Cancer Treatment

Extra or Missing Chromosomes May Help Cancer Cells Survive Treatment

Around 90% of tumors have cancer cells with extra or missing chromosomes—a phenomenon
known as aneuploidy. Despite this frequency, scientists have struggled to understand whether
aneuploidy is harmful or helpful to cancer cells. But a new NCI-funded study has shown that the
gain or loss of chromosomes may actually benefit cancer cells, particularly when they are
exposed to cancer treatments.

“There wasn’t a good explanation as to why cancer cells would have such a high frequency of
aneuploidy,” said Devon Lukow, a graduate student at Cold Spring Harbor Laboratory in New
York and lead researcher of the study. There were some theories, including that aneuploidy
might help tumors better adapt to stressful conditions, he added.

The new study, published August 4 in Developmental Cell, found evidence to support that idea.
In lab experiments, aneuploidy helped human cancer cells survive treatment with cancer
drugs like chemotherapy and targeted therapy. What’s more, the cells that thrived tended to have
the same pattern of extra or missing chromosomes. 
A separate research team in Europe found similar results when they examined human cancer
cells with aneuploidy. Their study was also published August 4 in Developmental Cell.

“This could turn out to be a common mechanism of drug resistance and might help us identify
ways to counteract that resistance,” said Keren Witkin, Ph.D., of NCI’s Division of Cancer
Biology, who was not involved in the study. 

When Cancer Resists Treatment

Most cells in our bodies have 46 chromosomes. When a cell is getting ready to divide, it makes a
copy of each chromosome. The chromosomes are then paired up and evenly split between the
two resulting cells. 

But sometimes when cells—especially cancer cells—divide, the chromosome pairs separate
unevenly, leaving one cell with more chromosomes than the other. The resulting aneuploidy
generally wreaks havoc on the cells, causing widespread problems
with metabolism, protein production, and growth. So why is it so common in tumors?
Lukow and his colleagues reasoned that cancer cells might use aneuploidy to circumvent
treatments like chemotherapy. Although cancer treatments can be effective, most eventually stop
working because cancer cells find ways to resist the effects of the treatment. Cancer cells use a
variety of tactics to evade anticancer treatments, and scientists are still learning just how sneaky
cancer can be in that regard.

To test their idea in the lab, the researchers exposed human cancer cells to a chemical that causes
aneuploidy by disrupting chromosome separation during cell division. For comparison, the team
left some cells untreated so that their chromosome number stayed the same.

In the absence of any cancer treatment, melanoma cells treated to become more aneuploid grew
slower than those that were untreated. But after several days of exposure to vemurafenib
(Zelboraf), a targeted therapy used to treat melanoma, the cells with more aneuploidy survived
and grew faster. 
Melanoma cells with aneuploidy also survived treatment with the chemotherapy drug paclitaxel.
And aneuploid colorectal cancer cells were able to withstand both vemurafenib and paclitaxel
treatment. 

Likewise, the European research team reported that several different types of human cancer cells
with aneuploidy had a survival advantage over cells without it when exposed to targeted
therapies or chemotherapies.

Small DNA changes called mutations are often the culprit for drug resistance, explained Dr.
Witkin. But when both research groups analyzed the DNA of different drug-resistant cancer
cells, they couldn’t find any mutations that accounted for the drug resistance.

“This is a new way to think about how drug resistance occurs—not just by mutating genes, but
by changing the number of copies of a gene,” Dr. Witkin said. 

To see whether aneuploidy was linked with therapy resistance in people with cancer, Lukow and
his colleagues turned to The Cancer Genome Atlas (TCGA), a collection of genetic and clinical
data from more than 20,000 people with cancer.

In line with other study findings, the researchers noticed that people with cancer cells that had
more chromosome alterations did not live as long as those whose cancer cells had fewer
chromosome alterations. In addition, people with more chromosome alterations in their cancer
cells were more likely to have their cancer come back after treatment.
A Pattern of Aneuploidy Emerges

Next, Lukow and his colleagues took a closer look at the pattern of extra and missing
chromosomes in cancer cells that had become resistant to drug treatment.

Before treatment with vemurafenib, the aneuploid melanoma cells had a random assortment of
extra or missing chromosomes. But after 3 weeks of treatment, nearly all of the cells had the
same pattern of aneuploidy, namely extra copies of chromosomes 11 and 18. The researchers
saw the same pattern—extra copies of chromosomes 11 and 18—each time they repeated the
experiment.

Melanoma cells that developed resistance to paclitaxel also had a consistent pattern of
aneuploidy, but they tended to lose chromosomes 16, 19, and 20. And colorectal cancer cells that
were resistant to vemurafenib often gained an extra copy of chromosome 7. 

These findings “suggest that the aneuploidies which can drive resistance are very context
dependent,” meaning it depends on the type of cancer and drug treatment the cells are exposed
to, Lukow said.

The European researchers also noticed consistent patterns of aneuploidy in cancer cells that had
become resistant to treatment. For instance, they found that lung cancer cells that had become
resistant to the chemotherapy drug topotecan tended to lose chromosomes 5 and 18 and gain an
extra copy of chromosome 22.

What’s happening is a kind of survival of the fittest, Lukow explained. During drug treatment,
cells with chromosome changes that confer resistance continue to survive and grow. On the other
hand, cancer cells with other chromosome changes that don’t confer resistance eventually die
off. 

Extra Copies of Resistance Genes

The finding that certain chromosomes were consistently gained or lost suggests that “maybe
there’s something on those chromosomes that’s driving resistance,” Lukow said.

Dr. Witkin agreed, saying, “it’s not all of chromosome 11, it’s probably one gene in there that’s
responsible, or a combination of two [genes].” But there can be thousands of genes in a single
chromosome, so it can be tough to narrow down.
The European researchers think they may have found the needle in the haystack. They
painstakingly searched through extra copies of chromosome 6 for genes that might confer
resistance to topotecan in lung cancer cells. 

Among the many thousands of genes they reviewed, MAPK13 and MAPK14 stood out because

together they produce a protein called p38. And p38 is known to raise the level of BCRP, a
protein pump that expels certain toxic drugs—including topotecan—out of cells. 

Indeed, the researchers saw that topotecan-resistant lung cancer cells had higher levels of BCRP
than lung cancer cells that were not resistant to the drug.

“Overall, both studies have added evidence to the long-held but seldom tested theory that
increased levels of aneuploidy really do give an advantage, in multiple cell lines, against multiple
cancer drugs,” wrote Nadeem Shaikh and Sarah McClelland in an accompanying
commentary in Developmental Cell.

The studies' findings, Drs. Shaikh and McClelland added, emphasize "the critical need to truly
comprehend how [chromosome instability] functions in tumors.”

Gut Microbes May Influence How Well Radiation Therapy Works against Cancer

Many studies have shown that bacterial communities in the gut may influence cancer in humans,
from how fast tumors grow and spread to how they respond to treatments like chemotherapy or
immunotherapy.

But new research suggests that bacteria aren’t the only microorganisms in the gut that affect how
tumors respond to cancer treatments. Fungi, the study found, may also be important players.

In studies in mice, scientists from Cedars-Sinai Medical Center found that, when normal
bacterial communities in the gut were disrupted, fungi moved in. And these fungi, in
turn, disrupted the immune response to tumors that may be important for radiation therapy to
work most effectively, the team reported in Cancer Cell on July 29.

