A Violin, a Teacher, and an Orchestra: Memories of Music in Calcutta

 A Violin, a Teacher, and an Orchestra: Memories of Music in Calcutta

 by blogger lim ju boo, alias  lim ru wu  (林 如 武)

When I look back on my student days in the early 1960s in Calcutta (now - Kolkata), I realize that some of the most precious memories of that period were not confined to my academic studies. Alongside the long hours devoted to medicine and science, there existed another world that nourished the spirit, a world filled with music.

During those years I had the privilege of learning the violin under the guidance of the distinguished violinist Stanley Gomes. At that time he served as the concertmaster - the leader and 1^st violinist of the Calcutta Symphony Orchestra, which performed under the baton of conductor Bernard "Bunny" Jacob.

Under Stanley Gomes’ kind and patient instruction I studied the violin until I reached Grade 6 of the examinations conducted by the Associated Board of the Royal Schools of Music.

My lessons took place once a week at his home. Each lesson lasted about an hour. I would travel there from my student hostel carrying my violin, usually after spending many evenings practising scales and études in my room.

Despite his reputation as a very famous violinist and the leader of the city’s orchestra, Stanley Gomes was an extraordinarily humble, jovial, and friendly man. There was not the slightest hint of pride in him. He spoke warmly, laughed easily, and taught with the patience of someone who truly loved music and enjoyed sharing it with younger students. I remember asking him to transcribe the song "Roses of Picady" a British ballad composed by Haydn Wood into musical notations for me to play on the violin, he immediately obliged into sheet music without difficulty. 

He even introduced me briefly to the piano. For a short period he showed me how to play it, but the violin had already captured my heart and remained the instrument on which I focused my efforts.

Those weekly lessons were not limited to technical instruction. Very often he would speak about orchestras—their structure, their discipline, and the remarkable cooperation required for so many musicians to perform together as one.

For readers who may wish to visualize how musicians are arranged on stage, a typical orchestral seating plan can be seen here:

 

https://en.wikipedia.org/wiki/Orchestra#Seating_arrangement

 

The arrangement of musicians in a symphony orchestra is the result of centuries of musical evolution. The string section—violins, violas, cellos, and double basses, sits closest to the audience and forms the foundation of the orchestra’s sound. Traditionally the first violins sit to the conductor’s left while the second violins sit on the opposite side. Violas occupy the centre area, with cellos and double basses usually placed to the right.

Behind the strings sit the woodwind instruments—flutes, oboes, clarinets, and bassoons, whose voices add colour and expressive nuance. Further back are the brass instruments - horns, trumpets, trombones, and tubas; capable of producing majestic power when required. At the rear of the orchestra are the percussionists, whose instruments provide rhythmic energy and dramatic emphasis.

At the centre front stands the conductor, guiding the orchestra with gestures of the baton. Yet among the musicians themselves the most important leader is the concertmaster— the principal first violinist.

In the Calcutta Symphony Orchestra, that leader was Stanley Gomes.

The concertmaster plays a crucial role in shaping the sound of the string section. One of the most fascinating aspects of orchestral performance is the synchronized movement of the violinists’ bows. To the audience it appears almost magical that dozens of bows move up and down together in perfect harmony.

This unity is not accidental. The bowing directions—up-bow and down-bow—are usually marked in the music (printed sheet music) but they are often modified during rehearsals. The concertmaster determines the bowings that will best shape the sound and phrasing of the section.

A down-bow generally produces a stronger tone because the bow begins near the frog where the player’s hand applies more weight. An up-bow often creates a lighter sound. By carefully choosing bow directions, the leader ensures that the entire violin section speaks with a single expressive voice.

During performance the violinists watch the concertmaster’s bow through peripheral vision. If the leader changes direction, the section follows immediately. The goal is not strict obedience to the printed page but unity of sound and movement.

There are exceptions, of course. In passages marked divisi, the violinists split into separate musical lines and their bowings may differ. Sometimes the first and second violins even bow in opposite directions because their musical phrases require different articulation. In rare situations a conductor may ask for “free bowing,” allowing players to change bow direction independently in order to produce an especially smooth, continuous tone.

Yet most of the time the bows rise and fall together with graceful precision. Watching the violinists can feel almost like observing a corps de ballet, their movements forming a silent choreography that mirrors the music.

During my student years I often had the pleasure of attending concerts by the Calcutta Symphony Orchestra at the historic Empire Theatre. Those evenings remain among the most vivid memories of my youth.

Sometimes the orchestra performed symphonies, and at other times the concerts featured visiting foreign soloists—perhaps a violinist performing a concerto, a brilliant pianist appearing as guest soloist, or occasionally a soprano whose voice soared above the orchestra.

For a young violin student these performances were deeply inspiring. I watched the musicians carefully, observing the unity of their playing and the effortless leadership of Stanley Gomes at the front of the violin section.

