Antibody Therapeutics in Cancer

Mark X. Sliwkowski and Ira Mellman

Science 341, 1192 (2013);
DOI: 10.1126/science.1241145

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Antibodies
REVIEW

Antibody Therapeutics in Cancer

Mark X. Sliwkowski and Ira Mellman
In a relatively short period of time, monoclonal antibodies have entered the mainstream of cancer
therapy. Their first use was as antagonists of oncogenic receptor tyrosine kinases, but today
monoclonal antibodies have emerged as long-sought vehicles for the targeted delivery of potent
chemotherapeutic agents and as powerful tools to manipulate anticancer immune responses.
With ever more promising results from the clinic, the future will likely see continued growth in the
discovery and development of therapeutic antibodies and their derivatives.

ince the discovery in 1948 that cytotoxic

folate antimetabolites could be used in the
treatment of childhood leukemia, our basic
approach to cancer therapy has remained fundamentally the same: surgery followed by sublethal
administration of various cytotoxic compounds
or radiation. However, over the past 16 years the
situation has started to change substantially with
the advent of targeted cancer therapies: the use
of drugs developed to inhibit oncogenic proteins
or survival factors selectively expressed by tumors. Although targeted agents are often thought
of as low molecular weight inhibitors that can be
given orally and gain access to cytoplasmic targets by diffusion across the plasma membrane,
the first and perhaps most effective targeted therapies involve the use of biotherapeutics, recombinant proteins (usually antibodies) that modulate
targets expressed at the cancer cell surface. This is
quite remarkable because, not so long before the
introduction of the first effective therapeutic antibodies in cancer (the CD20 antibody rituximab
and the HER2 antagonist trastuzumab), there were
severe doubts that antibodies could ever be safely
used in humans. One major impediment was that
monoclonal antibodies were typically produced
in mice and therefore would be expected to be
immunogenic in humans. The discovery that one
could humanize murine antibodies by grafting
complementarity-determining regions (CDRs)
from the desired mouse antibody onto a recombinant human immunoglobulin backbone changed
everything (1, 2).
Today, a variety of sophisticated strategies
exist to engineer humanized antibodies and to
produce human antibodies by using rodents partially reconstituted with human immunoglobulin
genes, human immune cells, or combinatorial
phage or yeast display libraries that can yield
high-affinity antibodies without requiring animal
immunization at all (3). These approaches have
led to an explosion of therapeutic antibodies both
in cancer and in other diseases (4). Thus far, the only
Food and Drug Administration (FDA)/European
Genentech, Incorporated, 1 DNA Way, South San Francisco, CA
94080, USA. E-mail: mellman.ira@gene.com (I.M.); marks@
gene.com (M.X.S.)

1192

Medicines Agencyapproved agents for oncology

are conventional immunoglobulin G (IgG) molecules or their conjugates (Fig. 1), but engineered
antibodies and novel antibody-like variants are increasingly making their way into clinical trials.
In this review we will discuss the general
classes of antibody therapeutics that are commonly in use, provide a detailed analysis of two
specific examples of oncogene-targeted antibody
drugs, and consider some of the most promising
new strategies, namely the use of antibodies for
targeted delivery of conventional chemotherapeutics and to enlist the power of the immune
system.
Classes of Antibody Therapeutics in Cancer
There are currently 13 antibodies approved by the
FDA for various oncology indications (Table 1),
and many more are currently being evaluated in
clinical trials. Antibodies for the treatment of hematologic cancers, such as non-Hodgkins lymphoma
or chronic lymphocytic leukemia, and antibodies
to B cellassociated targets (CD20, CD52) act, at
least in part, because of their ability to induce
apoptosis after binding to B cell tumors (5). The
first of the approved antibodies directed against
targets expressed on solid tumors were selected
in cell culture as antagonists of the oncogenic receptor tyrosine kinases epidermal growth factor
receptor (EGFR) and HER2 (6).
One antibody, bevacizumab, binds and sequesters vascular endothelial growth factorA
(VEGF-A), a key factor that is required for the
growth of blood vessels and exerts its antitumor
effect by functionally altering or slowing the formation of the tumor vasculature (7). Although this
is at present the only approved antibody in oncology that targets a secreted protein, this class
of therapeutic is common in the case of chronic
inflammatory diseases, where multiple approved
agents target proinflammatory cytokines such as
tumor necrosis factora (4).
Two antibodies are now approved that are covalently modified with cytotoxic microtubule antagonists. These antibody-drug conjugates (ADCs),
one of which is a modified version of trastuzumab
for HER2-positive breast cancer patients (8), enable a form of targeted chemotherapy. These recent

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successes have led to a plethora of ADCs in clinical development (see below).