The researchers also identified a fungi-sensing protein in tumors that may play a role in this
phenomenon. Using samples from human tumors, they found that people with breast cancer
or melanoma that had higher levels of this protein did not live as long as those who had lower
levels.
“We’re just [beginning] to understand how the microbiota help in terms of host immunity in
cancer therapeutics,” said Mansoor Ahmed, Ph.D., of NCI’s Division of Cancer Treatment and
Diagnosis, who was not involved with the study. A more detailed picture of these interactions
could eventually help researchers design personalized treatments to alter the
gut microbiome prior to cancer therapy, Dr. Ahmed explained.

Complex Interactions

The details of how the immune system helps fight cancer are still being uncovered. Early work in
the field led to the rise of immunotherapies: cancer treatments that coax the immune system to
attack and kill tumor cells. These therapies have already revolutionized the treatment of several
types of advanced cancer, including melanoma and lung cancer.
But recent research has revealed that the immune system can also influence how well
chemotherapy and radiation therapy work. And research has shown that the microorganisms
normally found in the human gut—known as the gut microbiome—affect how immune cells do
their job throughout the body.

The new study, led by Stephen Shiao, M.D., Ph.D., and David Underhill, Ph.D., both of Cedars-
Sinai Medical Center, sought to build on this earlier research.

The role of the immune system in controlling cancer after radiation therapy has been under
intensive study, Dr. Underhill explained. Without the contribution of immune cells, cancer cells
are likely to grow back right after treatment. 

“Radiation therapy kills tumor cells, then immune cells infiltrate [the tumor] and make it an
inhospitable environment for the tumor cells to grow back," he said. "It’s like a forest fire, where
you can put it out, but there has to be a team to go in and clean up all the hotspots and make sure
they don’t flare up and start all over again.”

“So why does a strong immune response happen sometimes [in tumors after radiation therapy]
and not other times?” Dr. Underhill asked. To investigate, the researchers looked more closely at
the complex interactions between the microbiome and the immune system.
Microbes Out, Microbes In

The researchers first used a cocktail of antibiotics to disrupt the normal gut bacterial
communities in mice that had been implanted with breast cancer cells. When they treated the
mice with radiation, the tumors continued to grow and the mice died quickly. The same thing
happened in mice implanted with melanoma cells and in mice treated with a different
combination of antibiotics.

The researchers also noticed something else in the mice: The gut bacteria that had been wiped
out by antibiotics were replaced by fungi. To see what role this overgrowth of fungi might be
playing in the response of immune cells after radiation therapy, the team treated another group of
mice with an antifungal drug before radiation.

The antifungal treatment had the opposite effect from the antibacterial treatment: more tumor
cells died after radiation therapy. 

Further experiments found that administering a large amount of fungi into the gut reduced the
effectiveness of radiation therapy even if bacteria weren’t depleted beforehand. This suggested
that it was the presence of extra fungi—not the reduction in bacteria—that impaired the response
to radiation therapy, the researchers reported.

After depleting bacteria in the gut with antibiotics and letting fungi expand, the researchers also
found fewer tumor cell–killing immune cells in the tumor microenvironment after the mice
received radiation therapy. But when the gut fungi were kept in check with an antifungal drug, a
larger number of these helpful immune cells reached the tumors after radiation therapy.

To see if gut fungi may affect how well radiation therapy works in people, the team measured
levels of a protein called Dectin-1 in samples taken from human tumors. Dectin-1, a protein that
is found on the surface of some immune cells, is one of the main tools the human body uses to
sense the presence of fungi.

People with higher levels of Dectin-1 in their breast or melanoma tumors tended to have worse
survival than those with lower levels, they found. Going back to mice, the researchers found a
corresponding result: Tumor cells in mice engineered to lack Dectin-1 were more vulnerable to
radiation therapy. 
While the mechanisms behind these observations are still unclear, Dectin-1 may mediate the
response to radiation therapy, depending on the levels of fungi that it senses, Dr. Underhill
explained.

Targeting the Microbiome

So how could something as seemingly unrelated as the body sensing a change in gut fungi
impact the immune response after radiation therapy? 

“That’s the $20,000 question,” said Dr. Underhill. “But what I think this study does is put up a
kind of red flag saying: ‘Let’s make sure we understand the fungi in the microbiome, because it
could be having important effects on the immune response.’”

Researchers have already begun to test whether tweaking the composition of the gut microbiome
can boost the effectiveness of some cancer treatments. In a recent study, making wholesale
changes in the makeup of the gut microbiome improved how well an immunotherapy drug
worked in some people with melanoma.
But scientists would like to try adjusting the microbiome in a more specific manner. For this,
“we need to understand which microbial species are most relevant” to cancer
treatment responses, said Dr. Ahmed.
“It would be really handy to be able to characterize a patient’s microbiome—both bacterial and
fungal— and determine their expected prognosis, or how they’ll respond to radiation therapy,
chemotherapy, or immunotherapy,” added Dr. Underhill. “Then we’d like to see whether it’s
feasible to change that microbiome to make those therapies work better.”

Proteins such as Dectin-1 could potentially serve as biomarkers to identify people with a
potentially unfavorable microbiome for future clinical trials, Dr. Ahmed said.

“I don’t think we’re too far away from that; I think human studies [targeting specific microbes
before cancer treatment] are in the not-so-distant future,” added Dr. Underhill. 

For now, Dr. Ahmed cautioned, people undergoing cancer treatment should avoid any temptation
to tweak their gut microbes on their own with over-the-counter probiotic supplements or
prescription drugs. 
“We don’t want people going out and taking antifungal drugs, because we don’t have evidence
yet that that would be helpful, and there could be reasons that it could be dangerous,” agreed Dr.
Underhill.

FDA Approves Belumosudil to Treat Chronic Graft-Versus-Host Disease

People with chronic graft-versus-host disease (GVHD), a common complication of bone marrow
and stem cell transplants, now have a new treatment option. On July 16, the Food and Drug
Administration (FDA) approved belumosudil (Rezurock) for people 12 years and older who have
already tried at least two other therapies for the disease. 

The approval is based partially on findings from a phase 2 clinical trial of 65 people with
chronic GVHD, who were in remission from cancer after treatment with a bone marrow or stem
cell transplant. Three-quarters of those patients responded to belumosudil, meaning their GVHD
symptoms improved. 
Although the standard treatment for chronic GVHD—high doses of a steroid such as prednisone
—works for about half of patients, it causes many toxic side effects that limit its long-term use.
And although there are more than 30 other treatment options, only one is FDA approved for
chronic GVHD and there’s no way to know which one will work best for an individual.

“Throughout most of transplant history, we have been taking drugs that were developed for other
[purposes], putting them into [patients with chronic GVHD], and seeing if they work,” said study
investigator Stephanie Lee, M.D., M.P.H., of Fred Hutchinson Cancer Research Center.

“This is the first time in history that [a drug] was developed, from animal experiments to clinical
application, as a therapy for chronic GVHD,” added study investigator Steven Pavletic, M.D., of
the Immune Deficiency Cellular Therapy Program in NCI’s Center for Cancer Research. 

Chronic Graft-Versus-Host Disease

GVHD occurs when transplanted immune cells (the graft) attack the recipient’s body (the host).
The disease can affect nearly every organ and can cause many painful and debilitating
symptoms.

GVHD is a concern for people with blood cancer because bone marrow and stem cell
transplantation are part of the standard treatments for blood cancers. 
“As techniques [for stem cell transplants] became safer and patients started living longer,
this late effect became a big issue,” Dr. Pavletic explained. “These patients are cured from
cancer, and now they are suffering from a new autoimmune disease that affects [them from] head
to toe.” 

