active immunotherapy for non-small-cell lung cancer: moving toward a reality

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Review

www.expert-reviews.com ISSN 1473-7140© 2011 Expert Reviews Ltd10.1586/ERA.11.155

Cesar A Perez1, Edgardo S Santos1 and Luis E Raez†2

1University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL 33136, USA 2Thoracic Oncology Program, Memorial Cancer Institute, Hollywood, FL 33028, USA †Author for correspondence:Tel.: +1 954 844 6868 Fax: +1 954 443 4747 [email protected]

Lung cancer remains the number one cause of cancer-related death worldwide. Active cancer immunotherapy is a growing field that is included as one of the most important modalities used to modify the host immune system for the treatment of malignancies. With the recent approval of sipuleucel-T for the treatment of prostate cancer, immunotherapy has become a reality in the treatment of solid tumors. Different therapeutic cancer vaccines, aimed to create specific anti-tumor immunity, are currently under clinical development in non-small-cell lung cancer (NSCLC). Whole-cell vaccines such as belagenpumatucel-L and antigen-specific vaccines targeting EGF, mucin 1 and melanoma-associated antigen A3 have shown promising results in clinical trials and are currently being evaluated in Phase III studies. In Cuba, the CIMAvax vaccine targeting EGF has shown encouraging results, leading to the approval of this therapy there and in other countries in Central and South America. Immunotherapy lacks long term clinical experience as chemotherapy does, however, its lower toxicity promises to be a potential option for the different stages of this disease. The ongoing Phase III trials on the different therapeutic vaccines like the ones targeting melanoma associated antigen-3 and blp-25 in NSCLC will probably be completed within the next few years, and, perhaps, a new era of therapeutic cancer vaccines in NSCLC will be a reality.

Keywords: antigens • EGF • lung cancer • MAGE • MUC-1 • vaccines

Active immunotherapy for non-small-cell lung cancer: moving toward a realityExpert Rev. Anticancer Ther. 11(10), 1599–1605 (2011)

antigen that can enhance the innate immunity. Sipuleucel-T is the first T cell-based therapy now approved by the US FDA for the treatment of hormone-refractory prostate cancer. Strategies to induce anti-tumor immunity in the treatment of NSCLC are also an area of active research; unfortunately, the trials developed so far for lung cancer have had limited success. One of the major difficulties in the development of therapeutic cancer vaccines are the tumor escape mechanisms from host immune surveil-lance since many tumors, including lung can-cer, are capable of promoting immune tolerance and escape host immune surveillance, resulting in an unsuccessful host anti-tumor immune response [4,5]. Improvement in the selection of more effective antigen targets together with the counteraction of the tumor-induced immuno-suppression seems to be improving the results of immunotherapy against a tumor that is not very immunogenic like other tumors such as melanoma due to a strong immuno suppressive environment probably related to the presence of Tregs.

Globally, lung cancer remains the number one cause of cancer-related death, accounting for approximately 1,378,400 deaths annually [1]. Of these, non-small-cell lung cancer (NSCLC) accounts for approximately 85% of them. Even in patient with completely resected NSCLC, the prognosis remains poor, with 5-year mor-tality after resection of 40% in stage I, 66% in stage II and 75% in stage IIIA disease [2]. Historically, patients with advanced or meta-static disease had a median survival of less than a year. Fortunately, the median overall survival (OS) for these patients has improved during the last decade with the introduction of biological agents in combination with conven-tional chemotherapy, yielding for the first time an OS beyond 12 months [3]. Cancer immuno-therapy is now a growing field that encom-passes the modalities used to modify the host immune system for the treatment of malignan-cies. Cancer vaccination can either expose the patient’s immune system to a target antigen with an attempt to stimulate the adaptive immune system against that antigen, or administer an

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Different anticancer vaccination strategies have been used in preclinical models with some demonstrated efficacy, but rarely has this translated into a benefit in the clinical setting. Immune system modulators, viral vaccines, DNA vaccines, dendritic cells, whole tumor cells peptides and vaccines combined with adoptive T-cell therapy are all different methods used in cancer immuno therapy, all with their advantages and disadvantages [6]. In NSCLC, these immunotherapy strategies can be grouped into two main approaches currently under clinical evaluation, and their difference is based on whether the experimental modal-ity aims to create specific anti-tumor immunity, as therapeutic cancer vaccines, or positively influence the immune system to allow de novo generation of anti-tumor immunity, as immune system modulators. Therapeutic cancer vaccines can be either whole-cell vaccines or vaccines that target specific antigens. In this article, we will review and discuss the most relevant clinical developments of therapeutic cancer vaccines in NSCLC review-ing ongoing Phase III trials (Table 1) and the most promissory Phase II trials in NSCLC (Table 2).

