**8. References**

142 Cancer Prevention – From Mechanisms to Translational Benefits

to treat DCIS patients with lesions that overexpress HER-2. No other DC-based vaccines have been designed specifically to treat HER-2 expressing DCIS tumors. We anticipate a significant reduction in disease burden in our patients after a complete vaccine course. We hope that this vaccine will also be preventative in terms of both disease recurrence and rate

Our strategy of vaccine production utilizes both MHC I and II peptides as well as ex vivo activation with IFN-γ and LPS to yield polarized DC cells that induce a unique set of soluble factors including high levels of IL-12 and Th1 chemokines not elicited through traditional vaccines methods. This innovative DC vaccine strategy called Immune Conditioning by Activated Innate Transfer (ICAIT) uses monocyte-derived DCs that are activated with and a special clinical-grade TLR 4 ligand, LPS and IFN-γ (ICAIT-DC). This unique DC activation method gives the DCs qualities that are not found in the so-called "gold-standard" DCs used in prior vaccine trials. The "gold standard" DC vaccines, activated with TNF, IL-6, PGE2, IL-1β, have the potential to simulate aseptic inflammation [91]. In contrast, ICAIT-DCs produce high levels of factors that specifically enhance aspects of anti-tumor immunity such as NK cells which augment tumor rejection, and TNF and IL-12 which are antiangiogenic [55, 92]. ICAIT-DCs also have the distinct ability to influence the quality of sensitized T cells and can condition T cells for recognition of HER-2 expressing tumors. Lastly, ICAIT-DCs posses a killer function that enables them to lyse breast cancer cells.

Our DC vaccine is unique in its design against DCIS rather than invasive breast cancer. Our first neoadjuvant trial involved treating patients with HER-2 expressing DCIS tumors. The patients were treated with a course of four weekly intranodal injections of ICAIT-DCs that had been pulsed with HER-2 derived proteins. This approach yielded promising results that have positive implications for the treatment and prevention of high risk breast cancers. Specifically, 85% of ICAIT-treated patients developed immune responses to at least one of the HER-2 peptides. Eleven of the 22 patients with residual DCIS treated with the vaccine in our initial studies showed loss of HER-2 expression and tumor regression. The immunized patients developed a specific immune response against the HER-derived peptides and presented high levels of CD4+ and CD8+ T lymphocytes. These results have potential positive implications not only for prognosis but also in terms of breast-conserving surgery [55]. Five of the 27 patients had no evidence of remaining disease. The vaccination was most effective in patients with hormone-independent DCIS as 40% of ER negative HER-2 positive patients had no residual disease whereas only 5% of ER positive HER-2 positive had no residual disease. The vaccine appeared to alter the phenotype of the remaining DCIS in the patients that were found to have residual disease. The rate of change to a different postvaccination phenotype was significantly different between the ER positive and ER negative patients. 43.8% of the patients that were initially ER positive and HER-2 positive phenotype converted to ER positive and HER-2 negative phenotype. In comparison, 50% of the patients that initially had tumors that were ER negative and HER-2 positive changed to the ER negative and HER-2 negative phenotype. These results supported the safety and efficacy of the DC based HER-2 vaccine. The vaccine induced a decline or eradication of HER-2

There are a number of molecules that have been discovered to be present in breast carcinomas that have not yet been exploited to their fullest potential. The future directions

of transformation into invasive breast cancer.

expression (work not yet published).

**7. Future direction and prevention** 


Targeting Molecular Pathways

for Prevention of High Risk Breast Cancer: A Model for Cancer Prevention 145

[30] Shacter, E. and S.A. Weitzman, *Chronic inflammation and cancer.* Oncology (Williston

[31] Peek, R.M., Jr., S. Mohla, and R.N. DuBois, *Inflammation in the genesis and perpetuation of* 

[32] Tlsty, T.D. and L.M. Coussens, *Tumor stroma and regulation of cancer development.* Annu

[33] Zou, W., *Immunosuppressive networks in the tumour environment and their therapeutic* 

[34] Dunn, G.P., L.J. Old, and R.D. Schreiber, *The three Es of cancer immunoediting.* Annu Rev

[35] Dunn, G.P., et al., *Cancer immunoediting: from immunosurveillance to tumor escape.* Nat

[36] Koski, G.K., et al., *Reengineering dendritic cell-based anti-cancer vaccines.* Immunol Rev,

[37] Boon, T., et al., *Tumor antigens recognized by T lymphocytes.* Annu Rev Immunol, 1994.

