was observed from the plotted spectra of relative transmittance that the maximum increase of transmitted light intensity has been obtained with glucose solution as a clearing agent. Noteworthy is the difference in the trend of spectral curves: relative transmittance spectrum for glycerol reveals, on the whole, a greater slope which may be indicative of higher extent of index matching between the scattering centers and base material for this index-matching agent. Under the transillumination of the skin sample by the wide flat beam the more effective clearing (the increase of transmitted intensity) is attained within the hemoglobin absorption bands; with the narrow quasi-collimated beam the higher relative transmittance was observed over the intervals of minimum absorption.

CONCLUSIONS

The use of specially designed island mask combined with non-laser intensive pulse irradiation produces a lattice of islands of limited thermal damage in SC that substantially enhances the penetration rate of topically applied index-matching agents. The suggested technique gave comparable magnitudes of clearing dynamics enhancement for glucose solution, glycerol solution, and propylene glycol solution applied to mammalian skin.

Importance of radiation time and dose factors on outcome for childhood medulloblastoma*

The purpose of this study was to investigate the relationship of posterior fossa radiation therapy duration (PFRTD) and relapse-free survival (RFS) following adjuvant craniospinal RT for childhood medulloblastoma. A retrospective audit was performed assessing all children aged <18 years managed with adjuvant craniospinal RT for medulloblastoma in Australia and New Zealand in 1980-1993. Children receiving prolonged (>180 days) pre-RT chemotherapy were excluded. Data were obtained for potential prognostic factors in domains of patient, tumour and treatment factors. Radiation therapy time factors assessed were PFRTD and time interval from surgery to commencement of RT (SRTD). The end-point assessed was RFS and analysis was performed using Cox regression and Kaplan-Meier survival. One hundred and eighty-nine children were identified from 10 oncology units, with data available from 182 children for analysis. Median follow up was 5.3 years. Seventy-three per cent of children presented with disease confined to the cerebellum; 13% had initial neuraxis disease. Macroscopic resection was described in 54%; 42% received adjuvant chemotherapy. Median RT dose and RT duration to PF was 55 Gy and 45 days, respectively. Seventy-eight relapses occurred with a 10-year actuarial RFS of 58.2% (standard error +/- 4%). On univariate analysis, increasing PF dose (P = 0.002), age >5 years (P = 0.006), and more thorough extent of surgical resection (P = 0.043) were associated with improved RFS; PFRTD (P = 0.20) and SRTD (P = 0.51) were not associated with RFS. On multivariate analysis, although both PF dose (P = 0.004) and extent of surgery (P = 0.045) remained strongly significant, RT duration was now associated with RFS (P = 0.049). Other factors assessed that did not reach significance were patient age, local tumour extent, presence of internal shunt and use of chemotherapy. The importance of local treatment factors was confirmed in this audit with established prognostic factors such as primary tumour macroscopic resection and adequate PF RT dose being associated with RFS. A treatment time effect is weakly suggested, although less significant than RT dose delivered.

Spatial dynamics and molecular ecology of North American rabies

Rabies, caused by a single-stranded RNA virus, is arguably the most important viral zoonotic disease worldwide. Although endemic throughout many regions for millennia, rabies is also undergoing epidemic expansion, often quite rapid, among wildlife populations across regions of Europe and North America. A current rabies epizootic in North America is largely attributable to the accidental introduction of a particularly well-adapted virus variant into a naive raccoon population along the Virginia/West Virginia border in the mid-1970s. We have used the extant database on the spatial and temporal occurrence of rabid raccoons across the eastern United States to construct predictive models of disease spread and have tied patterns of emergence to local environmental variables, genetic heterogeneity, and host specificity. Rabies will continue to be a remarkable model system for exploring basic issues in the temporal and spatial dynamics of expanding infectious diseases and examining ties between disease population ecology and evolutionary genetics at both micro- and macro-evolutionary time scales.

