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More information about this activity can be found here: http://bit.ly/ST0uRp Chairperson Jedd D. Wolchok, MD, PhD Memorial Sloan-Kettering Cancer Center Faculty Antoni Ribas, MD, PhD University of California, Los Angeles Mary L. Disis, MD University of Washington School of Medicine Charles G. Drake, MD, PhD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins John Powderly II, MD, CPI Carolina BioOncology Institute, PLLC Cancer Therapy & Research Center Activity Overview Advances in basic immunology have led to an improved understanding of the interactions between the immune system and tumors, generating renewed interest in novel immunologic approaches to the treatment of cancer. Indeed, there have been multiple FDA approvals of immunologic agents in recent years and there are many ongoing trials of novel immunotherapies in lung cancer, colorectal cancer, and other tumor types. In this series of half-day conferences, leading oncologists will provide an overview of immune system–cancer interactions, the safety and efficacy of recently approved immunologic agents for the treatment of melanoma and prostate cancer, the latest data from ongoing trials in non-small cell lung cancer, colorectal cancer, and others, and the management of immune-related adverse events (IRAEs). These sessions will include case studies to stimulate interactive discussion of real-world treatment scenarios. Learning Objectives Upon completion of this activity, participants should be better able to: • Describe the biological foundations of immunotherapy approaches to the treatment of cancer • Identify the mechanisms of action of immuno-oncologic agents such as vaccines and immune system-modulating antibodies • Evaluate new safety and efficacy data on recently approved and emerging immunotherapies across tumor types • Describe how new immunotherapies are integrated into existing treatment evidence-based guidelines • Identify ongoing research efforts in immuno-oncology including how to appropriately select patients who would be candidates for clinical trials More information about this activity can be found here: http://bit.ly/ST0uRp
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Disclosure of Conflicts of InterestDisclosure of Conflicts of Interest
Jedd D. Wolchok, MD, PhD, reported a financial interest/relationship or affiliation in the form of: Consultant, Bristol-Myers Squibb Company.
Mary (Nora) L. Disis, MD, reported a financial interest/relationship or affiliation in the form of: Consultant, Bristol-Myers Squibb Company, EMD Serono, Inc., Immunovaccine, Inc., Hoffmann-La Roche, Inc., VentiRX Pharmaceuticals; Contracted Research, GlaxoSmithKline plc.; Ownership Interest, Epigenomics AG.
Charles G. Drake, MD, PhD, reported a financial interest/relationship or affiliation in the form of: Royalty, Amplimmune, Inc., Bristol-Myers Squibb Company; Receipt of Intellectual Property Rights/Patent Holder, Amplimmune, Inc., Bristol-Myers Squibb Company; Consultant, Bristol-Myers Squibb Company, Dendreon Corporation, Pfizer, Inc.; Ownership Interest, Amplimmune, Inc.
John Powderly II, MD, CPI, reported a financial interest/relationship or affiliation in the form of: Receipt of Intellectual Property Rights/Patent Holder, BioCytics®; Consultant, Amplimmune, Inc., Bristol-Myers Squibb Company; Speakers' Bureau, Bristol-Myers Squibb Company; Contracted Research, Amplimmune, Inc., Bristol-Myers Squibb Company, Genentech, Inc.; Ownership Interest, BioCytics®.
Disclosure of Conflicts of InterestDisclosure of Conflicts of Interest
Antoni Ribas, MD, PhD, reported a financial interest/relationship or affiliation in the form of: Consultant, Amgen, Inc., Celgene Corporation, Genentech- A member of the Roche Group, GlaxoSmithKline plc., Millennium Pharmaceuticals, Inc., Prometheus.
Scott N. Gettinger, MD, has no real or apparent conflicts of interest to report.
Mario Sznol, MD, reported a financial interest/relationship or affiliation in the form of: Consultant, Anacor Pharmaceuticals, Inc., BeiGene LTD, Bristol-Myers Squibb Company, Genesis Biopharma, Necktar Pharmaceuticals Inc., Prometheus; Ownership Interest, Genesis Biopharma.
5
Welcome and IntroductionWelcome and Introduction
Jedd D. Wolchok, MD, PhDMemorial Sloan-Kettering Cancer Center
Immuno-Oncology: Immuno-Oncology: The Biological FoundationsThe Biological Foundations
Mary L. Disis, MDUniversity of Washington School of Medicine
Immuno-Oncology:Immuno-Oncology:The Biological FoundationsThe Biological Foundations
The immune system
Cancer and the immune system
The basics of immune therapy
CHARACTERISTICS INNATE ADAPTIVE
Specificity Non-Specific Specific
Antigens Not Needed Required
Memory None Generated
Time Course Immediate Slowly Developing
Duration Transient Lifelong
Cell Types MØ, DC, NK, Neutrophil
T Cells, B Cells
T cell (orange) killing a cancer cell (magenta)
First Line of DefenseImmune Sensors
Effectors
The Immune SystemThe Immune System
MØ = macrophages; DC = dendritic cell; NK = natural killer cell.Alberts et al, 2002; Murphy et al, 2008.
Neutrophil
Dendritic Cell
Macrophage
Natural Killer Cell
ADCC = antibody-dependent cell-mediated cytotoxicity; MHC = major histocompatibility center; IFN = interferon; CTL = cytotoxic T lymphocytes.Alberts et al, 2002; Murphy et al, 2008.
Cells of the Innate Immune SystemCells of the Innate Immune SystemPhagocytosis and debris clean upSecrete chemokines that call in other innate immune cells
Potent antigen presenting cells (APC)Uptake and process antigenBoth “class I” and “class II” pathwaysWill stimulate both CTL and T helper (Th) cells
Phagocytosis and cleaning up debris,secrete cytokinesType 1 can turn on adaptive immunityType 2 will limit adaptive immunity
Can directly kill tumor without docking to MHCSecrete high levels of IFN-gamma (critical cytokine)Antibodies can activate them via FC receptor (ADCC)
Cells of the Adaptive Immune SystemCells of the Adaptive Immune System
PMN = polymorphonuclear leukocyt.Kumar, et al 2007.