[38] Mittendorf, E.A., G.E. Peoples, and S.E. Singletary, *Breast cancer vaccines: promise for the* 

[39] Disis, M.L., et al., *Existent T-cell and antibody immunity to HER-2/neu protein in patients* 

[40] Jerome, K.R., N. Domenech, and O.J. Finn, *Tumor-specific cytotoxic T cell clones from* 

[41] Menard, S., et al., *Lymphoid infiltration as a prognostic variable for early-onset breast* 

[42] Mahmoud, S.M., et al., *Tumor-Infiltrating CD8+ Lymphocytes Predict Clinical Outcome in* 

[43] Draube, A., et al., *Dendritic cell based tumor vaccination in prostate and renal cell cancer: a* 

[44] Disis, M.L., et al., *Effect of dose on immune response in patients vaccinated with an her-2/neu intracellular domain protein--based vaccine.* J Clin Oncol, 2004. 22(10): p. 1916-25. [45] Hakim, F.T., et al., *Constraints on CD4 recovery postchemotherapy in adults: thymic* 

[46] Mellios, T., H.L. Ko, and J. Beuth, *Impact of adjuvant chemo- and radiotherapy on the cellular immune system of breast cancer patients.* In Vivo. 24(2): p. 227-30. [47] Rotstein, S., et al., *Long term effects on the immune system following local radiation therapy* 

[48] Czerniecki, B.J., R.E. Roses, and G.K. Koski, *Development of vaccines for high-risk ductal* 

[49] Altintas, S., et al., *Prognostic significance of oncogenic markers in ductal carcinoma in situ of* 

*carcinoma in situ of the breast.* Cancer Res, 2007. 67(14): p. 6531-4.

*the breast: a clinicopathologic study.* Breast J, 2009. 15(2): p. 120-32.

*insufficiency and apoptotic decline of expanded peripheral CD4 cells.* Blood, 1997. 90(9):

*for breast cancer. I. Cellular composition of the peripheral blood lymphocyte population.* Int

*systematic review and meta-analysis.* PLoS One. 6(4): p. e18801.

*patients with breast and pancreatic adenocarcinoma recognize EBV-immortalized B cells transfected with polymorphic epithelial mucin complementary DNA.* J Immunol, 1993.

*cancer: summary and recommendations from a national cancer institute-sponsored* 

Park), 2002. 16(2): p. 217-26, 229; discussion 230-2.

*meeting.* Cancer Res, 2005. 65(19): p. 8583-6.

*relevance.* Nat Rev Cancer, 2005. 5(4): p. 263-74.

*future or pipe dream?* Cancer, 2007. 110(8): p. 1677-86.

*with breast cancer.* Cancer Res, 1994. 54(1): p. 16-20.

*carcinomas.* Clin Cancer Res, 1997. 3(5): p. 817-9.

*Breast Cancer.* J Clin Oncol. 29(15): p. 1949-55.

J Radiat Oncol Biol Phys, 1985. 11(5): p. 921-5.

Rev Pathol, 2006. 1: p. 119-50.

Immunol, 2004. 22: p. 329-60.

Immunol, 2002. 3(11): p. 991-8.

2008. 222: p. 256-76.

151(3): p. 1654-62.

p. 3789-98.

12: p. 337-65.


[8] Perou, C.M., et al., *Molecular portraits of human breast tumours.* Nature, 2000. 406(6797): p.

[9] Sotiriou, C. and L. Pusztai, *Gene-expression signatures in breast cancer.* N Engl J Med, 2009.

