THE FUTURE OF VACCINES ASCO ANNUAL MEETING MAY 30, 2015

Transcription

1 THE FUTURE OF VACCINES ASCO ANNUAL MEETING MAY 30,

2 BAVARIAN NORDIC INVESTOR & ANALYST UPDATE & RECEPTION Welcome and Introduction to Bavarian Nordic s Development Programs and Value Drivers Paul Chaplin, Ph.D. President & Chief Executive Officer, Bavarian Nordic Presentation of Combination Data of PROSTVAC and ipilimumab + Recent Developments in the Cancer Immunotherapy Space and the Promise of Combination Strategies James L. Gulley, M.D., Ph.D., National Cancer Institute Chief, Genitourinary Malignancies Branch, Head, Immunotherapy Section, Director, Medical Oncology Service, Office of the Clinical Director, National Cancer Institute Brachyury, a Novel Target for Cancer Immunotherapy Jeffrey Schlom, Ph.D. Chief, Laboratory of Tumor Immunology and Biology, Senior Investigator, National Cancer Institute Q&A Moderator: James B. Breitmeyer, M.D., Ph.D., Chief Development Officer, Bavarian Nordic 2

3 WELCOME AND INTRODUCTION TO BAVARIAN NORDIC S DEVELOPMENT PROGRAMS AND VALUE DRIVERS PAUL CHAPLIN, PH.D. PRESIDENT & CHIEF EXECUTIVE OFFICER, BAVARIAN NORDIC 3

4 A FOUNDATION OF VALUE CREATING ASSETS 1 approved product 7 active programs Validated Productive Platforms 2 Phase 3 products and near term value drivers Broad Pipeline & Late-Stage Candidates Trial supply to commercial product Flexible GMP Manufacturing Facility >$1bn from US government in past 10 years; $187m Janssen, Bristol Myers collaboration potential of ~$975m Track Record of Collaboration & Development Funding 4

5 SUCCESSFUL COLLABORATION WITH NCI Since 2008, BN has collaborated with the National Cancer Institute Collaborative Research and Development Agreement (CRADA) allows for BN and NCI to jointly develop new immunotherapies for cancers BN has rights to license IP that results from collaborations Strong leverage of BN s manufacturing and poxvirus expertise along with NCI s world class R&D and clinical trial network Multiple clinical studies exploring BN candidates alone and in combination: PROSTVAC alone and in combination Enzalutamide, Flutamide, ipilimumab, radiotherapy, etc. CV-301 in solid tumors MVA-BN Brachyury (phase 1 ongoing) The world s pre-eminent cancer research organization The National Cancer Institute is part of and based at the National Institutes of Health in Maryland, USA. 5

6 CLINICAL PIPELINE Phase 1 Phase 2 Phase 3 Market Product Indication Partner IMVANEX/ IMVAMUNE 1-4) Smallpox BARDA IMVAMUNE freeze-dried 1) Smallpox BARDA PROSTVAC Prostate Cancer Bristol-Myers Squibb PROSTVAC + enzalutamide Prostate Cancer NCI PROSTVAC + ipilimumab Prostate Cancer NCI CV-301 Bladder Combo 1) Bladder Cancer NCI MVA-BN Brachyury 1) Metastatic Tumors NCI MVA-BN Filo + AdVac 1) Ebola/Marburg Janssen, NIH MVA-BN RSV RSV In ) Externally funded programs 2) Sold to government stockpiles 3) Approved in the European Union under the trade name IMVANEX and in Canada under the trade name IMVAMUNE 4) Phase 3 registration studies are ongoing in the United States 6

7 5 KEY INDEPENDENT VALUE DRIVERS IMVAMUNE Janssen Collaboration VISION 2020 PROSTVAC Commercial Vaccines Additional Government Programs 7

8 POXVIRUSES IDEAL VACCINE VECTORS Vaccinia Used in millions of people to eradicate smallpox Large DNA viruses Induce robust Th1 biased immune response MVA (Modified Vaccinia Ankara) Attenuated, replication incompetent Fowlpox Multiple boosts, non-neutralizing 8

9 MANUFACTURING CAPABILITIES Expertise in poxvirus manufacturing Commercial partnerships in place with Janssen & BMS All manufacturing retained by Bavarian Nordic. Modern vaccine facility meets or exceeds EU and US regulatory guidelines Company has developed IP and extensive knowhow in the production of live poxvirus based vaccines Multipurpose Facility: Highly scalable, fully integrated, reduces dependency on subcontractors Fill/Finish established to support commercial launch of PROSTVAC Production of all clinical trial materials, IMVAMUNE, PROSTVAC, etc. Fully Approved Manufacturing Facility Over 28mm doses of IMVAMUNE delivered, to date Production of 2mm doses of MVA-BN Filo underway 400,000 doses already produced and delivered to Janssen 9

10 PROSTVAC TRICOM TAA LFA-3 ICAM-1 B7.1 V F Heterologous prime/boost regimen Vaccinia or MVA + Fowlpox Subcutaneous administration PSA CEA, MUC-1 HER-2 Brachyury Tumor antigens with epitopes enhanced for HLA binding Prostate, lung, head&neck, bladder, colorectal, breast, ovarian and renal cancers TRICOM (TRIad of COstimulatory Molecules) Enhance T cell activation in synergistic manner Strengthen the anticancer immune response Safe and well tolerated (11 clinical trials) Injection site reactions and flulike symptoms 10

11 PROSTVAC DEAL WITH BRISTOL-MYERS SQUIBB Global commercialization agreement on PROSTVAC License and option agreement Up to USD 975 million in upfront and milestone payments Supply contract Bavarian Nordic to manufacture PROSTVAC Clinical collaboration agreement Explore combinations of PROSTVAC and BMS oncology assets 11

12 CLINICAL COLLABORATION BN-BMS Looking to explore the full potential of PROSTVAC as stand-alone treatment and in combination with other treatment paradigms Under the agreement the companies may conduct one or more exploratory combination studies of PROSTVAC and agents from Bristol- Myers Squibb s immuno-oncology portfolio. Scientific rationale exists to evaluate PROSTVAC in combination with agents from Bristol-Myers Squibb s immuno-oncology portfolio. Based on existing preclinical and clinical data, an investigator sponsored Phase 2 study will investigate the combination of Yervoy and PROSTVAC. 12

13 CV-301 TRICOM TAA LFA-3 ICAM-1 B7.1 V F Heterologous prime/boost regimen Vaccinia or MVA + Fowlpox Subcutaneous administration PSA CEA, MUC-1 HER-2 Brachyury Tumor antigens with epitopes enhanced for HLA binding Prostate, lung, head & neck, bladder, colorectal, breast, ovarian and renal cancers TRICOM (TRIad of COstimulatory Molecules) Enhance T cell activation in synergistic manner Strengthen the anticancer immune response Safe and well tolerated (6 clinical trials) Injection site reactions and flulike symptoms 13

14 PD-L1 EXPRESSION IS PROGNOSTIC FOR OUTCOME FOLLOWING ANTI-PD1 THERAPY OF NSCLC EB Garon, et al. Pembrolizumab for the Treatment of Non Small-Cell Lung Cancer.KEYNOTE-001. NEJM Prevalence of PD-L1 positivity and objective response rate by quartiles of PD-L1 proportion score in patients whose samples were evaluable, regardless of the interval between cutting and staining. The prevalence and ORR in treated patients are calculated in those who had measurable disease per RECIST v1.1 by central review at baseline. The error bars for ORR represent the 95% CIs. 14

