Putting the Pieces Together: Completing the Mechanism of Action Jigsaw for Sipuleucel-T
2020
Sipuleucel-T is an autologous cellular immunotherapy that induces an immune response targeted against prostatic acid phosphatase (PAP) to treat asymptomatic or minimally symptomatic metastatic castration-resistant prostate cancer (mCRPC). In the phase III IMPACT study, sipuleucel-T was associated with a statistically significantly increased overall survival (OS) (median 4.1 months) versus placebo. Patients with baseline prostate-specific antigen levels in the lowest quartile (= 22.1 ng/mL) exhibited a 13-month improvement in OS with sipuleucel-T. Together, this led sipuleucel-T to be approved and recommended as first-line therapy in various guidelines for treatment of mCRPC. This review discusses the varied findings about the mechanisms of action of sipuleucel-T, bringing them together to form a more coherent picture. These pieces include inducing a statistically significant increase in antigen-presenting cell activation; inducing a peripheral immune response specific to the target/immunizing antigens PAP and/or PA2024; stimulating systemic cytotoxic T-lymphocyte activity; and mediating antigen spread (i.e. increased antibody responses to secondary proteins in addition to PAP and PA2024). Each of these pieces individually correlates with OS. Sipuleucel-T also traffics T cells to the prostate and is associated with long-term immune memory such that a second course of treatment induces an anamnestic immune response. Prostate cancer does not have a strongly inflamed microenvironment, thus has limited response to immune checkpoint inhibitors. Since sipuleucel-T is able to traffic T-cells to the tumor, it may be an ideal combination partner with immunotherapies including immune checkpoint inhibitors or with radiation therapy.
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