Medullary thyroid cancer (MTC) accounts for ~4% of all thyroid malignancies. MTC derives from the neural crest and secretes calcitonin (CTN) and carcinoembryonic antigen (CEA). Unlike differentiated thyroid cancer, MTC does not uptake iodine and I-131 RAI (radioactive iodine) treatment is ineffective. Patients with metastatic disease are candidates for FDA-approved agents with either vandetanib or cabozantinib; however, adverse effects limit their use. There are ongoing trials exploring the role of less toxic immunotherapies in patients with MTC. We present a 61-year-old male with the diagnosis of MTC and persistent local recurrence despite multiple surgeries. He was started on sunitinib, but ultimately its use was limited by toxicity. He then presented to the National Cancer Institute (NCI) and was enrolled on a clinical trial with heat-killed yeast-CEA vaccine (NCT01856920) and his calcitonin doubling time improved in 3 months. He then came off vaccine for elective surgery. After surgery, his calcitonin was rising and he enrolled on a phase I trial of avelumab, a programmed death-ligand 1 (PD-L1) inhibitor (NCT01772004). Thereafter, his calcitonin decreased > 40% on 5 consecutive evaluations. His tumor was subsequently found to express PD-L1. CEA-specific T cells were increased following vaccination, and a number of potential immune-enhancing changes were noted in the peripheral immunome over the course of sequential immunotherapy treatment. Although calcitonin declines do not always directly correlate with clinical responses, this response is noteworthy and highlights the potential for immunotherapy or sequential immunotherapy in metastatic or unresectable MTC. RET (Rearranged during Transfection) proto-oncogene are characteristic, with germline activating RET mutations seen in fMTC  and MEN (multiple endocrine neoplasia) 2a/MEN2b (Medullary thyroid cancer (MTC) accounts for ~4% of all thyroid malignancies. It is a neuroendocrine tumor deriving from the neural crest-derived parafollicular or C cells of the thyroid gland . About 72a/MEN2b . The gro2a/MEN2b , 7.The role of immunotherapy in MTC is not fully studied. However, previous studies have identified evidence of T-cell infiltration on MTC . DendritRET proto-oncogene). Subsequently, he underwent a total thyroidectomy with bilateral neck lymph node dissection. He then had multiple local recurrences, resulting in a total of five neck surgeries, the last one occurring 12 years after diagnosis. Based on the elevated CTN levels and persistent local recurrence, he then started systemic treatment with off-label sunitinib 13 years after diagnosis  . During Approximately 3 months after surgery, his calcitonin had risen to 9,765 pg/ml and CEA 17.1 ng/mL and the patient was enrolled on a phase I trial of avelumab, a PD-L1 inhibitor , a monoclonal anti-PD-L1 antibody, in subjects with metastatic or locally advanced solid tumors (NCT01772004)) . He thenThese findings coincided with an immune-related adverse event (asymptomatic rise in grade 3 lipase) that led to protocol-mandated treatment discontinuation. A subsequent analysis of the patient's lymph node resected post-vaccination revealed that the tumor was PD-L1 positive . No base+ and CD8+ T cell responses before vaccination, and after six and seven vaccinations with yeast-CEA, corresponding to 3 and 4 months, respectively; PBMCs were also examined 15 days following one cycle (administered every 2 weeks for 30 days) of avelumab (in vitro stimulation (IVS) with overlapping 15-mer peptide pools encoding the tumor-associated antigen CEA or the negative control pool HLA, as previously described  were available from this patient to analyze CEA-specific CD4avelumab . This asescribed , 17. The+, CD8+, natural killer (NK) or NK-T compartments noted at any time point examined.The frequency of 123 PBMC subsets was also evaluated in this patient over his course of treatment at the National Cancer Institute using 11-color flow cytometry on cryopreserved PBMC as previously described  18, 19), 1918, 1For many years, doxorubicin was the only US Food and Drug Administration (FDA)–approved treatment for patients with advanced thyroid cancer; however, response rate in patients with MTC is up to 20% with significant toxicity –23. ReceEvidence for cell-mediated immunity to tumor-specific antigens has been found in medullary thyroid cancer  and earlThis case report may demonstrate the potential for therapeutic cancer vaccines to synergize with immune checkpoint inhibition sequentially in MTC and that principle could be applied as well to other cancers that may have tumor microenvironments (TMEs) devoid of baseline immune recognition. The therapeutic cancer vaccine in this trial was a heat-killed yeast-based vaccine designed to stimulate an immune response against CEA. After a phase I trial demonstrated safety (transient injection site reaction was the most common adverse event) and preliminary evidence of immunologic and clinical activity, a phase II study was developed in MTC (NCT01856920) . The phaDespite the significant recent advances of anti-PD-1 and anti-PD-L1 therapy, they still impact only a minority of patients whose TMEs express those molecules at baseline. One hypothesis is that sequential use of vaccine can drive immune cells to the TME, resulting in an adaptive reaction by tumor cells ; upregulating PD-L1 and perhaps defining a role for anti-PD-L1/PD-1 therapies in patients who may not have otherwise benefited from such immunotherapies , 39. BasInduction of CEA-specific T cells was noted in the peripheral blood of this patient following vaccination with yeast-CEA, but not at later time points. It is possible the CEA-specific cells homed in on the TME inducing PD-L1 expression subsequently seen on the tumor. In addition, fluctuations in the peripheral immunome were noted in this patient over the course of therapy with yeast-CEA vaccine and subsequent avelumab therapy; these changes included both immune-potentiating and immune-suppressive alterations, with the most notable fluctuations occurring after several administrations of avelumab. The increase in suppressive elements may be a compensatory mechanism induced to tamper down the immune activation induced by the different immunotherapy treatments. However, as this patient had metastatic disease, it is unknown whether the changes in the peripheral immunome were directly induced by the sequential immunotherapy regimens or potentially related to disease progression.As with all case reports, these presentations have limitations: the fact that the patient did not have a biopsy at baseline, prior to starting the vaccine, limits understanding of the baseline TME. Thus, it is unclear if the vaccine drove PD-L1 expression or if it was pre-existing in this patient. Little data exist for the presence of PD-L1 expression on MTC tumor cells. To further complicate this case's assessment, the patient was previously treated with sunitinib, which has been able to deplete Tregs, which alone or in combination with vaccine could have impacted the PD-L1 status of this patient . NonetheAlthough a decline in calcitonin does not directly correlate with clinical responses in this case or in MTC in general, the magnitude and consistency of the decline are noteworthy amidst data that suggest the predictive value of calcitonin doubling time and disease progression . Also, mWritten informed consent for publication of clinical details and/or clinical images was obtained from the patient.JD, RD, and RM were responsible for study concept and design. JD and RD acquired the data from the study and prepared the manuscript. RD was responsible for the immune analysis and interpretation. RM reviewed the manuscript. JM, AG, MB, MR, LC, MM, WD, JS, and JG read and approved the final version of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


COVID-19, the pandemic caused by the severe acute respiratory syndrome coronavirus-2, is challenging healthcare systems worldwide. Little is known about problems faced by emergency medical services—particularly helicopter services—caring for suspected or confirmed COVID-19 patients. We aimed to describe the issues faced by air ambulance services in Europe as they transport potential COVID-19 patients.Nine different HEMS providers in seven different countries across Europe were invited to share their experiences and to report their data regarding the care, transport, and safety measures in suspected or confirmed COVID-19 missions. Six air ambulance providers in six countries agreed and reported their data regarding development of special procedures and safety instructions in preparation for the COVID-19 pandemic. Four providers agreed to provide mission related data. Three hundred eighty-five COVID-19-related missions were analysed, including 119 primary transport missions and 266 interfacility transport missions.All providers had developed special procedures and safety instructions in preparation for COVID-19. Ground transport was the preferred mode of transport in primary missions, whereas air transport was preferred for interfacility transport. In some countries the transport of COVID-19 patients by regular air ambulance services was avoided. Patients in interfacility transport missions had a significantly higher median (range) NACA Score 4 (2-5) compared with 3 (1-7), needed significantly more medical interventions, were significantly younger (59.6 ± 16 vs 65 ± 21 years), and were significantly more often male (73% vs 60.5%).All participating air ambulance providers were prepared for COVID-19. Safe care and transport of suspected or confirmed COVID-19 patients is achievable. Most patients on primary missions were transported by ground. These patients were less sick than interfacility transport patients, for whom air transport was the preferred method. COVID-19, the pandemic caused by the severe acute respiratory syndrome (SARS) coronavirus-2 (SARS-CoV-2), is challenging healthcare systems worldwide. In some countries, the number of serious cases has exceeded the resources available and the health care system’s ability to cope. By definition this is a disaster situation, and the SARS-Cov-2 outbreak has been referred to as a mass casualty incident of the highest degree [The COVID-19 virus is highly contagious and can survive for up to 5 days on a variety of surfaces , 4. ThisThe healthcare providers and transferred patients are at high risk of infection if the ambulances and aircrafts are insufficiently disinfected before the next mission . PossiblUntil now, data on COVID-19 patients’ care and transport by air ambulance systems across Europe are very limited . We aimeNine physician staffed air ambulance providers in seven European countries were invited to participate in the study, to give information, and to share their experiences when transporting COVID-19 patients  service, which mainly uses helicopters and to a minor degree fixed-wing aircraft, provided data regarding preparation, special procedures and safety instructions for COVID-19-related missions. The database of the service was used to identify COVID-19-related missions.Luxembourg: The LAR-Luxembourg Air Rescue service, which uses helicopters and fixed-wing aircraft, provided data regarding preparation, special procedures and safety instructions for COVID-19-related missions. The service’s database was analysed to identify COVID-19-related missions.Norway: The Norwegian Air Ambulance service, which uses helicopters and fixed-wing aircraft, provided data regarding preparation, special procedures and safety instructions for COVID-19-related missions.Switzerland: The Swiss Air Rescue service Rega, which uses helicopters and fixed-wing aircrafts provided data regarding preparation, special procedures and safety instructions for COVID-19-related missions. The database was used to identify COVID-19-related missions.Of the nine invited air ambulance providers, six agreed to participate. The participating providers were based in six European countries and agreed to provide the following information :Different providers have special patient isolation units (PIUs) in stock for transport of infectious patients, which can also be used to transport COVID-19 patients. The most common PIUs are the EpiShuttel® and the