Last, the recent approval of ipilimumab has
introduced yet another therapeutic strategy for
anticancer antibodies, namely active immunotherapy (9). Ipilimumab blocks the activity of the
negative regulator of T lymphocytes, CTLA4,
resulting in the activation of a patients immune
response to cancer. This exciting approach has
already demonstrated long-term, durable benefit.
Most of the approved antibodies in oncology
are of the human IgG1 subclass, the subclass that
is the most effective at engaging Fcg receptors
(FcgRs) on natural killer (NK) cells, macrophages,
and neutrophils (Table 1). Antibody engagement
of these receptors leads to the killing of antibodybound target cells by antibody-dependent cellular cytotoxicity (ADCC) or antibody-dependent
phagocytosis (ADP) (1012). This is an important
consideration given that ADCC or ADP likely contributes to the efficacy of these antibodies, above
and beyond any direct effect on modulating signal transduction. FcgR-mediated cross-linking of
surface-bound antibodies may be important in some
settings, for example, to induce apoptosis (13).
The next generation of antibody therapeutics
will likely extend beyond the IgG1 isotype and/or
include modifications to the Fc domain, the region that binds to FcRs. Where it may be beneficial to reduce ADCC, the IgG4 subclass has been
used, although here the hinge region of the antibody must be engineered to prevent premature
dissociation and reassembly of heavy chainlight
chain half molecules with endogenous IgG4s in
the plasma (14). Complete elimination of ADCC
can be achieved by modifying specific residues in
the Fc domain that bind to FcgR or by producing
recombinant antibodies that lack the N-glycosylation
of heavy-chain Fc regions, required for recognition
by FcgRs (15). Conversely, alterations in glycosylation have been identified that enhance FcgR
binding (effector domainenhanced antibodies),
thereby increasing the potential for ADCC or FcgR
cross-linkingdependent signaling. Still other Fc
domain mutations are being tested that either enhance or reduce binding the neonatal FcR for IgG
(FcRn), the receptor responsible for returning IgGs
to the circulation after their internalization by endothelial cells. Thus, enhanced FcRn binding will serve
to increase the half-life of injected antibodies,
whereas reduced FcRn binding will decrease halflife (16). These may prove to be important considerations in controlling the pharmacokinetic
exposure levels of a given antibody, with a potential
toxicity possibly mitigated by faster clearance.
New formats are also being developed, such
as two types of bispecific antibodies. In the first,
single heavy chainlight chain pairs derived from
antibodies with distinct specificities can be covalently or noncovalently linked to yield a single
IgG molecule bearing arms targeted to two different
antigens. To overcome the issue of monovalent
binding that comes with this approach, phage

