Molecular Basis of Lung Cancer Therapy

James R. Rigas Comprehensive Thoracic Oncology Program

Traditional View of Lung Cancer

Small Cell Large Cell

Adenoca Squamous

Presentation

• • • •

EGFR mutations

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RADIANT adjuvant results in EGFR mutations

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Uncommon EGFR mutations

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Resistance in EGFR mutations (+) patients ALK gene rearrangements

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Resistance in ALK gene rearrangement (+) patients BRAF mutations Other mutations, fusions and amplifications

Locations and Types of the 134 EGFR Gene Mutations Detected in Lung Cancers

Shigematsu H et al. JNCI J Natl Cancer Inst 2005;97:339-346

Journal of the National Cancer Institute, Vol. 97, No. 5, © Oxford University Press 2005, all rights reserved.

Del 19 T790M L858R

EURTAC Study Design

     Stage IIIB/IV NSCLC

EGFR

exon 19 deletion or exon 21 L858R mutation (DNA sequencing/Genescan and Taqman) Chemonaive ECOG PS 0 –2 Measurable or evaluable disease

R

Erlotinib 150 mg/day

Stratification

• Mutation type • ECOG PS (0 vs 1 vs 2) Platinum-based doublet chemotherapy q3wks x 4 cycles* •

Primary endpoint

Progression-free survival (PFS) US FDA approval May 14, 2013 Cobas ® EGFR Mutation Test 41 mutations in Exons 18, 19, 20 and 21

Secondary endpoints

• Objective response rate • Overall survival (OS) • Location of progression • • Safety

EGFR

mutation analysis in serum • Quality of life ECOG = Eastern Cooperative Oncology Group; PS = performance status; PD = progressive disease *Cisplatin 75mg/m 2 d1 / docetaxel 75mg/m 2 d1; cisplatin 75mg/m 2 d1 / gemcitabine 1250mg/m 2 d1,8; carboplatin AUC6 d1 / docetaxel 75mg/m 2 d1; carboplatin AUC5 d1 / gemcitabine 1000mg/m 2 d1,8 PD PD

Primary endpoint: PFS in ITT population (updated analysis 26 Jan 2011)

1.0

0.8

0.6

Erlotinib (n=86) Chemotherapy (n=87)

HR=0.37 (0.25

–0.54) Log-rank p<0.0001

0.4

0.2

0 0 3 5.2

6 Patients at risk Erlotinib Chemo 86 87 63 49 Data cut-off: 26 Jan 2011 54 20 9 9.7

12 15 18 Time (months) 21 32 8 21 5 17 4 9 3 7 1 24 4 0 27 2 0 30 2 0 33 0 0 US FDA approval May 14, 2013

Study design

Stage IIIB (wet)/IV lung adenocarcinoma (AJCC version 6) EGFR mutation in tumor (central lab testing; Therascreen EGFR29* RGQ PCR) Randomization 2:1

Stratified by: EGFR mutation (Del19/L858R/other) Race (Asian/non-Asian)

Afatinib 40 mg/day † Cisplatin + Pemetrexed

75 mg/m 2 + 500 mg/m 2 i.v. q21 days, up to 6 cycles

Primary endpoint: PFS (RECIST 1.1, independent review) ‡

Secondary endpoints: ORR, DCR, DoR, tumor shrinkage, OS, PRO § , safety, PK *EGFR29:19 deletions in exon 19, 3 insertions in exon 20, L858R, L861Q, T790M, G719S, G719A and G719C (or G719X), S768I. † Dose escalated to 50 mg if limited AE observed in cycle 1. Dose reduced by 10 mg decrements in case of related G3 or prolonged G2 AE.

‡ Tumor assessments: q6 weeks until Week 48 and q12 weeks thereafter until progression/start of new therapy. § Patient-reported outcomes: Q-5D, EORTC QLQ-C30 and QLQ-LC13 at randomization and q3 weeks until progression or new anti-cancer therapy.

US FDA approval July 12, 2013

Yang JC, et al.

