Biomarkers to Optimize Drug Development in Hematology Oncology Development in Hematology Oncology Steven M Fruchtman MD Steven M Fruchtman, MD CMO Spectrum and Syndax Pharmaceuticals (Formerly) Associate Professor of Medicine Mount Sinai Medical Center; New York l i i Evolution Summit May 8, 2014
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The Importance of Biomarkers in Hematology/Oncology Drug Development - Steven Fruchtman
The Importance of Biomarkers in Hematology/Oncology Drug Development - Presentation by Steven Fruchtman, Former Chief Medical Officer, Syndax Pharmaceuticals, at the marcus evans Evolution Summit 2014 held in Palm Beach, FL May 7-9
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Biomarkers to Optimize Drug Development in Hematology OncologyDevelopment in Hematology Oncology
Steven M Fruchtman MDSteven M Fruchtman, MD
CMO Spectrum and Syndax Pharmaceuticals (Formerly)( y)
Associate Professor of Medicine
Mount Sinai Medical Center; New York
l i iEvolution Summit
May 8, 2014
Dual Epigenetic TherapyDual Epigenetic Therapy
Lung Cancer
3rd / 4th Line NSCLC: Azacitidine + entinostatNCI
2
Oncogenic Mechanisms
DNA
GENETICChromatin
EPIGENETICDNA
M i / l i
Replicationerrors
O / l d h i
Enzyme modification errors
Mutations/translocations Open/closed chromatin
DNA sequence altered
DNA sequencenot altered
Altered DNA/mRNA/proteins
Altered mRNA/proteins
Transformed cells
Oncogenesis
Can be caused by:
• Modifications to histone proteins
• Modifications of DNA
The contents of this slide are confidential and for internal training purposes only. Not for distribution. 3
methylation
DefinitionsTERM DEFINITIONTERM DEFINITION
1. Biological marker A characteristic that is objectively measured and evaluated as an indicator of normal biologic or pathogenic processes or pharmacologic response to an
intervention
2. Clinical endpoint A characteristic or variable that reflects on a function or survival
3 Surrogate endpoint A biomarker intended to substitute for a3. Surrogate endpoint A biomarker intended to substitute for a clinical endpoint. An investigator uses epidemiological, therapeutic, pathophysiologic or other scientific evidence to select a surrogate endpoint that is expected to predict clinical benefit or harm
4 U f l bi k I f i k/b fi i h h i4. Useful biomarker Informs risk/benefit ratio when there is a decision to be made. Does so in a better/
faster/cheaper way than existing approaches.
Generally applicable: sample and technology must be available and accessible.
BIOMARKERS in Hematology/Oncology( l l )(partial list)
Biomarker INDICATIONBCR/ABL CMLER/PR/HER2 Breast Cancer
The contents of this slide are confidential and for internal training purposes only. Not for distribution.6
Pan-HDAC InhibitionHDAC depicts individual deacetylases, e.g. HDAC1, HDAC4, HDAC6
Proteins d l d b
HDAC6
HDAC HDACHDAC HDAC HDAC
modulated by DACs
Histone α‐tubulin HSP90HIF‐1αp53
Tumor suppressor gene activity
Loss of tumor suppressor function
Microtubule depolymerization/ aggresome formation
VEGF Oncoproteins Downstream
effects
p53
Cell-cycle arrest Cell motility and Invasion
Cell proliferation and survival
Tumor effects
The contents of this slide are confidential and for internal training purposes only. Not for distribution.7
Apoptosis Angiogenesis
Mechanism of ActionMechanism of Action
Cell transformation from normal to cancerous requires shutdown of tumor suppressor genes. Belinostat restores aberrant cellular control inBelinostat restores aberrant cellular control in tumour cells by reactivation of tumor suppressor genes.
HDACi in Clinical Development
Name Company Dev Status Formulation Lead Indication(s) Structure / Class
vorinostat Merck Launched Oral / IV CTCL; B Cell Lymphomas Hydroxamic Acid / Pan
romidepsin Gloucester NDA filed IV PTCL; CTCL Cyclic Peptide / Pan
panobinostat Novartis AG Phase II Oral / IV CTCL; CML; HL Hydroxamic Acid / Pan
belinostat TopoTarget UK Ltd Phase II IV / Oral PTCL Hydroxamic Acid / Pan
• Over the past generation, the economics burden of drug development has grown substantially.
