Molekylært målrettet medicinsk kræftbehandling for klinikere Behandlingsprincipper og medicamina SKA kursus i Vejle, oktober, 2013

Molekylært målrettet medicinsk kræftbehandling for klinikere Behandlingsprincipper og medicamina SKA kursus i Vejle, oktober, 2013 Morten Mau-Sørensen Fase I Enhed, Onkologisk Klinik, Rigshospitalet MS/2013 Målrettet behandling - Vejle 1

% survival Outcomes with chemotherapy may have reached a plateau in some cancer types Non-small cell lung cancer 100 80 60 Median Survival (mo) Paclitaxel/cisplatin 7.8 Gemcitabine/cisplatin 8.1* Docetaxel/cisplatin 7.4* Paclitaxel/carboplatin 8.1* 40 20 0 0 5 10 15 20 25 30 Months MS/2013 Målrettet behandling - Vejle 2 *p = not significant vs paclitaxel/cisplatin Schiller, et al. N Engl J Med 2002;346:92.

MS/2013 Målrettet behandling - Vejle 3

Nøgle i lås Glivec (Imatinib) MS/2013 Målrettet behandling - Vejle 4

GIST - konstitutiv aktiv c-kit receptor Imatinib hæmmer c-kit MS/2013 Målrettet behandling - Vejle 7

GastroInstestinal Stromal Tumor (GIST) -Sjælden mesencymal GI tumor - 4 tilfælde per mill - Ventrikel (70%) Tyndtarm (25 %) - 2001: Kirurgi eneste behandlingstilbud Ingen effekt af kemo- og radioterapi ved inop eller metastatisk sygdom Mutation MS/2013 i konstitutivt aktiv c-kit receptor Målrettet behandling - Vejle 8

Er målrettet behandling nyt? Målrettet behanding før Glivec? MS/2013 Målrettet behandling - Vejle 10

Ja - tamoxifen MS/2013 Målrettet behandling - Vejle 11

~5 years Tamoxifen vs not RECURRENCE ER-poor disease ER+ disease ER+ disease MS/2013 Målrettet behandling - Vejle 12 Peto SABCS 2007

Hvad er målrettet behandling Irinotecan rettet mod topoisomerase I? Etoposid rettet mod topoisomerase II? Epirubicin rettet mod topoisomerase II? 5-FU rettet mod thymidylat Syntase? Bevacizumab mod VEGF A? Sorafenib? MS/2013 Målrettet behandling - Vejle 13

Definition på målrettet behandling Target udelukkende/fortrinsvis til stede i tumor væv Target udelukkende tilstede i en given patient tumor Behandlingen retter sig specifikt mod target Behandlingen er kun virksom hvis target er til stede MS/2013 Målrettet behandling - Vejle 14

What is targeted therapy Target a defined process in cancer growth and/or development i.e hallmarks of cancer Target measurable or identiable in tumors in patients Outcome of targeted therapy is correlated to the presence or absence of target Sledge, JCO editorial, p1614, 2013 MS/2013 Målrettet behandling - Vejle 15

Hvad er målrettet behandling Irinotecan rettet mod topoisomerase I: nej Etoposid rettet mod topoisomerase II: nej Epirubicin rettet mod topoisomerase II: hmm, jae 5-FU rettet mod thymidylat Syntase: måske Bevacizumab mod VEGF A: nej Sorafenib: nej MS/2013 Målrettet behandling - Vejle 16

Benefit of epirubicin in mbc related to TOP2A status targeted therapy? MS/2013 Målrettet behandling - Vejle 17

6 karakteristika ved kræftcellen Manglende vækstkontrol Ikke følsomhed for væksthæmning Mangler apoptose (programmeret celledød) Uendeligt delingspotentiale Angiogenese (dannelse af blodkar) Proteolyse (invasion, metastasering) Målrettet behandling - Vejle Hanahan and Weinberg Cell 2000 MS/2013 19

Flere vigtige karakteristika MS/2013 Målrettet behandling - Vejle 20 Mab og TKI Hanahan UL/2012 and Weinberg Cell 2011

