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Viroimmunotherapy for Breast Cancer: Promises, Problems and Future Directions

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Viroimmunotherapy for Breast Cancer: Promises, Problems and Future Directions Cancer Gene Therapy (2021) 28:757–768 https://doi.org/10.1038/s41417-020-00265-6 REVIEW ARTICLE Viroimmunotherapy for breast cancer: promises, problems and future directions 1 1 Shyambabu Chaurasiya ● Yuman Fong Received: 18 May 2020 / Revised: 26 August 2020 / Accepted: 12 November 2020 / Published online: 2 December 2020 © The Author(s), under exclusive licence to Springer Nature America, Inc. 2020 Abstract Virotherapy, a strategy to use live viruses as therapeutics, is a relatively novel field in the treatment of cancer. With the advancements in molecular biology and virology, there has been a huge increase in research on cancer virotherapy. For the treatment of cancer, viruses could be used either as vectors in gene therapy or as oncolytic agents. A variety of viruses have been studied for their potential usage in gene therapy or oncolytic therapy. In this review, we discuss virotherapy with a special focus on breast cancer. Breast cancer is the most common cancer and the leading cause of cancer-related deaths in women worldwide. Current treatments are insufficient to cure metastatic breast cancer and are often associated with severe side effects that further deteriorates patients’ quality of life. Therefore, novel therapeutic approaches such as virotherapy 1234567890();,: 1234567890();,: need to be developed for the treatment of breast cancer. Here we summarize the current treatments for breast cancer and the potential use of virotherapy in the treatment of the disease. Furthermore, we discuss the use of oncolytic viruses as immunotherapeutics and the rational combination of oncolytic viruses with other therapeutics for optimal treatment of breast cancer. Finally, we outline the progress made in virotherapy for breast cancer and the shortcomings that need to be addressed for this novel therapy to move to the clinic for better treatment of breast cancer. Breast cancer ever-evolving. Traditional classifications of BrCa were based on the histology and biology of the tumors, whereas Breast cancer (BrCa) is the second most commonly diag- recent classification schemes are mainly based on molecular nosed cancer in the world and according to the last Global differences [5, 6]. Comprehensive gene expression profiling Cancer Statistics (GLOBOCON 2018), BrCa represented by different independent groups using a large set of breast 11.6% of all cancers and caused 6.6% of all cancer-related tumors has led researchers to categorize BrCa into five deaths [1]. Major advancements in the diagnosis and treat- major molecular sub-types, which vary in the expression ment of BrCa made over the last three decades have levels of the estrogen receptor (ER) and human epidermal improved the quality of life and overall survival of patients. growth factor receptor 2 (HER2). The five molecular sub- However, despite improvements in diagnostic methods, types are normal breast-like, luminal A, luminal B, HER2 20–50% of patients develop metastatic disease which +/ER−, and basal-like or triple-negative [7, 8]. Treatments remains difficult to treat and accounts for the majority of for BrCa are dictated to some extent by the molecular sub- deaths [2, 3]. BrCa is a highly heterogeneous disease, and types and prognosis varies among the sub-types, but in the extensive intra- and inter-tumoral heterogeneity are general, patients with basal-like (or triple-negative) tumors thought to be the result of the distinct cells of origin and have the worst prognosis whereas patients with luminal A specific alterations at genetic and epigenetic levels [4]. BrCa tumors have the best prognosis [4, 9]. has been classified in many ways and the classification is Current therapies * Shyambabu Chaurasiya Surgery is commonly used to remove primary breast tumors [email protected] while radiation and chemotherapies are used as adjuvants in 1 Department of Surgery, City of Hope National Medical Center, the treatment of BrCa [2, 10]. For most of the twentieth Duarte, CA, USA century, the Halsted radical mastectomy, an aggressive form 758 S. Chaurasiya, Y. Fong of surgery that includes removal of the breast together with chemotherapy are initially observed in TNBC patients, they muscles of the chest wall, was the standard form of surgery quickly develop resistance to the drugs, and disease relapse for the treatment of BrCa [11, 12]. This approach was based is very common with the median survival of only 13 months on the premise that metastasis in BrCa occurs through the [29]. Taken together, with the advancements in knowledge locoregional spread and thus could be cured by aggressive about BrCa many therapeutic options have been developed, surgery. However, studies in the 1970s