15 CV-301 COMBINED WITH IMMUNE CHECKPOINT INHIBITOR: NSCLC High prevalence, high unmet medical need Majority do not benefit from PD-1/PD-L1 blockade 70-80% CEA/Muc-1 positive 70% PD-L1 negative/low Phase 2 program starting 2016 Safety and pharmacodynamics of CV-301 added to an approved immune checkpoint inhibitor Explore endpoints and expedited status with regulators 15

16 This image cannot currently be displayed. MVA-BN BRACHYURY NOVEL IMMUNOTHERAPY CANDIDATE WITH BROAD POTENTIAL MVA-BN Brachyury Preclinical Phase 1 Phase 2 Phase 3 Market Indications Chordoma (ultra-orphan disease) Triple negative breast cancer NSCLC Multiple solid tumors Rationale Brachyury highly expressed and mechanistic in chordoma Responses observed with yeast brachyury vaccine Synergism with brachyury vaccines and chemo/radiation and checkpoint inhibitors Development Strategy NCI Phase 1 and Phase 2 studies NCI Phase 2 chemotherapy combination study(s) NCI erlotinib combination study(s) NCI and BN immune checkpoint inhibitor combinations Brachyury a driver of TNBC biology in genomic studies Fernando Palena. J Clin Invest. 2010; 120: Ben-Hamo R et al. Bioinformatics 2014;30:

17 VISION 2020 PROSTVAC 2015 Target enrollment reached, data maturing, partnership in place, BLA/manufacturing prep begins 2020 Approved & partnered Data on checkpoint inhibitors & anti-androgen combinations IMVAMUNE IMVANEX approved EU/Canada IMVAMUNE/LF US Phase 3 IMVAMUNE/FD Phase 2 completed IMVAMUNE/IMVANEX Approved in US/EU/Canada FD acquisitions in US VISION 2020 Janssen Collaboration Clinical trials initiating w/janssen 2m doses of Ebola vaccine in 2015 MVA-BN Filo approved Expansion of collaboration in 3 commercial targets Commercial Vaccines Preparing RSV Phase 1 initiation H RSV in Phase III (Phase 2 POC) CV PD1 combination Phase 2 POC (lung + 2 add. indications) 2nd ID candidate in Phase II Additional Government Programs Ongoing funded collaboration with NIH, BARDA, DOD, DHS, NCI Brachyury Phase 2 data Continued expansion of platform opportunities 17

18 SUCCESSFUL COLLABORATION WITH NCI Since 2008, BN has collaborated with the National Cancer Institute Collaborative Research and Development Agreement (CRADA) allows for BN and NCI to jointly develop new immunotherapies for cancers BN has rights to license IP that results from collaborations Strong leverage of BN s manufacturing and poxvirus expertise along with NCI s world class R&D and clinical trial network Multiple clinical studies exploring BN candidates alone and in combination: PROSTVAC alone and in combination Enzalutamide, Flutamide, ipilimumab, radiotherapy, etc. CV-301 in solid tumors MVA-BN Brachyury (phase 1 ongoing) The world s pre-eminent cancer research organization The National Cancer Institute is part of and based at the National Institutes of Health in Maryland, USA. 18

19 PRESENTATION OF COMBINATION DATA OF PROSTVAC AND IPILIMUMAB RECENT DEVELOPMENTS IN THE CANCER IMMUNOTHERAPY SPACE AND THE PROMISE OF COMBINATION STRATEGIES JAMES L. GULLEY, M.D., PH.D. CHIEF, GENITOURINARY MALIGNANCIES BRANCH, HEAD, IMMUNOTHERAPY SECTION, DIRECTOR, MEDICAL ONCOLOGY SERVICE, OFFICE OF THE CLINICAL DIRECTOR, NATIONAL CANCER INSTITUTE 19

20 BRACHYURY, A NOVEL TARGET FOR CANCER IMMUNOTHERAPY JEFFREY SCHLOM, PH.D. CHIEF, LABORATORY OF TUMOR IMMUNOLOGY AND BIOLOGY, SENIOR INVESTIGATOR, NATIONAL CANCER INSTITUTE 20

21 Q&A JAMES B. BREITMEYER, M.D., PH.D., CHIEF DEVELOPMENT OFFICER, BAVARIAN NORDIC 21

22 This presentation includes "forward-looking statements" that involve risks, uncertainties and other factors, many of which are outside of our control, that could cause actual results to differ materially from the results discussed in the forward-looking statements. Forward-looking statements include statements concerning our plans, objectives, goals, future events, performance and/or other information that is not historical information. We undertake no obligation to publicly update or revise forward-looking statements to reflect subsequent events or circumstances after the date made, except as required by law.

23 Emerging Concepts of Immunotherapy Vaccine Therapy: Monotherapy and Combination Therapy Jeffrey Schlom, Ph.D. Laboratory of Tumor Immunology and Biology (LTIB) Center for Cancer Research National Cancer Institute, NIH

24 I ve always been a tumor immunologist! I was in style, out of style, in style, out of style, in style! 24

25 I ve always been a tumor immunologist! I was out of style, but now I m in style! 25

26 Immuno-Oncology Platform: Strategic Plan Cancer Vaccine and Immune Modulator Development: Focus on human carcinomas Focus on development of agents that can be widely evaluated Ultimate Use: Early in disease process / low tumor burden Survival as the endpoint / minimal toxicity Combination immune therapies immune stimulation strategies reduction of immune inhibitory entities Combination therapies: Immunotherapy plus: conventional therapies Immune Analyses: Analyses of specific immune cell subsets (n=136) Define which patients will most likely benefit from immunotherapy - early in the therapeutic regimen - prior to initiation of therapy 26

27 Spectrum of Cancer Immunotherapeutics Recombinant Vaccines Cytokines/Immunocytokines Immune Checkpoint Inhibitors Immuno-Oncology Platform: Combination Therapies Chemotherapy Radiation Therapy Small Molecule Targeted Therapies - Hormonal Therapy 27

28 Hypotheses Tumor Associated Antigens (TAA) are, by definition, either weakly immunogenic or functionally non-immunogenic. Vaccine strategies must be developed in which the presentation of these TAAs to the immune system results in far greater activation of T cells than is being achieved naturally in the host. 28

29 Recombinant Vaccine Vectors Pox vectors Vaccinia (rv-) elicits a strong immune response host induced immunity limits its continuous use MVA (replication defective) 29

30 Recombinant Vaccine Vectors Pox vectors Vaccinia (rv-) elicits a strong immune response host induced immunity limits its continuous use MVA (replication defective) Avipox (fowlpox rf-, ALVAC) derived from avian species safe; does not replicate can be used repeatedly with little if any host neutralizing immunity 30

31 Recombinant Vaccine Vectors Pox vectors Vaccinia (rv-) elicits a strong immune response host induced immunity limits its continuous use MVA (replication defective) Avipox (fowlpox rf-, ALVAC) derived from avian species safe; does not replicate can be used repeatedly with little if any host neutralizing immunity Can insert multiple transgenes Do not integrate into host DNA Efficiently infect antigen presenting cells including dendritic cells 31

32 Comparison of T-cell Responses in CEA-Transgenic Mice Vaccinated with CEA Protein vs. rv-cea 20 rv-cea Stimulation Index CEA Protein [CEA], (mg/ml) 32

