Development of a teaching module for quality-of-life assessment of terminal patients. The AACE Multi-Institutional Palliative Cancer Education Section. American Association for Cancer Education.

To enhance the teaching of students to assess quality of life of patients with serious disease, the AACE Palliative Cancer Education Section has developed a teaching module. The module, which focuses on four desired learning objectives, is to be used in an hour-long small-group session. The authors describe the development of the module, as well as its objectives, teaching method, evaluation, and future challenges.

Practicing physicians' assessments of the impact of their medical-school clinical hospice experience.

BACKGROUND: The authors measured the impact of a clinical hospice experience in medical school on present medical practice by surveying former students after graduation. METHODS AND RESULTS: Of the graduates who apparently received anonymous questionnaires, 46 (71%) completed and returned them. Most were still in residency, and about a third were in private practice. Using a Likert scale, most gave the highest possible rankings in response to questions about how the experience had affected their present day-to-day communication with patients and their working knowledge of pain control, and the general question that asked about understanding quality-of-life issues. Written responses noted positive effects of the experience on the physicians' present practices, including improved knowledge of and attitudes towards dying patients, assessment of the effects of disease on patients and families, and quality-of-life. CONCLUSIONS: Although course work about death and dying is increasingly encountered in medical-school curricula, an intensive, focused clinical exposure is often lacking. This type of exposure has positive effects on physicians' self-assessments of their knowledge, attitudes, and skills in their present practices.

Approach to the seriously ill or terminal cancer patient who has a poor appetite.

Lack of appetite is a frequent complaint of patients with serious illness and is particularly bothersome to cancer patients and their families. As patients enter the terminal phase of their illness, poor appetite becomes an even more distressing problem that affects not only physical symptoms but also functional, social, and psychological aspects of a patient's quality of life. Family and friends frequently relate a patient's poor appetite as a specific contributor to their perception of lack of health. We have investigated a number of ways to approach the seriously ill or terminal cancer patient who has a poor appetite with education, dietary changes (including the use of smaller, more frequent meals but still providing the patient's favorite foods), and at times dietary supplements. Appetite stimulants such as Megace Oral Suspension (Bristol-Myers Squibb, Princeton, NJ) are used not so much for facilitating weight gain as for adding to the quality of life, including social and psychological well-being, by allowing patients to enjoy foods they like in a social family setting.

Measurement of soluble transferrin receptor in serum of healthy adults.

The concentration of soluble transferrin receptor (sTfR) in serum is reported to be useful in the diagnosis of iron deficiency, especially for patients with concurrent chronic disease, where routine tests of iron status are compromised by the inflammatory condition. A new diagnostic assay for sTfR is calibrated against natural plasma sTfR, thus minimizing calibration discrepancies that result from differences between the analyte and the cellular transferrin receptor used in other assays. Use of the new assay to measure sTfR concentrations in 225 healthy, hematologically normal adults provided a reference interval against which pathological samples could be compared. There was no difference in the reference intervals for men and women and no correlation of [sTfR] with the age of the subject. Black subjects had significantly higher concentrations than nonblacks, and people living at high altitude had higher concentrations than those living closer to sea level. These differences were additive.

Serum ferritin as a predictor of the acute respiratory distress syndrome.

We investigated serum ferritin levels as a predictor of the acute respiratory distress syndrome (ARDS) because: (1) proinflammatory cytokines, which are implicated in ARDS, increase ferritin synthesis; and (2) oxidative stress in patients at risk for ARDS might liberate iron from ferritin, accelerating toxic hydroxyl radical (.OH) formation. Serum ferritin levels measured by radioimmunoassay (RIA) were greater in 75 patients at risk for ARDS (women, p < 0.0001; men, p < 0.0001) and 8 patients with ARDS (women, p = 0.001; men, p = 0.0009) than in healthy control subjects. Serum ferritin levels were also greater in female (p = 0.003) and male (p = 0.003) at-risk patients who developed ARDS than in patients who did not develop ARDS. In women, a value exceeding 270 ng/ml predicted ARDS with an 83% sensitivity, 71% specificity, 67% positive, and 86% negative predictive value. In men, a value exceeding 680 ng/ml predicted ARDS with a 60% sensitivity, 90% specificity, 75% positive, and 82% negative predictive value. Serum ferritin levels did not correlate with C-reactive protein levels, were not different in medical or surgical at-risk patients, and were not accounted for by liver disease. Evaluating serum ferritin levels in at-risk patients may help predict the development of ARDS and thereby improve study and treatment of ARDS. Elevated serum ferritin levels may also regulate the participation of iron in the oxidative responses that contribute to ARDS.

Effects of agents that inhibit cellular iron incorporation on bladder cancer cell proliferation.

