Scientific Activities and Progress 2022

In TEAM 1, projects are focusing on how tumor cells interact with and instruct their surrounding microenvironment, by influencing key drivers such as immune responses, angiogenesis, neurogenesis, cancer associated fibroblasts, and matrix involvement, favoring tumor growth and metastatic spread, and explaining development of treatment resistance.

The Gullberg group has been working on fibroblast biology and the importance of integrin α11 in the tumor microenvironment, by the characterization of novel integrin α11 function blocking antibodies and development of a mouse model to explore the role of α11 in tumor stroma. Establishing the ITGA11-Cre mouse strain was a major milestone in the group’s work after 10 years of focused efforts. The further breeding into a fluorescent reporter strain will be another step forward. The detailed epitope mapping of mAb 210F4 and mAb 203E1 to a few amino acids also illustrates the importance of consistent work spanning several years to reach long-lasting and well-cited results. One of the translational projects relates to the role of integrin α11 absence in the stroma of squamous cell carcinoma (SCC) and is performed in collaboration with Dr. Ritva Heljasvaara (University of Oulu).

In the Kalland group, focus has been on two strategies: drug discovery by repurposing, and the concept of cryoimmunobased dendritic cell (DC) therapy. In a phase I clinical trial for cryoimmuno-therapy (CryoIT) for patients with advanced prostate cancer, immature DCs are placed in the inflammatory cryoablated prostate cancer tissue to detect and process the entire panel of tumor-associated neo-antigens, accounting for tumor heterogeneity. Treatment effects were suggested according to radiology, circulating tumor cells, serum autoantibody profiling, and ultradeep T-cell receptor sequencing (Thomsen et al., Cancer Immunol Immunother, in press). The group continues to explore biomarkers in order to uncover positive results from clinical trials, including an in vivomimicking ex vivo-model of standardized tissue explants. A second CryoIT clinical trial is being prepared for startup (fall 2023). Work is ongoing to secure and improve the manufacturing practice of DCs with optimal and robust operating procedures, to secure potency and viability. The role of beta-catenin and STAT3 signaling in dendritic cell re-programming are also studied (Azeem et al., Biomedicines 2021). Notably, the European Patent Office has approved the patent application of CryoIT combined with intratumoral injection of an immune checkpoint inhibitor. The national implementation phase is ongoing.

The McCormack group has had a major focus on appropriate preclinical models (organoids, PDX) before clinical trials are performed. In 2022, the group’s intrabursal orthotopic PDX model of ovarian cancer – critical to the development of personalized therapies in this disease – was presented in detail (Popa et al., Methods Mol Biol 2022). Kleinmanns et al. (Cancers 2022) described, for the first time, the development and application of a humanized orthotopic PDX model of highgrade serous ovarian cancer. In this work, Kleinmanns reported the parameters necessary to develop such a model, extensive functional analysis of humanization with CyTOF (34 markers), and application with anti-PD-1 inhibition. The group surveyed the use of preclinical modelling systems within academia and industry (Fosse et al., J Pers. Med 2022). Subsequently, Fosse leads a team of internationally recognized scientists to establish guidelines for robust and reproducible preclinical research in personalized medicine (Fosse et al., BMC Med 2023). The group has several biomarkers under development as novel targets for CAR-T, which will be developed in their novel immunocompetent PDX models.

In TEAM 2, studies are being performed on biomarker discovery and validation in several human tumors, with additional work on how markers are related to mechanisms for tumor progress, especially within the tumor microenvironment. Candidate biomarkers are used to map tumor diversity including associations with clinico-pathologic phenotypes and patient outcome.

