Triple negative breast cancer SABCS 2013. L. Dirix

Triple negative breast cancer SABCS 2013 L. Dirix

Triple Negative Breast Cancer 20 % of invasive breast cancers ER, PR and HER2 negative More in A-A, Hispanics, younger and BRCA1 carriers Poor prognosis compared to ER+ or HER2+ Early recurrence, visceral and CNS relapse Median OS < 1 year in advanced disease 70-80 % have basal-type expression profile

Semantics TN Basal-like : Perou-Sorlie terminology (derived from IDC) Myo-epithelial like (expressing epithelial and mesenchymal markers) -Tumours arising from these cells Defines a population of basal-cytokeratin expressing cells that may be found in either luminal of basal positions Triple negative (definitions based on negative observations should provoke some minor unrest) A lack of expression of both ER, PR and HER-2 Basal-like, TN and BRCA-ness are not synonymous but they do overlap substantially

Overall survival as a function of response to chemotherapy pcr v residual disease and TNBC v non-tnbc

Rates of breast-specific survival in triple-negative and other breast cancers

SABCS 2013 TNBC Triple negative subtyping TIL in TNBC CTC and DTC Mutational spectrum in TNBC Use of pre-operative chemotherapy Activity of chemo-therapeutics in TNBC in metastatic trials

Sub-types of triple negative breast cancer Evaluated gene expression profiles from 21 breast cancer data sets (14 training and 7 validation = 587 cases of TNBC) Used cluster analysis to sub-divide TNBC into 6 sub-types displaying unique gene expression and ontologies Identified breast cancer cells lines representative of each subtype Lehmann et al JCI 2011

Basal-like 1: cell cycle, DNA repair and proliferation genes Basal-like 2: Growth factor signaling (EGFR, MET, Wnt, IGF1R) IM: immune cell processes M: Cell motility and differentiation, EMT processes MSL: similar to M but growth factor signaling, low levels of proliferation genes (metaplastic cancers) Lehmann et al JCI 2011 LAR: Androgen receptor and downstream genes, luminal features

Sub-types demonstrate differential response to therapies in vivo Vehicle Cisplatin Anti-androgen P13K/mTOR inhibitor Lehmann et al JCI 2011

Tumor-Infiltrating Lymphocytes in the Breast Cancer Microenvironment in TNBC Tumour-infiltrating lymphocytes (TILs) NK cells, B cells (CD20+), T-Ly (CD3+) CD3+ either CD4+, CD8+, FOXP3+ ly (Treg) Distinction itil, stil, LPBC Indicator of good prognosis after chemotherapy; mainly in HER2+ and TNBC Predictor of response in PST SABCS 2013 Significantly associated with trastuzumab benefit Immune system enhances effectiveness of chemotherapy (drug and/or regimen specific?) Chemotherapy converts TIL- to TIL+, mainly increase in CD8+ SABCS 2013 GeparQuattro and FinHER trials assessing neoadjuvant trastuzumab in HER2+ BC GeparSixto phase II trial investigating addition of carboplatin to neoadjuvant therapy in HER2+ BC and TNBC ECOG 2197 and ECOG 1199 phase III trials exploring adjuvant therapy in TNBC

Prognostic significance of TIL in E 2197 and E 1199 N = 481 TNBC, Anthracycline based CT Endpoints DFS/OS/DRFI itil/stil/lpbc Pearson correlation: 0.79 for stil and 0.75 itil; 2 breast pathologists 80% have stil, 15% itil, LPBC in 4.4% Intratumoral Stromal Score N (%) N (%) 0 411 (85) 95 (20) 10 57 (12) 237 (49) 20 9 (2) 82 (17) 30 3 (<1) 37 (8) 40 0 9 (2) 50 1 (<1) 9 (2) 60-80 0 8 (2) 90-100 0 0 Adams S, et al. SABCS 2013. Abstract S1-07..