Whole-cell vaccinesBelagenpumatucel-LTransforming growth factor-b regulates growth and function of normal and neoplastic cells. TGF-b2 induces cancer-related immunosuppression by having antagonistic effects on natural killer (NK) cells, lymphokine activated killer cells and den-dritic cells [7–9]. Levels of TGF-b2 have been correlated with prognosis in patients with NSCLC [10]. Belagenpumatucel-L is a vaccine derived from four irradiated NSCLC cell lines, each transfected with the antisense gene for TGF-b2, which decreases the expression of this immunosuppressive cyto-kine [11]. Because this vaccine uses four NSCLC cell lines,

this obviates the need to identify specific tumor antigens in the attempt to cover, theoretically, all NSCLC patients. DNA microarray studies of lung cancer cells have revealed that most of the genes are coexpressed among different tumor classifica-tions with a limited set of genes capable of delineating differ-ing subclasses of NSCLC [12,13]. Promising preclinical data has been seen with genetically altered whole tumor cell vaccines as B7 transfected NSCLC tumor cell vaccines, GVAX, and an ongoing trial incorporating a NSCLC cell line transfected with a fusion protein of gp96 and a modified immunoglobulin protein to induce secretion of tumor antigens bound to gp96 for presentation to dendritic cells [14–16].

Belagenpumatucel-L was evaluated in a Phase II trial in 75 patients with stages II–IV NSCLC where patients were randomly assigned to one of three dose cohorts (1.25, 2.5, or 5 × 107 cells/injection) on a monthly or every other month sched-ule to a maximum of 16 injections [11]. A dose-related survival difference was demonstrated in patients who received more than or equal to 2.5 x 107 cells/injection. There was a 15% partial response rate on the 61 late-stage (IIIB and IV) assessable patients and the estimated 1- and 2-year survival rates were 68 and 52%, respectively, for the higher dose groups. Positive enzyme-linked immunospot reactions to belagenpumatucel-L demonstrated to be correlated with clinical responsiveness in patients achieving at least stable disease. The vaccine was well tolerated and only two grade 3 adverse events were observed in a patient with edema at the injection site and in another who developed chronic myelo-genous leukemia, which was thoroughly vetted as not related to the study vaccine.

Based on these results, the Survival, Tumor-free, Overall and Progression-Free (STOP) trial was designed [101]. This is a Phase III placebo-controlled randomized trial with the primary

end point of comparing the OS of patients with stage III or IV NSCLC treated with belagenpumatucel-L. Patients will receive 18 monthly immunizations followed by two booster injections in 3-month inter-vals. Prior to enrollment, patients must have responded to or have stable disease following chemotherapy with a platinum-based regimen. The study is currently enrolling patients and the estimated enroll-ment is 700 patients, with an estimated study completion date of October 2011.

Antigen-specific vaccinesTumors develop within tissues and release tumor antigens into local lymphoid organs. Several proteins expressed in the lung cancer cells can be used as antigens to induce anti-tumor immunity. Together with this anti-tumor effect, a worrisome autoimmunity has been reported in some of the trials of patients with melanoma using peptide-based vaccines combined

Table 1. Therapeutic cancer vaccines currently in Phase III clinical trials in non-small-cell lung cancer.

Vaccines

Whole-cell vaccines Target antigen Characteristics

Belagenpumatucel-L NSCLC tumor cells Four irradiated NSCLC cell lines transfected with antisense gene for TGF-b2

Antigen-specific vaccines

CIMAvax-EGF EGF Human EGF protein complexed to the Neisseria meningitidis P64K protein

MAGE-A3 Melanoma-associated antigen A3

MAGE-A3 protein complexed with Haemophilus influenzae protein D and CpG 7909

L-BLP25 Mucin 1 Lyophilized preparation consisting of BLP25 lipopeptide and a immunoadjuvant monophosphoryl lipid A

TG4010 Mucin 1 Viral suspension of modified virus of Ankara with sequences coding Mucin 1 protein IL-2

MAGE: Melanoma-associated antigen; NSCLC: Non-small-cell lung cancer. Data taken from [105].