Humoral Immunity Cellular Immunity
Extracellular microbes (e.g., bacteria)
B lymphocytesB
B
TSecretedantibody
Neutralization
Lysis (complement)
Phagocytosis(PMN, macrophage)
Intracellular microbes (e.g., viruses)
Antigen-presenting cell
HelperT-cell
T-cellreceptor
Processed and presented antigen
Cytokines
CytokinereceptorProliferation and
activation of effector cells
(cytotoxic T-cells, natural killer cells,
macrophages)
Lysis of infected cell
Critical Link Between Innate and Critical Link Between Innate and Adaptive ImmunityAdaptive Immunity
TCR = T cell receptor; TLR = Toll-like receptors.Bevan, 2004.
Apoptotic cell
Necrotic cell
Pathogen
Immaturedendritic cell
Immaturedendritic cell
TLR
Activation
Activation
Maturedendritic cell
CD8
CD8+T-cell
CD4+T-cell
CD4TCRMHC II
CD40L
CD40MHC I
• Activation• Proliferation• CTL generation
IL = Interleukin; TNF = tumor necrosis factor; TGF = transforming growth factor.DeNardo et al, 2010.
The Immune System Is All About The Immune System Is All About ““Checks and BalancesChecks and Balances””
NK/NKT TH1 TH17 TH17 B cell TH2 TREG
Tumor Regression Tumor Progression
Angiostatic Pro-angiogenic
Directcytotoxicity
Tissueremodeling
Immunesurveillance
Immunesuppression
Myeloid Phenotype
Regulatory loops
IL-12, IL-2, IFN-g, TNF-a IL-4, IL-5, IL-10, TGF-b
N2 M2 DC2DC1 M1 N1
Immuno-Oncology:Immuno-Oncology:The Biological FoundationsThe Biological Foundations
The immune system
Cancer and the immune system
The basics of immune therapy
Steps in Stimulating Cancer Specific ImmunitySteps in Stimulating Cancer Specific Immunity
Melanoma
“Danger”e.g. HSP
IFN-α
MAGE IMARTI(TAAs)
Immature DC
Activated mature DC
Migration to lymph node
Lymph node
Migration fromlymph node
CD8CD4
DC
CD4TH
CD8CTL
APCCD40
CD40
B7
TCR
MHC I
CD28 CD40
CD40L
TCRMHC II
CD40L
CD40
B7CD28
Helpe.g. IL-2
MIP-1α= macrophage inflammatory protein 1α.Vanderlught et al, 2002.
Epitope Spreading Is the Endpoint of an Epitope Spreading Is the Endpoint of an Effective Immune Response in CancerEffective Immune Response in Cancer
237 breast cancers MVA: Density of Treg+ in ER+ tumors predictor of survival
Type I Inflammation Modulation of Self-Regulation
186 advanced ovarian cancers MVA: Intratumoral T cells independent predictor survival
High Density of T CellsPenetrating Tumor
75 colorectal cancers 7 gene classifier Inverse correlation of gene expression and relapse
MVA = multivariate regression analysis; ER+ = estrogen receptor positive; Treg = regulatory T cells.Galon et al, 2006; Zhang et al, 2003; Bates et al, 2006.
What Is Needed for Clinical Effective What Is Needed for Clinical Effective Antitumor Immunity?Antitumor Immunity?
Murine breast tumor
after activating the
Immune system
Murine TNBC
Murine ER+ BC
CD4
FO
XP
3
Murine TNBC
Murine ER+BC
VEGF = vascular endothelial growth factor; CT = center; IM = invasive margin.Bindea et al, 2010.
Optimal Immune ReactionOptimal Immune Reaction
Many cancer patients have demonstrated an “optimal immune reaction”
Lake et al, 2005; Cheever et al, 2009.
Foreign Antigens
Self Antigens
LMP2 HER2 GD2
HPV WT1 CEA
HepB MUC1 MART-1
MAGE A2 gp100
NY-ESO-1 PR1
PSMA Tyrosinase
PSA PAP
PSCA NA17
Antigens Associated With Clinical Response
What Does the Immune System What Does the Immune System See in Cancer?See in Cancer?
Dangerous• Cell damage (uric acid)• Innate immunity activated• TLRs triggered • Inflammation• Cytokines• CD40 signals• Others
Weak• No danger signals• No CD40 signals• Pro- inflammatory cytokines
Tolerizing• None of these signals
Cell and Self Protein Only
Cell and Tumor Antigen
Cell and Virus
Why Do Most Tumors Evade Why Do Most Tumors Evade Immune Recognition?Immune Recognition?
Murphy et al, 2008.
Foxp3 = forkhead box P3.Fridman et al, 2011; Disis, 2010a.
Multiple Factors Impact the Multiple Factors Impact the Tumor Immune Microenvironment Tumor Immune Microenvironment
Pro-Tumorigenic Inflamation
AnticancerImmunosurveillance
Cell Types M2 macrophagesMyeloid-derived suppressor cells NeutrophilsFoxp3+ T reg. Th17 cells
Dendritic cellsM1 macrophagescytotoxic CD8+ T cells with a memory effector phenotype
Cytokine Profiles
Th2, Th17 Th1CX3CL1CXCL9, CXCL10
Distribution Peritumoral Intratumoral, close to cancer cells, as well as in the invasive front
Associated Features
Stat3 phosphorylation High endothelial venules
Functional Impact
Negative prognostic impact Positive prognostic and predictive impact
Immuno-Oncology:Immuno-Oncology:The Biological FoundationsThe Biological Foundations
The immune system
Cancer and the immune system
The basics of immune therapy
PASSIVE ACTIVE
Transferred Generated
Ready Made Must Be Developed
Immediate Protection Takes Time
No Memory Long Lived
Immune System May Function Poorly
Requires Functional Immune System
Ig Infusions, Some MoAB Therapy, T-Cell Transfer
Vaccines, Anti-CTLA-4
Types of Types of ImmuneImmune Therapy Therapy
Ig = immunoglobulins; MoAB = monoclonal antibody; CTLA-4 = cytotoxic T-lymphocyte antigen-4. Murphy et al, 2008.
HER-2/neu = human epidermal growth factor receptor 2.Ferris et al, 2010; Taylor et al, 2007; Ladoire et al, 2011.
