Combining Against Cancer | Editorials

Cancer cells have many ways to stop the immune system from recognizing and destroying them.¹ Some of the biological components that may have a role in how the immune system identifies and attacks cancer cells include:

PD-1 and TIGIT: Receptors found at high levels on the surface of certain immune cells in various types of cancer, that are part of a pathway that can block recognition and destruction of cancer cells.¹

Imagine cars — as our body’s immune cells — heading towards the Golden Gate Bridge to get to the other side in order to attack and destroy cancer cells.

As they approach the bridge, think of PD-1 and TIGIT like a stop sign and a red traffic light, respectively, that block the cars from crossing the bridge.
ADENOSINE: A compound that can accumulate in the area surrounding cancer cells, and is made by receptors found at high levels on cancer cells. It binds to other receptors on the surface of immune cells, which deactivates them from attacking cancer cells.²

Picture the cars are now driving on the bridge, but a thick, dense fog – this is like adenosine – rolls in and doesn’t allow the cars to see clearly to get across the bridge as they slowly roll to a stop, preventing them from attacking and destroying the cancer cells on the other side.

Other biological components are also involved helping cancer cells survive, such as:

HIF2α: Tumors often have low oxygen levels, and this regulator can promote growth of tumors in these conditions.³

In many cancers, more than one of these biological components are involved in preventing cancer cell death.^4,5,6 Research is underway to determine whether stopping more than one of these biological components at the same time may improve the body’s ability to detect and destroy cancer cells.

Take a closer look at some different cancer types where a biology-driven, combination approach may lead to the development of new treatment approaches and help address unmet needs for people with cancer.

According to the American Cancer Society:

Non-small cell lung cancer

(NSCLC) represents about

Non-small cell lung cancer (NSCLC) represents about

85%

of all lung cancer diagnoses.⁷

Lung cancer is the:

2^nd

most common

type of cancer^7*

^#1

cause of cancer-

related deaths.⁷

* Excluding skin cancers

Current Status of Immunotherapy in NSCLC

Cancer treatment primarily depends on disease stage, which characterizes how big the tumor is and if it has spread throughout the body.⁸ One treatment approach is immunotherapy, which harnesses the body’s natural immune system to attack and destroy the cancer.¹

Anti-PD-1s are a type of immunotherapy used to treat different stages of cancer.⁹ They are believed to work by blocking the PD-1 pathway and activating immune cells to attack cancer cells.¹

Combination Strategies Under Investigation

In many people, however, the cancer can continue to grow even with anti-PD-1 treatment.¹ Researchers are working to understand if combining multiple investigational medicines, that each target different immune-evading pathways, may lead to the development of new medicines to treat people with cancer.

TIGIT, like PD-1, has been found at higher levels on the surface of immune cells in people with NSCLC and is associated with worse clinical outcomes.^10,11 TIGIT and PD-1 may both play a role in controlling anti-cancer immune responses, but they do so in different ways.^5,12

Clinical trials are ongoing to understand if the combination of an anti-TIGIT and an anti-PD-1 can activate the immune system to destroy cancer cells better than anti-PD-1 alone, much like, in the analogy of a car crossing the bridge, removing both the stop sign and traffic light is important for the cars, or immune cells, to cross the bridge and attack cancer cells.

Adenosine can be found at high levels in NSCLC and may disable immune cells from recognizing and attacking cancer cells.¹³ Adenosine also acts on anti-cancer immunity, but in a different way than the PD-1 and TIGIT pathways. It is believed adenosine can deactivate a broader set of immune cells.^14,15 Reducing adenosine along with blocking TIGIT and PD-1, may help immune cells to attack cancer cells.^16,17

In the analogy of a car crossing the bridge, lifting the fog (adenosine) may help the cars, or immune cells remain active. If the fog is lifted and both the stop sign (PD-1) and red traffic light (TIGIT) are also removed, the combined approach may help the cars, or immune cells, cross the bridge to attack and destroy the cancer cells.