Years later I had the pleasure of corresponding with his son, Ian Gomes. I had known Ian when he was still a young boy in Calcutta. He later became a very accomplished pianist and eventually worked in London as a pianist at the famous The Ritz London.

Like many musicians, he had first been taught by his father. Writing to him after so many years brought back a flood of memories of those earlier days—of his father’s warm personality and the music that had filled those years of my youth.

But perhaps my most vivid memory remains one particular evening at the Empire Theatre.

The orchestra had gathered on stage, and the audience waited in quiet anticipation. Stanley Gomes stood at the front of the violin section, and the conductor raised his baton. The concerto began softly, almost like a whisper.

Then the solo violin entered.

Its sound rose gently above the orchestra—clear, singing, and luminous. The violin seemed to speak in a human voice, at times tender and reflective, at times soaring with passion. Beneath it the orchestra breathed like a living organism, supporting and answering the soloist’s phrases.

The bows of the violinists moved together like a field of wheat swaying in the wind.

For a young student like me sitting quietly in the audience, that moment felt almost magical. It was as if the entire orchestra had become a single instrument—many musicians united by discipline, listening, and shared purpose.

Even now, many years later, whenever I think of orchestral music, my mind returns to that stage in Calcutta, to the sound of that violin concerto, and to the gentle guidance of Stanley Gomes.

A few years later as a postgraduate student at the University of London Queen Elizabeth College, I had a good fortune with the help of British Council,  to listen to Yehudi Menuhin (1916 - 1999),  who was the world most famous violinist during his time,  performed   Beethoven's two Romances for Violin and Orchestra (No. 1 in G major and No. 2 in F) on April 26, 1966 for his 50th birthday with the London Symphony Orchestra at the Royal Festival Hall. It was so amazing to watch him play the violin. The violin was just like a toy to him. 

For alongside science and medicine, music too has the power to shape a life—and to leave behind memories that resonate long after the final note has faded.

Today it gives me much joy playing the violin - thanks to the dedication of Stanley Gomes. 

The Joy of Playing a Violin 

https://scientificlogic.blogspot.com/search?q=joy+of+playing+violin

A Quiet Reflection Before the Next Dawn: When Science Meets the Human Heart”

“A Quiet Reflection Before the Next Dawn: On Science and the Human Heart”

Dear Friends,

I could not sleep the entire night.

As I lay awake in the quiet stillness before dawn, I found myself wondering what subject I should write next in my blog. Many ideas came and went, but none seemed to settle comfortably in my mind.

Just before Chap Goh Meh ended at midnight, the final evening of the Chinese New Year celebrations — I took out my German violin, the one that cost me RM 65,000, and played ten different Chinese New Year songs.

To my ears, they sounded quite horrible.

I have not played my violin for at least eight months. When one loses daily practice, the fingers lose their memory. The delicate precision of fingering falters. Intonation suffers. The bow no longer glides with confidence. And with my poor eyesight, I struggled to read the musical notes on the sheet music, those little black symbols that look like “taugay” or bean sprouts to anyone without musical training.

In my younger days, I passed Grade 6 in violin performance and also in music theory under the Associated Board of the Royal Schools of Music (ABRSM) in England. That foundation has always remained precious to me.

But a violinist rarely plays alone. A violinist is usually accompanied by a pianist — or better still, surrounded by fellow violinists within an orchestra, blending with violas, cellos, double basses, woodwinds, brass, and percussion. Music, especially orchestral music, is a communal experience.

Years ago, I was a member of the Symphony Club of the Malaysian Philharmonic Orchestra. I played together with other violinists in symphonic settings. The collective sound, the harmony, the shared breathing of the orchestra — that was music in its full glory. I have since lost touch for many years.

That is why, perhaps, it sounded so harsh to me, playing alone after months of neglect, without accompaniment, without the warmth of an orchestra.

I own four violins. This German violin is the most expensive of them all, almost the cost of a small car. Yet the price of an instrument does not guarantee beauty of sound. Only disciplined practice, sensitive listening, and musical companionship can do that.

If you ask me honestly, I would say I prefer being a violinist rather than being a research scientist or a doctor. Medicine and research were my profession. Music is my love.

Just like astronomy — another passion of mine. Even after retirement, I studied astronomy at Oxford, simply for the joy of learning and looking up at the heavens.

Perhaps life is not only about achievement, titles, or productivity. Perhaps it is also about returning, again and again, to the things that make our hearts quietly happy, even if, at times, they sound imperfect.

