Features Bugging cancer Microbes have a natural affinity for tumours opening up incredible new ways to fight cancer, discovers Alice Klein Ss bacteriaarenormally associated with violent food poisoning, ut in 2019, rit Balboul, 27-year-old Canadian, volunteeredto drink liquid containing1 billion live Salmonella typhimurium bacteriaasalast resort against her pancreatiecancer, which had spread to other organs and given her just monthstollve. The bacteria had been genetically engineered totriggeran immune attackon her cancer cells, while being less toxicthan regular Salmonella tothe rest of her body. Balboul was the first person inthe world totrialthem along with chemotherapy and her tumours shrank toJusto percent oftheir former size. Itmay sound strange tousebacteriato treat cancer, but the approach harks back tothe late x800s, when William Coley,a New Yorksurgeon, began inectingStreprococcus bacteria into the inoperable tumours ofsome ofhis patients, resulting in regressions he described as “nothing short of marvellous’ Despite this promise, the approach fellout offavour. Morethan a century later, however, wearewitnessingColey’s comeback. Itisnow clearthat many bacteriaare naturally attracted totumours, which are hometoarich microbial ecosystem. This tumour microbiome can influence how cancer progresses and respondsto treatment. clearer appreciation of thissystem is leading othe development of new microbial medicines targeting cancer, some of which are now Inclinical trials including the engineered ‘Salmonella. These microbes can burrow deep into places that are hardto reach with existing treatments suchas chemotherapy and canbe equipped with extra, cancer-fighting weapons through genetic engineering, offering alternative waysto attack tumours. “Most peoplearenow familiar withthe gut ‘401NcwrScentist|2g)une2023 microbiome -the complex community of bacteria, ung), viruses and other microbes that inhabitourguts and influence our health ‘nmyriad ways. But the idea that tumours are also teeming with microbes only came tothe fore in2020, when lana Livyatan at the Weizmann Institute of Scencein Israel and her colleagues analysed bacteria in more than 1000 human tumour samples Using genetic sequencing, they identified bacteria in all eight tumourtypes they studied: breast, brain lung, skin, bone, ovary pancreas, and colon. it madeus raise our eyebrows and say, Hey, what ae they doingthere?" says Livyatan. On average, they found roughly ‘one bacterial cell for every 150 tumour cells, bbutsometumourtypes, such as thoseofthe colon and breast, typically harboured more bacteriathan others, Even more surprising was the discovery that each tumourtype hhadits own distinct microbial signature. Last year Livyatan and her colleagues ‘dropped another bombshell: they had found fungi in tumours too, inall eight types that had previously tested positive forbacteria, {At the same time, a team led by Hiyanliev at Cormell University in New York revealed that ithadalso sequenced fungal DNA ina range foftumours. These included Candida fungi hich are more commonly associated with vaginal andoralthrush-in cancers ofthe stomach, colon, head and neck (though theamounts weretiny:about onefungal cellper 10,000 tumour cells). "Tt was kindof mind-blowing, says liev. Something seems tobe attracting the fungi to some tumours DbecauseWwhen Welookat tumour tissueand the adjacent tissue from the same patient, \wesee that the fungal cells are preferentially abundant in the tumour,” he say. There are many reasons Why microbes might be attracted to tumours (see “ideal home forbacteria’, page 42),but whats becoming ‘learis that their presence can influence the course of cancer and its treatment. Bacteria called Pusobectertum nucleatum, forexample,can promotecoloncancer, accompany its spreadto other parts of the body and dampen itsresponse to ‘chemotherapy. These bacteria mostly vein the mouth, but can invade the bloodstream, and then circulate othe colon. There, they can colonise polyps~clumpsofeellsthat formon the lining of the colon~and turn them cancerous, Similarly, the presence of ‘Malasseziaglobosa funglin breast tumours, Which arethought to travel there viaducts connecting the skin and breast, hasbeen associated with poorer survival rates Wehave aso known for decades thatcertain viruses can trigger cancer formation: forinstance, human papillomavirus (HPV) and hepatitis Bvirus (HBV), which are ited with cancers ofthe cervixand respectively. HPV insert its DNA into snomes of healthy cervical cells and them to grow out of control, becoming cancerous, and we are now getting clearer picture ofthe mechanisms by which other microbes can influence the progression of| ‘cancer (see “Microbial manipulations", page 43) Vaccine hope Fortunately, we now hax PV and Hi tohelp prevent thelrassociated cancers.In the same way, wemay be able to ccines agains! tumour-promoting Hottat the British CColumbiaCancer Research Institute in Canada, These have the potentialto inhibit the growth ofbacteriainexisting tumours slowing their progression and making them moreresponsive tochemotherapy. They couldeven stop tumours from forming in the first place Holt and his teamare specifically working onavaccineagainstF nucleatum. The vaccine contains messenger RNA (miRNA) that i