Monoclonal Antibody Therapy: TrastuzumabMonoclonal Antibody Therapy: Trastuzumab
Time (Weeks)
50% response rate20/93 complete responders
Adoptive T Cell TherapyAdoptive T Cell Therapy
TIL = tumor-infiltrating lymphocytes; CR = complete response; PR = partial response; NR = no response; MART-1/ Melan-A = melanomaantigen recognized by T-cells, gp100 = glycoprotein 100; NY-ESO-1 = immunogenic peptide derived from the cancer-testis antigen.Topalian et al, 2011; Rosenberg et al, 2011.
Objective Response
34%-50%
49%-72%
13%-30%
0%-11%
Diversity
Specificity
Unfractionated TIL
Selected tumor- reactive TIL
TCR gene transfer (MART-1/Melan-A, gp100,NY-ESO-1)
Individual T cell clones (MART-1/Melan-A, gp100,NY-ESO-1)
po
lyclon
al
mo
no
clon
al
Factors Associated With Clinical Response
Tx = treatment.Disis, 2010b.
Immuno-Oncology: Immuno-Oncology: The Biological FoundationsThe Biological Foundations
T1
T2
Key TakeawaysKey Takeaways Innate immunity, our first responders that don’t require antigen recognition,
can support and enhance the efficacy of adaptive immunity cells that are specific to an invader
Therapeutic immunity can be either passive (supplying an antibody response) or active (vaccinating to create your won antibody response) which requires your immune system to do the work
There is strong evidence that most cancers stimulate the immune system
Efficacy of cancer-induced immunity is limited by both factors secreted by the tumor and stroma, but also normal defense mechanisms activated to prevent autoimmunity
Our improved understanding of tumor-immune system interactions has led to design of therapeutic approaches that both stimulate immunity and address mechanisms of immune escape
There are now several promising immunologic agents that have demonstrated significant antitumor efficacy in advanced stage clinical trials or have been approved for standard of care use
Audience Q&A:Audience Q&A:The Biological FoundationsThe Biological Foundations
of Immunotherapyof Immunotherapy
Mary L. Disis, MDUniversity of Washington School of Medicine
Immuno-Oncology: Immuno-Oncology: Genitourinary CancersGenitourinary Cancers
Charles G. Drake, MD, PhDThe Sidney Kimmel Comprehensive Cancer
Center at Johns Hopkins
OutlineOutline
Cancer “Vaccines”
– Sipuleucel-T
– ProstVac VF
– Argos AGS-003
Immune Checkpoint Blockade
– Anti-CTLA-4, ipilimumab
– Anti-PD-1, BMS-936558 (MDX-1106)
– Phase III trial design
Combination Immunotherapy
– With androgen-ablation
– With TKIs
Integrating immunotherapy into the current (and future) prostate cancer treatment paradigm
PD-1 = programmed cell death protein-1; TKIs = tyrosine kinase inhibitors.
Cancer Vaccines:Cancer Vaccines:An Immunological MOAAn Immunological MOA
CD4 T Cell
TCR
CD8 T Cell
TCR Cytokines = HELP
Activated CD8 T Cells Traffic to Tumor and Lyse Tumor Cells
Class II MHC
Class I MHC
ActivatedDendritic Cell
Tumor Antigen
MOA = mechanism of action. Burch et al, 2000; Small et al 2000; Fong et al, 1997.
Patient WBC Harvested
Short-Term Culture With Protein “Cassette”
Shipping
Cells Infused BACK Into Patient (IV)
GM-CSF
PAP
Active Cellular Immunotherapy Active Cellular Immunotherapy Sipuleucel-TSipuleucel-T
WBC = white blood count; GM-CSF = granulocyte-macrophage colony stimulating factor;PAP = prostatic acid phosphatase; IV = intravenous.Burch et al, 2000; Small et al, 2000.
D9902B – IMPACTD9902B – IMPACTImmunotherapy Prostate Immunotherapy Prostate
Adenocarcinoma TreatmentAdenocarcinoma Treatment
Patients: Asymptomatic or minimally symptomatic mCRPC Primary end point: OS Secondary end point: TTP
mCRPC No Visceral
Mets N = 512
Sipuleucel-T q2wks x 3
RANDOMIZE
PROGRESSION
Physician’s Discretion
Eligible forSipuleucel-Ta
aPrepared from cryo-preserved lymphocytes.mCRPC = metastatic castration-resistant prostate cancer; OS = overall survival; TTP = time to progression.Kantoff et al, 2010a.
Placebo q2wks x 3
IMPACT OS: Primary End Point IMPACT OS: Primary End Point ITT PopulationITT Population
0 6 12 18 24 30 36 42 48 54 60 660
25
50
75
100
Per
cent
Sur
viva
l
Survival (Months)
p = .032 (Cox model)HR = 0.775 [95% CI 0.614, 0.979]
Median Survival Benefit = 4.1 mos
Sipuleucel-T (n = 341)Median Survival = 25.8 mos
Placebo (n = 171)Median Survival = 21.7 mos
ITT = intent-to-treat; HR = hazard ratio; CI = confidence interval.Kantoff et al, 2010a.
PSA
LFA-3 ICAM-1 B7-1
Co-Stimulatory Molecules
Target Antigen
Plasmid DNA
Vaccinia VirusFowlpox Virus
rV-PSA-TRICOMrF-PSA-TRICOM
Packaging Cell Line
Vaccine
A Viral Vaccine Approach: ProstVac VFA Viral Vaccine Approach: ProstVac VF
DNA = deoxyribonucleic acid; PSA = prostate-specific antigen.Madan et al, 2009; Sonpavde et al, 2011.
Viral Vaccines – Same Idea:Viral Vaccines – Same Idea:But Starting At A Different StepBut Starting At A Different Step
ProstVac VFCD4 T Cell
TCR
CD8 T Cell
TCR
Class II MHC
Class I MHC
Epithelial Cells
Cell Death - Necrosis
ACTIVATED
CD8 T Cell
Madan et al, 2009; Sonpavde et al, 2011.
TBC-PRO-002 Survival DataTBC-PRO-002 Survival Data
CRPC = castration-resistant prostate cancer; TTP = time to progression.Kantoff et al, 2010b.