If you would like to read more about my reflections on music and the violin, do visit my earlier write-up:

“The Joy of Being A Violinist”

https://scientificlogic.blogspot.com/search?q=joy+of+playing+violin

 

With warm regards in the stillness of this pre-dawn hour

From Molecule to Medicine: The Hidden Army of Scientists Behind Every New Drug

I have already written an article on the various scientists involved in the development of new drugs here in this link:

https://scientificlogic.blogspot.com/2025/04/the-immense-contributions-of-scientists.html

It was written and published in this blog of mine on Wednesday, April 9, 2025

Yesterday, on 2^nd March 2026 - towards the end of Chinese New Year of the Horse we get readers in WhatsApp chat group asking me almost the same issue on who are the scientists who develop drugs for medical doctors to prescribe for their patients?

Let me on this last day of CNY in Chinese Hokkein dialect  called “Chap Goh Mei” in  rewrite my article in a different language style and in greater technical depths  for  doctors, biomedical scientist, their patients and also for curious,  but highly knowledgeable and intelligent ordinary readers. Below is my rewritten version entitled:  

 

From Molecule to Medicine: The Hidden Army of Scientists Behind Every New Drug

Technical Abstract for Medical Doctors and Biomedical Scientists.

 

Technical Abstract

 

Modern drug discovery and development is a multidisciplinary, capital-intensive, and highly regulated enterprise requiring 10–15 years of coordinated scientific effort and investments frequently exceeding several billion US dollars per approved therapeutic agent. The process encompasses target identification and validation, hit discovery, lead optimization, preclinical pharmacology and toxicology, clinical development (Phases I–III), regulatory review, large-scale manufacturing, and post-marketing pharmacovigilance.

This article provides a comprehensive overview of the scientific ecosystem underlying pharmaceutical innovation, detailing the expertise, methodologies, regulatory frameworks, computational tools, and educational backgrounds of the diverse specialists involved — including molecular biologists, medicinal chemists, pharmacologists, toxicologists, pharmacokineticists, formulation scientists, analytical chemists, biostatisticians, clinical investigators, pharmaceutical engineers, quality assurance professionals, regulatory affairs experts, and emerging artificial intelligence scientists. Emphasis is placed on the translational continuum from molecular design to population-level therapeutic deployment, highlighting the scientific rigor, attrition rates, compliance standards (GLP, GMP, GCP), and technological platforms that collectively enable safe and effective drug approval.

 

Main text for All Readers:

 

When a new medicine appears in a pharmacy, it looks deceptively simple,  a tablet in a blister pack, a vial for injection, a capsule in a bottle. Yet behind that small object lies 10 to 15 years of work, thousands of experiments, regulatory scrutiny across continents, and investments that often exceed several billion US dollars. What the public rarely sees is the vast multidisciplinary team of scientists whose combined expertise makes modern drug development possible.

Drug discovery and development is not the work of a lone genius in a laboratory. It is a coordinated scientific orchestra in which chemists, biologists, pharmacologists, toxicologists, clinicians, engineers, statisticians, and regulatory experts each play indispensable roles.

The journey begins in discovery laboratories, often long before a compound has a name.

In the earliest phase, disease biologists and molecular biologists identify a therapeutic target, typically a protein, receptor, enzyme, gene product, or signalling pathway believed to drive a disease. Their work relies on genomics, proteomics, transcriptomics, CRISPR gene editing, and advanced microscopy. They use software tools such as bioinformatics platforms (BLAST, Gene Ontology tools), pathway analysis systems (Ingenuity Pathway Analysis), and molecular databases to understand disease mechanisms at the cellular and molecular levels.

Once a viable target is identified, medicinal chemists enter the scene. These are specialists in organic and pharmaceutical chemistry who design and synthesize new chemical entities. Their task is intellectually demanding: they must design molecules capable of binding precisely to the biological target while maintaining favourable physicochemical properties such as solubility, stability, and membrane permeability. They use computer-aided drug design software such as Schrödinger Suite, MOE (Molecular Operating Environment), AutoDock, and molecular dynamics simulation tools. High-performance liquid chromatography (HPLC), nuclear magnetic resonance (NMR) spectroscopy, and mass spectrometry are essential laboratory instruments in their daily work.

Parallel to medicinal chemists, computational chemists and structural biologists use X-ray crystallography, cryo-electron microscopy, and AI-driven protein modelling tools to visualize target structures at atomic resolution. Structure-based drug design allows refinement of molecules into optimized “lead compounds.”

After promising compounds are synthesized, pharmacologists test them in vitro and in vivo. Pharmacologists study how drugs interact with biological systems and determine their mechanisms of action. Using cell-based assays, receptor binding studies, and animal models, they measure potency, efficacy, selectivity, and functional outcomes. Laboratory techniques include ELISA, Western blotting, flow cytometry, and electrophysiology. Their software tools often include GraphPad Prism for dose-response curves and statistical analysis platforms.