designed to instruct the body to makecertain, protein fragments foundin this bacterium. ‘Theideaistotrain the immunesystemto recognise and kill he microbe. At this stage, the vaccine i still beingtested in mice, but Holt andhis colleagues hopeto one day trialitin people with F nucleatum positive colon cancer that is resistant to conventional treatments, ‘Taking "bad! microbes out of tumoursis one strategy to tackle cancer, but anothermaybeto send in “good” microbes. Thisisthe approach that Coley took inspired by reading about a man whose largeneck tumour disappeared afterhe developed. streptococcus pyagenes infection atthe site yeon had unsuccessfully triedtocut the tumour out. Injected live pyogenes into xoofhis patients’ tumours halfhad parti ‘or complete tumour regressions. However, he foundit difficult to get the dose right and some of his later patients died from thetreatment. Theturof the 20th of radiation thera and Coley’s approach fellby the wayside, stillaren'sure ‘worked. It is most likey that the: bacteriahe injected into patients'tumours made hem more visible to their immune tems says ivyatan.Althoughsmall > ere hiss tury saw thearrival ‘which wasseen assafer, 24)ume2003|New Scientist 42‘Dotumours have an electrome as well as a biome? Ideal home for bacteria ‘The reason certain bacteria are attracted to tumoursisstillanopen ‘question saysiianaLivyatan at ‘the Weizmann stitute of Science infsrael. "if you grow a tumourin amouse and then inject bacteria Intoitsbloodstream the bacteria ‘withome tothe tumour, but we ‘dont really know why yet.” (One suggestionis that blood ‘vesselsintumours growina {ast chaotic way, forming twists ‘and dead ends that may trap bacteria. Another is that therapid ‘metabolism of tumours provides. abundant nutrients for bacteria to {feedon. Low-oxygen pockets that ‘typically form inside tumours may ‘alsoattract oxygen-hating bacteria ‘alled anaerobes. And tumours ‘often develop ways to evade ‘detection from the immune system, making them perfect hiding spots for microbes. Certain tumours provide the Fight kind of food for particular microbes. Lung tumours of ‘smokers, for instance, seem ‘ofavourthe growth of bacteria ‘that can degrade components of. cigarette smoke such as nicotine. ‘21NewsSciontist 4 June2073 Sally Adee reveals the extraordinary power ofbioelectricity| atNew Scientist Live newscfentistlive.com amounts of bacteria can hidein tumours becauseof.cancer’s immune-evading ‘mechanisms, injecting large doses of them into tumours may be enough to trigger alarmbellssothat the immune system launches an assault on thecancercellsthat the bacteriaare ving in, she says. Research by another group at the Weizmann, Institute of Science led by YardenaSamuels has provided some clues as to how Coley’s bacteria may have made tumours more visibleto the immunesystem. The team discovered that protein fragments from, bacteria that colonise melanomaskin cancers are exprestedon the surfaceofthe cancer cells. These signpost the tumours foreign totheimmune system, sothat itrealises “Hey, something's wrong here" and attacks the cancercells, says Livyatan, ‘TheSalmonelia that were used totreat Balboul had been genetically engineeredto rev this mechanism up even further. They were ‘made toexpressa protein called interleukin-2 that activates the immune system. "The Salmonella goes directly tothe tumour and brings along the interleukin-2sothat the ‘hole body’snot exposed tothe interleukin-2, justthe tumour," says Gerald Batist, the “oncologist who oversaw Balbou!'s treatment atthe ewish General Hospital in Montreal “Itcreates an immune activity against the tumourright a thesiteofthe tumour” Living longer Balboul trialled the treatment alongside standard chemotherapy. The dramatic shrinkage of hertumours was afar stronger responsethan wouldbe expected with chemotherapy alone. “Itwas very striking ~ none of us had seen anything quite ikeit before” says Batis What's more, the bacteria didn’t make her sick he says. “The idea that \wewould have someone drinking bacteria really freaked out the infectious disease peopleon ourethics committee, but she hhadno sideeffects whatsoever: ‘After Balbou’s promising responsetothese bacteria, Batist and his colleagues launched aaphasell clinical trialin 2020 involving 20people with stage 4 metastatic pancreatic ‘cancer considered one ofthe worst ofthe ‘worst cancers. Thetrial participants were alltreated with standard chemotherapy plus the engineered Salmonella,The results, ‘hich were released in January, showed ‘that theparticipants lived for2g months ‘onaverage, which is ore than double the typicalsurviva length of11 months for standard chemotherapy alone. The Salmonella didn't make these volunteers sick either. “itsnotamiracle cure, butadoubling ‘of survivals quite significant ifwe can ‘onfirmit in larger trials saysBatist.A major advantage ofthis approach isthat bacteria are far cheaper to manufacture than other cancer immunotherapies like checkpoint inhibitors, CAR Teel therapies and personalised vaccines, hesays. The US Foodand Drug Administration, (DA) recently gavethe Salmonella therapy fast-track tatus to make itavailableas soon as, possible fit passes future rials, And last year, study in mice showed that tumour homing bacteria could be controlled by