Update on Targeted Therapies of NSCLC Tanja Cufer, MD, PhD University Clinic Golnik Medical Faculty Ljubljana, Slovenia Bled 2014 1
Systemic Therapy of Advanced NSCLC: Chemotherapy Range Cht improves survival rates by 1.5 mos (from 4.5 to 6.0 mos) Platinum doublets are standard 21st Century: Chemotheray has reached a plateaou in NSCLC, with novel tretament strategies urgently No significant or meaningful differences among needed! various third-gen platinum doublets Similar outcomes, RR from 20% to 30%, mpfs 3.5 5 months, mos of 8 10 months Survival Distribution Function 1.0 0.8 0.6 0.4 0.2 0 Cisplatin/paclitaxel Cisplatin/gemcitabine Cisplatin/docetaxel Carboplatin/paclitaxel 0 5 10 15 20 25 30 Months 2
Evolution of NSCLC Subtyping from Histologic to Molecular Based NSCLC as one disease ALK EGFR Li T et al. J Cin Oncol 2013
Hitting the Mark: Biomarker-driven Treatment Strategies Over 50% of NSCLC cases are linked to known molecular markers At least 10 known molecular markers in NSCLC Mainly Adenocarcinoma No mutation detected KRAS NRAS IDH1 CTTNB1 HER2 MET PIK3CA BRAF EML4-ALK- 4% EGFR 17% Sequist LV et al., Ann Oncol. 2011 4
2004: Activating EGFR Mutations Discovered EGFR TKI- sensitizing mutations are present in 10-20% of NSCLC in Western population, mainly in adenocarcinomas, non-smokers, female population. Remarkable and rapid responses to 1 st generation EGFRdirected TKIs. Lynch et al. NEJM 2004; Paez et al. Science 2004 5
INTEREST: Gefitinib vs. Cht in Second-line Therapy : PFS Biomarkers Overall High EGFR-gene-copy number Low EGFR-gene-copy number EGFR protein expression positive EGFR protein expression negative EGFR mutation positive EGFR mutation negative K-RAS mutation positive K-RAS mutation negative N=1316 N=158 N=179 N=258 N=87 N=38 N=229 N=47 N=203 0 0.5 1.0 1.5 2.0 2.5 HR (gefitinib vs docetaxel) and 95% CI Favours gefitinib Favours docetaxel Douillard et al, JCO 2009 6
First-line Gefitinib vs Carbo/Pacli in Clinically Selected pts with Advanced NSCLC in Asia (IPASS trial) Patients Chemonaïve Age 18 years Adenocarcinoma histology Never or light exsmokers* Life expectancy 12 weeks PS 0-2 Measurable stage IIIB / IV disease Gefitinib (250 mg / day) 1:1 randomisation Carboplatin (AUC 5 or 6) / paclitaxel (200 mg / m 2 ) 3 weekly # Carboplatin / paclitaxel was offered to gefitinib patients upon progression Endpoints Primary Progression-free survival (non-inferiority) Secondary Objective response rate Overall survival Quality of life Disease-related symptoms Safety and tolerability Exploratory Biomarkers EGFR mutation EGFR-gene-copy number EGFR protein expression Mok et al, NEJM 2009 7
IPASS: PFS in EGFR Mutation Positive and Negative Patients EGFR mutation positive EGFR mutation negative Probability of progression-free survival 1.0 0.8 0.6 0.4 0.2 0.0 At risk : Gefitinib C / P Gefitinib (n=132) Carboplatin / paclitaxel (n=129) HR (95% CI) = 0.48 (0.36, 0.64) p<0.0001 0 4 8 12 16 20 24 Months 132 108 71 31 11 3 0 129 103 37 7 2 1 0 Probability of progression-free survival 1.0 0.8 0.6 0.4 0.2 0.0 Gefitinib (n=91) Carboplatin / paclitaxel (n=85) HR (95% CI) = 2.85 (2.05, 3.98) p<0.0001 0 4 8 12 16 20 24 Months 91 21 4 2 1 0 0 85 58 14 1 0 0 0 Treatment by subgroup interaction test, p<0.0001 Mok T et al, NEJM 2009 8
