Emerging Therapeutic Strategies of Different Immunotherapy Approaches Combined with PD-1/PD-L1 Blockade in Cervical Cancer

An antibody targeting an immune checkpoint molecule BTN2A2 enhances anti-tumor immunity

Tumors exploit immune checkpoints to evade immune responses. Therefore, targeting these checkpoints has become a key strategy in cancer immunotherapy. In this study, we have developed a novel immune checkpoint inhibitor (ICI) targeting the B7 family-related molecule BTN2A2. The human BTN2A2 protein, which was highly expressed in some tumor tissues and activated antigen-presenting cells (APCs), can inhibit T cell activation and proliferation. The anti-BTN2A2 monoclonal antibody (mAb) can neutralize the inhibitory effect of BTN2A2 on T cells. In mouse models of pancreatic cancer and glioma, compared to the control group, the anti-BTN2A2 treatment group exhibited tumor shrinkage of 35.8 % (P < 0.05) and 51.2 % (P < 0.01), respectively, along with increased CD8+ tumor-infiltrating lymphocytes (TILs) by 1.7-fold (P < 0.001) and 2.2-fold (P < 0.001), respectively. In addition, anti-BTN2A2 mAb also increased the infiltration of B cells, M1 macrophages, and the expression of inflammatory cytokines in T cells, while reducing the infiltration of M2 macrophages, myeloid-derived suppressor cells (MDSCs), and regulatory T cells (Tregs). Thus, anti-hBTN2A2 mAb normalizes the immunodeficient tumor microenvironment (TME) and inhibits tumor growth. Our results suggest that targeting the BTN2A2 immune checkpoint may represent a novel strategy for cancer treatment, especially in immunosuppressive 'cold' tumors.

Cadonilimab plus chemotherapy as first-line treatment for persistent, recurrent, or metastatic cervical cancer: a cost-effectiveness analysis

Background

Immunotherapy has made significant advancements in cervical cancer (CC) treatment; however, its efficacy remains limited in programmed death ligand 1 (PD-L1)-negative patients. Cadonilimab, the first bispecific antibody targeting both programmed death 1 (PD-1) and cytotoxic T lymphocyte-associated antigen-4 (CTLA-4), demonstrated superior efficacy and manageable safety as a first-line treatment for persistent, recurrent, or metastatic CC (p/r/m CC) in the phase III COMPASSION-16 trial. Notably, it showed significant survival benefits in PD-L1-negative patients. This study aimed to evaluate its cost-effectiveness from the perspective of the Chinese healthcare system.

Methods

A partitioned survival model was developed based on data derived from the COMPASSION-16 trial. The model utilized a 3-week cycle length and a 10-year time horizon. The primary outcomes included costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratio (ICER), incremental net monetary benefit (INMB), and incremental net health benefit (INHB). Additionally, sensitivity analyses, scenario analyses, and subgroup analyses were performed.

Results

The cadonilimab plus chemotherapy regimen provided an additional 0.61 QALYs compared to chemotherapy alone, at an incremental cost of $42,486.54. This yielded an ICER of $70,220.88/QALY, exceeding the willingness-to-pay threshold of $38,042/QALY. The corresponding INMB and INHB were -$19,469.55 and -0.51 QALYs, respectively. Consequently, cadonilimab plus chemotherapy was not deemed to be cost-effective. Sensitivity analyses showed that the results remained consistent when each parameter varied within the predetermined range, indicating the model's robustness. Subgroup analyses demonstrated no significant positive correlation between economic outcomes and PD-L1 expression levels. Notably, in the subgroup of patients who did not receive bevacizumab, cadonilimab plus chemotherapy emerged as a cost-effective alternative.

Conclusion

In China, cadonilimab plus chemotherapy is not considered cost-effective compared to standard chemotherapy as a first-line treatment for the general p/r/m CC population. However, it represents a cost-effective option for patients ineligible for bevacizumab therapy.