Agents that interfere with cellular iron (Fe) incorporation inhibit tumor cell proliferation, including metals that bind to transferrin (Tf) such as gallium (Ga) or indium (In) and Fe chelators such as desferrioxamine (DFO). Ga nitrate is effective in the treatment of metastatic bladder cancer and these patients exhibit evidence for interference with Fe metabolism. We show here that bladder cancer cell proliferation in vitro is dependent on Tf-Fe. Concentrations of DFO that can be readily achieved in vivo inhibit cellular proliferation even in the presence of physiologic concentrations of Tf-Fe. Inhibition of proliferation by Tf-Ga is associated with decreased cellular Fe incorporation. However, when a physiologic concentration of Tf-Fe is added to an equimolar concentration of Tf-Ga, significant Fe incorporation is evident despite inhibition of proliferation. Thus, besides interference with Fe incorporation, Ga may also interfere with intracellular Fe distribution and/or directly inhibit an Fe- (or non-Fe-) requiring process necessary for cellular proliferation. DFO followed sequentially by Tf-Ga results in marked potentiation of inhibition of proliferation. The effects of this combination appear to be related to both interference with Fe metabolism and increased Ga uptake. This sequential combination may be useful in the treatment of bladder cancer.

Treatment with gallium nitrate: evidence for interference with iron metabolism in vivo.

Gallium, when bound to transferrin, has been previously shown to cause tumor cell cytotoxicity by preventing cellular uptake of transferrin bound iron in vitro. Patients treated with constant infusion gallium nitrate for carcinoma show a rise in serum iron within 6 hr of the start of treatment. Serum iron returns to baseline by 24 hr post-infusion. Atomic analysis of iron and gallium content of Sephadex G-150 fractions of treatment sera indicate that about an equimolar amount of gallium and iron are associated with transferrin. These gallium and iron concentrations result in inhibition of transferrin mediated iron uptake in vitro, and in vivo allow for > 90% saturation of transferrin with metal. All seven patients who completed two courses of gallium therapy exhibited hypochromic microcytic anemia (mean fall in hemoglobin 3.5 grams %). Evidence for red cell iron depletion was confirmed by an increase (mean 3.3-fold) in zinc protoporphyrin levels. Since transferrin receptor increases on gallium treated iron requiring cells in vitro, we assessed cell surface transferrin receptor on peripheral blood lymphocytes by measuring fluorescent transferrin receptor antibody binding. A population of highly transferrin receptor positive cells peaks at 48 hr into the infusion. DNA analysis as well as double staining indicate the majority of transferrin receptor positive cells are unstimulated B lymphocytes. These studies provide the first documentation that constant infusion gallium treatment results in significant interference with iron metabolism and evidence for tissue iron depletion in vivo. These changes may correlate with therapeutic effects of gallium such as tumor response.

Lymphocyte proliferation is controlled by both iron availability and regulation of iron uptake pathways.

Cell culture data have demonstrated that transferrin, the major iron (Fe) transport protein, is a necessary requirement for cellular proliferation. Evidence suggests that transferrin supports proliferation by providing Fe for critical cellular processes including DNA synthesis. Lymphocytes, similar to other cell types, respond to an increased Fe requirement during proliferation by increased synthesis and expression of surface transferrin receptors. Moreover, under transferrin-Fe-deplete conditions, certain lymphocyte lines exhibit other specialized adaptations that allow for sufficient Fe uptake to support cellular proliferation. These other adaptations include specialized transferrin synthesis and utilization of a transferrin-independent Fe uptake pathway. Lymphocyte proliferation is inhibited by agents that interfere with cellular Fe metabolism; these agents include Fe chelators, class 3a metals that bind to transferrin, and antibodies directed against the transferrin receptor. The data presented in this paper, demonstrate that differences in sensitivity to the effects of these agents are influenced by the amount of available transferrin-Fe and differences in the mechanisms that individual lymphocyte cell lines utilize to ensure adequate Fe uptake to support proliferation. These data support the hypothesis that these agents, if used appropriately, will be useful in the treatment of different lymphoproliferative disorders.

Transferrin-independent iron uptake supports B lymphocyte growth.

Raji, a malignant B-lymphocyte cell line containing Epstein-Barr virus genomic elements, has been conditioned to proliferate optimally in transferrin (Tf)-free medium containing a very low concentration of an iron salt. We provide evidence that an Tf-independent iron uptake system is physiologically important for maintaining the growth of these cells. The data show that Raji cells take up iron from iron salts using a relatively high-capacity, low-affinity, temperature- and calcium-dependent uptake system. The apparent capacity of this system increases when: (1) cells are cultured in Tf-free medium containing high concentrations of iron salt as opposed to medium containing Tf; and (2) when the iron salt concentration of Tf-free medium is lowered to about 1.6 mumol/L. Cellular iron uptake also increases when a maximum number of cells are in S and G2 and M cell phases of the cell cycle. The cells are sensitive to growth inhibition by the addition of deferoxamine. This evidence supports the hypothesis that certain malignant lymphocytes, under iron deplete conditions, fulfill an iron requirement for proliferation by an adaptation such as Tf-independent iron uptake.