Design: Nearly identical to IMPACT but NO crossover
Patients: mCRPC with either no or minimal symptoms
Primary end point: TTP
Time (mos)
Prospect Trial: Design (SPA)Prospect Trial: Design (SPA)Phase III Global (US-CAN-AUS/WE/EE/Latin America) Phase III Global (US-CAN-AUS/WE/EE/Latin America)
Non/Minimally Symptomatic
mCRPC
Non/Minimally Symptomatic
mCRPC
PROSTVAC-(V)(F) TRICOM + Low-Dose Adjuvant GM-CSF
PROSTVAC-(V)(F) TRICOM + Low-Dose Adjuvant GM-CSF
Vector PlaceboAdjuvant Placebo Vector PlaceboAdjuvant Placebo
SURVIVAL
SURVIVAL
No Crossover
PROSTVAC-(V)(F) TRICOMAdjuvant Placebo
PROSTVAC-(V)(F) TRICOMAdjuvant Placebo
Standard of Care
Primary End Point: OS
SPA = special protocol assessment.US NIH, NCT01322490.
Kidney Cancer Sample
Leukapheresis Product
Intranodal Injection
TumorRNA Isolation
DC
Manufacture
Load DC With RNAAnd Activate
(AGS-003)
Cryopreserve
Using RNA to Load Dendritic CellsUsing RNA to Load Dendritic CellsArgos AGS-003Argos AGS-003
RNA = ribonucleic acid.Figlin et al, 2012.
ADAPT:ADAPT:Autologous Dendritic Cell Immunotherapy With AGS-003 Autologous Dendritic Cell Immunotherapy With AGS-003
Plus Sunitinib for the Treatment of Advanced RCCPlus Sunitinib for the Treatment of Advanced RCC
Primary end point: OS Secondary end point: PFS (30% increase), ORR, safety FDA approved the SPA for the phase III clinical study of AGS-003 for the treatment of
metastatic RCC Study has initiated and is expected to begin dosing patients in the second half of 2012
Metastatic, Unfavorable Risk Clear Cell RCC
N = 450
RANDOMIZE
AGS-003q3mos
1 Cycle Sunitinib(6 wks)
1 Cycle Sunitinib(6 wks)
Placeboq3mos
AGS-0035 dosesq3wks
Placebo5 dosesq3wks
Ongoing Sunitinib (4 wks on, 2 wks off)
RCC = renal cell carcinoma; ORR = overall response rate; PFS = progression-free survival.US NIH, NCT01582672.
T Cell
HLA
TCR
antigenSignal 1Signal 1
B7.1/2
CD28
Antigen Presenting Cell
Signal 2Signal 2
Normal T-Cell ActivationNormal T-Cell Activation
HLA = human leukocyte antigen.Kirkwood et al, 2008; Ribas et al, 2005; Attia et al, 2005.
T Cell
HLA
TCR
antigenSignal 1Signal 1
B7.1/2
CD28
Antigen Presenting Cell
Signal 2Signal 2
CTLA-4
Immune Checkpoints (CTLA-4) Prevent Normal Immune Checkpoints (CTLA-4) Prevent Normal T-Cell ActivationT-Cell Activation
Kirkwood et al, 2008; Ribas et al, 2005; Attia et al, 2005.
T Cell
HLA
TCR
antigenSignal 1Signal 1
B7.1/2
CD28
Antigen Presenting Cell
Signal 2Signal 2
CTLA-4
CTLA-4
Ipilimumab (Anti-CTLA-4) Blocks the CTLA-4 Ipilimumab (Anti-CTLA-4) Blocks the CTLA-4 Checkpoint, Restoring T-Cell ActivationCheckpoint, Restoring T-Cell Activation
Kirkwood et al, 2008; Ribas et al, 2005; Attia et al, 2005.
CTLA-4 Blockade:CTLA-4 Blockade:(Ipilimumab, Tremelimumab)(Ipilimumab, Tremelimumab)
Single-agent activity
– RR = 15%–20%
Regressions = durable
Regressions = delayed
Grade III/IV SAE = 10%–15%
– Colitis
– Hypophysitis
PSA Responses in PC
(N = 200)
– 20%
RR = response rate; SAE = serious adverse event; PSA = prostate-specific antigen; PC = prostate cancer. Saenger et al, 2008; courtesy of Jedd D. Wolchok, MD, PhD.
Ipilimumab in Melanoma: The First Ipilimumab in Melanoma: The First ““DrugDrug”” Ever to Ever to Show a Survival Benefit in a Randomized Clinical TrialShow a Survival Benefit in a Randomized Clinical Trial
Hodi et al, 2010.
Years
Ipilimumab + gp100 (A)Ipilimumab + gp100 (A)Ipilimumab alone (B)Ipilimumab alone (B)gp100 alone (C)gp100 alone (C)
1 2 3 4
Comparison HR Comparison HR PP--valuevalue Arm A vs CArm A vs C 0.680.68 0.00040.0004 Arm B vs CArm B vs C 0.660.66 0.00260.0026 Arm A vs BArm A vs B 1.041.04 0.75750.7575
Survival Rate Ipilimumab + gp100 Ipilimumab alone gp100 alone
1-yr 44% 46% 25%
2-yr 22% 24% 14%
Randomized, Double-Blind, Phase III Trial Comparing Randomized, Double-Blind, Phase III Trial Comparing Ipilimumab Vs. Placebo Following Radiotherapy in Subjects Ipilimumab Vs. Placebo Following Radiotherapy in Subjects
With CRPC That Have Received Prior Treatment With With CRPC That Have Received Prior Treatment With Docetaxel (CA184-043)Docetaxel (CA184-043)
ICF, Baseline Assessments
Radiotherapy (8 gy) to bone metastases
Day -2 or -1
INDUCTION MAINTENANCE
Placebo Wks 1, 4, 7, 10
Placeboq12wks
Ipilimumab 10 mg/kg Wks 1, 4, 7, 10
Ipilimumab 10 mg/kgq12wks
TA: Wks 12, 24PSA: Wks 7, 12, 18, 24OA: Wks 7, 10, 12, 18, 24
IVRS
Day -28 to -2 Day -2 to Wk 24 Wk 24 to 48+
SCREENING
TA: q12wksPSA: q6wksOA: q12wks
CRPCPriorDocetaxel
N = 800
Completed Accrual 1/2012TA = tumor assessment; OA = outcome assessment; ICF = informed consent form; IVRS = interactive voice response system.US NIH, NCT00861614.
