Fabio Calabrò Oncologia Medica
Azienda Ospedaliera San Camillo Forlanini
Tumori Genito-Urinari
Prostate cancer treatment paradigm is evolving
PROSTATE CANCER TREATMENT PARADIGMIS EVOLVING
Clinically
localized Metastatic CRPC
Metatastic non
castrate
AbirateroneEnzalutamide
Radium-223 Cabazitaxel
Sipuleucel-T**
*Not licenced
**USA only
Supportive care (eg
denosumab/bisphosphonates) Docetaxel (if no prior use) ADT + Docetaxel*
ADT + Abiraterone*
Rising PSA
Non metatastic CRPC
Local treatment with curative intent +/- adjuvant RT or RT+ADT
?
?
Advanced prostate cancer consensus conference 2017
Gillesen S, Eur Urol 2017
Prostate cancer treatment paradigm is evolving
Year Trial/Treatment/Setting mOS
1990 Prednisone M1 mCRPC 12.6
2004 TAX 327 Docetaxel prednisone M1 CRPC 18.9
2010 TROPIC/Cabazitaxel M1 CRPC 29.4
2011 COU-AA-301 Abiraterone post docetaxel M1 CRPC 32.6 2013 COU-AA-302 Abiraterone pre docetaxel M1 CRPC 34.7 2014 PREVAIL Enzalutamide pre docetaxel M1 CRPC 35.3
2015 CHARTEED (ADT + docetaxel M1 HSPC 57.6
2016 STAMPEDE ADT + Docetaxel M1 HSPC 65
2017 LATITUDE STAMPEDE ADT + Abiraterone M1 HSPC nr
Prostate cancer treatment paradigm is evolving
Why Did Patients Live So Long?
Ryan C, Lancet Oncol. 2015; Beer TM, N Engl J Med. 2014
Subsequent Therapy 2
ENZA (n = 872)
Placebo (n = 845)
N (%) with ≥1 subsequent life-extending therapy
457 (52.4%) 685 (81.1%)
Subsequent therapies
Docetaxel 358 (41.1%) 504 (59.6%) Abiraterone acetate 256 (29.4%) 417 (49.3%) Cabazitaxel 79 (9.1%) 149 (17.6%) Enzalutamide* 21 (2.4%) 249 (29.5%) Sipuleucel-T 17 (1.9%) 11 (1.3%)
Radium-223 16 (1.8%) 22 (2.6%)
Subsequent Therapy1
ABI + P (n=546 )
P (n=542) N (%) with selected
subsequent therapy 365 (67%) 435 (80%) Subsequent therapies
Abiraterone 69 (13%) 238 (44%) Cabazitaxel 100 (18%) 105 (19%) Docetaxel 311 (57%) 331 (61%) Enzalutamide 87 (16%) 54 (10%) Ketoconazole 42 (8%) 68 (13%)
Radium-223 20 (4%) 7 (1%)
Sipuleucel-T 45 (8%) 32 (6%)
a. Prometaphase b. Metaphase
c. Anaphase d. Telophase
Taxanes stabilize microtubules leading to cell-cycle arrest in metaphase-anaphase
Jordan & Wilson. Nature Reviews Cancer 2004
Normal cell cycle
Taxanes
Taxanes stabilize microtubules,
inhibit disassembly and inhibitboth ligand-dependent and ligand independent AR transcriptional activity
AR blockade induce proliferation of AR independent clones
AR-BLOCKADE INDUCE PROLIFERATION OF AR- INDEPENDENT CLONES
Isaacs J et al, The prostate 1984; 5: 1-17
Isaac J, The prostate 1984
Intratumor heterogeneity
Intratumor heterogeneity
Broutos PC, Nat Genetics 2015
SWOG Trial 9346
Hussain M, J Clin Oncol 2006, NEJM 2013
A PSA of 4 ng/mL or less after 7 months of AD is a strong predictor of survival
Halabi S, J Clin Oncol 2014
Prognostic tools
Halabi S, J Clin Oncol 2014
Prognostic tools
Many Nomograms are available
Is an old story
Dawson NA, J Clin Oncol 1998
Author Year published
N pts Duration of 2
ndtreatment
PSA
≥ 50%
Median PFS
ENZ ABI
Loriot et al. 2013 38 3 mo 8% 2.7 mo
Noonan et al. 2013 30 13 wks 3% 3.6 mo
ABI ENZ
Schrader et al. 2013 35 4.9 mo 29% -
Badrising et al. 2014 61 3 mo 21% -
Bianchini et al. 2014 39 2.9 mo 23% -
Schmid et al. 2014 35 2.8 mo 10% -
Brasso et al. 2014 137 3.2 mo 18% -
Cross-resistance between AR-targeted agents
Only retrospective evidence
Integrative landscape analysis of somatic and germline aberrations in mCRPC
90% of mCRPC harbor clinically actionable
molecular alterations
20% of mCRPC harbor DNA repair pathway aberrations