33 T-Cell Costimulation Costimulatory molecules are expressed on professional antigen presenting cells (APC): dendritic cells, B cells, macrophages, monocytes Costimulatory molecules are not expressed on the vast majority of solid tumors 33

34 T-Cell Dependence on Costimulation Signal 1 + Signal 2 No Signal 1 No Signal 2 Antigen Presenting Cell Antigen Presenting Cell Antigen Presenting Cell MHC TCR Costimulatory Molecule MHC TCR Costimulatory Molecule MHC TCR T-Cell T-Cell T-Cell Activation of Antigen-Specific T-cells Clonal Anergy Apoptosis Ignorance Clonal Anergy Apoptosis Ignorance 34

35 Costimulatory Molecule Candidates l Major Costimulatory Effect must be on the T-cell l No Overlap of T-cell Ligands l No Redundancy of Costimulatory Mechanisms APC MHC + Peptide Costimulatory Molecule B7-1 (CD80) ICAM-1 (CD54) TCR Ligand CD28 CTLA-4 LFA-1 T-Cell Costimulatory Mechanism IL-2-R upregulation, IL-2 secretion Tyrosine Kinase, Phospholipase C T-cell Activation (CPM x 10 5 ) LFA-3 (CD58) CD2 (Region 1) Tyrosine Kinase, Ca 2+ Mobilization camp Production None LFA-3 ICAM-1 B7-1 TRICOM Costimulatory Molecule

36 CEA-Tg CEA-Specific T-cell Responses Following Vaccination with rf-cea, rf-cea/b7-1, or rf-cea/tricom CEA Specific T-cell Response (Lymphoproliferation, CPM x 10 3 ) * HBSS FP-WT 4x rf-cea 4X rf-cea/b7 rf-cea/tricom Number of Vaccinations rf-cea/b7 rf-cea/tricom Vaccination Schema Grosenbach Hodge, Cancer Research, 61: ,

37 Therapy of 14-Day Established CEA + Experimental Metastases in CEA-Tg Mice Using CEA/TRICOM Vectors % Survival CEA/TRICOM (P<0.02 vs CEA) VAAA Regimen CEA CEA/TRICOM All groups with GM-CSF and low dose IL-2 20 CEA 10 Buffer Control Tumor Vaccine Weeks Post Tumor Transplant Aarts, Schlom, Hodge. Cancer Res. 62:

38 TRICOM Vaccines 38

39 TRICOM TRIad of COstimulatory Molecules Costimulatory Molecule Ligand on T cell B7-1 (CD80) CD28/CTLA-4 ICAM-1 (CD54) LFA-1 LFA-3 (CD58) CD2 TRICOM = B7-1/ICAM-1/LFA-3 CEA/TRICOM = CEA/B7-1/ICAM-1/LFA-3 CEA/MUC-1/TRICOM = CEA/MUC-1/B7-1/ICAM-1/LFA-3 (PANVAC) PSA/TRICOM = PSA/B7-1/ICAM-1/LFA-3 (PROSTVAC) BRACHYURY/TRICOM = BRACHYURY/B7-1/ICAM-1/LFA-3 All vaccines contain: rv- as a prime vaccine avipox (fowlpox, rf-) as multiple booster vaccines 39

40 PANVAC/CV-301 Vaccine Platform rec. Vaccinia: prime vaccination rec. fowlpox: multiple booster vaccinations Each off the shelf vector (vaccine) contains 5 transgenes: Carcinoembryonic antigen (CEA) MUC-1 containing the C-terminus associated with poor prognosis and aggressiveness CEA and MUC-1 expressed on the majority of human carcinomas 3 T-cell Costimulatory Molecules immune intensification B7-1 (CD80) ICAM-1 (CD54) LFA-3 (CD58) 40 40

41 Overexpression of CEA and MUC-1 in Human Carcinoma CEA MUC-1 Colorectal >90% >90% Pancreatic >95% >95% Lung 70% >80% Breast 50% >90% Ovarian 15% >90% PSA in prostate cancer 41

42 CEA/MUC-1/TRICOM: PANVAC V/F (CV-301) 42

43 Vaccination (Panvac) of Patients with Metastatic Colorectal Cancer (Liver or Lung) Post-Metastectomy Primary endpoint: Relapse-free survival Multicenter trial (n = 74) M. Morse and K. Lyerly, PIs, Duke University Panvac vs. Panvac-infected D.C. no statistical difference between the 2 arms Comparison with Concurrent Control Group treated at Duke 43

44 Multicenter (Duke/Georgetown, etc.) Study Characteristic Categorical Variable PANVAC (n=68) N (percent) Duke* (n=132) N (percent) Male 34 (50.0) 78 (59.0) ns Race: White 60 (89.5) 111 (86.0) ns Years to diagnosis of 59 (86.7) 103 (78.0) ns metastases 2 years >1 Lesion (vs. 1 lesion) 40 (57.6) 45 (34.1) Chisq p=0.003 Continuous Variable Mean Age at Resection (years) 53.5 years (sd 10.8; range 25-77) 61.3 years (sd 11.0; range 34-82) n=37 n=123 t-test p< Median CEA 1.9 (range ) 8.0 (range ) Wilcoxon p< *Concurrent control (negative margins, modern combination 5FU based chemotherapy with irinotecan, oxaliplatin and biologics and a RFS > 6 months) PIs: M. Morse, H.K. Lyerly, Duke Comprehensive Cancer Center

45 Recurrence-Free Survival Recurrence-Free Probability Duke Controls Panvac Months from Resection PI, Morse: Duke, Georgetown, MD Anderson + 4 other sites

46 Overall Survival Survival Probability Duke Controls Panvac PANVAC (n=74) <25% Duke Concurrent Control (n=161) Months from Resection Number of Patients at Risk Duke Controls Panvac Number of Events Duke Controls Panvac PI, Morse: Duke, Georgetown, MD Anderson + 4 other sites

47 Recurrence-Free Survival Overall Survival Recurrence-Free Probability Duke Controls Panvac Months from Resection Survival Probability Duke Controls Panvac <25% PANVAC (n=74) Duke Concurrent Control (n=161) Months from Resection 47

48 Delayed Effects of Modern Immunotherapy When Used as Monotherapy Multiple randomized/multicenter trials have demonstrated no change in time to progression, yet improved survival Sipuleucel-T (Phase III prostate) Sipuleucel-T (Phase III prostate) PSA-TRICOM (Phase II prostate) Ipilimumab (Phase III melanoma) 48

49 PANVAC/CV-301: Bladder CEA expression IHC - approximately 70% cases positive - expression increases with grade MUC-1 expression IHC - approximately 65% cases positive (up to 95% +) - expression increases with grade Stojneu et al. Int J Clin Exp Pathol 2014;7(8):

50 Cancer Vaccine Therapy Antigen does not need to be on cell surface for T-cell recognition Potential for targeting of transcription factor(s) - Brachyury Antigens are processed and presented on the cell surface as short peptides in the context of MHC molecules 50

51 Identification of Brachyury as a Novel Tumor Antigen Data mining on the Human Unigene Database for comparison of gene expression in tumorvs. normal tissue-derived EST libraries (Collaborative effort with Dr. A. Kozlov, Biomedical Center, St. Petersburg, Russia) The gene encoding for Brachyury, a transcription factor, is preferentially expressed in tumor-derived libraries (Lung Ca, Breast Ca, Germ cell tumors, CLL) 51