Simultaneously, pharmacokineticists — experts in drug metabolism and pharmacokinetics (DMPK) — examine how the body handles the compound. They study absorption, distribution, metabolism, and excretion (ADME). Using in vitro liver microsomes, hepatocyte assays, and in vivo animal studies, they determine half-life, bioavailability, clearance rates, and metabolic pathways. They frequently use modeling software such as Phoenix WinNonlin and physiologically based pharmacokinetic (PBPK) modeling platforms like GastroPlus or Simcyp.

Toxicologists then perform rigorous safety assessments. No matter how effective a molecule may be, unacceptable toxicity ends its development. Toxicologists conduct acute, sub-chronic, and chronic toxicity studies, genotoxicity testing, reproductive toxicity studies, and carcinogenicity assessments in animal models under Good Laboratory Practice (GLP) standards. Histopathology, clinical chemistry analysis, and organ system monitoring are routine. Safety pharmacology also examines effects on the cardiovascular, respiratory, and central nervous systems. Specialized assays such as hERG channel testing evaluate cardiac arrhythmia risk.

Once a compound demonstrates acceptable efficacy and safety in preclinical studies, it enters the clinical phase. Here, clinical research physicians and clinical pharmacologists design and oversee human trials. Phase I trials test safety and dosing in healthy volunteers. Phase II trials explore efficacy and dose-ranging in patients. Phase III trials involve large patient populations to confirm effectiveness and monitor adverse events.

Clinical research scientists coordinate trial logistics across hospitals and countries. Biostatisticians design the study protocols, calculate sample sizes, define endpoints, and perform complex statistical analyses to determine whether observed benefits are significant and clinically meaningful. They rely heavily on statistical software such as SAS, R, and SPSS. Data managers ensure data integrity, while clinical operations teams ensure compliance with Good Clinical Practice (GCP).

Throughout clinical development, pharmacovigilance experts monitor safety signals. They analyse adverse event reports and conduct risk-benefit assessments. After regulatory approval, this monitoring continues in Phase IV post-marketing surveillance.

While clinical trials proceed, formulation scientists work on transforming the active molecule into a usable medicine. A compound must not only be effective — it must remain stable, bioavailable, manufacturable, and convenient for patients. Formulation scientists determine excipient compatibility, optimize dissolution rates, control-release mechanisms, and ensure shelf stability. Techniques include differential scanning calorimetry (DSC), powder X-ray diffraction, and stability chambers under ICH guidelines.

Analytical chemists develop and validate methods to measure drug purity, potency, degradation products, and impurities at every stage. They ensure compliance with pharmacopeial standards (USP, EP, JP). Their instruments include HPLC, GC-MS, LC-MS/MS, UV spectroscopy, and capillary electrophoresis. Method validation follows strict regulatory requirements for accuracy, precision, specificity, and robustness.

When a drug approaches commercialization, pharmaceutical engineers and chemical engineers design large-scale manufacturing processes. Scaling up from milligram laboratory batches to multi-ton industrial production is a highly complex endeavor. Process engineers optimize reaction conditions, ensure reproducibility, manage heat transfer and solvent recovery, and design reactors compliant with Good Manufacturing Practice (GMP). Increasingly, they use process analytical technology (PAT) and continuous manufacturing systems.

Quality control scientists test every batch produced. Quality assurance teams oversee documentation, audits, and regulatory inspections. Regulatory affairs specialists compile massive dossiers, sometimes exceeding hundreds of thousands of pages — for submission to agencies such as the U.S. FDA, EMA in Europe, and other global regulatory authorities. They ensure compliance with international standards, interpret regulatory guidelines, and manage communication between the company and authorities.

Educationally, these professionals are highly trained. Medicinal chemists typically hold PhDs in organic chemistry or pharmaceutical sciences. Pharmacologists and toxicologists often hold PhDs or MD / PhDs. A PhD in Medicine is far, far more advanced and sophisticated  than just an ordinary MD. 

Clinical investigators are medical doctors with research training. Biostatisticians possess advanced degrees in statistics or biostatistics. Pharmaceutical engineers are trained in chemical or biochemical engineering. Regulatory affairs professionals may come from pharmacy, law, or biomedical science backgrounds with specialized regulatory certification.

Increasingly, artificial intelligence and machine learning specialists are joining drug development teams. AI models assist in target identification, virtual screening, toxicity prediction, and clinical trial optimization. Software environments such as Python, TensorFlow, and machine learning frameworks are becoming integral tools.

Thus, the creation of a single medicine represents the coordinated labour of hundreds, sometimes thousands  of highly specialized professionals over more than a decade. Many promising compounds fail along the way. Only a small fraction of molecules entering preclinical testing ever reach approval. This high attrition rate contributes significantly to the enormous cost of drug development.