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HER2 Therapeutics
Three mAbs (trastuzumab, pertuzumab, and adotrastuzumab emtansine) and a small-molecule
TKI (lapatinib) are approved for the treatment of
HER2-positive breast cancer (Table 1), yet interpretation of the clinical data is less complex than
that observed with EGFR antagonists. Lapatinib,
a low molecular weight HER2 and EGFR TKI,
effectively blocks HER2 signaling and was approved on the basis of compelling clinical data
generated in patients whose tumors had progressed
on trastuzumab-based therapy (26). Thus, HER2
tyrosine kinase antagonism alone is an effective
treatment for this form of breast cancer. Indeed,
trastuzumab and pertuzumab, antibodies against
HER2, were selected for their ability to block proliferation (27) and signaling activity (28). Although
these antibodies were also humanized to IgG1,
suggesting that ADCC might add to their clinical
activity, human FcgR polymorphisms that enhance
binding are not linked to improved responses in
patients (29). Yet the relative importance of ADCC
remains an active area of debate.
In contrast to EGFR antagonists, HER2directed antibodies and small molecules are very
effective in the treatment of HER2-positive breast
cancer in combination with conventional chemotherapy. Because of favorable tolerability profiles,
HER2 targeting can also be combined with standard cytotoxic chemotherapy. Indeed, pertuzumab
EGFR Therapeutics
is approved only in combination with trastuzumab
and docetaxel (30). As is often the case in cancer
The EGFR family (ErbB/HER) has proved to be
therapy, the ability to combine multiple drugs
a fruitful area for the development of cancer
produces better clinical outcomes; combinations
therapeutics. To date, eight agents are approved
are enabled by better safety profiles.
for the treatment of various solid tumors, and at
Because trastuzumab and pertuzumab bind to
least a dozen other compounds are currently in
different regions of HER2 (Fig. 2), dual antibody
clinical development.
therapy should allow for simultaEGFR therapeutics are divided
neous antagonism of both activated
into two classes, both of which informs of HER2. Support for this
hibit EGFR: monoclonal antibodies
Antigen
hypothesis was initially obtained in
(mAbs), cetuximab and panitumumab,
binding
Light chain
a phase II clinical trial that tested
and low molecular weight tyrosine
combination antibody therapy in pakinase inhibitors (TKIs), gefitinib and
tients whose tumors progressed on
erlotinib. mAbs directed against EGFR
trastuzumab and cytotoxic chemowere first developed in advanced cotherapy. The findings in this trial demlorectal cancer. The pivotal trial for
onstrated an objective response (tumor
cetuximab demonstrated tumor shrinkshrinkage) of 25% and a clinical benage when used in combination with the
efit rate of 50% (31). A neoadjuvant
Heavy chain
topoisomerase I inhibitor irinotecan in
Fab' region
(i.e., treatment before surgery) trial
patients whose tumors were progressfurther confirmed that the antibody
ing on irinotecan-based therapy (20).
combination was also effective in paDiscernable single-agent cetuximab actients who were nave to therapy (32).
tivity was also observed. The murine
Equipped with the knowledge that
parent mAb, 225, was reengineered
dual HER2 antibody blockade was
as a human chimera, which allows for
active in early breast cancer and lateADCC. In contrast, panitumumab was
stage metastatic breast cancer, a pivderived from a transgenic mouse caotal trial validated the approach for
pable of producing human antibodies
the treatment of first-line metastatic
and exhibits considerably higher bindbreast cancer patients and led to the
ing affinity for EGFR than cetuximab.
accelerated, full approval of pertuzumab
Panitumumab is a human IgG2, which
is less effective in mediating ADCC Fig. 1. Space-filling model of IgG1. Light chain, magenta; heavy chain, dark in June 2012 (30). Indeed the magnitude of patient benefit, as measured
than IgG1 (21). Both antibodies are blue; carbohydrate, yellow. [Credit: C. Eigenbrot, Genentech, Incorporated]
restricted to use in patients whose tumors overexpress EGFR and are wild type for the protooncogene KRAS but have not yet been compared
directly, making it impossible to judge the contribution of ADCC.
Although both EGFR mAbs and smallmolecule inhibitors have been commercially available for more than a decade, there is remarkably
little overlap in how the two classes of antagonists
are used clinically. Combining mAbs and small
molecules is ineffective, despite preclinical data
suggesting increased efficacy (22). Similarly, antagonism of EGFR was originally predicted to
synergize with cytotoxic chemotherapy. Combination therapy of irinotecan with cetuximab was
key to cetuximab FDA approval. Yet erlotinib or
gefitinib failed to show clinical benefit in combination with several chemotherapies (23, 24).
Indeed, there is a suggestion that patient outcome
may be worse when treated with the combination
(25). Many factors contribute when preclinical
observations fail to predict clinical responses,
including differences in pharmacokinetics and,
most importantly, differences in tolerability. Although both mAb and chemical inhibitors of
EGFR cause skin rash, erlotinib and gefitinib
cause additional toxicities that further limit tolerability when combined with conventional chemotherapies. Of interest in this regard is the recent
clinical demonstration (and FDA approval) that
erlotinib is more effective against tumors expressing an activated mutant allele of EGFR (24).
Although both wild-type and mutant kinases are
inhibited, selectivity for the mutant kinase might
be expected to increase therapeutic index by
sparing, relatively, the activity of the wild-type
kinase in normal cells and tissues.

Fc region

display has been used to make single CDRs that

exhibit dual specificities. Such dual-action Fabs
are otherwise normal antibodies that retain high
affinity and bivalent affinity for two antigens
simultaneously. One such antibody (MEHD7945A)
that detects EGFR and the HER3 co-receptor
simultaneously is currently in phase II clinical
trials (17). In other cases, one-armed antibodies
(i.e., an intact IgG missing one Fab domain,
onartuzumab) have been deployed where it was
desirable to avoid the cross-linking of a potentially activating receptor (c-Met) (18).
Even less traditional formats are being evaluated, involving attenuated single-chain antibodies
that have either single or dual specificities (19).
These antibodies have the limitation that smaller
antibody constructs have shorter in vivo halflives after injection, which necessitates frequent
or continuous injections. Larger, multiple-armed
antibodies or antibodies genetically fused to
other mediators (e.g., cytokines, hormones, and
toxins) as well as a variety of synthetic minibodies and antibody mimetics are also on the
horizon and, if successful, could increase the potential range of therapeutic strategies. However,
one caution is that the farther one strays from
the conventional, the greater the chances are for
unanticipated behavior, adverse effects, or inherent immunogenicity.

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Antibodies
Table 1. Antibody therapies and their indications.
Antibody type

Target

Tumor types

Dx test

Cetuximab (Erbitux; Bristol-Myers Squibb):

chimeric human-murine IgG1

EGFR

Colon, head, and neck

Yes

Panitumumab (Vectibix; Amgen):

human IgG1

EGFR

Colon

Yes

Trastuzumab (Herceptin; Genentech):

humanized IgG1

HER2

Breast, gastric

Yes

Pertuzumab (Perjeta; Genentech):

humanized IgG1

HER2

Breast

Yes

Ado-trastuzumab emtansine (Kadcyla, Genentech): HER2

trastuzumab, derivative of DM1, 4-(Nmaleimidomethyl)cyclohexane-1-carboxylate linker
Bevacizumab (Avastin; Genentech/Roche):
VEGF
humanized IgG1