TKIs vs. Chemotherapy in EGFR-mutated Advanced NSCLC Study (n) Comparison ORR (%) PFS (Mos) HR OS (Mos) IPASS** (n=261) WJOTG (n=172) NEJ002 (n=230) EURTAC (n=174) OPTIMAL (n=165) Geftinib v. Carbo/Pac Geftinib v. Cis/Doce Geftinib v. Carbo/Pac Erlotinib v. Chemotherapy Erlotinib v. Carbo/Gem 71 vs. 47% 9.5 v. 6.3 0.48 (0.36-0.64) 21.6 vs. 21.9 *62 vs. 32% 9.2 v. 6.3 0.49 (0.34-0.71) 35.5 vs. 38.8 74 vs. 31% 10.8 v. 5.4 0.30 (0.22-0.41) 27.7 vs. 26.6 *58 vs. 15% 9.7 v. 5.2 0.37 (0.25-0.54) 19.3 vs. 19.5 *83 vs. 36% 13.1 v. 4.6 0.16 (0.10-0.26) 22.7 vs. 28.9 LUX-lung 3 (n=345) Afatinib v. Cis/Pem *61 vs. 22% 56 vs. 23% *13.6 v. 6.9 11.1 v. 6.9 0.47 (0.34-0.65) 0.58 (0.34-0.65) 30.3 vs. 26.2 28.1 vs. 28.2 Lux-Lung 6 (n=364) Afatinib v. Cis/Gem 67 vs. 23% 11.0 v. 5.6 0.28 (0.20-0.39) 22.11 vs.22.24 * Del 19, L858 mu, ** Post-hoc analysis of EGFR mutant patients 9
2007: EML4-ALK Rearrangements in NSCLC EML4 EML4-ALK variant 1 ALK 1 1 HELP 496 981 Basic WD 1 496 1059 1058 1620 Kinase TM EML4-ALK frequency: ~ 4% (64/1709) Primarily in adenocarcinoma More common in younger patients More common in never-smokers First discovered in 2007, EML4-ALK is now a validated therapeutic target in a small but significant subset of NSCLC patients Soda M, et al. Nature 2007 10
Notable Trials ALK Tyrosine Kinase Inhibitor Study (Phase) Author Study arms No. of pts RR (%) PFS Median (mo) HR (95% CI) OS Median (mo) HR (95% CI) PROFILE 1001 (I)1 Crizotinib 149 60.8 9.7 18.7 FL NA Not yet reached 74% at 1y NA PROFILE 1005 (II)2 Crizotinib 261 60 8.1 NA NR NR PROFILE 1007 (III)3 Crizotinib Cht. Pemetrexed 347 65 20* 29 7.7 3.0 4.2 0.49 (0.37 0.64) 20.3 22.8 1.02 (0.68 1.54) Docetaxel 7 2.6 1.Camidge DR et al., Lancet Oncol 2012, 2. Kim D-W et al., J Clin Oncol 2012, 3. Shaw A et al., N Engl J med 2013. 11
Driver Mutations with Predicted Likelihood of Response to Current Targeted Therapies Oncogene Mutation Prevalence EGFR Asians: 30-40% Whites: 10-20% ROS1 drugs. 1.7%, more in Asians? Mutation-Predicted Response Sensitive to EGFR TKIs ( most mutations) Sensitive to Alk inhibitors Predicted RR erlotinib, gefitinib, afatinib: 60-83% Predicted mpfs (months) Predicted mos (months) 9-14 mos 19-35 mos Targeted therapy based on the presence of EGFR mutations and ALK gene rearrangements has become a standard practice. EML4-ALK EGFR and ALK Sensitive testing to is ALK now recommended Crizotinib, for 9-18all mos advanced up to 24 NSC 1-7% NSCLC,, no clear in order inhibitors, guide resistant treatment LDK378: decisions, 50- with most of mos the racial difference to EGFR TKIs 80% countries implementing diagnostic tests after approval of targeted Crizotinib: 64 % NR NR 12
Phase III Trials Comparing Cht with or without Targeted Therapy in Biomarker Unselected NSCLC Study Design Response rate Median PFS (months) Median OS (months) FLEX 1 CV + cetuximab 35 4.8 11.3* (EGFR IHC+ NSCLC) CV 28 4.8 10.1 BMS 009 2 CT + cetuximab 26 4.4 9.6 (All NSCLC) CT 17 4.2 8.3 ECOG 3 CarboP + beva 35 6.2* 12.3* CarboP 15 4.5 10.3 AVAIL 4,5 CG + beva (7.5 mg) 34.1 6.8* 13.6 CG + beva (15 mg) 30.4 6.6* 13.4 CG + placebo 20.1 6.2 13.1 *=significant The efficacy of targeted therapy without identifiable target is limited! 1. Pirker R et al., Lancet 2009. 2. Lynch TJ et al., J ClinOncol 2010, 3. Sandler et al. N engl J Med 2006, 4. Manegold et al. ESMO 2008 5. Reck et al. J Clin Oncol 2009. 13
