Is autoimmunity the Achilles' heel of cancer immunotherapy?
Open accessAbstract
The emergence of immuno-oncology as the first broadly successful strategy for metastatic cancer will require clinicians to integrate this new pillar of medicine with chemotherapy, radiation, and targeted small-molecule compounds. Of equal importance is gaining an understanding of the limitations and toxicities of immunotherapy. Immunotherapy was initially perceived to be a relatively less toxic approach to cancer treatment than other available therapies-and surely it is, when compared to those. However, as the use of immunotherapy becomes more common, especially as first- and second-line treatments, immunotoxicity and autoimmunity are emerging as the Achilles' heel of immunotherapy. In this Perspective, we discuss evidence that the occurrence of immunotoxicity bodes well for the patient, and describe mechanisms that might be related to the induction of autoimmunity. We then explore approaches to limit immunotoxicity, and discuss the future directions of research and reporting that are needed to diminish it.
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Immune monitoring is not standard practice for long-term survivors after immunotherapy or cytokine release syndrome, although these patients may still experience late effects and immune-related adverse events.
“For long-term survivors who received immunotherapy or following CRS, immune monitoring is not yet standard of care, despite evidence that such patients may continue to experience secondary effects of treatment and irAEs [1, 3].”
From Immune reconstitution and clinical recovery following anti-CD28 antibody (TGN1412)-induced cytokine storm (2021) · cites this paper as [1]
The opening discussion (page not supplied) says cancer trials typically follow patients for only about six months and that immunotoxicity can have delayed onset. “Efforts to predict and understand toxicity” (page not supplied) calls for better long-term tracking of irAEs. These passages support concern about late effects, but do not establish that immune monitoring is not standard of care for long-term survivors or for patients following cytokine release syndrome. (LLM, conf=0.86)
Experimental — accuracy not yet measuredClinical-pathologic correlation in these individuals resulted in valuable observations that may be instructive in understanding mechanisms of immune-induced pathologies, including those of checkpoint inhibitors, CAR-T cells, and infections such as COVID-19.
“Clinical–pathologic correlation in these individuals resulted in valuable observations that may be instructive in understanding mechanisms of immune-induced pathologies, including those of checkpoint inhibitors, CAR-T cells, and infections such as COVID-19, known to target mucosal tissues and cause severe CRS [1, 5, 8, 18, 19].”
From Immune reconstitution and clinical recovery following anti-CD28 antibody (TGN1412)-induced cytokine storm (2021) · cites this paper as [1]
Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredAutoimmune colitis, vitiligo, and autoantibody production are now included in CTCAE grading of immune-related adverse events due to immunotherapy.
“Autoimmune colitis, vitiligo, and autoantibody production are now included in CTCAE grading of irAEs due to immunotherapy [1, 4, 6, 20, 22, 34].”
From Immune reconstitution and clinical recovery following anti-CD28 antibody (TGN1412)-induced cytokine storm (2021) · cites this paper as [1]
The section on efforts to predict and understand toxicity describes vitiligo and colitis following immunotherapy. The autoimmune consequences section discusses autoantibodies, but not their production as a graded adverse event. Neither section establishes that these conditions are included in CTCAE grading. (LLM, conf=0.83)
Experimental — accuracy not yet measuredIn some cancer patients, immune checkpoint blockade produces immune-related adverse events during short-term follow-up, but reliable immune biomarkers for these effects remain under study.
“Immune checkpoint blockade induces irAEs during short-term follow-up of some patients with cancer, though robust immune biomarkers correlating with adverse effects of therapy are still being investigated [1, 4, 7, 20–25].”
From Immune reconstitution and clinical recovery following anti-CD28 antibody (TGN1412)-induced cytokine storm (2021) · cites this paper as [1]
Cancer immunotherapies based on antibodies or cells carry intrinsic risks of activating bystander immune responses beyond their intended anti-tumor action.
“Antibody or cell-based immunotherapeutics for cancer carry inherent risks of bystander immune activation, in addition to the effects of treating the intended tumor target [1–5].”
From Immune reconstitution and clinical recovery following anti-CD28 antibody (TGN1412)-induced cytokine storm (2021) · cites this paper as [1]
Therapy for cytokine release syndrome and its neurological toxicity chiefly targets IL-6, which probably originates from monocytes or activated endothelial cells.
