The use of these adjuvants may thus overcome the detrimental effect that some study reported for W/O emulsions, related to the persistent release of antigen and the inflammation in the injection site. decline over time, others paradoxically increase. Indeed, aging is known to be associated with a low level of chronic inflammationinflamm-aging. Given that the median age of cancer diagnosis is usually 66 years and that immunotherapeutic interventions such as cancer vaccines are currently given in combination with or after other forms of treatments which themselves have immune-modulating potential such as surgery, chemotherapy and MK-571 radiotherapy, the choice of adjuvants requires careful consideration in order to achieve the maximum immune response in a compromised environment. In addition, more clinical trials need to be performed to carefully assess how less conventional form of immune adjuvants, such as exercise, diet and psychological care which have all be shown to influence immune responses can be incorporated to improve the efficacy of cancer vaccines. In this review, adjuvants will be discussed with respect to the above-mentioned important elements. vaccinations (intralesional injection of immune- modulatory molecules) are not included in these graphs. HPV, Human Papilloma Virus; CRC, colorectal cancer; VLP, virus like particle. Open in a separate window Physique 2 Adjuvants and combinatorial immunomodulatory therapies being used in cancer vaccine MK-571 trials. Cancer vaccine trials listed as open at ClinicalTrials.gov on August 2020. The number of trials using each adjuvant (A) and associating each immunomodulatory therapy with the cancer vaccine (B) are shown in the bar graph. Adjuvants and combinatorial therapies used in less than 2 clinical trials are not shown. GM-CSF, Granulocyte-macrophage colony-stimulating factor; IL-2, interleukin-2; Td, Tetanus/diphtheria toxoid; HSP, heat shock protein; CAF09b, cationic liposomes (DDA-MMG1) with complex bound synthetic double-stranded RNA (Poly(I:C)2); IL-12, Interleukin- 12; P64k, Neisseria meningitides protein; PD-1, Programmed cell death 1; PD-L1, Programmed cell death ligand 1; CTLA-4, cytotoxic T-lymphocyte-associated protein 4; RT, radiotherapy; M7824, fusion protein composed of a human IgG1 monoclonal antibody against PD-L1 fused with 2 extracellular domains of TGF-RII; IFNalfa, Interferon alfa; IDO1, indoleamine 2,3-dioxygenase 1; ALT-803, IL-15 superagonist; Other vaccines, Salmonella, pneumococcal vaccines; HSC, hematopoietic stem cells. Table 1 Completed phase 3 cancer vaccine trials. vaccination/BCG/Different doses ofvaccination/BCG/RT or mitomycin CNANo survival benefit with RT (versus BCG or chemotherapy) (28)Intravesical BCG01442519Bladder vaccination/BCGElectromotive mitomycinBCG aloneNAYes (PFS, OS)vaccination/BCG +/- IFN //NAHigher recurrence in patients with CIS, NRAMP1vaccination/BCG/Observation or chemotherapyNAYes (OS) compared to observation (46)Gardasil02087384AnusVLPHPV-6, 11, 16, 18Alum/PlaceboPendingPending ClinicalTrials.gov Abagovomab00418574Ovaryanti-idiotypic antibodyCA-125//PlaceboAntibody-mediatedNo (PFS and OS) (47) Open in a separate window Phase 3 cancer vaccine trials listed as completed at ClinicalTrials.gov on August 2020. Immune responses results are reported as published in phase III data when available or in phase II respective data of the same MK-571 vaccine and same authors group. 5FU, 5-fluoruracil; BCG, Bacillus CalmetteCGurin; CA-125, carcinoma antigen 125; CEA, Carcinoembryonic antigen; CRC, colorectal carcinoma; Detox, detoxified Freunds adjuvant; DC, dendritic cell; EGF, epidermal growth factor; GBM, glioblastoma; GM-CSF, Granulocyte-macrophage colony-stimulating factor; HER2, human epidermal growth factor receptor 2; HSPPC-96, Heat Shock Protein Peptide Complex-96; HPV, human papillomavirus; IL-2, Interleukin-2; Ig, immunoglobulin; KLH, keyhole limpet hemocyanin; MUC1, Mucin 1; MVA, modified vaccinia virus Ankara; NSCLC, non-small cell lung cancer; ORR, objective response rate; OS, overall survival; PAP, Prostatic acid phosphatase; PFS, progression free survival; PSA, Prostate-specific antigen; SCLC, small cell lung cancer; RCC, renal cell carcinoma; MK-571 RT, radiotherapy; TGF-2, Transforming growth factor-beta 2; TUMAP, PLIN2, APOL1, CCND1, GUCY1A3, PRUNE2, MET, MUC1, RGS5, MMP7, HBcAg; TRICOM, B7.1 + ICAM-1, InterCellularAdhesion Molecule-1 + LFA-3, Leukocyte function-associated antigen-3; VLP, virus like EPLG1 particle. Another potentially confounding issue with regards to the efficacy of cancer vaccines is age, given that the median age of cancer diagnosis is usually 66 years, and the immune system is known to decline with age. This phenomenon, known as immunosenescence, is usually characterized by functional changes in both innate and adaptive cellular immunity as well as in lymph node.