REGA PIU. The Epishuttle® is a CE 1789 compliant reusable single-patient isolation and transport system that can be used in ambulances, helicopters and airplanes. The shuttle can either be used to protect the surroundings from an infectious patient or to protect the patient from the surroundings. During transport, the medical crew does not need to wear full personal protective equipment. The EpiShuttle® is equipped with different ports  and a ventilation system that generates more than 15 air exchanges per hour and can be used with negative or positive pressure inside, depending on who needs to be protected (the patient or the crew). The Rega PIU comprises a flexible safety hull stabilised by arched wires mounted on a hard floor plate. It is maintained under negative pressure by a high-efficiency particulate air filtered ventilation system that uses aircraft power and/or battery power. The PIU barrier performance has proven equal to that provided by protective clothing. Its fixation system allows transportation on any commonly available patient stretcher. The PIU is designed to fit in a fixed-wing ambulance, a medium-sized helicopter, and ground-based ambulances .General data: Age, gender, National Advisory Committee for Aeronautics (NACA) Score, suspected or confirmed SARS-CoV-2 infection.Mode of transport: Ground ambulance accompanied by doctor, ground ambulance without HEMS doctor attendance, helicopter transport, fixed-wing aircraft transport, transport to maximum care hospital or basic care hospital, no transport to medical facility.Medical interventions during missions: intravenous (i.v.) access, fluid therapy, drug administration, oxygen therapy, non-invasive ventilation (NIV), airway management, lung ultrasound, cardiopulmonary resuscitation (CPR) including the use of an automated chest compression device (ACCD), extracorporeal membrane oxygenation (ECMO).Hygiene: face mask for spontaneously breathing patients, use of a filtering face piece (FFP) mask by the crew, use of common surgical face masks by the crew, use of safety glasses/goggles by the crew, use of complete personal protective equipment, final disinfection of the aircraft, use of a PIU.Four air ambulance providers (see above) agreed to provide data of COVID-19-related missions. Of these COVID-19-related missions, the following variables were studied:All missions from February 1, 2020, to April 30, 2020, were included in the retrospective data collection and analysis. The data management systems of the providers agreed to provide mission related information were analysed regarding general data of potential COVID-19-related missions and the above mentioned study variables.p value of less than 0.05 was considered significant. Statistical analyses were performed using GraphPad Prism 8 for Windows .COVID-19-related primary missions were compared with interfacility transport missions regarding general data, mode of transport, medical interventions and hygienic procedures. Data are presented as number (%), mean (SD), or median (range) as appropriate. Fisher’s exact test was used to compare the categorical data of two independent groups, while the Mann-Whitney U test was used to compare continuous or ordinal data of two independent groups. Nonparametric statistical methods were used to compare these groups because these methods compare the ranks and not the crude numbers, without the need for a normal distribution or equal variance of the data, and they protect against small numbers of events. A The study is in line with the current European general data protection regulation (GDPR).During the study period, the participating air ambulances cared for 385 potential COVID-19 patients with a mean age of 61.3 ± 10.8 years and 266 of these were males (69%).The median (range) NACA-Score of these 385 patients was 4 (1-7) and 233 patients  had confirmed COVID-19.A majority of the European countries participating had some time to prepare a response to the expected corona pandemic. Accordingly, all participating air ambulance providers used this time to develop special procedures and safety instructions for managing COVID-19 patients . The safety instructions of all providers are very similar see Fig. .Fig. 1ATable There were significant differences in the mode of transport used by the air ambulance services for primary and interfacility transport missions. Ground transport was the preferred mode of transport in primary missions (72%), with 28.6% of patients being transported without a physician present. On the other hand, air transport was preferred for interfacility transport (87%). In some countries , transport by regular HEMS was generally avoided. Only COVID-19 patients with a true time-critical condition were transported in an HEMS aircraft, which is a safer and faster method. All other transport missions in both countries were carried out by the Search and Rescue (SAR) service of the armed forces. The 48 long-distance flights  were carried out by fixed-wing aircraft.The majority of patients treated needed medical interventions during the missions. Table Table Ground emergency medical services and HEMS are part of the medical chain in the care of patients with COVID-19. Due to the pandemic, they are faced with new challenges, and different countries and health care systems vary in their reactions to the problem. Our study’s data demonstrate that, although care and transport of COVID-19 patients may be handled in different ways in different European countries, it is nevertheless safe. As the number of patients with COVID-19 could increase, however, aeromedical crews must be able to adapt.All participating air ambulance providers developed special procedures and safety instructions to be followed when transferring COVID-19 patients, including equipping the aircrafts with full PPE, and training their crews in its proper use. This and the training of crews in how to deal with COVID-19 patients could have contributed to the fact that no COVID-19 infections were reported in crew members flying these missions. During the “hot period” of the pandemic, it was difficult to get supply of PPE and disinfectant on short term basis, but the involved air ambulance providers never went out of stock.At present, ground transport of COVID-19 patients seems to be the preferred mode of transport when caring for patients in a primary mission. This data is in line with recommendations across Europe . On the In a primary mission for a noncritical patient who needs further medical treatment in a hospital, transport by ground ambulance without physician attendance is practical, safe and resource sparing. In the case of critically ill patients, the HEMS team has to decide whether an HEMS physician should accompany the patient and which mode of transport is most useful, taking into account the distance to the hospital, possible changes of equipment, potential deterioration of the patient during transport, and the need for final disinfection. After air transport of a COVID-19 patient, the aircraft is out of service until the final disinfection, if no PIU was used.Patients in critical condition who are being transferred to a higher-level care facility may need medical interventions en route. Air transport is the logical method in many of these cases. Data in the literature show that patients who are transferred using expedited helicopter transfer protocols have better post-transfer survival . In the In the study involved Scandinavian countries, HEMS transport of COVID-19 patients is avoided, with the search and rescue (SAR) service of the armed forces being in charge instead. Denmark, for example, like many other European countries, has a tight network of ground-based pre-hospital critical care services, and rapid-response vehicles are staffed with consultant anaesthetists and paramedics. Most COVID-19 patients in Denmark were transported by these services in collaboration with the local EMS. Patients from islands not attached to the Danish mainland who are suspected of having or confirmed to have COVID-19 are as a rule transported in the Merlin 101 SAR helicopters. These are operated by the Danish Air Force, with critical care capabilities provided by physician-paramedic teams from the Central Denmark Region. These teams are using the EpiShuttle® to isolate patients during transport. In Norway, the procedure of dealing with COVID-19 patients is similar to Denmark.In some countries, the number of serious cases was beyond what the health system could accommodate while still maintaining high European standards of care. Accordingly, some serious cases were transported to neighbouring European countries with additional intensive care capacity. Long-distance transport was primarily performed by fixed-wing aircraft, as was repatriation of European inhabitants from overseas. Especially the REGA and LAR fixed wing air ambulance services transported COVID-19 patients from south of Europe  to central European countries like Germany, Switzerland, Luxembourg. The DRF-Luftrettung used EpiShuttel® equipped helicopters for cross-border transport between France and Germany. Figure SMany medical interventions were carried out in emergency situations, such as airway management and suction which are associated with high risk of contamination. Therefore, it is of utmost importance to equip the EMS and HEMS with PPE to wear when taking care of patients with suspected or confirmed COVID-19. Modern air ambulance services are able to provide advanced interventions during transport, including intensive care procedures, differentiated catecholamine therapy, volume resuscitation, modern ventilation strategies, ECMO, inhaled nitric oxide, or even the use of heart-assisted devices (e.g. like Impella®) during transport –15. SeveFluid therapy and drug administration are common in emergency medicine and intensive care, and are performed in COVID-19 patients as well. Surprisingly, the use of lung ultrasound in the pre-hospital setting is very limited, although it could help diagnose emergency patients with dyspnoea. Portable point-of-care ultrasound (POCUS) is a safe and effective bedside pre-hospital tool which can be used for initial evaluation and management in patients with confirmed or suspected COVID-19 infection . The datDue to lack of information on infection status and limited resources and space, the risk of virus transmission in a helicopter or airplane is possibly higher than for in-hospital healthcare providers. Furthermore, many medical interventions increase the risk of virus transmission –8. ExampInterfacility transport missions can be very exhausting and physically stressful for the medical team. They often involve several hours of work in full PPE, conditions which may contribute to medical errors . Therefo. First, it presents a selection of European HEMS providers, and cannot be generalized for all European air ambulance services. All studied services were physician staffed and the results may not apply to non-physician staffed services. Second, not all invited providers were able to report COVID-19 patients’ mission-related data because COVID-19 patients were transported by the SAR service of the armed forces in their country. We do not have any information about patients’ comorbidity or hospital mortality. Third, European countries with a very high incidence of COVID-19, like Italy, France and Spain, did not participate in this study. Nevertheless, this study clearly shows that safe care during long transport of COVID-19 patients is achievable.Our study has some limitations with a relatively short study period in a fast changing pandemic situationParticipating air ambulance providers were prepared in advance for COVID-19-related missions. Safe care and transport of suspected or confirmed COVID-19 patients is achievable. Most patients transferred after on-scene calls are transported by ground. These patients tend to be less sick than patients being transferred from one facility to another, whom needed significantly more mission-related interventions. Air transport was the preferred method for these patients, and long-distance flights were carried out by fixed-wing aircrafts.Additional file 1.Additional file 2: Table S1. Information regarding the air rescue service of the participating countries.