8% harbor germline mutations
Robinson D, Cell. 2015
Distribution of Presumed Pathogenic Germline Mutations
Pritchard CC et al. N Engl J Med 2016;375:443-453
Shown are mutations involving 16 DNA-repair genes
Pritchard, N Engl J Med 2016
Defects in DNA repair genes associated with PARP inhibitor sensitivity
49 heavily pretreated mCRPC men
PARP inhibitor (olaparib 400 mg BID)
Genomic signature of PARP inhibitor sensitivity in 16/49 (33%) pts
BRCA2, ATM, BRCA1, PALB2, CHEK2, FANCA, HDAC2
Response to PARP in 14/16
Mateo J et al. New Engl J Med. 2015
The begin at the beginning
Yang JC, NEJM 2003
An Era of discovery in RCC
Immunotherapeutic strategies in mRCC
Clinical experience
CTLA-4-directed antibodies. Ipilimumab — a mono- clonal antibody against CTLA-4 — was the first check- point inhibitor to be tested in large-scale trials. It received FDA approval for the treatment of melanoma in 2011, after patients demonstrated superior overall survival in a phase III trial with either ipilimumab alone or in com- bination with the peptide gp100 vaccine compared with vaccine alone33. During its early clinical development, ipilimumab was evaluated for the treatment of advanced RCC. In a phase II trial, 61 patients were treated in one of two dosing cohorts (high or low) for up to 1 year, unless tumour progression or limiting toxicity was observed34. Response rates were 12.5% and 5% in the high-dose and low-dose cohorts, respectively. No complete responses or durable regressions were seen, in contrast to the experi- ence in patients with melanoma. Higher toxicities were recorded for patients in the high-dose group than the low- dose group: 43% of these participants had grade 3, 4, or 5 toxicities compared with 18% for the low-dose group.
Of note, a highly significant positive correlation between development of autoimmune toxicities and response was reported. The response rate for those who experienced toxicities was 30%, compared with 0% of those who did not experience toxicities (P <0.001). This correlation was only observed in a small cohort of patients, but could be important and should be further evaluated in larger phase III trials of checkpoint inhibitors in RCC. Some of the increased toxicity might be attributed to the dos- ing schedule used in this early study — nearly half of the patients who developed toxicities did so after five or more doses. In the phase II studies investigating ipilimumab for melanoma a total of four doses were used, which is now
the widely practiced dosing regimen. Given the improved adverse-effect profile and efficacy of the newer PD-1 inhibitors, CTLA-4 antibody monotherapy in RCC has been largely abandoned in favour of combination trials with other checkpoint inhibitors35.
PD-1-directed antibodies. Nivolumab — a monoclonal antibody that blocks the PD-1 pathway — is the first checkpoint inhibitor to demonstrate a survival benefit in patients with metastatic RCC (TABLE 1). Motivated by the encouraging overall survival results of a dose-ranging phase II nivolumab trial, CheckMate 025 was designed as a phase III, open-label study comparing nivolumab with everolimus in patients with advanced RCC who had failed an anti-VEGF therapy, with overall survival as the primary end point36,37. A total of 821 patients were randomly assigned 1:1 to receive 3 mg/kg of nivolumab every 2 weeks (selected on the basis of its safety and efficacy profile in multiple tumour types) or 10 mg of everolimus daily.
