Molecular Targets for Cancer PreventionMolecular Targets for Cancer Prevention

Raymond N. DuBois, M.D., Ph.D.Raymond N. DuBois, M.D., Ph.D.Gastroenterology DivisionGastroenterology Division

The VanderbiltThe Vanderbilt--Ingram Cancer CenterIngram Cancer CenterNashville, Tennessee USANashville, Tennessee USA

Falk Symposium 149Falk Symposium 149Berlin, GermanyBerlin, Germany

Epidemiologic Studies of NSAID Use and Colorectal Cancer

Thun MJ et al. Thun MJ et al. J Natl Cancer Inst.J Natl Cancer Inst. 2002;94:2522002;94:252--266.266.

0 0.5 1 1.5 2

Relative Risk

Kune 1988Rosenberg 1991Suh 1993, menSuh 1993, womenPeleg 1994Muscat 1994, menMuscat 1994, womenMuller 1994Reeves 1996Bansal 1996La Vecchia 1997Rosenberg 1998Friedman 1998Coogan 2000, study aCoogan 2000, study b

CyclooxygenaseCyclooxygenase--11

CyclooxygenaseCyclooxygenase--22

Arachidonic AcidArachidonic Acid

PGHPGH22

PGGPGG22

NSAIDs NSAIDs (1(1--55 μμMM))

COXIBsCOXIBsPeroxidasePeroxidase

EPEP11--44 IPIP FPFPDPDPTPTP

PGDPGD22 PGEPGE22 PGIPGI22 PGFPGF22ααTXATXA22

PG SynthasesPG Synthases

COOH

OHOH

O

O

COOHO

OH

COOH

OH

OH

O

COOH

OHOH

OH

OHOH

O

COOH

COOH

OH

O

O

Is COXIs COX--2 a relevant target of NSAIDs 2 a relevant target of NSAIDs which could help explain the which could help explain the decreased risk of colorectal decreased risk of colorectal

adenomas and cancer in humans?adenomas and cancer in humans?

COXCOX--2 Expression in Colorectal Cancer2 Expression in Colorectal Cancer

COXCOX--22

COXCOX--11

N T N TN T N T

1 1 2 2 33

Colorectal Colorectal CancerCancer

Colorectal Colorectal adenomasadenomas

COXCOX--22

COXCOX--11

Eberhart Eberhart et al. & DuBoiset al. & DuBois Gastroenterology Gastroenterology 107, 1183, 1994107, 1183, 1994

Increased COXIncreased COX--2 Expression Is Associated With 2 Expression Is Associated With A Poor Clinical OutcomeA Poor Clinical Outcome

1Sheehan KM et al. JAMA. 1999;282:1254-1257. 2Khuri FR et al. Clin Cancer Res. 2001;7:861-867. 3Ristimäki A et al. Cancer Res. 2002;62:632-635.4Gaffney DK et al. Int J Radiat Oncol Biol Phys. 2001;49:1213-1217.5Buskens CJ et al. Gastroenterology. 2002;122:1800-1807. NSCLC = non-small cell lung cancer

Tumor typeTumor type PrognosisPrognosis P P valuevalue

ColorectalColorectal11 ↓↓ survival ratesurvival rate 0.020.02

NSCLCNSCLC22 ↓↓ survival ratesurvival rate 0.0010.001

BreastBreast33 ↓↓ survival ratesurvival rate 0.00010.0001

CervicalCervical44 ↓↓ survival ratesurvival rate 0.0210.021

EsophagealEsophageal55 ↓↓ survival ratesurvival rate 0.0020.002

Cancer Epidemiol Biomarkers Prev. 2005 Mar;14(3):616-9.

COX-2 - 765 G > C genotypeOR (95% CI) Cases/Controls

GG (wt) 1.00 (reference) 217/228GC (het) 1.02 90/85CC (hmzyg) 0.26 5/11

The (COX-2) 765G > C promoter variant is located in a SP1 binding site and has been documented to affect COX-2 expression.