In multivariate regression, individuals in neighborhoods with the highest income quartile were more adherent to PAP therapy than those in the lowest income quartile after adjusting for various confounders (adjusted Odds Ratio (adjOR) 1.18; 95% confidence interval (CI) 1.14, 1.21; p < 0.0001). Over the past decade, PAP adherence improved over time , but health inequities in PAP adherence remained even after the Affordable Care Act was passed. (d) Conclusion: In a nationally representative population, disparities in PAP adherence persist despite Medicaid expansion. Interventions aimed at promoting health equity in sleep apnea need to be undertaken.(a) Background: In patients with sleep apnea, poor adherence to positive airway pressure (PAP) therapy has been associated with mortality. Regional studies have suggested that lower socioeconomic status is associated with worse PAP adherence but population-level data is lacking. (b) Methods: De-identified data from a nationally representative database of PAP devices was geo-linked to sociodemographic information. (c) Results: In 170,641 patients, those in the lowest quartile of median household income had lower PAP adherence  than those in neighborhoods with highest quartile median household income (4.5 + 2.5 hrs/night; 47% adherent by Medicare criteria;  Obstructive sleep apnea (OSA) is a prevalent condition that is most frequently treated with positive airway pressure (PAP) therapy ,2. HowevSpecifically, Platt and colleagues showed that in the Veteran population in Philadelphia, PAP adherence (>4 h/night for 70% of nights) was great among higher SES neighborhoods (64%) compared to lower neighborhoods (34%) . SimilarPAP adherence has been proposed as a quality metric . If PAP ®™, Philips-Respironics, Inc., Murrysville, PA, USA) was geo-linked to publicly available de-identified data that provides median household income information by 5-digit ZIP code of residence contained in both datasets [We performed a bioinformatics-based study whereby de-identified data obtained from the national-level adherence database . Therapy data were uploaded from the patient’s PAP device to the database through wireless technology, Secure Digital (SD) cards, or telephone modem dating from 2000 to 2016. Database contained variables of interest including the following: (a) year of set-up; (b) 5-digit ZIP code ; (c) device type; days of PAP therapy; (d) average daily adherence (hours and minutes); (e) average daily adherence (days used); (f) minimum usage hours; maximum usage hours; (g) percent days used; (h) percent days not used; (i) days with usage; (j) percentage of days with > 4 h of usage; (k) percentage of days with < 4 h of usage; (l) average leak; percentage of night spent in high leak; (m) apnea–hypopnea index; (n) central apnea index; (o) whether Medicare criteria for adherence was met; and (p) the days it took to meet such a Medicare adherence criterion. De-identified data were extracted from the web-based patient management system that supports the monitoring of PAP therapy in patients with sleep apnea  were associated with PAP adherence. We evaluated age, gender, race, ethnicity, device type, residual sleep-disordered breathing events , and altitude of residence as covariates. Variables were included in the multivariate model if the p-value was < 0.10. We performed collinearity diagnostics and sensitivity analysis as appropriate. We analyzed group differences between various income groups and year of PAP set-up using Kaplan–Meier curves to visualize the time taken to achieve Medicare-defined adherence from the date of set-up; log rank test to compare the curves across various income groups or set-up years, and Cox proportional hazards regression to describe the effect of the determinants (various income groups) on time to Medicare-defined adherence. Statistical analyses were performed using the SPSS software . Unadjusted comparison of various baseline characteristics across the four different quartiles of median household income groups was performed using Analysis of Variance (ANOVA), χFor our analyses of the effect of the Affordable Care Act on the time to Medicare-defined PAP adherence, we used multivariable regression, with a generalized linear model. The independent variable of interest was the interaction between timing after Medicaid expansion and median income quartile, which compared the average difference in time to time to Medicare-defined PAP adherence between the various income quartiles in the period before ACA expansion with that after expansion, with adjustment for covariates. Similar analysis was performed for 90 days and 120 days for effect of various income quartiles on time to Medicare-defined PAP adherence to determine the difference in differences between various income quartiles before and after the 90- or 120-day time point following PAP set-up date. We had complete data in 170,641 (63.7%) of the 267,793 individuals that were extracted from the database. The adherence data within the database contained the individual-level five-digit ZIP code data which was mapped to the U.S. Census collected at the ZIP Code Tabulation Areas (ZCTA) . Adherence data and demographic information are provided in Raw unadjusted average daily adherence to PAP therapy was greater in higher income groups than lower income groups . Proportp < 0.0001). Raw unadjusted adherence by device type revealed best adherence for autoPAP devices followed by progressively lower levels of adherence to continuous positive airway pressure (CPAP), bilevel PAP, auto-bilevel PAP, adaptive servo-ventilation (ASV), and averaged volume assured pressure support . A closer review of the time point when differences between the income quartile groups began points to the inflection at the 90 and 120-day time points . Similarly, the difference-in-difference analysis for the 120-day timepoint revealed a greater difference in time taken to achieve Medicare-defined adherence across all four income groups .Temporal patterns of adherence for individual patients as well as for the entire cohort over the past 17 years for all patients were evaluated. For the former, the time taken to achieve adherence based upon Medicare definition was greater in the lower income groups than higher income groups (e points  inset. Tp < 0.0001). However, difference-in-difference analysis across the various income groups did not reveal any effect of the 2014 ACA on health inequities in PAP adherence when compared to before 2014 (p = 0.7).For the temporal pattern over the past 17 years, with various time periods expressed as quartiles by year for PAP device set-up, progressively more recent calendar year of PAP therapy initiation was associated with greater PAP adherence , but theWe found health inequities in a nation-wide analysis of PAP adherence. Such findings are consistent with other prior reports of health inequities from state or multiple city datasets ,10,11. SWe found two time-based effects that pertain to patient-level data as well as temporal change in adherence over the 17-year time period by the year of PAP device initiation or set-up. First, for the patient-level temporal pattern, we noticed that the inequities in adherence began at the 90-day period which corresponds to the “90-day Medicare rule”. Essentially, the Center for Medicare and Medicaid Services (CMS) propounded a National Carrier Determination for PAP benefits in 2008 which proposed a 12-week trial period (90 days) soon after PAP device set-up. This 90-day rule proposes that for continued PAP benefits, the CMS beneficiary needs to use the PAP device in an adherent manner  and benefit symptomatically. Failing the achievement of PAP adherence, depending on the insurance type, individuals may lose PAP medical benefits or may need to make a visit to see a provider in order to maintain continued insurance coverage for the PAP therapy. The Kaplan–Meir plots were revealing in that they showed separation or appearance of differences in Medicare-defined PAP adherence at the 90- and 120-day time points  inset. DA second time-based effect was the association between the year of set-up and adherence ; Table 5The device technology surprisingly revealed greater adherence to CPAP when compared to other PAP devices after adjusting for household income. CPAP devices had better adherence than all other PAP devices after adjusting for confounders including household income  AlthoughAn important consideration that needs discussion is the clinical significance of the effect size of the association between socioeconomic status (measured as median household income) and PAP adherence in our study. Most ascertainments of clinically meaningful differences in adherence are derived from clinical trials or consensus of experts rather than real-world population-based studies. Although, the average adherence measured as hours per day is seemingly small between the extremes of median household income  the proportion of individuals who are nonadherent as per Medicare criteria is much more significant at 7.4% ) can havIn conclusion, in a nationally representative population of patients with sleep apnea, socioeconomic inequities in PAP adherence persist despite Medicaid expansion. Considerations for change in health policy for individuals in lower income neighborhoods in addition to patient-level interventions aimed at promoting PAP adherence would be responsive to calls for promoting health equity in lower income populations ,37,38,39