[10] Holmes, P., et al., *Prognostic markers and long-term outcomes in ductal carcinoma in situ of* 

[11] Roses, R.E., et al., *HER-2/neu overexpression as a predictor for the transition from in situ to invasive breast cancer.* Cancer Epidemiol Biomarkers Prev, 2009. 18(5): p. 1386-9. [12] Panet-Raymond, V., et al., *Clinicopathologic factors of the recurrent tumor predict outcome in patients with ipsilateral breast tumor recurrence.* Cancer. 117(10): p. 2035-43. [13] Kerlikowske, K., et al., *Biomarker expression and risk of subsequent tumors after initial ductal carcinoma in situ diagnosis.* J Natl Cancer Inst. 102(9): p. 627-37. [14] Carlson, R.W., et al., *Invasive breast cancer.* J Natl Compr Canc Netw. 9(2): p. 136-222. [15] Lee, S.C., et al., *Natural killer (NK):dendritic cell (DC) cross talk induced by therapeutic* 

*monoclonal antibody triggers tumor antigen-specific T cell immunity.* Immunol Res.

*overexpressing breast cancer: a systematic review.* Cancer Treat Rev, 2008. 34(6): p. 539-

*response: crosstalk between adaptive and innate immune cells during breast cancer* 

*regulates cancer development.* Cancer Immunol Immunother, 2005. 54(11): p. 1143-52.

[16] Madarnas, Y., et al., *Adjuvant/neoadjuvant trastuzumab therapy in women with HER-2/neu-*

[17] Haffty, B.G., et al., *Locoregional relapse and distant metastasis in conservatively managed triple negative early-stage breast cancer.* J Clin Oncol, 2006. 24(36): p. 5652-7. [18] Anderson, K.S., *Tumor vaccines for breast cancer.* Cancer Invest, 2009. 27(4): p. 361-8. [19] DeNardo, D.G. and L.M. Coussens, *Inflammation and breast cancer. Balancing immune* 

[20] de Visser, K.E. and L.M. Coussens, *The interplay between innate and adaptive immunity* 

[21] Coussens, L.M. and Z. Werb, *Inflammation and cancer.* Nature, 2002. 420(6917): p. 860-7. [22] Johansson, M., et al., *Immune cells as anti-cancer therapeutic targets and tools.* J Cell

[23] Disis, M.L. and K.H. Park, *Immunomodulation of breast cancer via tumor antigen specific* 

[24] Almand, B., et al., *Increased production of immature myeloid cells in cancer patients: a mechanism of immunosuppression in cancer.* J Immunol, 2001. 166(1): p. 678-89. [25] Serafini, P., et al., *Derangement of immune responses by myeloid suppressor cells.* Cancer

[26] Gabrilovich, D.I., et al., *Mechanism of immune dysfunction in cancer mediated by immature* 

[27] Yang, L., et al., *Expansion of myeloid immune suppressor Gr+CD11b+ cells in tumor-bearing host directly promotes tumor angiogenesis.* Cancer Cell, 2004. 6(4): p. 409-21. [28] Ernst, P.B. and B.D. Gold, *The disease spectrum of Helicobacter pylori: the* 

[29] Kuper, H., H.O. Adami, and D. Trichopoulos, *Infections as a major preventable cause of* 

*immunopathogenesis of gastroduodenal ulcer and gastric cancer.* Annu Rev Microbiol,

747-52.

360(8): p. 790-800.

50(2-3): p. 248-54.

57.

*the breast treated with excision alone.* Cancer.

*progression.* Breast Cancer Res, 2007. 9(4): p. 212.

*Th1.* Cancer Res Treat, 2009. 41(3): p. 117-21.

Immunol Immunother, 2004. 53(2): p. 64-72.

*Gr-1+ myeloid cells.* J Immunol, 2001. 166(9): p. 5398-406.

*human cancer.* J Intern Med, 2000. 248(3): p. 171-83.

Biochem, 2007. 101(4): p. 918-26.

2000. 54: p. 615-40.


Targeting Molecular Pathways

4228-36.

180(1): p. 83-93.

73.

12-7.

708.

Immunol. 186(3): p. 1325-31.

Immunol, 2000. 12(5): p. 583-8.

Engl J Med. 363(5): p. 411-22.

*cancer.* Cancer, 2009. 115(16): p. 3670-9.