Unresolved Issues regarding Biomarker-driven Therapies? Why biomarker-driven therapies should preferentially be used as first-line therapy? How to overcome resistance to biomarkerdriven therapies? Treatment beyond progression 14
Why Biomarker-driven Therapy should be used as First-line Therapy There are no comperative data between FL and SL EGFR TKIs. However, there is a strong beleive that the most effective drugs are to be used in first line, thus ensuring benefit to all patients (approx. 25% of NSCLC pts are lost between Fl and SL therapy! Adopted from Mok T et al. JCO 2013 15
Resistance to EGFR- and ALK- inhibitors Despite marked activity of EGFR TKIs and crizotinib resistance develops in one to two year time. Genetic alterations of target (second-site mutations, T790M), activation of aberrant signalling pathways, histologic changes (SCLC transformation). Various drugs and their combinations targeted to the resistance pathways are under development. 16
Phase I Study of 3 rd generation TKI (AZD9291) in EGFR-Mutant Patients Beyond Progression on EGFR TKI Population: patients with target lesion data (n=24) Dose (mg/day) received noted on bar Promising clinical activity and tolerability with mostly G1/2 rash and diarrhoea % change 45 30 15 0-15 -30-45 -60-75 -90 PD D 40 D D D 40 20* 20* *D D 20 40 80 SD 80 20 80 20 20 80 20 T790M negative T790M positive Mutation status unknown Discontinued treatment PR 20 20 20 40 40 80 80 20 20 20 Ranson M, et at. ECCO 2013 17
Response to Ceritinib in ALK-Rearranged Non Small-Cell Lung Cancer (NSCLC). Shaw AT et al. N Engl J Med 2014;370:1189-1197. 18
Afatinib+Cetuximab in EGFR-mutant NSCLC with Acquired Resistance to TKI: Phase 2 Data from 100 eligible patients Majority of patients with acquired resistance to erlotinib and gefitinib derived benefit from afatinib + cetuximab ORR 32%, CB 75% in heavily pretreated population with T790Mpositive and T790M-negative tumours mpfs = 4.67m Y. Janjigian et al., ESMO 2012 19
Clinical Benefit of Continuing Crizotinib beyond Progression in ALK-positive NSCLC Targeted therapy beyond progression on targeted therapy might represent the best approach in oncogene-driven NSCLC as well! Sai-Hong I. Ou et al, WCLC Sydney 2013 20
Optimising EGFR TKI treatment duration: upcoming data Advanced NSCLC with EGFR mutation (n=208) Primary endpoint PFS 1 Erlotinib PFS 1 ASPIRATION (Phase II, Asia) 1 PD by RECIST PFS 2 Erlotinib PD by physician discretion IMPRESS (Phase III, Europe/Japan/Asia) 2 Advanced NSCLC with EGFR mutation (n=287) First-line gefitinib PD by RECIST Gefitinib + pemetrexed/cisplatin Randomised within 4 weeks of disease progression Primary endpoint PFS Pemetrexed/cisplatin 1. NCT01310036 2. NCT01544179
NCCN Guidelines Version 2.2014: NSCLC Local therapy with continuation of TKI can improve disease control rate and delay start of another systemic therapy in oligometastatic progressive disease! www.nccn.org
Future Directions Recognition of new oncoge-drivers Development of novel biomarker-targeted agents Harnessing the immune system Treatment tailored to cancer evolution, a move from individualized to so called precision medicine 23