ECOG 2197 and 1199: TILs in Adjuvant Therapy for TNBC Stromal TILs associated with better prognosis (DFS, DRFI, OS) after standard adjuvant therapy in TNBC (multivariate model) DFS HR: 0.84 (95% CI: 0.74-0.95; P =.005) DRFI HR: 0.81 (95% CI: 0.68-0.97; P =.02) OS HR: 0.79 (95% CI: 0.67-0.92; P =.003) For every 10% incremental gain of stromal TILs: 14% reduction of risk for recurrence/death (P =.02) 18% reduction of risk for distant recurrence (P =.04) 19% reduction of risk for death (P =.01) Adams S, et al. SABCS 2013. Abstract S1-07..

SABCS 2013 2013

TIL in Geparsixto 2013

SABCS 2013 013

GeparSixto: TILs for Carboplatin Neoadjuvant Tx for TN and HER2+ EBC Stromal TILs predictive of pcr to neoadjuvant chemotherapy in HER2+ and TN EBC 20-30% had LPBC and increased pcr (75% in Carbo arm) Stromal TILs are a continuous predictor of chemotherapy response Predictive effect particularly high in carboplatin arm: pcr increased from 34% to 75% Stromal TILs (per 10%) OR (95% CI) P Value Test for Interaction All patients PM 1.11 (1.00-1.22).04 0.006 PM + carboplatin 1.35 (1.21-1.49) <.0005 Triple negative PM 1.09 (0.96-1.25) NS 0.27 PM + carboplatin 1.22 (1.06-1.39).004 HER2+ PM 1.13 (0.98-1.30) NS 0.007 PM + carboplatin 1.53 (1.29-1.82) <.0005 Denkert C, et al. SABCS 2013. Abstract S1-06..

Panitumumab + FEC100 + TXT N= 60 TNBC FEC100x4-TXT100x4 + anti-egfr Ab pcr 55.3% pcr related to high CD8+ TIL (p=0.000003) pcr related to ratio CD8+/FOXP3+, > 1.23 (p=0.00008) High pre-nact IGF-1R related to pcr Residual tumour in 17 cases : 9 high and increased HER3 and in 7/9 decreased Met 7 unchanged HER3, increased MET P5-08-07/P3-14-19

CTC in MBC CONSORT Letter of intent #2,400 potentially eligible pts in 18 centers Patients / Centres Call for data 1 center off study 2,174 pt data received Data cleaning 230 ineligible pts 1,944 individual patient data from 17 centers included

Results CTC at baseline 5 CTC / 7.5mL were detected in 47% of the 1,944 patients at baseline 1st quartile Median 3rd quartile Maximum 0 CTC 3 CTC 25 CTC 58160 CTC CTC count at baseline was associated with First line (N=1,110) All patients Performance status p<0.0001 p<0.0001 Liver metastases p<0.0001 p<0.0001 Bone metastases p<0.0001 p<0.0001 Elevated CEA p<0.0001 p<0.0001 Elevated CA15-3 p<0.0001 p<0.0001 Tumor subtype p=0.71 p<0.0001 5 CTC HR+ 51% HER2+ 38% T. Neg 44%

