Targeting novel molecular networks underlying bladder cancer recurrence and progression

Bladder cancer (BC) is a very significant world public health problem, in terms of prevalence, mortality, clinical management and cost. For most patients (around 70%), the disease is detected as a non-muscle invasive BC (NMIBC) at the surface of the bladder. For many years, it has been treated with BCG instillation and tumor resection within the bladder. This treatment is efficient, but most patients will undergo tumor recurrence and will necessitate several rounds of treatment over the years. The disease can also evolve into muscle invasive bladder cancer (MIBC, 30%). In these cases, the treatment consists in chemotherapy and bladder removal (cystectomy). Despite this radical treatment, the overall survival is low, with half of the patients not surviving beyond five years. Survival does not exceed 15 months when the disease is metastatic. In the last years, the tremendous success of immunotherapy has also led to some success in the treatment of MIBC. Immunotherapy, in this case, will restore the capacity of the immune system to fight the disease. 20 to 30% of the patients treated with antibodies blocking the PD-1/PD-L1 pathway showed a response to the treatment. But this rate of response is lower than in other cancer types and there is a clear need to understand why the patients do not respond to the treatment in order to improve and find new immunotherapeutic treatments.

In this optic, we plan to combine the expertise of our two research teams to decipher the molecular mechanisms driving BC recurrence/progression. We will carry out studies directly in patient samples and in a genetically engineered mouse model (GEMM) of BC that recapitulates the human BC tumor progression stages. Furthermore, we will dissect and validate novel therapeutic axes and biomarkers in this GEMM, in view of phase I/II clinical trials in BC patients to improve patient survival.

Preliminary genetic studies on primary and recurrent tumor tissues of a cohort of 12 BC patients led to the discovery of a gene signature associated with BC progression/recurrence. In our study, we will focus on two pathways found in this signature that can be targeted to improve tumor control/elimination. We validated that these two pathways were higher in recurrent versus non-recurrent tumors in a larger cohort of 36 patients. This same gene signature was also detected in the progressive stage of our BC GEMM, confirming the known clinical relevance of this model. Based on these findings, we hypothesize the existence of a therapeutically targetable crosstalk between immune and BC cells that involves the studied genes and their regulation.

Understanding how clonal hematopoiesis feeds lymphoma

Patients with lymphoma who do not respond to treatment have a bleak outcome. Annually, over 1100 patients die with leukemia and lymphoma in Switzerland. Lymphoma can arise when the DNA inside a lymphocyte changes in a way that prevents the lymphocyte from responding to signals that usually keep it under control. To outgrow and disseminate, lymphoma hijacks normal inflammatory cells to acquire protection and nurturing, while at the same time deceiving them by hiding from their attack. Inflammation may be age-related and can foster manifestations such as clonal hematopoiesis or can be sustained by chronic infections of the lymphoma cell itself.

The new avenues of lymphoma therapy rely on a combination of approaches that target both tumor cells and the supporting host environment, including: i) repairing the operative system inside lymphoma cells, which can be achieved by using small molecules that precisely identify and attack the factors that led to its failure; ii) reverting the stunned inflammatory cells from lymphoma feeders to lymphoma predators. The experiments will also allow us to understand how aging-related inflammation facilitates lymphoma development. We aim to understand how aging of the normal immune functions (designed to cause inflammation) modulate the tumor and the surrounding immune system. Single cell resolution now puts us in the unique position to track the aging of cells of the immune system (locally and globally) and to connect them to the behavior of cancer cells. We will use this knowledge to develop strategies to engage the healthy immune compartment in the fight against the tumor. This is of particular interest as the advent of multiple immunotherapy approaches puts increasing emphasis on the efficacy of drugs on immune responses or the fitness (exhaustion) of the anti-tumor response.

Project

Modeling and investigating the tumor microenvironment of non-small cell lung cancer brain metastases

Lung cancer, including the most common type, non-small cell lung cancer, is the leading cause of cancer-related deaths worldwide. Metastasis represents the final stage of lung cancer progression, when cancer cells have successfully spread to a new organ and colonized it. Critically, 20-40% of lung cancer patients develop brain metastasis over the course of the disease progression. We urgently need to devise novel therapies for lung cancer brain metastasis because, first, more than 50% of the patients die in the year following diagnosis, and second, these metastases cause deaths in patients in which the disease in the lung and other sites of metastasis is under control.

However, the lack of animal models that faithfully represent human lung cancer brain metastasis impedes our current understanding of the underlying molecular mechanisms. Yet this information is urgently required for the identification of the unique vulnerabilities of these mechanisms for future therapeutic targeting.

