Potential Biomarkers for the Efficacy of PD-1-PD-L Blockade in Cancer

Figures & data

Table 1 Immune Checkpoint Inhibitors Approved by FDA by 22nd of July 2021²⁰

Drug	Mechanism	Tumor	Setting	Trial	Approval
Ipilimumab	CTLA-4 inhibitor	Melanoma	2nd line	MDX010-020	28th of March2011
			1st line (in combination with nivolumab)	CheckMate-069/CheckMate-067	1st of October 2015
			Adjuvant	CA 184-029	18th of October 2015
		RCC^a with clear cell histology – intermediate and poor risk groups	1st line (in combination with nivolumab)	CheckMate-214	18th of April 2018
		MSI- H or dMMR CRC^b	3rd line (in combination with nivolumab)	CheckMate-142	10th of July 2018
Nivolumab	PD-1 inhibitor	Melanoma	2nd line	CheckMate-037	22nd of December 2014
			Adjuvant	CheckMate-238	1st of December 2017
		NSCLC^c	2nd line	CheckMate-017	4th of March 2015
			2nd line	CheckMate-057	1st of October 2015
			1st line (in combination with ipilimumab)	CheckMate-227	15th of May 2020
			1st line (in combination with ipilimumab + chemotherapy)	CheckMate-9LA	27th of May 2020
		SCLC^d	3rd line	CheckMate-032	17th of August 2018
		Mesothelioma	1st line (in combination with ipilimumab)	CheckMate-743	2nd of October 2020
		RCC	2nd line	CheckMate-025	1st of November 2015
			1st line (in combination with cabozantinib)	CheckMate-9ER	22nd of January 2021
		Hodgkin’s lymphoma	2nd line	CheckMate-205	1st of May 2016
		HNSCC^e	2nd line	CheckMate-141	1st of November 2016
		MSI- H or dMMR CRC	2nd line	CheckMate-142	1st of August 2017
			3rd line (in combination with ipilimumab)	CheckMate-142	10th of July 2018
		HCC^f	2nd line	CheckMate-040	1st of September 2017*
			2nd line (in combination with ipilimumab)	CheckMate-040	11th of March 2020
		Bladder cancer	2nd line	CheckMate-275	1st of February 2017
		Esophagus cancer	2nd line	ATTRACTION-3	11th of June 2020
			1st line (in combination with chemotherapy)	CheckMate-649	16th of April 2021
			Adjuvant (in combination with chemoradiotherapy)	CheckMate-577	20th of May 2021
		Gastric cancer	1st line (in combination with chemotherapy)	CheckMate-649	16th of April 2021
Pembrolizumab	PD-1 inhibitor	Melanoma	2nd line	KEYNOTE-001	1st of September 2014
			2nd line	KEYNOTE-002	1st of December 2015
			1st line	KEYNOTE-006	1st of December 2015
			Adjuvant	EORTC 1325/KEYNOTE-054	15th of February 2019
		NSCLC	2nd line	KEYNOTE-001; KEYNOTE-006	1st of October 2015
			1st line	KEYNOTE-024	1st of October 2016
			1st line (in combination with chemotherapy)	KEYNOTE-021	1st of May 2017
			1st line (in combination with chemotherapy)	KEYNOTE-189	20th of August 2018
			1st line (in combination with chemotherapy)	KEYNOTE-407	31st of October 2018
			1st line	KEYNOTE-042	11th of April 2019
		SCLC	3rd line	KEYNOTE-158; KEYNOTE-028	18th of June 2019**
		RCC	1st line (in combination with TKI)	KEYNOTE-426	19th of April 2019
		HNSCC	2nd line	KEYNOTE-012	1st of August 2016