The disease can develop quickly (acute GVHD) or slowly (chronic GVHD). Chronic GVHD
usually develops within 12 months after the transplant and can take 3 to 5 years to resolve, if at
all. Around 5,000 people in the United States develop chronic GVHD every year.

Common symptoms of chronic GVHD include skin thickening or rashes, dry mouth and mouth
sores, dry eyes, joint stiffness, lung disease, and recurrent infections. In some cases, severe
chronic GVHD can even cause death.

Clinical Trial of Belumosudil

The clinical trial that led to the FDA approval included 65 participants who took belumosudil as
a pill once per day. The drug works by turning down the activity of immune cells and preventing
the buildup of scar tissue—another hallmark of GVHD. The study was supported by Kadmon
Pharmaceuticals, the company that makes belumosudil.

At the start of the study, 46 participants (71%) had chronic GVHD that was considered severe.
Most participants had previously received three or more treatments for the disease. 

The research team assessed each patient’s symptoms over time using guidelines established by
Dr. Pavletic and others in 2014. Symptoms are evaluated in eight organs that are most commonly
affected by chronic GVHD, namely the eyes, mouth, skin, joints, liver, gut, lungs,
and connective tissue (fascia). 

For 4 people (6%), belumosudil completely resolved disease symptoms in all eight organs. For
45 others (69%), the treatment partially improved symptoms, meaning there was a meaningful
improvement in at least one organ and no worsening of symptoms in other organs. 

Those improvements lasted for a median of 50 weeks, and fewer than half of those who
responded to belumosudil needed additional treatments. In addition, 20% of participants stopped
taking steroids for chronic GVHD and 65% were able to take smaller doses. 

Across the board, the researchers saw improvements in every organ that they evaluated,
including difficult-to-treat organs such as the lungs and skin. The disease can cause irreversible
changes in some organs, so it’s challenging to resolve symptoms in those organs, the researchers
explained in a study report published July 15 in Blood. 
In an earlier study of belumosudil, Dr. Lee and her colleagues also found that half of the study
participants experienced an improvement in quality of lifeExit Disclaimer. “For a chronic disease
like this, [quality of life] is big. Patients [with chronic GVHD] are suffering from [it] every day,”
Dr. Lee said.

Another benefit of belumosudil, Dr. Lee said, is that it seems to be safe to take with most other
drugs. That’s “helpful because our patients are on a lot of different kinds of medications, and
sometimes those [drug] interactions prevent us from using other medicines” to treat chronic
GVHD, she said.

The most common side effects seen in the two clinical trials of belumosudil were infections, lack
of energy, nausea, and diarrhea. Some participants stopped the treatment, either temporarily
(29%) or permanently (18%), due to side effects. One person died from organ failure and
infection, but it was unclear whether this was related to treatment.

The Impact of GVHD Consensus Guidelines

Nearly 2 decades ago, “the bone marrow transplant community realized something should be
done [to address] this disease, but there were no tools or rules for how to [study] it,” Dr. Pavletic
said. 

So, in 2003, NIH put together a multidisciplinary team and developed a comprehensive research
program focused on chronic GVHD. This team, led by Dr. Pavletic and collaborating with other
scientists around the world, created guidelines and tools to diagnose, stage, and study chronic
GVHD in preclinical and clinical studies. 

For the first time, researchers could measure chronic GVHD symptoms in a patient and tell if
they were getting better or worse, Dr. Lee said. “That laid the groundwork so that, as new
[drugs] came along, we had a framework and an infrastructure to test them.” All of that work
“really [got] us to this point” of the new FDA approval, she added.

While the approval of belumosudil is a major step forward, Dr. Pavletic said, more research is
needed because most patients in the trial only experienced a partial improvement. “It tells us how
much more work we have to do to [develop] even better drugs, or combine drugs, or give them at
an earlier stage,” he said.
The addition of a new treatment option for chronic GVHD also makes the management of
patients more complex because there are so many choices, Dr. Lee said. It’s currently difficult
for a doctor to know which of the more than 30 available treatments will be best for their patient.

“Trying to match the right treatment to each patient is more complicated [now]. It’s a good
problem to have, but we have to understand it better,” she said.

Prevention and Earlier Treatment of Chronic GVHD

In addition to studying treatments for chronic GVHD, Drs. Pavletic and Lee are also searching
for ways to prevent the disease from developing or getting too severe. Dr. Pavletic’s group is
developing approaches to predict which patients will go on to develop chronic GVHD, so that
they have the option to take medicines to help prevent the disease. Because these prevention
treatments come with the risk of serious side effects, it would be helpful if they could be given
only to patients who really need them, Dr. Pavletic explained.

Can an Antibiotic Treat Cancers that Become Resistant to PARP Inhibitors?

For a second time, researchers will test an antibiotic discovered in the 1950s as a potential
treatment for cancer. 

The first attempt to study the drug, novobiocin, in patients with cancer was a small clinical trial
conducted 30 years ago. A young woman with advanced breast cancer responded to the drug and
survived for 2 years, but most of the other participants in the trial did not benefit. 
Three decades later, researchers at the Dana-Farber Cancer Institute have “rediscovered”
novobiocin. They found it while testing thousands of compounds against cancer cells that had
become resistant to drugs known as PARP inhibitors. These drugs are used to treat patients with
various cancers, including ovarian, breast, and prostate cancers.

“Lo and behold, novobiocin was one of the very top hits in our drug screen,” said Alan
D’Andrea, M.D., who directs the Center for DNA Damage and Repair at Dana-Farber. Although
novobiocin is no longer used to treat bacterial infections in people, the drug is still produced for
veterinary medicine and remains in drug libraries for research. 

Novobiocin blocks the activity of a protein called DNA polymerase theta (Polθ or POLQ), which
helps repair DNA that has become damaged as cells grow and divide. Cancer cells that cannot
repair their damaged DNA die. 
Polθ and the protein targeted by PARP inhibitors are both involved in a “backup” form of DNA
repair. These backup pathways become particularly important when a repair process known as
homologous recombination stops working, as happens in some cells with mutations in
the BRCA1 or BRCA2 genes.
In a new study, Dr. D’Andrea and his colleagues found that novobiocin killed cancer cells with
deficiencies in homologous recombination repair. The drug also shrank tumors in mouse models
of triple-negative breast cancer that had mutations in DNA-repair genes. The researchers
reported their findings in Nature Cancer on June 17.  
 
“Most important, we found that novobiocin killed tumors that had become resistant to a PARP
inhibitor,” said Dr. D’Andrea. “Novobiocin was even more effective in combination with a
PARP inhibitor.” 

Based on these results, his team is developing NCI-supported clinical trials to test the drug’s
ability to treat cancers that have become resistant to PARP inhibitors.

The Dana-Farber team is not alone in finding that a Polθ inhibitor may have anticancer activity.
Scientists from the Institute for Cancer Research in London and their colleagues have reported
that a Polθ inhibitor called ART558 also can kill cancer cells and tumors that have become
resistant to PARP inhibitors. 
Using a Polθ inhibitor in combination with a PARP inhibitor in patients with cancers that have
mutations in BRCA genes might prevent resistance from emerging in the first place, the latter
group of researchers reported in Nature Communications on June 17.

The company that developed the drug, Artios, said that it plans to test the drug in clinical trials.