Perez, Santos & Raez

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with the antagonistic anti-CTLA-4 antibody [17,18]. Fortunately, when the anti-CTLA-4 antibody has been combined with anti-gen-specific immunotherapy in melanoma, autoimmunity has been lower, suggesting that the increased autoimmunity seen in those trials is possibly explained by the emancipation of all self-reactive cytotoxic T lymphocytes by the nonspecific anti-CTCL-antibody, causing the reported increased autoimmunity. In highly immunogenic tumors such as melanomas, the released antigens lead to cytotoxic T-lymphocyte (CTL) activation and subsequent infiltration of the tumor by tumor-antigen specific CTLs [19]. Despite this, immunogenic tumors can develop regulatory characteristics that lead to resistance to tumor cell killing by CTL. However, low immunogenic tumors release antigens that do not efficiently induce an anti-tumor immune response, consequently there is no need to develop regulatory mechanisms to counteract the killing activity of tumor-antigen primed CTL [19]. Therapeutic vaccination aims to prime the immune system against these tumor antigens, and hence, it is anticipated that such a response will be more effective against tumors (low-immunogenic) that have not already acquired an immune regulatory phenotype. Owing to the low immuno-genicity of their antigens, vaccines generally have to include potent immunoadjuvants to induce a more potent anti-tumor immune response [6].

EGF vaccineEpidermal growth factor is now a well-established target for biologic therapy in several solid malignancies and the small molecule EGF receptor tyrosine kinase inhibitor is one of the most successful developments of the last decade in the treat-ment of NSCLC. A vaccine incorporating the EGF protein with the intent of creating a humoral response to antagonize

the EGF–EGF receptor axis is the basis of several studies that led to the approval of this immunotherapy in Cuba and other countries, currently known as CIMAvax-EGF [20]. The vaccine consisted of the full-length human EGF protein complexed to the Neisseria meningitides P64K protein to increase immuno-genicity. Thus far, three trials have been reported in patients with stage IIIB/IV NSCLC [21,22]. However, the immuno-adjuvant used to emulsify the EGF protein was different in the trials with one using aluminum hydroxide, one using mon-tanide ISA 51 and another one using montanide ISA 51 and the use of a single dose of cyclophosphamide prior to vaccination to positively condition the patient’s immune system [23]. In a pooled ana lysis of the data of the three trials, the vaccine elic-ited specific anti-EGF antibody titers in 83% of the patients. The patients with seroconversion had a significant improvement in median survival (8.4 vs 3.5 months; p = 0.005); this ben-efit was higher in those patients who achieved antibody titers higher than the median (median value of maximal antibody titers was 1:4000). The vaccines were well tolerated with only grade 1 and 2 gastrointestinal and constitutional adverse effects and no evidence of autoimmunity. A Phase I study treated 20 advanced stage NSCLC patients using two doses of the EGF vaccine in Montanide ISA 51 with cyclophosphamide pretreat-ment, administered prior to standard chemotherapy, and later three additional doses were administered starting one month after vaccination [24]. Two of the patients achieved a partial response and a median survival of almost 13 months, similar to previous trials. An increased survival of 25.6 months compared with 10.5 months was also seen on patients with titers above the mean in comparison with those whose titers were below. The results of these trials are being validated in a Phase III trial currently in progress in Cuba.

Table 2. Phase II trials of therapeutic vaccines in patients with non-small-cell lung cancer.

Vaccine Study (year) Study Phase

Total patients (n)

TNM stage

Results Ref.

Whole-cell vaccines

Belagenpumatucel-L Nemunaitis et al. (2006)

II 75 II–IV Improved survival in patients treated with higher doses.15% response rate in advanced stages

[11]

Antigen-specific vaccines

CIMAvax-EGF Gonzalez et al.†

(2003)II 83 IIIB–IV 4 month improvement in survival in patients with

seroconversion (8 vs 4 months)[21]

MAGE-A3 Vansteenkiste et al. (2007)

II 182 IB–II Trend towards improvement of the disease-free interval in MAGE-A3-treated group

[29]

L-BLP25 Butts et al. (2005) II 171 IIIB–IV Stage IIIB patients in vaccinated group disease has an median OS survival 30.6 vs13.3 months in the non-vaccinated group

[33]

TG4010 Acres et al. (2009) II 140 III/IV Patients with activated NK phenotype had higher median OS when treated with the vaccine plus chemotherapy than with chemotherapy alone (18 vs 11 months)

[36]

†Pooled data from three trials.MAGE: Melanoma-associated antigen; NK: Natural killer; OS: Overall survival; TNM: Tumor, Node, Metastasis.