Signal transduction by tyrosin kinases Growth factor Binding site Plasma membrane Signal transduction to nucleus Tyrosine kinase activity Cytoplasm Nucleus Gene activation CELL DIVISION MS/2013 Målrettet behandling - Vejle 21

ErbB Family of Tyrosine Kinase Receptors Family of evolutionarily conserved type I receptor tyrosine kinases Extracellular Domain (Binds Ligand) TM Domain Four members: ErbB-1 (EGFR/HER1) ErbB-2 (HER2) ErbB-3 (HER3) ErbB-4 (HER4) Cytoplasmic Domain (Kinase Activity) UL/2012 Mab og TKI

Overexpression of ErbB-1 and ErbB-2 in Solid Tumors Tumor Type Overexpressing ErbB-1 (%) Overexpressing ErbB-2 (%) Bladder 31%-48% 7%-36% Breast 14%-91% 10%-37% Colorectal 25%-77% 7% Esophageal 71% 13%-73% Glioma 40%-50% NSCLC 40%-80% 3%-56% Ovary 30%-75% 20%-32% Pancreatic 30%-50% Renal 50%-90% 24%-40% Head and Neck 30%-75% 32%-62% Stomach 5%-55% Mab og TKI Rowinsky. Horiz Cancer Ther 2001; 2:3-35; Itakura et al. Cancer 1994; 74:795-804

ErbB-1 Also known as epidermal growth factor receptor (EGFR) First family member identified Involved in normal cell growth and differentiation Disturbances in ErbB-1 signaling can lead to cell transformation Ligands specific for ErbB-1 include EGF, transforming growth factor (TGF)-α, and amphiregulin

ErbB-2 Also known as HER2/neu No known ligands Activation thought to occur through heterodimerization with other ErbB family members ErbB-2 is the preferred heterodimerization partner with other family members Most resistant to intracellular degradation, slower to inactivate compared to other family members ErbB-2 overexpression in tumors correlates with poor prognosis and decreased survival times

ErbB-3 Lacks intrinsic tyrosine kinase activity Often found in heterodimers with ErbB-2 Cytoplasmic domain contains 6 sites where the p85 subunit of PI3 kinase can bind Heterodimers containing ErbB-3 (especially ErbB-2/ErbB-3) are thought to be particularly strong activators of the PI3K/Akt pathway that is associated with cell survival and resistance to cancer therapy PI3K Akt Cell survival UL/2012 Mab og TKI PI3K Binding Site

ErbB-4 Important in cardiac and brain development Expression might correlate with presence of hormone receptors in breast tumors, more favorable prognosis Multiple splice variants, some of which contain binding sites for PI3K Slow internalization Ligands include neuregulins, betacellulin, epiregulin, and heparin-binding (HB) EGF UL/2012 Mab og TKI

Homodimers and Heterodimers 1+1 2+2 1+2 2+3 2+4 Ligand binding causes ErbB receptors to associate in pairs in a process called dimerization. Dimerization and autophosphorylation must occur for downstream signal transmission. Pairs can be formed between 2 identical receptors (homodimers) or between 2 different family members (heterodimers). ErbB-2 is the preferred dimerization partner with other ErbB receptors. UL/2012 Mab og TKI

Strategies to Inhibit ErbB MoAbs to block ligand binding or receptor dimerization Small-molecule kinase inhibitors Competitive receptor antagonists Ligand-toxin or Ab-toxin conjugates Antisense oligonucleotides Vaccines MoAb Kinase Inhibitor Antagonist Ligandtoxin UL/2012 Mab og TKI

Nib og Mab nib er (tyrosinkinase inhibitorer) mab er (monoklonale anti-bodies) MS/2013 Målrettet behandling - Vejle 30

Monoklonale antistoffer - Mab Kimerisk antistof en af to kæder stammer fra en anden art (ex mus), resten humant. - Højt allergent potentiale - xi foran mab - ex. Cetuximab (Erbitux), Rituximab (MabThera) Humaniseret antistof begge kæder er humane. Mindre bindende del er artsfremmed eller syntetisk Lavt allergent potentiale - zu foran mab - ex. Trastuzumab, Bevacizumab Humant antistof rent humant -Minimalt allergent potential - u foran mab - ex. Panitumumab, Zalutumumab MS/2013 Målrettet behandling - Vejle 31

