Farmacogenetica germinale

Oncologia di precisione

Roma, 24 - 25 maggio 2019

Farmacogenetica germinale

Giuseppe Toffoli, MD

CRO – IRCCS, Aviano

Roma 24-25 maggio 2019

Adverse Drug Reactions

in pharmacological treatment

 Over 2 millions ADRs yearly in US, 100,000 resulting in death (Inst Med, Nat Acad Press, 2000)

 They are estimated to cost £1 billion in UK (Pirmohamed, Br Med J, 2004), and $4 billion annually in the US (Lazarou J et al, JAMA, 1998)

 A revision of 4,158 patients treated for mCRC in the US in 2014 pointed out

that about 90% developed at least one ADR after the first cycle (66%>1 AE

category) with a significant economic burden mainly related to severe

hematological AE related to chemotherapy (Latremouille et al, J Med Economics,

2016)

https://www.pharmgkb.org/

https://cpicpgx.org/guidelines/

B A C K G R O U N D

29° CONGRESSO NAZIONALE SOCIETA' ITALIANA

di CHEMIOTERAPIA, TRIESTE 23-24 NOV. 2018

“Pharmacogenetics” in

PubMed

•TPMT/ 6-mercaptopurine

•UGT1A1*28/ irinotecan

•DPYD/ fluoropyrimidines

•CYP2D6/ tamoxifen Gene-drug interactions currently included in the PGx guidelines

for oncology

Roma 24-25 maggio 2019

This prospective clinical study shows no association between endoxifen concentrations or CYP2D6 genotypes and clinical outcome in 662

patients with early-stage breast cancer receiving adjuvant tamoxifen

1 . N E L L A R I C E R C A C L I N I C A 2 . N E L L A P R A T I C A C L I N I C A 3 . F A R M A C O E C O N O M I A

Implementazione farmacogenetica

Roma 24-25 maggio 2019

Phase 1b studies based on the patient genotype for re-definition of Maximun Tolerated Dose (MTD)

•Registrative phase 1 studies for

FOLFIRI regimen did not take patients genotype into account

•A re-definiton of proper irinotecan dose for *1/*1 or *1/*28 patients by genotype is requested

5’ Exon 1 2 3 4 3’

-53 (TA)nTAA (UGT1A1*28)

5

Genotyping for UGT1A1 *28 Stratification into two groups

GROUP 1:

UGT1A1 *1/*1

WILD TYPE PTS GROUP 2:

UGT1A1 *1/*28

HETEROZYGOUS PTS

Phase I clinical trial of irinotecan: Protocol design

Eligible mCRC patients

Patients with *28/*28 genotype excluded.

Phase 1b studies based on the patient genotype for re-definition of MTD: the study design

IRI dose escalation IRI dose escalation

Clinical and pharmacokinetic monitoring

Roma 24-25 maggio 2019

*1/*28genotype, Dose (mg/m

)

Phase 1b studies based on the patient genotype for re-definition of MTD: the results

Therapy

FOLFIRI, standard dose

FOLFIRI

FOLFIRI plus BEVACIZUMAB

*1/*1 genotype, Dose (mg/m

)

180

370

310

180

310

260

Ducreux et al, J Clin Oncol, 1999

Toffoli et al, J Clin Oncol , 2010

Toffoli et al, Clin Cancer Res, 2017

The interaction with bevacizumab

is unlikely to be related to a PK interaction

Roma 24-25 maggio 2019 Toffoli et al, Clin Cancer Res, 2017

The stratification of patients

in FOLFIRI or FOLFIRI plus

bevacizumab regimens

according to UGT1A1*28

genotype led to a higher

MTD both in UGT1A1*1/*28

and UGT1A1*1/*1 patients.