Yet despite the complexity and cost, this multidisciplinary enterprise has given humanity antibiotics, vaccines, targeted cancer therapies, immunotherapies, antivirals, and life-saving biologicals and biosimilars. Each pill carries within it not merely chemical ingredients, but the cumulative knowledge of molecular biology, organic chemistry, physiology, engineering, statistics, ethics, and regulatory science.

Happy and A Blessed  Chap Goh Mei to all my interested readers

The Lady of the Moon in Chinese mythology is called  Change's  (嫦娥, pronounced Cháng-é). 

Here are the key details about her name and story:

Original Name: She was originally called Heng'e (姮娥, Héng'é), but her name was changed to Chang'e due to a naming taboo during the reign of Emperor Wen of Han. She is said to live in the Guanghan Palace (廣寒宮, Vast-Cold Palace) on the moon. She is accompanied by the Jade Rabbit (玉兔, Yù Tù), who pounds the elixir of life, and sometimes a toad.

The Year of the Rabbit is also my year of Birth in Batu Pahat, Johore, Malaya, then called

Look up for her tonight on Chap Goh Mei, shinning in all her glory. 

Coincidentally, there is a lunar eclipse tonight, but the moon is below the horizon part of time over Kuala Lumpur and Malaysia. By the time the moon at maximum eclipse rises over the horizon in Malaysia, it is 7:33:46 pm. The full eclipse ends at 8:02:49 pm and the eclipse  penumbra phase ends at 10:23:06 pm. Only certain parts of the world  the full lunar eclipse is visible from beginning to finish.     

-   Lim ju boo

3^rd March, 2036

Technical Paper on Immunotherapy for Cancers vs Cancer Vaccines

Immune Checkpoint Inhibitors Versus Cancer Vaccines:

Mechanistic Distinctions, Immunological Foundations, and Implications for Preventive Oncology

Lim JB¹ & Sage P²
¹Independent Medical Scholar / Researcher
²Department of Theoretical Immunology

 

Abstract

Cancer immunotherapy has transformed modern oncology by harnessing endogenous immune mechanisms to eliminate malignant cells. Among its most successful modalities are immune checkpoint inhibitors (ICIs), including programmed death-1 (PD-1) pathway blockers such as Pembrolizumab. Concurrently, therapeutic cancer vaccines aim to induce tumour-specific immune responses through antigen-directed priming. Although frequently grouped under the umbrella of immunotherapy, these modalities differ fundamentally in mechanism, immunological impact, and suitability for preventive applications. This review examines the biological basis of immune checkpoint inhibition and cancer vaccination, emphasizing mechanisms of central and peripheral tolerance. We analyse why checkpoint inhibitors, despite their therapeutic efficacy, are biologically unsuitable for use in healthy individuals as preventive agents. The distinction between immune amplification and immune education is critical for guiding future strategies in immuno-prevention and maintaining the balance between anti-tumour immunity and self-tolerance.

Executive Summary

Cancer immunotherapy has fundamentally transformed modern oncology by shifting treatment strategies from direct cytotoxic destruction of tumour cells to modulation of the host immune system. Among the most impactful advances are immune checkpoint inhibitors (ICIs), particularly programmed death-1 (PD-1) pathway blockers such as Pembrolizumab. These agents restore anti-tumour T-cell activity by disrupting inhibitory signalling pathways that normally maintain immune tolerance.

However, checkpoint inhibition and cancer vaccination represent mechanistically distinct immunological strategies. Checkpoint inhibitors amplify immune activity by releasing peripheral inhibitory control mechanisms such as PD-1 and CTLA-4. In contrast, cancer vaccines aim to induce antigen-specific immune responses through targeted priming and immunological memory formation.

This distinction carries profound implications. While checkpoint inhibitors have demonstrated significant survival benefits across multiple malignancies, their mechanism inherently disrupts immune tolerance and may precipitate immune-related adverse events, including organ-specific autoimmune disorders. The same biological mechanism that enables tumour eradication also increases the risk of collateral tissue damage.

A question a medical specialist colleague asked whether checkpoint inhibitors could be used prophylactically in healthy individuals to stimulate anti-cancer immunity raises critical immunological and ethical concerns. Unlike vaccines, checkpoint inhibitors do not introduce tumour-specific antigens or enhance immune precision. Rather, they remove regulatory restraints that are essential for preventing autoimmunity. In the absence of active tumour antigen stimulation, broad immune activation may lead to loss of peripheral tolerance without conferring meaningful protective benefit.

Preventive oncology requires enhancement of immune surveillance while preserving immunological equilibrium. Based on current mechanistic understanding, immune checkpoint blockade is biologically unsuitable as a generalized preventive strategy in healthy populations. The contrast between immune amplification and immune education underscores the need for precision in future immuno-preventive research.