Active immunotherapy for non-small-cell lung cancer: moving toward a reality


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Melanoma-associated antigen A3 vaccineThe melanoma-associated antigen (MAGE)-A gene family is exclusively presented on the cell surface of cancer cells, there-fore being a potential target for immunotherapy. MAGE-A3 is expressed in about 35% of NSCLC tumors and is may be associ-ated with a worse outcome [25]. A MAGE-A3 vaccine has been developed consisting of a full length MAGE-A3 protein com-plexed to a fragment of the Haemophilus influenzae protein D and admixed with the adjuvants, saponin and monophosphoryl lipid A together with a Toll-like receptor 9 agonist, CpG 7909, known to enhance immunity in human trials of hepatitis B virus vac-cination [26–28]. The improved outcome with the use of adjuvant chemotherapy in patients with early disease NSCLC confirms the fact that the high rate of relapse seen after curative resection is likely secondary to the presence of postoperative micrometastatic disease. Therefore, enhancement of the anti-tumor immunity in the adjuvant setting seems ideal since it has the advantage of low tumor burden and better patient performance status given the early stage of disease. Thus, a Phase II study evaluated MAGE-A3 vaccine in 182 patients with completely resected tumors which expressed MAGE-A3 [29]. Patients with stage IB or II NSCLC were randomly assigned to receive postoperative MAGE-A3 vac-cine or placebo, intramuscularly every 3 weeks for five doses and then every 3 months for 2 years. A trend towards improvement of the disease free interval favored the MAGE-A3-treated patient group with a hazard ratio of 0.74 (95% CI: 0.44–1.20), prompt-ing the development of a Phase III clinical trial in early stage NSCLC, the trial MAGE-A3 as Adjuvant Non-Small-Cell Lung Cancer Immunotherapy (MAGRIT) [102]. The MAGRIT trial will include patients with NSCLC stage IB–IIIA with tumors that express MAGE-A3 and is planned to enroll 2300 patients. Patients will received four cycles of platinum-based chemotherapy as adjuvant therapy, and will then be randomized into placebo (13 intramuscular injections of this compound will be adminis-tered) or MAGE-A3 vaccine over 27 months. The primary end point will be disease-free survival and the secondary end points will include OS and seropositivity of MAGE-A3.

MUC1-targeted vaccines Mucin 1 is a highly glycosylated type 1 transmembrane protein that is aberrantly overexpressed in NSCLC cells and induces gene signatures that are associated with poor survival of NSCLC patients [30]. Moreover, MUC1 may also play a role in immuno-suppression with MUC1-associated inhibition of human T-cell proliferation being reversible by IL-2 [31]. Two vaccines are cur-rently in clinical development in NSCLC, the BLP25 liposome vaccine (L-BLP25, Stimuvax®) and the TG4010 vaccine.

The safety of the L-BLP25 vaccine was initially evaluated in a Phase I study of 17 patients with stage IIIB or IV NSCLC that received either 20 or 200 µg of the vaccine preparation [32]. The vaccine was well tolerated with clinically irrelevant grade 3 lymphopenia in two patients and mild and self-limited non-hematologic toxicities as grade 1 and 2 fatigue and liver enzymes elevation; no autoimmune processes were reported. Although no objective responses were seen, median survival was 5.4 months

in the 20-µg group and 14.6 months in the 200-µg group. A subsequent randomized Phase II trial enrolled 171 patients with stage IIIB or IV NSCLC after any first-line chemotherapy [33]. Patients were randomized between receiving a single intravenous dose of cyclophosphamide at 300 mg/m2 followed by 8-weekly subcutaneous immunizations with 1000 µg of L-BLP25 ver-sus best supportive care. Patients in the vaccinated arm had a median survival of 17.4 months compared with 13.0 months in the best supportive care (p = 0.11). Subset ana lysis of patients with stage IIIB disease revealed an improvement in the median sur-vival to 30.6 versus 13.3 months (p = 0.07), respectively. Adverse events attributable to the vaccine arm included nausea attributed to the cyclophosphamide and grade 1 skin reactions in half of the patients and one grade 2 skin reaction. The safety profile of L-BLP25 vaccine and the strong trend towards improved sur-vival prompted the launch of a Phase III trial called Stimulating Targeted Antigenic Responses To NSCLC (START) [103]. The START trial is a randomized, placebo controlled trial of unre-sectable stage III NSCLC patients with a targeted enrollment of 1476 patients who have completed at least two cycles of chemo-therapy. The study’s primary outcome is OS and secondary end points are safety and time to progression. The estimated primary completion date is June 2012.

