Case studies of the development of targeted therapies for ... · As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011 13 Other investigators have already tested chloroquine

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

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Case studies of the development

of targeted

therapies for cancer:1. BRAF inhibitors in melanoma

2. Autophagy Inhibitors

Ravi Amaravadi, MDAssistant Professor of Medicine

Division of Hematology-Oncology Department of Medicine

Abramson Cancer CenterPerelman School of MedicineUniversity of Pennsylvania

Disclosures

Laboratory Grant FundingNCIAbramson Cancer CenterPenn-Pfizer AllianceMillenium Pharmaceuticals Tetralogics Pharmaceuticals

Industry Support for clinical trials Advisory Board/Speakers FeePfizer Tetralogics MilleniumNovartis Roche Roche Merck BayerMillenium (Takeda) Genentech

Patent PendingUS 61/177,697 Combination antineoplastic therapy with mTOR and autophagy inhibitorsUS 61/486,641 Novel autophagy inhibitors for cancer therapy


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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, DacarbazineTemozolomideHigh dose temozolomideTamoxifen

Dacarbazinev.

Median Survival: 8 monthsMedian Survival Brain Metastases: 3 months


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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


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Ibrahim and Haluska Ann rev. pathology mech. Disease 2009

Suppression of BRAF induces cell deathin BRAF mutant cell lines

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


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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, PDGFrβ 28–38 nM

FLT-3, c-KIT 40–80 nM

EGFR, PKC, MEK, ERK

Inactive at 10 mM

NH

NH

OO

N

NH

OCF3

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 sorafenibsorafenib in melanoma: 2% response rate. in melanoma: 2% response rate.

2002: phase I/II trial of 2002: phase I/II trial of sorafenibsorafenib + + carboplatincarboplatin and and paclitaxelpaclitaxel105 patients: 27% response rate/8 month PFS105 patients: 27% response rate/8 month PFS

2005: 2005: SorafenibSorafenib approved for renal cell caapproved for renal cell ca2007 2007 SorafenibSorafenib approved for HCC approved for HCC

20072007--2009: 2 large randomized phase III trials (n=>1000 patients) 2009: 2 large randomized phase III trials (n=>1000 patients) of of sorafenibsorafenib + + carbocarbo//taxoltaxol versus versus carbocarbo//taxoltaxol 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 sorafenibsorafenib to chemotherapy to chemotherapy


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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 online 16 December 2009; Corrected 14 January 2010A comprehensive catalogue of somatic mutations from a human cancer genomeErin D. Pleasance1,8 et al.

Could targeting BRAF be too simplistic or even misguided?


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Pharmacodynamics: Does the drug hit its target in patient tumors?

Sorafenib:No

PLX4032:Yes

Pre-treatment Post-treatment


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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 15Day 0

Flaherty, ASCO 2009


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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:


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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


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Chloroquine derivatives impair the lysosome, blockingthe 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…


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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 of 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


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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 10WK

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 6-28DAY

HCQ 200 mg po qd…MTD

TMZ

HCQ

Hydroxychloroquine 200 mg po qd…MTD

1 2 3 4 5 6 7 8 9 10WK

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 6-28DAY

HCQ 200 mg po qd…MTD

TMZ

HCQ

Sample Size: Phase I: 6-18Phase II: 7680% power to detect a 40% v. 26%2-year overall survival rate.

HCQ Trial #1: ABTC 0603: A phase I/II trial of hydroxychloroquinewith radiation therapy and concomitant and adjuvant temozolomide

in patients with newly diagnosed GBM

PI: Myrna Rosenfeld, MD, PhD

Setting ABTC (15 centers)


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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, MerckNCT01023737

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)

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

*

Auto

phagic

vesic

les/c

ell *

*

* *

PBMC samples

Baseline

Week 3

Week 9

A

BC

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


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BA

C

HC

Q c

oncentr

ation

(ng/m

L)

Significant AV accumulation

HCQ sulfate daily dose (mg)

Estim

ate

d p

eak H

CQ

concentr

ation (

ng/m

L)

HC

Q c

oncentr

ation

(ng/m

L)

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


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Jeffrey Winkler, PhDMerriam Professor of Organic Chemistry Department of Chemistry School of the Arts and SciencesUniversity 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 companieshave 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


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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


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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 methylationAssays 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 patientsYes 3) Are first generation autophagy inhibitor trials up and running? Yes4) Can we find a more potent and specific drug?Yes-early stages5) Does phase I testing include PK and PD analysis?Yes 6) Are we pushing the dose to the maximal tolerated dose?Not fully done7) 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 championedby other causes. 9) LUCK

Can autophagy inhibitors help cancer patients?


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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

Thank you to all of the patients and families who Thank you to all of the patients and families who Thank you to all of the patients and families who Thank you to all of the patients and families who have participated in clinical research have participated in clinical research have participated in clinical research have participated in clinical research

Case studies of the development of targeted therapies for ... · As Presented at the NCCS Cancer Policy Roundtable October 18-19, 2011 13 Other investigators have already tested chloroquine

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