Intense research on immunotherapy has been conducted during recent years. As advances in the field have started changing the landscape of cancer therapy, it is necessary to assess the impact of immunotherapeutic modalities in the treatment of various cancers. Ten years ago, in 2011, ipilimumab was the first of the newest immunotherapeutic drugs against cancer to be approved by the FDA. Then several drugs followed and formed a therapeutic arsenal to fight cancer. Initial studies were performed on metastatic patients, but there are currently several studies in patients with potentially curable cancers. All these developments have created a new environment for oncology which we will present in this article. This review examines the current evidence related to the impact of immunotherapy on various cancers and discusses its potential clinical and research implications, including its effectiveness in comparison to other treatment modalities , its toxicity and prospective research opportunities. While constant updates and further research is critical to understand the impact of immunotherapy in cancer therapy, not only does it seem to be important to assess the current state of knowledge highlighting the success but also to determine the challenging aspects of cancer immunotherapy. Immunologic manipulations to control tumor growth can essentially be either passive or active. The difference between active immunotherapy and passive immunotherapy is related to their impact on the immune system of the patient. Active immunotherapy aims to produce a durable immune response on the grounds of induced immunological memory. The concept of active immunotherapy simulates a physiological immune response .Agents commonly administered in the context of active immunotherapy consist of interferons and interleukins, as well as microbial strains. The bacillus Calmette Guerin (BCG), the microorganism causing tuberculosis, is a typical example of active immunotherapy administered in the context of non-muscle invasive urinary bladder cancer. The immune response induced by BCG has been proven to lead this type of cancer to regression ,3.Passive immunotherapy substitutes the roles of the human immune system without requiring an active response of the immune system to cancer cells. Passive immunotherapy consists of administering immunologic reagents, including serum, cells, or cell products with antitumor activity, to a tumor-bearing patient. Monoclonal antibodies (mAb’s) represent the largest class of commercially available passive cancer immunotherapies to date and are directed to a single cellular target .Anticancer immunotherapeutic regiments that have received approval by regulatory authorities all over the globe so far include dendritic cell-based immunotherapies (Sipuleucel-T), immunostimulatory cytokines , immunomodulatory mAb’s , oncolytic viruses (vitespen), pattern recognition receptor (PRR) agonists  . AnticanDuring the past decades, anticancer immunotherapy has evolved from a promising research concept to an incremental part of clinical oncology. Not only has a wide variety of immunotherapeutic agents been licensed by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA), which have already been available for use in cancer patients, but also many other agents are under investigation. In most cases, immunotherapy is administered as an addition to conventional therapeutic means. Moreover, there is a growing tendency of developing existing or novel immunotherapeutic agents as standalone therapeutic interventions . To the The inception of anticancer immunotherapy can be traced back to Hippocrates as a concept although we should seek its whereabouts in the work of William Coley . The iniDespite the spectacular effect of this primitive immunotherapy, its etiological basis was not understood. Its effectiveness proved to be sporadic and when radiotherapy appeared, Coley toxins were abandoned for long. The concept of Coley toxins remained intriguing sparkling relevant basic research attempts. Between 1930 and 1945, several animal studies with bacteria contaminating various tumors were conducted. The principal findings were that not only did bacteria cause tumor necrosis, but also serum from endotoxin-treated tumors could be reintroduced to tumors .The fact that the serum contributed to tumor necrosis, led researchers to conclude that it contained a “tumor necrotizing factor”. In the next years, investigators comprehended that the destruction was invoked by host cells as a response to bacterial endotoxins and not by the endotoxin itself. Subsequently, the term was modified to tumor necrosis factor (TNF). TNF failed as a systemic treatment because of serious side effects including fever, rigor, headache, hypotension and pulmonary edema ,9. Soon after, researchers at John Hopkins University observed a lower prevalence of cancer among patients who have recovered from tuberculosis. This observation led to the use of BCG as anticancer immunotherapy. However, clinical implementation was halted for about thirty years due to an unfortunate administration of a contaminated vaccine to numerous newborns in Germany, also known as the Lubeck disaster .A decisive turn in the history of anticancer immunotherapy was observed in the early 1970s, when the discovery of IL-2 sparked hypotheses that led to promising results. From 1990 onwards intense research is conducted including real-world data from clinical trials and every day clinical practice .The future history of anticancer immunotherapy is expected to be more fascinating taking into consideration the potential that novelties such as artificial intelligence, machine learning, the internet of things and quantum computing tend to play a more active role in healthcare. Accelerated screening and identification of therapeutic targets, immunotherapeutic agents’ repurposing and clinical trial data analysis are only some of the features that have the potential to speed up the evolution of cancer immunotherapy unraveling new therapeutic paths .In the meantime, the key concept of the evolution of cancer immunotherapy has yet to be deeply understood. A concept can be discovered by mistake or through an unfortunate incident. Even though its development can be halted, it might still be worthy of being revisited when knowledge progresses to reveal previously hidden insights.Overall, the accumulating wealth of knowledge concerning anticancer immunotherapy needs to be promptly assessed and assimilated in clinical practice and medical/postgraduate education. Hence, the purpose of this article is to review the status of immunotherapy impact in new anti-cancer treatments.The current evidence about immunotherapy impact on new anti-cancer treatments is reviewed in this article. Particularly, preclinical and clinical data from phase I/II clinical trials, which evaluate the efficacy and toxicity of immunotherapeutic agents for patients with cancer, are summarized based on PubMed/MEDLINE search and relevant articles, which have been presented at international conferences. In addition, future perspectives about the emerging role of immunotherapy regarding variant types of cancer, such as small cell lung cancer (SCLC) are highlighted in light of potentially useful biomarkers and health policy. We searched Pubmed and Google Scholar with the following strategy: {[prospective (Title/Abstract) OR cohort (Title/Abstract) OR follow-up (Title/Abstract) OR review (Title/Abstract) OR longitudinal (Title/Abstract) OR meta-analysis (Title/Abstract) OR systematic review (Title/Abstract)] AND [immunotherapy (Title/Abstract) OR cancer (Title/Abstract)] AND [cancer treatment OR melanoma OR colon cancer OR urothelial cancer OR lung cancer OR breast cancer (MeSH Terms)]}, up until September 2020. This search strategy aims to identify: (1) Clinical trials involving immunotherapy; (2) Other original studies or metanalyses related to the use of immunotherapy. Original, peer-reviewed studies in English were included. Immunotherapy has been deployed in the context of anal, breast, colorectal and head and neck cancer , hepatocImmunotherapy has been demonstrated to be beneficial to patients with refractory metastatic anal squamous cell carcinoma (SCC) with progression disease (PD) after chemotherapy. The anti-PD1 moAbs, Pembrolizumab and nivolumab, as well as, the PD-L1 moAb, durvalumab, have been studied in the metastatic disease showing promising results in terms of PFS and OS . Specifip = 0.002), whereas the mPFS was 7.5 months and 5.0 months, respectively among patients with PD-L1 positive tumors, . Furthermore, the median OS benefit in favor of the immunotherapy arm was approximately 10 months  in case of PD-L1 positive malignancies, whereas it was estimated 3.7 months ; among patients with PD-L1 negative tumors. Consequently, both groups have reaped the PFS benefit of immunotherapy irrespective of the PD-L1 status. However, noteworthy is the fact that no statistically significant benefit has been documented regarding overall survival [The high prevalence of breast cancer as well as the fact that this disease can still be diagnosed at a late stage or show minimal response to other treatments creates a need for the involvement of immunotherapeutic agents in this field, as well. As far as hormone receptor (ER and PR) negative and HER2-negative triple-negative breast cancer (TNBC) is concerned, the checkpoint inhibitor atezolizumab has been approved by the FDA for use with the chemotherapeutic agent nab-paclitaxel in patients with advanced TNBC . This suggestion stands as long as PD-L1 stained, tumor-infiltrating immune cells of any intensity cover ≥1% of the tumor area. The TNT phase III clinical trial provided modest but statistically significant evidence favoring atezolizumab in terms of progression-free survival . More spsurvival . Furthersurvival .p = 0.0002) and mOS after 1 year of follow-up (13.7 months versus 10.8 months). ORR was 43.8% of the patients in the immunotherapy arm in comparison with 33.1% in the chemotherapy arm. Last but not least, there was a threefold increase in the treatment-related toxicity grade 3 or higher when it comes to patients who received chemotherapy compared with those who received pembrolizumab (66% versus 22%) [Anti-PD-1 agents, pembrolizumab and nivolumab as well as the combination of nivolumab with ipilimumab are currently investigated in the context of colorectal cancer (CRC). Evidence for pembrolizumab derives from a phase 2 trial by Dung et al. in 2015. 