Combinations of anti-transferrin receptor monoclonal antibodies inhibit human tumor cell growth in vitro and in vivo: evidence for synergistic antiproliferative effects.

Thirty-two murine monoclonal antibodies (MAbs) against the external domain of the human transferrin (Tf) receptor have been obtained using human Tf receptor glycoprotein produced in a baculovirus expression system as immunogen. The MAbs were tested separately, and in combination, for their ability to inhibit growth of CCRF-CEM leukemic T-cells in tissue culture. One MAb, D65.30, an IgG1, inhibited growth of CCRF-CEM cells as effectively as the anti-Tf receptor MAb 42/6, an IgA, previously found to have the highest antiproliferative activity in this assay. Some combinations of two or more MAbs inhibited the in vitro growth of CCRF-CEM much more effectively than single MAbs. Eleven IgG1 anti-Tf receptor MAbs, when combined individually with D65.30, increased the inhibition of CCRF-CEM growth from approximately 65% to greater than 90% in a 7-day growth assay. Similarly, many IgG MAbs in combination with 42/6 also inhibited CCRF-CEM growth by greater than 90%. The growth-inhibitory effects of certain combinations of MAbs were clearly synergistic, because either one or both MAbs tested separately were inactive. These pairs of MAbs also inhibited the growth of HL-60 and KG-1 leukemic cells by greater than 90% and partially inhibited the growth of K562 erythroleukemia and M21 melanoma cells, which are resistant to MAb 42/6. However, not all combinations of anti-Tf receptor MAbs were more effective; eight MAbs markedly antagonized the antiproliferative effects of D65.30, whereas 12 others had little or no effect. Preincubation of HL-60 cells with three different pairs of MAbs, D65.30 and A27.15, B3/25 and 42/6, and B3/25 and TR3A, inhibited subsequent colony formation by greater than 95%, demonstrating that their action is cytotoxic, not cytostatic. The antiproliferative activity of these pairs of MAbs correlates with their ability to block Tf-mediated 59Fe uptake and perturb Tf receptor expression. Treatment of nude mice bearing established s.c. CCRF-CEM tumors with a combination of MAbs D65.30 and A27.15 inhibited tumor growth and in some animals led to complete tumor regression. Each MAb administered separately was much less effective. We conclude that combinations of two or more anti-Tf receptor MAbs can interact synergistically to inhibit cell growth in vitro and tumor growth in vivo.

Effects of transferrin-indium on cellular proliferation of a human leukemia cell line.

In previous studies, we have demonstrated that transferrin-gallium inhibits cellular proliferation by a mechanism whereby cellular iron utilization is impaired. Since indium, a similar class 3A metal, has not been well studied, we examined its effects on cellular iron uptake and cellular proliferation. In these studies, we provide evidence that indium, when bound to transferrin, has a 50-fold higher effect on inhibition of cellular proliferation than indium added as indium salt. Cells exposed to relatively low concentrations of transferrin-indium exhibit markedly increased transferrin receptor expression but, as with transferrin-gallium, these cells incorporate an inappropriately low amount of iron, suggesting that there is a defect in the release of internalized iron from transferrin. In further studies, we utilize a monoclonal antibody against transferrin receptor that inhibits transferrin-mediated iron uptake. This antibody exhibits a dose-related inhibition of cellular proliferation, and when both transferrin-indium and monoclonal antibody are added to media, there is a more than additive effect on inhibition of cellular proliferation.

The role of aluminum in the pathogenesis of anemia in an outpatient hemodialysis population.

Anemia is a well-defined complication of aluminum overload in chronic dialysis patients which may be present before other manifestations of aluminum toxicity are obvious. Causes of anemia in chronic renal failure are multiple, and at the present time there is no marker for aluminum-induced anemia. Deferoxamine (DFO) treatment can correct aluminum-related anemia and microcytosis, but may be associated with side effects. Because of the possible role of aluminum in red blood cells in causing the anemia associated with aluminum overload, we attempted to test red blood cell (RBC) aluminum as a marker for aluminum-associated anemia and to assess the prevalence of aluminum-associated anemia in an outpatient dialysis population. Both random plasma aluminum and RBC aluminum correlated well with the increase in plasma aluminum seen following DFO challenge. However, RBC aluminum was affected less by changes in oral aluminum intake than plasma aluminum. There were strong correlations of RBC and plasma aluminum to corpuscular volume (MCV) in our patients. Moreover, patients within the highest quartile of RBC aluminum had a lower mean MCV (82.1 +/- 1.7 vs 89.6 +/- 1.7, p less than .01) and hematocrit (HCT) (24.3 +/- 4 vs 28.2 +/- 1.5, p less than .05) than those within the lowest quartile. These data suggest that aluminum toxicity is an important cause of microcytic anemia in outpatient hemodialysis patients. Prospective long-term studies are needed to further define the usefulness of RBC aluminum in diagnosing and following hemodialysis patients with aluminum-induced anemia.