Immune Checkpoint Blockade 2: PD-1Immune Checkpoint Blockade 2: PD-1
T CellTumor Cell or
Antigen Presenting Cell
antigenHLA TCR
CTLA-4
PD-1B7-H1(PD-L1)
Signal 1
B7.1/2 CD28
Signal 2
LAG-3Class II MHC
Others: ICOS, GITR, Tim-3
Weber, 2010; Pardoll, 2012a.
Adaptive Immune Resistance
Tumor
OncogenicPathway
T Cell
TCR
PD-1
MHC + Peptide
PD-L1
Oncogene-Driven PD-L1Expression
Tumor
PD-L1
Adaptive Up-Regulation Of PD-L1 Turns T Cell OFF
Tumor
Interferon g
Immune Resistance: PD-1Immune Resistance: PD-1Innate Immune Resistance
Pardoll, 2012a.
T Cell T Cell
First BMS-936558 (MDX-1106) First BMS-936558 (MDX-1106) Phase I TrialPhase I Trial
PR or CR
Day 160 minute IV infusion 10mg/kgOptional tumor bx
Day 85 2 years Or until PD
SD or mixed response
Follow up every month x 2 then every 2 months,Re-treat on progression
2 doses 4 wks apart, follow 12 more weeks, can repeat
1st Treatment CycleFollow Up or Additional Treatment Cycle(s)
Day 29Optional tumor bx
Day 57
Scans
PR or CR
Day 160 minute IV infusion 10mg/kgOptional tumor bx
Day 85 2 years Or until PD
SD or mixed response
Follow up every month x 2 then every 2 months,Re-treat on progression
2 doses 4 wks apart, follow 12 more weeks, can repeat
1st Treatment CycleFollow Up or Additional Treatment Cycle(s)
Day 29Optional tumor bx
Day 57
Scans
SD = stable disease; MR = mixed response; PD = progression disease.Brahmer et al, 2010.
BMS-936558 (MDX-1106) BMS-936558 (MDX-1106) Phase I: SummaryPhase I: Summary
Toxicities (39 patients)
Grade 1: Pruritis, rash, fatigue
Grade 2:
– Polyarticular arthropathy, 2 patients (3 mg/kg and 10 mg/kg), treated with oral steroids
– TSH elevation, 4 patients (1 patient requiring levothyroxine)
Grade 3: Colitis, 1 patient after multiple doses at 1 mg/kg
Response – MR (2), PR (2), CR (1)
Brahmer et al, 2010.
3.9 cm 2.6 cm 2.4 cm
Pre-Rx 12-wk Post Dose 1 8-wk Post Dose 3
Pre-Rx 4-wk Post Dose 1
Anti-CD8 Anti-CD8 Anti-CD8
4-wk Post Dose 3
Rx = treatment.Brahmer et al, 2010.
PD-1 Blockade: Results in Increased PD-1 Blockade: Results in Increased CD8 T Cells in Tumors CD8 T Cells in Tumors
0 1 yr 2 yr 3 yr 4 yr
CR Stop Rx
Latest Evaluation: CR
Pt 2-2013
0 1 yr 2 yr 3 yr 4 yr
Stop Best Rx resp.(PR) Latest Evaluation: CR
Pt 1-4033
Sustained PR
? new brain met on MRI resected: - no viable tumor
Sustained PR
0 1 yr 2 yr 3 yr 4 yr
Stop Best Rx resp.(PR)
New LN metsPt 1-3019
Restart a PD-1
Durable Responses to Anti-PD-1 Durable Responses to Anti-PD-1 OFF THERAPYOFF THERAPY
MRI = magnetic resonance imaging; LN = lymph node. Brahmer et al, 2010.
Multidose Phase Ib Trial of Anti-PD-1Multidose Phase Ib Trial of Anti-PD-1(BMS-936558/MDX 1106)(BMS-936558/MDX 1106)
cCR = confirmed complete response; uCR = unconfirmed complete response; uPD = unconfirmed progressive disease; wPD = worsening progressive disease.McDermott et al, 2011.
Efficacy Results: RCC PatientsEfficacy Results: RCC Patients
McDermott et al, 2012.
Changes in Target Lesions Over Time in RCC Patients
Anti-PD-1 (BMS-936558) Dose Anti-PD-1 (BMS-936558) Dose Finding Study CA209010Finding Study CA209010
Arm 1 n = 50BMS-936558 (0.3 mg/kg) IV q3wks
Arm 2 n = 50BMS-936558 (2 mg/kg) IV q3wks
Arm 3 n = 50BMS-936558 (10 mg/kg) IV q3wks
1° end point: PFS as measured by TA2° end points: PFS, ORR, OS
Prior Anti-Angiogenic Tx(1:1:1 Randomization)N = 150
Completed Accrual 12/2011
US NIH, NCT01354431.
Anti-PD-1 (BMS-936558) Biomarker StudyAnti-PD-1 (BMS-936558) Biomarker StudyCA209009CA209009
Treatment Naïve
Arm 1 n = 20BMS-936558 (0.3 mg/kg) IV q3wks
Arm 2 n = 20BMS-936558 (2 mg/kg) IV q3wks
Arm 3 n = 20BMS-936558 (10 mg/kg) IV q3wks
1° end point: Measurement of immunomodulatory activity2° end points: PFS, ORR, safety, and tolerability
Arm 4 n = 20 (treatment naïve arm)BMS-936558 (10 mg/kg) IV q3wks
Prior Anti-Angiogenic Tx(1:1:1 Randomization)N = 80
Treatment NaïveCohort Closed 2/2012Other Cohorts Open
US NIH, NCT01358721.
Why Has Immunotherapy Been Why Has Immunotherapy Been Successful in Prostate Cancer?Successful in Prostate Cancer?
Better “Vaccines” ?