The benefit and risk of addition of PD-1/PD-L1 inhibitors to chemotherapy for advanced cervical cancer: a phase 3 randomized controlled trials based meta-analysis

BACKGROUND

Chemotherapy has been confirmed as an effective treatment for advanced cervical cancer. However, whether combining PD-1/PD-L1 inhibitors with chemotherapy (PIC) offers superior efficacy remains a subject of debate. This meta-analysis aims to compare the antitumor effects and safety profile of PIC versus chemotherapy.

METHODS

We conducted a comprehensive search across six databases to identify eligible randomized controlled trials (RCTs). The primary outcomes assessed were overall survival (OS) and progression-free survival (PFS), while the secondary endpoints included response rates and adverse events (AEs).

RESULTS

Four RCTs (BEATcc, CALLA, KEYNOTE-826, and KEYNOTE-A18) analyzing 2,857 patients were included. The PIC regimen notably enhanced OS (hazard ratio [HR]: 0.70 [0.61, 0.80], P < 0.00001), PFS (HR: 0.69 [0.61, 0.77], P < 0.00001), objective response rate (ORR) (risk ratio [RR]: 1.11 [1.02, 1.22], P = 0.02), and disease control rate (DCR) (RR: 1.05 [1.01, 1.08], P = 0.004). Improvements in OS and PFS for the PIC group were evident across nearly all subgroups. Moreover, the survival benefit for the PIC group increased with longer patient survival and elevated PD-L1 expression. The PIC group encountered higher rates of grade 3-5 AEs, and serious AEs. The top 5 grade 3-5 AEs were anemia (19.47%), hypertension (12.65%), decreased white blood cell count (11.76%), decreased neutrophil count (11.38%), and neutropenia (10.99%).

CONCLUSIONS

The PIC regimen appears superior to chemotherapy alone for advanced cervical cancer (metastatic/recurrent or locally advanced), demonstrating improved survival and response rates. However, the associated increase in AEs warrants careful consideration in its clinical application.

The Prominence of the Broad-Spectrum Protease inhibitor gene A2ML1 as a potential biomarker in cervical cancer diagnostics using Immunotherapeutic and Multi-Omics approaches

One of the venereal tumors that threaten human life is cervical cancer. A2ML1 is detected in advanced-stage cancer patients and is found to be strongly associated with cervical cancer. A2ML1 was shown to be substantially expressed in cervical cancer in this study, which used data from the TCGA database. Those with high A2ML1 expression had a lower chance of survival than patients with low A2ML1 expression. Both univariate and multivariate Cox regression analyses were utilized to investigate the relationship between clinical variables and overall survival rates. An investigation into the link between A2ML1 and immune infiltration was subsequently conducted. Utilizing the immune cell database, research was conducted to investigate the dispersion of 24 immune cells and their correlation to A2ML1 expression. In addition to this, the favorable correlation between immune cells and A2ML1 was validated using all three immune cell methodologies. The Genomics of Drug Sensitivity in Cancer database was used to confirm the idea that there is a link between A2ML1 expression and the efficacy of chemotherapy or immunotherapy. The findings demonstrated that A2ML1 is a potential biomarker for cervical cancer diagnostics. This biomarker may be used to chaperone immunotherapy, as well as to explain the elucidates of cervical cancer caused by the immunological microenvironment.