41 patients with adenocarcinomas (32 of 41 with CRC) were treated with pembrolizumab for the treatment of tumors with and tumors without mismatch-repair deficiency (MMR-d) investigating the hypothesis that MMR-d tumors are more responsive to PD-1 blockade in comparison to mismatch repair proficient tumors . The resNivolumab in a phase II trial (CheckMate 142) demonstrated activity in patients with microsatellite instability (MSI)-high or mismatch repair deficient metastatic colorectal cancer . FollowiThe extent of antitumor activity of immunotherapy in gynecological malignancies has yet to be established. Among these malignancies, besides cervical cancer, the inhibition of the PD-1/PD-L1 pathway may also be beneficial to women who have been diagnosed with ovarian cancer and vulvar cancer. There is a plethora of ongoing studies when it comes to the efficacy of immune checkpoint inhibitors (ICIs) against cervical cancer. Initial studies of pembrolizumab, nivolumab, atezolizumab and durvalumab either as single-agents at the metastatic disease or in combination with chemoradiotherapy at the locally advanced setting have yet to bear encouraging results regarding cervical cancer ,24. As fp = 0.0007) and in the CPS of 1 or more population: 12.3 vs. 10.3, 0.78 (0.64–0.96), p = 0.0086). Moreover, the combination of pembrolizumab with chemotherapy led to OS benefit up to 3.7 months versus cetuximab with chemotherapy , p = 0.0034, in the CPS of 20 or more population: 14.7 vs. 11.0, 0.60 (0.45–0.82), p = 0.0004 and in the CPS of 1 or more population: , p < 0.0001). On the contrary, PFS benefit has not been observed in favor of immunotherapy in this study [As far as head and neck cancer is concerned, pembrolizumab has received FDA approval in combination with platinum-based chemotherapy or as a single agent for patients with high PD-1 expression. The KEYNOTE-048 open-label phase III trial included 882 patients with inoperable recurrent or metastatic head and neck squamous cell carcinoma treated with single-agent pembrolizumab, chemotherapy plus pembrolizumab or a combination of targeted therapies (cetuximab) and chemotherapy . Within 13 months of evaluation, the combination of pembrolizumab and chemotherapy demonstrated improved overall survival in patients expressing PD-1, and especially those expressing high-level PD-1 (according to PD-L1 combined positive score (CPS) stain gradient) in comparison to other regimens. More particularly, monotherapy with pembrolizumab yielded an OS benefit up to 4.2 months versus cetuximab with chemotherapy  0.61 (95% CI 0.45–0.83), is study .As far as metastatic nasopharyngeal cancer is concerned, to date, there is no available immunotherapy. However, several experimental approaches are spanning from adoptive immunotherapy to active immunotherapy. Adoptive immunotherapy is based on the direct activation of effector immune cells, while active immunotherapy is using Epstein–Barr virus (EBV) vaccination to stimulate tumor antigen recognition by the host immune system. Anti-PD-1 agents are also assessed in the context of metastatic nasopharyngeal carcinoma ,30,31.Active immunotherapy is being investigated with the form of vaccines. Three trials have been reported so far. Three phase II trials testing a vaccine based on dendritic cells. The first study recruited 16 patients with local recurrence or distal metastasis. More than 50% of them reported favorable outcomes. The second study also included 16 patients with stage II/III nasopharyngeal cancer. More than 9 patients reported favorable outcomes, however, 9 patients presented with delayed hypersensitivity later. The third trial focused on patients with extensive metastatic disease and reported poor outcomes. More potent vaccines administered at the early stage of the disease ought to be studied .Checkpoint inhibitors are investigated in the KEYNOTE-028 study. 27 patients who have received treatment previously being diagnosed with, PD-L1 positive, metastatic or recurrent nasopharyngeal carcinoma were treated with pembrolizumab (10 mg/kg every 2 weeks for up to two years). 26% of the patients showed a partial response. Disease stabilization was achieved in 14 patients (52%) who were followed-up for a median of 20 months. The median progression-free survival reached 6.5 months, with progression-free survival 50 and 33% rates at 6 and 12 months, respectively .Another phase II study included 44 patients, who were on nivolumab (3 mg/kg every two weeks) having previously received at least one dose of platinum-based chemotherapy for recurrent disease. With 12.5 months of a median follow-up, the objective response rate reached 20.5 percent. One patient showed a complete response and eight showed partial responses. The one-year progression-free rate reached 19% and the overall survival rate was 59% .To date, two ongoing randomized trials have been acknowledged. They investigate pembrolizumab  or a different anti-PD-1 antibody (NCT02605967), known as PDR001, in comparison to the indicated chemotherapy regimens for recurrent or metastatic nasopharyngeal cancer that progressed after platinum-based chemotherapy ,32.p < 0.001). Grade 3 or 4 adverse events, mainly hypertension, were reported in 56.5% of the atezolizumab–bevacizumab group and 55.1% of the sorafenib group. These findings suggest the combination of atezolizumab–bevacizumab as a first-line treatment for unresectable HCC [Immunotherapy for hepatocellular cancer (HCC) has emerged in recent years due to its predominance among liver cancers, its prevalence among cancers in general and the paucity of treatments ,34,35. Iable HCC .Pembrolizumab has recently received accelerated access approval from the FDA as a second-line treatment after sorafenib based on an open-label, phase II KEYNOTE-224 trial including 104 patients were not responsive to sorafenib. Pembrolizumab was associated with an objective response of 17% with a complete response in one patient, partial response in 17 patients, and disease stabilization in 46 patients . HoweverTremelimumab, a monoclonal anti-CTLA4 antibody was assessed in a phase II multi-center clinical trial including 20 patients with advanced HCC from hepatitis C viral etiology. The administration of tremelimumab at the dose of 15 mg/Kg intravenous (IV) every three months lead 18% of patients to partial response and 60% of patients of disease stabilization with progression-free survival of 6.48 months .Testing a variety of agents and combinations of them in patients with HCC is of paramount importance, therefore, at present, numerous clinical trials are active. A striking example is the phase I trial of the combination of pembrolizumab and lenvatinib, which was well tolerated with promising anti-tumor activity in patients with unresectable HCC ,43. FurtVarious forms of lung cancer have been a target for immunotherapy. Recent evidence or ongoing studies focus on resectable non-small lung cancer (NSCLC), extensive-stage small cell lung cancer, metastatic small cell lung cancer and refractory and relapsed small cell lung cancer ,47,48.p = 0.02) and PFS  among patients with metastatic non squamous NSCLC, regardless of PD-L1 expression and EGFR or ALK genetic alteration status [Choosing the treatment of NSCLC lacking a driver mutation takes into consideration the level of PD-L1 expression, the extent of disease and pathology. Recently, two clinical trials concerning combinations of chemotherapy with immunotherapy constitute the hallmarks of the current therapeutic manipulations of metastatic lung cancer. Firstly, according to the KEYNOTE-407 clinical trial, the addition of pembrolizumab to chemotherapy with carboplatin plus nab-paclitaxel or paclitaxel contributed to significantly longer OS  and PFS  than chemotherapy alone regardless of the level of PD-L1 expression . On the n status . These an status . The addn status .Anti-PD-1 and anti-CTLA4 based immunotherapies are investigated as adjuvant or neo-adjuvant treatments for resectable NSCLC. More specifically, adjuvant treatment aims to the regression of micrometastatic disease while neoadjuvant treatment aims to “downstage” primary tumors or decrease the morbid effects of surgery and enable a subsequent analysis of the treated tumor. Phase II trials currently exploring immune checkpoint inhibitors include the NEOMUN (NCT03197467) and NADIM (NCT03081689) studies, as well as the platform NeoCOAST (NCT03794544) trial ,52,53.NSCLC metastasizing to the brain can also be a target of immunotherapy. Experience in this field is limited, given that the existing insights derive from the use of anti-PD-1 agents to resectable NSCLC with significant PD-1/PD-L1 presence. Old evidence supported PD-1/PD-L1 based immunotherapy as monotherapy with promising objective intracranial responses in up to 30% of patients with NSCLC related-brain metastases. A retrospective study of 255 patients suggests durable intracranial outcomes that can be accompanied by favorable extracranial responses in 13% of patients ,55. ThisConcerning the initial management of extensive-stage SCLC, immunotherapy can be combined with chemotherapy according to the latest evidence . Anti PDWhen it comes to refractory and relapsed small cell lung cancer, immunotherapy is considered as a first choice second-line treatment. Nivolumab, alone or in combination with ipilimumab is evidenced for most patients with extensive SCLC after progression on initial chemotherapy, provided that: (1) they did not also receive immunotherapy in the frontline setting; (2) the relapse did not occur within 6-months—in that case, chemotherapy is preferred. Pembrolizumab has also received approval by the FDA for patients with metastatic SCLC who have experienced progression on or after platinum-based chemotherapy and at least one other line of therapy. Ongoing clinical trials investigate whether pembrolizumab stands as a monotherapy for patients who experienced adverse events with nivolumab and ipilimumab ,58.Chemoimmunotherapy has been established as the cornerstone of the management of non-Hodgkin’s lymphoma (NHL) for decades. More specifically, it has been documented by a majority of studies and meta-analyses that the combination of conventional chemotherapy with rituximab, which is an anti-CD20 agent, contributed to superior RR and OS . ConsequAs far as classic Hodgkin’s lymphoma (HL) is concerned, there is a very alluring strategy that entails the delivery of chemotherapy to CD30-expressing cells, such as the Reed Sternberg (RS) cells of HL embracing the assistance of the antibody-drug conjugate, brentuximab vedotin . When itCutaneous melanoma as well as advanced melanoma can be treated with immunotherapy. Nivolumab was approved by the US Food and Drug Administration (FDA) in December 2017 for adjuvant treatment of patients who had undergone definitive resection of cutaneous melanoma and had metastatic lymph node involvement, and for patients with stage IV disease who had undergone definitive resection of all sites of disease. Following surgical resection of cutaneous melanoma, nivolumab showed superiority over ipilimumab . Pembrolp < 0.001) [Checkpoint inhibitors, such as nivolumab, ipilimumab and pembrolizumab have recently been approved for the treatment of advanced melanoma. Monotherapy with ipilimumab tends to be replaced by nivolumab and pembrolizumab due to its toxicity