– Sipuleucel-T = Ex-Vivo Culture
– ProstVac = Heterologous Prime Boost (+ costimulation)
Better Antigens?
– PAP (no tolerance in animals)
– PSA (role in tumor progression)
Prostate Cancer = Better Target?
– Slow Growing
– Patient Selection (asymptomatic or minimally symptomatic)
– Patients = Castrate
Cha et al, 2011; Makarov et al, 2009.
Effect of Androgen-AblationEffect of Androgen-Ablationon T-Cell Response on T-Cell Response
Drake et al, 2005.
Testing the Optimal Sequencing of Testing the Optimal Sequencing of Androgen-Ablation and Androgen-Ablation and ““VaccinationVaccination””
P10-2P10-2Eligibility• Post Primary Rx (RP or XRT or RP + XRT)• PSADT ≤ 12 mos• Non-Metastatic (bone and CT scan)
Stratification• PSADT ≤ 3 mos or > 3 mos and ≤ 12 mos• RP or XRT or RP + XRT
Primary Objective: To determine whether ADT started before or after sipuleucel-T leads to superior augmentation of immune response
Primary End Point: Immune response, which will be evaluated with an INF-γ ELISPOT specific for PA2024
Treatment Arm 1
Sipuleucel-T ADTN = 30
Treatment Arm 2
ADT Sipuleucel-TN = 30
Immune Response, Safety
18-mos visit
Stu
dy
Par
tici
pat
ion
Co
ncl
ud
es
ADT = androgen deprivation therapy; RP = radical prostatectomy; XRT = radiation therapy; CT = computed tomography;PSADT = prostate-specific antigen double time; ELISPOT= enzyme-linked immunospot; INF= interferon.Antonarakis et al, 2011.
RENCA
Orthotopic
(0.5M Cells)
Treatment Ends
Days -8 -3
Sunitinib 40 mg/kg daily
0
Anti-PD-110 mg/kg
3 6 9 Day 12
Orthotopic RENCA Model Hypoxia High VEGF Levels Growth Inhibition With Sunitinib
Combining PD-1 Blockade Combining PD-1 Blockade With TKIs in RCCWith TKIs in RCC
Courtesy of Hans Hammers, MD, PhD.
Tumor ResponseTumor Response
Courtesy of Hans Hammers, MD, PhD.
14x 49x
Courtesy of Hans Hammers, MD, PhD.
Antibody ResponseAntibody Response
Phase I Study Combining Anti-PD-1 Phase I Study Combining Anti-PD-1 With Sunitinib or Pazopanib in Patients With Sunitinib or Pazopanib in Patients
With Metastatic RCCWith Metastatic RCC
Primary End Points: Safety, Tolerability, MTD
Metastatic RCC(Prior Pazopanib)
Arm S EscalationSunitinib + BMS-936558
Arm S ExpansionSunitinib + BMS-936558
MTD
Metastatic RCC(Prior Sunitinib)
Arm P EscalationPazopanib + BMS-936558
Arm P ExpansionPazopanib + BMS-936558
MTD
MTD = maximum tolerated dose.US NIH, NCT01472081.
Integrating Immunotherapy Into the Integrating Immunotherapy Into the Prostate Cancer Treatment ParadigmProstate Cancer Treatment Paradigm
Docetaxel Chemotherapy
AndrogenAblation
2004
Docetaxel Chemotherapy
AndrogenAblation
2010
Sipuleucel-T Sipuleucel-T
20122012
Docetaxel Chemotherapy
AndrogenAblation
Sipuleucel-T Sipuleucel-T
Cabazitaxel
AbirateroneAbiraterone
and beyond… Enzalutamide (MDV3100)
Iplimumab?
Key TakeawaysKey Takeaways
Sipuleucel-T
– FDA approved in US for CRPC
– Precise MOA under investigation
– T cell and antibody data consistent with an adaptive immune response
In development for prostate cancer
– ProstVac VF
• Phase III ongoing
– Anti-CTLA-4 (ipilimumab)
• Post-Tax phase III trials ongoing
In development for kidney cancer
– AGS-003
• Randomized phase III ongoing
– Anti-PD-1 (BMS-936558)
• Phase II dose finding completed
• Biomarker study ongoing
• TKI combination trial ongoing
Case Study: Prostate CancerCase Study: Prostate Cancer
Charles G. Drake, MD, PhDThe Sidney Kimmel Comprehensive Cancer
Center at Johns Hopkins
Clinical States ModelClinical States Model
Rising PSAHormone Naive
Non-Metastatic CastrateResistant
Metastatic CastrateResistantAsymptomatic
MetastaticCastrateResistantSymptomatic
PrimaryDisease
Metastatic Disease
(de novo)
MetastaticCastrateResistantPost Docetaxel
Sipuleucel-T
Abiraterone
Cabazitaxel
Enzalutamide (MDV3100)
DocetaxelADT
Modified from Scher et al, 2008.
Case StudyCase Study
64-yr-old man presented with an elevated PSA of 4.5 ng/mL
Negative DRE
Prostate Bx: Gleason 7 (3+4)
4/12 cores positive, all on right
10%–50% of each core involved
Bone scan and CT negative
PMH/PSH: None
DRE = digital rectal exam; PNBx = prostate needle biopsy; PMH = past medical history; PSH = past surgical history.
Question 1Question 1
What would you suggest as primary therapy?
1. RT alone
2. Brachytherapy in combination with RT
3. RT with ADT
4. Primary ADT
5. Radical prostatectomy
6. Cryotherapy
RT = radiation therapy; ADT = androgen deprivation therapy.NCCN, 2012a.
Case Study (cont.)Case Study (cont.)
Patient undergoes radical retropubic prostatectomy
– Gleason 7 (3+4)
– Organ Confined
– Negative Margins
– 5/5 LN negative
Question 2Question 2
Which subsequent therapy would you choose?
1. Observation
2. Adjuvant RT
3. Adjuvant ADT
4. Clinical Trial
NCCN, 2012a.
Case Study (cont.)Case Study (cont.)Course of TreatmentCourse of Treatment
Observed
3 yrs later presents with rising PSA
– Post-surgery nadir = 0.1
– 0.2, 0.2, 0.5
Referred to radiation oncology
Salvage RT (66 Gy over 8 wks)
– Well tolerated
NCCN, 2012a.