Chemotherapy, a common cancer treatment that attacks fast-growing cells, still remains an important component of therapy.^18,19 In some cases, chemotherapy, in addition to removing barriers to immune cell function, may further help the body destroy fast-growing cancer cells.

Clinical trials are ongoing to understand if combining different investigational medicines to stop more than one biological pathway at the same time, with or without chemotherapy, may improve the ability of the immune system to detect and destroy cancer cells and lead to new treatment options.

Colorectal cancer (CRC) is any cancer that starts in the colon or rectum, collectively known as the large intestine.²⁰

According to the American Cancer Society, CRC is the:

3^rd

most common diagnosed cancer in the United States^*²⁰

2^nd

leading cause of cancer-related deaths.²⁰

^*Excluding skin cancers

Current Status of Immunotherapy in CRC

Cancer treatment primarily depends on disease stage, which characterizes how big the tumor is and if it has spread throughout the body.⁸ One treatment approach is immunotherapy, which harnesses the body’s natural immune system to attack and destroy the cancer.¹

Anti-PD-1s are a type of immunotherapy that are typically used at later stages of disease for people who have certain genetic changes in their cancer cells.²¹ They are believed to work by blocking the PD-1 pathway and activating immune cells to attack cancer cells.¹

Combination Strategies Under Investigation

In many people, however, the cancer can continue to grow even with anti-PD1 treatment.²² Researchers are working to understand if combining anti-PD1 with other investigational medicines that each target different immune-evading pathways may lead to the development of new medicines to treat more people with metastatic cancer, or cancer that has spread to other parts of the body.

Increased levels of adenosine surrounding CRC cells is believed to contribute to cancer growth and suppress immune activity.²³ Adenosine also acts on anti-cancer immunity, but in a different way than the PD-1 pathway. It is believed that adenosine can deactivate a broader set of immune cells.^14,15

Reducing adenosine along with blocking PD-1, may help immune cells to attack cancer cells.^16,17 In the analogy of a car crossing the bridge, lifting the fog (adenosine) may help the cars, or immune cells, remain active. If the fog is lifted and the stop sign (PD-1) is removed, the combined approach may help the cars, or immune cells, cross the bridge to attack and destroy the cancer cells.

Chemotherapy, a common cancer treatment that attacks fast-growing cells, still remains an important component of therapy.^18,19 In some cases, chemotherapy, in addition to removing barriers to immune cell function, may further help the body destroy fast-growing cancer cells.

Clinical trials are ongoing to understand if combining different investigational medicines to stop more than one biological pathway at the same time, with or without chemotherapy, may improve the ability of the immune system to detect and destroy cancer cells and lead to new treatment options.

Upper gastrointestinal (GI) cancer includes cancers that occur in the stomach, esophagus (the tube that carries food and drinks from the throat to the stomach) and gastroesophageal junction (where the esophagus connects to the stomach).²⁴

More than 90% of gastric cancers are adenocarcinomas, a type of cancer that forms in tissues which line certain internal organs and release fluids, like those that help with digestion.^25,26
A majority (up to 80%) of esophageal cancers are adenocarcinomas.^27,28

According to the National Cancer Institute, upper GI cancers are the:

2^nd

most common cause of death among digestive system cancers.²⁴

They have poor 5-year survival rates when diagnosed in later stages.²⁹

Current Status of Immunotherapy in Upper GI Cancer

Cancer treatment primarily depends on disease stage, which characterizes how big the tumor is and if it has spread throughout the body.⁸ One treatment approach is immunotherapy, which harnesses the body’s natural immune system to attack and destroy the cancer.¹

Anti-PD-1s are a type of immunotherapy that are typically used at later stages of disease, including for people who have certain genetic changes in their cancer cells.^30,31 They are believed to work by blocking the PD-1 pathway and activating immune cells to attack cancer cells.¹

Combination Strategies Under Investigation

In many people, however, the cancer can continue to grow even with anti-PD-1 treatment.^32,33 Researchers are working to understand if combining multiple investigational medicines, that each target different immune-evading pathways, may lead to the development of new medicines to treat people with cancer.