Targeted agents at NCI s website januar 2011 44 nib er (tyrosinkinase inhibitorer) 109 mab er (monoklonale anti-bodies) 6 imus er (immun-suppression) Targeted agents at NCI s website januar 2012 60 nib er (tyrosinkinase inhibitorer) 146 mab er (monoklonale anti-bodies) 7 imus er (immun-suppression) MS/2013 Målrettet behandling - Vejle 32

Herceptin (trastuzumab): humanised anti-her2 monoclonal antibody Targets HER2 oncoprotein High affinity (K d =0.1nM) and specificity 95% human, 5% murine decreased potential for immunogenicity increased potential for recruiting immune-effector mechanisms MS/2013 Målrettet behandling - Vejle 33

Probability of survival Trastuzumab plus paclitaxel: 39% increase in survival (IHC 3+) 1.0 0.8 0.6 trastuzumab + paclitaxel Paclitaxel 0.4 0.2 0 39% 17.9 24.8 0 5 10 15 20 25 30 35 40 45 50 Time (months) MS/2013 Målrettet behandling - Smith Vejle IE. Anticancer Drugs 2001;12:S3 10 34

Herceptin adjuvant trials: HER2 pos. breast MS/2013 Målrettet behandling - Vejle 35

First line HER 2 mbc Trastuzumab+docetaxel+pertuzumab vs. Trastuzumab+docetaxel+placebo MS/2013 Målrettet behandling - Vejle 37

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On Target MS/2013 Målrettet behandling - Vejle 41

Off Target................ MS/2013 Målrettet behandling - Vejle 42

~5 years Tamoxifen vs not RECURRENCE ER-poor disease ER+ disease ER+ disease MS/2013 Målrettet behandling - Vejle 43 Peto SABCS 2007

BR21 2nd an 3rd treatment of NSCLC Tarceva (150 mg) + BSC Randomization 2:1 ratio Primary endpoint: SURVIVAL Placebo + BSC ISEL 2nd an 3rd treatment of NSCLC IRESSA (250 mg) + BSC Randomization 2:1 ratio Primary endpoint: SURVIVAL Placebo + BSC MS/2013 Målrettet behandling - Vejle 44

Patients surviving (%) Survival - ISEL 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 IRESSA ------ Placebo 0.0 Month: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 At risk: 1692 1348 876 484 252 103 31 IRESSA Placebo Median (mo) 5.6 5.1 1 yr survival 27% 22% HR = 0.89 (0.78, 1.03), P =.11 N = 1692, deaths = 969 Cox analysis, P =.042 MS/2013 Målrettet behandling - Vejle 46

Survival ISEL EGRF pos og negativ Iressa EGRF pos Placebo Placebo Iressa EGRF neg MS/2013 Målrettet behandling - Vejle 47

HER1/EGFR TK mutations and response to gefitinib in patients with NSCLC 275 patients with advanced chemorefractory NSCLC received gefitinib at Massachusetts General Hospital (clinical trial, compassionate use, or onlabel) 25 patients responded All exons were sequenced in nine of the 25 responders eight had TK mutations DNA from seven non-responders were sequenced no mutations In 25 patients not treated with gefitinib (15 BAC), two patients had TK mutations (both BAC) Lynch TJ, et al. N Engl J Med 2004;350:2129 39

EGFR mutations and response to EGFR-TKI in advanced NSCLC Mutation frequency approximately 12% in Caucasians More frequent in never-smokers, women, adenocarcinoma, BAC and Asians Rare or absent in other tumor types Presence of a mutation predicts response to small molecules EGFR inhibitors MS/2013 Målrettet behandling - Vejle 50

NSCLC - EGFR mut (exon 19 deletion + L858R in exon 21) Erlotinib vs Chemotherapy MS/2013 Målrettet behandling - Vejle 54