In this project, we will take advantage of our collaborations with pathologists, surgeons and scientists within the Swiss Cancer Center Léman and overseas, to reveal novel therapeutic combinations that target the non-cancerous cells in the tumors (the tumor microenvironment), including the immune cells. We will generate a first of its kind mouse model of lung cancer that recapitulates all the steps of lung cancer brain metastasis. Since these mice will have an intact immune system (which is not the case in many current models), we will be able to determine how the body’s defenses react to lung cancer metastasis in the brain, and identify therapies that can boost this response.

In parallel, we will leverage novel technologies that describe the cellular interactions that determine how the non-cancerous cells react to the cancer cells and where these interactions occur in the tumor. By performing these analyses in patient samples and in our animal model, we aim to identify yet unappreciated vulnerabilities in the non-cancerous cells of lung cancer brain metastasis, which we will target in our novel mouse model. We hope that this will ultimately lead to a personalized management of non-small cell lung cancer brain metastasis, whereby rationally designed treatments will target distinct molecular subtypes.

Patient and healthcare provider experience in adoptive cell therapies: An experience-based co-design study

Adoptive cell therapy with tumor-infiltrating lymphocytes (TIL) or chimeric antigen receptor T-cells (CAR-T) is a new and rapidly growing strategy in the field of cancer therapies. It aims to enhance a patient’s anti-cancer response by delivering specific anti-tumor immune cells. The fact that the procedure involves multiple professionals adds complexity to the care delivery, for both patients and healthcare providers (HCP). Patients’ experience and specific needs during these novel and particularly demanding therapies have not been examined so far.

Person-centered care (PCC) has been identified as one of the six main drivers of health care quality, in addition to safety, effectiveness, efficiency, as well as timely and equitable care. PCC approaches rely on building a provider-patient partnership relationship, improving communication techniques, and encouraging patients to actively participate in patient-provider interactions.

Experience-Based Co-Design (EBCD) is a multi-stage process that uses qualitative research methods to engage HCPs and patients in co-designing healthcare services. EBCD facilitates a high level of patient and HCP engagement, enables discussions about difficult topics in a supportive environment, leads to the identification of improvement priorities, and results in meaningful changes in how services are delivered with an impact on patient experience.

The overarching goal of this study is to investigate and improve the current delivery of care during TIL and CAR-T cell therapies by examining the experiences and perspectives of patients and HCPs across the treatment trajectory. Specifically, we aim to:

Exploring the role of neutrophils in brain metastasis

The development of metastases unfortunately remains the leading cause of death in cancer patients. Of all metastatic cancers, those invading the brain represent a particularly difficult challenge to treat. Brain metastases (BrM) frequently arise from melanoma, lung and breast cancers. Although considerable advances have been made in treating these cancers at the primary site, a steep increase in mortality is observed in patients who develop BrM. This is partly due to our limited knowledge about the BrM tumour microenvironment (TME), which directly translates into a lack of clinical treatment options.

While the importance of immune and stromal cells in the TME in shaping a favourable environment for tumour growth is well-established, much less is known about the complexity of these interactions during metastasis. This is particularly true for BrMs, where the unique properties of the brain create an environment that is very different to other organs. By comprehensively analysing the TME in diverse brain tumour patient samples, we recently identified neutrophils, the most numerous circulating white blood cell population in humans, as among the most abundant immune cells infiltrating BrM specifically.

The aim of this project led by Prof. Johanna Joyce (Department of oncology, UNIL,
Ludwig Institute for Cancer Research Lausanne), is to unravel how neutrophils may functionally contribute to the colonisation and metastatic outgrowth of cancer cells in the brain. It represents the first in-depth study of neutrophil phenotypes and functions in BrM patients and preclinical models.

The rigorous and integrated experimental strategy devised by the Joyce lab, including both mouse models and human tissue analyses, will provide the first comprehensive view of how neutrophils may regulate metastatic progression to the brain. Neutrophils have generally been associated with poor prognosis in cancer patients, but have also been found to serve opposing functions in other metastatic settings, specifically breast-to-lung metastasis, in a context-dependent manner. By contrast, the role of neutrophils in the context of BrM remains virtually unexplored. Thus, a rigorous analysis of their functions in BrM is urgently needed. The combination of functionally analysing neutrophils in human BrMs and utilising state-of-the-art murine BrM models represents a comprehensive strategy to explore neutrophil education by brain-colonising cancer cells. Critically, these data will reveal how neutrophils in the periphery and the brain TME evolve with, and contribute to, the progression of metastatic cancers. Regardless of whether we discover neutrophils to be tumour-supporting or tumour-suppressing in BrM, this is an essential question to answer, which we are uniquely capable to address.