EGFR Gene Mutations in Adenocarcinoma Lung Cancer

3% 2% 1% 1% 2% 0% 1% 1% 0% 0% 40% N=138 N=170 49%

n = 345

Del 19 L858R

89%

Exon 20 ins L858R + T790M L861Q G719X Del19 + T790M T790M L858R + S768I G719X + S768I G719X + T790M S768I Therascreen ® EGFR (29) RGQ PCR Kit

PFS: Common mutations (Del19/L858R)

Independent review – patients with Del19/L858R (n=308)

1.0

0.8

Afatinib n=204 Cis/pem n=104

PFS event, n (%) 130 (64) Median PFS (months) Hazard ratio (95% confidence interval)

13.6

61 (59)

6.9

0.47

(0.34

–0.65) p<0.0001

0.6

51% 0.4

0.2

21% 0.0

0 Number at risk Afatinib 204 Cis/Pem 104 3 169 62 6 143 35 US FDA approval July 12, 2013 9 12 15 18 Progression-free survival (months) 115 17 75 9 49 6 30 2

Yang JC, et al.

21 10 2 24 3 0 27 0 0

RADIANT Study Schematic

Patients with Stage IB-IIIA NSCLC Tumor Tissue Analysis EGFR Negative by both IHC and FISH Complete Surgical Resection

Screening Consent

No Chemotherapy or Up to 4 Cycles of a Standard (non-investigational), Platinum-based, Adjuvant Chemotherapy Regimen EGFR Positive by IHC and/or FISH

Treatment Consent

Randomization (2:1) 150 mg/day Tarceva Placebo Ineligible 2 yrs or until one of the following: relapse, death, patient request or investigator decision to discontinue study drug therapy, or intolerable toxicity Follow-up Visit Once Every 6 Months for Up to 5 Years after Randomization, then Yearly

RADIANT Study Results

Hierarchical testing rendered all secondary endpoints non-significant.

LUX-Lung clinical trials and eligibility Treatment

LUX-Lung 2 Phase II N=129 Afatinib LUX-Lung 3 Phase III N=345 Afatinib vs. Pemetrexed/ cisplatin LUX-Lung 6 Phase III N=364 Afatinib vs. Gemcitabine/ cisplatin

Line of treatment Mutation test

First- and second-line (after chemo) Direct sequencing (central) First-line EGFR29* (central) First-line EGFR29* (central) *EGFR mutations detected by TheraScreen EGFR29 test: – Common: 19 deletions in exon 19 and L858R in exon 21 – Uncommon: 3 insertions in exon 20, L861Q, T790M, G719S, G719A and G719C, S768I 2

EGFR mutation-positive patients in LUX-Lung trials Del19 n=408

LUX-Lung 2 Phase II N=129 n=52

L858R n=330

n=54

Uncommon n=100 Uncommon n=75

LUX-Lung 3 Phase III N=345 n=170 n=138 LUX-Lung 6 Phase III N=364 n=186 n=138 n=23 n=37 n=40

Patients with uncommon mutations treated with afatinib

n=23 n=26 n=26 3

Subgroups of patients with uncommon mutations Categories

n= Mutations (n)

De novo

T790M

14 T790M alone (3) T790M+Del19 (3) T790M+L858R (6) T790M+G719X (1) T790M+L858R+G719X (1)

Exon 20 insertions

23 n/a

Other (exon 18, 19, 20, 21)

38 L861Q alone (12) G719X alone (8) G719X+S768I (5) G719X+L861Q (3) E709G or V+L858R (2) S768I+L858R (2) S768I alone (1) L861P alone (1) P848L alone (1) R776H+L858R (1) L861Q+Del19 (1) K739_1744dup6 (1) 5

40 20 0 -20 -40 -60 -80 -100

Tumour shrinkage in patients with uncommon mutations

Independent review (n=67 † ) 120 * 100 80 60 7

De novo T790M (n=14):

T790M alone(*), T790M+Del19, T790M+L858R, T790M+G719X, T790M+L858R+G719X

Exon 20 insertions (n=20) Other (n=33):

L861Q, G719X, G719X+S768I, G719X+L861Q, E709G or V+L858R, S768I+L858R, S768I, L861P, P848L, R776H+L858R, L861Q+Del19, K739_1744dup6 * * † 8 patients were not included due to insufficient data

T790M+ EGFR- TKI failures 2

nd

/3

rd

line NSCLC An area of high unmet medical need

There are no current proven treatment options for these patients.