Trying to Solve a Pressing Clinical Problem

PARP inhibitors, including olaparib (Lynparza) and talazoparib (Talzenna), block an enzyme

called poly (ADP-ribose) polymerase, or PARP, that helps repair damaged DNA. The drugs are
used to treat cancers that have alterations in DNA-repair genes, namely BRCA1 or BRCA2. 
Cells that have BRCA mutations are forced to rely on an alternative DNA repair process that
involves PARP. As a result, these cells are particularly sensitive to PARP inhibitors and die. This
is known as synthetic lethality.
BRCA gene alterations occur most often in ovarian, breast, pancreatic, and prostate cancers.
PARP inhibitors have been mainstays for treating breast cancers that have BRCA mutations, and
the drugs have recently been approved for treatment of prostate cancers with the mutations. 
However, cancers eventually find ways to bypass the loss of PARP. “Nearly all women with
ovarian cancer who are treated with PARP inhibitors will experience a relapse,” said Dr.
D’Andrea. “When the tumor grows back, it is resistant to PARP inhibitors, and at this point there
are no treatments—it’s a terrible clinical problem.” 

In 2015, Dr. D’Andrea’s team reported that tumors that are deficient in homologous
recombination repair become overly dependent for their growth and survival on POLθ. 

The new study of novobiocin suggests that synthetic lethality may arise from the inhibition of
Polθ in cancer cells that have defects in homologous recombination repair. The researchers
cautioned that novobiocin “can overcome some but not all mechanisms of PARP resistance.”

In an editorial in Nature CancerExit Disclaimer, Thomas Helleday, Ph.D., of the Karolinska
Institute, wrote that novobiocin showed “impressive anticancer activity” in the laboratory and
was “even better when used in combination with a PARP inhibitor.”
 
Dr. Helleday noted that although ART558 and novobiocin inhibit Polθ through different
mechanisms, the results were similar. In the laboratory, ART558 killed cancer cells and shrank
tumors in rats, the researchers found. 

Both novobiocin and ART558 “constitute powerful tools that demonstrate the relevance of
targeting Polθ in cancer,” Dr. Helleday wrote. It remains to be seen whether these drugs benefit
people with cancer, he added, but the strategy of inhibiting Polθ in tumors with defects in
homologous recombination appears “promising.” 

A Clinical Trial through NCI’s NExT Program 

In recent months, Dr. D’Andrea has worked with Geoffrey Shapiro, M.D., Ph.D., of Dana-Farber
and Percy Ivy, M.D., of NCI’s Division of Cancer Treatment and Diagnosis, to develop clinical
trials of novobiocin through the NCI Experimental Therapeutics (NExT) Program. 
NExT provides resources to develop promising treatments that address unmet needs in cancer
care and that might not be adequately supported by the private sector. As part of this general
support, NCI’s Developmental Therapeutics Program will ensure that capsules containing the
appropriate doses of novobiocin (the drug is given by mouth) are available for participants in the
trial. 
The study will test novobiocin, both alone and in combination with a PARP inhibitor, in patients
whose tumors have developed resistance to PARP inhibition, according to Dr. D’Andrea. The
study will primarily include patients with ovarian or breast cancers and could start enrolling
patients later this year. 

“We all want to better understand how to effectively treat patients whose cancers develop
resistance to PARP inhibitors,” said Dr. Ivy. “I’m cautiously optimistic about novobiocin based
on the outstanding preclinical data, but we have to do the study.” 

The clinical trial could help researchers understand the impact of inhibiting Polθ on multiple
DNA repair pathways. “We want to know whether novobiocin pushes a cancer cell beyond its
ability to compensate for losing DNA repair pathways, leading to its death,” Dr. Ivy said. 

How Science Happens: A Patient’s Legacy 

One of the challenges in the research, Dr. D’Andrea said, has been to identify patients with
cancer who are likely to respond to novobiocin. “Identifying potential responders to any cancer
therapy is a challenge, and until now, we haven’t known whom to give novobiocin to,” he
added. 

Their efforts got a big boost from the first attempt to repurpose the drug for patients with cancer.
“As we read about that research, we thought that we might be on to something and moved
forward with our own study of novobiocin,” said Dr. D’Andrea. 

The researchers were most intrigued by the woman with advanced breast cancer in the trial who
responded to the drug after running out of other treatment options. At the time, surviving with
metastatic disease for 2 years was exceptional. 

“Although there was no way of knowing with any certainty, we suspected that this patient may
have had a BRCA mutation,” said Joseph Paul Eder, M.D., who led the 1991 clinical trial of
novobiocin. “She had the right family history and family background for a BRCA mutation.” 
At the time, the BRCA genes had not yet been discovered, but the woman’s exceptional response
suggested that the drug might help treat certain cancers. 

Now at the Yale Cancer Center, Dr. Eder credits Dr. D’Andrea and others for identifying the
target of novobiocin and demonstrating the drug’s potential as a cancer therapy. But the “chance
finding” of his patient’s exceptional response 30 years ago may have played a small role in the
current research, he noted. 
“We always hope that no patient’s willingness to participate in a clinical trial will be in vain,”
said Dr. Eder. “Here we have an example of how people who have volunteered for a clinical trial
and have died from cancer can, decades later, bring us a step closer to helping others with this
dreaded disease.” 

Another author of the 1991 study, Lowell E. Schnipper, M.D., of Harvard Medical School
agreed.

“It’s striking that when you plant a seed, it may germinate three decades later and take a form
you had no idea about,” Dr. Schnipper said. “That is how science works.”

“A Victory of Sorts”

Thirty years later, Dr. Paul Eder vividly remembers the woman with advanced breast cancer who
responded to novobiocin and survived for 2 years. She was in her late 30s, and her breast cancer
had relapsed multiple times, including during prior treatment with chemotherapy.

The woman was of Ashkenazi Jewish descent and, therefore, was at increased risk of inherited
forms of breast or ovarian cancers, Dr. Eder noted. The woman’s sister and mother had both died
of breast cancer before age 50.

Based on her family history and clinical disease, the woman likely had a BRCA gene mutation,
Dr. Eder said. And if that were the case, then a BRCA mutation may have contributed to the
woman’s response to novobiocin, he noted.

When the woman joined the trial, she told Dr. Eder she had a 2-year-old daughter. “The woman
had heard or read that, starting at age 4, children will remember a parent, and she asked if I could
give her 2 years,” Dr. Eder said. “In the strange world of cancer, we were able to find a victory
of sorts.”
Avasopasem Shields Normal Cells from Radiation, Helps Kill Cancer Cells

Cancer treatments aim to kill cancer cells. Other treatments often used to help people with
cancer, called supportive therapies, protect normal tissues or make the side effects from cancer
treatments more bearable. What if one drug could play both of these roles at the same time?

In new studies in mice, researchers found that a drug called avasopasem manganese (AVA),
which has been found to protect normal tissues from radiation therapy, can also make cancer
cells more vulnerable to radiation treatment.
AVA provides this dual effect by exploiting the differences in the way normal and tumor cells
produce hydrogen peroxide, explained Douglas Spitz, Ph.D., professor of radiation oncology at
the University of Iowa, who helped lead the study.

With any cancer treatment, “you try to find this sweet spot where you’re balanced between an
effective therapeutic dose for killing cancer cells, but not causing excessive harm to normal
tissues,” said Michael Espey, Ph.D., of NCI’s Division of Cancer Treatment and Diagnosis, who
was not involved in the study. “If you can [have a single drug that] lowers the toxicity in normal
tissues while increasing the toxicity in cancer cells, then you really have sort of a game changer.”