Keywords

Cancer immunotherapy; immune checkpoint inhibitors; PD-1; pembrolizumab; cancer vaccines; immune tolerance; autoimmunity; immuno-prevention

 

1. Introduction

The development of cancer immunotherapy represents a paradigm shift in oncology. Rather than directly targeting tumour cells through cytotoxic agents, immunotherapy modulates host immune responses to enhance tumour recognition and destruction. Major modalities include immune checkpoint inhibitors (ICIs), adoptive cell therapies, monoclonal antibodies, antibody-drug conjugates, oncolytic viral therapy, therapeutic cancer vaccines, and cytokine-based immunomodulators.

While these approaches share the objective of enhancing anti-tumour immunity, their mechanisms differ substantially. In particular, immune checkpoint inhibitors and cancer vaccines operate at distinct regulatory levels of immune activation. This distinction becomes critically important when considering theoretical preventive applications in individuals without established malignancy.

2. Immune Checkpoint Inhibition: Mechanistic Foundations

2.1 Physiological Role of Immune Checkpoints

T-cell activation is tightly regulated by stimulatory and inhibitory signals. Two principal inhibitory pathways are cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) and programmed death-1 (PD-1).

CTLA-4 regulates early T-cell activation within secondary lymphoid organs by competing with CD28 for B7 ligands on antigen-presenting cells. PD-1, in contrast, primarily regulates T-cell activity in peripheral tissues. Upon engagement with its ligands PD-L1 or PD-L2, PD-1 signalling suppresses T-cell proliferation, cytokine production, and cytotoxic function.

These checkpoints are essential for maintaining peripheral tolerance and preventing immune-mediated tissue injury.

2.2 Tumour Immune Evasion

Many tumour cells upregulate PD-L1 expression, thereby engaging PD-1 on tumour-infiltrating lymphocytes and inducing T-cell exhaustion. This immune evasion strategy allows malignant cells to persist despite antigenic recognition.

Checkpoint inhibitors disrupt this inhibitory interaction, restoring cytotoxic T-cell function.

2.3 Clinical Application of Pembrolizumab

Pembrolizumab is a humanized monoclonal antibody targeting PD-1. By blocking PD-1 receptor engagement, it enhances T-cell-mediated tumour destruction.

It has received regulatory approval for multiple malignancies, including:

(a) Melanoma

(b) Non-small cell lung cancer

(c) Head and neck squamous cell carcinoma

(d) Triple-negative breast cancer

(e) Classical Hodgkin lymphoma

(f) Microsatellite instability-high (MSI-H)

(g) or mismatch repair-deficient tumours (tumour-agnostic approval)

Its tumour-agnostic approval marked a milestone in biomarker-driven oncology, reflecting a shift from organ-based to molecularly guided therapy.

3. Immunological Tolerance: Central and Peripheral Control

3.1 Central Tolerance

During thymic development, T cells undergo negative selection to eliminate strongly self-reactive clones. This establishes central tolerance but is not absolute.

Autoreactive T cells may escape deletion and enter peripheral circulation.

3.2 Peripheral Tolerance

Peripheral tolerance mechanisms prevent escaped autoreactive T cells from causing pathology. These include:

• Regulatory T cells (Tregs)
• Anergy induction
• Immune checkpoint pathways such as PD-1

PD-1 signaling therefore serves a physiological role in restraining self-reactivity.

 

4. Immune-Related Adverse Events and Loss of Tolerance

Checkpoint inhibition disrupts peripheral tolerance and may precipitate immune-related adverse events (irAEs). Documented toxicities include:

• Pneumonitis
• Colitis
• Hepatitis
• Nephritis
• Hypophysitis
• Thyroiditis
• Insulin-dependent diabetes mellitus
• Inflammatory arthritis

These toxicities are mechanistically linked to enhanced autoreactive T-cell activation rather than off-target drug toxicity.

In patients with advanced malignancy, this risk may be justified. In individuals without cancer, such risk would lack ethical justification.

5. Cancer Vaccines: Antigen-Specific Immune Education

Therapeutic cancer vaccines operate through antigen-specific immune priming. By introducing tumour-associated or tumour-specific neoantigens, vaccines promote:

1. Antigen uptake by dendritic cells

2. Presentation via major histocompatibility complex (MHC) molecules

3. Activation of naïve T cells

4. Clonal expansion of antigen-specific cytotoxic T lymphocytes

5. Development of immunological memory

This strategy enhances specificity rather than indiscriminate activation.

Vaccines do not remove immune checkpoints globally; instead, they provide targeted immune instruction.

6. Conceptual Distinction: Immune Amplification Versus Immune Education

Checkpoint inhibitors amplify immune intensity by removing inhibitory signalling. Cancer vaccines increase immune specificity through antigen-directed priming.

This distinction is fundamental.

Without antigenic direction, checkpoint inhibition lacks precision. In the absence of tumour antigen stimulation, broad immune activation risks self-tissue damage without therapeutic benefit.