On the other hand, the TG4010 vaccine consists in a viral sus-pension of a modified virus of Ankara containing the sequences coding for the human MUC1 protein and for the human IL-2 [34]. In two separate Phase I trials, 13 patients with different solid tumors were treated with repeated intramuscular injection with increasing doses of TG4010, six patients at a dose of 5 × 106 plaque-forming units (pfu), three patients at 5 × 107 pfu and four patients at 108 pfu. The vaccine was well tolerated and one patient with adenocarcinoma of the lung had a delayed partial response with a 64% decrease in the maximum diameter of its target lesions, with a survival of 2 years after the first administration of the TG4010 vaccine [34]. Based on its safety and early encouraging results, a multicenter, randomized Phase II study explored two schedules of the combination of TG4010 with first-line chemotherapy in patients with stage IIIB/IV NSCLC [35]. In the first arm, TG4010 was combined with cisplatin and vinorelbine, and in arm two, patients were initially treated with TG4010 monotherapy until disease progression, this was followed by TG4010 plus the same chemotherapy as in arm one. Of the 44 patients in arm one, partial response was observed in 13 patients, compared with one complete and one partial response in arm two, but two patients in arm two experienced stabilization of disease for more than 6 months with TG4010 alone. Interestingly, the 1-year survival rate was 53% for arm one and 60% for arm two, and the vaccine was well tolerated with mild-to-moderate injection site reactions as well as mild constitutional symptoms [35]. A MUC1-specific cellular immune response was observed in lymphocyte samples from all responding patients evaluable for immunologic response assessment [35]. In another Phase IIB study, 140 patients were randomized to be treated with the TG4010 vaccine plus cisplatin and gemcitabine versus the same chemotherapy regimen (cispla-tin/gemcitabine alone) [36]. In the 101 patients with normal levels



Review

of lymphocytes and an activated NK phenotype, the response rates and median OS were higher in the in the immunochemo-therapy arm versus the chemotherapy only arm (58 vs 38%; 18 vs 11 months). To date, a Phase IIB/III trial of TG4010 in patients with MUC1-expressing stage IV NSCLC and normal levels of activated NK cells (at baseline) is being developed in Europe [104].

Expert commentaryThe improvement in survival of patients with metastatic, castrate- resistant prostate cancer treated with the vaccine sipuleucel-T is a proof of principle for immunotherapy. This has been one of the most important advances in the treatment of solid tumors in the last decade. Immunotherapy for NSCLC is also becom-ing a reality due to the promising results of several therapeutic cancer vaccines strategies seen in Phase II trials (Table 2). The current development of large Phase III trials looking for possible registration of new vaccines are fostering hope for improvement in survival in these patients.

However, the different current approaches have several impor-tant differences. In reality, we are still in search of the proper antigens to fight lung cancer, but we have several different anti-gens and approaches to induce immune response. An important distinction separating the STOP trial from the GVAX trials is the use of allogeneic tumor cell lines as a vaccine to augment reactive immunity through mismatched MHC molecules. Thus, the use of the allogenic NSCLC tumor cell lines in the STOP trial could potentially provide a stronger vaccine with the greatest applicabil-ity to the breadth of patients with NSCLC. We know how difficult is to make autologous vaccines for NSCLC for several reasons, including the fact that a new biopsy had to be made, and the fact that is very important to know that we have a large number of NSCLC patients that might benefit from these vaccinations if one of these vaccines gets approved.

In addition, it is important to learn from the lesson of tyrosine kinase inhibitors in NSCLC: we need a proper biomarker to be used as a target before we can see the full benefit of the new intervention in these case the vaccines need to have targets, its hard to believe that any vaccine will work for all types of NSCLC.