A surprising complete response to cadonilimab in a primary metastatic cervical cancer: a case report

The outcome of patients with recurrent/metastatic cervical cancer (R/M CC) is poor, with a 5-year survival rate of only 10%-20%. Recent advances in immunotherapy renewed its interest in R/M CC treatment. It has been suggested that cadonilimab, a novel bispecific antibody targeting programmed death 1 (PD-1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4), significantly improved the survival outcomes of the R/M CC. In the present study, we reported a programmed death ligand 1 (PD-L1) and human epidermal growth factor receptor 2 (HER-2) positive CC case at stage IV who was treated with cadonilimab and achieved a surprising radiographic complete response (CR) for 10 months, even in the PD-L1 negative metastatic site. Demographic, clinical, histopathological, laboratory, treatment regime and imaging data were recorded. Unfortunately, the patient progressed rapidly during maintenance therapy when cadonilimab was replaced by sintilimab, the monoclonal antibody against PD-1, indicating the more powerful anti-tumor activity of dual blockade immunotherapy. To conclude, cadonilimab offers a promising and effective therapeutic approach for R/M CC. Notably, HER-2 is also expected to be a new reference target for cadonilimab therapy.

Bridging the Gap: Immune Checkpoint Inhibitor as an Option in the Management of Advanced and Recurrent Cervical Cancer in Sub-Saharan Africa

Cervical cancer remains a leading cause of cancer-related mortality in women in low and middle-income countries despite efforts to improve prevention and standard-of-care interventions. Sub-Saharan Africa (SSA) leads the numbers for global cervical cancer incidence and mortality, with the majority of the incidence diagnosed in the late stage of the malignancy. Although the global cervical cancer death rate has been on the decline for the last two decades owing to advancements in screening and treatment options, the mortality rate in SSA has not declined very much. Chemotherapy has been the treatment of choice for cervical cancer in SSA without meeting the expected survival outcomes in these patients, with the majority having advanced diseases at diagnosis. Immune checkpoint inhibitors have recently shown clinical promise in improving the survival of patients with advanced cervical cancer and have been integrated into the treatment guidelines in most high-income countries, which have helped further reduce the mortality rate of cervical cancer. However, many SSA countries are yet to fully benefit from using immune checkpoint inhibitors in cervical cancer. In this review, we discuss the challenges hindering the effective use of immune checkpoint inhibitors for advanced cervical cancer in Africa and possible solutions.

The evolving role of immune checkpoint inhibitors in cervical and endometrial cancer

The introduction of immune checkpoint inhibitors (ICIs) has revolutionized the treatment landscape for numerous tumor types, including cervical and endometrial cancers. Multiple ICIs against programmed cell death-1 (PD-1), programmed death-ligand 1 (PD-L1), and cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) have demonstrated encouraging outcomes in controlled clinical studies for advanced cervical and endometrial cancers. For advanced cervical cancer, approved ICIs as second-line treatment include cemiplimab, nivolumab, and pembrolizumab as single agents. In the first-line treatment setting, options include pembrolizumab alone or in combination with bevacizumab, as well as atezolizumab combined with a backbone platinum-based chemotherapy plus bevacizumab. Additionally, for locally advanced cervical cancer, pembrolizumab is recommended alongside concurrent chemoradiotherapy. For endometrial cancer, pembrolizumab monotherapy, pembrolizumab in combination with lenvatinib, and dostarlimab are currently approved as second-line treatment options. Moreover, either dostarlimab or pembrolizumab can be added to first-line platinum-based chemotherapy for mismatch repair deficient malignancies. Although the inclusion of these agents in clinical practice has led to improved overall response rates and survival outcomes, many patients still lack benefits, possibly due to multiple intrinsic and adaptive resistance mechanisms to immunotherapy. This review aims to highlight the rationale for utilizing ICIs and their current role, while also delineating the proposed mechanisms of resistance to ICIs in cervical and endometrial cancer.

Cadonilimab Combined with Chemotherapy with or without Bevacizumab as First-Line Treatment in Recurrent or Metastatic Cervical Cancer (COMPASSION-13): A Phase 2 Study

PURPOSE

Immune checkpoint inhibitors (ICI) have been a potential treatment option for patients with cervical cancer in several clinical studies. We investigated the safety and efficacy of cadonilimab, a bispecific antibody targeting PD-1 and CTLA-4, plus standard therapy for the first-line treatment of R/M CC (recurrent and/or metastatic cervical cancer).