with an exception for BRAF wild type melanoma, which seems to respond better to ipilimumab. Nivolumab has been introduced to the treatment of advanced melanoma in 2015 and has been further supported by trials published in 2019 and its dosage was later adjusted based on more recent evidence ,67,68,69< 0.001) .As far as neuroendocrine tumors (NETs) of the gastrointestinal tract are concerned immune checkpoint inhibitors immunotherapy has attracted the attention for the treatment of patients with well-differentiated NETs. Limited data suggest that anti- PD-1 antibodies have minimal activity as single-agent therapy. Spartalizumab (PDR001), which was evaluated in a multicenter phase II trial with including 116 patients with various NETs reported a radiographic response rate of 7.4% for well-differentiated NETs and 0% for gastrointestinal neuroendocrine tumors (GI NET). The stable disease rate in almost 2/3 of patients with both well-differentiated NET and GI NET, was quite promising though ,74.The KEYNOTE-028 study assessed pembrolizumab in the context of well-differentiated PD-1 positive gastrointestinal and thoracic NETs. Objective responses were limited to few patients with non-pancreatic NETs and the stable disease rate among all the patients was 60% . SimilarThe immunotherapy approach for castration-resistant prostate cancer is twofold. It consists of anti-PD-1 agents and a vaccine. KEYNOTE 028 and KEYNOTE 199 phase II trial suggest that pembrolizumab can result in durable responses in castration-resistant prostate cancer as long as the tumors express PD-L1 in ≥1% of tumor or stromal cells. Partial responses accounted for 17% while stable disease accounted for up to 35%. The median duration of response was 13.5 months ,72.KEYNOTE-199 phase II study studied the effect of pembrolizumab in 258 men with docetaxel-refractory metastatic prostate cancer suggesting higher efficacy of pembrolizumab in patients with PD-L-1 overexpression or disease spread to the bones .Recently, the vaccine sipuleucel-T was studied in three randomized trials. In the first two trials the primary endpoint was progression-free survival, and overall survival was a planned secondary endpoint. A subsequent, larger phase III trial was designed with overall survival as the primary endpoint. Patients were allocated randomly at a 2:1 ratio against placebo, and the primary outcomes appear to be encouraging enough in patients with advanced disease, including local and peritoneal metastases .Immunotherapy seems to have more applications in the advanced RCC. When it comes to localized RCC, immunotherapeutic agents have failed to show statistically significant outcomes in phase II clinical trials, while several vaccines have also been of controversial efficacy ,77.p < 0.001). As far as the combination of pembrolizumab and axitinib is concerned, mOS was not also reached vs. 35.7 months (95% CI 33.3—not reached) with sunitinib; ((HR) 0.68 (95% CI 0.55–0.85), p = 0.0003) and mPFS was 15.4 months (12.7–18.9) vs. 11.1 months (9.1–12.5); ((HR) 0.71 (0.60–0.84), p < 0.0001) respectively. [Advanced clear cell renal cancer can be initially treated with immunotherapy, targeted therapy, or a combination of both including nivolumab and pembrolizumab, avelumab and atezolizumab, ipilimumab and/or VEGF inhibitors such as axitinib, sunitinib, pazopanib, and bevacizumab. Most recent evidence suggests combinations of nivolumab and ipilimumab or pembrolizumab and axitinib for symptomatic patients with a significant burden of disease. The superiority of these agents over sunitinib as first-line treatments has been supported by phase III clinical trials ,79,80. Tctively. ,82,83 OtAs far as advanced STS are concerned, immunotherapy has only been indicated in case of MSI high tumors. Monotherapy with pembrolizumab, the combination of pembrolizumab and axitinib, which is an anti-angiogenic agent, as well as nivolumab with or without ipilimumab have been studied, but they have yet to yield promising results ,85. To sp = 0.002) [Immunotherapy can be applied to metastatic or advanced urothelial carcinoma. Recent evidence supports the administration of anti-PD-1 and anti-PD-L1 to patients who have progressed during or after platinum-based chemotherapy. According to the KEYNOTE-045 trial, pembrolizumab showed an OS benefit up to 2.9 months as second-line therapy for advanced urothelial carcinoma as compared to the chemotherapy group ((HR) for death, 0.73; 95% CI, 0.59 to 0.91; = 0.002) . Besides= 0.002) .Moreover, safety concerns regarding patients with low levels of PD-L1 expression have been raised by two randomized phase III trials, KEYNOTE-361 and IMvigor130. Hence, atezolizumab and pembrolizumab are now indicated for cisplatin-ineligible patients with advanced bladder cancer who have low PD-L1 expression or are ineligible for any platinum-containing chemotherapy ,90.Cancer immunotherapy—either active or passive—manipulates the immune system inducing durable effects on cellular, tissue and organic levels. These effects are primarily toxic for tumors but patients may also suffer their consequences; cancer immunotherapies can lead to unique toxicity profiles distinct from the toxicities of other cancer therapies, depending on their mechanism of action .Immune checkpoint inhibitors and CAR-T among others have revolutionized the treatment of multiple malignancies, including but not limited to melanoma, RCC, lung cancer , head and neck squamous cell carcinoma, gastric cancer, ovarian cancer, Hodgkin lymphoma, and tumors with DNA mismatch repair defects have been correlated with various inflammatory side effects, also known as immune-related adverse events (irAEs). Given that indications for ICIs therapy have been expanded and multiple clinical trials for both solid and hematologic malignancies have been completed, several aspects of ICIs toxicity ought to be considered. The principal recorded toxicity include colitis/diarrhea, hypophysitis, thyroid dysfunction, dermatological lesions and hepatitis . From a As far as hypophysitis is concerned, patients with ipilimumab-induced hypophysitis may develop antibodies against thyroid-stimulating hormone (TSH) secreting cells and some of them may also develop antibodies against follicle-stimulating hormone-secreting or adrenocorticotropic hormone (ACTH) secreting cells . DefectsThyroid dysfunction, predominantly hypothyroidism, has been associated with PD-1 blockade when a study of patients with advanced non small cell lung cancer (NSCLC) treated with pembrolizumab reported the presence of antithyroid antibodies in 80% of patients who developed hypothyroidism compared with 8% of patients who did not. According to these findings, PD-1 toxicity seems to be mediated by humoral immunity but further investigation ought to be conducted .Pneumonitis is the most common and life-threatening pulmonary toxicity of ICI therapy. A meta-analysis of fatal side effects of ICI reported that about one third of antiPD-1 and antiPD-L1 related fatalities occurred because of pneumonitis. Dual checkpoint inhibition and PD-1 monotherapy are more likely to cause pneumonitis in comparison to CTLA-4 monotherapy . A largeRenal toxicity irAEs are rare. According to a review of published phase 2 and 3 trials, their incidence does not exceed 2% of patients receiving ICI monotherapy and 5% of patients receiving combination therapy . More reCytokine release syndrome (CRS) has been reported after the infusion of CAR-T CD19 therapy. Its mechanism has been attributed to T-cell activation following the engagement of CAR-T cells with their targets. The initial presentation consists of constitutional symptoms such as malaise, myalgias, fatigue, and rash, with fever being required for the diagnosis of CRS . AlthougDuring the last 10 years, the therapeutic applications of immunotherapy have been explored to a great extent, providing healthcare professionals and researchers with approved and promising treatments. Immunotherapeutic agents have shown their potential as only-agents or combination either with one another or with chemotherapy, targeted therapy and invasive procedures. Attention has also been paid to vaccines and their therapeutic applications, a viewpoint that may change the perception of vaccines in the future.An attempt to predict the future of cancer immunotherapy requires an inclusive viewpoint spanning from promising immunotherapy regimens to health policy in terms of access to medicines and sustainability. When it comes to promising immunotherapy regiments, some studies focus on therapeutic targets applicable to several malignancies, others follow a malignancy-specific approach and others address advanced malignancies, that have either remained or failed to be treated. There is a wealth of concepts and studies that are either in preclinical stages or have received approval for Phase 1 clinical trials regarding the innate immunity targeting immunotherapy .The innate immune system provides a wealth of therapeutic targets. Overall, it is considered that several malignancies tend to escape immune responses by tackling innate immunity and subsequently antigen-specific adaptive immunity. Toll-like receptors (TLRs) have already been targeted in bladder cancer (BCG immunotherapy) or breast cancer (Imiquimod). A novel concept suggests that TLRs exist on tumor cells and can work as tumor markers and targets triggering cytotoxic activity and immune effector cells to extinguish cancer cells . This haRIG-I like receptors (RLRs) are a family of DExD/H box RNA helicases playing an important role in antiviral immunity. The activation of RLRs induces an immunological torrent resulting in the release of interferon (INF) and the apoptosis of the virus-host cell. Mimicking this mechanism offers hope for novel cancer immunotherapy agents. The principal target is the 5′ ppp-SiRNA  which induces TGF-b production enhancing immunosuppression. This pattern has been particularly observed in pancreatic cancer and melanoma . A viralAs far as CRC is concerned tackling molecular targets within the tumor immune microenvironment is a key concern for future treatments. CKD-516, the vascular disrupting agents, invokes Rho signaling to activate dendritic cells and to exhibit immune-modulatory effects. Synergistic action of CKD-516 combination and anti-PD-1 mAbs have given promising enough preclinical data for the SMAD-4 deficient MSS-CRC to proceed with the clinical testing of CKD-516/anti-PD1 