The inclusion of vaccines consisting of tumor antigens of lipopolypeptides (START), full length protein (MAGRIT) or tumor cell lines (STOP) may also allow comparison of the effi-cacy between different antigen formulations. These trials will

not only improve our knowledge concerning the use of vaccines for the treatment of NSCLC but hopefully will also have a posi-tive impact on survival of lung cancer patients. Although immu-notherapy for solid tumors can improve the survival of patients with metastatic disease as is the case of sipuleucel-T in metastatic prostate cancer, its use may also be promising in improving the cure rates of patients with early-stage disease where micrometa-static disease is thought to play a critical role in the high relapse rates of these patients. The START and MAGRIT trials are good attempts to change the natural history of lung cancer.

Five-year view The better understanding of antigen presentation and costimula-tory molecules will hopefully improve the development of thera-peutic vaccines in NSCLC in the present decade. Immunotherapy lacks the long-term clinical experience that chemotherapy has, but its lower toxicity promises to be a potential option for the different disease stages of this disease. However, as many of the vaccines target self-proteins, concerns for autoimmunity processes have defined and limited their clinical evaluation and develop-ment, despite the fact that curative therapy does not exist for the majority of NSCLC patients. As more trials are now reported, the initial worrisome autoimmunity factor has been proven to be more of a hypothetical concept than a reality. Moreover there are no reports of inducing autoimmune diseases in many reported Phase I and II lung cancer vaccine trials.

The ongoing Phase III trials on the different antigen-specific and whole-tumor cell therapeutic vaccines will be likely com-pleted within few years, and we hope that they validate clinical observations in terms of efficacy and safety seen in early stud-ies. If these trials are positive, the era of immunotherapy for NSCLC will be arriving especially if we can define with the help of biomarkers the proper NSCLC patients that will benefit from these interventions.

Financial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Therapeutic cancer vaccines are classified in either whole-cell vaccines or vaccines that target specific antigens.

• Belagenpumatucel-L is a whole-cell vaccine derived from four irradiated non-small-cell lung cancer cell lines, each transfected with the antisense gene for TGF-b2 that has shown promising results in clinical studies and is currently being evaluated in Phase III trials.

• Several proteins expressed in the lung cancer cells can be used as antigens to induce anti-tumor immunity, but because of the low immunogenicity of these antigens, vaccines generally have to include potent immunoadjuvants to induce a more potent immune response.

• The EGF vaccine CIMAvax-EGF is currently approved in Cuba and South America and Phase III studies are ongoing to validate earlier results.

• Other antigen specific vaccines as melanoma associated antigen-A3, L-BLP25 and TG4010 are also in Phase III studies in the USA and Europe and trials are planned to be completed within the next 5 years.



Review

ReferencesPapers of special note have been highlighted as:• of interest•• of considerable interest

1 Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J. Clin. 61(2), 69–90 (2011).

2 Rosell R, Skrzypski M, Jassem E et al. BRCA1: a novel prognostic factor in resected non-small-cell lung cancer. PLoS One 2(11), e1129 (2007).

3 Sandler A, Yi J, Dahlberg S, Kolb MM et al. Treatment outcomes by tumor histology in Eastern Cooperative Group Study E4599 of bevacizumab with paclitaxel/carwboplatin for advanced non-small-cell lung cancer. J. Thorac. Oncol. 5(9), 1416–1423 (2010).

4 Gross S, Walden P. Immunosuppressive mechanisms in human tumors: why we still cannot cure cancer? Immunol. Lett. 116(1), 7–14 (2008).

5 Holt GE, Podack ER, Raez LE. Immunotherapy as a strategy for the treatment of non-small-cell lung cancer. Therapy 8(1), 43–54 (2011).

6 Kochenderfer JN, Gress RE. A comparison and critical analysis of preclinical anti-cancer vaccination strategies. Exp. Biol. Med. 232, 1130–1141 (2007).

7 Kasid A, Bell GI, Director EP. Effects of transforming growth factor-b on human lymphokine activated killer cell precursors: autocrine inhibition of cellular proliferation and differentiation to immune killer cells. J. Immunol. 141, 690–698 (1988).

8 Tsunawaki S, Sporn M, Ding A et al. Deactivation of macrophages by transforming growth factor-b. Nature 334, 260–262 (1988).

9 Naganuma H, Sasaki A, Satoh E et al. Transforming growth factor-b inhibits interferon-g secretion by lymphokine-activated killer cells stimulated with tumor cells. Neurol. Med. Chir. 36, 789–795 (1996).