Physician knowledge of the diagnosis and management of Rocky Mountain spotted fever: Mississippi, 2002

Rocky Mountain spotted fever (RMSF), a tick-borne illness that has its highest incidence in the south central and southeastern United States, is often a diagnostic challenge, as patients frequently present with nonspecific symptoms during the early stages of illness. RMSF has a high case fatality rate among untreated individuals, and the median time from onset of symptoms to death is only eight days, making early recognition and treatment of RMSF crucial. In two Mississippi public health districts, 148 primary care physicians were randomly selected and mailed surveys regarding RMSF diagnosis, treatment, and prevention. Eighty-four of the 148 (57%) physicians responded. Responses from different specialties and different health districts were compared using chi square statistics. Almost all (99%) physicians correctly identified doxycycline as the antibiotic agent of choice for treating adults and adolescents. However, only 21% of family practice physicians, and 25% of emergency medicine physicians correctly identified the antibiotic of choice for treating children with RMSF. Twenty-three percent of physicians responded that waiting for the development of a rash before prescribing antibiotics is an appropriate treatment strategy. The current standard of care-doxycycline as the agent of choice among children 8 years of age or younger with suspected RMSF-has not been effectively communicated to all physicians caring for children. Also, many physicians are not familiar with the rationale underlying initiation of antibiotic therapy prior to the development of rash in patients with suspected RMSF. Continuing education efforts should focus on antibiotic selection in pediatric patients and initiation of therapy prior to the onset of rash in appropriate patients.

Impacts of heterogeneous organic matter on phenanthrene sorption: different soil and sediment samples

Organic petrography has been proposed as a tool for characterizing the heterogeneous organic matter present in soil and sediment samples. A new simplified method is proposed as a quantitative means of interpreting observed sorption behavior for phenanthrene and different soils and sediments based on their organic petrographical characterization. This method is tested under singe solute conditions and at phenanthrene concentration of 1 microg/L. Since the opaque organic matter fraction dominates the sorption process, we propose that by quantifying this fraction one can interpret organic content normalized sorption distribution coefficient (Koc) values for a sample. While this method was developed and tested for various samples within the same aquifer, in the current study the method is validated for soil and sediment samples from different sites that cover a wide range of organic matter origin, age, and organic content. All 10 soil and sediment samples studied had log Koc values for the opaque particles between 5.6 and 6.8. This range of Koc values illustrates the heterogeneity of opaque particles between sites and geological formations and thus the need to characterize the opaque fraction of materials on a site-by-site basis.

Recruitment strategies in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial: the first six years

The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial has a total enrollment goal of almost 150,000 participants. These participants are being recruited at ten screening centers across the United States. All screening centers tested recruitment methodologies during a 1-year pilot phase. The main phase of recruitment was planned to take place over a 3-year period. The majority of participants are being recruited during the main phase of the study. Each of the screening centers tailors recruitment to its individual catchment area. Recruitment strategies in the PLCO trial are described. As the trial began, several protocol changes were made to help to increase enrollment. The National Cancer Institute (NCI) initiated recruitment efforts at the national level. The individual screening centers describe some of the specific recruitment experiences encountered. As the study progressed, the NCI implemented special initiatives to increase the enrollment of minority participants.

Treatment of sialorrhea with glycopyrrolate: A double-blind, dose-ranging study

OBJECTIVE

To determine the safety and efficacy of glycopyrrolate in the treatment of developmentally disabled children with sialorrhea.

DESIGN

Placebo-controlled, double-blind, crossover dose-ranging study.

SETTING

Outpatient facilities in 2 pediatric hospitals.

PATIENTS

Thirty-nine children with both developmental disabilities and excessive and bothersome sialorrhea.

MAIN OUTCOME MEASURES

Parent and investigator evaluation of change in sialorrhea and adverse effects.

RESULTS

Glycopyrrolate in doses of 0.10 mg/kg per dose is effective at controlling sialorrhea. Even at low doses, 20% of children may exhibit adverse effects severe enough to require discontinuation.