• It is estimated that the costs of developing an approved drug has
i d 10 f ld j i f $199 illi t $1 9 billionincreased 10-fold, jumping from $199 million to $1.9 billion since the 1970s!!!!
• The Office of Health Economics identified 4 key factors:The Office of Health Economics identified 4 key factors: 1. soaring out of pocket research costs
2. a success rate cut in half
3. a vastly longer time spent in the clinic
4. an increased cost of capital as regulatory demands grew alongside scientific complexity.
14
Factors Contributing to Rising Costsacto s Co t but g to s g Costs
• The average time to acquire the data needed for an approval jumped from 6 to
13 513.5 years.
• High priced drugs listed in 2012 were: – Gattex for short bowel syndrome (>$200k per patient per year )
– Kalydeco for CF (>$200k per patient per year )
– Elelyso for Gaucher’s (>$200k per patient per year )
– Juxtapid for homozygous familial hypercholesterolemia (>$200k per patient per year )
– Soliris for PNH ($440,000/year.)
• In 2012, 10% of the approved drugs by the FDA cost more than a house, with a
44% increase in the number of such high priced rare disease drugs on the g p g
market.
• The cost of Zaltrap ($9600/week) decreased 50% after an article in NYT by
MSKCC physicians stated the drug would not be used due to cost.
• Histone H3 and H4 lysine acetylation may be viewed as PD endpoint but has not correlated with efficacywith efficacy
• Most analysis done in PBMCs so may not reflect tumor activity/concentration• Unclear how lysine acetylation relates to various MOA, i.e. apoptosis requires higher doses
than histone hyperacetylation• Acetylation of specific proteins may provide insight into clinical responses i e HSP90 tubulin• Acetylation of specific proteins may provide insight into clinical responses, i.e. HSP90, tubulin,
p53, etc
Cell cycle / DNA damage markers• p21 induction a consistent marker of HDACi activity• γH2AX induction as marker of DNA damage effects (or attenuation of DNA repair)
HDAC expression• Histone and tubulin acetylation reduced in DCIS, IDC vs normal epithelium (Suzuki et al 2009
Clin Canc Res)Clin Canc Res)• Class 1 HDAC protein expression may be linked to tumor progression (reviewed Weichert
Canc Lett 2009)
Question still remains for whether HDAC expression levels or its inhibition correlate with response to HDACi
Entinostat + Letrozole Effective in vivo in ERα-/PR-/HER2- Tumors
ENCORE 301 – Rigorous Ph 2 Study ENCORE 301
• Randomized, double-blind, placebo-controlled• Multi-center international study to ensure Ph 3-like populationMulti center, international study to ensure Ph 3 like population• Endpoints include: Progression-Free Survival, Overall Survival• Biomarker in subset: Protein lysine acetylation in blood cells
Exemestane + entinostat (EE) PO 5 mg weeklyR O 5 g ee y
N = 64ANDOM
Post-menopausal women with
metastatic or locally advanced ER+
Exemestane + placebo (EP)N = 66
MIZE
hormone refractory breast cancer
Syndax Pharmaceuticals ‐ Confidential
ENCORE 301 Baseline Patient Characteristics
EEN=64
EPN=66
Median Age (range) 63 (37 – 85) 62 (37 – 88)
ECOG Performance Status , n (%)0 1
