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Mohamed A, Kruse M, Tran J. Progress in immune checkpoint inhibition in early-stage triple-negative breast cancer. Expert Rev Anticancer Ther 2023; 23:1071-1084. [PMID: 37747062 DOI: 10.1080/14737140.2023.2262764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors have been particularly effective in treating cancers with robust immune microenvironments and have been successfully incorporated into the management of metastatic ER-negative and HER2-negative breast cancer. This has prompted investigation of immunotherapy in early-stage triple negative breast cancer (TNBC) to address the suboptimal clinical outcomes and limited therapeutic options. AREAS COVERED This review highlights the studies examining the use of neoadjuvant immunotherapy with standard chemotherapy in the management of early-stage TNBC and explores ongoing areas of study including the role of adjuvant checkpoint inhibition and novel combination therapies with immunotherapy. EXPERT OPINION The current standard of care for early-stage ER-negative, HER2-negative breast cancer measuring ≥2 cm or with lymph node involvement is neoadjuvant chemotherapy with pembrolizumab followed by ongoing pembrolizumab in the adjuvant setting to complete 1 year of total therapy as per the KEYNOTE-522 study. This approach is associated with improved pathologic complete response (pCR) rate and event free survival, irrespective of PD-L1 status. Many questions remain regarding the optimization of chemotherapy partner(s) for immunotherapy, necessity of adjuvant immunotherapy for patients who achieve pCR, inclusion of other therapies in the adjuvant setting (particularly capecitabine or olaparib), and use of adjuvant immunotherapy when it was not received in the neoadjuvant setting.
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Affiliation(s)
- Ahmed Mohamed
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, United States of America
| | - Megan Kruse
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, United States of America
| | - Jennifer Tran
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, United States of America
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Abdou Y, Goudarzi A, Yu JX, Upadhaya S, Vincent B, Carey LA. Immunotherapy in triple negative breast cancer: beyond checkpoint inhibitors. NPJ Breast Cancer 2022; 8:121. [PMID: 36351947 PMCID: PMC9646259 DOI: 10.1038/s41523-022-00486-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 10/13/2022] [Indexed: 11/10/2022] Open
Abstract
The development of immunotherapy agents has revolutionized the field of oncology. The only FDA-approved immunotherapeutic approach in breast cancer consists of immune checkpoint inhibitors, yet several novel immune-modulatory strategies are being actively studied and appear promising. Innovative immunotherapeutic strategies are urgently needed in triple negative breast cancer (TNBC), a subtype of breast cancer known for its poor prognosis and its resistance to conventional treatments. TNBC is more primed to respond to immunotherapy given the presence of more tumor infiltrating lymphocytes, higher PD-L1 expression, and higher tumor mutation burden relative to the other breast cancer subtypes, and therefore, immuno-oncology represents a key area of promise for TNBC research. The aim of this review is to highlight current data and ongoing efforts to establish the safety and efficacy of immunotherapeutic approaches beyond checkpoint inhibitors in TNBC.
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Affiliation(s)
- Yara Abdou
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, 27599, USA.