CONCLUSIONS

Glycopyrrolate is effective in the control of excessive sialorrhea in children with developmental disabilities. Approximately 20% of children given glycopyrrolate may experience substantial adverse effects, enough to require discontinuation of medication. Arch Pediatr Adolesc Med. 2000;154:1214-1218.

Critical incident stress management

Recent studies have indicated implementation of the CISM Program has impacted and reduced the cost of workers' compensation claims for stress related conditions and the number of lost work days (Ott, 1997; Western Management Consultants, 1996). Occupational health professionals need to be ready to develop and implement a comprehensive critical incident stress management process in anticipation of a major event. The ability to organize, lead, or administer critical incident stress debriefings for affected employees is a key role for the occupational health professional. Familiarity with these concepts and the ability to identify a critical incident enhances value to the business by mitigating the stress and impact to the workplace. Critical Incident Stress Management Systems have the potential for decreasing stress and restoring employees to normal life function--a win/win situation for both the employees and the organization.

Projected requirements for radiation oncologists and trainees in Australia and New Zealand to 2007

Workloads in radiation oncology facilities in Australia and New Zealand have been increasing steadily for many years and it is anticipated that this trend will continue. In the present paper the projected number of radiation oncologists required to meet this demand to the year 2007 are estimated, along with the number of trainees required. The estimates are based on data from regular surveys by the Royal Australian and New Zealand College of Radiologists (RANZCR) for the years 1988-97 (inclusive). From these surveys profiles of numbers, age and gender of specialists and trainees are documented together with increases from the training programme and losses from retirement. It is concluded that if the current trainee numbers are increased by 12 in Australia and two in New Zealand, there will be approximately 10 radiation oncologists per million of population by the year 2007. This number is considered appropriate considering the anticipated increase in demands and complexity of treatment. Because projections too far forward are unreliable, careful monitoring of progress is essential to obtain the appropriate balance between requirement and supply. Comparisons are made with other estimates of needs including the 1998 Australian Medical Workforce Advisory Committee (AMWAC) Report and the New Zealand Clinical Agency Workforce Project Report in 1997.

Editorial

With this issue Optics Express begins Volume 6 of publication. We've been in business long enough that most OSA members, and a large fraction of the world-wide optics community, are aware of Optics Express, even if many have not yet felt a strong push toward all-electronic peer-reviewed publishing. One reason for hesitation can be a natural concern for permanence of the scientific record, a concern about archiving. What is the assurance that articles published electronically will be openly available to scientists in the future?

An epidemiologic and entomologic investigation of a cluster of Rocky Mountain spotted fever cases in Delaware

BACKGROUND

Rocky Mountain spotted fever (RMSF) continues to be the most common fatal tick-borne illness in the United States. In August of 1996, four children attending a summer camp in Delaware were diagnosed with RMSF. This report summarizes the results of the epidemiologic and entomologic investigation conducted by the Delaware Division of Public Health and the Centers for Disease Control and Prevention regarding this cluster of RMSF cases. Epidemiologic and clinical aspects of RMSF, as well as previously reported clusters of the disease, are also reviewed.

METHODS

A questionnaire regarding symptoms and activities was administered via telephone to 163 (73 percent) of the 223 attendees. A suspected case was defined as an illness in a person attending the camp between August 11 and 17 that occurred during the two-week period following the session, characterized by either 1) fever with one or more symptoms (i.e., headache, rash, myalgia, or fatigue) or 2) no fever with two or more symptoms. Cases of RMSF were confirmed by serologic evaluation.

RESULTS

Seven of 13 patients with suspected RMSF submitted sera for testing. Four patients had confirmed RMSF; three were males, and the median age was 12.5 years compared with 12 years for all attendees. All confirmed patients reported fever, headache, fatigue, and rash. An increased risk of becoming ill was associated with overnight camping at site A (Odds Ratio (OR) undefined, p = 0.02), visiting or overnight camping at site B (OR undefined, p = 0.003 and 0.002), and leaving the trails when hiking (OR undefined, p = 0.02).