52 Brachyury s Role During Embryo Development Member of the T-box transcription factor family T-box d Brachyury-GFP mouse embryo Active in early embryo Tissue-specific transcription factor Controls mesoderm development Mesoderm From Huber et al, Nature 2004; 432:625 MESODERM DEVELOPMENT IS AN EXAMPLE OF A PHYSIOLOGICAL EPITHELIAL-TO-MESENCHYMAL TRANSITION 52

53 Role of Tumor EMT in Metastasis and Therapeutic Resistance Circulation Normal cell Epithelial tumor cell Tumor dissemination Mesenchymal-like tumor cell Apoptotic tumor cell Induction of EMT Chemotherapy Radiation Other? 53

54 Brachyury Overexpression Induces EMT in Epithelial Tumor Cells E-cadherin Epithelial Plakoglobin Mesenchymal Fibronectin Vimentin PANC-1-pcDNA Brachyury PANC-1-pBrachyury Number of cells Migration * Invasion * pcdna pbrachyury pcdna pbrachyury 0 PANC-1 Fernando Palena. J Clin Invest

55 Brachyury Inhibition Induces a Mesenchymal-Epithelial Switch in Human Lung Cancer Cells Epithelial Plakoglobin Fibronectin Mesenchymal Vimentin H460-control shrna BRACHYURY HIGH Brachyury knock-down H460-Brachyury shrna BRACHYURY LOW 20 Migration Invasion 125 Number of cells 10 ** * control Br.shRNA control Br.shRNA 0 Fernando Palena. J Clin Invest H460 cells 55

56 Brachyury Promotes Metastasis In Vivo LUNG MICROMETASTASIS MODEL EXPERIMENTAL LUNG METASTASIS MODEL Day 0 Day 15 Day 0 Day 45 H460 cells implantation (subcutaneous) Euthanasia and tissue harvesting H460 cells implantation (intravenous) Euthanasia and tissue harvesting 24 p = Number of nodules per lung Lung metastases H460-control.shRNA H460-Brachyury.shRNA Fernando et al, J Clin Invest

57 Brachyury Is Aberrantly Overexpressed in Lung Tumors Collaboration with Drs. Guadagni and Roselli, Rome, Italy ADENOCARCINOMA SQUAMOUS CA. TUMOR-STROMA S T S T S T Brachyury expression in lung cancer correlates with tumor stage Roselli et al, Clin Can Res Fernando et al, J Clin Invest

58 Brachyury Is Aberrantly Overexpressed in Breast Tumors (*) focal staining PRIMARY TUMOR PRIMARY TUMOR * Matched primary tumor and lymph nodes show higher expression of Brachyury in metastatic tissue BONE METASTASIS LYMPH NODE MET 58

59 Immunohistochemistry Analysis of Brachyury Expression in a Bone Metastatic Lesion of a Breast Cancer Patient Case #2 59

60 Immunohistochemistry Analysis of Brachyury Expression in a Brain Metastatic Lesion of a Breast Cancer 60

61 Brachyury Is Aberrantly Overexpressed in Breast Tumors PRIMARY TUMOR PRIMARY TUMOR * (*) focal staining BONE METASTASIS LYMPH NODE MET Brachyury expression correlates with high risk recurrence in breast cancer patients treated with Tamoxifen only CONFIDENTIAL Data provided by Kim Lyerly, Duke Univ. 61

62 Brachyury and Tumor Prognosis Brachyury mrna expression correlates with poor clinical outcome in lung cancer, breast, prostate, colon, oral squamous, hepatocellular carcinoma Lung Cancer Lung Cancer Hepatocellular Ca. IHC, P<0.001 Ann Surg Oncol (2013) Mol Med Rep (2015) J Exp Clin Can Res (2014) 62

63 63

64 Brachyury Expression in Non-neoplastic Tissues, PIN Lesions, Prostate Cancer, and Metastatic Tissues Brachyury is absent or expressed at low levels in nonneoplastic tissues (A, normal gland). Primary prostate cancer Brachyury-positive cases exhibited only cytoplasm staining (B) or both cytoplasm and nuclear staining (C). Metastatic lesion showing both cytoplasm and nuclear (D). Magnification, x200 (A) and x400 (B D). Pinto et al. Clin Cancer Res 2014;20:

65 Correlation Between Brachyury Subcellular Localization and Clinicopathologic Features in Prostate Cancer Tissues by Univariate and Multivariate Analyses Overall staining Positive Clinical parameters n (%) Gleason score (grouped) <7 7 >7 Gleason differentiation Differentiated Undifferentiated Pinto, et al. Clin Cancer Res 2014;20:

66 This image cannot currently be displayed. Predominant Expression of Brachyury in Triple Negative Breast Cancer Using breast cancer RNA-seq data from TCGA, the protein network identified as the most significant in distinguishing between triple negative and non-triple negative breast cancer was dominated by the T-gene (also known as Brachyury) Palena, Hamilton, unpublished data Ben-Hamo R et al. Bioinformatics 2014;30:

67 Transcription factors (TFs) are regarded as undruggable targets with conventional small molecules inhibitors Absence of a hydrophobic pocket for tight binding of small molecules CAN WE TARGET AN OTHERWISE UNDRUGGABLE MOLECULE VIA IMMUNOTHERAPY? 67

68 Patients Who Have Generated T-cell Responses to Brachyury Post-vaccination Pt Vaccine Metastatic Tumor Type 1 PSA-TRICOM + αctla-4 2 PSA-TRICOM + αctla-4 Prostate Ca. Prostate Ca. 3 Yeast-CEA Medullary Thyroid Ca. 4 Yeast-CEA Colorectal Ca. Pre Post Pre Post Pre Post Pre Post ELISPOT PSA/CEA Brachyury HIV <1/200,000 1/150,000 <1/200,000 1/40,000 <1/200,000 1/9,677 <1/200,000 <1/200,000 <1/200,000 1/46,000 <1/200,000 1/41,000 <1/200,000 1/12,766 <1/200,000 1/60,000 <1/200,000 <1/200,000 <1/200,000 <1/200,000 <1/200,000 <1/200,000 <1/200,000 <1/200,000 No autoimmune thyroid events or thyroid function changes in patients 1, 2, and 4. Patient 3 had prior thyroidectomy. ANA remained negative for patients 1 and 2 and TSH within normal limits. No autoimmune work-up was performed or indicated for patients 3 and 4. 68

69 MVA-brachyury-TRICOM infected DCs Expand Brachyury-specific CD4+ T Cells Normal donor 635 Normal donor 1228 MVA-Brachyury-TRICOM (and not MVA-WT) infected human DCs expand CD4+ T cells from PBMCs of normal donors that recognize purified Brachyury-protein 69

70 Brachyury Vaccine Development LTIB is focused on the development of vector-based cancer vaccines 70

71 Brachyury as a Vaccine Target for the Control of the EMT Phenotype High degree of selective expression of Brachyury in a wide range of human tumors vs. normal adult tissues Human T cells can be generated: lyse human carcinoma cells endogenously expressing Brachyury Patients receiving anti-cea vaccine, or PSA-TRICOM vaccine plus anti-ctla-4, developed Brachyury T-cell responses post-vaccination 71