The study was stopped after a prespecified interim analysis determined that the primary end point had been reached. The median overall survival was 25 months for nivolumab and 19.6 months for everolimus37. The over- all survival benefit of nivolumab was present irrespective of Memorial Sloan Kettering Cancer Center risk group, number of previous therapies, or PD-L1 tumour expres- sion level. The objective response rate (ORR) was also higher with nivolumab than everolimus (25% versus 5%), but complete responses were rare — only 1% for nivolumab and <1% for everolimus. Interestingly, the median progression-free survival was similar in both groups (4.6 months for nivolumab and 4.4 months for
Nature Reviews | Urology Single peptide
• TroVax®
• TG4010 Dendritic cell
• AGS-003 Multipeptide
• IMA901
CAR T cells CIK cells
Cytokines
• IL-2
• IFN-g
• IL-21
Agonist antibodies
• CD137
• OX40
• CD27
• GITR CTLA-4 inhibitors
• Ipilimumab
• Tremelimumab PD-1 inhibitors
• Nivolumab (FDA approved)
• Pembrolizumab
• Pidilizumab PD-L1 inhibitors
• Atezolizumab
• BMS-936559
• Durvalumab
• Avelumab
T-cell agonists Adoptive T-cell therapy
Vaccines Checkpoint inhibitors
Novel immunotherapies being studied for renal cell carcinoma
Figure 1 | Selected immune therapies under investigation for renal cell carcinoma (RCC). Checkpoint inhibitors under investigation include the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) inhibitors ipilimumab and
tremelimumab, the programmed cell death protein 1 (PD-1) inhibitors nivolumab (which is FDA approved),
pembrolizumab and pidilizumab, and the programmed cell death 1 ligand 1 (PD-L1) inhibitors atezolizumab, BMS-936559, durvalumab, and avelumab. Vaccine strategies investigated in RCC include the single peptide vaccines TroVax® and
TG4010, the dendritic cell vaccine AGS-003, and the multipeptide vaccine IMA901. Adoptive T-cell therapies such as chimeric antigen receptor (CAR) T cells and cytokine-induced killer (CIK) cells are also being investigated. Multiple T-cell agonists have been or are being studied, including the cytokines IL-2, IFNγ, and IL-21, as well as agonist antibodies to the co-stimulatory molecules CD137, OX40, CD27 and GITR.
REV I EW S
422 | JULY 2016 | VOLUME 13 www.nature.com/ nrurol
Combinatorial explosion
Ledford H, Nature 2016
First Line Phase III Trials
Eligibility:
• Locally advanced or mRCC
• Previously untreated with any systemic therapy
• Karnofsky PS ≥70 Sunitinib
50 mg PO daily, 4 weeks on/2 weeks off
Phase III N=1070 CheckMate214 - NCT02231749: Combination PD-1 + CTLA-4 inhibition
RANDOMIZATION
• Co-Primary endpoint: PFS, OS
Eligibility:
• Locally advanced or mRCC with
clear-cell and/or sarcomatoid component
• Previously untreated with any systemic therapy
• Karnofsky PS ≥70 Sunitinib
50 mg PO daily, 4 weeks on/2 weeks off
Phase III N=900 IMmotion 151 - NCT02420821: Combination PD-L1 + VEGF inhibition
RANDOMIZATION
• Co-Primary endpoint: PFS, OS
Eligibility:
• Locally advanced or mRCC with clear cell component
• Previously untreated with any systemic therapy
• Karnofsky PS ≥70 Sunitinib
50 mg PO daily, 4 weeks on/2 weeks off
Phase III N=583 Javelin Renal 101 - NCT02684006: Combination PD-L1 + VEGFR TKI
RANDOMIZATION
• Primary endpoint: PFS
Nivolumab + Ipilimumab
3mg/kg IV + 1mg/kg IV every 3 weeks X4
then Nivolumab 3mg/kg IV q2w
Atezolizumab + Bevacizumab 1200 mg IV +
