EPSA Science! Monthly: The Science of Modern Advances in Cancer Treatment by EPSA

The Science of Modern Advances in Cancer Treatment February Edition 2022

Introduction For years, it is well-known that cardiovascular diseases were the leading cause of death among middle-aged adults. However, deaths due to cancer have been slowly and steadily rising as well, surpassing cardiovascular diseases as the leading cause of death eventually. Improved prevention and treatment of cardiovascular diseases partly contributed to this epidemiological transition. Whereas cancer prevention and treatments are yet to become sufficiently effective to lead to large reductions in cancer mortality. To discover or improve cancer treatment, a lot of research is being conducted. In this edition, we are going to shed light on some promising cancer treatment therapies. You will read more about CAR-T cell therapy, prepared by students from ANEPF. Furthermore, as vaccines already play a very important role in the pandemic, they could also be a promising treatment against cancer as written by fellow pharmacy students of GPSF. As future pharmacists, we should not miss out on the latest advances in cancer treatment. Enjoy this educational reading!

Yours in EPSA,

Yong Xin Cao Science Coordinator 2021/2022

EPSA – European Pharmaceutical Students’ Association

Association Nationale des Etudiants en Pharmacie de France (ANEPF) The National Association of Pharmacy Students of France is an association founded on March 14, 1968, in Paris and governed by the law 1901, making it a non-profit association. It gathers the 24 student associations of the 24 faculties of pharmacy in France, and thus represents a total of 33.000 students. Our main goal is to bring the students' claims to different levels, with the objective of improving the initial training while promoting interprofessionalism and quality of care. It also has various networks: Elected Students, Public Health, Solidarity, International, Tutorships, Ecological Transition & Environmental Health, Industry and Social Affairs which testify to the strong involvement of the generation of tomorrow's pharmacists in solidarity commitments, peer support and the influence of our profession.

EPSA – European Pharmaceutical Students’ Association

Greek Pharmaceutical Students’ Federation (GPSF) The Greek Pharmaceutical Students' Federation is a non-profit, non-governmental, non-trade union organisation in which undergraduate and postgraduate students of Pharmacy participate. The vision of the association is to represent every student of pharmacy in Greece and to promote cooperation for the development of pharmaceutical and health care. Our Association's main goals are the following: ~ Strengthening the relations and the communication between students and graduates of Pharmacy and other Schools of Health Sciences of Greece and other countries through collaboration in matters of common scientific or social interest, as well as noble rivalry in the scientific arena; ~ Encouraging students to take action relative to their scientific and social interests. Informing them about the latest medical and pharmaceutical achievements, new fields of research and applications of modern technology in science; ~ The participation of students in research in the context of clinical and basic health sciences and their information on issues of medical and social nature, which are of direct interest to the Greek and international community; ~ The participation of students in programs developed by the European Union and national bodies (such as Universities, Hospitals, Industries); ~ The organisation of events of scientific interest, as well as meetings covering issues of education, vocational guidance, and training; ~ The participation of Pharmacy students in programs aiming to inform the public on matters of hygiene, prevention, and treatment, with the goal of improving their life quality.

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Car T-Cells: An innovative immunotherapy Chimeric antigen receptor T cells, also known as CAR-T cells, are T cells taken from the patient's blood and changed in the lab by adding a gene for a man-made receptor (CAR)1. These CAR-T cells are designed to recognise and target a specific protein on the cancer cells. The CAR-T cells are then given back to the patient. CAR-T cell therapy is a breakthrough therapy of the twenty-first century for the management of different malignancies including lymphomas and leukaemias. Since different cancers have different antigens, each CAR is made for specific cancer's antigen. Approvals around CAR-T cell therapy are rapidly changing. The types of cancer that are currently treated using CAR-T cell therapy are diffuse large B-cell lymphoma (DLBCL), follicular lymphoma, mantle cell lymphoma, multiple myeloma, and B-cell acute lymphoblastic leukemia2 (ALL) in paediatric and young adult patients up to age 25. Currently, 5 CAR-T cell drugs have been approved by the U.S. Food and Drug Administration (FDA)3. All of these approvals are for people whose cancer has returned after receiving at least 1 previous type of therapy, depending on the indication. Currently, a great amount of research regarding CAR-T cell therapy is being conducted2, including studying the use of current FDA-approved products for new indications or in less treated patients and finding ways to make CAR-T cell therapy safer for patients. Regarding the mechanism of action, the CAR receptor combines an antibody fragment recognising the tumor cell and a fragment of the natural T cell receptor. Armed with this CAR, the T cells directly recognise the tumor cell, activate, and destroy their target by different mechanisms (cell death receptor, perforin/granzyme release, etc.). CAR-T cells are manufactured in 6 steps1: 1. Patient eligibility To be eligible, it is essential to be in good general condition, and the decision will be conditioned by certain main criteria, including: Absence of contraindications related to existing pathologies; Absence of active infections; Validated marketing authorisations. The patient's eligibility is confirmed after certain tests have been performed, followed by several interviews, in order to fully understand the patient's pathway and its risks. 2. Leukapheresis collection Leukapheresis is a technique for separating the different components of blood by a filtration technique using a machine called a cell separator. This allows the removal of white blood cells from the patient's blood that are used to make the medication.Once the collection is completed, the small bag is sent to the Cellular Therapy Unit, where quality controls are performed before sending it to the pharmaceutical establishment.