More work is needed to see if the effects observed in mice can be replicated in people. But in
April, Galera Therapeutics, which manufactures AVA, reported positive findings from a
small clinical trial of AVA added to a targeted form of radiation therapy in people with
pancreatic cancer. Two other ongoing clinical trials are also testing AVA in combination with
radiation therapy in lung and pancreatic cancer.

Building on Cells’ Natural Defense Mechanisms

In radiation therapy, high doses of x-rays or other charged particles are aimed at a tumor. The
radiation can damage cancer cells’ DNA to the point where the cells stop dividing or die. While a
single radiation dose is administered in minutes, many of the resulting changes in cells that cause
them to die take days to occur. 

When a dose of radiation hits a cell, its high energy creates compounds called free radicals that
can damage many parts of the cell, including DNA. 
For example, water molecules consist of two hydrogen atoms and one oxygen atom: H2O. A
beam of radiation can rip hydrogen atoms from water molecules in a cell. This loss of hydrogen
atoms sets off a domino effect, starting with the generation of free radicals that, in turn, fuel the
production of hydrogen peroxide, which can damage DNA.

Compounds in cells called free-radical scavengers protect them from normal levels of free
radical production and damage. AVA mimics a type of natural free-radical
scavenging enzymes called SODs. These enzymes convert a free radical called superoxide into
hydrogen peroxide and oxygen. In normal cells, hydrogen peroxide is removed by other
enzymes. But in cancer cells, because of their compromised metabolism, the hydrogen peroxide
is not removed, causing the formation of additional free radicals that damage DNA.  
“It’s a unique concept, that [AVA] mimics something that the body does already,” but has been
engineered to do it more efficiently, Dr. Espey said. Accordingly, drugs of this type are called
SOD mimetics.

In a recent clinical trial, treatment with AVA was shown to substantially reduce mucositis, sores
in the mouth caused by radiation and chemotherapy, in people undergoing treatment for head and
neck cancer. The effects of SOD mimetics on cancer cells, however, have not been as closely
examined.

“But it was anticipated that [SOD mimetics] would protect normal tissue and sensitize tumor
tissue because of the difference in free radical biology between the two,” Dr. Spitz explained.
For AVA, the main difference that matters is that cancer cells exposed to radiation process
superoxide and other free radicals far less efficiently.

So, while AVA protects normal cells by scavenging the superoxide they produce in response to
radiation, it could potentially have the opposite effect in cancer cells. By turning their superoxide
into bursts of hydrogen peroxide, AVA treatment could potentially increase the DNA damaging
effects of radiation in cancer cells specifically.

A Potent Combination

To test this idea, the two research teams grew human non-small cell lung cancer cells in the legs
of mice, then treated them with radiation, with or without AVA. Tumors shrank much more in
mice that received AVA just before radiation than in mice that got radiation alone. 

When additional doses of AVA were given to the mice daily for 4 days after radiation—during
the time cancer cells could be expected to be producing superoxide—the effect was greatly
increased, with many tumors disappearing entirely. 

“We expected to see an enhanced tumor response, but we never expected the effect to be as large
as it was,” said Michael Story, Ph.D., of the University of Texas Southwestern Medical Center,
who co-led the study with Dr. Spitz. “And what was more interesting was that the effect was
dependent on the size of the radiation dose that we used.” 

That is, additional experiments found that AVA enhanced the response to radiation only when
that radiation was given at higher doses, such as the levels that would be seen with a more
precisely delivered form of radiation called stereotactic body radiation therapy (SBRT), which is
commonly used for treating lung cancer. However, the dose of radiation required to totally
eliminate tumors was much lower with the addition of AVA than without. 

Further experiments in lung cancer cells confirmed that AVA caused a boost in hydrogen
peroxide production by lung cancer cells exposed to radiation while the same combination of
AVA plus radiation protected normal lung cells. 

When the combination of radiation and AVA was given to mice with tumors that produced an
abundance of an enzyme that scavenges hydrogen peroxide, there was almost no added benefit,
and tumors in those mice continued to grow. These findings, the researchers concluded, indicate
that it’s the boost in hydrogen peroxide from AVA that kills the tumor cells after radiation
therapy.

Lung cancer cells weren’t the only type of cancer cell that appeared to be extra sensitive to the
combination treatment. The researchers also found that AVA enhanced radiation-induced death
of both head and neck cancer cells and pancreatic cancer cells. 

Based on these results, two clinical trials are underway testing the combination of AVA and
radiation therapy in people with lung cancer and pancreatic cancer. 

The two trials' goals are slightly different, Dr. Spitz explained. With lung cancer, researchers
want to see if adding AVA can protect normal cells enough to use a higher-than-usual dose of
radiation—enough to potentially shrink tumors entirely.
Pancreatic cancer is often resistant to treatment with radiation. The new trial in pancreatic cancer
is testing whether adding AVA to SBRT can improve how long people with this aggressive
cancer live.

Beyond Radiation Therapy

The uses for AVA and similar SOD mimetics may go beyond radiation therapy, Dr. Spitz
explained. For example, early studies have suggested that these compounds can protect the
kidneys from the damaging effects of the chemotherapy drug cisplatinExit Disclaimer. In one
such study, “everybody who got a full [dose] of cisplatin had chronic kidney disease. But none of
those that got AVA did,” he said.

Researchers are also starting to test whether the combination of drugs like AVA and radiation
can boost the effectiveness of immune checkpoint inhibitors, a type of immunotherapy, Dr. Story
added.
“That’s a very hot topic these days,” said Dr. Espey. The core idea, he explained, is that cancer
cell DNA that’s been damaged by radiation can be recognized by parts of the immune
system that normally respond to a viral threat. The immune system would then perceive the
cancer cells as a target.
“So the idea is that you could prime the immune system using radiation to elicit DNA damage,
then [add] immune checkpoint inhibitors,” Dr. Espey explained. The checkpoint inhibitors would
then block the mechanisms cancer cells normally use to suppress the immune system and, the
hope is, supercharge the immune response. 

Researchers have already been testing this idea with radiation alone. But extending the period of
hydrogen peroxide production—and the resulting DNA damage—with a compound like AVA
has the potential to make the strategy more effective, he added. 

Dr. Story is even starting to test whether SOD mimetics could be used to protect astronauts from
exposure to ionizing radiation in space.

“I think there’s going to be a bonanza of other uses [for these drugs],” Dr. Spitz said. “There’s
going to be other studies in different organs, different diseases, and different toxins. Cancer is the
tip of an iceberg.”

Study Details Long-Term Side Effects of Immune Checkpoint Inhibitors

Immune checkpoint inhibitors are a type of immunotherapy used to treat many kinds of cancer.
In some patients, these drugs can lead to long-lasting remissions. While doctors are familiar with
the short-term side effects of these drugs, less is known about the possibility of long-term, or
chronic, side effects. According to a new study, immune checkpoint inhibitors can cause a range
of long-term side effects, most of them mild.

Immune checkpoint inhibitors like nivolumab (Opdivo) and pembrolizumab (Keytruda) take the

brakes off of cancer-killing immune cells. But these activated immune cells can also harm
healthy tissues, leading to side effects.

Most side effects of immune checkpoint inhibitors are short-lived (acute) and can be treated
with steroid drugs. Until now, less was known about the frequency, timing, and spectrum of
long-term side effects of these treatments.

The new study looked at real-world data on people with melanoma who were recently treated
with an immune checkpoint inhibitor. The researchers focused on side effects that were caused
by the immune system.

More than 40% of the patients developed a long-term immune-related side effect, the researchers
reported March 25 in JAMA Oncology. Most of these side effects did not go away during the
nearly 1.5 years that patients were tracked.