85 su 95 pts (89%) patients with G3-5 toxicity are not carriers of any of the 3 DPYD SNPs (*2A, *13, 2846A>T)

Nuove strategie per la farmacogenetica: varianti rare

Kozyra et al., Genetics in Medicine 2016

Rare and novel variants can significantly contribute to inter-

patients variability

Preliminary Results II-DPYD novel and rare variants

Variant Rs Location Functional Consequences

Freq

ExAC_NFE Observed Toxicity c.G345C p.M115I rs377169736 Exon5 Missense 0,0001 G4 Non Hematologic

c.G481A p.E161K / Exon5 Missense / Splice / G4 Hematologic

c.C800T p.T267I / Exon 8 Missense / Splice / G3 Non Hematologic

c.G958A p.G320R / Exon9 Missense / Splice / G4 Hematologic

c.A1110G p.I370M / Exon 10 Missense / Splice / G4 Non Hematologic c.C1579T p.P527S / Exon13 Missense / Splice / G3 Non Hematologic c.A2137G p.N713D rs773407491 Exon 17 Missense 0.000008247 G4 Non Hematologic

c.*431A>G / UTR3 / / G4 Hematologic

c .-416A>G / Upstream / / G4 Non Hematologic

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

5’UTR 3’UTR

A110G G481A A1110G C1579T A2137G *431A>G

G9858A

G345C C800T

PARADIGM SHIFT IN CANCER THERAPY

Knowledge of tumor dependencies and immunologic vulnerabilities

CRO

Int. J. Mol. Sci. 2017, 18, 1366; doi:10.3390/ijms18071366

PGx studies

Immunosystem

Exploratory research of new genetic markers of treatment sensitivity:

the immunogenetic approach

Roma 24-25 maggio 2019

Significant associations between HLA-G 3’UTR haplotypes and G3-4 toxicities

Immunogenetic germline variants can interact with the effect of chemotherapy and

identify profiles of pateints at high risk of severe

rs4143815- PDL1 and 10-year Biochemical Recurrence (BCR)

Immunogenetic Biomarker of Biochemical

Recurrence in Locally Advanced Prostate Cancer after Radiotherapy.

Roma 24-25 maggio 2019

Int J Mol Sci. 2019 Apr 27;20(9) C. Zanusso C. ……and G.Toffoli

549 Cancer

Prostate patients treated with

Radiotherapy

*

*

*

SNPs on TGF-β PATHWAY SCORE predicts Overall Survival

SNPs significantly associated with OS and involved in TGF-β pathway:

230 ovarian cancer pts treated with Platinum-based therapy

FSC Unpublished data

Score legend

0-2 unfavorable genotypes 3 unfavorable genotypes 4 unfavorable genotypes 5 unfavorable genotypes 6 unfavorable genotypes 7-8 unfavorable genotypes Log-rank test

(months)

BRCA mutations and treatment of ovarian cancer

 OC of BRCA origin are more sensitive to platinum based chemotherapy than sporadic OC cases

 Pegylated liposomal doxorubicin is active in

BRCAm OC (Kaye SB et al. J. Clin. Oncol. 2012)

 PARP inhibitors are active in BRACAm OC

1 . N E L L A R I C E R C A C L I N I C A 2 . N E L L A P R A T I C A C L I N I C A 3 . F A R M A C O E C O N O M I A

Implementazione

farmacogenetica

UGT1A1-Irinotecan

5’ Exon 1 2 3 4 3’

-53 (TA)nTAA (UGT1A1*28)

5

An impaired SN38 detoxification by an UGT1A1*28 polymorphic form increases the risk of acute severe toxicity

*1/*1 or *1/*28 patients have lower toxicity than *28/*28

Roma 24-25 maggio 2019

OUR RESULTS ON HAPLOTYPE II (as reported by us, all “defective” UGT1A allelesWERE REPLICATED IN

AN INDEPENDENT COHORT OF 167 CANADIAN mCRC PATIENTS TREATED WITH FOLFIRI- BASED

REGIMENS.