Chemotherapy or EGFR TKIs are used, but their benefit isn’t proven EGFR TKI resistance mechanisms AZD9291 or CO1686 “Patients with EGFR-mutant lung adenocarcinoma develop acquired resistance to EGFR tyrosine kinase inhibitors (TKIs) after a median of 10-16 months. In half of these cases, a second EGFR mutation, T790M, underlies acquired resistance” Oxnard, et al.

Clin Cancer Res Dec 6, 2010

Clinical activity AZD9291 in T790M+

 Fast Track status granted by FDA in October 2013  Breakthrough Therapy Designation submission early February 2014

Best % change from baseline in target lesions in central testing T790M+

T790M+ Response Rate* = 64% (95% CI 53%-74%) For the 89 T790M+ evaluable patients there are 57 PRs (35 confirmed), 28 SDs, 4 PDs

Population: T790M+ patients with observed or imputed target lesion data (n=89) *Confirmed+ unconfirmed response

Response ongoing for 34/35 T790M+ patients with confirmed PR

D Discontinued treatment * Imputed T790M status is assigned by central testing of a recent tumour sample Independent review of scans is underway as per FDA request 41/43 confirmed so far Preliminary data, data cut off 16 th January 2014

CO1686

FISH Assay for ALK Rearrangement*

p25.2

p24.3

p24.1

p23.2

p22.3

p22.1

p16.3

p16.1

p14 p13.2

p12 p25.2

ALK 29.3

p24.3

p24.1

p23.2

p22.3

p22.1

EML4 42.3

p16.3

p16.1

p14 p13.2

p12 Telomere 2p23 region 3’ 5’ Centromere t(2;5) ALK gene breakpoint region q31.3

q32.1

q32.3

q33.2

q34 q36.1

q36.3

q37.2

q12.1

q12.3

q14.1

q14.3

q21.2

q22.1

q22.2

q23.2

q24.1

q24.3

~250 kb q31.3

q32.1

q32.3

q33.2

q34 q36.1

q36.3

q37.2

q12.1

q12.3

q14.1

q14.3

q21.2

q22.1

q22.2

q23.2

q24.1

q24.3

Split signal ALK break-apart FISH assay [Courtesy John Iafrate, Massachusetts General Hospital] *Assay is positive if rearrangements can be detected in ≥15% of cells FISH = fluorescence in situ hybridization ~300 kb Break-apart FISH assay for ALK-fusion genes 1 Non-split signal 1 Shaw AT et al. J Clin Oncol 2009;27:4247 –4253

Crizotinib: First-in-human/Patient Trial

Part 1: Dose escalation Cohort 5 (n=6) 2 DLTs: grade 3 fatigue 300 mg BID Cohort 4 (n=7) 200 mg BID Cohort 6 (n=9) 250 mg BID MTD/RP2D Cohort 2 (n=4) 100 mg QD Cohort 1 (n=3) 50 mg QD Cohort 3 (n=8) 200 mg QD 1 DLT: grade 3 ALT elevation Part 2: Molecularly enriched cohorts (ALK and c-MET) Enrolling patients with ALK-positive NSCLC after preliminary observation of impressive activity in a few patients

•

Data from database April 7, 2010

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Data presented for 82 patients, study ongoing ALT = alanine aminotransferase

Tumor Responses to Crizotinib for Patients with ALK-positive NSCLC

60 40 20 Progressive disease Stable disease Confirmed partial response Confirmed complete response 0 –20 –40 –60 –80 –100 –30%

US FDA accelerated approval Aug 26, 2011 Full approval Nov 21, 2013

*Partial response patients with 100% change have non-target disease present *

Study Design – LDK378 ( Ceritinib )

Completed n=59 Advanced ALK-rearranged malignancies Dose escalation started at 50 mg/day Escalate to MTD (750 mg/day) NCT01283516 ALK-rearranged NSCLC Additional n=71 enrolled Crizotinib naive Crizotinib pretreated Other ALK activated tumors

 

Primary objective:

determination of MTD

Secondary objectives:

characterize safety, PK, and antitumor activity  Patients received treatment until disease progression, unacceptable toxicity, or withdrawal of consent Shaw AT et al.

N Engl J Med

. 2014;370:1189-1197.