“These therapies are providing the opportunity for long-term survival for many patients,” said
the study’s leader, Douglas Johnson, M.D., of Vanderbilt University Medical Center. But with
longer survival comes the possibility of long-term side effects, he explained.

Better understanding the long-term effects of immune checkpoint inhibitors is increasingly

important because these drugs are being used to treat more kinds of cancer and in more treatment
combinations, Dr. Johnson added.

The bottom line is that doctors should talk with their patients about the possibility of chronic side
effects, he said, so they can weigh the potential benefits and harms.

Short-Term, or Acute, Side Effects

The researchers looked at the medical records of 387 people with advanced melanoma who were
treated at eight hospitals in the United States or Australia.

These patients had received standard therapy: surgery to remove their tumors completely,
followed by treatment with an immune checkpoint inhibitor (either nivolumab or
pembrolizumab). For most patients, the cancer didn’t come back and almost all were still alive
after a median of 18 months.
The majority of patients (267, or 69%) experienced a short-term immune-related side effect—
meaning, a problem that arose during treatment. The most common short-term effects were skin
rash or itchy skin, inflammation of the thyroid (thyroiditis) or low thyroid hormones
(hypothyroidism), and joint pain.
Short-Term Side Effects

Mild 87%

Severe to deadly 13%

Two patients died from short-term side effects, one from inflammation of the heart muscle
(myocarditis) and another from an autoimmune condition resembling Guillain-Barré syndrome.

The frequency and severity of short-term side effects are in line with what has been observed in
other studies, Dr. Johnson said.

Long-Term, or Chronic, Side Effects

Overall, 167 patients (43%) had an immune-related side effect that lasted for at least 3 months
after the patient finished taking the immune checkpoint inhibitor—what the researchers labeled a
chronic, or long-term, side effect.

That frequency was “higher than what I would have thought based on studies of [patients
with] metastatic disease,” said James Gulley, M.D., Ph.D., who has led a number of
immunotherapy clinical trials for NCI’s Center for Cancer Research but was not involved in this
study.
Long-Term Side Effects  

Mild 96%

Severe to deadly 4%

Persisted during study 86%

Went away during study 14%

The vast majority of these long-term side effects were mild, meaning they interfered somewhat
with the patient’s daily activities and may have required treatment. The most common chronic
effects were skin rash, hypothyroidism, and joint pain.

Most of the long-term side effects didn’t go away during the study. Certain side effects were
more likely than others to persist, namely:

 Addison disease (adrenal insufficiency)

 arthritis/joint pain
 eye-related issues, such as conjunctivitis and blurred vision
 inflammation of the pituitary gland
 thyroiditis or hypothyroidism

“We don’t know how long some of these chronic side effects will last. That’s certainly an area
we need to study further,” Dr. Johnson said. Data recorded in medical charts are not collected as
systematically as they are in clinical trials, he added, so more rigorous data collection on long-
term side effects may be warranted.

Research on the best way to treat or control these chronic conditions is also needed, Dr. Gulley
noted. While some long-term side effects can be easily treated with steroids or other drugs, other
issues like dry mouth and brain-related effects (such as Guillain-Barré syndrome), are not.

Stopping Treatment Early

A quarter of the patients in the study stopped taking the checkpoint inhibitor because of an acute
side effect.

“That’s definitely higher than what’s being reported in clinical trials [of immune checkpoint
inhibitors]. But it’s actually about what I would expect from the real-world setting,” Dr. Johnson
said.

People with melanoma are recommended to take an immune checkpoint inhibitor for 12 months,
he explained. But in clinical practice, some patients and their doctors decide to stop the therapy a
few months earlier if the patient is in remission and has a mild, but bothersome side effect.

That calls into question the necessary length of treatment, Dr. Gulley said. It’s possible that
shortening the duration of therapy might be just as effective but less toxic, he explained.

Weighing the Pros and Cons of Checkpoint Inhibitors

This study focused on immune checkpoint inhibitors as adjuvant therapy, meaning therapy given
after surgery to reduce the chances of the cancer coming back. For some people, melanoma can
be cured with surgery alone, and the adjuvant therapy is just extra protection. So, the long-term
harms of adjuvant treatment are particularly important for this group, Dr. Johnson explained.

That’s a different scenario than someone with actively growing metastatic cancer, who is not
likely to be cured with treatment, Dr. Gulley said.
Patients and their doctors should weigh the potential harms and benefits of adjuvant therapy with
an immune checkpoint inhibitor, the researchers noted. But for an individual, the chances of
experiencing those benefits and harms is not so clear cut.

Doctors use certain features, like the extent of cancer in the body (the disease stage), to estimate
the general risk of a person’s cancer returning and the potential benefit from adjuvant treatment.
But there’s currently no way to precisely determine an individual’s risk.

And while this new study provides a better idea of the range of side effects, it’s impossible to
know whether someone will develop a chronic side effect and how severe it will be. That’s
something Dr. Johnson’s team hopes to change by studying ways to predict who might develop
severe or chronic side effects.

The impact of chronic side effects on people’s quality of life is also not well known, Dr. Gulley
said. Some may be easily managed, while others may have a major impact on a person’s day-to-
day life, he added.

And the fundamental question, Dr. Gulley said, is “where is that tipping point” at which the
benefits outweigh the harms?

This study will hopefully open the door to more research that delves further into these
unanswered questions, Dr. Johnson said.

Could Cholesterol-Lowering Drugs Improve Cancer Immunotherapy?

Immune checkpoint inhibitors work well, and even cure, some people with advanced cancer. But
for most patients, these immunotherapies work only for a short time or not at all. Now
researchers have evidence that cholesterol-lowering drugs might offer a way to improve those
success rates. 

In studies of mice, two cholesterol-lowering drugs slowed the growth of tumors on their own and
when combined with an immune checkpoint inhibitor, a team from Duke University has found.
Both drugs, evolocumab (Repatha) and alirocumab (Praluent), are used to treat some people with
high cholesterol.

“The exciting part is these drugs have been [FDA] approved since 2015 and have been used by
thousands of patients around the world,” said lead investigator Chuan-Yuan Li, D.Sc., of Duke
University Medical Center. “They’re generally pretty safe,” Dr. Li said.
There may be other advantages, too, including that patients can take the medicines at home. The
drugs are also less expensive than most cancer treatments, noted James Gulley, M.D., Ph.D.,
head of the immunotherapy group in NCI’s Center for Cancer Research.

“It opens up the possibility of doing a study to look at this combination” in people with cancer,
Dr. Gulley added. Dr. Li and his colleagues are hoping to get a clinical study of the drug
combination off the ground.

Both evolocumab and alirocumab block the activity of PCSK9, an enzyme that controls levels of
“bad” cholesterol, also called LDL cholesterol. But the researchers found that the drugs’ effects
on tumors had nothing to do with cholesterol. Instead, blocking PCSK9 made cancer cells more
visible to cancer-fighting immune cells. Findings from the NCI-funded study were published
November 11 in Nature.

The researchers are still exploring PCSK9’s role in cancer. The protein has multiple functions in
healthy cells, Dr. Li said, so it may have other roles in cancer cells, too. 

“We think there’s more to the story,” he added. The team is now doing experiments to see what
other gene and protein changes occur in cancer cells lacking PCSK9.