The Akslen group is concentrating on tumor proteomics and spatial mapping of tissue biomarkers related to the tumor microenvironment in human breast cancer (BC). The overall aim is to improve tumor stratification and treatment response prediction. The focus is currently on profiling of luminallike and basal-like breast tumors, using mass spectrometry proteomics (MSP) and imaging mass cytometry (IMC). During 2022, the group identified a stromal proteomic signature which could improve BC stratification, in particular among luminal tumors (Finne et al., submitted). By integrating BC cell line secretome data after hypoxia with stromal proteome information, significantly improved prognostic information and potential treatment predictive ability was found (Kjølle et al., in revision). The group also found that neurogenesis and angiogenesis are linked in aggressive breast cancer (Wik et al., submitted) and that co-cultivation of BC cells and neural cells leads to proteomic responses in both cell populations (Bjørnstad et al., submitted). In a study of breast and prostate cancer, the group recently reported, in collaboration with Drs. Watnick and Brekken, that PRSS2 and TSP1 interactions could influence programming of the tumorimmune microenvironment (Sui et al., Nat Commun 2022). The expression patterns of Stathmin in relation to immune cell populations in breast cancer has been studied by singlecell spatial mapping, supporting an immune regulatory role (Askeland et al., in preparation).

The Lorens group has been studying various aspects of how the Axl receptor tyrosine kinase is involved as a key regulator of normal adult epithelial progenitor cells and a determinant of carcinoma cell plasticity and interactions at the tumorimmune interface relevant for resistance to immunotherapy. Results have indicated an important role of Axl in epithelialmesenchymal transition (EMT) and immune evasion (Engelsen et al., Front Immunol 2022), and studies have demonstrated how anti-Axl treatment (by bemcentinib) can reverse these processes. Thus, in a study of STK11/LKB1 mutant lung cancer (NSCLC), the team reported that AXL targeting can restore PD-1 blockade sensitivity (Li et al., Cell Rep Med 2022).

The Costea group studies mechanisms of tumor-stroma interactions in oral and vulvar squamous carcinoma, with focus on metabolic changes in carcinoma associated fibroblasts (CAFs), and the association with genetic alterations including HPV subtypes and their role for tumor progression. The group has presented data on miRNA profiling in head and neck cancer and found 12 differentially expressed miRs. Two of the significantly downregulated miRNAs in CAF, miR-204 and miR-138, have tumor-suppressive function through inhibition of fibroblast migration by modulating the expression of several different motility-related molecules (Rajthala et al., Int J Mol Sci 2021; Rajthala et al., Front Oncol 2022). A link between miR-204 and integrin α11 was found, and in a cohort of 169 patients with HPV-negative primary oral squamous carcinoma, stromal presence of miR-204 predicted better overall and recurrence free survival (Rajthala et al., Cancers 2021).

The Engelsen group has focused on how phenotypic plasticity interferes with therapeutic efficacy and immune cell-mediated killing. The group has now established lung cancer (NSCLC) patient-derived organoid and explant models recapitulating the complex tumor-immune microenvironment, and the current project aims to elucidate the effect of phenotypic plasticity on the spatial organization of tumor-immune microenvironment. This might illuminate how therapeutic targeting of phenotypic plasticity and intermediate E/M phenotype cells synergize with immune checkpoint inhibition (ICI) therapy. Recently, the team reported how organoid and immune-competent explant models can be applied to explore how hypoxia and therapeutic interventions alter the cancer cell metabolism and the tumor-immune microenvironment (Zaarour et al., Cancers 2021; Engelsen et al., Front Immunol 2022). Also, tumor-stroma interactions in lung cancer were reported by spatial mapping using heterotypic spheroid models (Lotsberg et al., Front Oncol, 2022).