showed that radical which have substantially increased the overall survival of mastectomy has no benefit over less aggressive surgeries in patients, however, there is still a need for better treatment terms of either disease recurrence or overall survival options to further improve patients’ quality of life as well as [11, 13]. Later, less aggressive breast conservation surgery overall survival. became more common for local therapy combined with a wide variety of systemic adjuvant therapies [14]. Adjuvant therapies given systemically are aimed at eradicating dis- Virotherapy for breast cancer seminated cancer cells in order to minimize the probability of metastatic growth [15]. Like many other types of cancer, During the course of evolution, cancer cells accumulate metastases are the main cause of death in BrCa patients, many mutations that confer the cells with the ability to resist accounting for more than 90% of total mortality [16]. Stu- cell death, acquire replicative immortality, and render them dies have shown that the use of adjuvant radiation-, chemo-, insensitive to immune surveillance [30]. Interestingly, many endocrine and HER2-directed therapies significantly redu- of the same mutations that allow cancer cells to thrive, also ces the risk of disease recurrence and improves the overall make them better hosts for viruses. Virotherapy, a strategy survival of patients [17–19]. Radiation is usually applied to to use live viruses as therapeutics, exploits these mutated the tumor bed and regional lymph nodes after the resection loopholes to target cancer cells. Cancer virotherapy could of the primary tumor [20]. The most common chemotherapy be broadly categorized into two sub-classes: (i) use of non- adjuvant regimens include the combination of cyclopho- replicating viruses as vectors in cancer gene therapy and (ii) sphamide with doxorubicin and/or docetaxel or methotrex- use of replicating viruses as oncolytic agents. In this review ate with 5-fluorouracil (an excellent review on this topic is article, we will discuss both aspects of virotherapy with provided by Anampa et al. [13]). However, the use of respect to BrCa. radiation- and chemotherapies is limited by off-target toxi- cities and development of resistance to these therapies [21, 22]. Off-target toxicities resulting from chemotherapies Non-replicating viruses for breast cancer substantially affect the quality of patients’ lives and ~40% therapy of patients suffer from disease recurrence and die of metastases [23]. More recent therapies for BrCa have been Many preclinical studies as well as clinical trials have developed to target the expression of estrogen receptor examined the feasibility of gene therapy for the treatment of (ER), progesterone receptor (PR) and human epidermal BrCa. Unlike gene therapy for monogenic disorders where the growth factor receptor 2 (HER2) expression. About 75% of goal is to restore the function of the defective gene, the goal of human BrCa express ER, and endocrine therapy is used for cancer gene therapy is to directly or indirectly kill cancer cells the treatment of such subtype [24]. Tamoxifen, an ER [31]. For direct killing of cancer cells, the strategy of suicide modulator, is the most commonly used endocrine therapy gene therapy is employed, which involves the delivery of a for ER/PR+ BrCa. Patients with HER2+ BrCa are treated toxic gene or a gene that could convert an inactive prodrug with trastuzumab, a monoclonal antibody against HER2. into a cytotoxic drug specifically in cancer cells causing cell Trastuzumab is usually given in combination with adjuvant death [32]. Two most studied strategies for suicide gene chemotherapy either concurrently or sequentially [25]. therapy are (i) herpes simplex virus (HSV)-thymidine kinase However, trastuzumab has been shown to induce some (TK) gene in combination with prodrug ganciclovir and (ii) degree of cardiac toxicity, and approximately half of the cytosine deaminase gene in combination with the prodrug treated patients experience disease relapse within 3 years 5-fluorocytosine [32]. [26, 27]. Majumdar et al. [33] studied adenovirus-mediated HSV- Basal-like or triple-negative breast cancer (TNBC) is the TK (Ad-HSV-TK) expression plus ganciclovir as suicide most aggressive subtype with the highest relapse rate and gene therapy in BrCa models . The authors found that HSV- high incidence of brain metastasis [28]. TNBCs are not TK-ganciclovir therapy had a minimal effect against the amenable to currently available targeted therapies as they murine 4T1 tumors, however, a combination of HSV-TK- lack these molecular targets. Anthracyclines and taxanes are ganciclovir therapy with adenoviruses expressing inter- usually used in the treatment of TNBC, however with very leukin(IL)-2 and granulocyte-macrophage colony-stimulat- limited success [28]. Although favorable responses to ing factor
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