Breast

Yes

Colon, nonsmall
cell lung, glioblastoma, kidney

Continued on next page

1194

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No

Indication
Indicated for the treatment of KRAS wild-type,
EGFR-expressing, metastatic colorectal cancer
(mCRC) in combination with FOLFIRI [irinotecan,
5-fluorouracil (5-FU) leucovorin] for first-line
treatment, in combination with irinotecan in
patients who are refractory to irinotecan-based
chemotherapy, as a single agent in patients who
have failed oxaliplatin- and irinotecan-based
chemotherapy or who are intolerant to irinotecan.
In combination with radiation therapy for the
initial treatment of locally or regionally advanced
squamous cell carcinoma of the head and
neck and in combination with platinum-based
therapy with 5-FU for the first-line treatment of
patients with recurrent locoregional disease or
metastatic squamous cell carcinoma of the head
and neck. As a single agent, is indicated for the
treatment of patients with recurrent or metastatic
squamous cell carcinoma of the head and neck for
whom prior platinum-based therapy has failed.
Indicated for the treatment of EGFR-expressing and
KRAS wild-type mCRC with disease progression
after fluoropyrimidine-, oxaliplatin-, and
irinotecan-containing regimens.
Indicated for adjuvant treatment of HER2overexpressing node-positive or node-negative
breast cancer. As part of a treatment regimen
containing doxorubicin, cyclophosphamide, and
either paclitaxel or docetaxel. Also with
docetaxel and carboplatin. As a single agent
after multimodality anthracycline-based
therapy. For metastatic breast cancer in
combination with paclitaxel for the first-line
treatment of HER2-overexpressing metastatic
breast cancer. As a single agent for treatment of
HER2-overexpressing breast cancer in patients
who have received one or more chemotherapy
regimens for metastatic disease. In combination
with cisplatin and capecitabine or 5-FU, for
the treatment of patients with HER2-overexpressing
metastatic gastric or gastroesophageal junction
adenocarcinoma, who have not received prior
treatment for metastatic disease.
In combination with trastuzumab and docetaxel for the
treatment of patients with HER2-positive metastatic
breast cancer who have not received prior anti-HER2
therapy or chemotherapy for metastatic disease.
Treatment of patients with HER2-positive metastatic
breast cancer who have received prior treatment
with Herceptin and a taxane chemotherapy.
mCRC for first- or second-line treatment in combination
with intravenous 5-FUbased chemotherapy. It is
also approved to treat mCRC for second-line
treatment when used with fluoropyrimidine-based
(combined with irinotecan or oxaliplatin)
chemotherapy after cancer progresses following
a first-line treatment that includes Avastin. Advanced
nonsquamous nonsmall cell lung cancer in
combination with carboplatin and paclitaxel in people
who have not received chemotherapy for their advanced
disease. Metastatic kidney cancer when used with IFN-a.
Glioblastoma when taken alone in adult patients whose
cancer has progressed after prior treatment.

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SPECIALSECTION
Antibody type

Target

Tumor types

Dx test

Ipilimumab (Yervoy; Bristol-Myers Squibb): IgG1

CTLA4

Melanoma

Yes

Rituximab (Rituxan/Mabthera; Roche):

chimeric human-murine IgG1

CD20 NHL, chronic lymphocytic leukemia

No

Ofatumubab (Arzerra; Genmab): human IgG1

CD20

Chronic lymphocytic leukemia

No

90

Y-labeled ibritumomab tiuxetan

(Zevalin; IDEC Pharmaceuticals):
murine IgG1, linker-chelator: tiuxetan
(N-(2-Bis(carboxymethyl)amino)3(Pisothio-cyanatophenyl)~propyl)N-(2-Bis(car-boxymethyl)-amino)2-(Methyl)ethyl)glycine
131
I-labeled tositumomab (Bexxar; GlaxoSmithKline):
murine IgG2, direct covalent linkage to
tositumomab

CD20

Low-grade or follicular B cell NHL

Yes

CD20

Low-grade or follicular B cell NHL

Yes

Alemtuzumab (Campath; Genzyme):

humanized IgG1
Brentuximab vedotin (Adcetris;
Seattle Genetics): chimeric IgG1, MMAE,
maleimidocaproyl valine-citrulline-PAB linker

CD52

Chronic lymphocytic leukemia

No

CD30

Hodgkins lymphoma

No

Acute myelogenous leukemia

Yes

Gemtuzumab ozogamicin (Mylotarg; Wyeth):

CD33
humanized IgG2), N-acetyl gamma-calichaemicin
dimethyl hydrazide, AcBut hydrazone linker

by progression-free survival (3.9 versus 6.1 months)

(33) and overall survival (34), is greater than what
was observed for the initial approval of trastuzumab.
In summary, the advent of mAbs to oncogenic receptor tyrosine kinases of the EGFR
family has represented a major advance in cancer therapy. Yet, there have also been attempts
that have not yet led to success in the clinic,
using mAbs to target other signaling receptors.
Notable among these are antibodies to insulinlike growth factor 1 receptor, despite this receptor having a mechanistic link to many types of
cancer. On the other hand, antibodies to c-Met

continue in clinical development. The number

of mAbs tested in clinical trials is small, which
makes it difficult to draw any clear lessons yet.
However, it should be noted that effective antibodies against solid tumors tend to recognize
targets that are either subject to mutation (EGFR,
c-Met) or overexpression (HER2) in cancer, even
if the antibody itself is inactive against the mutant
allele. Conceivably, mAb therapy against signaling receptors may prove most effective in cases
where targets can be shown genetically to be
important drivers of cancer or clear drivers of
resistance to other forms of therapy.