Clin Oncol, 2006. 24(19): p. 3089-94.

*study.* Breast Cancer Res Treat. 119(3): p. 673-83.

J Clin Immunol, 1999. 19(1): p. 12-25.

for Prevention of High Risk Breast Cancer: A Model for Cancer Prevention 147

[70] Disis, M.L., et al., *High-titer HER-2/neu protein-specific antibody can be detected in patients* 

[71] Park, J.M., et al., *Early role of CD4+ Th1 cells and antibodies in HER-2 adenovirus vaccine* 

[72] Shumway, N.M., et al., *Therapeutic breast cancer vaccines: a new strategy for early-stage* 

[73] Soliman, H., *Developing an effective breast cancer vaccine.* Cancer Control. 17(3): p. 183-90. [74] Ladjemi, M.Z., et al., *Anti-HER2 vaccines: new prospects for breast cancer therapy.* Cancer

[75] Romani, N., et al., *Proliferating dendritic cell progenitors in human blood.* J Exp Med, 1994.

[76] Palucka, K., H. Ueno, and J. Banchereau, *Recent developments in cancer vaccines.* J

[77] Gulley, J.L. and C.G. Drake, *Immunotherapy for prostate cancer: recent advances, lessons learned, and areas for further research.* Clin Cancer Res. 17(12): p. 3884-91. [78] Dallal, R.M. and M.T. Lotze, *The dendritic cell and human cancer vaccines.* Curr Opin

[79] Palucka, K. and J. Banchereau, *Dendritic cells: a link between innate and adaptive immunity.*

[80] Palucka, K., et al., *Dendritic cells and immunity against cancer.* J Intern Med. 269(1): p. 64-

[81] Andrews, D.M., E. Maraskovsky, and M.J. Smyth, *Cancer vaccines for established cancer:* 

[82] Chambers, J.D. and P.J. Neumann, *Listening to Provenge--what a costly cancer treatment* 

[83] De Vries, I.J., et al., *Effective migration of antigen-pulsed dendritic cells to lymph nodes in* 

[84] Kantoff, P.W., et al., *Sipuleucel-T immunotherapy for castration-resistant prostate cancer.* N

[85] Higano, C.S., et al., *Integrated data from 2 randomized, double-blind, placebo-controlled,* 

[86] Small, E.J., et al., *Placebo-controlled phase III trial of immunologic therapy with sipuleucel-T* 

[87] Wiedermann, U., et al., *A virosomal formulated Her-2/neu multi-peptide vaccine induces* 

[88] Avigan, D., et al., *Fusion cell vaccination of patients with metastatic breast and renal cancer* 

[89] Park, J.W., et al., *Treatment with autologous antigen-presenting cells activated with the HER-*

*melanoma patients is determined by their maturation state.* Cancer Res, 2003. 63(1): p.

*phase 3 trials of active cellular immunotherapy with sipuleucel-T in advanced prostate* 

*(APC8015) in patients with metastatic, asymptomatic hormone refractory prostate cancer.* J

*Her-2/neu-specific immune responses in patients with metastatic breast cancer: a phase I* 

*induces immunological and clinical responses.* Clin Cancer Res, 2004. 10(14): p. 4699-

*2 based antigen Lapuleucel-T: results of a phase I study in immunologic and clinical activity in HER-2 overexpressing breast cancer.* J Clin Oncol, 2007. 25(24): p. 3680-7.

*how to make them better?* Immunol Rev, 2008. 222: p. 242-55.

*says about future Medicare policy.* N Engl J Med. 364(18): p. 1687-9.

*protection against autochthonous mammary carcinomas.* J Immunol, 2005. 174(7): p.

*with early-stage breast cancer.* J Clin Oncol, 1997. 15(11): p. 3363-7.

*disease.* BioDrugs, 2009. 23(5): p. 277-87.

Immunol Immunother. 59(9): p. 1295-312.