Expires April 2015 MED.ONC.LDK.U.EISEX

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U

Best Change (%) in Tumor Response from Baseline in NSCLC Patients Treated with Ceritinib

100 80 60 40 Crizotinib Pretreated Crizotinib Naive PFS Event 20 0 -20 -40 -60 -80

US FDA accelerated approval Apr 30, 2014

-100

Based on investigator assessment of response.

PFS, progression-free survival.

Shaw AT et al.

N Engl J Med

. 2014;370:1189-1197.

From

N Engl J Med

, Shaw AT, Kim DW, Mehra R, et al, Ceritinib in ALK-Rearranged Non –Small-Cell Lung Cancer, Vol 370, Page 1194. Copyright © 2014 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

Expires April 2015 MED.ONC.LDK.U.EISEX

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BRAF-Mutations in NSCLC

W. Pao, N. Girard

Lancet Oncology, February 2011

A. Marchetti et al., J. Clin. Oncol. 29, 1, 2011

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1,046 NSCLC samples

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Frequency of BRAF-mutations 3.5%

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BRAF-mut. in 4.9% adeno- and 0.3% SCC

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57% BRAF V600E -mutations

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43 % non-activating BRAF mutations P. Paik et al., J. Clin. Oncol. 29, 2046, 2011 1.5-2.5 % of NSCLC harbor BRAF V600E-mutations

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697 NSCLC-adeno. ca. Samples

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Frequency of BRAF-mutations 3%

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50% BRAF V600E -mutations

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50% non-activating BRAF mutations

BRF113928: Initial Study Design

• Single arm, Phase II, open label • Green-Dahlberg 2-stage: H(0): ORR ≤ 10% versus H(1): ORR ≥30%

Primary objective

: Investigator-assessed ORR

NSCLC (Adenocarcinoama) BRAF V600E mutation ≥ 2 nd Line N = 40 dabrafenib 150 mg twice daily Secondary objectives

: PFS, duration of response, OS, safety and tolerability, population PK

Interim Analysis (ASCO 2013)

US FDA granted Breakthrough Therapy Jan 13, 2014  Investigator based response assessments demonstrated:  7PRs (5 confirmed —duration 29 and 49 weeks for 2 pts and remaining 3 patient 6+ to 24+ weeks)  1 stable disease  4 progressive disease

Planchard et. al. 2013 ASCO Annual Meeting Proceedings

Rationale for the Combination

 Sustained target inhibition to observe more prolonged and durable anti-tumor effect RAS  Delay and potentially prevent the development of resistance  Prevent/delay hyperproliferative lesions and secondary malignancies (Cu SCC) BRAF V600 BRAF WT mut BRAF BRAFi + MEKi MEK pERK Proliferation, survival Invasion , Metastasis

Molecular Subsets Adenocarcinoma Lung Cancer

MAP2K1 NRAS ROS1 fusions AKT1 KIF5B-RET PIK3CA BRAF HER2 ALK Fusions EGFR Unknown KRAS 1. Mascaux C et al. Br J Cancer 2005;92:131 –9; 2. Winton et al. N Engl J Med 2005;352:2589–97; 3. Eberhard et al JCO 2005;23:5900–9; 4. Pao et al. PLOS Medicine 2005 2(1): e17; 5. Pao et al. Nat Med 2012;18:349 –51; 6. Kris et al. ASCO 2011

• • • Structural variants Translocations Fusions Inversion • • • Copy number alterations Amplifications Deletions LOH • • • • Point mutations & indels Missense Nonsense Splice site Frameshift Wild type AG T GA Mutant AG A GA • • • Gene expression Outlier expression Isoform usage Pathways & signatures Adapted from: Roychowdhury et al. Sci Transl Med; 20122

32

•

Conclusion

Molecular selection of patients improves therapy outcomes for patients with advanced adenocarcinoma of the lung • • • • •

Future Directions

Extent patient selection and targeted therapies to squamous cell and earlier stages of NSCLC (i.e. RADIANT) Next generation sequencing needed Molecular characterization of resistance Development of a structure to conduct studies in uncommon molecular selected populations (BRAF, HER2, RET, etc) Clinical integration of tumor genomic and proteomic testing to better direct therapy for NSCLC (Gerber)