CONCLUSIONS

These data suggest that development of RMSF was associated with visiting or camping at specific sites and behavior likely to increase contact with ticks. Camp supervisors were advised to educate campers regarding tick bite prevention measures, reduce underbrush around campsites, and encourage campers to remain on the trails. Health care providers should remain aware of the increased risk for RMSF during the spring, summer, and fall months.

Krabbe's disease presenting as a peripheral neuropathy

A 13-year-old female initially presented with scoliosis and pes cavus. Initial examination revealed distal lower extremity weakness and sensory loss, as well as greater auricular nerve hypertrophy. There was a Babinski sign on the right. Nerve conduction velocities were consistent with a demyelinating neuropathy. Four years after initial presentation she developed lower extremity spasticity and bilateral Babinski signs. Magnetic resonance imaging of the brain showed diffuse white matter disease. Laboratory evaluation revealed an abnormally low galactocerebroside beta-galactosidase level. Nerve biopsy demonstrated inclusions consisting of globoid clusters and evidence of demyelination. DNA analysis was used to identify mutations consistent with Krabbe's disease. Patients presenting with an atypical peripheral neuropathy should be evaluated for Krabbe's disease.

Peer relationships of young children: affiliative choices and the shaping of aggressive behavior

Examined the occurrence of selective peer affiliation, and its impact on the development of aggressive behavior in four classrooms serving 72 preschool-age, high-risk boys and girls. Children classified as aggressive and nonaggressive were both highly selective in their peer affiliations, spending the majority of their time with a few same-sex classmates. Children generally established strong, stable, mutual affiliations with peers similar to themselves in aggression, but aggressive children had more difficulty establishing such affiliations. The interaction of peer dyads containing at least one aggressive child were characterized by more frequent, lengthy, and intense conflicts regardless of the affiliative relationship characterizing the dyad. The amount of time children spent interacting with aggressive peers predicted changes in observed and teacher-rated aggressiveness 3 months later.

Five years and counting: the path to self-directed work teams

In 1989, Roberts Express launched its first self-directed work team. Today it has more than 25 such teams, and they essentially have the responsibility of running operations. Those involved in the move to self-directed teams know it hasn't been easy. They have learned a number of important lessons along the way, some of which are described in this article.

Functional neurological outcome in leukaemic children receiving repeated cranial irradiation

Long-term outcome defined by educational or employment history has been recorded in a group of children with acute lymphoblastic leukaemia (ALL) who received cranial radiotherapy at some stage prior to TBI conditioned bone marrow transplant (BMT). Median follow-up in 24 survivors of 69 consecutive patients was 4 years and 2 months. Individual risk factors for poor functional outcome were considered, including calculations of biological effective radiation doses. There was no incidence of CNS treatment-related mortality. All survivors are in normal school or employment, although three who had CNS relapse are receiving remedial teaching. No individual risk factors could be identified but the worst outcome was seen in children who were of young age at the time of initial treatment, who suffered CNS relapse and who had received the highest total dose of cranial irradiation.

Quantitative analysis of ribosome binding sites in E.coli

185 clones with randomized ribosome binding sites, from position -11 to 0 preceding the coding region of beta-galactosidase, were selected and sequenced. The translational yield of each clone was determined; they varied by more than 3000-fold. Multiple linear regression analysis was used to determine the contribution to translation initiation activity of each base at each position. Features known to be important for translation initiation, such as the initiation codon, the Shine/Dalgarno sequence, the identity of the base at position -3 and the occurrence of alternative ATGs, are all found to be important quantitatively for activity. No other features are found to be of general significance, although the effects of secondary structure can be seen as outliers. A comparison to a large number of natural E.coli translation initiation sites shows the information profile to be qualitatively similar although differing quantitatively. This is probably due to the selection for good translation initiation sites in the natural set compared to the low average activity of the randomized set.