72 Vaccine Combination Therapies Vaccine Plus Preclinical (e.g.) Clinical Non-Immune Therapies Chemotherapy Radiation Targeted Therapies Docetaxel Radionuclide Enzalutamide Immunotherapeutic anti-ctla4 72

73 Attacking Tumor Cells That Survive Therapy: Exploiting Immunogenic Modulation 73

74 Interaction of Non-Immune Therapies with Immune-Based Therapies Prior studies: inverse correlation between the number of prior chemotherapies and immune response to vaccine Rationale for the concomitant use of non-immune and immune-based therapies: cisplatin/vinorelbine in patients with lung cancer docetaxel in patients with prostate cancer 74

75 Human Carcinoma Cells Resistant to Chemotherapy Are Sensitive to CTL Killing After Treatment 75

76 Docetaxel Modulates Phenotype of Human Tumors in vivo Prostate:LNCaP (MUC-1) No Treatment Docetaxel 76 76

77 Combination Therapy with a Second-Generation Androgen Receptor Antagonist and a Metastasis Vaccine Improves Survival in a Spontaneous Prostate Cancer Model Major Therapy of Metastatic Prostate Cancer is Androgen Blockade Enzalutamide (MDV3100) FDA approved in 2012, label 2014 Antagonist to the androgen receptor (AR) that lacks any agonist activity Exposure of tumor cells to hormone therapy modulates tumor phenotype Ardiani, Hodge. Clin. Can. Res. 19(22): ,

78 Poxvirus Platform: Combination Therapy of MDV MVA-Twist-TRICOM Improved Tramp-Tg Survival Treatment No Treatment (n=15) Median Overall Survival (weeks) Vaccine (n=19) 11 (+7) MDV mg/day (n=17) 4 19 (+15) Unpublished Data Vaccine + MDV3100 (n=16) 35.5 (+31.5) Mice were vaccinated 3 times. Average age at the beginning of treatments: 27 weeks (moderately to poor differentiated adenocarcinomas) 78

79 Combination Therapy: Vaccine + External Beam Radiation. Day Tumor (MC38- CEA + SQ) 0 V Gy (2 Gy x 4) V2 15 V3 22 V4 29 rv-cea/tricom rf-gm-csf rf-cea/tricom rf-gm-csf Tumor volume (mm 3 ) No Treatment Vaccine Irradiation Vaccine + Irradiation n=12 12 (36) n=13 11 (41) n=12 66 (435) n=9 54 (415) % Fas + n=0 n=0 n=0 n= D a y s P o s t T u m o r T r a n s p l a n t Chakraborty, Abrams Schlom, Hodge. Cancer Res. 15:

80 Treatment of LnCaP Prostate Cells with Palliative Levels of 153 Sm (Quadramet) Modulates Phenotype, Upregulates TAA, and Increases Sensitivity to Antigen-specific CTL Killing Treatment of LnCaP prostate cancer cells with palliative doses of 153 Sm results in the upregulation of MHC class I and Fas Treatment of LnCaP prostate cancer cells with palliative doses of 153 Sm results in increased sensitivity to multiple CTLs 25 gy 100 p<0.001 p<0.001 Cell Number 0 Gy 0 Gy 25 gy 0 Gy 25 gy FAS MHC-I % Lysis (Mock) Day 4 Sm-153 delivered Dose (Gy) 10 0 Tumor antigen genes g MFI 0 G y 25 G y PS A PSM A PAP CE A MUC Sm Prostvac Sm Chakraborty et al., Clin Cancer Res. 2008;14:

81 Immune Assays Antigen Specific Elispot: 9-mer peptides, HLA-A2-restricted FACS intracellular cytokines 15-mer peptides reflecting entire protein CD4 and CD8 responses non-hla-restricted Specific Immune Populations Phenotype/Function Tregs, MDSC Effectors (CD4/CD8) NK Analyses of Tumor Biopsies Digital IHC Soluble Factors Abs to TAAs scd27, scd40l Abs to glycans Circulating Tumor Cells Immune Cell Subsets in PBMC changes post- vs. pre-immunotherapy identification of patients most likely to benefit from immunotherapy Analyses of the immune repertoire via FACS Gene Chip Human Gene Arrays - collaboration CII, 2010 CCR, 2010 Vaccine, 2011 Expert Opin Biol Ther, 2011 CCR, 2011 J Biomed Biotechnol, 2011 CII, 2011 Blood, 2012 Prostate Ca Dis, 2012 Lancet Oncol, 2012 CCR, 2013 CII, 2013, JI, 2013 Int J Cancer, 2013 CIR, 2013 CII, 2014 CII, 2014 In J Cancer, 2014 PNAS, 2014 Exploratory Not surrogates of efficacy Require: Validated assays Certified laboratories 81 81

82 Docetaxel +/- PANVAC Patient Population: Metastatic Breast Cancer (Docetaxel Naïve) n=43 R A N D O M I Z E Arm A: Weekly Docetaxel + PANVAC Arm B: Weekly Docetaxel alone Primary endpoint: Progression-Free Survival (PFS) NCI 6977: PI, Dr. James Gulley MDA (Ibrahim) 82 82

83 Immunophenotyping: Changes post- vs. pre-immunotherapy Flow-cytometry analysis of PBMC immune subsets: 30 markers, 127 subsets Subsets analyzed: 9 standard immune cell subsets, and 118 additional subsets relating to maturation/function 1. CD4: Helper T lymphocytes (32 subsets) 2. CD8: Cytotoxic T lymphocytes (29 subsets) Markers of PD-1 pathway and T cell activation (in CD4 and CD8): EOMES: activation TCR-αβ: activation Tbet: activation BATF: activation/exhaustion Maturation status of T lymphocytes (in CD4 and CD8): Naïve: CD45RA + CCR7 + Central Memory: CD45RA - CCR7 + Effector Memory: CD45RA - CCR7 - Terminal (EMRA): CD45RA + CCR7 - T lymphocyte markers (in CD4 and CD8): CTLA-4: inhibition PD-1: activation/inhibition PD-L1: activation/cross-inhibition TIM-3: inhibition ICOS: activation (only on CD4) 3. Tregs: Regulatory T lymphocytes (CD4 + CD25 + FoxP3 + CD127 - ) (7 subsets) CD45RA: Tregs highly expandable in vitro CTLA-4: Treg suppression CD49d: contaminating effector lymphocytes (non-tregs) ICOS: Treg suppression PD-1: activation/inhibition PD-L1: cross-inhibition 4. B lymphocytes: CD19 + (5 subsets) CTLA-4: inhibition TIM-3: inhibition PD-1: activation/inhibition PD-L1: cross-inhibition 5. NK: Natural killer cells (CD56 + CD3 - ) (20 subsets) CD16 + CD56 br : Functional intermediate, lytic and cytokine production CD16 + CD56 dim : Mature NK, cytokine production CD16 - CD56 br : Immature, abundant in human placenta CD16 - CD56 dim : non-lytic, non-cytokine production TIM-3: activation PD-1: activation/inhibition PD-L1: cross-inhibition 6. NK-T: CD56 + CD3 + (4 subsets) TIM-3: activation PD-1: activation/inhibition PD-L1: cross-inhibition 7. cdcs (Conventional DCs): CD3 - CD56 - CD1c + CD303 - (5 subsets) 8. pdcs (plasmacytoid DCs ): CD3 - CD56 - CD1c - CD303 + (5 subsets) Markers of DC activation CD83: activation TIM-3: inhibition PD-1: activation/inhibition PD-L1: cross-inhibition 9. MDSCs: Myeloid-derived suppressor cells (CD11b + HLA-DR low/- CD33 + ) (20 subsets) CD14: Common Myeloid Marker (high in monocytes, dim in granulocytes) CD15: Granulocyte marker CD16: most immature monocytic MDSCs PD-1: activation/inhibition PD-L1: cross-inhibition 83 83