In studies of gynecologic cancers by the Krakstad group, tissue and serum-based biomarkers as well as genetic alterations are being explored. The international MOMATEC2 study (NCT02543710), a phase 4 implementation trial for validation of ER/PR status to stratify for lymphadenectomy in endometrial cancer, is coordinated by the group. Models for endometrial cancer are being established and characterized, and integration of molecular and radiologic data with clinical phenotypes is ongoing. In a study investigating MMR status in paired preoperative and operative endometrial cancer biopsies, the group demonstrated a substantial agreement in MMR status between paired lesions (Berg et al., Br J Cancer 2022). In addition to determining MMR status, protein expression levels for MMR, particularly MSH6, may add prognostic information in endometrial cancer. Patients with endometrial cancer undergoing lymph node staging (LNS) without receiving chemotherapy are comparable with those not undergoing LNS (Forsse et al., Am J Obstet Gynecol 2022). The team found similar diagnostic performance in the low- and high-risk histology groups for central staging parameters by preoperative MRI and FDG-PET/CT (Fasmer et al., Eur Radiol 2022). Selective [18F]FDG-PET/CT in patients with high-risk MRI findings yields better detection of lymph node metastases than MRI alone, and similar diagnostic performance to that of MRI and [18F]FDG-PET/CT in all.

The Strell group studies regulatory mechanisms of early breast cancer evolution with focus on genetic alterations and changes in the tumor microenvironment. The group aims to identify novel prognostic and predictive biomarkers which can support clinical decisions. Strell joined CCBIO during 2022 after receiving a starting grant from the Trond Mohn Foundation for the project EvoMaps – understanding early breast cancer evolution in space and time. Strell has been working on spatial tissue profiling techniques in Stockholm and Uppsala (Svedlund et al., EBioMedicine 2019; Micke, Strell et al., EBioMedicine 2021). Previous work in the Mats Nilsson group (Science for Life Laboratory, Stockholm University) in collaboration with Lucy Yates (Wellcome Sanger Institute) has demonstrated a base specific in situ sequencing (BaSISS) approach to map mutations in breast cancer tissue sections in a highly multiplexed manner, allowing, for the first time, spatial lineage tracing of cancer cell clones in the histological context, with Strell being a key member of this team (Lomakin et al., Nature 2022). The affiliation with CCBIO will enable Strell to adapt the in situ sequencing approach to the Hyperion mass imaging system for simultaneous mapping of genetic alterations and protein based cell typing. Also, Strell is working to decipher the immune architecture in DCIS; data on tumor infiltrating lymphocytes might define low risk DCIS (Schiza et al., Eur J Cancer 2022; Strell et al., Clin Cancer Res 2021). Strell recently received a pioneer grant from The Norwegian Cancer Society.

The Wik group has a focus on breast cancer of the young and why these patients often experience a more aggressive disease behavior. A patient cohort has been established with multiple molecular and clinico-pathologic annotations, including primary tumors and metastases. Further genetic and imaging mass cytometric (IMC) profiling is ongoing. So far, studies on estrogen related signaling networks and transcriptomic profiles have revealed an age-related gene expression signature tightly linked to proliferation and prognosis (Ingebriktsen et al., Br J Cancer 2022). Another study has shown a relationship between reduced GATA3 expression and poor patient survival (Sæle et al., in preparation).

In TEAM 3, the main focus is to perform clinical trials with associated biomarker studies, and to promote novel findings on markers and treatments for clinical implementation and change of practice.

The Bjørge group is engaged in multicenter trials with translational research programs related to high-grade ovarian cancer, aiming to improve patient stratification and treatment efficacy. The group also has a focus on improved imaging guided cytoreduction surgery in this disease. In addition to clinical studies, PDX models and organoid cultures are being established. High-dimensional tissue profiling of ovarian cancer samples have been initiated with special attention to immune responses. During 2021-22, Bjørge and colleagues reported on spatial profiling and phenotypic characteristics of the microenvironment in ovarian cancers (Anandan et al., Cancers 2021). Data on immune profiling in ovarian cancer xenograft models after anti-PD-1 therapy has been presented (Kleinmanns et al., Cancers 2022). In a collaboration study, Bjørge and colleagues have presented data on the DNA methylome of cervical cells and risk of ovarian cancer (Barrett et al., Nat Commun 2022). Bjørge is currently president for NSGO (Nordic Society of Gynaecological Society), she is a faculty member for gynecologic oncology at ESMO and the leader of Oncology Forum (Norway). From November 2022, Bjørge is the Co-Director of CCBIO.

