Case studies of the development of targeted therapies for cancer: - - PDF document

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Case studies of the development

• f targeted

therapies for cancer:

• 1. BRAF inhibitors in melanoma
• 2. Autophagy Inhibitors

Ravi Amaravadi, MD

Assistant Professor of Medicine Division of Hematology-Oncology Department of Medicine Abramson Cancer Center Perelman School of Medicine University of Pennsylvania

Disclosures

Laboratory Grant Funding NCI Abramson Cancer Center Penn-Pfizer Alliance Millenium Pharmaceuticals Tetralogics Pharmaceuticals Industry Support for clinical trials Advisory Board/Speakers Fee Pfizer Tetralogics Millenium Novartis Roche Roche Merck Bayer Millenium (Takeda) Genentech Patent Pending US 61/177,697 Combination antineoplastic therapy with mTOR and autophagy inhibitors US 61/486,641 Novel autophagy inhibitors for cancer therapy

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Case 1: BRAF inhibitors for metastatic melanoma Treatment of Metastatic Melanoma: No standard 1st Line therapy identified Interferon Interleukin-2 Cisplatin, Vincristine, Dacarbazine Temozolomide High dose temozolomide Tamoxifen Dacarbazine v. Median Survival: 8 months Median Survival Brain Metastases: 3 months

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Clinical trial preferred Or Interleukin 2 Or Dacarbazine Or Temozolomide ± cisplatin and vinblastine

2010 NCCN guidelines for first line treatment of Stage IV melanoma

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Ibrahim and Haluska Ann rev. pathology mech. Disease 2009

Suppression of BRAF induces cell death in BRAF mutant cell lines

Karasarides et al. Oncogene (2004) 23, 6292–6298

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Sorafenib

Kinase assays IC50 C-Raf 2 nM mVEGFR2, VEGFR3 6-10 nM wt B-Raf, V599E B- Raf 20–40 nM p38, PDGFr 28–38 nM FLT-3, c-KIT 40–80 nM EGFR, PKC, MEK, ERK Inactive at 10 mM

N H N H O O N N H O CF3 Cl

Wan PT et al. Cell. 2004 Mar 19;116(6):855-67

Sorafenib in Melanoma

2002: phase II trial of 2002: phase II trial of sorafenib sorafenib in melanoma: 2% response rate. in melanoma: 2% response rate. 2002: phase I/II trial of 2002: phase I/II trial of sorafenib sorafenib + + carboplatin carboplatin and and paclitaxel paclitaxel 105 patients: 27% response rate/8 month PFS 105 patients: 27% response rate/8 month PFS 2005: 2005: Sorafenib Sorafenib approved for renal cell ca approved for renal cell ca 2007 2007 Sorafenib Sorafenib approved for HCC approved for HCC 2007 2007-2009: 2 large randomized phase III trials (n=>1000 patients) 2009: 2 large randomized phase III trials (n=>1000 patients)

• f
• f sorafenib

sorafenib + + carbo carbo/taxol taxol versus versus carbo carbo/taxol taxol found absolutely no found absolutely no difference in response rate, or survival with the addition of difference in response rate, or survival with the addition of sorafenib sorafenib to chemotherapy to chemotherapy

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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33,345 mutations were found in the melanoma genome compared to the normal genome from the same patient. 187 mutations were predicted to alter the known function of specific proteins.

Nature 463, 191-196 (14 January 2010) | doi:10.1038/nature08658; Received 30 July 2009; Accepted 4 November 2009; Published

• nline 16 December 2009; Corrected 14

January 2010 A comprehensive catalogue of somatic mutations from a human cancer genome Erin D. Pleasance1,8 et al.

Could targeting BRAF be too simplistic or even misguided?

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Pharmacodynamics: Does the drug hit its target in patient tumors? Sorafenib: No PLX4032: Yes Pre-treatment Post-treatment

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Dose and schedule 960 mg bid maximal tolerated dose and phase II dose Safety Common side effects include a rash, squamous cell carcinoma, and fatigue.

