Immune induction strategies in metastatic triple-negative breast cancer to enhance the sensitivity to PD-1 blockade: the TONIC trial

L Voorwerk, M Slagter, HM Horlings, K Sikorska… - Nature medicine, 2019 - nature.com
L Voorwerk, M Slagter, HM Horlings, K Sikorska, KK van de Vijver, M de Maaker, I Nederlof
Nature medicine, 2019nature.com
The efficacy of programmed cell death protein 1 (PD-1) blockade in metastatic triple-
negative breast cancer ( TNBC) is low,,,–, highlighting a need for strategies that render the
tumor microenvironment more sensitive to PD-1 blockade. Preclinical research has
suggested immunomodulatory properties for chemotherapy and irradiation,,,,,,–. In the first
stage of this adaptive, non-comparative phase 2 trial, 67 patients with metastatic TNBC were
randomized to nivolumab (1) without induction or with 2-week low-dose induction, or with (2) …
Abstract
The efficacy of programmed cell death protein 1 (PD-1) blockade in metastatic triple-negative breast cancer (TNBC) is low, , , –, highlighting a need for strategies that render the tumor microenvironment more sensitive to PD-1 blockade. Preclinical research has suggested immunomodulatory properties for chemotherapy and irradiation, , , , , , –. In the first stage of this adaptive, non-comparative phase 2 trial, 67 patients with metastatic TNBC were randomized to nivolumab (1) without induction or with 2-week low-dose induction, or with (2) irradiation (3 × 8 Gy), (3) cyclophosphamide, (4) cisplatin or (5) doxorubicin, all followed by nivolumab. In the overall cohort, the objective response rate (ORR; iRECIST) was 20%. The majority of responses were observed in the cisplatin (ORR 23%) and doxorubicin (ORR 35%) cohorts. After doxorubicin and cisplatin induction, we detected an upregulation of immune-related genes involved in PD-1–PD-L1 (programmed death ligand 1) and T cell cytotoxicity pathways. This was further supported by enrichment among upregulated genes related to inflammation, JAK–STAT and TNF-α signaling after doxorubicin. Together, the clinical and translational data of this study indicate that short-term doxorubicin and cisplatin may induce a more favorable tumor microenvironment and increase the likelihood of response to PD-1 blockade in TNBC. These data warrant confirmation in TNBC and exploration of induction treatments prior to PD-1 blockade in other cancer types.
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