On target off target Ingen target ingen effekt Target skal være tilstede EGRF Target skal være følsomt - muteret MS/2013 Målrettet behandling - Vejle 55

Mechanism of action: synthetic lethality in DNA repair defective backgrounds 10,000 s DNA SSBs occur each day in cells PARP olaparib Olaparib traps PARP on the DNA single strand break preventing repair and effectively generating a protein-dna adduct During replication unrepaired SSBs bound by PARP result in fork collapse and DNA DSBs Replicating cells Combination with DNA damaging therapies (chemotherapy and IR) Normal cell Cancer cell with HRD Repair by Homologous Recombination Survival Tumour-specific killing by single agent olaparib (Synthetic Lethality) No effective repair (No HRR pathway) Cell death MS/2013 Målrettet behandling - Vejle 56

Proportion of patients progressionfree Study 19: PFS by BRCA mutation Number at risk Olaparib BRCAm Placebo BRCAm Olaparib BRCAwt Placebo BRCAwt 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0 Olaparib BRCAm Placebo BRCAm Olaparib BRCAwt Placebo BRCAwt status BRCA mutated (n=136) BRCA wildtype (n=118) Olaparib Placebo Olaparib Placebo Events: total pts (%) 26:74 (35.1) 46:62 (74.2) 32:57 (56.1) 44:61 (72.1) Median PFS, months 11.2 4.3 5.6 5.5 3 6 9 12 15 Time from randomization (months) HR=0.18 95% CI (0.11, 0.31); P<0.00001 74 59 33 14 4 0 62 35 13 2 0 0 57 44 17 9 2 0 61 35 10 4 1 0 HR=0.53 95% CI (0.33, 0.84); P=0.007 Statistically significant treatment benefit in patients with and without a BRCA mutation MS/2013 Målrettet behandling - Vejle 57 Ledermann J et al. ASCO 2013

Vismodegib inhibitor of hedge hog signaling in basal cell carcinoma Gorlin Syndrome MS/2013 Målrettet behandling - Vejle 58

Epidermal growth factor receptor (EGFR) signal transduction via K-ras MS/2013 Målrettet behandling - Vejle 61

Waterfall plots in wild-type and mutant K-ras Randomised to Panitumumab or Best Supportiv Care Panitumumab Mutant K-ras Panitumumab Wild-type K-ras Best supportiv care Mutant K-ras Best supportiv care Wild-type K-ras MS/2013 Målrettet behandling - Vejle 62

Mutant K-ras Wild-type K-ras MS/2013 Målrettet behandling - Vejle 63

On target off target Selv om target er tilstede - Ingen effekt Det hjælper ikke at blokkere højt (EGRF) i strømmen af vækst signaler hvis uhæmmet vækst signaler opstår distalt herfor (K-ras) MS/2013 Målrettet behandling - Vejle 64

ALK-inhibitorer Anaplastic lymphoma kinase (ALK) inhibitor Abnorm expression of ALK drives certain types of non-small cell lung cancer (NSCLC), neuroblastomas, and anaplastic largecell lymphoma. ALK is not expressed in normal tissue, representing a promising molecular target for cancer therapy. 31 heavily pre-treated patients with NSCLC with ALK re-arrangement studied Among these 20 had regression, (1 CR; durable reponse - median 24 weeks). The fusion gene was first described in NSCLC in 2007, and clinical activty was reported for the first time in 2009. UL/2012 Mab og TKI

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BRAF V600E Mutation Oncogenic mutation of BRAF ~8-15% of all solid tumors ~50% of malignant melanomas shrna knock down experiments support its role in neoplastic behavior BRAF mutation knock-in mice develop melanoma-like malignancies RG7204 arrests abnormal cell growth in melanoma models Melanoma B-Raf ~ 50% UL/2012 Mab og TKI 70

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The Target: BRaf Kinase An important mediator of cellular proliferation RTK RAS ATP ATP BRAF V600E Raf MEK RG7204 UL/2012 ERK Cellular Proliferation Mab og TKI RG7204 co-structure with kinase domain of B-RAF V600E (Bollag et al., Nature 2010)