PATIENTS AND METHODS

Eligible patients were assigned to 3 cohorts: cohort A-15 (cadonilimab 15 mg/kg every 3 weeks (Q3W) plus chemotherapy), cohort A-10 (cadonilimb 10 mg/kg Q3W plus chemotherapy), and cohort B-10 (cadonilimab 10 mg/kg Q3W plus chemotherapy and bevacizumab). They received the corresponding treatments until disease progression, unacceptable toxicity, withdrawal of consent, or investigator decision. The primary objective was safety; the secondary endpoints included objective overall response (ORR), duration of response, disease control rate, progression-free survival, and overall survival. This study is registered with ClinicalTrials.gov (NCT04868708).

RESULTS

As of February 13, 2023, treatment-related adverse events (TRAE) occurred in 45 (100.0%) patients. Grade ≥3 TRAEs were reported in 33 (73.3%) patients. Immune-related adverse events (irAE) occurred in 29 (64.4%) patients and grade ≥3 irAEs were observed in 9 (20.0%) patients. Seven (15.6%) of 45 patients permanently discontinued cadonilimab treatment due to TRAEs. One death due to hemorrhagic shock occurred in cohort B-10. Among 44 patients who underwent at least one post-baseline tumor assessment, the ORR was 66.7% in cohort A-15, 68.8% in cohort A-10, 92.3% in cohort B-10, and 79.3% in cohorts A-10 and B-10 combined.

CONCLUSIONS

Cadonilimab combined with standard therapy was acceptable, with encouraging antitumor activity in patients with R/M CC.

Advancements in the Management of Cervical Intraepithelial Neoplasia: A Comprehensive Review

Cervical intraepithelial neoplasia (CIN) represents a significant precursor to cervical cancer, posing a considerable threat to women's health globally. This comprehensive review examines recent advancements in the management of CIN, encompassing screening, diagnosis, and treatment modalities. The etiology and pathogenesis of CIN are explored alongside an analysis of traditional and emerging screening techniques, including liquid-based cytology and molecular biomarkers. Treatment options, from minimally invasive procedures to immunotherapy approaches, are evaluated for efficacy and potential impact on patient outcomes. Furthermore, this review highlights the implications of these findings for clinical practice, emphasizing the importance of staying abreast of evolving guidelines and integrating innovative strategies into routine care. Recommendations for future research and practice are provided, emphasizing personalized approaches, disparities in access to care, and the exploration of novel therapeutic avenues. By addressing these challenges and opportunities, this review aims to contribute to the ongoing efforts to mitigate the burden of CIN and cervical cancer, ultimately improving women's health outcomes worldwide.

Potential role of immune cell therapy in gynecological cancer and future promises: a comprehensive review

Gynecological malignancies are most leading causes of death among women worldwide. The high prevalence of gynecologic malignancies remains significant, necessitating to turn the novel treatment approach like immunotherapy, wherein cancer cells are killed by the invasion of immune system. In recent year, immunotherapy has mostly an advanced treatment approach to repressing the tumor cells survival, proliferation, and invasion via the activation of immune systems. Moreover, various types of immune cells including T-cells, B-cells, and dendritic cells are associated with the immunotherapeutic strategy in cancer treatment. Although the significant role of T-cells against cancer is well established, while B-cells and dendritic cells also play an important role against different gynecological cancer by regulating the immune system. This review focuses on that arena and highlight the role of immune cells in the treatment of gynaecological cancer. Various immune cell-based anticancer therapies such as T-cell therapies, Adoptive Cellular transfer, B-cell therapies as well as approaches to Dendritic Cell therapies have been discussed in detail. Furthermore, the clinical settings and future avenues regarding immunotherapy on gynecological cancer have also been reviewed and illuminated in the recent study.