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3. Control of bag contents Following the leukapheresis step, the patient's sample is sent to the Cell Therapy Functional Unit (CTU) to verify the quality of the sample. The sample is sent to a pharmaceutical company where the genetic transformation of contained cells occurs. 4. Shipment of the leukapheresis bag The sample can be sent to a pharmaceutical establishment either fresh or cryopreserved at the laboratory of the pharmaceutical establishment, which may be located abroad. 5. CAR insertion step into the T-cell In this step, the patient's T lymphocytes are genetically modified. They become a drug, composed of CAR-T cells. These cells now express a chimeric receptor (called CAR) on their surface and are then put into culture where they multiply by millions. The purpose of this artificial CAR receptor is to identify and allow the T lymphocytes to destroy the cancerous cells after administration to the patient. 6. CAR T cell reception and storage The prepared CAR-T cells are then sent back to the hospital expert centre, to the hospital pharmacy department and are always stored at -196°C. The processing is under the responsibility of the pharmacist of the hospital pharmacy. CAR-T cells are either thawed in a water bath or prepared for the patient to receive their treatment. The estimated time between the collection of the patient's white blood cells and the return of the CAR-T cell drug is 4 to 5 weeks.

The innovative strategies developed to improve efficacy of tumour killing, improve CAR-T cell persistence, and increase control of activity and toxicity, are in parallel being pursued in efforts to bring CAR-T cell therapies to bear against other diseases. Myeloma: There are no curative chemotherapy options for myeloma despite recent progress, so there is significant potential for CAR-T cells to disrupt this treatment landscape. Meloïd malignancies: The use of CAR-T cells in this type of pathology poses many problems. Indeed, there is no specific antigen for the pathology to be targeted. The use of CAR-T cells would therefore lead to numerous undesirable effects. There are however several proposed strategies to overcome these obstacles and trials are in process.

T cell malignancies: T cell malignancies are hardly treated by chemotherapy. CAR-T cells can be an effective alternative, but still presents obstacles like the potential “contamination” of CAR-T cells by malignant T cells. Trials are however encouraging. Solid tumors: This technology has not yet proven its effectiveness in solid tumors. This is due to the reduced accessibility of tumor antigens, coupled with the immunosuppressive EPSA – European Pharmaceutical Students’ Association

environment of cancer, among other reasons. However, developments in the technology may allow this therapeutic horizon to be developed.4 The technical design of CAR-T cells has undergone many improvements and innovations, in the aim to improve efficacy and avoid toxicity. The objective is the diversity of possible treatments. These improvements are linked to the mastering of new technologies, like geneediting. The development of CAR-T cells will not happen in isolation, but is very correlated to scientific progress. It seems that cancers are best treated with a combination of CAR-T cells with other treatments. Moreover, we are moving into the era of personalised medicine, and trials ,that would offer CAR-T cells designated against a wider range of targets determined by immunophenotyping of the patient disease, instead of a specific CAR-T cell,are underway. It is clear that this technology has the potential to combine with the developing field of personalised medicine.

Conclusion Since the reporting of the first CAR-T cell in 1993, this technology has been developed and optimised. Although we are not yet able to treat “solid” cancers and the results of earlyclinical trials were disappointing, researchers are very confident in the potential of CAR-T cells. This is a technology that could, and probably will, revolutionise the way medicine works.

