Silvia C. Formenti, MD, Chairman & Professor, Radiation Oncology, Cornell University
Radiotherapy has revealed an ideal adjuvant to cancer immunotherapy, because of its ability to convert the irradiated tumor into an individualized, in situ vaccine. Radiation-induced DNA damage response (DDR) is sensed by the innate immune system and can contribute to immune rejection of tumors. When successful at immunizing, radiotherapy evokes T cell memory, and induces effects outside the treated field, defined as abscopal effects (responses at a distant, synchronous, un-irradiated established tumor or metastasis). In the clinical setting, however, abscopal effects are extremely rare, because of immune-suppressive microenvironment of established solid tumors. Thus, strategies to exploit the pro-immunogenic effects of radiotherapy require combination with immunotherapy: preclinical metastatic cancer models successfully testing the combination of local radiotherapy and immune checkpoint blockade (ICB) have matured to clinical translation. Recent evidence has demonstrated how as part of DNA damage response, tumor mutations can generate neoantigens that contribute to sustained immune responses in patients. Recently, preclinical and clinical evidence have emerged to define optimal radiation protocols to be used during immunotherapy. The issue of radiation dose and fractionation is relevant to the success of abscopal responses. For instance, the role of Trex1 exonuclease has been elucidated in the dose/fraction dependency of abscopal response, confirmed by clinical results in clinical trials conducted in metastatic cancers. Moreover, optimal sequencing of radiation with immunotherapy and immunogenic systemic therapy is gradually being elucidated. Preclinical data have found confirmation in clinical settings.