Our hypothesis external validation in collaboration with Universitè Laval-Quebec

UGT1A HAPLOTYPES

UGT1A1 UGT1A7 UGT1A9

*93 *60 *28 *2 *4 *22 Allelic frequency

I *1 *1 *1 G T *22 34.2%

II *93 *60 *28 T C *1 23.2%

III *1 *1 *1 G T *1 14.4%

IV *1 *60 *1 G T *1 4.6%

others 23.0%

DPYD-Fluoropyrimidines



5-FU bolus



5-FU infusion – 24 hrs – 48 hrs – 46 hrs – 120 hrs – ∞ hrs



LV + 5-FU



5-FU + LV



5-FU + Lev



5-FU + everything



………

5-FU for 40 Yrs

•FL are the mainstay of many

chemotherapeutic schemes in different combination for different pathologies and settings

•10 to 26% of patients experiencing acute severe or life-threatening toxicity even in monotherapy regimens (Twelves. N. Engl.

J. Med., 352, 2005)

Roma 24-25 maggio 2019

DPYD*2A DPYD*13

c. 1236 G>A / Hap B3

DPYD pharmacogenetics

Clinical validity of a DPYD-based pharmacogenetic test to predict severe toxicity to fluoropyrimidines.

Toffoli G, Giodini L, Buonadonna A, Berretta M, De Paoli A, Scalone S, Miolo G, Mini E, Nobili S, Lonardi S, Pella N, Lo Re G, Montico M, Roncato R, Dreussi E, Gagno S, Cecchin E

.

 603 solid cancer patients treated with FL-based regimen

 Clinical End-Point: Severe (≥G3) or lethal toxicity related to FL administration

Roma 24-25 maggio 2019 Genotype

Total N

Toxicity

G≥3

n (%) OR 95% CI² p³

DPYD-rs3918290 (*2A)

GG 591 87 (14.7) 1

AG 12 8 (66.7) 12.6 2.9-51.0 0.003

DPYD-rs67376798 (2846 A>T)

AA 583 92 (15.8) 1

AT 5 3 (60.0) 7.8 1.5-41.8 0.048

• Frontline genotyping could have allowed the identification of 10 patients at risk for severe toxicity and 1 toxic death (11.6% of severe toxic events)

• The patient with toxic death was compound

heterozygous for DPYD*2A, and DPYD*13 and

was treated in an adjuvant regimen for gastric

cancer

DPWG pharmacogenomics recommendations

Henricks et al, Pharmacogenomics, 2015

FP dose reduction in DPYD*2A patients- is the treatment still effective?

40 heterozygous DPYD*2A carriers, treated with a ~50% reduced FP dose, were identified. A matched pair- analysis was performed in which for each DPYD*2A carrier a DPYD*2A wild-type patient was identified.

DPYD*2A genotype-guided dosing appears to have no negative effect on

effectiveness of FP-based

chemotherapy, while resulting in significantly improved

patient safety.

Henricks LM et al., Int J Cancer, 2019

Roma 24-25 maggio 2019

Raccomandazioni

Farmaco Gene Polimorf SIF-AIOM CPIC DPWG

Irinotecano UGT1A1 *28 *28/*28: ridurre la dose del 30%;

*1/*28: 100% della dose

Nessuna linea guida presente *”28/*28: ridurre la dose del 30%;

*1/*28: 100% della dose

Fluoropirim DPYD *2A,

*13,

c.2846 A>T, HapB3 (solo per CPIC e DPWG)

PM (allele variante/allele

variante): selezionare un farmaco alternativo;

IM (*1/allele variante): riduzione dose del 50%; .

PM (allele variante/allele variante): selezionare un farmaco alternativo;

IM: (*1/allele variante):

riduzione dose del 50%.

Sulla base del “gene activity score”

riduzione dal 25% al /75%

Allele *2A e *13 in combinazione omozigosi selezionare un farmaco alternativo

Tiopurine TPMT Es. *2, *3A,

*3B, *3C

PM: riduzione dose del 90% e titolare successivamente in base a tollerabilità.

IM: riduzione dose del 50% .

PM (allele variante/allele variante): riduzione dose del 90%, 3 somministrazioni a settimana;

IM (*1/allele variante):

riduzione dose del 30-50%.