Transferrin synthesis by small cell lung cancer cells acts as an autocrine regulator of cellular proliferation.

Since transferrin is required for cellular proliferation, we investigated transferrin synthesis by a small cell lung cancer line (NCI-H510) that survives in serum-free media without added transferrin. Immunoassays for human transferrin demonstrated that these cells contained immunoreactive human transferrin. Immunofluorescence studies showed that the protein is expressed on the surface of cells, presumably bound to transferrin receptor. Media conditioned by NCI-H510 cells support proliferation of human leukemic cells that would not survive in media lacking transferrin. [35S]Methionine incorporation documented transferrin synthesis by NCI-H510 cells as well as three other small cell lines. Transferrin synthesis by NCI-H510 cells increased more than 10-fold when cells entered active phases of the cell cycle, and this increase was seen before large increases in transferrin-receptor expression. Further experiments examining the effects of agents that affect iron metabolism show that the addition of transferrin-iron or hemin to the media is associated with a more rapid initial rate of proliferation and lower rates of transferrin synthesis than control cells. Gallium salts, which inhibit iron uptake, inhibited proliferation of these cells. If the cells recovered from this effect, transferrin synthesis remained greatly increased compared to control. We conclude that transferrin synthesis by these malignant cells is ultimately related to an iron requirement for cellular proliferation. It appears that this synthesized transferrin acts as part of an important autocrine mechanism permitting proliferation of these cells, and perhaps permitting tumor cell growth in vivo in areas not well vascularized.

Effects of different transferrin forms on transferrin receptor expression, iron uptake, and cellular proliferation of human leukemic HL60 cells. Mechanisms responsible for the specific cytotoxicity of transferrin-gallium.

We have previously shown that human leukemic cells proliferate normally in serum-free media containing various transferrin forms, but the addition of transferrin-gallium leads to inhibition of cellular proliferation. Because gallium has therapeutic potential, the effects of transferrin-gallium on leukemic cell proliferation, transferrin receptor expression, and cellular iron utilization were studied. The cytotoxicity of gallium is considerably enhanced by its binding to transferrin and cytotoxicity can be reversed by transferrin-iron but not by other transferrin forms. Exposure to transferrin-gallium leads to a marked increase in cell surface transferrin binding sites, but despite this, cellular 59Fe incorporation is inappropriately low. Although shunting of transferrin-gallium to another cellular compartment has not been ruled out, other studies suggest that transferrin-gallium impairs intracellular release of 59Fe from transferrin by interfering with processes responsible for intracellular acidification. These studies, taken together, demonstrate that inhibition of cellular iron incorporation by transferrin-gallium is a prerequisite for inhibition of cellular proliferation.

The p97 antigen is mapped to the q24-qter region of chromosome 3; the same region as the transferrin receptor.

Since the p97 antigen, a membrane-associated iron-binding protein, has extensive amino acid sequence with homology with transferrin, is functionally related to the transferrin receptor, and has been previously mapped to chromosome 3, we have performed additional studies for regional mapping of the gene expressing p97 antigen. In these experiments, Chinese hamster-human cell lines were chosen that contained a large spectrum of autosomal human chromosomes, but mainly consisted of clones expressing all or a part of chromosome 3. These cell lines included a clone that previously allowed for mapping of human transferrin receptor to q22-qter region. Human p97 expression was assessed by specific binding of [125I]monoclonal antibody 96.5, and human transferrin receptor expression was tested by specific [125I]human transferrin binding and [125I]monoclonal antibody OKT-9 specific for human transferrin receptor. Based on these analyses, both human p97 antigenic expression and human transferrin receptor are mapped concordantly to the q24-qter region. These data and previous reports, therefore, suggest that the related iron-transport proteins are closely linked and may be under coordinate regulation. However, studies of several cell lines that exhibit up-regulation of human transferrin receptor expression with cellular proliferation, and down-regulation of receptor with increased transferrin-iron in the media, showed no change in expression of p97 antigen. p97 antigenic expression increased when melanocyte-stimulating hormone was added to a human melanoma cell line in tissue culture. These latter studies suggest that in mammalian cells the two proteins do not show coordinate regulation.(ABSTRACT TRUNCATED AT 250 WORDS)