Response Definition No % Complete response No evidence of disease 1 4 Partial Response >30% tumor shrinkage from baseline 18 67 Stable Disease <30% shrinkage and <20% growth from baseline 6 (all had shrinkage) 22 Progressive Disease >20% growth from baseline or new tumors 2 7

Total 27 100

Phase I Results of PLX4032 in patients with BRAF mutant melanoma

V600E+ melanoma patient PET scan at baseline and day +15 after PLX4032 treatment at 720 mg BID

Day 15 Day 0 Flaherty, ASCO 2009

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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1st interim analysis found that Vemurafenib reduces the risk of progression by 74% and the risk of dying by 63% compared to chemotherapy

Chapman et al NEJM 2011

1) The molecular target was identified and validated in preclinical models 2) The target is present in a large fraction of patients 3) Lessons learned from the failure of the first generation Raf inhibitor sorafenib were used by persistent investigators 4) A more potent and specific second generation inhibitor was found 5) Phase I testing with PK and PD analysis was performed with rigor 6) The phase I dose was increased to the maximal tolerated dose 7) The drug was tested in a biomarker-restricted population (BRAF mutant melanoma) 8) An OPEN collaboration between multiple academic investigators, Pharma teams, and the FDA 9) LUCK

The rapid success and approval of vemurafenib in BRAF mutant melanoma depended on the following:

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Case 2: Autophagy a new therapeutic target in cancer

Autophagy, the cell’s garbage disposal and built in recycling plant gets rid of waste and feeds the cancer cell when it is faced with stresses.

Lysosome Autophagic Vesicle Damaged cell component Recycled building blocks

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Chloroquine derivatives impair the lysosome, blocking the last step of autophagy

Nutrient Limitation Lum et al. Cell 2005 Growth Factor Limitation Lum et al. Cell 2005 P53 activation or Alkylating chemotherapy Amaravadi et al. JCI 2007 Tumorigenesis McLean et al. JCI 2008 HDAC inhibitor Carew et al. Blood 2007 Dormant tumor cells Luo et al. JCI 2008 Akt inhibitor Degtyarev M (Genentech) J Cell Bio 2008 Imatinib Bellodi JCI 2009 Velcade Ding et al. MBC 2009

Autophagy Inhibition augments cancer cell death in the context of…

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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• Chloroquine derivatives used in humans since 1940’s
• Used for decades for malaria, rheumatoid arthritis
• Extensive preclinical testing, hundreds of thousands of patients worth
• f safety data
• Hydroxychloroquine is a safer drug than chloroquine at high doses
• Generic drug with no pharmaceutical company interested in marketing

for cancer indications

Excellent brain penetration Could chloroquine (CQ) or hydroxychloroquine (HCQ) be used to treat cancer?

Drug Monthly Cost Erbitux $ 9600 Avastin $ 4400-8800 Sorafenib $ 5614 Gleevec $ 3816 Herceptin $ 3195 Tarceva $ 2697 Hydroxychloroquine $ 50-200

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Other investigators have already tested chloroquine for cancer

Sotelo, et al. Ann Int. Med. 2006. Kaplan Meier Analysis of Overall Survival in GBM patients treated on the phase III trial of CQ/carmustine/RT v. placebo/carmustine/RT ( p>0.05)

Randomized phase III trial of RT/carmustine +/- low dose CQ in newly diagnosed Glioma (Brain Tumors)

Hydroxychloroquine 200 mg po qd…MTD 1 2 3 4 5 6 7 8 9 10

WK RT TMZ HCQ

Radiation 59.4 Gy/33 fractions Temozolomide 75 mg/m2 po qd

Initiation Cycle Maintenance Cycle:

TMZ 150 mg/m2 po d1-5 1-5 6-28 DAY HCQ 200 mg po qd…MTD TMZ HCQ Hydroxychloroquine 200 mg po qd…MTD 1 2 3 4 5 6 7 8 9 10

WK RT TMZ HCQ

Radiation 59.4 Gy/33 fractions Temozolomide 75 mg/m2 po qd

Initiation Cycle Maintenance Cycle:

TMZ 150 mg/m2 po d1-5 1-5 6-28 DAY HCQ 200 mg po qd…MTD TMZ HCQ

Sample Size: Phase I: 6-18 Phase II: 76 80% power to detect a 40% v. 26% 2-year overall survival rate.

