The knowledge gained in the last 10 years offers the opportunity to learn how to deploy specific countermeasures to reverse the situation in favor of the immune system and, eventually, the patient. This new information could be channeled to address what seem to be the three major hallmarks for the immune control of cancer progression:
1.
Effective procedures to activate immune reactivity
2.
Characterization of not-disposable oncoantigens
3.
Counteract immune suppression.
Effective procedures to activate immune reactivity
Chronic inflammation can be dampened with anti-inflammatory drugs, which in some cases reduce the risk of cancer (sulindac, aspirin) [
38]. However, a more sensitive strategy is to re-orient inflammation from tumor promotion to a tumor-preventive reaction [
39‐
41]. Both passive (antibodies) and active (vaccines) immunization effectively protect the host from tumor onset [
42,
43]. However, a much larger body of evidence favors active immunization.
The high efficacy of vaccines in the prevention of infection by carcinogenic viruses and other infectious agents causing cancer is currently getting an extraordinary social impact. Vaccines aimed at removing an infective risk factor are being commonly used.
Hepatocellular carcinoma accounts for more than 4% of all human cancers, and 80% of cases are associated with viral infection. Vaccination against hepatitis B virus (HBV) markedly reduced the incidence of post-hepatitis hepatocellular carcinoma [
44]. Since chronic inflammation plays a significant role in the onset of liver cancer that follows HBV infection, this vaccine can be viewed as a form of primary prevention of a carcinogenic chronic inflammation.
HPV causes neoplastic disorders ranging from benign warts to malignant cervical and anogenital carcinomas [
45]. The worldwide implementation of vaccination programs against HPV began only a few years ago, and their long-term efficacy in the prevention of cervical carcinoma is not yet completely assessed. Initial results are extremely favorable, and almost complete prevention of carcinogenesis is foreseen [
46]. Current HPV vaccines are effective in cancer prevention but devoid of therapeutic efficacy. Vaccines able to cure cervical carcinomas are actively studied [
47].
The Epstein–Barr virus (EBV) is implicated in a variety of diseases worldwide: infectious mononucleosis in Western countries, nasopharyngeal carcinoma in Asia, Burkitt’s lymphoma in Africa, and lymphoproliferative diseases in immunodeficient patients. The use of some promising candidate vaccines is being actively pursued [
48,
49].
While vaccines to prevent tumors related to an infectious agent are becoming a medical reality, a large series of studies on genetically engineered mice suggest that vaccines to prevent tumors not related to an infectious agent may also be a new form of prevention [
50,
51]. Numerous data on healthy mice carrying oncogenes that predestine to lethal cancer show that vaccines addressing oncogene products block the onset of neoplastic lesions. Repeated boosts of the vaccine afford a persistent protection that may last as long as the natural murine life span.
Somewhat surprisingly, the T-cell-mediated cytotoxic response plays a minor role in the protection afforded by several of these vaccines. Since the target oncogene products are self molecules, they elicit a kind of split-tolerance that mainly causes the disappearance of high-affinity CD8
+ T cells [
52]. In addition, this response is inhibited by the expansion of natural T
Reg cells that recognize the target antigen as a self-protein [
53]. Therefore, most of the antitumor action elicited by preventive vaccines rests on the multiple direct and indirect antitumor activities of antibodies [
54‐
56].
Characterization of not-disposable oncoantigens
Vaccines that must elicit and sustain a virtually lifelong immune response carry the risk of downmodulation or loss of the target antigen by neoplastic cells. A suitable target antigen that preempts the loss of immune recognition should
(a)
have an essential role in tumor growth or progression;
(b)
be a target of cytotoxic cells and antibodies.
We have chosen the term “oncoantigens” for tumor antigens that fulfill these two requirements [
50]. When carcinogenesis is driven by an oncoantigen, antigen-loss variants can occur, but their tumorigenic potential would be markedly impaired [
57,
58]. In the later course of tumor progression, the driving role of the targeted oncogene can be taken by different genes [
59,
60], whose products, in turn, will offer further oncoantigen targets.
Tumors evade T-cell recognition through the downmodulation of antigen-processing machinery and MHC glycoprotein expression. However, antibody recognition of accessible molecules is not affected, and antibodies still ensure a functional inhibition of the target oncoantigen together with the activation of complement-mediated cytotoxicity and ADCC. Class I oncoantigens expressed on the cell surface can be attacked by both antibodies and cell-mediated immunity and are probably the best target for a preventive vaccine [
50]. Class II oncoantigens are tumor-secreted molecules or molecules in the tumor microenvironment that play essential roles in tumor expansion [
61]. These can be targeted by antibodies but not by T-cell-mediated immunity. Class III oncoantigens are tumor molecules that cannot be reached by antibodies because of their intracellular localization, and thus can only be targeted by T cells [
62,
63].
One could imagine that in the future, vaccines to prevent cancer will be administered to the general population, as is happening now to prevent infectious tumors. In a more realistic perspective, there are several human groups at risk of cancer that could benefit from specific vaccines, especially in the case of genetic risk, preneoplastic syndromes, cohorts of individuals previously exposed to environmental carcinogens, and cancer survivors with increased risk of a new primary tumor. Of particular interest appears the finding that a vaccine against ERBB2, an archetypal class I oncoantigen, impairs chemical carcinogenesis in hamsters since it may open a new way to treat healthy persons with a specific risk of a chemically induced cancer for whom no active therapeutic option exists at present [
64].
Counteraction of immune suppression
The efficacy of vaccines is diminished by the tumor-driven expansion of immunosuppressive cells, including T
Reg and myeloid-derived suppressor cells (MDSC) [
50], that results in both a far less significant immune response and suppression of its effector arm [
65,
66]. Strategies that counteract suppression during vaccination can make the difference between a poorly effective vaccine and a sterilizing one. T
Reg cells accumulate in both human and mouse tumors, as well as in secondary lymphoid organs, and are recruited [
67] and expanded by either the proliferation of preexisting T
Reg cells [
68] or the conversion of CD25-negative T cells [
34,
69]. Tumor-driven T
Reg cell expansion also changes the tumor-specific T-cell repertoire [
53,
70] and inhibits the reaction of low-avidity T cells against tumor antigens [
53,
69].
When vaccination is coupled with T
Reg depletion by the administration of anti-CD25 monoclonal antibody, a long-lasting tumor immunity is induced, and the antibody response is enhanced. In addition, the low-avidity CTL response against the immunodominant peptide is restored, due to the freeing of CD8
+ T cells from T
Reg constraints [
53]. These effects of T
Reg depletion render the vaccination efficacious at tumor stages at which vaccination alone is ineffective [
53]. Similarly, T
Reg cell functional inhibition, by means of OX40 triggering, protects mice from subsequent tumor challenge and induces a complete rejection of already-established nodules [
71].
T
Reg are not the sole suppressive cells than can be attacked to counteract immune suppression. Myeloid-derived suppressor cells (MDSC) are an underdeveloped target of growing importance [
72‐
74]. It has been shown that powerful vaccines inhibit MDSC [
41,
75]; however, a more direct strategy can be more effective. Four lines of attack were outlined in a recent review [
76]: induction of MDSC maturation, inhibition of MDSC generation, accumulation, and suppressive function.
The clinical use of antisuppressive approaches will benefit all cancer patients, in particular more advanced ones, who frequently display higher levels of immune suppression and suppressive cells. As novel immunotherapies are first tried in advanced patients, we think that the success rate of such clinical trials would be significantly enhanced by the simultaneous implementation of counter-suppression approaches.