%Change From Baseline (Sum of Lesion Size) Phase I Trial: Tumor responses occurred in majority (81%) of patients in V600E+ melanoma extension cohort (960 mg BID) 100 75 50 25 0-25 -50-75 -100 UL/2012 Investigator assessments Includes confirmed & unconfirmed responses Mab og TKI 73

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Tumor Regression (Target Lesions) Occurred in Majority of Patients (IRC) RECIST 30% Decrease *** *** 7 patients had 100% tumor shrinkage, 3 of which had confirmed CR; 1 patient had unconfirmed CR and 3 patients had non-target lesions present 122 patients had baseline and 1post-baseline scan with measurable disease UL/2012 Mab og TKI 75

BRIM 3 UL/2012 Mab og TKI

Potential Mechanisms of Drug Resistance After Lo, et al. Nature, in press. 78

BRAF mut malign melanom MEK hæmmer vs chemotherapy

Cutaneous SCC Keratoacanthoma (KA) Subtype UL/2012 Characteristics of KA subtype Raised button-like, central crater Well-differentiated neoplasm with low probability of invasion/metastasis Can grow rapidly; may involute and regress Typically treated by excision Observed with other agents (e.g., sorafenib) KA in the Phase I RG7204 Trial Occurred on sun-exposed skin Did not result in treatment discontinuation Mab og TKI 80

76 yr old pt with st IV BRAF V600K mut MM treated with vemurafenib

Why is vemurafenib less active in BRAF V600K mut Colon Cancer In colon cancer ERK inhibits EGFR/RAS via negative feed back Vemurafenib distrubts negative feed back resulting in increased RAS signaling MS/2013 Målrettet behandling - Vejle 85

Waterfall plot - MoA against PD-1 in melanoma MS/2013 Målrettet behandling - Vejle 89

Anti-tumor activity of anti PD-L1 MoA in melanoma and NSCLC MS/2013 Målrettet behandling - Vejle 90

Goal Select the right patients for the right treatment at the right time and in the right sequence Solution: Biomarkers Caveats: Small numbers Subpopulations Loss of statistical power MS/2013 Målrettet behandling - Vejle 91

Modern drug development: Biomarker driven early clinical trials UL/2012 Mab og TKI

Marker x Treatment Interaction Design Marker Strategy Design MS/2013 Målrettet behandling - Vejle 93

New track for clinical trials UL/2012 Mab og TKI

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Genetic Intratumor Heterogeneity and Phylogeny in Patient 1. Gerlinger M et al. N Engl J Med 2012;366:883-892

Causes of failure (or relative ineffectiveness) Biological redundancy, either by escape through alternative pathways or input to downstream convergence sites (EGRF og K-ras) Lack of biological information or tools to identify patients who will benefit (Tarceva og Iressa i NSCLC) MS/2013 Målrettet behandling - Vejle 98

Tak for opmærksomheden MS/2013 Målrettet behandling - Vejle 99

Indicators of increased HER2 production Normal HER2 receptor protein HER2 mrna Amplification/Overexpression 3 2 1 4 Cytoplasm Cytoplasmic membrane HER2 DNA Nucleus 1 = gene copy number 2 = mrna transcription 3 = cell surface receptor protein expression 4 = release of receptor extracellular domain MS/2013 Målrettet behandling - Vejle 100

Positive or negative HER2 status Normal 0 Normal 1+ Abnormal 2+ Abnormal 3+ Normal Normal Abnormal low amplification Abnormal high amplification MS/2013 IHC Images Målrettet courtesy behandling of MJ - Kornstein, Vejle MD, Medical College of Virginia 101

Randomised evidence of effect of trastuzumab in 1. line HER2+ ABC AC or paclitaxel +/- trastuzumab (1) Paclitaxel +/- trastuzumab (2) Docetaxel +/- trastuzumab (3) (1) Slamon N Engl J Med 2001;345:783 (2) Gasparini Breast Cancer Res Treatment 2007;101:355 (3) Marty JCO 2005;23:4265 MS/2013 Målrettet behandling - Vejle 102