7. Implications for Preventive Oncology

The concept of administering checkpoint inhibitors prophylactically in healthy individuals has been suggested in theoretical discussions. However, such an approach is biologically unsound for several reasons:

1. Absence of target antigen stimulation

2. Disruption of peripheral tolerance

3. Risk of irreversible autoimmune disease

4. Unfavourable risk-benefit ratio

Research into immuno-prevention is ongoing in high-risk populations (e.g., hereditary cancer syndromes or premalignant lesions), but these investigations occur under controlled clinical trial conditions. These individuals are not immunologically “healthy” controls.

Preventive strategies must preserve immune tolerance while enhancing tumour surveillance. Checkpoint blockade intrinsically compromises tolerance.

 

8. Ethical Considerations

The ethical principle of proportionality in medicine requires that therapeutic risk be justified by disease burden. In metastatic cancer, immune-related toxicities may be acceptable. In asymptomatic individuals, exposure to systemic immune dysregulation would be medically indefensible.

 

A Summary for Non-Technical Readers:

Immune checkpoint inhibitors such as Pembrolizumab have revolutionized oncology by restoring anti-tumour immunity through release of peripheral inhibitory control. Their success reflects the power of immune amplification in established malignancy.

However, checkpoint inhibitors and cancer vaccines are mechanistically distinct. Vaccines educate the immune system with antigen-specific precision. Checkpoint inhibitors remove regulatory restraints, increasing immune force but risking autoimmunity.

Preventive oncology requires strategies that enhance immune surveillance without disrupting tolerance. Based on current immunological understanding, checkpoint inhibition is unsuitable for use in healthy individuals as a preventive modality.

The immune system is a finely regulated network. Its therapeutic manipulation must respect the equilibrium between activation and tolerance upon which physiological integrity depends.

Cancer vaccines are a specific type of immunotherapy designed to teach the immune system to recognize and destroy cancer cells by targeting unique antigens. While broader immunotherapies (like checkpoint inhibitors) "release the brakes" on the immune system, vaccines actively "train" it. Vaccines generally offer higher specificity and fewer, but sometimes different, side effects compared to broader, more toxic immunotherapy.

References

1. Pardoll DM. The blockade of immune checkpoints in cancer immunotherapy. Nat Rev Cancer. 2012;12:252–264.

2. Topalian SL, et al. Safety, activity, and immune correlates of anti–PD-1 antibody in cancer. N Engl J Med. 2012;366:2443–2454.

3. Robert C, et al. Pembrolizumab versus ipilimumab in advanced melanoma. N Engl J Med. 2015;372:2521–2532.

4. Sharma P, Allison JP. The future of immune checkpoint therapy. Science. 2015;348:56–61.

5. Finn OJ. Cancer vaccines: between the idea and the reality. Nat Rev Immunol. 2018;18:183–194.

Immunotherapy for Cancer vs Cancer Vaccines

by: lim ju boo, alias lin ru wu (林 如 武)

This article is a simple version on the question about Immunotherapy for Cancer vs Cancer Vaccines.  It is written for ordinary medical doctors, biomedical scientists including patients with cancers who may be interested in other therapeutic options other than chemotherapies 

I shall write a much more technical version together with my research colleague later for oncologists and research scientists involved in cancer research

There are several major types of immunotherapy drugs used to treat cancer, generally classified by how they help the immune system fight cancer cells. The primary types include immune checkpoint inhibitors, adoptive cell therapies, monoclonal antibodies, treatment vaccines, and immunomodulators. 

Examples of the main types of immunotherapies.  

1. Immune Checkpoint Inhibitors. These are the most common type of immunotherapy. They block checkpoint proteins (like PD-1/PD-L1 and CTLA-4) that prevent T cells from destroying cancer cells.  

2. Adoptive Cell Therapy (T-cell transfer): This involves removing a patient's own T cells, modifying them in a lab to better recognize and kill cancer cells (such as CAR T-cell therapy), and returning them to the body.  

3. Monoclonal Antibodies (mAbs): Laboratory-made proteins designed to bind to specific targets on cancer cells, either flagging them for destruction or stopping them from growing. 

4. Antibody-Drug Conjugates (ADCs): A type of monoclonal antibody that is linked to a chemotherapy drug, allowing it to deliver the toxin directly to the cancer cell. 

5. Oncolytic Virus Therapy: Uses genetically modified viruses to infect and destroy cancer cells. 

6. Cancer Vaccines: Therapeutic vaccines that help the immune system recognize and attack specific antigens on cancer cells. 

7. Immunomodulators (Non-specific): These generally boost the immune system, including cytokines like interleukins and interferons, which help coordinate the immune response. 