10 Kong F, Jirtle RL, Huang DH et al. Plasma transforming growth factor-b1 level before radiotherapy correlates with long term outcome of patients with lung carcinoma. Cancer 86, 1712–1719 (1999).

11 Nemunaitis J, Dillman RO, Schwarzenberger PO et al. Phase II study of belagenpumatucel-L, a transforming growth factor b-2 antisense gene-modified allogeneic tumor cell vaccine in non-small-cell lung cancer. J. Clin. Oncol. 24, 4721–4730 (2006).

• PhaseIItrialofthewhole-celltherapeuticcancervaccinethatreporteda15%responserateassingleagentinpatientswithnon-small-celllungcancer(NSCLC).

12 Hayes DN, Monti S, Parmigiani G et al. Gene expression profiling reveals reproducible human lung adenocarcinoma subtypes in multiple independent patient cohorts. J. Clin. Oncol. 24(31), 5079–5090 (2006).

13 Bhattacharjee A, Richards WG, Staunton J et al. Classification of human lung carcinomas by mRNA expression profiling reveals distinct adenocarcinoma subclasses. Proc. Natl Acad. Sci. USA. 98(24), 13790–13795 (2001).

14 Raez LE, Cassileth PA, Schlesselman JJ et al. Allogeneic vaccination with a B7.1 HLA-A gene-modified adenocarcinoma cell line in patients with advanced non-small-cell lung cancer. J. Clin. Oncol. 22(14), 2800–2807 (2004).

15 Nemunaitis J, Sterman D, Jablons D et al. Granulocyte-macrophage colony-stimulating factor gene-modified autologous tumor vaccines in non-small-cell lung cancer. J. Natl Cancer Inst. 96(4), 326–331 (2004).

16 Schreiber TH, Deyev VV, Rosenblatt JD, Podack ER. Tumor-induced suppression of CTL expansion and subjugation by gp96-Ig vaccination. Cancer Res. 69(5), 2026–2033 (2009).

17 Phan GQ, Yang JC, Sherry RM et al. Cancer regression and autoimmunity induced by cytotoxic T lymphocyte-associated antigen 4 blockade in patients with metastatic melanoma. Proc. Natl Acad. Sci. USA 100(14), 8372–8377 (2003).

18 Attia P, Phan GQ, Maker AV et al. Autoimmunity correlates with tumor regression in patients with metastatic melanoma treated with anti-cytotoxic T lymphocyte antigen. J. Clin. Oncol. 23(25), 6043–6053 (2005).

19 Schreiber TH, Raez L, Rosenblatt JD, Podack ER. Tumor immunogenicity and responsiveness to cancer vaccine therapy: the state of the art. Semin. Immunol. 22(3), 105–112 (2010).

20 González G, Crombet T, Neninger E, Viada C, Lage A. Therapeutic vaccination with epidermal growth factor (EGF) in advanced lung cancer: analysis of pooled data from three clinical trials. Hum. Vaccin. 3(1), 8–13 (2007).

•• AnalysisofthethreetrialsthatledtotheapprovaloftheEGFvaccineforNSCLCinCuba.

21 Gonzalez G, Crombet T, Torres F et al. Epidermal growth factor-based cancer vaccine for non-small-cell lung cancer therapy. Ann. Oncol. 14(3), 461–466 (2003).

22 Ramos TC, Vinageras EN, Ferrer MC et al. Treatment of NSCLC patients with an EGF-based cancer vaccine: report of a Phase I trial. Cancer Biol. Ther. 5(2), 145–149 (2006).

23 Lutsiak ME, Semnani RT, De Pascalis R, Kashmiri SV, Schlom J, Sabzevari H. Inhibition of CD4(+)25+ T regulatory cell function implicated in enhanced immune response by low-dose cyclophosphamide. Blood 105(7), 2862–2868 (2005).

24 Neninger E, Verdecia BG, Crombet T et al. Combining an EGF-based cancer vaccine with chemotherapy in advanced nonsmall cell lung cancer. J. Immunother. 32(1), 92–99 (2009).

25 Sienel W, Varwerk C, Linder A et al. Melanoma associated antigen (MAGE)-A3 expression in stages I and II non-small-cell lung cancer: results of a multi-center study. Eur. J. Cardiothorac. Surg. 25, 131–134 (2004).

26 Atanackovic D, Altorki NK, Stockert E et al. Vaccine-induced CD4+ T cell responses to MAGE-3 protein in lung cancer patients. J. Immunol. 172(5), 3289–3296 (2004).