Knowledge mapping of immunotherapy in cervical carcinoma: a bibliometric analysis (2000-2023)

Background

Cervical carcinoma is a type of malignant tumor that primarily develops in the cervix, the lower part of the uterus. In recent years, Despite the considerable progress made in immunotherapy research for cervical carcinoma, an important aspect has been largely overlooked - the absence of a comprehensive bibliometric analysis in this field. By employing bibliometric techniques, this study aims to fill this gap and provide a comprehensive overview of the knowledge structure and research hotspots within the realm of immunotherapy in cervical carcinoma.

Method

A comprehensive search was conducted on the web of science core collection(WoSCC) database to identify publications related to immunotherapy specifically for the treatment of cervical carcinoma. The search spanned the period from the year 2000 to 2023. Several analytical tools were employed. These included VOSviewers, CiteSpace, and the R package "bibliometrix".

Results

A total of 654 research articles from 66 different countries have been included in the analysis. The United States and China have emerged as the leading countries in publishing research on immunotherapy in cervical carcinoma. Leiden University and Memorial Sloan-Kettering Cancer Center from the Netherlands and the United States respectively have a close cooperation. Fudan University from China and the German Cancer Research Center are also among the key institutions leading research in this area. Frontiers in Oncology has emerged as the most popular and widely recognized publication in the field of immunotherapy in cervical carcinoma. Journal of Clinical Oncology is frequently cited by researchers in this area. Van Der Burg, Sjoerd H has published the highest number of papers. Tewari, Krishnansu S has been the most co-cited author. Keywords such as PD-L1, chemotherapy, and immune checkpoint inhibitors have gained significant attention in recent years.

Conclusion

This is the first bibliometric study that comprehensively summarizes the research trends and developments of immunotherapy in cervical carcinoma. This groundbreaking study not only summarizes the current research trends and developments in immunotherapy for cervical carcinoma but also provides a reference for scholars studying the treatment of cervical cancer.

Stapled peptide PROTAC induced significantly greater anti-PD-L1 effects than inhibitor in human cervical cancer cells

Introduction

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target immune checkpoints that suppress immune cell activity. Low efficiency and high resistance are currently the main barriers to their clinical application. As a representative technology of targeted protein degradation, proteolysis-targeting chimeras (PROTACs) are considered to have potential for addressing these limitations.

Methods

We synthesized a stapled peptide-based PROTAC (SP-PROTAC) that specifically targeted palmitoyltransferase ZDHHC3 and resulted in the decrease of PD-L1 in human cervical cancer cell lines. Flow cytometry, confocal microscopy, protein immunoblotting, Cellular Thermal Shift Assay (CETSA), and MTT assay analyses were conducted to evaluate the effects of the designed peptide and verify its safety in human cells.

Results

In cervical cancer celllines C33A and HeLa, the stapled peptide strongly downregulated PD-L1 to < 50% of baseline level at 0.1 μM. DHHC3 expression decreased in both dosedependentand time-dependent manners. MG132, the proteasome inhibitor, can alleviate the SP-PROTAC mediated degradation of PD-L1 in human cancer cells. In a co-culture model of C33A and T cells, treatment with the peptide induced IFN-γ and TNF-α release in a dose-dependent manner by degrading PD-L1. These effects were more significant than that of the PD-L1 inhibitor, BMS-8.

Conclusions

Cells treated with 0.1 μM of SP-PROTAC or BMS-8 for 4 h revealed that the stapled peptide decreased PD-L1 more effectively than BMS-8. DHHC3-targeting SP-PROTAC decreased PD-L1 in human cervical cancer more effectively than the inhibitor BMS-8.

Immunotherapy in cervical cancer: From the view of scientometric analysis and clinical trials

BACKGROUND

Cervical cancer is the fourth most cancer and the fourth leading cause of cancer-related deaths in women worldwide. Current treatment for patients with advanced cervical cancer is limited. And in the urgent demand for novel effective therapies both as the first and the second line treatment for these patients, immunotherapy is developing fast and has made some achievements.