40 (63%)24 (38%)
50 (76%)16 (24%)
S i f AI P i (%)Setting of AI Progression, n (%)AdjuvantAdvanced/ Metastatic
10 (16%)54 (84%)
9 (14%)57 (86%)
Sites of Metastases, n (%)Bone 49 (77%) 47 (71%)BoneBone Only DiseaseLymph nodesVisceral Involvement
49 (77%)13 (20%)30 (47%)34 (53%)
47 (71%)11 (17%)32 (48%)44 (67%)
Measurable Disease, n (%) 52 (81%) 54 (82%), ( ) ( ) ( )Prior Chemotherapy, n (%)
Adjuvant DiseaseMetastatic Disease
22 (34%)22 (34%)
28 (42%)21 (32%)
Geographic Region, n (%)h iNorth America
Central Europe/Russia42 ( 66%)22 ( 34%)
43 ( 65%)23 ( 35%)
Syndax Pharmaceuticals ‐ Confidential
Positive Phase 2 POC: PFS and OS ENCORE 301
EE: median PFS 4 3 months
PFS ‐ Intent‐to‐treat population OS ‐ Intent‐to‐treat population
EE: median PFS 4.3 monthsEP: median PFS 2.3 months
Hazard ratio 0.73 (95% CI: 0.50, 1.07)P=0.055 (1‐sided)
Consistent PFS Benefit Across All Subsets ENCORE 301
1 AI iti ( i d i t ) d fi d CR PR SD > 6 th d i t t t ith i (l t) AI f ABC
Syndax Pharmaceuticals ‐ Confidential
1 AI‐sensitive (acquired resistance) defined as CR, PR or SD > 6 months during treatment with prior (last) AI for ABC. All other patients, including all those who received the AI as adjuvant therapy, defined as AI‐resistant (primary resistance).
Feb ‘12 data cut
Consistent Survival Benefit Across All Subsets ENCORE 301
1 AI iti ( i d i t ) d fi d CR PR SD > 6 th d i t t t ith i (l t) AI f ABC
Feb ‘12 data cut
1 AI‐sensitive (acquired resistance) defined as CR, PR or SD > 6 months during treatment with prior (last) AI for ABC. All other patients, including all those who received the AI as adjuvant therapy, defined as AI‐resistant (primary resistance).
Syndax Pharmaceuticals ‐ Confidential
Post Study Treatment Well Balanced ENCORE 301
First Subsequent Therapy All Subsequent Therapies
Post Study Treatment Therapy
EE EP
Chemotherapy 48% 43%
Post Study Treatment Therapy
EE EP
Chemotherapy 66% 71%py
Hormone therapy 37% 35%
Bisphosphonates 2% 0%
py
Hormone therapy 47% 45%
Bisphosphonates 5% 2%
Radiation 6% 5%
Surgery 0% 2%
Other 0% 6%
Radiation 16% 8%
Surgery 0% 2%
Other 6% 11%Other 0% 6% Other 6% 11%
*Patients may be counted under more than one category81% of EE patients and 85% of EP patients confirmed to have received post study treatment
Syndax Pharmaceuticals ‐ Confidential
Favorable Side Effect Profile ENCORE 301
Adverse Event1EE (N=63) EP (N=66)
Any G3 G4 Any G3 G4Any G3 G4 Any G3 G4Fatigue 29 ( 46%) 7 11% 1 2% 17 ( 26%) 2 3% ‐
Nausea 25 ( 40%) 3 5% ‐ 10 ( 15%) 1 2% ‐
Neutropenia2, 3 16 ( 25%) 7 11% 1 2% 0 ( 0%) ‐ ‐
Oedema peripheral 13 ( 21%) ‐ ‐ 3 ( 5%) ‐ ‐
Vomiting 13 ( 21%) 3 5% ‐ 3 ( 5%) ‐ ‐
Anemia2 12 ( 19%) 1 2% ‐ 8 ( 12%) 1 2% 1 2%
Dyspnoea 12 ( 19%) 2 3% ‐ 7 ( 11%) ‐ ‐
Weight decreased 11 ( 17%) ‐ ‐ 12 ( 18%) ‐ ‐
Thrombocytopenia2 11 ( 17%) ‐ ‐ 4 ( 6%) ‐ 1 2%
Diarrhoea 10 ( 16%) ‐ ‐ 8 ( 12%) 1 2% ‐
Pain 10 ( 16%) 1 2% ‐ 4 ( 6%) 1 2% ‐
Back pain 9 ( 14%) ‐ ‐ 11 ( 17%) 1 2% ‐
Arthralgia 7 ( 11%) 1 2% ‐ 11 ( 17%) ‐ ‐
Constipation 6 ( 10%) ‐ ‐ 10 ( 15%) 1 2% ‐