As of 2023, there were over 11 FDA-approved immune checkpoint inhibitors (ICIs) covering more than 20 cancer types, with over 70 different immunotherapy drugs in clinical pipelines. 

For instance, Pembrolizumab (brand name Keytruda) is a widely used immunotherapy medication that helps the body's immune system fight cancer by blocking the PD-1/PD-L1 pathway. It is used to treat numerous advanced cancers, including melanoma, non-small cell lung cancer (NSCLC), head and neck cancer, triple-negative breast cancer, cervical cancer, and others, often as a first-line treatment.  Key uses and indications for Pembrolizumab are, 1.  melanoma treats advanced, unresectable, or metastatic melanoma, and is used to prevent recurrence after surgery. 2. Lung Cancer (NSCLC). This is used in various stages, often as first-line treatment for metastatic disease, particularly when tumours express high levels of PD-L1. 3. Head and Neck Cancer. It is used for recurrent or metastatic squamous cell carcinoma. 4. Breast Cancer: Pembrolizumab treats high-risk early-stage and metastatic triple-negative breast cancer (TNBC). 4. Gynaecological / GI Cancers. It is used to treats cervical, endometrial, oesophageal, and gastric cancers. 5. Lymphoma / Other Solid Tumours Used for classical Hodgkin lymphoma, cutaneous squamous cell carcinoma, and

tumours with specific genetic features (MSI-H or dMMR).

Mode of action -  It is a monoclonal antibody that inhibits the PD-1 protein on immune T-cells, allowing them to better recognize and kill cancer cells. It is given intravenously (through a vein), either alone or in combination with chemotherapy. It is also  approved for a wide variety of cancer types, often regardless of the tissue of origin, provided specific biomarkers are present. Treatment decisions are made by an oncologist  based on specific biomarkers (like PD-L1 expression) and the cancer type.

When I mentioned this casually in one of my WhatsApp chat group , a specialist doctor friend in the chat group asked if we can we use pembrolizumab to stimulate the auto immunity against cancer even in healthy individual who do not have cancer instead of using cancer vaccines

My answer to him is a straight -  NO. Here are my reasons.

Using pembrolizumab (Keytruda) in healthy individuals who do not have cancer, with the goal of stimulating immunity to prevent cancer instead of using cancer vaccines, is currently not an approved or standard medical practice. While some research is exploring the concept of "immuno-prevention" for high-risk, pre-cancerous conditions, treating healthy individuals with checkpoint inhibitors like pembrolizumab poses significant, often severe, risks to overall health. This approach is not used in healthy people because of these reasons: 

1. High Risk of Severe Autoimmunity
Pembrolizumab is an "immune checkpoint inhibitor." Its mechanism involves taking the "brakes" off the immune system (blocking the PD-1 receptor) so T-cells can attack cancer cells. A healthy person’s immune system is tightly regulated to prevent it from attacking its own body. By removing these brakes, pembrolizumab causes the immune system to attack healthy cells and tissues.

Then we need to consider the side effects of immunotherapy drugs They can lead to 1. severe or life-threatening autoimmune conditions, including pneumonitis (lung inflammation), colitis (bowel inflammation), hepatitis (liver damage), nephritis (kidney damage), and damage to endocrine glands. See link:

www.keytrudahcp.com

2. "Unmasking" Autoimmunity
In healthy individuals, the PD-1/PD-L1 pathway is crucial for maintaining tolerance to self-tissues. If this pathway is blocked, the immune system may attack organs, resulting in autoimmune diseases like Type 1 diabetes, thyroid problems, or severe arthritis.

3. Different Mechanisms: Vaccines vs. Inhibitors
Cancer Vaccines: These are designed to teach the immune system to recognize specific, foreign-looking antigens on cancer cells, providing a targeted response.
Pembrolizumab: This is a broad activator of T-cells. It does not teach the immune system to recognize cancer; it simply stops the immune system from stopping itself. If there is no cancer present, it has no specific target and primarily attacks healthy tissue.

4. Current Research on Immuno-prevention
Researchers are exploring "immuno-prevention" in very specific, high-risk scenarios, such as in patients with lung nodules that have begun to change but are not yet cancer. These are not "healthy individuals" but rather individuals with pre-cancerous conditions, and these treatments are performed within strictly controlled, experimental clinical trials.

No, it is not safe or effective to use pembrolizumab as a general, preventative, "vaccine-like" measure in healthy individuals. The potential risks.  Using pembrolizumab (Keytruda) in healthy individuals who do not have cancer, with the goal of stimulating immunity to prevent cancer instead of using cancer vaccines, is currently not an approved or standard medical practice.

While some research is exploring the concept of "immuno-prevention" for high-risk, pre-cancerous conditions, treating healthy individuals with checkpoint inhibitors like pembrolizumab poses significant, often severe, risks to overall health.