Modification of the tumor microenvironment to enhance immunity.

The growth and spread of cancer depends as much on the host response to tumor as on the biological characteristics of the tumor itself. This interaction is at its most intimate and dynamic within the tumor microenvironment. It is here that the battle is fought that leads to mutual evolution of tumor and host cell phenotypes. Contributing to this evolutionary process are physiological changes distinctive for the tumor microenvironment, such as hypoxia, low nutrient levels, low extracellular pH, and high interstitial fluid pressure. These largely result from the chaotic intratumoral vasculature but are impacted by the nature of the tumor and the inflammatory and wound healing responses that are generated. Numerous infiltrating immune cells, including macrophages, lymphocytes, natural killer cells and dendritic cells infiltrate the tumor, contributing to high levels of growth factors, hormones, and cytokines. We suggest that the integrated interplay between host and tumor factors results in distinct phenotypes that determine the response to therapy as well as tumor behavior. Targeting the tumor microenvironment to awaken or reawaken immune cells, or to redirect it from a pro-tumor to an anti-tumor state, will require understanding of this phenotype. Current conventional therapies target tumors not tumor cells and clearly affect the host infiltrate and the physiological characteristics of the tumor microenvironment. This may an advantage that has yet to be effectively exploited due to lack of knowledge of existing phenotypes resulting from the tumor-host interactions. The same lack of knowledge impacts outcomes of clinical immunotherapy (IT) trials that have so far not broken through the ceiling of 10% success rate that seems to exist even in melanoma. It seems obvious that more could be achieved by combining therapies that tackle malignancies from multiple angles, with the tumor microenvironment conditioned to support a powerful effector arm generated by IT. The challenge is how to design combination therapies that modify the tumor microenvironment so as to promote immunity and better combat both local and systemic disease.