The Gjertsen group focuses on how intracellular signal transduction can be decoded to tell responders from nonresponders early during cancer therapy. The experimental framework is based on tumor cells collected in clinical trials, dissecting how signaling in tumor cells is related to therapy response. In a recent key paper, Tislevoll et al. reported on early response evaluation by single cell signaling profiling in acute myeloid leukemia (Nat Commun 2023). In this study, it was reported that mass cytometry can be a valuable tool for early response evaluation and elucidate the potential of functional signaling profiling in precision oncology diagnostics. Further, Gjertsen is involved in multiple network projects. Huuhtanen et al. is the first to demonstrate a biological rationale for combining a small molecule inhibitor of ABL1 with immune therapy interferon alpha in a clinical trial (J Clin Invest 2022). Malani et al. follows up on a 2013 publication on ex vivo drug sensitivity screening in therapy guidance of the aggressive blood cancer AML. Notably, it is reported that as much as 60% of relapsed refractory patients can obtain therapy response if guided by drug sensitivity screen and gene expression analysis (Cancer Disc 2022). Also, Othman et al. indicate the complexity of AML genetics and how mutational panels are needed to optimize prognostication in AML (Blood 2022).

The Straume group is focusing on tissue biomarker studies in clinical trials. The group has reported an association between surgical tissue trauma and recurrence dynamics in high-risk breast cancer patients. A national academic trial combining anti-Axl treatment with immunotherapy is now closed (n=80) and is currently explored for treatment predictive markers of anti-Axl therapy in advanced melanoma cases. A national interventional study of patients with aggressive melanoma (IPI4; ipilimumab) is being analyzed, and some results have been presented. In 2021, data on ipilimumab treatment in metastatic melanoma from a phase IV trial was presented (Aamdal et al., Int J Cancer 2022; Aamdal et al., ESMO Open 2022).

In TEAM 4, the projects on ethics and economics of biomarkerbased therapy are expanding and integrated in clinical trials. As CCBIO performs research on cancer biomarkers along the entire chain from studies of biological mechanism to clinical projects, the main societal impact resides in this sense in the improvement of cancer diagnostics and therapies and in medical innovation. The main measure of this impact is ultimately its effect on the quality and cost-effectiveness of cancer management, whereas it cannot be precisely measured in the short-term. Better knowledge of cancer biomarkers is likely to affect the prioritization dilemmas, although the nature of that effect depends on the nature of the knowledge to be discovered.

CCBIO integrates work on societal perspectives and has established a team structure led by Strand to improve interdisciplinary humanities and social science programs to study the opportunities and challenges of precision cancer medicine. The team will continue their collaborations on the more conceptual research into RRI and the coproduction of science, technology, and society.

A key insight in Team 4 is that the quality of a biomarker is a complex issue with scientific and technical but also clinical, economic, ethical and political dimensions. Collaboration has increased between the Strand group and CCBIO economists (Cairns group) and ethicists (Norheim group). The team is responsible for the basic course CCBIO903 – “Cancer Research: Ethical, Economic and Social Aspects”.