New Targeted Agents in Development Target HER2 amplification, mutations BRAF mutations Agents Afatinib, Neratinib, Dacomitinib Vemurafenib, dabrafenib RET re-arrangements Vandetanib, Sorafenib, Sunitinib KRAS mutations PI3KCA mutations Selumetinib, Trametinib GDC-0941, XL147 MET/HGF amplification Onartuzumab, Rilotumumab, Tivantinib, FGFR1 DDR2 Brivanib Dasatinib 24
Dominant Mutations in Squamous Cell Lung Cancer FGFR1 Amp FGFR2 Mut Compared to adenocarcinoma, there are NO proven molecularly targeted therapies for squamous cell carcinoma and fewer potential targets. 25
Cancer Immunotherapy: Balance between Inhibitory and Stimulatory Receptors Tumour cell or APC T cell T cell targets for modulating activity Activating Receptors Inhibitory Receptors CD28 CTLA-4 OX40 PD-1 GITR TIM-3 CD137 BTLA B7.1 CTLA-4 CD27 VISTA B7.1 MHC I CD28 TCR HVEM LAG-3 PD-L1 PD-1 CDI37-L CDI37 OX40-L CD40-L OX40 CD40R Agonistic Antibodies T cell stimulation Blocking Antibodies CD70 CD27 Light HVEM Mellman Nature 2011; Pardoll Nat Rev Cancer 2012 26
MPDL3280A (anti-pdl1) Phase Ia: Potential Predictors of Activity NSCLC Diagnostic Population (n=53) ORR % (n/n) PD Rate % (n/n) IHC 3 83% (5/6) 17% (1/6) IHC 2/3 46% (6/13) 23% (3/13) IHC 1/2/3 31% (8/26) 38% (10/26) All Patients 23% (12/53) 40% (21/53) Patients With PR, % BIRCH phase II study (GO28754; NCT02031458) PD-L1 PD-L1 positive positive locally locally advanced or advanced metastatic or metastatic NSCLC* ECOG NSCLC* PS 0 1 ECOG PS 0 1 Response by smoking status (ORR) 50 40 30 20 10 Treatment period MPDL3280A 1200mg iv q3w x16 cycles ( 1y) 0 26% Former/current smokers n = 43 10% Never smokers n = 10 Horne, et al. WCLC 2013 Patients with CR/PR/SD followed every 12 weeks until PD Primary endpoint: ORR 27 27
Cancer Evolution: The Final Frontier of Precision Medicine? Tumor Darwinism : Reducing sensitive clones by therapy permits unopposed growth of less fit resistant clones or emergence of a new Pooled cdna genomic analysis from liquid clone. biopsies might allow us to follow cancer clonal evolution during the disease course and tailor biomarker-driven therapy accordingly. Burrell RA, et al. Nature 2013; Lawrence MS, et al. Nature. 2013 Lawrence MS, et al. Nature. 2013 28
The SPECTA Collaborative Platform Molecular Screening Platform Academia investment Because of the low frequency of the majority of these aberrations, a single master protocol assigning patients to different agents based on molecular characteristics Standard appears treatment to be (no the open ideal trial) approach. 1 st line trial Standard treatment First line 2 nd line trial Third line Industry cooperation First line Second line 3 rd line trial Standard treatment (no open trial) 29
We are getting faster! Precision medicine Median progression free and overall survival (mos) 30 20 10 BSC 2-4 mos Thank you for your attention! ALK directed Individualized Cht therapy 20-24 mos One size fits all 4 8 Cht 6-8 mos 10 P-based doublets 3rd gen. 8-10 mos 11 Histology driven cht 11 mos Biomarkerdriven therapy 14 Maintenance therapy 11-13 mos 24 10 mpfs 7-10 mos 30 EGFR directed FKIs 22-35 mos 13 mpfs 10-13 mos 1970s 1970s 1990-2005 2005-2010 2010 30