84 Analyses of a Peripheral Immunoscore to Identify Patients More Likely to Benefit from Immunotherapy R A N D O M I Z E Docetaxel +/- PANVAC Patient Population: Metastatic Breast Cancer (Docetaxel Naïve) n=43 Arm A: Weekly Docetaxel + PANVAC Arm B: Weekly Docetaxel alone Primary endpoint: Progression-Free Survival (PFS) NCI 6977: PI, Dr. Gulley; MDA (Ibrahim) Immunoscore Based on Standard Immune Populations STANDARD IMMUNE SUBSETS Description Expected effect on PFS % CD4 Positive % CD8 Positive % Treg Negative % MDSC Negative % NK Positive Ratio CD4:Treg Ratio CD8:Treg Ratio CD4:MDSC Ratio CD8:MDSC Positive Positive Positive Positive 84

85 R A N D O M I Z E Analyses of Peripheral Immunoscore to Identify Patients More Likely to Benefit from Immunotherapy Docetaxel +/- PANVAC Patient Population: Metastatic Breast Cancer (Docetaxel Naïve) n=43 Arm A: Weekly Docetaxel + PANVAC Arm B: Weekly Docetaxel alone Primary endpoint: Progression-Free Survival (PFS) NCI 6977: PI, Dr. Gulley; MDA (Ibrahim) Immunoscore Based on Phenotypes Reflecting Immune Function IMMUNE PHENOTYPES WHITH DEFINED BIOLOGIC RELEVANCE Expected Description effect Ref. on PFS % central memory CD4 Positive 1,2 % CD4 expressing 2 suppressive markers Negative 3-6 % central memory CD8 Positive 1,2 % CD8 expressing 2 suppressive markers Negative 3-6 % Treg CD49d - Negative 7,8 % MDSC Lin - Negative 9,10 % NK CD56 br CD16 - Negative Ratio central memory CD4:Treg CD49d - Positive Ratio central memory CD8:Treg CD49d - Positive Ratio central memory CD4:MDSC Lin - Positive Ratio central memory CD8:MDSC Lin - Positive Ratio central memory CD4:NK CD56 br CD16 - Positive Ratio central memory CD8:NK CD56 br CD16 - Positive 1. J Clin Invest. 2004; 114(1): PNAS. 2005; 102(27): J Exp Med. 2010; 207(10): J Exp Med. 2010; 207(10): Nat Imm. 2008; 10: J Clin Invest. 2011;121(6): Blood. 2009; 113(4): J Immunol. 2011;186: J Immunol. 2009;182(8): J Immunol. 2008;181(3): Gene chip human gene arrays of PBMCs Collaboration with Dr. E. Wang, NIH Transfusion Med. Dept. Seven genes associated with PFS in docetaxel + vaccine arm Docetaxel + Vaccine Accuracy=85%, P=0.03 Docetaxel alone Accuracy =62%, P= Trends Immunol. 2001;22(11): Thyroid. 2013; May Clin Dev Immunol. 2011; Feb Clin Can Res. 2006;1(12):

86 mab Mechanisms of Action Direct Effect on Receptor Function Ribas, New Engl J Med. 2012; 366(26):

87 Effect of Multiple Costimulatory Modalities to Enhance CTL Avidity CEA-Tg Vaccine Modality Precursor Frequency/10 5 CD8 T Cells Precursor Peptide Concentration for CTL (nm) Avidity* rv-cea x x rv-cea/tricom x x rv-cea/tricom+ anti-ctla-4 1, x 0.4 1,275x Avidity defined as the natural log of the peptide concentration that results in 50% maximal target lysis. Derby, Berzofsky. J Immunol 166: Hodge, Chakraborty, Kudo-Saito, Garnett, Schlom. J Immunol 174:

88 Combination Therapy: Vaccine and a-ctla N o t r e a t m e n t V a c c i n e o n l y C T L A - 4 A n t i b o d y o n l y n = 10 n = 10 n = 10 n = 10 C T L A - 4 A n t i b o d y a n d V a c c i n e Tumor Volume (mm 3 ) Tumor Free n=0 Tumor Free n=0 Tumor Free n=0 Tumor Free n= Days Post Tumor Transplant Mouse : CEA/Tg Tumor : MC32a Vaccine : Prime on Day 4 and Boost on Day 11,18 and 25 CTLA-4 antibody on Day 4,7 and Day 10 Hodge et al. 88

89 mab Mechanisms of Action Direct Effect on Receptor Function Ribas, New Engl J Med. 2012; 366(26):

90 anti-pd1 or anti-pd-l1 Lung Cancer Melanoma + Ipi Bladder Cancer Gastric Cancer Pancreas Cancer Gastroesophageal Cancer 90

91 Effect of Vaccination on Tumor PD-L1 Expression CEA-Tg mice MC38 (CEA) cells s.c. rmva-ceamtricom rf-ceamtricom Harvest tumors for IHC Vaccine HBSS Vaccine Isotype PD-L1 Gajewski T et al. Current Opinion in Immunology, 25, Similar results with LLC lung carcinoma cells Unpublished 91

92 Spectrum of Cancer Immunotherapeutics Recombinant Vaccines Cytokines/Immunocytokines Immune Checkpoint Inhibitors Immuno-Oncology Platform: Combination Therapies Chemotherapy Radiation Therapy Small Molecule Targeted Therapies - Hormonal Therapy 92

93 James L. Gulley M.D., Ph.D., F.A.C.P. Head, Immunotherapy Section Chief, Genitourinary Malignancies Branch & Director, Medical Oncology Service Center for Cancer Research National Cancer Institute,

94 Immune response capable of being: Rapid Self propagating Durable Adaptable

95 1. Antigen presenting cells in skin-antigen uptake

96 1. Antigen presenting cells in skin-antigen uptake 2. Antigen presentation in lymph nodes

97 How Pox viral vaccines activate TAA specific T-cells Pox virus- TAA Tarassoff, Gulley The Oncologist, 2006

98 1. Antigen presenting cells in skin-antigen uptake 2. Antigen presentation in lymph nodes 3. Tumor attack

99

100 1. Antigen presenting cells in skin-antigen uptake 2. Antigen presentation in lymph nodes 3. Tumor attack 4. Cross-presentation of multiple tumor antigens in draining lymph nodes

101 A. Degenerating tumor expresses different immunogenic targets Dying tumor cells PAP PSCA MUC-1 PSA

102 A. Degenerating tumor expresses different immunogenic targets Dying tumor cells PAP PSCA MUC-1 PSA B. Immature dendritic cell phagocytoses dying tumor cell along with a transfer of tumor-specific antigens

103 A. Degenerating tumor expresses different immunogenic targets Dying tumor cells PAP PSCA MUC-1 PSA B. Immature dendritic cell phagocytoses dying tumor cell along with a transfer of tumor-specific antigens C. Mature dendritic cells present tumor-specific antigens to T-cells