TIGIT, like PD-1, has been found at higher levels on the surface of immune cells in people with upper GI cancers, and is associated with worse clinical outcomes.^34,35,36,37 TIGIT and PD-1 may both play a role in controlling anti-cancer immune response, but they do so in different ways.^5,12

Clinical trials are ongoing to understand if the combination of an anti-TIGIT and an anti-PD-1 can activate the immune system to destroy cancer cells better than anti-PD-1 alone, much like, in the analogy of a car crossing the bridge, removing both the stop sign and traffic light is important for the cars, or immune cells to cross the bridge and attack cancer cells.

Adenosine is believed to play a key role in suppressing immune activity in certain upper GI cancers, contributing to the growth and survival of cancer cells.^38,39 Adenosine also acts on anti-cancer immunity, but in a different way than the PD-1 and TIGIT pathways. It is believed adenosine can deactivate a broader set of immune cells.^14,15 Reducing adenosine along with blocking TIGIT and PD-1, may help immune cells to attack cancer cells.^16,17

In the analogy of a car crossing the bridge, lifting the fog (adenosine) may help cars, or immune cells remain active. If the fog is lifted and the stop sign (PD-1) and red traffic light (TIGIT) are also removed, the combined approach may help the cars, or immune cells cross the bridge to attack and destroy cancer cells.

Chemotherapy, a common cancer treatment that attacks fast-growing cells, still remains an important component of therapy.^18,19 In some cases, chemotherapy in addition to removing barriers to immune cell function, may further help the body destroy fast-growing cancer cells.

Clinical trials are ongoing to understand if combining different investigational medicines to stop more than one biological pathway at the same time, with or without chemotherapy, may improve the ability of the immune system to detect and destroy cancer cells, and lead to new treatment options.

Pancreatic cancer occurs in the pancreas, an organ that sits behind the stomach and helps with digestion and controlling blood sugar.⁴⁰

Over 90% of pancreatic cancers are adenocarcinomas, a type of cancer that forms in tissues which line certain internal organs and release fluids, like those that help with digestion.^40,41

Pancreatic cancer is one of the most aggressive cancers with an extremely poor prognosis and an average 5-year relative survival rate of

13%⁴²

Over 80% of pancreatic cancers are diagnosed at late stage⁴³

Current Status of Pancreatic Cancer Treatment

Cancer treatment primarily depends on disease stage, which characterizes how big the tumor is and if it has spread throughout the body.⁸ Some common types of treatments used for advanced pancreatic cancer include:

IMMUNOTHERAPY

Harnessing the body’s natural immune system to detect and destroy cancer.¹

CHEMOTHERAPY

A common cancer treatment that attacks fast-growing cells.¹⁹

TARGETED THERAPY

Treatments that address specific changes in cancer cells.⁴⁴

There have been limited advancements for treating pancreatic cancer and chemotherapy has been the standard of care for more than 30 years, which is why new treatment options are needed.^45,46,47

Combination Strategies Under Investigation

There are still substantial unmet needs in pancreatic cancer: cancer can come back despite treatment with chemotherapy and there are limitations with immunotherapy as pancreatic tumors are particularly good at hiding from the immune system.^48,49 Researchers are working to understand if combining investigational medicines that target immune-evading pathways along with chemotherapy could lead to the development of new therapies to treat more people with metastatic cancer, or cancer that has spread to other parts of the body.

Adenosine is believed to contribute to suppressed immune activity around pancreatic cancer cells and increased adenosine activity could contribute to worse clinical outcomes.^50,51 Adenosine is thought to deactivate a broad set of immune cells and reducing it may help immune cells to attack cancer cells.^14,15,17

In the analogy of a car crossing the bridge, lifting the fog (adenosine) may help cars, or immune cells, remain active.

Chemotherapy, a common cancer treatment that attacks fast-growing cells, still remains an important component of therapy.^18,19 In some cases, chemotherapy in addition to removing barriers to immune cell function, may further help the body destroy fast-growing cancer cells.

Clinical trials are ongoing to understand if combining different investigational medicines to stop more than one biological pathway at the same time, with or without chemotherapy, may improve the ability of the immune system to detect and destroy cancer cells, and lead to new treatment options.