Clinical Response by RECIST (%) Progression Free Progression Free Progression Free Progression Free Progression Free Progression Free Progression Free Progression Free ork City, NY, US, 10065 and San Antonio Johns Breast Cancer Hopkins Symposium- Sidney Cancer Therapy Kimmel and Research Comprehensive Center at UT Health Science Center-December Cancer 10-14, Center, 2013 Baltimore, MD, US, 2123 Significance of Circulating Tumor Cells in metastatic triple negative breast cancer: Results of an open label, randomized, phase II trial of nanoparticle albumin-bound paclitaxel (Nab-PAC) with or without the anti-death receptor 5 (DR5) Tigatuzumab (TBCRC 019) 1 Costanza Paoletti, 2 Yufeng Li, 1 Maria C. Muñiz, 1 Kelley M. Kidwell, 1 Kimberly Aung, 1 Dafydd G. Thomas, 1 Marty E. Brown, 3 Vandana Abramson, 4 William Irvin Jr., 5 Nancy Lin, 6 Minetta Liu, 7 Rita Nanda, 8 Julie Nangia, 9 Anna Maria Storniolo, 10 Tiffany Traina, 2 Christos Vaklavas, 1 Catherine Van Poznak, 11 Antonio C. Wolff, 2 Andres Forero, 1 Daniel F. Hayes on behalf of the TBCRC 1 Department of Internal Medicine Div Hem/Onc, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, US, 48105; 2 University of Alabama at Birmingham, Birmingham, AL, US, 35205; 3 Vanderbilt Breast Cancer Center One Hundred Oaks, Nashville, TN, US, 37204; 4 Bon Secours Cancer Institute, Midlothian, VA, US, 23114; 5 Dana-Farber Cancer Institute, Boston, MA, US, 02215; 6 Mayo Clinic, Rochester, MN, US, 55905; 7 University of Chicago, Chicago, IL, US, 60637; 8 Baylor College of Medicine, Houston, TX, US, 77030; 9 Melvin and Bren Simon Cancer Center, Indiana University, Indianapolis, IN, US, 46202; 10 Memorial Sloan-Kettering Cancer Center, New York City, NY, US, 10065 and 11 Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, US, 21231. s he e ve: ives: he CO 2013 2. CTC Materials and levels Methods ( 5 CTCs/7.5 Results ml) are Prognostic Conclusions (PFS) 2. CTC levels ( 5 CTCs/7.5 ml) are Prognostic (PFS) BLOOD FOR CTC EVALUATION CTC counts were determined in CTC VS. PFS 7.5 ml of CTC AT BASELINE ENUMERATION N= 52 DAY 15 N= 52 VS. DAY PFS 29 N= 49 whole blood (WB) using the Day 1 Day 15 Day 29 Logrank p = 0.0037 Logrank p = 0.0010 Logrank p = 0.0002 CXC Kit cycle 1 cycle 2 Using the AT 1 BASELINE 2 3 N= 52 CellSearch DAY 15 N= 52 assay, M-30 Ab Morphologi 1.9 3.6 mo 3.3 mo Y/N pos Y/N cally 3.3 mo APOPTOSIS: 1.8 1.8 apoptotic mo mo mo CTC Relative Y/N Evaluated using a <5CTCs (63.5%) compos M-30 PE <5CTCs (73.1%) ite staining monoclonal <5CTC (73.5%) Image antibody (M-30) 5CTCs (36.5%) 5CTCs (26.9%) 5CTCs (26.5%) (Peviva, Intact cell satisfying the Viable Y N N Stockholm, 0 5 10 15 20 0 5 10 15 20 Category Figure related Description CTC Perfect event Apoptotic cells due to M-30 + Apoptotic cells due to M-30 + Morphologically apoptotic Morphologically apoptosis Cell Fragments Sweden) conjugated to phycoerythrin (PE) Visual inspection (nucleic condensation and/or fragmentation, as well as granular cytokeratin). This presentation is the intellectual property of the author/presenter. Contact them at pcostanz@umich.edu for permission to reprint and/or distribute. CTCs are elevated ( 5CTCs/7.5 ml) in 30-40% of TN MBC patients at baseline using CellSearch assay In this group of homogeneous prospectively enrolled patients, regardless