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Indication
Treatment of unresectable or metastatic melanoma
in patients who have failed or do not tolerate
other systemic therapy for advanced disease.
As a single agent, in patients with relapsed or
refractory, low-grade or follicular, CD20-positive,
B cell non-Hodgkins lymphoma (NHL). Previously
untreated follicular, CD20-positive, B cell NHL in
combination with first-line chemotherapy and in
patients achieving a complete or partial response
to Rituxan in combination with chemotherapy, as
single-agent maintenance therapy. Nonprogressing
(including stable disease), low-grade, CD20-positive,
B cell NHL as a single agent after first-line CVP
chemotherapy. Previously untreated diffuse large
B cell, CD20-positive NHL in combination with
CHOP or other anthracycline-based chemotherapy
regimens. Previously untreated and previously
treated CD20-positive chronic lymphocytic leukemia
in combination with fludarabine and cyclophosphamide.
As a single agent for the treatment of patients with
chronic lymphocytic leukemia refractory to fludarabine
and alemtuzumab.
Treatment of B cell NHL (relapsed or refractory, low
grade, follicular, transformed, or rituximabrefractory). Patients with previously untreated
follicular NHL who achieve a partial or complete
response to first-line chemotherapy.
Treatment of patients with CD20-positive relapsed
or refractory, low-grade, follicular or transformed
NHL who progressed during or after rituximab
therapy, including patients with rituximabrefractory NHL.
As a single agent for the treatment of B cell chronic
lymphocytic leukemia
For the treatment of patients with Hodgkin
lymphoma after failure or autologous stem cell
transplant (ASCT) or after failure of at least two
prior multiagent chemotherapy regimens in
patients who are not ASCT candidates. The
treatment of patients with systemic anaplastic
large cell lymphoma after failure of at least one
prior multiagent chemotherapy regimen
Withdrawn from the market in June 2010.
Previously indicated for the treatment of
patients with CD33-positive acute myeloid
leukemia in first relapse who are 60 years of age
or older and who are not considered candidates
for other cytotoxic chemotherapy.

Antibody-Drug Conjugates (ADCs)

The concept that antitumor antibodies could be
used as vehicles for the selective delivery of cytotoxic agents to tumors has been around nearly
as long as mAbs. However, until very recently,
the idea has eluded successful implementation,
probably for three reasons: (i) the use of antibodies against targets that were not sufficiently
restricted to tumor cells, (ii) the use of drugs with
insufficient potency or (in the case of bacterial or
plant toxins) that were immunogenic, and (iii) the
linker chemistry used to attach drugs to antibodies
was not optimized. The latter consideration is

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Antibodies
one that required an enormous empirical effort
to solve. A linker that was too labile allowed too
much of the toxic drug to dissociate from the
antibody in the blood. This then exposed normal
tissues to the freed drug and, as a result, reduced
the doses of the ADC that could be used. Stable
linkers require complete proteolytic digestion of
the ADC, releasing the derivatized amino acid,
linker, and cytotoxic drug as the active metabolite
(35). Similarly, the choice of drug required a great
deal of trial and effort, with current successes being
seen by using microtubule antagonists.
Gemtuzumab ozogamicin was the first ADC
to reach the market in 2000. It is directed against
CD33, a surface glycoprotein characteristic of acute
myeloid leukemia (36). The conjugate is composed
of a humanized IgG4, a pH labile linker, and
calicheamicin, a very potent DNA minor groove
binder. Unfortunately, the drug was withdrawn
from the market in 2010 because of the failure of
subsequent confirmatory studies to reproduce the
initial clinical benefit profile (37, 38).
More recently, brentuximab vedotin, a mAb
against CD30 that was covalently modified with
the microtubule antagonist monomethyl auristatin
E (MMAE), was approved for use in advanced
Hodgkins lymphoma given its efficacy and good
safety profile (39). The linker used to tether MMAE
to the antibody contains a peptidic moiety that was
designed as a substrate for cathepsin B; the antibody was delivered to cathepsin Bcontaining endosomes and lysosomes after internalization by the
CD30-positive lymphoma cells (40).
Another ADC that has also recently gained approval is T-DM1, which is composed of trastuzumab
(T) conjugated to a maytansine derivative (DM1)
(41). In this instance, the linker is designed not to
be cleaved by lysosomal proteases, suggesting that
the drug is released only after limited digestion of
the entire antibody. T-DM1 was found to prolong
progression-free survival (9.6 versus 6.4 months)
and overall survival (30.9 versus 25.1 months) in
late-stage HER2-positive breast cancer patients who
progressed on multiple other treatments (42).
The clinical successes of T-DM1 and brentuximab
vedotin have stimulated a great deal of activity in
developing ADCs to different solid and hematologic
tumor targets using mAbs to a variety of antigens,
most often conjugated to microtubule antagonists
(MMAE and DM1 or their derivatives). In addition,
new toxic payloads and linkers are under development in an effort to further increase therapeutic
index and provide for combination therapy.
Novel engineered antibody platforms are also
being investigated. For example, the typical cleavable MMAE linker drug (vc-MMAE) is coupled to
antibodies after the reduction and then the derivatization of endogenous cysteine residues normally
engaged in interchain disulfide bonds. Methods are
being developed to engineer specific conjugation
sites (e.g., unpaired cysteine residues) and defined
sites on the heavy or light chains, leading to greater
ease of conjugation and control over the number of