104 A. Degenerating tumor expresses different immunogenic targets D. Newly activated tumor-specific T-cells form in greater concentration and variation Dying tumor cells PAP PSCA MUC-1 PSA B. Immature dendritic cell phagocytoses dying tumor cell along with a transfer of tumor-specific antigens C. Mature dendritic cells present tumor-specific antigens to T-cells

105 A. Degenerating tumor expresses different immunogenic targets D. Newly activated tumor-specific T-cells form in greater concentration and variation E. Fully activated T-cell destroys tumor cells Dying tumor cells PAP PSCA MUC-1 PSA B. Immature dendritic cell phagocytoses dying tumor cell along with a transfer of tumor-specific antigens C. Mature dendritic cells present tumor-specific antigens to T-cells

106 1. Antigen presenting cells in skin-antigen uptake 2. Antigen presentation in lymph nodes 3. Tumor attack 4. Cross-presentation of multiple tumor antigens in draining lymph nodes 5. Broadened immune response/attack at secondary tumor site

107 Antigen Cascade Improved clinical outcomes associated with antigen cascade (aka antigen spreading) Disis ML et al. Concurrent trastuzumab and HER2/ neu-specific vaccination in patients with metastatic breast cancer. J Clin Oncol 2009 Hardwick N, et al. Epitope spreading contributes to effective immunotherapy in metastatic melanoma patients. Immunotherapy 2011 Walter S. et al. Multipeptide immune response to cancer vaccine IMA901 after single-dose cyclophosphamide associates with longer patient survival. Nature Medicine, 2012 Gulley JL. Therapeutic vaccines: The ultimate personalized therapy? Hum Vaccin Immunother, 2012

108 Immune response capable of being: Rapid Self propagating Durable Adaptable

109 OS but not PFS Δ mos 4.5 months HR = 0.59 (p=0.01) HR (p value) Δ mpfs 0.4 months 4.1 months HR = 0.78 (p=0.032) 0.1 months 8.5 months HR = 0.56 (p=0.006) 0.1 months 3.6 months HR = 0.66 (p=0.003) 0.1 months

110 Therapeutic vaccines vs. Conventional therapy Target Pharmacodynamics Conventional Therapy Tumor or its microenvironment Therapeutic Vaccines Immune system Often immediate action Delayed (adaptable, may get better over time) Memory Response No Yes Tumor Evolution / new mutations Resistance to therapy New immunogenic targets Limitations Toxicity Requires adequate immune system function (both systemically and at tumor site) Gulley et al., ASCO Education Book,

111 Tumor Growth Rate Vaccine Tumor Burden Cytotoxic Therapy Stein W, Gulley JL, et al. Clin Ca Res, 2011 Time

112 PROSTVAC Reduces Tumor Growth Rate Population: Biochemical relapse, hormone-naïve, M0 Prostate Cancer N = 50 Tumor growth rate significantly reduced within 3 mo of treatment start Days PROSTVAC dosing 112 Gulley et al, ASCO GU 2013 (ECOG9802)

113 PROSTVAC PSA Effects in a Patient with Early Stage Disease Early stage disease, M0 Hormone-naive Patient never underwent hormonal therapy Radical Prostatectomy Rojan Gulley, Bubley et al. Clin. GU Ca, 2013

114 PROSTVAC NCI Safety Data

115 PROSTVAC-VF Gr 2 Adverse Events PROSTVAC-V: 139 Injections PROSTVAC-F: 679 Injections Adverse Event # (%) of Injections Injection Site Reaction 230 (28.1) Fever 18 (2.2) Fatigue 10 (1.2) Myalgias 6 (0.7) Bone Pain 4 (0.5) Arthralgias 3 (0.4) Headache 3 (0.4) Diaphoresis 2 (0.2) Flu-like Syndrome 2 (0.2) Hypotension 2 (0.2) Allergic Rhinitis 1 (0.1) 6 NCI Trials, n=145 patients, 818 vaccines (NCT , NCT , NCT , NCT , NCT ) 115

116 PROSTVAC Human Immune Response

117 Test Result Comment PSA Specific Immune response 56.7% (59/104) 28 days after last vaccine --Median fold increase in PSA specific immune response 5X Antigen Cascade 67.9% (19/28) PSA response 30 / 10 6 cells flu response 33 / 10 6 cells Anti-PSA Ab 0.57% (2/349) Gulley et al., 2014

118 PROSTVAC : Robust Immune Responses within Target Organ 21 pts. with local recurrence after radiation, hormone-naive Intra-prostatic PROSTVAC (VFFF) Biopsies (13 pts.) taken before and after PROSTVAC (day 113) TILs significantly increased after PROSTVAC T reg proportion significantly decreased after PROSTVAC Gulley et al. Cancer Immunol Immunother Neoadjuvant study using a s.c. PROSTVAC regimen to open Q

119 PROSTVAC Clinical Trial Data

120 100 PSA-TRICOM: Overall Survival Overall survival (% patients) PSA-TRICOM Control N Deaths Median Control PSA-TRICOM Δ 8.5 months Hazard ratio: 0.56 (95% CI ) p= Months Kantoff Schlom, Gulley et al. J Clin Oncol 2010

121 Phase III data Current and Emerging Therapies in CRPC Number of patients Stop treatment 2º AE PSA 50% Improvement in Median OS Hazard Ratio Reduction in Death Rate Approved Docetaxel % 45% 2.4 months % 2004 Cabazitaxel % 39% 2.4 months % 2010 Sipuleucel-T % <5% 4.1 months % 2010 Abiraterone % 38% 3.9 months % 2011 Enzalutamide % 54% 4.8 months % 2012 Ra (47% PAP) 2.8 months % 2013 Phase II PROSTVAC data Multi-Center 125 ~2% <5% 8.5 months % --- N=154 treated with Prostvac at NCI with no IND related AE requiring stopping vaccine

122 Phase 3 PROSPECT Trial Design Asymptomatic/ minimally symptomatic mcrpc patients R a n d o m i z a t i o n Treatment Phase (5 mo)* PSA-TRICOM + GM-CSF** (n = 400) PSA-TRICOM (n = 400) Vector Placebo (n = 400) Long-term Follow-up (every 6 mo for 5 yr) S U R V I V A L Prime Boosts Vaccination Weeks *at the end of the 5 month treatment phase, use of other therapies for mcrpc is at the discretion of the investigator **low-dose adjuvant (100 µg) SC days 1-4 of each vaccination 122

123 MVA-Brachyury TRICOM Brachyury involved with EMT, drug resistance and cell stemness. Previous NCI study targeting brachyury demonstrated: Safety Ability to make brachyury specific T-cells Preliminary evidence of activity (including tumor marker changes and 1 PR) MVA Brachyury TRICOM phase 1 now completed accrual (n=38). No DLT Immunologic / clinical efficacy ongoing

124 Making a good thing better

125 Immune Checkpoint Modulation Proportion Alive Immunogenic Intensification Yrs Hodi FS, et al. N Engl J Med. 2010;363:

126 Anti-CTLA4 Ab (Ipilimumab) May also --increase T-cell avidity (Hodge J Imm 2005) --decrease Treg in tumor (Simpson, J Exp Med, 2013) --expand T-cell repertoire (Cha, Sci Trans Med, 2014) Adapted from Tarassoff, Arlen, Gulley The Oncologist, 2006

