Why did the antibodies fail in adjuvant treatment? Heinz-Josef Lenz Associate Director, Clinical Research Kathryn Balakrishnan Chair for Cancer Research.

Why did the antibodies fail in adjuvant treatment?

Heinz-Josef Lenz

Associate Director, Clinical Research

Kathryn Balakrishnan Chair for Cancer Research

Co-Director, USC Center for Molecular Pathways and Drug Discovery

Co-Leader GI Oncology Program

USC/Norris Comprehensive Cancer Center

Why Treatment Failures in Adjuvant Therapy

• Tumor Biology (Genetic Make Up)

– What do we know?

• Host Response (Host Genome/ Microenvironment)

– What do we know?

Tumor Biology (PETACC)Tumor Biology (PETACC)Multivariate Analysis in whole Multivariate Analysis in whole

populationpopulationMarkers

Stage II Stage III

HR§ p value* HR§ p value*

T Stage (T4 vs T3) 2.8 0.0001 1.6 0.0006

N Stage (N2 vs N1) N/A N/A 2.2 <0.0001

Histologic Grade (3-4 vs 1-2)

0.6 0.55 1.4 0.07

Age (>60 vs ≤60) 1.8 0.026 1.1 0.3

MSI (High vs Stable) 0.3 0.027 0.7 0.12

p53 (High) 0.7 0.27 1.3 0.015

SMAD4 (any loss) 1.0 0.9 1.6 0.0002

Treatment, Sex, Site, KRAS, BRAF,TS, 18qLOH (Stage II: HR 1.4, p=0.33), hTERT: not significant* p values from the Wald test in a multiivariate Cox regression§ HR = hazard ratio Tejpar ASCO 2010

Bertagnolli, M. M. et al. J Clin Oncol; 27:1814-1821 2009

Influence of MSI: Prognostic relevance in mutant BRAF

22% (16%-29%)

18% (13%-24%)

12% ( 9% -16%)

Kaplan-Meier Estimates (95% CI) of Recurrence Risk at 3 years

Tumor Biology: Tumor Biology: Gene Expression Signature in Gene Expression Signature in

QUASAR QUASAR

Comparison of High vs. Low Recurrence Risk Groups using Cox Model: HR = 1.47 (p=0.046)

Years

Recurrence Risk Group

High

Intermediate

Low

Pro

po

rtio

n E

ven

t F

ree

0.0

0.2

0.4

0.6

0.8

1.0

0 1 2 3 4 5

Recurrence Risk Group

Range of RS

Proportion of patients

Low <30 43.7%

Intermediate

30-40 30.7%

High ≥41 25.6%

Kerr et al ASCO 2010

Why an active therapy in advanced disease is not active in the adjuvant setting?

Cytotoxic agents such as Irinotecan failedMonocloncal Antibodies targeting EGFR

and VEGF failed

Is this TRUE in Other Cancers? Or is this Colon Cancer Specific?

Disease-free Survival: Stage II and Stage III Patients

Data cut-off: June 2006

HR [95% CI] p-value

Stage II 0.84 [0.62–1.14] 0.258

Stage III 0.78 [0.65–0.93] 0.005

FOLFOX4 stage II

LV5FU2 stage II

FOLFOX4 stage III

LV5FU2 stage III

Months

Pro

bab

ilit

y

1.0

0.8

0.6

0.4

0.2

0

0.9

0.7

0.5

0.3

0.1

0 6 12 18 24 6030 36 42 48 54 66 72

3.8%

7.5%

p=0.258

p=0.005

Benefits of Adjuvant Tamoxifen (5 yrs, ER+)Benefits of Adjuvant Tamoxifen (5 yrs, ER+)

EBCTG Lancet 2005

Hazard Ratio 0.59 (SE 0.03) Hazard Ratio 0.66 (SE 0.04)

Summary of Trastuzumab AdjuvantTrial DFS Benefits

Study FU, yrs N

HERA1 3,387

2 3,401

NSABP B-31/NCCTG 9891

2 3,351

4 3,968

BCIRG 006 3 3,222

FinHer 3 231

0 1 2In favor of T In favor of Obs.