15 mg/kg IV q3w
Avelumab + Axitinib 10mg/kg IV q2w
+ 5mg PO BID
First Line Phase III Trials
Eligibility:
• Advanced/mRCC, predominantly clear cell histology
• Previously untreated with any systemic therapy
• Karnofsky PS ≥70 Sunitinib
Phase III N=450 ADAPT - NCT01582672: Autologous Dendritic Cell Vaccine
RANDOMIZATION
• Primary endpoint: OS Eligibility:
• Advanced/mRCC with clear cell component
• Previously untreated with any systemic therapy
• Karnofsky PS ≥70
Sunitinib
50 mg PO daily, 4 weeks on/2 weeks off
Phase III N=840 KEYNOTE 426 - NCT02853331: Pembrolizumab + Axitinib
RANDOMIZATION
• Co-Primary endpoint: PFS, OS
Pembrolizumab + Axitinib 200 mg IV every 3 weeks +
5 mg PO BID
Eligibility:
• Advanced/mRCC with clear cell component
• Previously untreated with any systemic therapy
• Karnofsky PS ≥70 Sunitinib
50 mg PO daily, 4 weeks on/2 weeks off
Phase III N=735 NCT02811861: Lenvatinib + Everolimus or Pembrolizumab
RANDOMIZATION
• Primary endpoint: PFS
Lenvatinib + Everolimus 18 mg PO daily +
5 mg PO daily
Lenvatinib + Pembrolizumab 20 mg PO daily +
200 mg IV q3w
AGS-003
8 intradermal injections in first year followed by quarterly boosters
Nuzzo R. Nature 2014
Management of metastatic UC until 2016
Management of metastatic UC until 2016
Cisplatin-eligible patients Cisplatin-ineligible patients
Dose-dense MVAC
Cisplatin- gemcitabine
Carboplatin- gemcitabine
Single-agent Or BSC
First-line metastatic urothelial cancer
Platinum-resistant metastatic urothelial cancer
No standard chemotherapy: Vinflunine and taxanes are options
How do these data translate in clinical practice? How do these data translate in clinical practice in the moving landscape of mUC ?
FDA approval EMA approval
Atezolizumab
Pembrolizumab (benefit on OS) Nivolumab
Avelumab Durvalumab Atezolizumab Pembrolizumab
Nivolumab Atezolizumab pembrolizumab 1st line
2nd line
Atezolizumab
pembrolizumab
Open questions and problems with immunotherapy
FDA approvals
Lack of predictive biomarkers
Treatment beyond progression
Hyperprogressive disease
Treatment option for patients who progress on CPI
Trial design and interpretation
ORR by PD-L1 status
Drug Phase setting n PD-L1
definition
ORR in favorable
ORR in negative
CR %
Atezolizumab 1 Post DDP 67 IC 2/3 43% 11% 7/0
Atezolizumab 2 Post DDP 315 IC 2/3 28% 11% 11/2
Atezolizumab 2 DDP unfit 119 IC2/3 28% 21% 3/5
Atezolizumab 3 Post DDP 912 IC 2/3 23% NR 8/0
Nivolumab 1/2 Post DDP 78 PD-L1>1% 24% 26% 1/4
Nivolumab 2 Post DDP 270 PD-L1>1% or 5%
23% 16% 4/0
Durvalumab 1 Post DDP 61 PD-L1 TC or IC
>25%
46% 0 NR
Avelumab 1b Post DDP 44 PD-L1>5% 25% 13% NR
Pembrolizumab 1b Post DDP 33 PD-L1>1% in TC 14% 27% NR
Pembrolizumab 2 DDP unfit 100 CPS>10% 51% 23% 13/5
Pembrolizumab 3 Post DDP 542 CPS> 10% 20% NR 8/NR
Outcome by subtypes
Drug Phase Setting n Better results in
Atezolizumab 1 Post DDP 67 ECOG PS=-1, smokers, no visceral mets
Atezolizumab 2 Post DDP 315 ECOG PS 0, LN only, high mutational load, Luminal II TCGA
Atezolizumab 2 DDP unfit 119 Upper tract, LN only, perioperative CT, TCGA luminal
Atezolizumab 3 Post DDP 912 Current smoker, urethra primary, LN only
Nivolumab 1/2 Post DDP 78 No visceral mets, LN only, Hb > 10
Nivolumab 2 Post DDP 270 Basal I and luminal II, 25 genes IGN gamma signature
Avelumab 1b Post DDP 44 No viscetal mets, HB > 10, > 3 lines of CT