1 Occurring in >15% in either Group ; Safety Population; Treatment‐emergent Adverse Events, regardless of treatment‐attribution. 2 Composed of combined MedDRA preferred terms.3 None of these 8 grade 3/4 patients experienced febrile neutropenia or associated infections during the time of the neutropenia. 1 patient with non‐measurable bone‐only disease given a myeloid growth factor for neutrophil support; patient had history of neutropenia & growth factor usage
Syndax Pharmaceuticals ‐ Confidential
1° data cut
ENCORE 301 Pharmacodynamic Analysis ENCORE 301
HDACi induce hyperacetylation of lysines on histones and a number of other proteins as their mechanism of actionof other proteins as their mechanism of actionWe hypothesized that HDACi-induced hyperacetylation will be associated with lower risk of disease progression
Cycle 1
Exemestane daily
Cycle 1
D22 D28D1
Entinostat Entinostat Entinostat Entinostat
C1D0 P C1D8 7 d
D8 D15
C1D15 7 dC1D0 Pre‐treatment baseline
C1D2 4‐36hrs
C1D8 ~7 days after previous entinostat
C1D15 ~7 days after previous entinostat
after entinostat
Syndax Pharmaceuticals ‐ Confidential
Patient Enrichment Strategy Identified ENCORE 301
Hyperacetylation associated with prolonged PFS in entinostat treated patients
EE HA-: median PFS 2.76 months
EE HA+: median PFS 8.55 months
1.00 EE HA+ (n=13) : median PFS 8.5 monthsEE HA‐ (n=14) : median PFS 2.8 months
Kaplan-Meier Estimates of PFS by Acetylation at Day 15 (n=27)
Hazard ratio 0.317 (95% CI: 0.127, 0.787)
Pro
babi
lity
0.75 Hazard ratio 0.32 (95% CI: 0.13, 0.79)
Pro
gres
sion
0.25
0.50 Potential to benefit may be determined by blood test within 1st two weeks of treatment 8.5 months
2.8 monthsP
0.000 2 4 6 8 10 12 14 16 18
Months Ordentlich AACR‐NCI‐EORTC Molecular Targets 20111° data cut
Syndax Pharmaceuticals ‐ Confidential
Ph 3 Registration StudyECOG 2112ECOG 2112
Clinical Development Plan in ER+ MBC
• Ph 3 E2112 – to start Q1 2014– Conducted by ECOG-ACRIN Cancer Research Group
(ECOG) and sponsored by the Division of Cancer Treatment and Diagnosis National Cancer Institute (NCI)Treatment and Diagnosis, National Cancer Institute (NCI).
– Incorporates FDA input on patient population, statistics, design• Syndax applying for SPA
– Randomized, 600 pts in hormone refractory ER+ post-menopausal metastatic breast cancermenopausal metastatic breast cancer
– Endpoints: Co-primary PFS and/or OS– 1st data in Q4 2016 – PFS
Syndax Pharmaceuticals ‐ Confidential
ECOG E2112 – Ph 3 Study Design E2112
A Randomized Phase III Trial of Endocrine Therapy plus Entinostat/Placebo in Patients with Hormone Receptor‐Positive Metastatic Breast Cancer
R Exemestane + entinostat 5mg wkly
p
ANDOM
Advanced breast cancer ER+/PR+, HER2-
Progression on prior
Exemestane + entinostat 5mg wkly N ≈ 300
1Refractory settingN=600M
IZE
non-steroidal AIExemestane + placebo
N ≈ 300
1N 600
Co‐1° Endpoints: PFS (in first 360 patients) and/or OS (N=600) Other 2° Endpoints: ORR, Safety
Biomarkers: Protein lysine acetylation; molecular and genomic tumor characterizationBiomarkers: Protein lysine acetylation; molecular and genomic tumor characterization
Syndax Pharmaceuticals ‐ Confidential
THANK YOUTHANK YOU
• Organizers – MarcusevansOrganizers Marcusevans
• Audience
i h i i i h i l• Patients who participate in research trials