Lots of preclinical studies Lots of preclinical studies indicate that COXindicate that COX--2 plays a role in 2 plays a role in

growth and progression of growth and progression of intestinal cancerintestinal cancer

Sheng et al.Sheng et al. J. Clin. Invest., 99, 2254, 1997J. Clin. Invest., 99, 2254, 1997

Williams et al. Cancer Res. 60, 6045, 2000DuBois: Gastroenterology 110, 1259-1262, 1996Kawamori et al. Cancer Res 58:409, 1998

Oshima Oshima et al. et al. CellCell 87, 199687, 1996Jacoby et al. Cancer Res. 60, 1864, 2000Jacoby et al. Cancer Res. 60, 1864, 2000

Tsujii Tsujii & DuBois & DuBois CellCell 83, 199583, 1995 Oshima Oshima et al. et al. EMBOEMBO 23, 166923, 1669--1678 20041678 2004Tsujii Tsujii & DuBois & DuBois CellCell 93, 199893, 1998

COXCOX--2 transgenic mouse studies2 transgenic mouse studies

•• MMTVMMTV--COXCOX--2 transgenic mice were prepared and all 2 transgenic mice were prepared and all develop breast carcinomasdevelop breast carcinomas

•• K19K19--COXCOX--2 transgenic mice develop gastric polyps2 transgenic mice develop gastric polyps

•• COXCOX--2 TG mice in which expression is localized to the 2 TG mice in which expression is localized to the skin have an dramatic increase in skin cancerskin have an dramatic increase in skin cancer

•• Lack of EP1, EP2 and EP4 receptors markedly reduces Lack of EP1, EP2 and EP4 receptors markedly reduces growth and progression of colon tumorsgrowth and progression of colon tumors

Mann JR and DuBois RN, Cancer J. 2004,10, 145.

TGFα, EGF & Other ErbB’s

IL1β

ras, src

Tumor Promoters

COX-2

PGE2

Cell growth Angiogenesis Apoptosis Immune function

LPS

Turini and DuBois Turini and DuBois Annual Rev. of MedicineAnnual Rev. of Medicine 2002;53:352002;53:35--57.57.Gupta and DuBois Gupta and DuBois Nature Rev. CancerNature Rev. Cancer 2001;1:112001;1:11--21. 21.

GastrinHCV

PGEPGE22 Accelerates Adenoma GrowthAccelerates Adenoma Growth

Wang et al. & DuBois: 2004 Wang et al. & DuBois: 2004 Cancer CellCancer Cell; 6, 285; 6, 285--9595

Tota

l Pol

yp N

umbe

r/Mou

seIn

Col

on

Tota

l Pol

yp N

umbe

r/Mou

seIn

Sm

all I

ntes

tine

Vehi

cle 150 300

0

50

100

150

PGE2 (μg)Vehi

cle

150 300

PGE2 (μg)

0

1

2

3

4 9/9(100%)

5/5(100%)

1/9(11%)

Vehicle

PGE2 (150 μg)

300μg+-

Akt

+-150μgPGE2

P-Akt

Colon

Vehicle PGE2(150 μg)

PGE2 Affects Cellular Organization

c d

PGEPGE22 (100 nM) (100 nM) Control Control

MucinMucin

Sheng et al. J. Biol. Chem. 276, 18075, 2001

PGE2 Affects Cell Migration & Invasion

Cell Number

10

20

30

40

Control PGE2

Sheng et al. J. Biol. Chem. 276, 18075, 2001

10

30

50

60

Control PGE2

40

20

Migration Invasion

Buchanan et al. J. Biol. Chem. 278, 35341, 2003

Important interactions between PGE2receptors and Arrestin

EP Activation and CRC Metastasis

Celecoxib FAP Phase II TrialSubjects with FAP (83)

Randomize to celecoxib treatment or placebo

Baseline evaluation: endoscopy, APC mutations, biopsies

6 month evaluation

Endpoint: Polyp number & size

Steinbach: NEJM 342, 1946, 2000

Percent Change in Colorectal Polyp Burden

* P = 0.001

-40

-35

-30

-25

-20

-15

-10

-5

0

Placebo- 4.9%

100 mg BID-14.6%

400 mg BID*-30.7%

N=15 N=32 N=30

% Change from Baseline

Mean ± SEM

Steinbach: NEJM 342, 1946, 2000

Before treatment

After treatment

Serum Proteomic Profiles Suggest Celecoxib-Modulated Targets and Response Predictors

Xiao et al: Cancer Res 64, 2904, 2004

Strong Responders

Non-Responders

RANDOMIZE

celecoxib 400 mg QD

placebo

RANDOMIZE

celecoxib 400 mg BID

placebo

200 mg BID

PreSAP – 1561 patients

APC – 2035 patients

AdenomaFree

2000 2005 2007

No

Year 1 Colonoscopy

Year 3 Colonoscopy

SAP Study Design

3 Years

Stratified by low-dose aspirin use

Stratified by low-dose aspirin use

Yes Continue Blinded Rx

Off-Rx FU

Year 5 Colonoscopy

Year 5 Colonoscopy

- durability- long-term

safety

- Follow Up colonoscopies

PRIMARY END POINT Occurrence of newly detected adenomas

2 Year Extension

DeclineDeclineParticipationParticipation

Are longAre long--term use of these term use of these inhibitors safe in humans?inhibitors safe in humans?