Without PCSK9, Tumors Grow Slower

Dr. Li’s team stumbled into PCSK9 by chance. They had come across a study linking the activity
of cancer-killing immune cells to an enzyme that regulates cholesterol. 
“We thought, maybe we can investigate other cholesterol-regulating enzymes,” Dr. Li recalled.
Around the same time, he learned that people who are born without PCSK9 have very low
cholesterol levels and are protected from heart disease. 

So, the team decided to look into whether PCSK9 plays a role in cancer. In lab experiments,
cancer cells engineered to lack PCSK9 (by deleting the gene for the enzyme) grew at the same
rate as cancer cells with PCSK9, the researchers found. 

But when these cells were implanted into mice, they grew much slower than cancer cells with
PCSK9. In addition, the PCSK9 inhibitors evolocumab and alirocumab both slowed the growth
of colon tumors in mice. 

PCSK9 affects blood cholesterol levels by controlling how much cholesterol receptor—a claw-
like protein that grabs onto cholesterol and brings it inside—sits on the surface of liver cells.
Blocking PCSK9 leads to more cholesterol receptors on cell surfaces and, in turn, less
cholesterol in the blood.

The team suspected that the cancer-slowing effects of deleting or blocking PCSK9 had
something to do with cholesterol. But, to their surprise, that didn’t appear to be the case. When
they deleted the gene for the cholesterol receptor in skin cancer cells, it didn’t slow their growth
down at all—nothing like the effects of deleting the gene for PCSK9 in those same cells.

Improving the Effects of Immune Checkpoint Inhibitors

Although PCSK9 is best known for its influence on the cholesterol receptor, it also controls the
levels of other receptors on cells, including some that are involved in immune responses. 

In line with that, Dr. Li’s group found that putting PCSK9-deleted cancer cells into mice
triggered an immune response that slowed tumor growth. 

What’s more, boosting the immune system with an immune checkpoint inhibitor slowed the
growth of PCSK9-deleted tumors even further. In some experiments, treatment with an immune
checkpoint inhibitor almost completely stopped the growth of PCSK9-deleted tumors. 

Likewise, the combination of evolocumab or alirocumab plus an immune checkpoint inhibitor

slowed the growth of tumors with PCSK9 more than any of the drugs alone. Mice treated with
the combination also lived longer.

Helping the Immune System See Cancer

Next, the researchers explored how the immune system interacts with tumors lacking PCSK9.
Given the enzyme’s role in regulating cell surface receptors, they focused there.

Before immune cells can kill cancer cells, they first have to find them. They do so by scanning
the cell surface for MHC I, a protein that essentially shows what’s happening inside that cell. For
cancer cells, MHC proteins often show that the cells are abnormal and should be removed. 

“The only way a T cell can see what’s going on in a tumor cell is through the MHC molecule.
It’s absolutely critical,” Dr. Gulley explained.

The researchers found that PCSK9 affects how much MHC I sits on the surface of cancer cells.
Deleting PCSK9 or blocking its activity with evolocumab substantially raised the amount of
MHC I on the surfaces of skin and breast cancer cells. In addition, PCSK9-deleted tumors
contained more cancer-killing immune cells, including T cells, than tumors with PCSK9. 

“If more [MHC] is around, T cells can interrogate more clearly what’s going on in the tumor.
And immunotherapy is going to work better because the immune system can function better,”
Dr. Gulley said. 

On the other side of the coin, research has shown that immunotherapy doesn't work well against
tumors with mutations in MHC genes or other genes that help T cells see cancer cells. Other
scientists are working on strategies to increase MHC levels in tumors, such as with radiation or
immune-signaling molecules called cytokines, noted Dr. Gulley. 

Nanoparticle Trains Immune Cells to Attack Cancer

Cancer researchers are exploring all kinds of new and creative approaches to immunotherapy,
treatments that help the immune system fight cancer. The latest involves nanoparticles that
trains immune cells to attack cancer.

The nanoparticles, which are made mostly of substances found in the human body, slowed the
growth of melanoma in mice, the NCI-funded study showed. 

The human immune system is split into two branches. The innate branch, which is the body’s
first line of defense, launches a quick and general response to all kinds of germs. The adaptive
branch, which includes T cells and antibodies, kicks in later and has a long-lasting and more
specific response to germs.

Most immunotherapies in use today engage the adaptive immune system. What’s novel about the
newly developed nanoparticle is that it alters the innate immune system, pushing it into a
temporary state known as trained immunity.

Trained innate immune cells are “more alert, so they respond more efficiently to infections and
cancer,” explained lead investigator Willem Mulder, Ph.D., of the Icahn School of Medicine at
Mount Sinai. 

The innate immune system can stay in this trained state for months to years, giving the
researchers reason to believe that the anticancer effects of the nanoparticle may last for a while.
The study findings were published October 29 in Cell. 
“Nanoparticles made from materials foreign to our bodies can cause unwanted side effects or
unintended accumulation and damage to vital organs. But this nanoparticle is biologically
friendly,” said Christina Liu, Ph.D., of NCI’s Nanodelivery Systems and Devices Branch, who
was not involved in the study. 

Dr. Mulder and his colleagues are hoping to start a clinical trial to test the nanoparticles in the
near future. They are currently working on follow-up studies needed to gain approval for human
studies.

Engineering a Nanoparticle

In 2016, Dr. Mulder sat in the office of Mihai Netea, Ph.D., of Radboud University Medical
Center in the Netherlands, and sketched an idea on a piece of paper.

The pair had recently developed a nanoparticle therapy that inhibits trained immunity. In mice,
the nanoparticles prevented the immune system from rejecting an organ transplant. 

This time, Dr. Mulder recalled, “Dr. Netea essentially asked me to do the opposite” and design
a nanoparticle that triggers trained immunity. The scientists reasoned that such a nanoparticle
could potentially be used to treat cancer.

Dr. Mulder, who is a biomedical engineer, looked to nature for inspiration. It turns out that the
tuberculosis vaccine, also known as the BCG vaccine, can elicit trained immunity. The vaccine,
which is based on a weakened version of the bacteria that causes tuberculosis, is also used as a
treatment for bladder cancer. 

The team engineered a set of nanoparticles using fragments of BCG as well

as lipids and proteins from human cells. These proteins help the nanoparticles get to the bone
marrow, where innate immune cells are formed. The team refers to nanoparticles made of lipids
and these proteins as “nanobiologics.”

Nanoparticles are extremely small—between ten and a thousand times smaller than a single
bacterium. Due to their small size, they behave differently in the human body than other
chemicals or drugs, Dr. Liu said. 
This nanoparticle travels to the bone marrow, where it trains innate immune cells to recognize
and attack tumors.
Credit: Image courtesy of Dr. Willem Mulder, Icahn School of Medicine at Mount Sinai

For example, nanoparticles last longer in blood and, depending on their size, accumulate in
tumors or certain organs, she explained. And, she added, using natural materials makes the
nanoparticle less likely to cause any harsh side effects.

Through a series of lab tests, the researchers identified a specific nanoparticle design that was the
best at training innate immune cells grown in dishes. It also had other desired characteristics,
such as accumulating in the bone marrow. 

Training Immune Cells to Kill Cancer Cells

Next, the team tested those nanoparticle in lab animals, including mice and monkeys. 

As intended, the nanoparticle was soaked up by innate immune cells in the bone marrow and
spleens of both mice and monkeys. The immune cells then showed several hallmarks of trained
immunity. For instance, they divided rapidly, responded quickly to threats, and produced certain
chemicals (called cytokines) that ramp up the immune system.