The Strand group performs research on the ethical, legal, and societal aspects (ELSA) of CCBIO’s research, distinguishing between three interrelated goals; 1: A better understanding of the developments, expectations and imaginaries of personalized and precision cancer medicine, including its political economy and ethical and social issues; 2: A better integration of this understanding into practices of “responsible cancer research” in the sense of RRI (Responsible Research and Innovation); 3: A better understanding of complexity in cancer as illness, disease and sickness. The ELSA group of CCBIO interacts with and is tightly linked to similar ongoing RRI projects (NFR Res Publica and AFINO, and Horizon 2020 SuperMoRRI and TRANSFORM). In 2020, the group enjoyed a major strengthening with the inclusion of Professor Marta Bertolaso as Adjunct Professor, and a formalization of the collaboration with Bjørge’s group. In 2022, the group reached an important milestone by the publication of the interdisciplinary research anthology “Precision Oncology and Cancer Biomarkers: Issues at Stake and Matters of Concern”, edited by Anne Blanchard and Roger Strand (Springer 2022). It constitutes a state-of-the-art volume on interdisciplinary research on goal 1 above and represents if not the final word from CCBIO on these issues, at least the major milestone. While research with a strong philosophical dimension rarely can be summarized in terms of "findings", we may say that the volume offers a range of suggestions for how to reframe cancer and how to resolve the various ethical and social dilemmas around cancer biomarkers and personalized/precision cancer medicine, including those of equity and social justice as well as challenges of excessive medicalization. The aspect of media debates has been further pursued in 2022, also suggesting reframing as the solution (Nilsen et al., Norsk Medietidsskrift 2022; Stenmarck et al., BMC Med Ethics 2022). In the first results from the collaboration with Bjørge's group (Gissum et al., Cancer Care Research 2022), the team shows how aspects of ovarian cancer as illness, are poorly represented in treatment of the corresponding disease. The results have direct clinical relevance.

The main idea for the following years is to deepen existing collaborations, including with Bjørge's group, and with Akslen and Bertolaso on the understanding of complexity in cancer, also along the lines of the Strand and Chu chapter Crossing the Styx: If Precision Medicine Were to Become Exact Science in the book Precision Oncology and Cancer Biomarkers, 2022, as well as to develop a stronger interdisciplinary collaboration with Cairns and Jiyeon Kang on the economic aspects of cancer biomarkers.

In the Cairns group, health economics research within CCBIO has focused on the economic evaluation of oncology drugs. Particular attention has been paid to the evaluation methods used and the contribution of different types of data (such as health outcomes recorded in clinical trials and real-world data). The most important project in recent years has been Jiyeon Kang’s PhD project Improving economic evaluation and decision-making for oncology drugs using real-world data. This has involved a detailed analysis of two hundred and twenty-nine appraisals undertaken 2011-2021 (UK). Another project has focused on how molecular targeted therapies and immune checkpoint inhibitors for the treatment of non-small cell lung cancer have been assessed.

Managed Access Agreements are being used increasingly in the UK as a means of improving access to treatments where the evidence of clinical effectiveness is too uncertain for the National Institute of Health and Care Excellence (NICE) to recommend routine commissioning. The Cancer Drugs Fund [CDF] was introduced in England in 2016 to give patients access to these potentially valuable treatments. The CDF provides the drugs for several years while additional data are collected before a final review of the drug takes place. An analysis by the Cairns group of the first twenty-four drugs to exit the CDF, highlighted the important role played by longer follow-up of patients in the original clinical trials used to support the introduction of these drugs and the very limited role played by the data collected from patients receiving the drugs provided through the CDF. This is an important finding given the widespread enthusiasm for using real-world data to inform drug reimbursement decisions. Clear differences were observed between the appraisal of checkpoint inhibitors and that of molecular targeted therapies, at least in the context of non-small cell cancers. These differences derive from the more limited clinical data and the more restricted application of targeted medicines. In 2022, results were reported on the use of real-world data in access agreements appraisals of targeted cancer therapy (UK) (Kang et al., Pharmacoeconomics Open 2022; Kang et al., BMC Cancer 2022). Notably, Jiyeon Kang successfully completed her CCBIO funded PhD thesis in 2022 (at LSHTM).