Symptoms of withdrawal: Loss of arthritis drug adds to group’s woes

Safety of other pain drugs is questioned

Vioxx patients review their options ; Other medicines, therapies can ease pain of arthritis

FDA Official Alleges Pressure to Suppress Vioxx Findings

A Painful Mistake Why a pharmaceutical giant withdrew its best- selling arthritis drug, and what that means for you

Merck Found Liable in Vioxx Case-Texas Jury Awards Widow $253 MillionSaturday, August 20, 2005; Page A01

APPROVe Confirmed Thrombotic Events

0 6 12 18 24 30 36

Patients at riskPlacebo

Rofecoxib 25 mg1299 1192 1148 1079 1039 1002 4701287 1123 1050 986 935 898 411

0

2

4

6

8

CummulativeIncidence (%)

Months

Bresalier et al. (2005) NEJM 352, 1092-1102

Rofecoxib

Placebo

Observed ~ 25% reduction in polyp recurrenceObserved ~ 25% reduction in polyp recurrence

Celecoxib and Cardiovascular Events

Solomon SD, et al. NEJM 352, 2005

A European trial of similar design showed no difference in cardiovascular side effects between placebo and 400 mg of celecoxib (daily dose)

*In this analysis, “serious CV events” include death from CV causes, MI, stroke, or heart failure

671

Solomon SD, et al. NEJM 352, 2005

Kaplan-Meier Estimates of the Risk of Serious CV Events in the APC Trial by Treatment Arm*

681 676 675 673 670 611669 665 655 651 648 594677 675 672 668 667 612

Months sincefirst dose

Sample size

C 200 BIDC 400 BIDPlacebo

Log-rank statistic 8.74 (p= 0.013)

E:\Proj\APC Cox2\Programs\f KMplot.sas v.010 death MI stroke CHF 005 01.cgm (last run: 02/14/2005, 10:46CEC adjudication data (received 02/03/2005) RAND data (received 11/23/2004) CRF data (received 02/03/2005)

Est

imat

ed p

roba

bilit

y of

CV

dea

th, M

I, st

roke

, or

CH

F

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

6 12 18 24 30 36

Kaplan-Meier Estimates of the Risk of Serious CV Events in the APC Trial by Treatment Arm

PlaceboPlacebo200 mg bid200 mg bid

400 mg bid400 mg bid

COXCOX--2 selective inhibitors will no 2 selective inhibitors will no longer be evaluated in patients at longer be evaluated in patients at

low risklow risk for cancer.for cancer.

What is responsible for increased What is responsible for increased cardiovascular risk?cardiovascular risk?

SummarySummary•• COXCOX--2 levels are increased in colorectal carcinomas and its 2 levels are increased in colorectal carcinomas and its

expression is affected by numerous factorsexpression is affected by numerous factors

•• LongLong--term use of term use of celecoxib celecoxib (800 mg per day) has adverse (800 mg per day) has adverse effectseffects

•• Downstream signals in the COXDownstream signals in the COX--2 pathway (PGE2 pathway (PGE22) may also ) may also serve as useful targets for cancer preventionserve as useful targets for cancer prevention

•• Personalized medicine approaches may reveal those who Personalized medicine approaches may reveal those who would benefit most from treatment with COXwould benefit most from treatment with COX--2 selective 2 selective inhibitorsinhibitors

• Dingzhi Wang• Yong Cha• Jason Mann• Yuko Kino• Pranathi Matta• Sharada Katkuri• Greg Buchanan• Suzy Wilkinson• Shi Qiong• Vijay Holla

• R. Daniel Beauchamp (VUMC)• Jason Morrow (VUMC)• Kay Washington (VUMC)• Larry Marnett & Lab (VUMC)• S.K. Dey & Lab (VUMC)• Masahiko Tsujii (Osaka U.)

DuBois Laboratory Others

Acknowledgements