EPSA – European Pharmaceutical Students’ Association

Authors of the article Alice BRAULT, 5th year pharmacy student, France

Théo FAVARD, 5th year pharmacy student, France

Thomas JULLIE, 5th year pharmacy student, France

Soha TOHIDI, 5th year pharmacy student, France

François DIB, 4th year pharmacy student, France

EPSA – European Pharmaceutical Students’ Association

New weapons in the fight against cancer! Cancer treatments vaccines – Perspectives[2] Cancer immunotherapy and treatment vaccines, in particular, is a constantly evolving field with many perspectives. There are already FDA approved vaccines being utilised in cancer treatment (Sipuleucel-T for prostate cancer, BCG vaccine for early-stage bladder cancer). Cancer types whose treatments are associated with high costs and therapies that are less effective, or therapies that involve the risk of serious side effects for the patient, such as lung cancer (a significant cause of cancer-related mortality), pancreatic cancer, and breast cancer are considered appropriate candidates for vaccine therapy. Taking into account that cancer is a genetic and epigenetic disease of multicellularity, a direction towards personalised treatment is the expected step. Technological advances such as genomic sequencing and bioinformatic algorithms for epitope prediction have directly facilitated the development of neoantigen vaccines for individual cancers. Pre-clinical models and human clinical trials have confirmed the ability of cancer vaccines to induce immune responses that are tumor-specific and, in some cases, associated with clinical response. Moreover, an important number of vaccine targets are under evaluation in clinical trials, such as neoantigen vaccines for melanoma, glioblastoma, and ovarian cancer. It is well–known that cancer immunotherapy is a multifaceted strategy and a single treatment modality will not suffice. Therefore, a better understanding of the tumor antigenic immunogenicity, immunogenic heterogeneity, and the inhibitory mechanisms used by the tumor to suppress the immune system seems to be a requirement. Further research on the alteration of the cancer microenvironment and the immune response could lead to more successful cancer treatment vaccines.

mRNA Vaccines Against Pancreatic Cancer Could a vaccine treat pancreatic cancer? Cancer vaccines that use messenger RNA (mRNA) technology are an interesting new approach to developing immunotherapies for cancers with poor prognoses, such as pancreatic cancer.[3]

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Personalised Vaccines – mRNA-4157 Moderna is creating individualised, mRNA-based personalised cancer vaccines to deliver one customised medicine for one patient at a time. Through next-generation sequencing, mutations found on a patient’s cancer cells are identified. These mutations (neoepitopes) can help the immune system distinguish cancer cells from normal cells. Using algorithms, 20 neoepitopes present in the patient’s cancer are predicted. Then a vaccine is created that encodes for each of these mutations, which are loaded onto a single mRNA molecule. The vaccine can direct the patient’s cells to express the selected neoepitopes and may help the patient’s immune system better recognise cancer cells as foreign and destroy them.[4]

EPSA – European Pharmaceutical Students’ Association

KRAS Cancer Vaccine An mRNA-based cancer vaccine that encodes for the four most common KRAS mutations (a frequently mutated oncogene in epithelial cancers such as pancreatic) has been designed. The vaccine generates and presents KRAS neoantigens to the immune system and in this way, the immune system recognises the mutated KRAS proteins and attacks the cancer cells. Currently, the necessary clinical trials for both vaccines are being conducted, evaluating their safety, tolerability, and immunogenicity.

