Immunotherapy for cancer

A promising innovative approach to cancer therapy is to try to persuade the immune system to attack cancer cells effectively. The immune system does kill cancer cells and presumably removes many tumours which we never suspect we had. At the same time established tumours are able to successfully resist this type of attack in many cases. The idea of taking advantage of the immune system in this way is an old one but it took a long time before it became successful enough to reach the stage of an approved drug. This goal was achieved with the approval of ipilimumab for the treatment of melanoma by the FDA in 2011. This drug is a monoclonal antibody which binds the molecule CTLA4 occurring on the surface of T cells.

To explain the background to this treatment I first recall some facts about T cells. T cells are white blood cells which recognize foreign substances (antigens) in the body. The antigen binds to a molecule called the T cell receptor on the surface of the cell and this gives the T cell an activation signal. Since an inappropriate activation of the immune system could be very harmful there are built-in safety mechanisms. In order to be effective the primary activation signal has to be delivered together with a kind of certificate that action is really necessary. This is a second signal which is given via another surface molecule on the T cell, CD28. The T cell receptor only binds to an antigen when the latter is presented on the surface of another cell (an antigen-presenting cell, APC) in a groove within another molecule, an MHC molecule (major histocompatibility complex). On the surface of the APC there are under appropriate circumstances other molecules called B7.1 and B7.2 which can bind to CD28 and give the second signal. Once this has happened the activated T cell takes appropriate action. What this is depends on the type of T cell involved but for a cytotoxic T cell (one which carries the surface molecule CD8) it means that the T cell kills cells presenting the antigen. If the cell was a virus-infected cell and the antigen is derived from the virus then this is exactly what is desired. Coming back to the safety mechanisms, it is not only important that the T cell is not erroneously switched on. It is also important that when it is switched on in a justified case it should also be switched off after a certain time. Having it switched on for an unlimited time would never be justified. This is where CTLA4 comes in. This protein can bind to B7.1 and B7.2 and in fact does so more strongly than CD28. Thus it can crowd out CD28 and switch off the second signal. By binding to CTLA4 the antibody in ipilimumab stops it from binding to B7.1 and B7.2, thus leaving the activated T cell switched on. In some cases cancer cells present unusual antigens and become a target for T cells. The killing of these cells can be increased by CTLA4 via the mechanism just explained. At this point I should say that it may not be quite clear whether this is really the mechanism of action of CTLA4 in causing tumours to shrink. Alternative possibilities are mentioned in the Wikipedia article on CTLA4.

There are various things which have contributed to my interest in this subject. One is lectures I heard in the series ‘Universität im Rathaus’ [University in the Town Hall] in Mainz last February. The speakers were Matthias Theobald and Ugur Sahin and the theme was personalized cancer medicine. The central theme of what they were talking about is one step beyond what I have just sketched. A weakness of the therapy using antibodies to CTLA4 or the related approach using antibodies to another molecule PD-1 is that they are unspecific. In other words they lead to an increase not only in the activity of the T cells specific to cancer cells but of all T cells which have been activated by some antigen. This means that serious side effects are very likely. An approach which is theoretically better but as yet in a relatively early stage of development is to produce T cells which are specific for antigens belonging to the tumour of a specific patient and for an MHC molecule of that patient capable of presenting that antigen. From the talk I had the impression that doing this requires a lot of input from bioinformatics but I was not able to understand what kind of input it is. I would like to know more about that. Coming back to CTLA4, I have been interested for some time in modelling the activation of T cells and in that context it would be natural to think about also modelling the deactivating effects of CTLA4 or PD-1. I do not know whether this has been tried.

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