1196

drug molecules per antibody molecule (43). Other

modifications are also being investigated in an
effort to increase specificity of cancer cell binding
(e.g., use of bispecific antibodies that recognize
two antigens at once) or decrease the nonspecific
uptake of the ADCs by normal cells that do not
express the targets. Use of antibody-conjugated
nanocarriers loaded with cytotoxic agents is also
under investigation. Although this would increase
the payload delivered after endocytosis, a potential limitation is the nonspecific loss of the cytotoxic in the plasma. We anticipate that the next
several years will witness explosive growth and
innovation in this area.
Antibodies and Cancer Immunotherapy
As was true for ADCs, the concept that a patients
immune system could be activated to generate
anticancer responses has been actively explored
for >30 years. For most of this time, however,
little progress was made in the clinical arena, largely
because of our incomplete knowledge concerning
the functional organization of the immune sys-

tem and how tumors manipulate the immune

response. Moreover, much of the field was long
fascinated by anticancer vaccines, an approach
limited by the immunosuppressive tumor microenvironments (44). Many cancer patients make
anticancer T cell responses because tumors nearly
always express mutant proteins or antigens to
which the immune system is not tolerized and
therefore are immunogenic. Yet these responses
rarely manifest in clinical benefit.
An appreciation has now emerged that overcoming immunosuppression and enhancing the
quality of the immune response may be key to
developing effective cancer immunotherapies (3).
This realization has generated enormous interest
and excitement fueled by the early clinical successes of two classes of mAbs. The first of these
is ipilimumab, which inhibits CTLA4, a negative regulator expressed on the surface of all T
cells (Fig. 3A) (45). CTLA4 normally binds to
CD80/CD86 on the surface of antigen-presenting
cells, providing a powerful brake or checkpoint
that limits the activation and proliferation of

B
um

tuz

s
Tra

HER2

Pertuzumab

ab
HER3

HER2

Ligand
HER3

Kin

Kin
P

Cetuximab
Panitumumab

D
M1

T-D

HER2

EGFR

**

HER3

Kin
P

Fig. 2. Epitope binding of HER2 and EGFR therapeutic antibodies. (A) Trastuzumab. (B) Pertuzumab.
(C) Cetuximab or panitumumab. (D) T-DM1 (ado-trastuzumab emtansine). In the case of HER2 signaling, a
functional and physical association with a second related receptor, HER3, is often important (60). HER2 kinase
phosphorylates the HER3 cytoplasmic domain, activating it as a scaffold to promote the phosphatidylinositol
3-phosphate kinase cascade. Conversely, activation of HER3 by binding ligands such as heregulin can allosterically activate HER2 kinase. Pertuzumabs likely mechanism of action is to block heterodimerization of HER2
and HER3. Asterisks indicate a cytotoxic agent, derivative of maytansine 1 (DM1).

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SPECIALSECTION
T cells after recognizing their cognate antigen.
Ipilimumab blocks this interaction, thereby releasing the checkpoint and amplifying T cell responses. CTLA4 blockade also induces the death
of regulatory T cells, which contribute to the immunosuppressive tumor microenvironment, by a
mechanism that is still being characterized (possibly ADCC in the tumor bed; ipilimumab is an
IgG1) (46, 47). In the clinic, ipilimumab was found
to provide robust and long-term survival benefit
or cures to patients with late-stage metastatic
melanoma who otherwise had no other treatment
options (9). Although the percentage of patients
receiving benefit was small (3-year survival of
23.5% versus ~10% in a control arm) and cannot
yet be diagnostically defined, the results are impressive and led to ipilimumab being approved
by the FDA in 2011. Subsequently, ipilimumab
has been reported to exhibit varying levels of
clinical activity in other indications, but its use is
complicated by the fact that it also induces occasionally serious immune-related adverse events
(e.g., autoimmune inflammation). In any event,
T cell