“Treatment for CRS and associated neurotoxicity primarily targets IL-6, likely arising from monocytes or activated endothelium [1, 6, 11–17].”
From Immune reconstitution and clinical recovery following anti-CD28 antibody (TGN1412)-induced cytokine storm (2021) · cites this paper as [1]
The ‘Emerging strategies to limit toxicity’ section discusses manipulating cytokine effects to modulate immunotoxicity, but does not say that treatment for CRS and associated neurotoxicity primarily targets IL-6. Searches for IL-6 treatment, monocytes, and activated endothelium found no passage in our copy establishing the claimed treatment or source of IL-6; the ‘Autoimmune consequences’ section mentions IL-6 only in a different context. (LLM, conf=0.75)
Experimental — accuracy not yet measuredAntigen or epitope spread occurs when tumor cell death releases additional antigens that are presented in an immune-activated microenvironment, allowing T cell activation against normal tissue.
“Antigen or epitope spread describes the phenomenon by which tumor cell death releases additional antigens; these antigens are presented in an “immune activated” microenvironment and T cells can be activated against normal tissue”
From Hallmarks of response, resistance, and toxicity to immune checkpoint blockade (2021) · cites this paper as June et al., 2017
Immune-related adverse events with autoimmune correlates do not always share histopathologic, clinical, or demographic features with the corresponding autoimmune diseases.
“those irAEs with autoimmune correlates do not always share histopathologic findings in the involved tissue, other clinical findings, or demographic factor associations with the respective autoimmune phenomena”
From Hallmarks of response, resistance, and toxicity to immune checkpoint blockade (2021) · cites this paper as June et al., 2017
Activation or re-activation of tissue-resident autoreactive T cells is thought to be a dominant factor in the development of immune-related adverse events.
“Activation or re-activation of tissue-resident autoreactive T cells is thought to be a dominant factor in the development of irAEs”
From Hallmarks of response, resistance, and toxicity to immune checkpoint blockade (2021) · cites this paper as June et al., 2017
Therapeutic resistance and immune-related toxicities remain major concerns for immune checkpoint blockade therapies.
“However, therapeutic resistance and immune-related toxicities remain major concerns.”
From Microbiota-centered interventions to boost immune checkpoint blockade therapies (2025) · cites this paper as June et al., 2017
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- Authors
- June, C. H., Warshauer, J. T., & Bluestone, J. A.
- Affiliations
- Parker Institute for Cancer Immunotherapy (US)
- University of California, San Francisco (US)
- Corresponding author
- June, Carl H
- Venue
- Nature Medicine
- Published
- 2017-05
- Volume
- 23
- Issue
- 5
- Pages
- 540-547
- ISSN
- 1078-8956 (ISSN-L)
- 1546-170X
- OpenAlex
- W2610389172
- Cited by
- 445
- References
- 105
- Citations by year
- 2026: 13 · 2025: 31 · 2024: 39 · 2023: 56 · 2022: 46 · 2021: 64 · 2020: 72 · 2019: 46 · 2018: 63 · 2017: 14
- FWCI
- 23.50
- Type
- journal article
- Language
- en
- Update notices
- erratum (2017-08-01)
- Open access
- green
- escholarship.org
- Locations
- Nature Medicine (publishedVersion)
- PubMed (publishedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- University of Pennsylvania
- Parker Institute for Cancer Immunotherapy
- National Institute of Allergy and Infectious Diseases (R01AI046643, R21AI107328)
- National Institute of Diabetes and Digestive and Kidney Diseases (P30DK063720)
- Topics
- Health Sciences › Medicine › Oncology › Cancer Immunotherapy and Biomarkers
- Life Sciences › Immunology and Microbiology › Immunology › Immunotherapy and Immune Responses
- Life Sciences › Immunology and Microbiology › Immunology › T-cell and B-cell Immunology
- Keywords
- autoimmunity, cancer immunotherapy, immunotoxicity, immune checkpoint inhibitors, immune-related adverse events, reporting practices
- MeSH terms
- Autoimmune Hypophysitis, Ipilimumab, Antibodies, Monoclonal, Antineoplastic Agents, Autoimmune Diseases, Humans, Immunologic Factors, Immunotherapy, Neoplasms, T-Lymphocytes, Autoimmunity, Tumor Escape, Adoptive Transfer, CTLA-4 Antigen, Programmed Cell Death 1 Receptor
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