27 Murad YM, Clay TM, Lyerly HK, Morse MA. CPG-7909 (PF-3512676, ProMune): toll-like receptor-9 agonist in cancer therapy. Expert Opin. Biol Ther. 7(8), 1257–1266 (2007).

28 Cooper CL, Davis HL, Morris ML et al. CPG 7909, an immunostimulatory TLR9 agonist oligodeoxynucleotide, as adjuvant to Engerix-B HBV vaccine in healthy adults: a double-blind Phase I/II study. J. Clin. Immunol. 24(6), 693–701 (2004).

29 Vansteenkiste J, Zielinski H, Linder A et al. Final results of a multi-center, double-blind, randomized, placebo-controlled Phase II study to assess the efficacy of MAGE-A3 immunotherapeutic as adjuvant therapy in stage IB/II non-small-cell lung cancer (NSCLC). J. Clin. Oncol. 25(18S), 7554 (2007).

• PhaseIIstudythatevaluatedthemelanomaassociatedantigen(MAGE)-A3vaccineasadjuvanttherapyinpatientswithMAGE-A3positiveNSCLCanddiscoveredatrendtowardsimprovementofthedisease-freeinterval.

30 Raina D, Kosugi M, Ahmad R et al. Dependence on the MUC1-C oncoprotein in non-small-cell lung cancer cells. Mol. Cancer Ther. 10(5), 806–816 (2011).



Review

31 Agrawal B, Krantz MJ, Reddish MA, Longenecker BM. Cancer-associated MUC1 mucin inhibits human T-cell proliferation, which is reversible by IL-2. Nat. Med. 4, 43–49 (1998).

32 Palmer M, Parker J, Modi S et al. Phase I study of the BLP25 (MUC1 peptide) liposomal vaccine for active specific immunotherapy in stage IIIB/IV non-small-cell lung cancer. Clin. Lung Cancer 3(1), 49–57 (2001).

33 Butts C, Murray N, Maksymiuk A et al. Randomized Phase IIB trial of BLP25 liposome vaccine in stage IIIB and IV non-small-cell lung cancer. J. Clin. Oncol. 23(27), 6674–6681 (2005).

• PhaseIItrialoftheL-BLP25therapeuticvaccinethatreportedanimprovementinthemediansurvivalofpatientswithstageIIIBNSCLCwhenadministeredafterfirst-linechemotherapy.

34 Rochlitz C, Figlin R, Squiban P et al. Phase I immunotherapy with a modified vaccinia virus (MVA) expressing human MUC1 as antigen-specific immunotherapy in patients with MUC1-positive advanced cancer. J. Gene Med. 5(8), 690–699 (2003).

35 Ramlau R, Quoix E, Rolski J et al. A Phase II study of Tg4010 (Mva-Muc1-Il2) in association with chemotherapy in patients with stage III/IV non-small-cell lung cancer. J. Thorac. Oncol. 3(7), 735–744 (2008).

36 Acres B, Quoix E, Ramlau R et al. Biomarkers associated with clinical outcome in advanced non-small-cell lung cancer patients treated with TG4010. J. Clin. Oncol. 27, 15s (2009) (Abstract 3027).

Websites

101 ClinicalTrials.gov: Phase III Lucanix™ vaccine therapy in advanced non-small-cell lung cancer (NSCLC) following front-line

chemotherapy (STOP) http://clinicaltrials.gov/ct2/show/NCT00676507 (Accessed 6 December 2001)

102 ClinicalTrials.gov: GSK1572932A antigen-specific cancer Immunotherapeutic as adjuvant therapy in patients with non-small-cell lung cancer http://clinicaltrials.gov/ct2/show/NCT00480025 (Accessed 6 December 2001)

103 ClinicalTrials.gov: cancer vaccine study for unresectable stage III non-small-cell lung cancer http://clinicaltrials.gov/ct2/show/NCT00409188 (Accessed 6 December 2001)

104 ClinicalTrials.gov. Immunotherapy with TG4010 in patients with advanced non-small-cell lung cancer http://clinicaltrials.gov/ct2/show/NCT00415818 (Accessed 6 December 2001)

105 ClinicalTrials.gov http://clinicaltrials.gov (Accessed 19 September 2011)


active immunotherapy for non-small-cell lung cancer: moving toward a reality

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