OnCo
ideasIdea

Making microsatellite-stable colorectal cancer immunotherapy-responsive

Ninety-five percent of bowel cancers ignore immunotherapy. Combinations that heat the tumour up (targeted drugs, radiation, new checkpoints) are the main hope.

MSS CRC has few neoantigens, TGF-β-rich stroma, and liver metastases that induce systemic tolerance. Approaches: botensilimab + balstilimab (Fc-enhanced anti-CTLA-4; ~20% ORR in liver-metastasis-free MSS CRC), KRAS G12C inhibitor + PD-1, anti-EGFR + PD-1 in RAS wild-type (AVETUX), radiation to liver metastases, CEA-directed T-cell engagers.

Hypothesis
Fc-enhanced CTLA-4 blockade plus PD-1 blockade, restricted to MSS CRC without active liver metastases, will show an OS benefit over trifluridine/tipiracil-based therapy in third line.
Rationale
Liver metastases deplete tumour-specific CD8 T cells; excluding them enriches for responders, as seen in the botensilimab expansion cohorts.
What would test it
Randomised phase 3 in third-line MSS CRC without liver metastases (BATTMAN-style), OS primary; ctDNA and TGF-β signatures as stratifiers.
Maturity
early clinical

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