Case Study (cont.)Case Study (cont.)Course of TreatmentCourse of Treatment
Post RT PSA continues to rise
3 mos post RT = 2.3
6 mos = 7.0
9 mos = 16.5
Asymptomatic
– CT scan = negative for recurrent or progressive disease
– Bone scan = negative for evidence of metastases
NCCN, 2012a.
Question 3Question 3
What would you recommend at this time?
1. Continued observation
2. Initiate intermittent androgen ablation
3. Initiate continuous androgen ablation
4. Refer for Sipuleucel-T
5. Refer for clinical trial
NCCN, 2012a.
Case Study (cont.) Case Study (cont.) Course of TreatmentCourse of Treatment
Based on rapidly rising PSA (doubling time < 12 mos), patient starts continuous androgen-ablation
3 mos later PSA nadirs at 0.4
– Stable x 2 yrs
– 2 yrs 3 mos 1.2
– 2 yrs 6 mos 3.5
– 2 yrs 9 mos 11.2
Bone scan + (3 small rib lesions, R femur)
NCCN, 2012a.
Question 4Question 4
Current recommendation?
Asymptomatic, mCRPC
1. Switch bicalutamide to nilutamide
2. DC bicalutamide (antiandrogen withdrawal)
3. Ketoconazole + hydrocortisone
4. Abiraterone acetate
5. Sipuleucel-T
6. Docetaxel chemotherapy
NCCN, 2012a.
Case Study (cont.) Case Study (cont.) Course of TreatmentCourse of Treatment
Patient choses Rx with Sipuleucel-T
PSA continues to rise
What is next treatment modality?
– Abiraterone acetate + prednisone
– Enzalutamide (MDV3100)
– Docetaxel + prednisone
– Cabazitaxel
NCCN, 2012a.
Clinical States ModelClinical States Model
Rising PSA
Hormone
Naive
Non-Metastatic CastrateResistant
Metastatic CastrateResistant
Asymptomatic
MetastaticCastrateResistant
SymptomaticPrimary
Disease
Metastatic
Disease
(de novo)
MetastaticCastrateResistant
Post Docetaxel
Sipuleucel-T
Abiraterone
Cabazitaxel
Enzalutamide (MDV3100)
DocetaxelADT
Modified from Scher et al, 2008.
Immuno-Oncology: MelanomaImmuno-Oncology: Melanoma
Jedd D. Wolchok, MD, PhDMemorial Sloan-Kettering Cancer Center
Agents Used for Cancer Agents Used for Cancer ImmunotherapyImmunotherapy
Immune modulators
– BCG (bladder cancer)
– Alpha interferon (melanoma, kidney, leukemia)
– IL-2 (melanoma, kidney cancer)
– CTLA-4 blockade
Monoclonal antibodies
– Anti-CD20, CD19 (lymphoma)
– Anti-HER2 (breast cancer)
– Anti-EGF receptor (colorectal cancer)
Vaccines
– Hepatitis vaccine
– HPV vaccine
– BCG?
Adoptive cellular therapy
– Allogeneic bone marrow transplant
BCG = Bacillus Calmette-Guerin; HPV = human papillomavirus.
CR (n = 17)
PR (n = 26)
CR + PR (n = 43)
High-Dose IL-2 TherapyHigh-Dose IL-2 Therapy
RR: 16% (43/270)
Durable responses
– Median 8.9 mos
– CR: not reached
Atkins et al, 1999.
0 10 20 30 40 50 60 70 80 90 130
0.8
0.6
0.4
0.2
0.0
1.0
100 110 120Pro
bab
ility
of
Co
nti
nu
ing
Res
po
nse
(%
)
Duration of Response (mos)
T-Cell Remains Active
Korman et al, 2006.
T-Cell
Inactivation
T-Cell Activation
Ipilimumab
APC
CTLA-4
T Cell
APC
T CellResting
T Cell
APC
B7
CD28TCR
HLA
CTLA-4
CTLA-4
Ipilimumab, A CTLA-4 Blocking MoAB, Ipilimumab, A CTLA-4 Blocking MoAB, Augments T-Cell Activation Augments T-Cell Activation
Experienced complete resolution of 2 subcutaneous nodules, 31 lung metastases and 0.5 cm brain metastasis
Clinical Response in Melanoma: NCI Clinical Response in Melanoma: NCI
Phan et al, 2003.
Immune-Related Adverse EventsImmune-Related Adverse Events
Rash (20%)
Colitis/Enteritis (15%)
Elevated AST/ALT (10%)
Thyroiditis (3%–5%)
Adrenal Insufficiency (< 1%)
Hypophysitis (3%–5%)
Severity is inversely related to vigilance of surveillance.If detected early, most are easily treated and reversible.
Wolchok, 2010.
MDX010-20 Study SchemaMDX010-20 Study Schema
Screening
Induction: Ipilimumab at 3 mg/kg, with or without gp100, q3wks for 4 treatments
Reinduction: Patients with SD for 3 mos’ duration from Wk 12, or a confirmed CR or PR, could receive additional therapy with their assigned treatment regimen upon PD
Ipilimumab + gp100
(n = 403)
Ipilimumab alone
(n = 137)
gp100 alone
(n = 136)
≥ 1 Re-Induction
(eligible patients)Induction
Previously treated,
HLA-A2*0201+ patients with
advanced melanoma(N = 676)
R
A
N
D
O
M
I
Z
E
Follow-Up
PD
PD
PD
3:1:1
Hodi et al, 2010.
Ipilimumab + gp100
Ipilimumab alone
gp100 alone
Years
Ipilimumab + gp100 (A)Ipilimumab + gp100 (A)Ipilimumab alone (B)Ipilimumab alone (B)gp100 alone (C)gp100 alone (C)
1 2 3 4
Comparison HR Comparison HR PP-value-value Arm A vs CArm A vs C 0.680.68 0.00040.0004 Arm B vs CArm B vs C 0.660.66 0.00260.0026 Arm A vs BArm A vs B 1.041.04 0.75750.7575
Survival Rate Ipilimumab + gp100 Ipilimumab alone gp100 alone
1-yr 44% 46% 25%
2-yr 22% 24% 14%
Kaplan-Meier Analysis of SurvivalKaplan-Meier Analysis of Survival
Hodi et al, 2010.