In the Norheim group, the main aim has been to explore how biomarkers inform and potentially improve fairness in health care priority setting. Eirik Joakim Tranvåg’s PhD thesis (Precision and Uncertainty) has been the main delivery. Findings in a conjoint analysis based on a survey of Norwegian medical oncologists suggest that biomarkers may be seen as relevant in clinical priority setting decisions for new and expensive cancer drugs. Results from an analysis of Norwegian drug appraisals also suggest that biomarkers are actively used and help facilitate drug coverage decisions at a national level. Despite this, Tranvåg argues in his thesis that priority setting actors still need to acknowledge that the increasing uncertainty in personalized medicine may lead to more difficult priority setting decisions. This cannot be dealt with only by developing better and more valid biomarkers, but also requires interaction between science and society, co-production of knowledge and a fair priority setting process.

Key publications from Norheim’s group were Tranvåg’s PhD thesis Precision and Uncertainty: Cancer biomarkers and new perspectives on fairness in priority setting, and the third and final paper in the thesis, Appraising Drugs Based on Cost-effectiveness and Severity of Disease in Norwegian Drug Coverage Decisions (published in JAMA Network Open, June 2022). The findings from this paper must be seen as a major result from the group, as it was highly relevant for the public debate about drug reimbursement in Norway. The group contributed to both of CCBIO’s anthologies on the ethical, legal and societal aspects of cancer biomarkers, the last issue being Precision Oncology and Cancer Biomarkers, Issues at Stake and Matters of Concern (editors Anne Blanchard and Roger Strand, Springer 2022).

During 2019-2022, the Global Health Priorities Research Group directed by Ole Frithjof Norheim has grown and developed into a center – the Bergen Centre for Ethics and Priority Setting (BCEPS), with funding from the Bill & Melinda Gates Foundation among others. Notably, in 2022, Norheim was awarded a Centre of Excellence (SFF) from the Research Council of Norway.

The Jonassen group performs research in developing computational methods for analyzing and discovering patterns in molecular biology data. Since the 1990s, the group has worked with a variety of different data types; new technologies have become available and new application areas have developed. In the context of CCBIO, the work has naturally focused on development of methods relevant for cancer studies and in particular to understand tumor microenvironments focusing on the use of RNA-seq gene expression data and later single-cell CYTOF and imaging mass cytometry (Hyperion) data. Within the frames of CCBIO, the group has had access to groups with leading expertise in different cancer types and the possibility to take part in experimental design of new studies coupled with planning the computational analysis of the resulting data and possible follow-up experiments.

An important sub-project has been the AML_PM project which has been funded by ERA_PerMed including Gjertsen from CCBIO and a consortium including groups from Germany, the Netherlands and Canada. In this project, the team has combined systems biology modeling of targeted signaling systems with machine learning approaches aiming to help select treatment options for individual patients based on the status of signaling pathways. Another important sub-project has been the application of the Hyperion instrument to explore spatial aspects of tumor microenvironments of breast cancer. The team has studied alternative workflows for image data processing and graph representations of the extracted data. This will indicate interactions between different cell types and their states and link this with patient prognosis and treatment response – and develop new biomarkers and information guiding design of new therapies.

In conclusion, a range of research projects along with science education and communication have been conducted and reported on continuously since 2013. In addition, multiple new research initiatives have been conceived, in part based on increasing intramural collaboration and international networking. In addition to an increasing number of highimpact publications and four books presented by CCBIO (two of them published in 2022), multiple activities are being performed by the CCBIO Research School for Cancer Studies, with 12 core courses. Notably, the CCBIO Masterclass Program is now in its second year (2022-2023), with teaching and training of young investigators aiming for independency and future positions as group leaders. The CCBIO-ARC (advanced research colloquium) has been initiated. Notably, in 2022, Norheim was awarded a Centre of Excellence (SFF) from the Research Council of Norway. When CCBIO is now approaching the transition phase to CCBIO 2.0 and post-RCN continuation of the center, we plan ahead as we optimistically reflect on the “core concepts” and integrated activities of CCBIO and the strive for responsible real-life impact.