| | - Atta Goudarzi
- Department of Medicine, University at Buffalo, Buffalo, NY, 14203, USA
| | - Jia Xin Yu
- Parker Institute for Cancer Immunotherapy, San Francisco, CA, 94129, USA
| | | | - Benjamin Vincent
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Lisa A Carey
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, 27599, USA
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Uliano J, Nicolò E, Corvaja C, Taurelli Salimbeni B, Trapani D, Curigliano G. Combination immunotherapy strategies for triple-negative breast cancer: current progress and barriers within the pharmacological landscape. Expert Rev Clin Pharmacol 2022; 15:1399-1413. [DOI: 10.1080/17512433.2022.2142559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jacopo Uliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Eleonora Nicolò
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Carla Corvaja
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Beatrice Taurelli Salimbeni
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
- Department of Clinical and Molecular Medicine, Oncology Unit, “La Sapienza” University of RomeAzienda Ospedaliera Sant’Andrea, Rome, Italy
| | - Dario Trapani
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
- Department of Medical Oncology, Medical Oncology Dana Farber Cancer Institute, Boston, MA, USA
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Tommasi C, Pellegrino B, Diana A, Palafox Sancez M, Orditura M, Scartozzi M, Musolino A, Solinas C. The Innate Immune Microenvironment in Metastatic Breast Cancer. J Clin Med 2022; 11:jcm11205986. [PMID: 36294305 PMCID: PMC9604853 DOI: 10.3390/jcm11205986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/27/2022] [Accepted: 10/09/2022] [Indexed: 11/30/2022] Open
Abstract
The immune system plays a fundamental role in neoplastic disease. In the era of immunotherapy, the adaptive immune response has been in the spotlight whereas the role of innate immunity in cancer development and progression is less known. The tumor microenvironment influences the terminal differentiation of innate immune cells, which can explicate their pro-tumor or anti-tumor effect. Different cells are able to recognize and eliminate no self and tumor cells: macrophages, natural killer cells, monocytes, dendritic cells, and neutrophils are, together with the elements of the complement system, the principal players of innate immunity in cancer development and evolution. Metastatic breast cancer is a heterogeneous disease from the stromal, immune, and biological point of view and requires deepened exploration to understand different patient outcomes. In this review, we summarize the evidence about the role of innate immunity in breast cancer metastatic sites and the potential targets for optimizing the innate response as a novel treatment opportunity.
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Affiliation(s)
- Chiara Tommasi
- Medical Oncology and Breast Unit, University Hospital of Parma, 43126 Parma, Italy
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- GOIRC (Gruppo Oncologico Italiano di Ricerca Clinica), 43126 Parma, Italy
- Correspondence:
| | - Benedetta Pellegrino
- Medical Oncology and Breast Unit, University Hospital of Parma, 43126 Parma, Italy
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- GOIRC (Gruppo Oncologico Italiano di Ricerca Clinica), 43126 Parma, Italy
| | - Anna Diana
- Medical Oncology Unit, Ospedale del Mare, 80147 Naples, Italy
| | - Marta Palafox Sancez
- Tumor Heterogeneity, Metastasis and Resistance Laboratory, University of Basel, 4001 Basel, Switzerland
| | - Michele Orditura
- Division of Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Mario Scartozzi
- Medical Oncology Department, University of Cagliari, 09042 Cagliari, Italy
| | - Antonino Musolino
- Medical Oncology and Breast Unit, University Hospital of Parma, 43126 Parma, Italy
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- GOIRC (Gruppo Oncologico Italiano di Ricerca Clinica), 43126 Parma, Italy
| | - Cinzia Solinas
- Medical Oncology Department, University of Cagliari, 09042 Cagliari, Italy
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PD-L1 protein expression in relation to recurrence score values in early-stage ER + breast cancer. Breast Cancer Res Treat 2022; 196:221-227. [PMID: 36028784 DOI: 10.1007/s10549-022-06712-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/12/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE We assessed associations between PD-L1 protein expression, RS, tumor grade, and stromal tumor-infiltrating lymphocyte (TIL) count in early-stage ER + cancers. METHODS FFPE tissue blocks of 213 patients with RS in 2012-2017 were identified. PD-L1 immunohistochemistry was performed with SP142 assay, cases with ≥ 1% tumor-infiltrating immune cell positivity in the tumor area were considered PD-L1 + . TIL scores were determined following the international TIL counting guidelines. PD-L1 expression positivity rates were compared across RS (< 11, 11-25, > 25) and TIL categories (< 10%, 10-29%, > 30%), and tumor grade using Wilcoxon and Chi-square tests. Multivariate analysis was performed using logistic regression. RESULTS PD-L1 and TIL results were available for 201 and 203 patients. Overall, 53% of cases were PD-L1 +. PD-L1 expression was higher among cases with RS > 25, versus RS < 11 (p = 0.00019) and RS 11-25 (p = 0.0017). PD-L1 positivity also correlated with TIL score, tumor grade, and tumor size. Among cancers with TIL > 30%, 92% were PD-L1 + versus 44% PD-L1 + among TIL < 10% (p = 2.8 × 10-6). Grade 3 cancers had higher PD-L1 positivity (79% PD-L1 +) versus grade 2 (49% PD-L1 +) or 1 tumors (48% PD-L1 +) (p = 0.00047). T2 and T3 tumors had more frequent PD-L1 positivity (67% and 83%, respectively) versus T1 cancers (46%) (p = 0.008). In multivariate analysis, only TIL and RS remained as independent predictors of PD-L1 positivity. CONCLUSION PD-L1 expression is significantly more frequent and higher in larger tumors (T2, T3), grade 3 cancers, and in cancers with RS > 25. PD-L1 expression also correlates with TIL score.