			1st line (alone or in combination with chemotherapy)	KEYNOTE-048	10th of June 2019
		Hodgkin’s lymphoma	2nd line	KEYNOTE-087	1st of March 2017
			2nd line	KEYNOTE-204	15th of October 2020
		PMBCL^g	3rd line	KEYNOTE-170	13th of June 2018
		Merkel cell carcinoma	1st line	CITN-09/KEYNOTE-017	19th of December 2018
		Cutaneous squamous cell carcinoma	1st line	KEYNOTE-629	24th of June 2020
		MSI-H or dMMR tumors	2nd line	NCT01876511	1st of May 2017
		TMB-H tumors	2nd line	KEYNOTE-158	16th of June 2020
		Esophagus cancer	2nd line	KEYNOTE-180; KEYNOTE-181	31st of July 2019
			1st line (in combination with chemotherapy)	KEYNOTE-590	22nd of March 2021
		CCR	1st line	KEYNOTE-177	29th of June 2020
		Gastric cancer	3rd line	KEYNOTE-059	1st of September 2017*
			1st line (in combination with Trastuzumab and chemotherapy)	KEYNOTE-811	5th of May 2021
		Hepatocellular carcinoma	2nd line	KEYNOTE-240	9th of November 2018
		Cervical cancer	2nd line	KEYNOTE-158	12th of June 2018
		Bladder cancer	2nd line	KEYNOTE-045	1st of May 2017
			1st line	KEYNOTE-052	1st of May 2017
			2nd line	KEYNOTE-057	8th of January 2020
		TNBC^h	1st line (in combination with chemotherapy)	KEYNOTE-355	13th of November 2020
		Endometrial carcinoma	2nd line (in combination with lenvatinib)	KEYNOTE-775/Study 309	22nd of July 2021
Cemiplimab	PD-1 inhibitor	Cutaneous squamous cell carcinoma	1st line	NCT02760498	28th of September 2018
		Basal cell carcinoma	2nd line	NCT03132636	9th of February 2021
		NSCLC	1st line	EMPOWER-Lung1	22nd of February 2021
Dostarlimab	PD-1 inhibitor	Endometrial carcinoma	2nd line	GARNET	22nd of April 2021
Avelumab	PD-L1 inhibitor	Merkel cell carcinoma	2nd line	JAVELIN Merkel 200	1st of March 2017
		Bladder cancer	2nd line	JAVELIN Solid Tumor	1st of May 2017
			1st line	JAVELIN Bladder 100	30th of June 2020
		RCC	1st line (in combination with Axitinib)	JAVELIN Renal 101	15th of May 2019
Atezolizumab	PD-L1 inhibitor	Bladder cancer	2nd line	IMvigor210	1st of May 2016**
			1st line	IMvigor210	1st of April 2017**
		NSCLC	2nd line	Birch, Poplar, FIR, Oak	1st of October 2016
			1st line (in combination with bevacizumab, carboplatin and paclitaxel)	IMpower150	6th of December 2018
			1st line (in combination with carboplatin/nab-paclitaxel)	IMpower130	3rd of December 2019
			1st line	IMpower110	18th of May 2020
		SCLC	1st line (in combination with carboplatin and etoposide)	IMpower133	19th of March 2019
		Melanoma	1st line (in combination with cobimetinib and vemurafenib)	IMspire150	30th of July 2020
		HCC	1st line (in combination with bevacizumab)	IMbrave150	29th of May 2020
		TNBC	1st line (in combination with nab-paclitaxexl)	IMpassion130	8th of March 2019
Durvalumab	PD-L1 inhibitor	Bladder cancer	2nd line	NCT01693562	1st of May 2017**
		NSCLC	Adjuvant	PACIFIC	16th of February 2018
		SCLC	1st line (in combination with etoposide and carbo/cisplatin)	CASPIAN	30th of March 2020