same way upon entry of tumor-specific IFN-g

secreting cytotoxic T cells. Thus, the binding of
tumor PD-L1 to PD-1 on activated T cells inhibits
their effector function. Mechanistically, this appears to occur by the recruitment of a phosphatase
to the PD-1 cytoplasmic domain that inactivates
the phosphatidylinositol 3-kinase pathway in T
cells, exhausting their ability to generate or release
cytotoxic granules (49). Thus, the PD-1/PD-L1
axis serves as a front-line mechanism of immune
suppression in the tumor bed. PD-L2 in particular
is also expressed by dendritic cells and may play a
role in maintaining peripheral tolerance.
Both preclinically and clinically, the addition
of mAbs to either PD-1 or PD-L1 blocks their
interaction, thereby rescuing T cell cytotoxic activity; often, this results in rapid and substantial
tumor shrinkage coupled with long-term, durable
responses (48). Presumably because the primary
mode of action is to overcome immunosuppression of antitumor T cells in the tumor bed (as
opposed to anti-CTLA4, which amplifies the production of Tcells of all specificities in lymph nodes),

these studies established critical proof of concept

for checkpoint inhibitors specifically and for
other immunomodulators in general.
Following closely behind the success of
ipilimumab are mAbs that antagonize the interaction of programmed death1 (PD-1), another
negative regulator of T cells, with its ligands PD-L1
and PD-L2 (Fig. 3B) (48). Two antibodies against
PD-1 (nivolumab and lambrolizumab) and one to
PD-L1 (MPDL3280A) are the most advanced in
the clinic. Although not as powerful of a brake as
CTLA4, PD-1s role is to prevent the unrestrained
activation of T cells that have been previously
activated. PD-L1 is often expressed by tumor cells
or immune cells infiltrating into tumors. Evolutionarily, its role probably developed as a regulatory node in viral immunity, preventing T cell
hyperactivation and bystander killing of noninfected cells during virus infection: For example,
normal cells react to interferon-g (IFN-g) release
by local effector T cells by expressing PD-L1 to
protect themselves against T cell killing. In cancer, tumor cells are thought to react in much the

C
IFN-!

CTLA4

CD28

CD80
CD86

PD-1

CD8

PD-L1

PD-L1

Tumor cell

Dendritic cell

Anti-CTLA4
Ipilimumab
Anti-PD-L1
MPDL3280A

Fig. 3. The use of antibodies in active and passive immunotherapy

of cancer. (A) Checkpoint blockade by anti-CTLA4. CD80 and CD86 are ligands
expressed on the surface of activated dendritic cells during the presentation of
MHC [human lymphocyte antigen (HLA)]peptide complexes to T cell receptors.
CD80/86 binds to the costimulatory molecule CD28 to help activate T cell proliferation and then to the checkpoint inhibitor CTLA4 to attenuate T cell proliferation. The antibody ipilimumab blocks the interaction of CTLA4 with its ligands,
thereby releasing the checkpoint inhibitor and favoring T cell proliferation. (B)
Checkpoint blockade and inhibiting immune suppression by anti-PD1 or antiPDL1. (Left) T cell influx into tumors results in the release of IFN-g, which up-regulates
PD-L1 expression by tumor cells. PD-L1 binds to PD-1, which is expressed by
activated T cells, generating a negative signal that causes T cell exhaustion (inhibiting the ability of T cells to recognize and kill their targets). (Right) During
antigen presentation by dendritic cells, PD1 can also act as a checkpoint inhibitor
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T cell
receptor