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Borgovan T, Yanamandra N, Schmidt H. INNATE IMMUNITY AS A TARGET FOR NOVEL THERAPEUTICS IN TRIPLE NEGATIVE BREAST CANCER. Expert Opin Investig Drugs 2022; 31:781-794. [DOI: 10.1080/13543784.2022.2096005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Theo Borgovan
- Oncology Research and DevelopmentGlaxoSmithKline, 1250 S. Collegeville Road, Collegeville, PA 19426,
| | - Niranjan Yanamandra
- Immuno-Oncology & Combinations Research Unit.GlaxoSmithKline, 1250 S. Collegeville Road, Collegeville, PA 19426,
| | - Hank Schmidt
- Oncology Research and DevelopmentGlaxoSmithKline, 1250 S. Collegeville Road, Collegeville, PA 19426,
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Brown M. Engaging Pattern Recognition Receptors in Solid Tumors to Generate Systemic Antitumor Immunity. Cancer Treat Res 2022; 183:91-129. [PMID: 35551657 DOI: 10.1007/978-3-030-96376-7_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Malignant tumors frequently exploit innate immunity to evade immune surveillance. The priming, function, and polarization of antitumor immunity fundamentally depends upon context provided by the innate immune system, particularly antigen presenting cells. Such context is determined in large part by sensing of pathogen specific and damage associated features by pathogen recognition receptors (PRRs). PRR activation induces the delivery of T cell priming cues (e.g. chemokines, co-stimulatory ligands, and cytokines) from antigen presenting cells, playing a decisive role in the cancer immunity cycle. Indeed, endogenous PRR activation within the tumor microenvironment (TME) has been shown to generate spontaneous antitumor T cell immunity, e.g., cGAS-STING mediated activation of antigen presenting cells after release of DNA from dying tumor cells. Thus, instigating intratumor PRR activation, particularly with the goal of generating Th1-promoting inflammation that stokes endogenous priming of antitumor CD8+ T cells, is a growing area of clinical investigation. This approach is analogous to in situ vaccination, ultimately providing a personalized antitumor response against relevant tumor associated antigens. Here I discuss clinical stage intratumor modalities that function via activation of PRRs. These approaches are being tested in various solid tumor contexts including melanoma, colorectal cancer, glioblastoma, head and neck squamous cell carcinoma, bladder cancer, and pancreatic cancer. Their mechanism (s) of action relative to other immunotherapy approaches (e.g., antigen-defined cancer vaccines, CAR T cells, dendritic cell vaccines, and immune checkpoint blockade), as well as their potential to complement these approaches are also discussed. Examples to be reviewed include TLR agonists, STING agonists, RIG-I agonists, and attenuated or engineered viruses and bacterium. I also review common key requirements for effective in situ immune activation, discuss differences between various strategies inclusive of mechanisms that may ultimately limit or preclude antitumor efficacy, and provide a summary of relevant clinical data.
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Affiliation(s)
- Michael Brown
- Department of Neurosurgery, Duke University, Durham, NC, USA.