HR

0.54

0.64

0.48

0.48

0.61

0.42

Interactions between Tumor and Normal Cells

1. Interactions between tumor cells and normal cells result in alterations in several important tumor cell characteristics other than proliferation

2. Response to Growth Factors are differentially expressed in different organs determining homing of cancer cells

3. Growth conditions may significantly affect chemosensitivity of tumor cells and metastases in different organs differ in their response to therapy

Fidler, 1986;Liotta, 1986; Cavanaugh and Nicolson, 1991a; Fodstad et al., 1988b; Hoffmann, 19921.

Toggle Switch Dormancy to Macroscopic

Tumor

Klauber-DeMore, N. et al. Biological behavior of human breast cancer micrometastases. Clin. Cancer

Res. 7 (2001), pp. 2434-2439. Folkman, J. et al. Cancer: looking outside the genome. Nat.

Rev. Mol. Cell Biol. 1 (2000), pp. 76-79. Hanahan, D. and Folkman, J. Patterns and emerging

mechanisms of the angiogenic switch during tumorigenesis.Cell 86 (1996), pp. 353-364.

1. Below a critical point of cancer cell density and endothelial cell density, cancer will not be able to keep its concentration of angiogenic factors high enough leading to destruction of capillaries

2. Factor of 17 was reported between MVD between microscopic and macroscopic disease

3. Switch from dormant to macroscopic disease through balance of pro and anti angiogenic factors.

Experimental models have shown that Dormancy can protect tumor cells from

chemotherapy

(Naumov et al. Breast Cancer Research and Treatment 82: 199–206, 2003)

Aguirre-Ghisos et al 2007

Dormancy Pathways

• Stem Cells

• Angiogenesis

• Mitosis/Apoptosis

• Immunological

The Wnt pathway is critical for maintaining homeostasis of the intestinal crypt

Van de Wetering et al. 2002Barker et al. 2009

Van de Wetering et al. 2002

Stem Cell Markers (LRG5, ALDH, CD44)

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

0 2 4 6 8 10 12 14 16 18

Est

imate

d r

ecu

rrence-

free p

rob

abili

ty

Years since diagnosis of stage II or III colon cancer

Node 1+2 (n=46): 10.7 (7.1, 11.4+)Node 3 (n=50): 11.3+ (4.8, 11.3+)Node 4 (n=88): 5.7 (2.4, 16.8+)Node 5 (n=25): 1.7 (1.0, 5.9)

Median, years (95%CI) Hazard Ratio (95%CI) 1 (Reference) 2.030 (0.821, 5.018) 4.052 (1.769, 9.279) 6.713 (2.710, 16.633)

Combined analysis of risk alleles of CD44 for overall survival

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

0 2 4 6 8 10 12 14

Est

ima

ted

Pro

babi

lity

of S

urv

ival

Years since Diagnosis of Resectable Gastric Cancer

OS: 3.6 yrs OS: 7.3 yrs

CD44 1–2 Favorable alleles (n=55)

CD44 0 Favorable alleles (n=67)

Adjusted P value = 0.019

Winder et al Annals of Oncology 2011

TCF

CBP

CBP

TCF

p300

cyclin D1axin 2HnkdSurvivinS100A4

p300

TCF

ICG-001

c-junfra-1

-catenin

-catenin

-catenin

-catenin-catenin

-catenin

Cytoplasm

Nucleus

Non-differentiationDifferentiation

A Critical Cellular Switch

Teo et al., PNAS 2005

ICG-001

Colon Cancer Stem Cell Models

Miyabayashi T, et al PNAS 104, 5668, 2007

normal Ig

G

1 3 2normal Ig

GB

A* C

Efficacy of CBP/β-catenin Antagonist on Drug-Resistant

Relapsed Primary Colon Tumorgraft

CBP(A22) IP

p300(N15) IP

β-catenin Western Blot

Oxl./PBS

Oxl./C88

Day 47 Mice VDL +/- ICG-001

VDL onlysacrificed day 52

VDL +ICG-001sacrificed day 115

Targeted Agents why did they fail?