Notes: ^aRenal cell carcinoma. ^bColorectal cancer. ^cNon-small cell lung cancer. ^dSmall cell lung cancer. ^eHead and neck squamous cell carcinoma. ^fHepatocellular carcinoma. ^gPrimary mediastinal B-cell lymphoma. ^hTriple-negative breast cancer. *As per April 2021, the FDA voted against maintaining accelerated approval. **Withdrawn due to failure to meet post-marketing requirements. Adapted with permission from FDA approval timeline of active immunotherapies; 2021. Available from: https://www.cancerresearch.org/en-us/scientists/immuno-oncology-landscape/fda-approval-timeline-of-activeimmunotherapies.²⁰

Table 2 Status of Current and Emerging Biomarkers

Biomarker	Current Status	Tumor Type	Testing Landscape	Relevance	Drawback
PD-L1	Validated	Multiple tumors (melanoma, NSCLC, HNSCC, bladder cancer, RCC, TNBC)	IHC-oriented assessment of PD-L1 expression on tumor and immune cells^Citation26	PD-L1 positivity associated with improved patient outcome^Citation40,Citation41	Heterogeneity of PD-L1 expression and not interchangeable staining clones, defy for pathologists^Citation49^–^Citation52
MSI and dMMR	Validated^Citation57	Multiple tumors, CRC	IHC for MMR proteins (MLH1, MSH2, PMS2, MSH6) PCR testing for MSI^Citation26	Immunogenicity due to a high amount of neoantigens secondary to MSI phenotype or deficient MMR system	Scarce prevalence of dMMR in solid tumors - 4%^Citation61
TMB	Under research	Melanoma, bladder cancer, NSCLC, SCLC, HNSCC	WES (whole-exome sequencing) or targeted NGS (net generation sequencing)^Citation26	- High mutational load correlated with T-cell enhancement^Citation64 - Possibility of using blood TMB^Citation75	- Difficult access to WES - Lack of standardization of calculation and reporting TMB^Citation26 - Access to tumor tissue
TILS and TLS	Under research	CRC, melanoma, breast cancer	Hematoxylin-eosin IHC identification of T cells in tumor stroma and in the invasive margin^Citation26	Elevated CD8+ TILS density and TLS assure local immune response^Citation76	- No standardized assessment of TILS, no cut-off value^Citation78
Microbiome	Under research	Melanoma, NSCLC, renal and bladder cancer	- PCR from stool samples - Shotgun-sequencing gene count - Ribosomal RNA gene amplicon sequencing^Citation26	Immune activating bacteria of innate and adaptive system^Citation87^–^Citation89	Difficulty in accessing gene sequencing
Systemic inflammation	Under research	NSCLC, melanoma, clear cell renal cancer	Blood count and biochemistry	Offers insight into patient’s inflammation status, predicting poor outcome^Citation90,Citation91	Variety of biomarkers, need for standardization
DNA repair mutated enzymes	Under research	dMMR tumors	- Targeted NGS - Allele-specific PCR testing^Citation26	Predispose to an ultramutator phenotype capable of exerting a competent immune response^Citation96,Citation97	- Access to testing - Less common
Genomic signatures	Under research	Melanoma, breast cancer, NSCLC, Merkel cell carcinoma	RNA gene expression assessment from tumor microenvironment^Citation26	IFN-γ signaling pathway major component of T-cell response^Citation104	Preexisting immunity of host modulates ICI effectiveness^Citation106,Citation107

Figure 1 Host-related biomarkers. Created by https://www.Biorender.com.

FDA approval timeline of active immunotherapies; 2021. Available from: https://www.cancerresearch.org/en-us/scientists/immuno-oncology-landscape/fda-approval-timeline-of-active-immunotherapies. Accessed September 29, 2021.

 Google Scholar

Walk EE, Yohe SL, Beckman A, et al. The cancer immunotherapy biomarker testing landscape. Arch Pathol Lab Med. 2020;144(6):706–724. doi:10.5858/arpa.2018-0584-CP

 PubMed Web of Science ®Google Scholar

Herbst RS, Giaccone G, de Marinis F, et al. Atezolizumab for first-line treatment of PD-L1–selected patients with NSCLC. N Engl J Med. 2020;383(14):1328–1339. doi:10.1056/nejmoa1917346

 PubMed Web of Science ®Google Scholar

Sezer A, Kilickap S, Gümüş M, et al. Cemiplimab monotherapy for first-line treatment of advanced non-small-cell lung cancer with PD-L1 of at least 50%: a multicentre, open-label, global, phase 3, randomised, controlled trial. Lancet. 2021;397(10274):592–604. doi:10.1016/S0140-6736(21)00228-2

 PubMed Web of Science ®Google Scholar

Hirsch FR, McElhinny A, Stanforth D, et al. PD-L1 Immunohistochemistry assays for lung cancer: results from Phase 1 of the blueprint PD-L1 IHC assay comparison project. J Thorac Oncol. 2017;12(2):208–222. doi:10.1016/j.jtho.2016.11.2228

 PubMed Web of Science ®Google Scholar

Rimm DL, Han G, Taube JM, et al. A prospective, multi-institutional, pathologist-based assessment of 4 immunohistochemistry assays for PD-L1 expression in non-small cell lung cancer. JAMA Oncol. 2017;3(8):1051–1058. doi:10.1001/jamaoncol.2017.0013

 PubMed Web of Science ®Google Scholar

André T, Shiu -K-K, Kim TW, et al. Pembrolizumab in microsatellite-instability-high advanced colorectal cancer. N Engl J Med. 2020;383(23):2207–2218. doi:10.1056/NEJMoa2017699