127 Trial: Vaccine + anti-ctla-4 Eligibility Patients with metastatic CRPC No bone pain requiring narcotics Amended to require no prior chemotherapy (6 in lower dose levels had prior chemo, 24 in 3, 5 and 10 mg/kg did not) Design Phase I fixed dose vaccine dose escalation of ipilimumab (1, 3, 5 and 10 mg/kg) Endpoints 1º Safety 2º Clinical responses, PSA kinetics, OS, Immune responses Madan Schlom, Gulley, Lancet Oncology,

128 Design 128

129 Baseline Characteristics 129

130 Immune-related Adverse Events Similar side effect profile as ipilimumab alone (21 of 30 with grade 2 or greater irae) Madan Schlom, Gulley, Lancet Oncology,

131 PSA Waterfall Plot Madan Schlom, Gulley, Lancet Oncology,

132 Case Studies PSA (ng/ml) Weeks on Trial Patient 12 5 mg/kg dose level No irae PSA (94.4% ) Patient mg/kg dose level PSA 39.3 <0.04 (99% ) Endocrine irae PSA (ng/ml) irae immune-related adverse event Weeks on Trial

133 Immunogenic Intensification Vaccines and Immune checkpoint inhibition Efficacy of immune checkpoint inhibition requires an underlying immune response to unleash Vaccines can provide that underlying immune response Median Halabi Predicted Survival* (months) Median Overall Survival in months (95% CI) Δ OS (months) Alive at 24 mos PSA-TRICOM % alone (n=32) 1 PSA-TRICOM Ipilimumab (n=30) ( >41) % *Halabi et al., JCO Gulley et al, Cancer Immunol Immunother, Madan et al, Lancet Oncology, 2012

134 Prostvac plus Ipilimumab Combination: Updated Overall Survival 100 survival (% of patients) <10 mg/kg Ipi 31.3 months 10 mg/kg Ipi 37.2 months Months Singh Gulley, ASCO GU 2015 N Events Median Ipi < Ipi =

135 Effect of Vaccination on Tumor PD-L1 Expression Vaccine CEA-Tg mice MC38 (CEA) cells s.c. rmva-cea-mtricom rf-cea-mtricom Harvest tumors for IHC New immune checkpoint inhibitors less likely to work HBSS New immune checkpoint inhibitors work much better Vaccine Isotype PD-L1 Similar results with LLC lung carcinoma cells Unpublished 135

136 Frequency of treatment-induced autoantibody responses Cancer-free controls (n = 15) AS (n = 9) EBRT (no vaccine; n = 8) EBRT + ADT (n = 15) EBRT+ Vaccine (n = 33) Western blot 0 (0%) 1 (11.1%) 1 (12.5%) 3 (20.0%) 15 (45.5%) Antigen array 0 (0%) 1 (11.1%) 0 (0%) 2 (13.3%) 7 (21.2%) Overall 0 (0%) 1 (11.1%) 1 (12.5%) 3 (20.0%) 17 (51.5%) Nesslinger Schlom, Gulley et al, Clin Ca Res, 2010

137 Conclusions PROSTVAC is an experimental off-the-shelf vaccine for prostate cancer Excellent safety profile Associated with robust immune responses Promising OS signal in phase II study Ongoing Phase III Immunotherapy alone may lead to delayed but prolonged clinical effects (manage expectations) Earlier use of effective immunotherapy may be better Combination studies may lead to improved PFS Therapeutic vaccines may provide the immune response necessary for efficacy of immune checkpoint modulators 13 7

138

139 Tumor Growth Rate Vaccine Tumor Burden Cytotoxic Therapy Combination Stein W, Gulley JL, et al. Clin Ca Res, 2011 Time 139

140 Hodge Gulley et al., Oncology 22: Potential Multiple Effects of Local Irradiation of Tumors

141 QUADRAMET is a therapeutic agent consisting of radioactive samarium ( 153 Sm) and chelator. It preferentially binds to osteoblastic metastatic tumor deposits in bone. 153 Sm is currently FDA approved and clinically utilized for palliation of bone metastasis in multiple tumor histologies.

142 99m TC MTP 153 Sm EDTMP 99m TC MTP 153 Sm EDTMP 142

143 Treatment of LnCaP Prostate Cells with Palliative Levels of 153 Sm (Quadramet) Modulates Phenotype, Upregulates TAA, and Increases Sensitivity to Antigen-specific CTL Killing Treatment of LnCaP prostate cancer cells with palliative doses of 153 Sm results in the upregulation of MHC class I and Fas Cell Number 0 Gy 0 Gy 25 gy 0 Gy 25 gy 25 gy FAS MHC-I Treatment of LnCaP prostate cancer cells with palliative doses of 153 Sm results in the upregulation of TAAs Tumor antigen genes g 0 G y 25 G y PS A PSM A PAP CE A MUC Treatment of LnCaP prostate cancer cells with palliative doses of 153 Sm results in increased sensitivity to multiple CTLs 100 p<0.001 p< MFI % Lysis Chakraborty, Wansley Schlom, Hodge, NCI. Clin Cancer Res Collaboration with Nuclear Medicine Branch 0 0 (Mock) Day 4 Sm-153 delivered Dose (Gy)

144 153 Sm +/- PSA-TRICOM Patient Population: CRPC Metastatic to bone R A N D O M IZ E Arm A: PSA-TRICOM Sm (n=34) Arm B: 153 Sm (n=34) NCT ; PI Gulley CINJ (DiPaola) and UC (Stadler) Vaccine: rv-psa/tricom s.c. d 1 rf-psa/tricom s.c. d 15, 29, q 4 wks 153 Sm: 1 mci/kg d 8, may be repeated q 12 wks upon hematologic recovery.

145 Final Data: 153 Sm +/- PSA-TRICOM Percent without Progression n= Sm Alone TTP = 1.7 months Kaplan Meier survival estimates 153 Sm+PSA-TRICOM TTP = 3.7 months analysis time Days from On-Study Date P 2 =0.03 Heery Gulley, ASCO GU 2013

146 Enzalutamide Mediates Immunogenic Modulation in TRAMP-C2 Prostate Cells LnCAP, AR POS PSA-specific CTL MHC Increased ~5-Fold Fas Increased ~1.7-Fold Ardiani A et al. Clin Cancer Res 2013; 19: Ardiani A et al. Oncotarget 2014; 5(19):

147 Enzalutamide/PSA-TRICOM Phase 2 Combo studies Protocol M0 hormone-naive PC mcrpc Primary Endpoint Decrease in tumor re-growth rate (PSA kinetics) after 3 months of enzalutamide Time to progression Study Design (open label) R Arm A: Enzalutamide (n = 17) Arm B: Enzalutamide + PSA-TRICOM (n = 17) R Arm A: Enzalutamide (n = 36) Arm B: Enzalutamide + PSA-TRICOM (n = 36) NCT

148 Figure 1

149 Figure 2 April Baseline 5.9 cm 5.5 cm A. B. July 2014 Restaging (SD) 4.4 cm 6.9 cm C. D. January 2015 Restaging (SD) 2.6 cm 6.6 cm E. F.

150 Figure 3 July Baseline 4.3 cm 3.5 cm A. B. December PR 2.2 cm 2.7 cm C. D. January 2015 Ongoing PR 2.4 cm 2.1 cm E. F.

151 PANEL Q&A ASCO ANNUAL MEETING MAY 30,