of treatment, CTC levels reflected PFS and response Baseline Day 15 Day 29 No apparent: Interaction between CTCs and treatment arm Prognostic effect of CTC-Apoptosis Association between CTC-Apoptosis and response to tigatuzumab Logrank p cell = 0.0037 0 5 Logrank Months p = 0.0010 Months Logrank p = 0.0002 10 15 20 Months HR: 2.38 (95% CI: 1.27-4.45) p=0.007 HR: 2.87 (95% CI: 1.46-5.66) p=0.002 HR: 3.40 (95% CI: 1.68-6.89) p=0.001 Early apoptotic Y Y N CTC 1 5 Nab-PAC Nab-PAC + Tig 0 5 10 15 20 Baseline 61.5% 36.5% Months 31.6% 39.3% (32/52) (19/52) (6/19) (13/33) Day 15 42.3% (22/52) Day 29 38.8% (19/49) morphology features Intact cell satisfying the morphology features Nucleic condensation and or fragmentation 26.5% (14/52) 26.5% (13/49) Y Y N/Y Granular CK Y Y N/Y Nucleic condensation and or fragmentation Y N Y Granular CK Y N Y 15.8% (3/19) 22.2% (4/18) Early apoptotic CTC Early apoptotic CTC Late apoptotic event Late apoptotic event 33.3% (11/33) 29% (9/31) 3. No overall difference for PFS according to treatment arm AT BASELINE N= 52 Logrank p = 0.025 <5CTCs nab-pac N=13 <5CTC nab-pac+ Tig N=20 CTC ENUMERATION VS. ORR 27/36 23/33 26/38 4. CTC-apoptosis is not more prognostic than CTC counts alone AT BASELINE N= 52 Logrank p = 0.0122 DAY 29 N= 49 FUTURE DIRECTIONS: ¾ Failure to clear CTCs might be used to direct patients onto novel/targeted trials ¾ In this trial, CTC Response ~ ORR: CTC response might be used as investigational endpoint in future Phase II trials Completely broken 1.9 3.6 mo cells, but part of the N NA 1.8 3.3 mo 1.8 3.3 mo nucleus is still 1.9 3.6 mo References surrounded by the CK mo mo 1.9 mo mo <5CTCs (63%) mo 5CTC nab- 5CTCs/ 25% Results <5CTCs (63.5%) apo (10%) 5CTCs/<25% apo (27%) PAC+ Tig N=13 1. CellSearch 0 5 10 15 20 <5CTCs 0 (73.1%) 5 10 15 20 5CTCs Months Months <5CTC (73.5%) assay detects CTCs in TN MBC nab-pac N=6 Acknowledgements 5CTCs 5. High CTC levels predict lower chance of response 5 (36.5%) CTCs/7.5 ml WB CTCs/7.5 ml WB 5CTCs (26.9%) 5CTCs (26.5%) By Randomized Arm 0 5 10 15 20 1 Cristofanilli M. et al. NEJM 2004; 2 Liedtke C et al. PPO Updat Prin Prac Oncol 2010; 3 Sieuwerts A.M. et al. JNCI 2009; 4 Buchsbaum D. et al. Clin Cancer Res 2003; 5 Smerage J.B. et al. Mol Oncol. 2013 We are grateful to all the patients who generously volunteered to participate in this study. We thank the TBCRC investigators, research nurses, & study coordinators for their efforts on behalf of the patients. 0 5 10 15 20 We are appreciative of the funding support provided to the TBCRC by its three foundation partners: Months The AVON Foundation Months 7/19 The Breast Cancer Research Foundation 4/14 Susan G. Komen for the Cure HR: 2.38 (95% CI: 1.27-4.45) p=0.007 HR: 2.87 (95% CI: 1.46-5.66) p=0.002 HR: 2/13 We 3.40 thank Veridex/Janssen, (95% CI: LLC, 1.68-6.89) Fashion Footwear Charitable p=0.001 Foundation of 3. No overall difference for PFS according to treatment arm Results New York/QVC Presents Shoes on Sale (DFH), Associazione Sandro Pitigliani and by a studentship from FIRC (CP) for their support. We thank the Susan G. Komen for the Cure and the Triple Negative Breast Cancer Foundation for the funding of the Promise Grant 4. CTC-apoptosis is not more prognostic than CTC counts alone AT BASELINE N= 52 AT BASELINE N= 52

