Many of the patients we treated at Beilinson Hospital arrived at the clinic in wheelchairs, with cancer that has already spread, while showing signs of resistance to standard treatment protocols.

“There’s something else you might want to try,” Professor Peled would suggest: Keytruda – a drug that had only recently been approved by the FDA and included in the Israeli health care “basket.” This last resort for dying patients turned out to be magical; weeks after starting treatment, many patients recovered. Instead of wheelchairs, they entered

the clinic by foot, and their PET-CT imaging that, at the start of the treatment, had shown metastases, were now clear of any signs of the disease.

Furthermore, and more importantly, today, five years after having received the drug, those patients are still alive and are without any sign of cancer in their bodies. Oncological medications are approved for use, even if they only extend patients’ life spans by three months. When a treatment prolongs life by five or more years, even the most experienced oncologists, armed with centuries of pessimism, dare, for the first time in history, to use the word “cure” alongside “cancer.”

Barely a year after my experience in the clinic watching the success of immunotherapy, James P. Ellison and Tasuko Honjo were awarded the Nobel Prize in Medicine in 2018. The idea they brought forth to the medical world was nothing short of revolutionary: instead of medicine that acts upon the tumour itself, it utilizes the patient's own defence mechanisms– the immune system– to identify and destroy cancerous cells. Since immunotherapy first appeared on the scene, it has taken the oncology market by storm, leading to an influx of regulatory approvals that dramatically enhanced oncologists’ tool kits. In acknowledgement of the great impact of the immunotherapy revolution on patients' quality of life, many scientists, patient advocates and clinicians across the globe are joining together throughout the month of June to honour immunotherapy research under the theme of #immune2cancer.

Today, Keytruda is approved for treating twenty different types of cancer. The drug is responsible for $16 billion worth of revenue each year for the pharmaceutical company that manufactures it, Merck, making it the second-most profitable drug in the world.

Nevertheless, as with any medical revolution, immunotherapy started off on the sidelines. Initially, it was improved for compassionate use; only once all other treatment options had already been exhausted. It later became the first line of treatment for Stage 4 cancer patients. Now, it is making its way from the sidelines to mainstream oncology; Merck recently released the findings of its latest clinical study, proving that Keytruda is extremely effective in treating lung cancer patients, not only in Stage 4 cases but also during earlier stages of the disease (I-III), following surgery.

If half of the patients are put into remission following surgery, immunotherapy is likely to change the rules of the game and heal nearly all intended patients. Integrating immunotherapy into cancer treatment protocols at earlier stages of the disease will transform immunotherapy into the likes of oncological antibiotics: a highly efficient and safe medication that can be used to treat nearly any cancer patient, at any stage.

Although this exciting treatment could potentially reduce cancer-related mortality at a dramatic rate, it also presents the healthcare system with several complex challenges. One year’s worth of Keytruda costs approximately $200 thousand and providing the drug to millions of patients each year comes at an astronomical cost – to healthcare systems worldwide.

The solution would be to introduce the development of new, custom medical tools that would help determine who needs the treatment, and who does not. While genomic information can precisely predict how patients will respond to targeted therapies, the prediction of responses to immunotherapy remains a significant challenge that has yet to be fully resolved. The solution seemingly lies in the maturity and spatial organization of immune cells surrounding the tumour, rather than in the tumour’s genomic profile. At Nucleai, we’ve performed and presented several studies at the American Society of Clinical Oncology that demonstrate how the analysis of biopsies using image processing enables the identification of “immune signatures” that can precisely predict which patients will respond to immunotherapy, and which will not.

One way or another, Immunotherapy is positioned to replace chemotherapy as a basic and accepted cancer treatment, curing millions of patients around the world.

Written by Ori Zelichov MD, VP Clinical Development, Nucleai

Credit: Nucleai