Cancer treatment Vaccines – HPV vaccines Human papillomavirus (HPV) infection is one of the most common sexually transmitted diseases, associated with condylomas and cancers (i.e., cervical, head, neck, anal). To date, more than 200 HPV types have been identified and there are three vaccines against up to nine HPV types: i) the quadrivalent HPV vaccine, Gardasil® (Merck&Co), approved by FDA in 2006 – 70% protection rate, ii) the bivalent HPV vaccine, Cervarix® (GSK), approved by FDA in 2009 – 70-75% protection rate, iii) the nine-valent HPV vaccine, Gardasil 9® (Merck&Co), approved by FDA in 2014 – 90% protection rate. All three vaccines require a 3-dose schedule and have mild vaccination-associated adverse effects12. The available vaccines are developed based on a viral-like particle (VLP) of the major papillomavirus capsid protein L1 (antigen). VLPs are virus-derived nanoscale structures made up of one or more different molecules with the ability to self-assemble. They mimic the form and size of a virus, are highly immunogenic and can efficiently trigger the immune responses. They lack viral genetic material and are non-infectious. The L1 VLPs are nonenveloped (absence of lipid envelope) single layer VLPs composed of a single capsid protein (L1). (21) The production process requires expression of viral proteins using yeast (Gardasil®, Gardasil 9®) or Baculovirus/insect cells system (Cervarix®), isolation of proteins, self-assembly of VLPs, purification and formulation. The HPV vaccines are given intramuscularly and activate the lymphocytes and other immune system cells by producing antibodies against L1 protein and memory B-cells. In this way, the immune system will recognise the virus and prevent infections in the future. (21) Current HPV vaccines are prophylactic vaccines and don’t treat pre-existing infections. Vaccination before first sexual contact could have a protection rate more than 90%, although vaccination after HPV exposure could still have a great benefit. Females have a 10 times higher risk of HPV-related cancers than males, but in order to eliminate the HPV infections, pan-gender vaccination programs should be implemented12. Globally, by 2020, about half of all countries have introduced HPV vaccination, covering about 1/3 of the eligible population of girls. As of December 2021, all EU/EEA countries have introduced HPV vaccination in their national programs, with 2/3 of them vaccinating both girls and boys13. EPSA – European Pharmaceutical Students’ Association

Figure 1 Human papillomavirus vaccination policies in EU/EEA countries and the United Kingdom, 2021(13). Peptide Vaccines Peptide-based synthetic vaccines, also called epitope vaccines, are subunit vaccines made from peptides. The peptides mimic the epitopes of the antigen that triggers direct or potent immune responses. Peptide vaccines can not only induce protection against infectious pathogens and non-infectious diseases but also be utilised as therapeutic cancer vaccines, where peptides from tumor-associated antigens are used to induce an effective anti-tumor T-cell response. Peptide vaccines administered subcutaneously reach the lymph nodes via host antigenpresenting cells and lymph flow, eventually inducing an immune response. This is accomplished through the following molecular mechanism: (i) the peptide binds to antigenpresenting cells, human leukocyte antigens (HLA) or major histocompatibility complex (MHC) molecules on the target cell surface; (ii) T-cell receptors (TCR) recognise the HLA-peptide complexes; and (iii) antigen-specific cytotoxic T-cells (specific CTL) are induced. Some of their additional applications are: ● ● ● ●

peptide-based vaccine against COVID-19 (EpiVacCorona); peptide vaccine candidate against the Hepatitis C virus; the most efficient peptide vaccine candidate against influenza; Alzheimer’s peptide vaccines.

It has been confirmed that peptides are rapidly degraded in vivo by dipeptidases into indigenous amino acids. Accordingly, the potential toxicity from metabolites is considered to be extremely low, and non-clinical safety testing for peptide vaccines should take this characteristic of peptides into account. [5]

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Table 1: Worldwide clinical trials of peptide vaccines Regarding the benefits of vaccines used for cancer treatment, they prevent the progression from premalignant lesions to a fully malignant state. This is achieved through immunity against specific tumor antigens - without the presence of an infectious agent is necessary. It is important to note that the potential of personalised vaccination can enhance the therapeutic result. However, cancer vaccination presents major drawbacks including a charge of administration, refrigerated storage, expiration costs, and accidental waste. Cancer vaccines are often accompanied by a short period of protection, which means that multiple shots are required, increasing the total cost of vaccination. While the cost of vaccination grows, so does the disparity of the uninsured or under-insured patients. This in turn leads to poor supply of vaccines due to poor reimbursement by insurance companies. Lastly, animal models prove to be partly insufficient and there is minimal efficacy and safety reported. The safety of cancer vaccination continues to remain a subject to intense debate. Caution is urged when it comes to identifying and dealing with life-threatening side effects. Discussion is also urged, so that the public is well-informed and makes the right choice for their health.