HCQ Trial #1: ABTC 0603: A phase I/II trial of hydroxychloroquine with radiation therapy and concomitant and adjuvant temozolomide in patients with newly diagnosed GBM

PI: Myrna Rosenfeld, MD, PhD

Setting ABTC (15 centers)

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Condition Intervention Phase Sponsors Collaborators ClinicalTrials.go v Identifier Title Multiple myeloma HCQ + Bortezomib I/II UPenn, Millenium NCT00568880 A Phase I/II Trial of HCQAdded to Bortezomib for Relapsed/Refractory Myeloma Brain, central nervous system tumors HCQ+ Temozolomide/RT I/II UPenn,,CTEP, NCI NCT00486603 A Phase I/II Trial of HCQ in Conjunction with Radiation Therapy and Concurrent and Adjuvant Temozolomide in Patients With Newly Diagnosed Glioblastoma Multiforme Adult solid tumors HCQ+ temozolomide I UPenn, Schering NCT00714181 A Phase I Study of HCQ in Combination with temozolomide in Patients with Advanced Solid Tumors Adult solid tumors HCQ+ temsirolimus I UPenn, Wyeth

NCT00909831

A Phase I Study of HCQ in Combination with temsirolimus in Patients with Advanced Solid Tumors Adult Solid Tumors HCQ + Vorinostat I San Antonio, NCI, Merck

NCT01023737

A phase I pharmacokinetic and Pharmacodynamic Study of Hydroxychloroquine in combination with vorinostat for the treatment of patients with advanced solid tumors Prostate cancer Docetaxel hydroxy- chloroquine II CINJ, NCI

NCT00786682

A Phase II Study of Docetaxel and Modulation of Autophagy with HCQ for Metastatic Hormone Refractory Prostate Cancer Prostate cancer HCQ II CINJ, NCI

NCT00726596

Autophagic Cell Death in Patients with Hormone-Dependent Prostate-Specific Antigen Progression after Local Therapy for Prostate Cancer Breast cancer HCQ+ ixabepilone I/II CINJ, NCI NCT00765765 Phase I/II Study of Ixabepilone in Combination with the Autophagy Inhibitor HCQ for the Treatment of Patients with Metastatic Breast Cancer Lung cancer HCQ+Bevacizumab carboplatin paclitaxel I/II CINJ, NCI NCT00728845 Modulation of Autophagy with HCQ in Combination with Carboplatin, Paclitaxel and Bevacizumab in Patients with Advanced/Recurrent Non-Small Cell Lung Cancer -A Phase I/II Study Advanced cancer HCQ + sunitinib I CINJ, NCI NCT00813423 Anti-Angiogenic Therapy in Patients with Advanced Malignancies: A Phase I Trial of Sunitinib and HCQ Non-small cell lung cancer HCQ + Gefitinib I/II Singapore, MGH NCT00809237 A Phase II with a Lead in Phase I Study to Examine the Tolerability, Safety Profile and Efficacy of HCQ and Gefitinib in Advanced Non- Small Cell Lung Cancer B-cell chronic lymphocytic leukemia HCQ II North Shore Long Island Jewish NCT00771056 Autophagic Modulation with Phase II Study to Evaluate the Tolerability and Efficacy of Treatment of Previously Untreated B- Cell Chronic Lymphocytic Leukemia (B-CLL) Patients with HCQ Pancreas Cancer HCQ+ Gemcitabine I

• U. Pittsburgh

Pending Phase I/II study of Preoperative Gemcitabine in Combination with Oral HCQ in Subjects With Resectable Stage IIb Or III Pancreatic Adenocarcinoma Renal Cancer HCQ IA

• U. Pittsburgh

Pending Neoadjuvant Study of Preoperative HCQ in Patients with Resectable Renal Cell Carcinoma