combination in CRC patients with MSS tumors . TargetiAs far as advanced malignancies are concerned, inducing a T-cells and natural killer (NK) cells mediated immune response has recently been brought under investigation. A Phase 1a, open-label, dose-escalation study evaluating the safety, tolerability, and initial efficacy of recombinant human anti-T-cell immunoreceptor with Ig and ITIM domains (TIGIT) monoclonal antibody injection (IBI939) in subjects with advanced malignant tumors was initiated in March 2020, in China. IBI939 can directly bind to TIGIT, disturb the interaction between CD155 and TIGIT, relieve the inhibition and depletion of T cells and NK cells and enhance the anti-tumor immune response of T cells and NK cells .Access to medicines is a major key aspect of novel anticancer immunotherapy. No matter how innovative or effective the current or future treatments may be, they will have no impact if they are not widely accessible.Access to immunotherapy can be approached from two angles. The first one pertains to licensed and commercially available immunotherapies. In this case, the main challenge is financial. According to the “Let’s talk access” White Paper of the Association of European Cancer Leagues, in 2018 patients with metastatic melanoma in Eastern Europe had limited access to immunotherapy ,111. TheThe second angle is related to compassionate access to unauthorized medicines. Any novel and evolving immunotherapy can be considered as an unauthorized medicine eligible for compassionate/palliative administration to patients who have failed continually to respond to the indicated licensed treatments ,113. ComBack in 2014, the European Union (EU) Regulation for the European Medicine Agency (EMA) laid the fundaments of an open database where results from clinical trials will be openly distributed to investigators across the EU . In termBroadening this policy to anticancer immunotherapy would be of paramount importance. Apart from growing data from ongoing clinical studies, researchers and clinicians would be able to access data from the use of licensed agents enhancing the reproducibility of the initial results that led to their license and perhaps the spectrum of their clinical applications. Data from the compassionate use of such agents would also be of crucial significance in accelerating the licensing of new agents or repurposing of existing ones ,115.In any case, compliance with the confidentiality standards as described by the General Data Protection Regulation (GDPR) within the EU and by relevant lawmaking elsewhere would be essential .Sustainability is a vague concept and a challenge that contemporary research and healthcare faces. A wide accepted context of sustainability is the one described by the United Nations Sustainable Development Goals (UN SDGs). Anticancer immunotherapy apart from clinical practice and basic or translational research has also close ties with policymaking and finance ,91.Advances in immunotherapy serve UN SDG 3, the goal dedicated to health and wellbeing. At the same time, taking into account the chain of developing or repurposing a treatment from the lab bench to clinical trials and eventually to licensing and clinical practice, we understand that immunotherapy is aligned to UN SDGs 4, 9 and 10  ,118. ImmRegardless of the problems that have already appeared or will appear in the future, resuscitation continues to be one of the greatest achievements of our time. This is confirmed by the awarding of the Nobel Prize in Medicine and Physiology in 2018 to the two immunologists, the American James P. Allison and the Japanese Tasuku Honjo, for their innovative approach to the treatment of cancer. Immunotherapy is now a safe treatment option against cancer and many patients are already enjoying its benefits.


Glycyrrhiza glabra. The study demonstrated that glycyrrhizin is a very promising phytochemical against SARS-CoV, which caused an outbreak in 2002–2003. Similarly, many phytochemical compounds  were isolated from different plants such as Isatis indigotica, Lindera aggregate, and Artemisia annua and were employed against SARS-CoV. However, owing to the geographical and seasonal variation, the quality of standard medicinal compounds isolated from plants varies. Furthermore, many of the important medicinal plants are either threatened or on the verge of endangerment because of overharvesting for medicinal purposes. Therefore, plant biotechnology provides a better alternative in the form of in vitro culture technology, including plant cell cultures, adventitious roots cultures, and organ and tissue cultures. In vitro cultures can serve as factories of secondary metabolites/phytochemicals that can be produced in bulk and of uniform quality in the fight against COVID-19, once tested. Similarly, environmental and molecular manipulation of these in vitro cultures could provide engineered drug candidates for testing against COVID-19. The in vitro culture-based phytochemicals have an additional benefit of consistency in terms of yield as well as quality. Nonetheless, as the traditional plant-based compounds might prove toxic in some cases, engineered production of promising phytochemicals can bypass this barrier. Our article focuses on reviewing the potential of the different in vitro plant cultures to produce medicinally important secondary metabolites that could ultimately be helpful in the fight against COVID-19.The current pandemic has caused chaos throughout the world. While there are few vaccines available now, there is the need for better treatment alternatives in line with preventive measures against COVID-19. Along with synthetic chemical compounds, phytochemicals cannot be overlooked as candidates for drugs against severe respiratory coronavirus 2 (SARS-CoV-2). The important role of secondary metabolites or phytochemical compounds against coronaviruses has been confirmed by studies that reported the anti-coronavirus role of glycyrrhizin from the roots of  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become the deadliest virus in a century. SARS-CoV-2, which originated in Wuhan, China in December 2019, has killed more than two million people so far. This is the third time that a coronavirus has caused an outbreak during the 21st century, SARS and Middle East respiratory syndrome (MERS) being the previous ones. This virus has been termed the novel coronavirus (SARS-CoV-2) and causes a severe respiratory syndrome collectively called coronavirus disease 2019 (COVID-19). The disease, because of the ease of spread of its causative virus, became a pandemic very quickly. Owing to this, 2.37 million people have died because of COVID-19 and 108.33 million have tested positive for the virus as of February 13, 2021 .Scientific advancements allowed researchers to advise governments across the world on quick prevention measures. Based on the rapid information coming out about the virus, including its transmission pattern, morphology, and deeper biological information, the World Health Organization (WHO) and other leading health organizations across the world advised on emergency containment and control measures. Control on a global scale allowed stakeholders from every sector to work toward mitigation measures more efficiently. Slowing down the spread and thus containment of the virus has also allowed scientists to work on many treatment options for COVID-19. Although the current option to treat COVID-19 patients is to alleviate symptoms and avoid co-infection with bacteria through medications, trials on different drug and vaccine candidates are underway . HoweverTreatment options currently explored include passive immunity , repurpoNicotiana benthamiana-based virus-like particle (VLP), to develop a potential vaccine against the coronavirus disease. The VLPs use genetic sequencing from the coronavirus to mimic it and produce an immune response in the body. Plant-based VLP technology offers a very safe alternative to the vaccines already approved or in the process of development. These vaccines are virus-free and do not rely on animal products.The fight against COVID-19 has now become one of the greatest challenges of the current times. The pandemic has lasted for over a year now since its inception in December 2019. To date, over 90 vaccines are being developed for the COVID-19 virus by different research groups in universities and major companies. Currently, two vaccines (Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine) have obtained emergency use authorization from the Food and Drug Administration in the United States. Pfizer and Moderna have developed messenger RNA-based vaccines that have been shown to be 90–95% effective when given at preventing doses 21 and 28 days apart, respectively . Some ofin vitro plant cultures and associated biotechnological manipulation in fighting SARS-CoV-2. Plants produce a diversity of organic compounds classified as primary and secondary metabolites based on either being directly essential to the growth and development of plants (primary metabolites) or indirectly playing their role and not essential to growth (secondary metabolites). Secondary metabolites are produced in plants in situations of intracellular and/or extracellular stress and are used for interaction with the environment and protection from pathogens. This implies that there are thousands of secondary metabolites produced in plants, classified in different classes by their chemical structures. The four major classes of plant secondary metabolites are alkaloids, glycosides, phenolics, and terpenes. The purpose of highlighting the groups of these metabolites is to relate the role these classes of compounds could play against SARS-CoV-2. Several different plant-based compounds have been shown to be effective against the previous type of coronavirus, i.e., SARS-CoV. These compounds have been employed for their different mechanisms of actions against SARS-CoV  has been shown to inhibit the replication of SARS-CoV (the coronavirus that causes the first coronavirus-related epidemic of this century). Reserpine could thus prove to be an important candidate against SARS-CoV-2. Similarly, other important alkaloids, palmatine, and chelidonine were also reported as intercalating alkaloids and could be easily suggested as potential drug candidates against SARS-CoV-2 . A synthetic derivative of quinine, i.e., chloroquine has recently been tested and found to be a good