Mutations and Protein Expression comparison between TN and non-tnbc in 5500 BCs ABCS 2013 O Shaughnessy et al. PD4-1, SABCS 2013 2013

Mutations and Protein Expression comparison between TN and non-tnbc in 5500 BCs AR is expressed in 50% of ER- HER2+ and 18% of TNBC Nearly all AR + cases have PI3KCA mutation or PTEN loss suggestive of pathway activation, Combined AR and PI3K inhibition should be evaluated In TNBC but not in ER+ or HER2+ disease, AR expression is associated with decreased Ki67. AR/Ki67 expression similar in primary versus metastatic cases. APC mutations occur in 5% of BC EGFR gene amplification occurs in about 10% of poor prognosis ER+ and 20% of ER- breast cancers O Shaughnessy et al. PD4-1, SABCS 2013

Mutations and Actionable Targets in TNBC Deep sequencing of residual disease in NAC treated TNBC N = 81, 182 oncogenes and tumour suppressor genes Mean depth of coverage was 635 (135-1207) JAK2 amplifications correlate with extreme poor prognosis JAK2 amplification correlates with EMT, TGF-beta and IL-6 overexpression 2013 SABCS 2013

NA Clinical Studies in TNBC Carboplatinum Bevacizumab Everolimus Eribulin Velaparib

SABCS 2013 Geparsixto

Neoadjuvant Chemo plus Carboplatin +/- Bevacizumab in Stage II-III TNBC (Open-Label Phase II CALGB 40603) Paclitaxel 80mg/m 2 wkly x4 ddac x4 Paclitaxel 80mg/m2 wkly x4 Bevacizumab 10mg/kg q2w x 9 Paclitaxel 80mg/m 2 wkly x4 Carboplatin AUC 6 q3w x 4 Paclitaxel 80mg/m 2 wkly x4 Bevacizumab 10mg/kg q2w x 9 Carboplatin AUC 6 q3w x 4 ddac x4 ddac x4 ddac x4 Surgery 4-8 wks after last ddac XRT No adjuvant chemo planned

Neoadjuvant Chemo plus Carboplatin +/- Bevacizumab in Stage II-III TNBC (Phase II CALGB 40603) ABCS 2013 SABCS 2013

Neoadjuvant Chemo plus Carboplatin +/- Bevacizumab in Stage II-III TNBC (Phase II CALGB 40603) SABCS 2013 SABCS 2013

Neoadjuvant Chemo plus Carboplatin +/- Bevacizumab in Stage II-III TNBC (Phase II CALGB 40603) pcr Breast No Carbo Carbo Bev Effect (ypt0/is N any), % (n = 212) (n = 221) No bev (n = 218) 42 53 48 Bev (n = 215) 50 67 59 Odds ratio: 1.58; P =.0089 Carbo effect 46 Odds ratio: 1.76; 60 P =.0018 Carbo/bev interaction P =.52 pcr Breast /Axilla (ypt0/is N0), % No Carbo (n = 212) Carbo (n = 221) Bev Effect No bev (n = 218) 39 49 44 Bev (n = 215) 43 60 52 Odds ratio: 1.36; P =.0570 Carbo effect 41 Odds ratio: 1.71; 54 P =.0029 Carbo/bev interaction P =.43 Sikov WM, et al. SABCS 2013. Abstract S5-01..

CALGB 40603: Safety Select Grade 3 AEs, % Chemo Chemo + Bev Chemo + Carbo Chemo + Carbo + Bev Neutropenia 22 27 56 67 Thrombocytopenia 4 3 20 26 Febrile neutropenia 7 9 12 24 Hypertension 2 12 0 10* Nausea/vomiting 6 6 5 12 Fatigue 10 12 10 20 Treatment discontinued 0 10 6 12 Serious AEs, n Total 15 39 29 46 FN during AC 5 15 10 17 Nausea/vomiting/dehydration 1 5 5 6 Bleeding 0 2 0 5 DVT or PE 1 6 1 4 Infection (normal ANC) 4 10 2 9 GI perforation 0 1 0 1 *1 death due to uncontrolled hypertension. Sikov WM, et al. SABCS 2013. Abstract S5-01.

CALGB 40603: Conclusions Addition of bevacizumab increased pcr in breast but not in breast/axilla Increases in grade 3 hypertension, febrile neutropenia, serious infections, bleeding, thromboembolic and surgical complications Addition of carboplatin increased pcr in breast and breast/axilla Increases in grade 3/4 neutropenia, thrombocytopenia Also increased frequency of paclitaxel dose modifications pcr benefit independent of bevacizumab No interaction between bevacizumab and carboplatin for efficacy Sikov WM, et al. SABCS 2013. Abstract S5-01.

Bevacizumab in Advanced Triple Negative Breast Cancer Stage IV trial Regimen DFS HR (95% CI) ECOG 2100 Weekly Paclitaxel 0.54(0.41-0.7) AVADO Docetaxel 0.68(0.41-1.0) RIBBON-1 CT 0.72(0.49-1.06) Meta-analysis OS CT +/- Bev 0.96(0.79-1.16) Stage IV pretreated RIBBON-2 Chemo +/- Bev 0.494(0.33-0.74) RIBBON-2 OS 0.624(0.39-1.007)