METHODS

This study incorporated 1,255 topic-related articles and reviews from 1999 to 2022 in the Web of Science Core Collection (WoSCC). The WoS platform, Citespace, and VOS viewer provided the annual distribution of publications and citations, the analysis of researching countries and institutions, references, keywords (co-occurrence analysis, burst analysis, and timeline view analysis), and researching authors, respectively. For clinical trials, 720 trials and 114 trials from ClinicalTrials.gov and ICTRP were retrieved, respectively. And 296 trials were finally incorporated into the analysis.

RESULTS

The scientometric analysis showed that the study of immunotherapies in cervical cancer developed fast in recent years. Most publications were from the United States, followed by China. Seven of the top 10 co-cited references belong to clinical trials, and five of them were published in recent five years. There are lots of clinical trials us specific treatment patterns, some of which have represented excellent effects.

CONCLUSIONS

Both the scientometric analysis of the 1,255 publications and the analysis of clinical trials showed that the field of immunotherapies in cervical cancer developed so fast in recent years. It was found that a lot of clinical trials using various immunotherapies (mainly vaccine therapy, adoptive cell therapy, immune checkpoint blockade, and antibody-drug conjugate) for advanced cervical cancer are currently ongoing or have represented considerable effect. Centered in immunotherapies, immune checkpoint blockades have represented great efficacy and huge potential, especially combined with other therapies such as chemotherapy, targeted therapy, and other immunotherapies.

CD8 and CD4 Positive NKT Subpopulations and Immune-Checkpoint Pathways in Early-Onset Preeclampsia and Healthy Pregnancy

Although many studies have investigated the clinical aspect of early-onset preeclampsia, our knowledge about the immunological consequences of improper placenta development is scarce. The maternal immunotolerance against the fetus is greatly influenced by the Th1 predominance developed by the mother's immune system. Thirty-two early-onset preeclamptic and fifty-one healthy pregnant women with appropriately matched gestational age were involved in our study. Mononuclear cells were separated from peripheral venous blood and the frequency of CD8⁺, CD4⁺, double positive (DP), and double negative (DN) NKT cell subpopulations was determined using multicolor flow cytometry. Following the characterization, the expression levels of different immune checkpoint receptors and ligands were also defined. Soluble CD226 levels were quantified by ELISA. Novel and significant differences were revealed among the ratios of the investigated NKT subsets and in the expression patterns of PD-1, LAG-3, TIGIT and CD226 receptors. Further differences were determined in the expression of CD112, PD-1, LAG-3 and CD226 MFI values between the early-onset preeclamptic and the healthy pregnant groups. Our results suggest that the investigated NKT subpopulations act differently in the altered immune condition characteristic of early-onset preeclampsia and indicate that the different subsets may contribute to the compensation or maintenance of Th1 predominance.

Evaluation of immunotherapy efficacy in gynecologic cancer

Various immunotherapies have demonstrated remarkable success over the past few decades, and have been approved for the treatment of different cancer types. However, patient responses to immunotherapy are variable, and approximately 50% of cases are refractory to these agents. Tumor biomarker-based stratification of cases may therefore help identify subpopulations that are sensitive/resistant to immunotherapy; it may also improve prediction of response in various cancers including gynecologic cancer. These biomarkers include the tumor mutational burden, microsatellite instability, mismatch repair deficiency, T cell-inflamed gene expression profile, programmed cell death protein 1 ligand 1, tumor-infiltrating lymphocytes, and numerous other genomic alterations. Future directions in the treatment of gynecologic cancer include the utilization of these biomarkers to select ideal candidates. This review focused on recent advances in the predictive ability of molecular biomarkers in patients with gynecologic cancer who undergo immunotherapy. The most recent developments in combined immunotherapy and targeted therapy strategies and novel immune interventions against gynecologic cancers have also been discussed.