ultrasound torelease cancer fighting substances, offering ‘apotential new route to precise targeting. ‘Acompany in Switzerland called '3Pharma Isalsousing bacteria to try to superchargethe Immune system against cancer. tis mainly ‘working with a bacterium called Yersinia enterocolitica, which sa contaminant of pork that can cause food poisoning, but has been ‘genetically engineeredto “down-tune its virulence’ says Christoph Kasper, the firm’s chief scientific officer. Anextrabonus of ¥. enterocolitica is that it has special “nano syringes” onits surface that itusesto inject proteins into cells.T3 Pharma has engineered astrain of. enterocolitica that ‘ean inject proteins into tumour cellsto make ‘them release signalling molecules that “act like ‘warning signals tobringthe immune system intoplay to fight the tumour’ says Kasper. When theengineered ¥ enterocolitica were Injected into the blood of mice with melanoma ‘rother tumours, they selectively homed in on ‘thetumours and caused them to disappearin Up otwo-thirds of the animals, with noserious “observable ide effects. The company has just launched clinicaltrialofthe engineered Yeenterocolitcain people with solid tumours. "We're very excited," says Kasper, BioMed Valley Discoveries, acompany based In Missouri, is pursulnga different approach to target the low-oxygen pockets inside tumours that are often resistant to existingcancer treatments. tis injecting spores of anaerobic ‘Clostridium nowy’ bacteria, which have been ‘genetically modified to makethem less toxic, directly into solid tumours. The spores only ‘germinate in the low-oxygen regions of, tumoursand,asthey proliferate they alerttheImmune systemto start attacking these areas Inafirs-in-humans trial published in 2021, the bacteria were injected direct intothe tumours of 24 people. There, they were found to essentially liquely the tumour’ low-oxygen innards."You stil had aring ‘oftumourcellson the outside, where the tumours were welloxygensted andthe bacteria couldn't grow, but in the middie, itwas just fuidand gas where thecells had been destroyed says Brent Kreider, president ‘of BioMed Valley Discoveries. The Clostridium bacteria are now being ‘evaluated ina second clinical tial, this time in combination withthe checkpoint inhibitor pembrolizumab more commonly known as Keytruda~thatcan target the outer tumourcells."Theidea isforthe bacteria to fight the tumour from the Inside out and the embrolizumab {to fight i] from the outside in’ says Kreider. Theresults willbe made available laterthis year, he says ‘Above: Bacteria such as ‘Salmonella (green)can be ‘weaponised fight cancer. Left: Vaccines against ‘tumour-promoting bacteria ‘areindevelopment Bacteria aren'tthe only microbes getting attention, however. Several tumour fighting ‘viruses are also under investigation. Oneof these, called T-VEC, was approved by the FDA {in2015 for treating melanomathat had spres toother parts of thebody. T-VECusesastrain ‘ofherpes simplex virus1, which normally ‘causes cold sores, but has been genetically ‘engineered to make it less harmfultohealthy tissue andto invitean immune attack when itisinsidetumours, These are some of the most promising stories, but there havealsobeen ‘disappointments in thefieldA tral of ‘genetically engineered Listeria bacteriain people with lung cancer, fo instance, was discontinued in 20:8 fterit was found to be ineffective, andanother of genetically ‘engineered Bifidobacterium in people with range of tumourtypes was terminated inz021 for the same reason. is stlla young field andit'snota classical Microbial manipulations We know that microbes can cause cancer o influence tumour growth, but how exactly do they do this? ‘Some bacteria, ike Escherichia cali(E coll) and Campylobacter jejuni release toxins that directly damage the DNA of human cells, tuming them cancerous. And microbes that make theirhomes Inalready-established tumours ‘analso help them to expand. For ‘example, certaintumour-dweling bacteria release chemicals that suppress the activity of nearby immune cells, making it easier forthe cancer to grow unchecked. ‘When bacteraareinside tumour cels, they can also reshape the cells cytoskeletons ~ the structures that maintain theirshapes to make them stronger. This allows the cells to resist damage while traveling through the body and seeding ‘ew tumours. In contrast, some bacteria seemtodampen tumour progression For instance, Helicobacter hepaticus has bbeenshownto shrink colorectal ‘tumours in mice, most likely by attracting nearby immune cells. ‘way to approach cancer intervention-you're injecting something lve isnot like a ill sothereisstillalottoleam anditcan bea bitofa struggle” says Krelder. “But Ithink thereis great hope” ‘As for Balboul,after being toldshe only ‘had months olive, she ended up living over three more years until recently passing away atthe age of74. "Her cancer came back andshe decided she didn't want further ‘treatment,’ says Batist.“But when [told her that we were able to get a phase Iltrial started [ofthe saimoneita bacteria}, she was extremely excited” hesays, Thanks to her courage ‘ntrialing the unusual treatment, Coley’ ‘once-shelved approach may finally find aplaceinmodemn medicine. & ‘AlcekKleinisa reporter for Now Scientist ‘24June2023| Now Scents 4g