Bevacizumab in Neoadjuvant Triple Negative Breast Cancer Gepar Quinto Gepar Quinto NSABP- 40 NSABP- 40 CALGB CALGB CT CT + B CT CT+B CT CT+B N 340 323 218 215 pcr breast - - 47.1% 51.5% 48% 59% pcr breast + LNN P=0.34 P=0.0089 27.9% 39.3% 23% 27.6% 44% 52% P=0.003 P=0.08 P=0.057

Cisplatin + Paclitaxel ± Everolimus in Patients With Stage II/III TNBC Randomized phase II trial Randomized 2:1 Patients with stage II-III TNBC; primary tumor > 1 cm (N = 145) Cisplatin + Paclitaxel + Everolimus Cisplatin + Paclitaxel + Placebo Surgery Cisplatin 25 mg/m 2 /wk for 12 wks; everolimus 5 mg/day for 12 wks; paclitaxel 80 mg/m 2 weekly for 11 wks starting on Wk 2. Mayer IA, et al. SABCS 2013. Abstract PD1-6.

Response, % Efficacy of Neoadjuvant Everolimus in Patients With TNBC 100 Chemo + everolimus Chemo + placebo 80 60 40 36 40 39 44 20 0 20 12 4 4 pcr Near pcr No pcr Not Evaluable Mayer IA, et al. SABCS 2013. Abstract PD1-6.

Neoadjuvant Carboplatin and Eribulin Mesylate in Patients With Stage I-III TNBC Phase II trial of eribulin (1.4 or 1.1 mg/m 2 IV on Days 1, 8) + carboplatin (6 AUC IV on Day 1) every 3 wks for 8 cycles (N = 30) Total 4 cycles before surgery pcr primary endpoint (RCB secondary endpoint) Eribulin + carboplatin showed activity in TNBC Pathologic complete response: 43.3% (95% CI: 0.25-0.61) Clinical response rate (CR + PR): 80% (95% CI: 0.66-0.94) Response by RCB: RCB 0: 44.8%; RCB I: 0%; RCB II: 51.7%; RCB III: 3.5% Additional analysis suggested association between cytoplasmic CDK2 and pathologic complete response In vitro proliferation assays showed combination effect for eribulin + CDK inhibitor Eribulin and carboplatin showed significant activity and tolerability as neoadjuvant therapy for patients with TNBC Giordano S, et al. SABCS 2013. Abstract P3-14-14.

I-SPY 1 TRIAL (Investigation of Serial Studies to Predict Your Therapeutic Response With Imaging and Molecular Analysis) schema. Esserman L J et al. JCO 2012;30:3242-3249

RFS stratified by pcr for the overall population of patients by BC Subtype Esserman L J et al. JCO 2012;30:3242-3249

2013

2013

I-SPY2: Neoadjuvant Veliparib/Carboplatin + Paclitaxel for Patients With High-Risk BC Veliparib: potent PARP inhibitor First efficacy results for 1 of 7 current experimental arms of the adaptive I-SPY 2 phase II trial Patients with HER2- BC randomized to veliparib + carboplatin + paclitaxel (n = 72) vs paclitaxel (n = 44), followed by 4 cycles AC prior to surgery Biomarker Subtype, % MP Hi-1 MP Hi-2 HR+ HR- HR+ HR- HER2+ -- -- -- - HER2-39 18 9 34 Rugo HS, et al. SABCS 2013. Abstract S5-02.

I-SPY2: Neoadjuvant Veliparib/Carboplatin + Paclitaxel for Patients With High-Risk BC

I-SPY2: Conclusions Adaptive trial design found veliparib/carboplatin treatment efficacious in patients with triple-negative breast cancer Trial not designed to evaluate individual contributions of veliparib and carboplatin Adverse events increased with veliparib/carboplatin regimen Toxicity may be managed with dose reductions and delay I-SPY2 trial design efficiently evaluated treatment regimen in patient subsets based on biomarker analysis Additional response predictors currently under investigation Rugo HS, et al. SABCS 2013. Abstract S5-02.

Enchant-1 Trial Ganetespib Hsp90 inhibitor 150 mg/sqm twice weekly iv 15 pts with TNBC 9 metabolic response 1 PR, 2 SD in 6 evaluable pts Awada et al, P2-16-23