PM (allele variante/allele variante):

riduzione dose del 90% o selezionare un farmaco alternativo ;

IM(*1/allele variante): riduzione dose del 50% o selezionare un farmaco alternativo.

Tamoxifene CYP2D6 varianti, delezione gene, duplicazion e gene

PM: incremento di dose; evitare la cosomministrazione di farmaci inibitori di CYP2D6 ;

IM: evitare la

cosomministrazione di farmaci inibitori di CYP2D6.

PM: selezionare un’alternativa (inibitori aromatasi);

IM: selezionare un’alternativa (inibitori aromatasi) o

aumentare il dosaggio del 100%;

PM: selezionare un’alternativa (inibitori aromatasi);

IM: selezionare un’alternativa (inibitori aromatasi) .

CRO AVIANO

Spreading of UGT1A1*28 pre-emptive genotyping to increase irinotecan safety is still limited. The definition of the cost consequences of patients genotype is one of the pending issues. A survey of the toxicity associated costs in 243 FOLFIRI treated mCRC

Roma 24-25 maggio 2019

The genotype for DPYD risk variants in colorectal cancer patients and the related toxicity management costs in clinical practice Analysis on 550 patients from everyday clinical practice

4-SNP Panel

Status n

Mean (Euros) 95% CI

Non-carriers 513 817 779-854

Carriers (at least 1 allele) 37 2,972 2,456-3,505 p<0.0001 GENE ACTIVITY SCORE

2 513 825 785-864 -

1.5 28 2,188 1,683-2,693

1 9 5,414 2,268-8,561 -

0 - - - p<0.0001

Cycle

1 2 3 4 5 6 7 8 9 10 11 12

Patients (%)

0 10 20 30 40

Non-carriers Carriers

A) B)

Cycle

1 2 3 4 5 6 7 8 9 10 11 12

Patients (%)

0 5 10 15 20

Carriers Non-carriers

Most of the costs are related to hospitalization (grade 4 toxicity).

The risk of grade 4 toxicity is DPYD allele dependent HOSP-related tox

Any costly tox

FUTURE PERSPECTIVES

 DRG represents the basis for hospital payment systems in many western countries.

 The introduction of DRG-based payment has been claimed to reduce the quality of care in many European countries because high-cost outlier cases are not properly taken into account.

 PGx profiling for the DRG-based reimbursement system could deliver a more

precise and efficient care that could be ultimately functional to save costs.

Coordinated by Leiden University-Prof HJ Guchelaar

PAESI BASSI

ITALIA

UK

SPAGNA SLOVENIA

GRECIA AUSTRIA

Experimental and Clinical Pharmacology Director Giuseppe Toffoli

Pgx group:

Erika Cecchin

Francesco Angelini, Alessia Bignucolo, Francesco Comello, Lisa Dal Cin, Chiara Dalle Fratte, Elena De Mattia, Tania Di Raimo, Eva Dreussi, Fabrizio Ecca, Marica Garziera, Michela Guardascione , Silvia Mezzalira, Loredana Romanato,

Rossana Roncato, Franca Sartor

Quebec University- Prof Chantal Guillemette University of Chapel Hill- Prof Federico Innocenti

Acknowledgements

Univ of Padova- Istituto Oncologico Veneto

Univ di Trieste- Burlo Garofolo- Prof G De Corti, Prof G Stocco Univ of Florence- Prof E Mini, Dr S Nobili

Hospital San Filippo Neri –Roma- Dr. M D’Andrea Hospital Ca Foncello- Treviso- Dr. A Favaretto U-Pgx European

van der Wouden CH, Cambon-Thomsen A, Cecchin E, Cheung K, Dávila-Fajardo CL, Deneer VH, Dolžan V, Ingelman-Sundberg M, Jönsson S, Karlsson MO, Kriek M, Mitropoulou C, Patrinos GP, Pirmohamed M, Samwald M, Schaeffeler E, Schwab M,

Steinberger D, Stingl J, Sunder-Plassmann G, Toffoli G, Turner RM, van Rhenen MH, Swen JJ

CRO AVIANO