• EGFR

• VEGF

Is Target expressed in Is Target expressed in EMT?EMT?

Adapted from Kalluri & Weinberg, J Clin Invest 119: 1420-8, 2009

EGFR SyndecanE-cadherin MUC1Cytokeratin DesmoplakinZO-1 1 (IV) collagenLaminin-1 miR200 familyEntactin

EGFR SyndecanE-cadherin MUC1Cytokeratin DesmoplakinZO-1 1 (IV) collagenLaminin-1 miR200 familyEntactin

FTS binding protein FAP SnailFSP-1 SlugN-cadherin SIP1Vimentin -SMAFibronectin Twist-catenin GoosecoidO-cadherin LEF-1Syndecan-1 FOXC2miR10b miR21

FTS binding protein FAP SnailFSP-1 SlugN-cadherin SIP1Vimentin -SMAFibronectin Twist-catenin GoosecoidO-cadherin LEF-1Syndecan-1 FOXC2miR10b miR21

EGFR expression during EGFR expression during Metastatic ProcessMetastatic Process

High Low High

“EMT status may be a broadly applicable indicator of sensitivity to EGFR inhibitors.” (Barr et al, Clin Exp Metastasis (2008) 25:685–693)

Primary Tumor

Metastasis Established Metastasis

EGFR

EGFR and VEGF gene expression in adjacent normal tissue predict

Recurrence

Schneider et al 2004, Pharmacogenomics

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 2 4 6 8 10 12

Years Since Diagnosis of Stage II or III Colon Cancer

Estim

ate

d P

rob

ab

ility

o

f R

ecu

rre

nce

-Fre

e S

urv

iva

l

VEGF≤ 4.80 (n=41)RR: 1 (reference)Median TTR: 10.7 yrs

VEGF> 4.80 (n=41)RR: 3.29 (95%CI: 1.46-7.43)Median TTR: 4.0 (95%CI:2.0-6.6 )yrs

Adjusted P value =0.004

VEGF mRNA associated with tumor recurrence in stage II and III colon

cancer

VEGF and Il-8 associated recurrence in Stage III disease

(n=121)

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

0 2 4 6 8 10 12 14

Estim

ate

d P

rob

ab

ility o

f B

ein

g R

ecu

rre

nce

-Fre

e

Years Since Diagnosis of Stage III Colon Cancer

Log-rank P value < 0.001

VEGF 936 C/C and IL8 A/A (n=15)

VEGF 936 T/T and IL8 T/T (n=33)

VEGF 936 C/C and IL8 T or VEGF 936 T and IL8 A/A (n=73)

VEGF936 and IL8 Median Years to Recurrence (95%CI) C/C and A/A 1.0 (0.7, 3.9) C/C or A/A 3.4 (2.0, 8.9+) T and T 11.1 (7.1, 12.4+)

Integrin SNPs associated with recurrence in stage III disease)

Conclusions • Cytotoxic Therapies miminal or no benefit in

adjuvant therapy in colon cancer

• Anti-VEGF/EGFR therapies no benefit in adjuvant

• Differences in Tumor Biology/Host interaction responsible for difference in chemosensitivity

• Toggle Switch: Dormancy in Immunotherapy, Angiogenesis and Growth Factors (Stem Cells)

Future Directions • To induce and/or maintain dormancy of

tumor cells • To induce cell death in residual dormant cells

by targeting their survival and drug resistance mechanisms

• To induce differentiation of cancer stem cells • To identify cellular/serum biomarkers of

dormant cancer