This project will significantly enhance our understanding of neutrophil functions in metastasis and may have important implications for devising therapeutics to target the BrM TME in the future. The cancer immune-microenvironmental perspective of this project additionally addresses a topic of intense focus at present, as different immunotherapies are rapidly advancing to first-line treatments for many cancer types. However, patients presenting BrMs have been largely excluded from clinical trials, resulting in a critical lack of knowledge for how novel treatment modalities might specifically affect or benefit intracranial metastases. Thus, the advance in knowledge that we expect to achieve through this ISREC-funded project will provide the necessary bridge linking fundamental research on BrM tumour immunity to answering essential clinical questions.

Project

Mechanisms and therapeutic targeting of the neuronal NMDAR signaling pathway promoting breast cancerpathogenesis

The research will focus on elucidating pathogenic mechanisms and exploring innovative therapeutic targeting strategies for breast cancer. The focus will be on a neuronal signaling pathway – centered upon the NMDA receptor (NMDAR) – that the Hanahan lab discovered to be hijacked by cancer cells to enhance invasion and metastasis, the hallmarks of malignancy that cause cancer mortality. The NMDAR’s role in cancer pathogenesis was initially discovered and described in 2013 (Li & Hanahan, Cell), and further characterized in 2018 (Li, Zeng et al., Cancer Cell), principally in pancreas cancer. Then in 2019, the role of NMDAR signaling in the metastasis of breast cancer to the brain was established in a major article in Nature (Zeng et al.). Unpublished data from the Hanahan lab suggest that the NMDAR may also be hijacked in certain primary breast tumors and in metastasis to other sites. Simge Yücel will use mouse models of breast cancer in conjunction with analysis of human breast cancer biopsies to pursue the following lines of investigation:

These lines of investigation are likely to reveal new opportunities, which will be incorporated in the research.

References

• Li, L., & Hanahan, D. (2013). Hijacking the neuronal NMDAR signaling circuit to promote tumor growth and invasion. Cell. 153: 86-100.
• Li, L., Zeng, Q., Bhutkar, A., Galvan, J., Karamitopoulou, E., Noordermeer, D., Peng, M.W., Piersgilli, A., Perren, A., Zlobec, I., Robinson, H., Iruela-Arispe, M.L., & Hanahan D. (2018) GKAP acts as a genetic modulator of NMDAR signaling to govern invasive tumor growth. Cancer Cell, 33: 736-751.
• Zeng, Q., Michael, I.P., Zhang, P. Saghafini, S., Knott, G., Jiao, W., Brian D. McCabe, B.D., José A. Galván, J.A., Robinson, H.P.C., Zlobec, I., Ciriello, G., and Hanahan, D. (2019). Synaptic proximity enables NMDAR signaling to promote brain metastasis. Nature, 573: 526-531.

Transcriptomic and phenotypic profiling of the white blood cells in breast cancer

Despite considerable improvements in breast cancer management, approximately one in four patients still die due to metastases. In order to decrease this mortality, the disease needs to be diagnosed as early as possible, and metastases must be prevented or treated effectively. Studies we have conducted show that the presence of breast cancer alters quantifiable phenotypic and transcriptomic characteristics of white blood cells (leucocytes) circulating in the blood. These results suggest that it may be possible to exploit these changes in the leucocytes circulating in the blood to reveal the presence of primary breast cancer (screening) or a relapse (monitoring).

The aim of our project is to generate additional data supporting these observations. To this end, we will use novel approaches and technologies (single cell RNA sequencing and multi-parameter analysis of the cell surface). We plan to compare first-diagnosis female patients with healthy women, and patients at the time of the first relapse after therapy with patients not having suffered a relapse. We will investigate the three biological subtypes of breast cancer (ER⁺, HER2⁺, triple negative). This multicentric study, conducted in the Lake of Geneva area, will be coordinated at the CHUV in Lausanne.

A 20 ml blood sample will be taken for the following lab tests: i) leucocyte phenotyping by flow cytometry; ii) transcriptomic analysis and phenotyping by single cell RNA sequencing, followed by bioinformatic analyses. The lab tests will be conducted at the University of Fribourg, the sequencing at the Genomic Technologies Facility of the University of Lausanne (LGTF) and the bioinformatic analyses at the Swiss Institute of Bioinformatics (SIB).

We hope that these analyses will help us validate our preliminary observations more precisely and that we will be able to identify candidate biomarkers (cells, phenotypes, gene expression) and combinations associated with primary breast cancer or the first relapse.

This study is part of a long-term goal to develop a cancer screening blood test and a monitoring blood test for early detection of relapses. The practical implications of these tests are potentially significant: the tests could contribute to changing the way women are screened and patients monitored, thereby greatly improving the quality of life of women in general (screening) and of breast cancer patients (monitoring). From a clinical point of view, the monitoring test would be a valuable new tool that could help support therapeutic choices in the treatment of breast cancer.

Project