PD-1

Tumor
antigen

PD-L2

Tumor cell

Dendritic cell

Anti-PD-1
Nivolumab
Lambrolizumab

Anti-CD-3

where a negative signal can be sent by its binding to either PD-L1 or the closely
related (and dendritic cellspecific) negative regulatory ligand PD-L2. Generally,
inhibition of both PD-L1 and PD-L2 (e.g., by antiPD-1) is required to block
negative regulation by dendritic cells, whereas only PD-L1 inhibition (by antiPD-1 or antiPD-L1) should relieve immunosuppression (immune rheostat)
activity in the tumor bed. Note that, for clarity, only the primary interactions of
PD-1, PD-L1, and PD-L2 are illustrated. (C) Bispecific antibodies against CD3
passively recruit cytotoxic T cells to tumor cells. Blinatumomab is a single-chain
bispecific antibody that is composed of an anti-CD3 arm that recognizes the T
cell receptor and an anti-CD19 arm that recognizes a surface antigen on the
surface of B cell lymphoma cells; diagrammed is a conventional bispecific IgG
for clarity. Recruitment of the T cells to the tumor cells in this way results in
efficient tumor cell killing, as if the T cell had recognized its cognate peptideMHC on the tumor cell target.
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Antibodies
adverse events associated with PD-1/PD-L1 blockade appear substantially less serious than with
ipilimumab. Although registrational trials are just
now getting under way, preliminary suggestions
are that mAbs against both PD-1 and PD-L1 are
active (5054); it is too soon to know whether one
or the other approach will distinguish itself on
the basis of safety or efficacy. In this respect, it
is interesting to note that PD-1 blockade will
also inhibit interactions of T cells with PD-L2 on
antigen-presenting cells (especially in the lung),
which may or may not increase chances for toxicity; pneumonitis is a risk factor in patients treated
with nivolumab, anantibody against PD-1. In addition, the PD-1 antibodies in the clinic are of the
human IgG4 subclass with reduced potential for
ADCC compared with the PD-L1 antibody, which
has been engineered to completely eliminate FcgR
binding and has yet to elicit serious pneumonitis (53).
This difference or the difference in target (PD-1
versus PD-L1) may or may not correlate with increased efficacy or safety.
Given the complementary mechanisms of action of ipilimumab and the antiPD-1/L1 antagonists, a recent clinical study has demonstrated
that the two agents can show impressive additive
activity, as well as additive toxicity, in melanoma
(55). Because different criteria were used to judge
clinical responses in this versus single-antibody
trials [e.g., use of Response Evaluation Criteria
in Solid Tumors (RECIST) versus World Health
Organization (WHO) criteria for tumor shrinkage], further study will be required to understand
the degree of enhanced benefit.
Antibodies that block immune checkpoints
and immune suppression in the tumor bed have
produced long-term, durable patient responses
rarely seen with other therapeutics and, as such,
may again change the face of cancer therapy
similar to the initial antibodies against EGFR and
HER2 15 years ago. It is likely that the coming
years will see many more antibodies in this space
as additional regulatory targets, both cell-associated
and secreted, are identified and investigated.
Other Related Approaches
At some level, all therapies involving mAbs are
immune therapies in that the immune system was
required to produce and engage the therapeutic.
However, it is useful to regard immunotherapies
as ones that seek to actively manipulate the immune system, most often the T cell compartment,
as is the case for antibodies to CTLA4, PD-1, and
PD-L1. Hybrid approaches are already being introduced. One example of note is a specific singlechain antibody, blinatumomab, comprising tandem
single-chain Fv fragments that bind CD19 on
lymphoma and normal B cells and CD3, the antigen receptor of T cells (56). Treatment of patients
with this small protein is effective at depleting
nonHodgkins lymphoma cells by recruiting T
cells to tumor cells and activating their cytotoxic
effector function regardless of the T cells own

1198

inherent specificity. Although active in early clinical trials, it is rapidly cleared from the circulation
because of its small size, necessitating continuous
infusion. Future work will no doubt investigate
modifying the platform to enable more convenient dosing (Fig. 3C).
Another approach accomplishes the same task,
except by fusing the anti-CD3 specificity to soluble, recombinant T cell receptors that can be
selected to detect tumor-specific peptidemajor
histocompatibility complex (MHC) class I molecules (57). As above, T cells are recruited regardless of their inherent specificity and triggered to
become antitumor effectors.
A third approach involves genetically modifying a patients own T cells to express a membranebound antibody against tumors fused to signaling
molecules that trigger T cell killing when the modified T cell detects a cognate tumor cell. The T cells
(CARs) have yielded a promising result, at least
in hematologic cancer in early clinical trials (58).
Last, conventional antibodies can be generated
with engineered Fc domains that increase, rather
than decrease, FcgR binding, in order to recruit
macrophages and NK cells to mediate ADCC (59).
The Past, Present, and Future
Antibody therapeutics in cancer have a rich history,
an exciting present, and a promising future. Although
it is uncertain what new platforms will emerge as
being efficacious and useful, it is certain that many
new approaches will be tried in the years to come.
The use of antibody therapeutics in combination
with each other is also emerging. Indeed, compelling
phase I data have recently been reported for dual
immune checkpoint therapy using ipilimumab and
nivolumab (55). These combinations have the potential to significantly lower or, in some cases, eliminate
the amount of cytotoxic chemotherapy that is still
currently the backbone of most oncology treatments.
Systemic treatment of patients, which includes targeted mAb therapy, before surgery is also emerging
(32). Moreover, one could imagine scenarios where
these approaches are likely to reduce the need for
extensive surgery. New delivery platforms, new
approaches to ADCs, and new ideas to manipulate
the immune response or the tumor microenvironment are certainly on the horizon and bode well for
a renaissance of interest in antibody biochemistry
and function, as well as for cancer patients.
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Acknowledgments: M.S. and I.M. are full-time employees of
Genentech, Incorporated, a member of the Roche Group. Both
authors have been granted options and own shares of Roche
Holding AG. Erlotinib, rituximab, trastuzumab, bevacizumab,
pertuzumab, and ado-trastuzumab emtansine are marketed
products from Genentech, Incorporated. MEHD7945A, onartuzumab,
and MPDL3280A are under clinical development by Genentech,
Incorporated and are not FDA approved.
10.1126/science.1241145

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