2 µm

Actin LC3 I LC3 II

Pre-treatment 3 wks 800 mg HCQ /TMZ/RT

P 3W

HCQ 200 400 800 400 600 (Mg/Day)

1 2 3 4 5 6 7 8 9 10 11 12 13 14

*

Autophagic vesicles/cell

* * * *

PBMC samples

Baseline Week 3 Week 9

A B C

Patient 1 2 4 5 8 9 11 12 13 14 15 16

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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B A C

HCQ concentration (ng/mL) Significant AV accumulation HCQ sulfate daily dose (mg) Estimated peak HCQ concentration (ng/mL) HCQ concentration (ng/mL) Time on study (hrs)

B

Figure 5. Whole blood hydroxychloroquine (HCQ) concentrations and pharmacodynamic response. (A) Range of HCQ concentrations demonstrates a proportional dose-concentration relationship. (B) HCQ concentrations are maintained over the course of months. (C) Patients with significant AV accumulation had significantly higher estimated peak HCQ concentrations; *p=0.028. (A-C) Patients/samples available: 14/45. Population pharmacokinetic modeling indicated data are best described using a one- compartment model with first-order elimination. Baseline Temsirolimus Tem + HCQ

MVP mean: 940.9 MVP mean: 526.3 MVP mean: 497.7

Encouraging activity of autophagy inhibition combined with mTOR inhibition

• Phase I trial of temsirolimus + HCQ completed dose escalation 27 pts
• Dose expansion in melanoma patients
• Safe and tolerable regimen
• 65% & 73% stable disease rate in solid tumors and melanoma
• Temsirolimus as a single agent has a 0% stable disease rate in melanoma

Presented at AACR 2011 and SMR 2011

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Jeffrey Winkler, PhD Merriam Professor of Organic Chemistry Department of Chemistry School of the Arts and Sciences University of Pennsylvania

• Lys01/Lys05 (water soluble)

are novel potent autophagy inhibitors designed by employing first principles of chemistry.

• Patent was filed April 2011
• A few pharmaceutical companies

have expressed initial interest Designing a more potent autophagy inhibitor

PBS HCQ 10 µM Lys05 10 µM

Within 4 hours of treatment Lys05 treatment results in an increased size and number of accumulated autophagic vesicles compared to HCQ

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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In vivo autophagy inhibition and antitumor efficacy of Lys05 in 2 different melanoma xenograft mouse models

Identifying the molecular target of lysosomal Autophagy inhibitors Lys01

Target 1 Target 2 Target 3 Target 4 Target 5

Lys02

Target 1 Target 2 Target 3 Target 4

• Target

5

Step 1:Subtractive chemical proteomics for target identification Active autophagy inhibitor Inactive autophagy inhibitor

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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A biomarker of sensitivity to autophagy inhibition has been identified

Figure 1. An autophagy inhibitor biomarker Predicts sensitivity to HCQ Figure 2. IHC and serum DNA methylation Assays can detect the candidate biomarker In patient samples Autophagy inhibitor Biomarker

+ -

1) Molecular target identified and validated in preclinical models? Not fully- we need to get more specific 2) Is autophagy and a biomarker of sensitivity to autophagy inhibitors present in a large fraction of patients Yes 3) Are first generation autophagy inhibitor trials up and running? Yes 4) Can we find a more potent and specific drug? Yes-early stages 5) Does phase I testing include PK and PD analysis? Yes 6) Are we pushing the dose to the maximal tolerated dose? Not fully done 7) Are we testing the drug in a biomarker-restricted population? Not yet- early stages of biomarker development and validation 8) Is there an OPEN collaboration between multiple academic investigators, Pharma teams, and the FDA? Emerging interest in pharmaceutical companies, but may need to be championed by other causes. 9) LUCK

Can autophagy inhibitors help cancer patients?

As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011

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Take Home Messages

• The successful development of vemurafenib for

BRAF mutant melanoma can serve as a model For development of other targeted therapies for cancer.

• Autophagy is an emerging target in cancer that if properly studied

could yield multiple drugs that benefit a large subfraction of cancer patients