Pembrolizumab 2 DDP unfit 100 Liver mets, upper tract, visceral disease, T cell inflamed GEP signature
Pembrolizumab 3 Post DDP 542 Current smokers, PS=2, LN only,
preoperatiove CT
Association among TCGA subtype, mutation load and clinical activity
C: Mutation load as a fuction of response D: Mutation load versus response disaggregated by subtype or PD-L1 IC score
E: Kaplan-Meier estimate of overall survival according to
estimated mutation load (per megabase), binned into quartile (log-rank p=0.0041for a difference in overall survival between quartiles 1-3 and quartile 4
Balar AV et al., Lancet. 2017
Predictors of response to Atezolizumab Predictors of Response to Atezolizumab
• PD-L1 IHC, TCGA subtype and mutation load were significant independent
predictors of response
• PD-L1 IC + subtype combination
significantly improved on PD-L1 IC alone or subtype alone
• 3-biomarker combination
significantly improved on PD-L1 IC + subtype combination
• These data highlight the importance of the interaction between the tumor and its microenvironment in understanding response to atezolizumab
PD-L1 IC
P = 0.0109
TCGA Subtype
P = 0.0384
Mutation Load
P < 0.0001
P = 0.0229 P = 0.0057
P = 0.0005
P = 0.0935
Based on data cutoff: March 14, 2016.
Rosenberg J, et al. IMvigor210: biomarkers of atezolizumab in mUC. ASCO 2016 PD-L1 IC
+ TCGA Subtype
PD-L1 IC + TCGA Subtype + Mutation Load
Rosenberg J. ASCO 2016
Outcome of Patients Treated Beyond Progression
(n=134)
Subsequent reductions in target lesion SLD were seen in patients treated with atezolizumab beyond progression, highlighting the potential the potential for non -classical responses
Patients without post-PD baseline tumor assessments (n = 29) are not included in plot. Data cutoff: March 14, 2016.
Dreicer R, J Clin Oncol 2016 In patients treated beyond PD
•19% (26/134) had SLD reductions ≥ 30% in target lesions
•28% (38/134) had disease stabilization (> -30% to +20% SLD change)
•mOS was 11.4 mo in all patients treated beyond progression
•12-mo OS was 50% in all patients treated beyond progression
•The safety of atezolizumab was consistent with that in the ITT population
Hyperprogressive disease
Champiat S, Clin Cancer Res 2016
10%
Not associated with higher tumor burden
Associated with increased age
Worse outcome
Slower growing tumors less likely to respond
Immunotherapy combinations in urothelial cancer
Study Arms Line of
therapy
n Phase
IMvigor 130 Atezolizumab vs atezolizumab + platinum based CT vs platinum based CT
1st 1200 3
KEYNOTE 361 Pembrolizumab +/- platinum based combination CT vs CT 1st 990 3 BISCAY Durvalumab +/- targeted agent matched to tu or profile
FGFR, PARP, PI3K inhibitor
1, 2, 3 140 1b/2
NCI Nivolumab + Cabozantinib +/- ipilimumab 2nd 66 1/2
BMS CA224-020 Anti-LAG3 +/- nivolumab 2nd 30 1
Celldex CDX1127- 06
Varlilumab + atezolizumab 2nd 55 1
CORVUS CPI-444- 001
CPI-444 +/- atezolizumab 2nd 534 1
PsiOxus
Therapeutics
Enadenotucirec (oncolytic virus) + nivolumab 2nd 30 1
Yale Ramuvirumab + pembrolizumab 2nd 155 1
Plexxicon CSF1R, KIT or FLT3 inhibitor + pembrolizumab 2nd 400 1/2
USC Pembrolizumab + sEphB4-HSA 2nd 60 2
Multiple factors influence tolerance and immunity
Chen DS and Mellman I, Nature 2017
Factors influencing the cancer-immune set point
Chen DS and Mellman I, Nature 2017
A stochastic process
Cancer evolution
Mutation, selection and drift
Lipinski KA, Trends in Cancer 2016