drug candidate against SARS-CoV-2 because its DNA-intercalating properties prove potent in alleviating the symptoms of coronaviruses based on its biocompatibility . ChloroqRS-CoV-2 .O-rutinoside, kaempferol 3-O-rutinoside, and kaempferol 3-O-robinobioside have proven effective against herpes simplex virus and thus points toward their potential role in working against human viruses (Rheum and Polygonum were tested positive for their achrysinctivity against the S protein and inhibition of ACE2 interaction (50) of 83.4 and 10.6 μM, respectively.Similarly, flavone glycosides, phenolics, and polyphenolic compounds which are characterized by aromatic rings and hydroxyl (−OH) groups have also demonstrated important antiviral activity in many studies. For example, three flavone glycosides, quercetin 3- viruses . It has  viruses . For inseraction . FlavonoChamaecyparis obtuse, betulonic acid, and cedrane-3β,12-diol, from Juniperus formosana, and cryptojaponol isolated from Cryptomeria japonica have been proven to be effective against SARS-CoV  and 6-benzylaminopurine (BAP).As indicated in Ajuga bracteosa  accumulated higher levels of monoterpene hydrocarbons, which could be potentially used as essential oil-based medicine against human viruses. These hydrocarbons included limonene (3.4%), α-pinene (5.3%), camphene (4.45%), α-thujone (9.4%), 1,8-cineole (14.3%), borneol (11.4%), camphor (12.2%), and nerol (9.2) in the shoots raised in vitro in response to the application of TDZ  which possesses the potential to work against SARS-CoV-2  less prone to various environmental variations, (2) stable production platforms of homogeneous and uniform yield, (3) rapid growth, (4) reproducible, and (5) able to synthesize novel products that do not normally exist in the native plants . In addi isora L . Callus RS-CoV-2 . In somey organs . Similare plants .in vitro cultures can influence the plant cell’s physiological and hormonal status through the initiation of distinct metabolic pathways that ultimately influence and regulate the biosynthesis of important essential oils  has been shown to possess potential against SARS-CoV through its root-derived phytochemicals . The signal reception is followed by transduction which includes steps like reversible phosphorylation and dephosphorylation of plasma membrane and cytosolic proteins, enhancement of Ca2+ in the cytosol, H+ influx/Cl– and K+ efflux, extracellular alkalinization and cytoplasmic acidification, mitogen-activated protein kinase (MAPK) activation, NADPH oxidase activation and production of reactive oxygen and nitrogen species (ROS and RNS), early defense gene expression, jasmonate production, late defense response gene expression, and secondary metabolite accumulation  or non-biological origin (abiotic), the compounds or physical factors that stimulate the plant defense are termed elicitors. Biotic elicitors include compounds that are of the pathogenic origin or are produced by the plants after being exposed to pathogens. Abiotic elicitors include chemical compounds such as salts or physical factors such as environmental triggers . The mosyrrhizin . Glycyrryrrhizin . Srivastin vitro cultures have been used as factories for the enhanced production of medicinally secondary metabolites through the application of many different exogenous and endogenous elicitors  . Plant licitors . Exogenoevisiae)  have als600 mg/L . Similar600 mg/L . Other bcatorius .trans-resveratrol, previously shown to act strongly against MERS-CoV, has been reported in cell suspension cultures of Vitis vinifera through the application of 2, 3-dihydroxypropyl jasmonate    have beenavirus) .3, CdCl2, etc.) and environmental stimuli such as continuous light/dark, different wavelengths of light, and osmotic stress, etc. have been employed to produce high-yield secondary metabolites in plant in vitro cultures.Just like biotic elicitors, chemical compounds of abiotic origin and physical factors such as environmental stimuli have also been proven effective in the elicitation of plant defense and thus increased production of phytochemicals . It is nin vitro cultures of Hypericum perforatum  was used for the overexpression of the reductoisomerase DXR of the mevalonate MEP pathway in peppermint, and a significantly higher (50%) increase in total essential oil production was observed. The yields of cyclic monoterpenes were enhanced by the overexpression of the limonene synthase enzyme in the plastid. The overexpression of the rate-limiting factors significantly enhanced the specific yield of monoterpenes  led to the endangerment of not only its source plant (Pacific yew) but also other species of the same genus  have been successfully produced in plants other than their native species. However, alongside attempting the increased production of certain end-products or producing new products/compounds via genetic engineering, it has been understood that biosynthetic engineering is a highly complicated process that demands diverse knowledge in all fields of biochemistry, biotechnology, and molecular biology , lettuce (Lactuca sativa), and petunia (Petunia hybrida)  gene from soybean (glycine max) to non-leguminous species tobacco (hybrida) . FurtherArtemisia annua) and its high demand in the pharmaceutical industry have led researchers to investigate its in-planta production as well as in other culture systems. Although little success has been made in this direction, a potential bottleneck has been identified which may lead to its biosynthesis in the near future.Artemisinin commercially known for its antimalarial activity is also reported for its antiviral activity . The lowAgrobacterium tumefaciens to produce taxane (a paclitaxel precursor)  . It shouecursor) .in vitro  to several other important compounds. For instance, these include 3−O−[α−l−arabinopyranosyl−(1→2)−β−D−glucuronopyran osyl]−24−hydroxy−18 β−glycyrrhetinic acid, 23,28−dihydroxy−18β−glycyrrhetinic acid−30β−glucopy ranosyl ester, and 28−hydroxy−18β−glycyrrhetinic acid−30β−glucopyranosyl ester which are reported to be important medicinal compounds  in taxus cell suspension cultures  occupies a unique place in the pharmaceutical industry around the globe as an active ingredient of activity . While t culture . For inslicitors .Jasmonates have been reported to induce oxidative stress and downregulate many genes which lead to an augmentation of ginsenoside in the cell suspension culture. The mechanism behind the role of the elicitor mainly involve the activation of phenylalanine amino lyase which in turn elevates the level of defense compounds and hence ginsenoside biosynthesis .in vitro cultures which incorporate genotypic changes in the culture is another popular method used for the enhanced production of ginsenoside. In this method, P. ginseng calli are exposed to varying doses of gamma radiation ranging from 10 to 100 Gy (Gray) and for various lengths of time to bring genetic changes and hence to increase the ginsenoside level in callus cultures (in vitro mutagenesis, direct gene transfer, and A. tumefaciens-mediated transformation could play an important role in the production/enrichment of natural products that are easily repeatable in a short time and thus can be exploited in the fight against COVID-19.Mutagenesis and cultures , 2013. Tcultures . Summingin vitro plant culturing into large-scale, economically feasible bioreactors provides the sustainable and continuous production of high-valued plant secondary metabolites. Secondary metabolite production in bioreactors depends on pharmacological significance as well as human health benefits. The production of rosmarinic acid and saponins are the selected examples of the commercial production of secondary metabolites in vitro (in-vitro culture systems for the biosynthesis of secondary metabolites. The ease of its upscale is attributed to its shorter cycle of production and simpler methods for bioreactor construction (Advances in biotechnological approaches, particularly plant cell culturing methods, provides new means for commercially valuable, medicinally important plant secondary metabolites . Differein vitro . Differetruction . The suctruction . Ginsenotruction , ginsenotruction . Althougtruction . Howevertruction .in vitro cultures is indeed an important prerequisite for the large-scale yield and commercialization of phytomedicine. This is linked with the fact that once carefully selected and optimized, in vitro cultures of plants could yield ten times higher phytomedicine than plants grown naturally. However, the production of phytomedicine in bioreactors requires the selection of suitable cell lines/cultures, optimization of culture conditions, application of proper elicitation strategy, immobilization of cells, and efficient downstream processing (Regarding commercialization, the most promising fact associated with plant tissue cultures is that they offer an avenue for the production of these medicinally important phytochemicals in an appropriate bioreactor. The production of the plant ocessing .Commercial production of secondary metabolites largely depends either on higher market value or high demand which will undoubtedly be high if any of the phytochemicals tested proved effective against the current SARS-CoV virus. The continuous efforts in this field will lead to the controllable and successful production of specific, valuable, and yet unknown plant secondary metabolites  against in vitro culture technology is an asset at our disposal to harness the diversity of secondary metabolites produced by different plants. In vitro culture technologies can potentially grow any plant anywhere and offer the added value of overproduction of plant cultures, enhanced production of secondary metabolites, and the generation of novel medicinal compounds.Plant biotechnology is a promising platform for exploring the unlimited potential of many diverse medicinal plants. Unfortunately, pandemics like COVID-19 are likely to occur again on a smaller or larger scale due to the array of known and unknown pathogens out there. Plant biotechnology tools and methods such as TK and MK conceived the idea. TK, KK, MK, NU, and AN each drafted a different section of the manuscript. MK critically reviewed the manuscript. KK and Z-U-RM gathered the data and prepared and formatted the tables. TK, KK, and MK performed the revisions. TK constructed the figures and formatted the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.