Challenges and Prospects of Chimeric Antigen Receptor T-cell Therapy for Metastatic Prostate Cancer

Context: Progress achieved in the treatment of prostate cancer (PCa) with surgical, radiation, and hormonal therapies has drastically reduced mortality from this disease. Yet, patients with advanced PCa have few, if any, curative options. Recent success in treating patients with hematological malignancies of B-cell origin using T cells engineered to express chimeric antigen receptors (CARs) has inspired multiple groups worldwide to adapt this approach to the problem of late-stage PCa. Objective: To summarize the available clinical results for CAR T-cell therapy of PCa and discuss future technological advancements in the CAR T-cell field that may help patients with metastatic PCa. Evidence acquisition: A literature review was conducted of clinical trial data, abstracts presented at recent oncology conferences, as well as reports highlighting critical bottlenecks of CAR T-cell therapy that became apparent from preclinical and clinical studies. Evidence synthesis: Current understanding of why CAR T-cell therapy may fail, particularly in the context of solid cancers, is as follows. First, a CAR design that provides potent activity and persistence of engineered T cells in the hostile tumor microenvironment is a must. The choice of the targetable epitope(s) is critical to counteract tumor antigen escape. Preclinical and clinical evidence indicates that the efficacy of CAR T-cell therapy can be enhanced significantly in combination with other therapeutic approaches. We propose that several improvements to CAR design and patient conditioning, such as unbiased identification of novel PCa-specific CAR targets, use of next-generation (multispecific, resistant to the tumor microenvironment, and with prolonged persistence) CAR T-cell products, and combination therapies may translate into improved patient outcomes and more durable responses. Conclusions: Although significant preclinical experience of testing CART cells in solid cancer models has identified important technological and biological bottlenecks, information from clinical trials, particularly those focusing on the PCa, will be instrumental to the rational design of advanced CART therapies that will be both safe and effective in patients with advanced PCa. Patient summary: So far, chimeric antigen receptor (CAR) T-cell therapy has not shown significant activity in patients with metastatic prostate cancer (PCa). CAR T-cell products used for such trials represent one of the pioneering efforts to adapt this technology to the problem of metastatic PCa. In retrospect, both CAR design and cell composition appear to have been suboptimal to expect strong patient responses. Given the impressive results of CAR-based approaches observed in preclinical models of solid cancers, emerging CAR T-cell products are expected to be more successful in the clinic. Here, we discuss the challenges that need to be overcome to boost the efficacy of PCa-targeted CAR T-cell therapy and call for dialogue between clinicians and cell biologists to address these challenges. (C) 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.