 PubMed Web of Science ®Google Scholar

Bonneville R, Krook MA, Kautto EA, et al. Landscape of microsatellite instability across 39 cancer types. JCO Precis Oncol. 2017;2017. doi:10.1200/PO.17.00073

 PubMed Web of Science ®Google Scholar

Samstein RM, Lee C-H, Shoushtari AN, et al. Tumor mutational load predicts survival after immunotherapy across multiple cancer types. Nat Genet. 2019;51(2):202–206. doi:10.1038/s41588-018-0312-8

 PubMed Web of Science ®Google Scholar

Gandara DR, Paul SM, Kowanetz M, et al. Blood-based tumor mutational burden as a predictor of clinical benefit in non-small-cell lung cancer patients treated with atezolizumab. Nat Med. 2018;24(9):1441–1448. doi:10.1038/s41591-018-0134-3

 PubMed Web of Science ®Google Scholar

Paijens ST, Vledder A, de Bruyn M, Nijman HW. Tumor-infiltrating lymphocytes in the immunotherapy era. Cell Mol Immunol. 2021;18(4):842–859. doi:10.1038/s41423-020-00565-9

 PubMed Web of Science ®Google Scholar

Chen P-L, Roh W, Reuben A, et al. Analysis of immune signatures in longitudinal tumor samples yields insight into biomarkers of response and mechanisms of resistance to immune checkpoint blockade. Cancer Discov. 2016;6(8):827–837. doi:10.1158/2159-8290.CD-15-1545

 PubMed Web of Science ®Google Scholar

Routy B, Le Chatelier E, Derosa L, et al. Gut microbiome influences efficacy of PD-1-based immunotherapy against epithelial tumors. Science. 2018;359(6371):91–97. doi:10.1126/science.aan3706

 PubMed Web of Science ®Google Scholar

Gopalakrishnan V, Spencer CN, Nezi L, et al. Gut microbiome modulates response to anti-PD-1 immunotherapy in melanoma patients. Science. 2018;359(6371):97–103. doi:10.1126/science.aan4236

 PubMed Web of Science ®Google Scholar

Buder-Bakhaya K, Hassel JC. Biomarkers for clinical benefit of immune checkpoint inhibitor treatment-a review from the melanoma perspective and beyond. Front Immunol. 2018;9:1474. doi:10.3389/fimmu.2018.01474

 PubMed Web of Science ®Google Scholar

Mezquita L, Auclin E, Ferrara R, et al. Association of the lung immune prognostic index with immune checkpoint inhibitor outcomes in patients with advanced non-small cell lung cancer. JAMA Oncol. 2018;4(3):351–357. doi:10.1001/jamaoncol.2017.4771

 PubMed Web of Science ®Google Scholar

Heitzer E, Tomlinson I. Replicative DNA polymerase mutations in cancer. Curr Opin Genet Dev. 2014;24(100):107–113. doi:10.1016/j.gde.2013.12.005

 PubMedGoogle Scholar

Mertz TM, Baranovskiy AG, Wang J, Tahirov TH, Shcherbakova PV. Nucleotide selectivity defect and mutator phenotype conferred by a colon cancer-associated DNA polymerase δ mutation in human cells. Oncogene. 2017;36(31):4427–4433. doi:10.1038/onc.2017.22

 PubMed Web of Science ®Google Scholar

Ribas A, Robert C, Hodi FS, et al. Association of response to programmed death receptor 1 (PD-1) blockade with pembrolizumab (MK-3475) with an interferon-inflammatory immune gene signature. J Clin Oncol. 2015;33(15_suppl):3001. doi:10.1200/jco.2015.33.15_suppl.3001

 Web of Science ®Google Scholar

Miao D, Margolis CA, Vokes NI, et al. Genomic correlates of response to immune checkpoint blockade in microsatellite-stable solid tumors. Nat Genet. 2018;50(9):1271–1281. doi:10.1038/s41588-018-0200-2

 PubMed Web of Science ®Google Scholar

Wang S, Jia M, He Z, Liu X-S. APOBEC3B and APOBEC mutational signature as potential predictive markers for immunotherapy response in non-small cell lung cancer. Oncogene. 2018;37(29):3924–3936. doi:10.1038/s41388-018-0245-9

 PubMed Web of Science ®Google Scholar