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Agostinetto E, Losurdo A, Nader-Marta G, Santoro A, Punie K, Barroso R, Popovic L, Solinas C, Kok M, de Azambuja V, Lambertini M. Progress and pitfalls in the use of immunotherapy for patients with triple negative breast cancer. Expert Opin Investig Drugs 2022; 31:567-591. [PMID: 35240902 DOI: 10.1080/13543784.2022.2049232] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Triple negative breast cancer (TNBC) is an area of high unmet medical need in terms of new effective treatment strategies. Although breast cancer is traditionally considered a 'cold' tumor type, TNBC is the most appropriate subtype for immunotherapeutic strategies; this is due to the high level of tumor infiltrating lymphocytes, PD-L1 expression and tumor mutational burden relative to other breast cancer subtypes. AREAS COVERED This review examines the use of immunotherapeutic strategies in early and advanced TNBC. The paper summarizes data on novel promising immunomodulatory approaches that have been explored in early phase trials and discusses the pitfalls and limitations often encountered in clinical research. EXPERT OPINION PD-1-blockade is approved for stage II/III TNBC and for first-line treatment of PD-L1-positive TNBC patients with metastatic disease and should be considered standard of care. However, question marks and difficulties remain; these include the identification of predictive biomarkers to select patients who benefit from the addition of PD1-blockade and the balance between efficacy and long-term toxicity for an individual patient. Numerous treatment combinations and new immunotherapeutic strategies beyond PD1 blockade are being evaluated, thus reflecting a promising evolution of a more personalized approach, and extended clinical benefit in TNBC.
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Affiliation(s)
- Elisa Agostinetto
- Academic Trials Promoting Team, Institut Jules Bordet and l'Université Libre de Bruxelles (U.L.B), Brussels, Belgium.,Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy
| | - Agnese Losurdo
- Humanitas Research Hospital - IRCCS, Humanitas Cancer Center, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Guilherme Nader-Marta
- Academic Trials Promoting Team, Institut Jules Bordet and l'Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy.,Humanitas Research Hospital - IRCCS, Humanitas Cancer Center, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Kevin Punie
- Department of General Medical Oncology and Multidisciplinary Breast Centre, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | | | - Lazar Popovic
- Oncology Institute of Vojvodina, Faculty of Medicine, University Novi Sad, Novi Sad, Serbia
| | - Cinzia Solinas
- Medical Oncology, ATS Sardegna, Ospedale San Francesco, Nuoro, Italy
| | - Marleen Kok
- Departments of Medical Oncology, Tumor Biology & Immunology. Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Vandro de Azambuja
- Academic Trials Promoting Team, Institut Jules Bordet and l'Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy.,Department of Medical Oncology, U.O.C Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Howard FM, Villamar D, He G, Pearson AT, Nanda R. The emerging role of immune checkpoint inhibitors for the treatment of breast cancer. Expert Opin Investig Drugs 2021; 31:531-548. [PMID: 34569400 DOI: 10.1080/13543784.2022.1986002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Breast cancer has traditionally been viewed as immunogenically 'cold,' but two immune checkpoint inhibitors have been approved in combination with chemotherapy for PD-L1 positive advanced triple-negative breast cancer (TNBC), and pembrolizumab was also recently approved for early stage TNBC. As the landscape is rapidly evolving, a comprehensive review of checkpoint inhibitors in breast cancer is needed to aid clinicians in selecting appropriate candidates for therapy, and to highlight ongoing promising studies in this area and topics in need of further investigation. AREA COVERED This review summarizes the latest evidence from completed and ongoing trials of immune checkpoint inhibitors. Ongoing studies were identified using a search of ClinicalTrials.gov with the term 'breast cancer' along with specific checkpoint inhibitor agents. EXPERT OPINION A number of novel combination strategies are under investigation to enhance response and overcome resistance to immunotherapy, with promising preliminary data from checkpoint inhibitors targeting TIGIT, combinations with small molecule inhibitors such as lenvatinib, and injectable agents directly influencing the immune microenvironment. As immunotherapy enters into the curative setting, biomarkers predictive of immunotherapy benefit are needed, as PD-L1 status has not been a helpful discriminator in completed trials in early-stage breast cancer.
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Affiliation(s)
| | - Dario Villamar
- Department of Medicine, University of Chicago, Chicago, USA
| | - Gong He
- Department of Medicine, University of Chicago, Chicago, USA
| | | | - Rita Nanda
- Department of Medicine, University of Chicago, Chicago, USA
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