The kidneys are a pair of organs that filter the blood to remove extra water, salt and waste products.⁵⁸

Renal cell carcinoma (RCC) is by far the most common type of kidney cancer, and clear cell renal cell carcinoma (ccRCC) represents 70% of RCC diagnoses in adults.⁵⁸

Carcinomas are cancers that start in cells lining organs or tissues⁵⁹
ccRCC is named “clear cell” because when looking at the tumor under a microscope, the cells look pale or clear.⁵⁸

According to the American Cancer Society, kidney cancer is one of the

10 most common cancers and rates have been rising in recent decades.⁶⁰

The average 5-year survival rate for those diagnosed with advanced disease is only

17%.⁶¹

There remains significant unmet need for patients with ccRCC, because the disease can recur after initial treatment and spread throughout the body.⁶²

Current Status of Kidney Cancer Treatment

Cancer treatment primarily depends on the disease state, which characterizes how big the tumor is and if it has spread throughout the body.¹³ Some common types of treatments used for advanced kidney cancer include:

illustration depicting cancer cells and combination therapy interactions, highlighting the role of targeted treatments to block tumor growth

TREATMENTS THAT ADDRESS CHANGES IN AND AROUND CANCER CELLS. For example:⁶³

Blocking angiogenesis, or the growth of new blood vessels that feed tumors.
Blocking tyrosine kinases, to prevent excess cell growth and survival. Some tyrosine kinases can also promote angiogenesis, so blocking tyrosine kinases could stop both excessive cell growth and new blood vessel growth.

illustration showing a molecular interaction blocking a targeted pathway, representing the mechanism of action in combination therapies to inhibit cancer progression

IMMUNOTHERAPY

Harnessing the body’s natural immune system to detect and destroy cancer.¹

illustration of an intravenous (IV) infusion bag, symbolizing the delivery method of cancer therapies

CHEMOTHERAPY

A common cancer treatment that attacks fast-growing cells.^23,24

Combination Strategies Under Investigation

There is a substantial unmet need for people with the most common form of metastatic kidney cancer, clear cell renal cell carcinoma (ccRCC), which is kidney cancer that has spread to other parts of the body.⁵⁴ Often, treatments at this stage are used one at a time; but, later stages of kidney cancer can become resistant or stop responding to available approaches.^63,65,66,67 Researchers are working to understand if combining multiple investigational medicines, that each address different biological pathways involved in tumor growth, may lead to the development of new treatment approaches for people with metastatic cancer.

HIF-2α plays a central role in the development and progression of kidney cancer, because it controls numerous genes involved in cancer growth.⁴ But it does not work alone. Overactive proteins, like tyrosine kinases, can further promote excessive cell growth, survival and angiogenesis.^68,69,70 Blocking more than one of these biological pathways at the same time may help slow cancer growth.

In the analogy of the wildfire, the combination of preventing the spark (HIF-2α) and controlling the other factors (tyrosine kinases), like heavy wind, could help stop wildfire spread (cancer growth).

In some cases, adding immunotherapy to other approaches that stop underlying processes that promote cancer growth, may further help slow cancer spread.

Clinical trials are ongoing to understand if combining different investigational medicines to stop more than one biological pathway at the same time may slow or stop cancer growth, and lead to new treatment options.

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33. Voutsadakis, Ioannis A. “A systematic review and meta-analysis of PD-1 and PD-L1 inhibitors monotherapy in metastatic gastric and gastroesophageal junction adenocarcinoma.” Euroasian journal of hepato-gastroenterology. 10.2 (2020): 56.

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Investigating Combination Therapies to Treat Cancer

Current Status of Immunotherapy in NSCLC

Combination Strategies Under Investigation

Current Status of Immunotherapy in CRC

Combination Strategies Under Investigation

Current Status of Immunotherapy in Upper GI Cancer

Combination Strategies Under Investigation

Current Status of Pancreatic Cancer Treatment

Combination Strategies Under Investigation

Current Status of Kidney Cancer Treatment

Combination Strategies Under Investigation

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