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Authors of the article

Violetta Krisilia, Postgraduate pharmacy student, Greece

Efrosini Kosti, Undergraduate pharmacy student, Greece

Iris Tripolitsioti, Undergraduate pharmacy student, Greece

Maria Vasileiou, Undergraduate pharmacy student, Greece

Paraskevi Sinou, Undergraduate pharmacy student, Greece

Creator of the infographic

Maria Lambrakopoulou, Postgraduate pharmacy student, Greece

EPSA – European Pharmaceutical Students’ Association

References[6] Infographic: Article:[7] 1 https://www.gustaveroussy.fr/fr/les-cellules-car-t 2 https://www.francelymphomeespoir.fr/contenu/comprendre/comment-soigner-unlymphome/les-car-t-cells 3 https://www.medecinesciences.org/en/articles/medsci/full_html/2019/05/msc180256/ms c180256.html 4 https://www.chu-lyon.fr/traitement-par-car-t-cells Infographic: Cancer treatment vaccines ● MedicalNewsToday. Everything to know about cancer vaccines. [Online]. Available from: https://www.medicalnewstoday.com/articles/cancer-vaccine#trials. [Assessed on January 31, 2022]. ● Guo, C., Manjili, M. H., Subjeck, J. R., Sarkar, D., Fisher, P. B., & Wang, X. Y., Therapeutic cancer vaccines: past, present, and future. 2013, Volume 119, p. 421– 475, 2013, Advances in cancer research Article: New weapons in the fight against cancer! 1. Changbo Sun, Shun Xu, Advances in personalized neoantigen vaccines for cancer immunotherapy, 2020, Volume 14, Issue 5, p. 349-353, Biosci Trends, National Library of Medicine. 2. The history of vaccines. Cancer Vaccines and Immunotherapy. [Online]. The ABCs of BCG: Oldest Approved Immunotherapy Gets New Explanation. Available from: https://www.historyofvaccines.org/content/articles/cancer-vaccines-andimmunotherapy[Assessed on January 31, 2022]. 3. Memorial Sloan Kettering Cancer Center. The ABCs of BCG: Oldest Approved Immunotherapy Gets New Explanation. Available from: https://www.mskcc.org/news/oldest-approved-immunotherapy-gets-newexplanation. [Assessed on January 28, 2022]. 4. Ugur Sahin, Özlem Türeci, Personalized vaccines for cancer immunotherapy, 2018, Vol 359, Issue 6382, p. 1355-1360, Science 5. Antonius Steven, Scott A Fisher, Bruce W Robinson, Immunotherapy for lung cancer, 2016, Volume 21, Issue 5, p. 821-833, Respirology 6. Issam Makhoul, Thomas Kieber-Emmons, Putting into perspective the future of cancer vaccines targeted immunotherapy, 2020, Volume 5, Edition 3, Pages 102113, European Medical Journal 7. Cancer Reseach Institute. Cancer Vaccines. Preventive, therapeutic, personalized. [Online]. Available from: https://www.cancerresearch.org/enEPSA – European Pharmaceutical Students’ Association

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Infographic: Kristen Rat Sarcoma ● Heydt C., Michels S., Thress K. S., Bergner S., Wolf J., Buettner R. Novel approaches against epidermal growth factor receptor tyrosine kinase inhibitor resistance. Oncotarget. 2018; 9: 15418-15434. ● Aleksakhina, S.N.; Imyanitov, E.N. Cancer Therapy Guided by Mutation Tests: Current Status and Perspectives. Int. J. Mol. Sci. 2021, 22, 10931. EPSA – European Pharmaceutical Students’ Association

● García-Olmo D. (2017) KRAS. In: Schwab M. (eds) Encyclopedia of Cancer. Springer, Berlin, Heidelberg. ● Riely, G.J., Marks, J.L., & Pao, W. (2009). KRAS mutations in non-small cell lung cancer. Proceedings of the American Thoracic Society, 6 2, 201-5. ● EMC. Lumykras. [Online]. Available from: https://www.medicines.org.uk/emc/product/12871/smpc#gref. [Accessed on January 16, 2022]. ● Addeo, A.; Banna, G.L.; Friedlaender, A. KRAS G12C Mutations in NSCLC: From Target to Resistance. Cancers 2021, 13, 2541. ● Wikipedia. Sotorasib (structure formula image). [Online]. Available from: https://en.wikipedia.org/wiki/Sotorasib. [Accessed on January 16, 2022]. Front page ● Front page image: https://www.cancercenter.com/community/blog/2017/08/fdaapproves-first-cancer-treatment-based-on-genetic-makeup-not-tumor-location

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