The researchers also tested the nanoparticles in mice with melanoma. These melanoma tumors
typically have more procancer immune cells than cancer-killing immune cells—what’s known as
an immunosuppressive microenvironment.
But in mice treated with the nanoparticles, the trained immune cells reversed that pattern, leading
to more cancer-killing immune cells and fewer procancer immune cells in the tumors. 

The treatment ultimately slowed the growth of tumors in the mice, the team found. But they
wondered if they could do even better by combining the nanoparticles with another
immunotherapy.

Immune checkpoint inhibitors are the most commonly used cancer immunotherapy, but they
don’t work for every person who gets them. One reason they may not work is if a patient’s tumor
has an immunosuppressive microenvironment, Dr. Mulder explained.

“We thought, ‘let’s see if we can induce trained immunity to rebalance the immune system to
make it more susceptible to checkpoint inhibitor therapy,’” he said.

As expected, treatment with either of two immune checkpoint inhibitors alone had little to no
effect on melanoma tumor growth in mice. However, combining both immune checkpoint
inhibitors with the nanoparticle therapy slowed tumor growth much more than any of the
checkpoint inhibitors alone. 

The nanoparticles also appeared to be safe. They didn’t cause any harsh side effects in either
mice or monkeys. Knowing that the treatment was safe in monkeys will make it easier to
transition to clinical studies in people, Dr. Mulder said.

Now a biotechnology startup founded by Drs. Mulder and Netea is performing further studies of
the nanoparticle that are needed to bring it into human studies. Dr. Mulder and his colleagues are
also investigating whether the nanoparticle works for other types of cancer in lab studies.

Study of “exceptional responders” yields clues to cancer and potential treatments

In a comprehensive analysis of patients with cancer who had exceptional responses to therapy,
researchers have identified molecular changes in the patients’ tumors that may explain some of
the exceptional responses. The results demonstrate that genomic characterizations of cancer can
uncover genetic alterations that may contribute to unexpected and long-lasting responses to
treatment, according to the researchers.
The results appeared in Cancer Cell on Nov. 19. Researchers at the National Cancer Institute
(NCI), part of the National Institutes of Health, conducted the study in collaboration with
investigators from other institutions, including NCI-designated Cancer Centers. 

“The majority of patients in this study had metastatic cancers that are typically difficult to treat,
yet some of the patient responses lasted for many years,” said Louis Staudt, M.D., Ph.D., director
of NCI’s Center for Cancer Genomics, who co-led the study. “Researchers and the doctors who
treat these patients have long been curious about the mechanisms underlying these rare responses
to treatment. Using modern genomic tools, we can now start to solve these fascinating puzzles.” 

“As clinical researchers, we have a lot to learn from these patients, and they have a lot to teach
us,” said Percy Ivy, M.D., of NCI’s Division of Cancer Treatment and Diagnosis, who co-led the
research. “The knowledge gained from studying exceptional responders can help inform how we
take care of patients in the future and will help move us closer to the goal of precision
oncology.” 

The retrospective study, which is now closed to accrual, included detailed medical histories and
tumor samples from 111 patients with various types of cancer who had received standard
treatments, such as chemotherapy. The patients had been identified by NCI’s Exceptional
Responders Initiative, a national project launched in 2014 to explore the feasibility of collecting
and analyzing the data and biospecimens needed to better understand the biological basis of
exceptional responses in cancer.

For 26 of the 111 (23.4%) patients, the researchers were able to identify molecular features that
could potentially explain exceptional responses to treatment, such as the co-occurrence of
multiple rare genetic changes in the tumor genome or the infiltration of the tumor with certain
types of immune cells. 

The study defined an exceptional responder as someone who had a partial or complete response
to a treatment that would be effective in less than 10% of similar patients. The duration of an
exceptional response is one that lasts at least three times longer than the median response time.   

To analyze the tumor tissue (and normal tissue, when available) from patients in the study, the
researchers used multiple genomic approaches—including analysis of DNA mutations, RNA
expression levels, DNA copy number alterations, and DNA methylation—as well as analysis of
the immune cells in the tumor microenvironment. 
The mechanisms underlying exceptional responses in the study fit into several broad categories,
including the body’s ability to repair DNA damage and the immune system’s response to tumors.
Another category described rare combinations of genomic alterations that resulted in the death of
tumor cells during treatment—a concept known as synthetic lethality.

For example, the researchers identified mutations in the BRCA1 or BRCA2 genes in two patients

with cancers that rarely involve alterations in these genes, which help repair DNA. But in these
patients, the researchers suggested, the mutations may have impaired the tumor’s ability to fix
damaged DNA, thereby increasing the effectiveness of treatments such as platinum-based
chemotherapy that harm DNA. 

“Our findings demonstrate the importance of testing patient tumors for alterations that may point
to available treatments,” Dr. Staudt said. “There is a need for a shift towards molecular diagnosis
of cancer that provides information that cannot be gleaned from looking at tumors through a
microscope.” 

The study also adds to the growing body of evidence highlighting the ability of the immune
system to “kick in” and help eradicate tumors. In some patients in the study, increased levels of
B lymphocytes, a type of immune cell, in tumors were associated with exceptional responses. 

Results and hypotheses developed during this retrospective analysis will need to be confirmed by
larger studies, according to the researchers. But if confirmed, the findings could potentially
provide leads for investigators trying to develop treatments that exploit the vulnerabilities of
tumor cells like those found in some exceptional responders, they noted.  

For example, in two patients treated with the DNA-damaging drug temozolomide, the
researchers identified two DNA-repair pathways that needed to be simultaneously inactivated to
achieve an exceptional response. This finding supports the development of drugs that block these
DNA repair mechanisms, which might generally improve the responses of patients with cancer to
temozolomide. 

“This proof-of-concept study demonstrates that the analysis of the tumors of exceptional
responders is not only possible but necessary to learn as much as we can from these patients,”
said Dr. Ivy. “We are immensely grateful to the many generous patients who participated in this
study, even though they had nothing to gain personally from doing so, and to our many
collaborators across the country, without whom this work would not have been possible.”
Since the Exceptional Responders Initiative began, researchers have reviewed the medical
histories of more than 500 patients who had been recommended to the initiative by a physician.
Chemotherapy is among the most widely used treatments for cancer, and the vast majority of the
patients considered for enrollment in the initiative had exceptional responses to chemotherapy
agents. 

For the majority of the patients in the analysis, multiple genomic approaches were needed to
characterize the tumor samples. Focusing on DNA mutations alone would not have provided the
clues the investigators needed to develop hypotheses about the biological underpinnings of the
responses, the researchers said. 

More research and additional analytical approaches are needed to describe the molecular
underpinnings of the unsolved cases of unexceptional responders, they noted. To encourage
participation in this effort by investigators around the world, the NCI team and their colleagues
have made their molecular profiling results and clinical information publicly available in the NCI
Genomic Data Commons.

About the National Cancer Institute (NCI): NCI leads the National Cancer Program and NIH’s
efforts to dramatically reduce the prevalence of cancer and improve the lives of cancer patients
and their families, through research into prevention and cancer biology, the development of new
interventions, and the training and mentoring of new researchers. For more information about
cancer, please visit the NCI website at cancer.gov or call NCI’s contact center, the Cancer
Information Service, at 1-800-4-CANCER (1-800-422-6237).

About the National Institutes of Health (NIH): NIH, the nation's medical research agency,
includes 27 Institutes and Centers and is a component of the U.S. Department of Health and
Human Services. NIH is the primary federal agency conducting and supporting basic, clinical,
and translational medical research, and is investigating the causes, treatments, and cures for both
common and rare diseases.