[50] Tamimi, R.M., et al., *Comparison of molecular phenotypes of ductal carcinoma in situ and* 

[51] Zafrani, B., et al., *Mammographically-detected ductal in situ carcinoma of the breast analyzed* 

[52] Evans, A.J., et al., *Correlations between the mammographic features of ductal carcinoma in* 

[53] Clark, S.E., et al., *Molecular subtyping of DCIS: heterogeneity of breast cancer reflected in* 

[54] Dawson, S.J., et al., *BCL2 in breast cancer: a favourable prognostic marker across molecular subtypes and independent of adjuvant therapy received.* Br J Cancer. 103(5): p. 668-75. [55] Czerniecki, B.J., et al., *Targeting HER-2/neu in early breast cancer development using* 

[56] Otto, K., et al., *Lack of toxicity of therapy-induced T cell responses against the universal* 

[57] Morse, M.A., et al., *Immunotherapy with autologous, human dendritic cells transfected with* 

[58] Brossart, P., et al., *Induction of cytotoxic T-lymphocyte responses in vivo after vaccinations* 

[59] Hynes, N.E. and G. MacDonald, *ErbB receptors and signaling pathways in cancer.* Curr

[60] Lee, M.K.t., A. Sharma, and B.J. Czerniecki, *It's all in for the HER family in tumorigenesis.*

[61] Mendelsohn, J. and J. Baselga, *Epidermal growth factor receptor targeting in cancer.* Semin

[62] Harding, J. and B. Burtness, *Cetuximab: an epidermal growth factor receptor chemeric human-murine monoclonal antibody.* Drugs Today (Barc), 2005. 41(2): p. 107-27. [63] Tanner, B., et al., *ErbB-3 predicts survival in ovarian cancer.* J Clin Oncol, 2006. 24(26): p.

[64] Engelman, J.A., et al., *ErbB-3 mediates phosphoinositide 3-kinase activity in gefitinib-*

[65] Slamon, D.J., et al., *Studies of the HER-2/neu proto-oncogene in human breast and ovarian* 

[66] Williams, T.M., et al., *Expression of c-erbB-2 in human pancreatic adenocarcinomas.*

[67] Holbro, T., G. Civenni, and N.E. Hynes, *The ErbB receptors and their role in cancer* 

[68] Ibrahim, S.O., et al., *Expression of c-erbB proto-oncogene family members in squamous cell carcinoma of the head and neck.* Anticancer Res, 1997. 17(6D): p. 4539-46. [69] Ross, J.S. and J.A. Fletcher, *The HER-2/neu Oncogene in Breast Cancer: Prognostic Factor, Predictive Factor, and Target for Therapy.* Oncologist, 1998. 3(4): p. 237-252.

*sensitive non-small cell lung cancer cell lines.* Proc Natl Acad Sci U S A, 2005. 102(10):

*carcinoembryonic antigen mRNA.* Cancer Invest, 2003. 21(3): p. 341-9.

*with peptide-pulsed dendritic cells.* Blood, 2000. 96(9): p. 3102-8.

*with a new classification. A study of 127 cases: correlation with estrogen and progesterone receptors, p53 and c-erbB-2 proteins, and proliferative activity.* Semin Diagn Pathol,

*situ (DCIS) and C-erbB-2 oncogene expression. Nottingham Breast Team.* Clin Radiol,

*dendritic cells with staged interleukin-12 burst secretion.* Cancer Res, 2007. 67(4): p.

*invasive breast cancer.* Breast Cancer Res, 2008. 10(4): p. R67.

*pre-invasive disease.* Br J Cancer. 104(1): p. 120-7.

*tumour antigen survivin.* Vaccine, 2005. 23(7): p. 884-9.

Opin Cell Biol, 2009. 21(2): p. 177-84.

Expert Rev Vaccines. 9(1): p. 29-34.

*cancer.* Science, 1989. 244(4905): p. 707-12.

*progression.* Exp Cell Res, 2003. 284(1): p. 99-110.

Pathobiology, 1991. 59(1): p. 46-52.

Oncol, 2006. 33(4): p. 369-85.

1994. 11(3): p. 208-14.

1994. 49(8): p. 559-62.

1842-52.

4317-23.

p. 3788-93.


**Section 2** 

**Dietary and Lifestyle Patterns** 

**in Cancer Prevention** 