Estimated Survival Rate 1 Yr 2 Yr 3 Yr*
Ipilimumab + DTICN = 250
47.3 28.5 20.8
Placebo + DTICN = 252
36.3 17.9 12.2
Study 024: Overall Survival Study 024: Overall Survival
*3-yr survival was a post-hoc analysis.Wolchok et al, 2011.
11/28/06 1/9/0711/28/06 1/9/07
Wolchok , 2010.
Ipilimumab Pattern of Response:Ipilimumab Pattern of Response:Responses After the Appearance and Responses After the Appearance and
Subsequent Disappearance of New LesionsSubsequent Disappearance of New Lesions
3 mg/kg Ipilimumab q3wks X 4
Pre-Treatment
Wk 36: Still Regressing
Wk 12: Progression
Wk 20: Regression
New lesions
Wolchok et al, 2008a.
July 2006
Four Patterns of Response to Four Patterns of Response to Ipilimumab Therapy Were ObservedIpilimumab Therapy Were Observed 2 conventional
– Response in baseline lesions
– SD with slow, steady decline in total tumor volume
2 novel
– Response after initial increase in total tumor volume
– Response in index plus new lesions at or after the appearance of new lesions
Wolchok et al, 2009.
CTLA-4 Blockade: A Case Study for CTLA-4 Blockade: A Case Study for Immunotherapy in Need of BiomarkersImmunotherapy in Need of Biomarkers
Knowns
Clinical benefit for a subset of patients with refractory melanoma
Reversible mechanism-based side effects
Tumor responses tend to be durable
Kinetics of response unlike cytotoxics
Unknowns
Biomarkers for response
Biomarkers for toxicities
Effect on effector vs regulatory T cells in humans
Antigens recognized after infusion
Importance of vaccination before treatment
Relevance of PBMC vs. tumor site findingsPBMC = peripheral blood mononuclear cell.
Wolchok, 2010.
This patient population comprises all patients (N = 73) available at the Immune Monitoring Facility of Memorial Sloan-Kettering Cancer Center, New York
Mean longterm ALC
1
2
3
4clinicalbenefit
no clinicalbenefit
-4 m
on
ths
-3 m
on
ths
-2 m
on
ths
-1 m
on
th
week 1
week 4
week 7
week 1
0w
eek 1
2
week 2
4
week 3
6
AL
C [
K/m
cl]
ALC = absolute lymphocyte count.Ku et al, 2010.
ALC Correlates With Clinical BenefitALC Correlates With Clinical Benefit
AMP-224, CT-011, MDX-1106, MK-3475
BMS-663513PF-05082566
Ipilimumab, Tremelimumab
Anti-OX40
Positive and Negative Signals Regulate Positive and Negative Signals Regulate T-Cell ActivationT-Cell Activation
Wolchok et al, 2008b, 2010.
PD-1: Role in T-Cell ActivationPD-1: Role in T-Cell Activation
Member of CD28 family involved in T-cell regulation
Expressed by activated T cells, memory T cells, and regulatory T cells
Down regulates T-cell activity upon binding to PD-L1/L2
Tumor PD-L1 expression may correlate with negative prognosis potential mechanism of tumor self defense
What is PD-1?
T CellDendritic Cell, Parenchymal Cell, Tumor Cell
Sznol et al, 2010.
MDX-1106 (BMS-936558/ONO-4538) MDX-1106 (BMS-936558/ONO-4538) Human Anti-PD-1 Antibody Human Anti-PD-1 Antibody
IgG4 (S228P) – no ADCC/CDCC activity
High affinity binding to human and cynomolgus PD-1
Blocks binding of PD-1 to PD-L1 and PD-L2
In vitro, BMS-936558
– Promotes cytokine production/proliferation
• Human allogeneic MLR
• Antigen reactive T cells in response to CMV or tumor antigen
– Reverses T reg-mediated suppression of allogeneic MLR
CDCC = complement-dependent cellular cytotoxicity; MLR = mixed lymphocyte reaction; CMV = cytomegalovirus. Sznol et al, 2010.
Change in Tumor BurdenChange in Tumor Burden 296 patients with advanced solid tumors, including 104 melanoma patients
– 26 objective responses observed at doses ranging from 0.1–10.0 mg/kg
– 3.0 mg per kilogram: Objective responses noted in 41%
– SD lasting 24 wks or more was observed in 6 patients (6%)
Topalian et al, 2012.
Preclinical DataPreclinical Data
PD-1 and CTLA-4 combination blockade expands infiltrating T cells and reduces regulatory T and myeloid cells within B16 melanoma tumors
Curran et al, 2010.
Time (days)
Ipilimumab
MDX-1106
Induction Maintenance
Dosing/Evaluation Schedule
Imaging Studies
Cohort MDX-1106 Ipilimumab
1 0.3 mg/kg 3 mg/kg
2 1 mg/kg 3 mg/kg
3 3 mg/kg 3 mg/kg
4 3 mg/kg 10 mg/kg
5 10 mg/kg 10 mg/kg
Dose Escalation
09-155 – Study Design 09-155 – Study Design
US NIH, NCT01024231.
PET Scans at Baseline and Day 15 PET Scans at Baseline and Day 15 After PLX4032After PLX4032
#63 MSKCC#69 MDA
#59 Peter MacCallum#56 Vanderbilt
PET = positron emission tomography; MDA = The University of Texas M. D. Anderson Cancer Center; MSKCC = Memorial Sloan-Kettering Cancer Center.Chapman, 2009.
Decreased immune suppressive factor
release
Activation of T cells and increased homing
DC
Increased antigen Cross-presentation
Increased direct antigen presentation
How Can BRAF Targeted Therapy Increase the How Can BRAF Targeted Therapy Increase the Activity of Tumor Immunotherapy?Activity of Tumor Immunotherapy?
BRAF BRAFi
DC = dendritic cell
Pre-clinical Evidence Supporting the Feasibility Pre-clinical Evidence Supporting the Feasibility of Combinations of BRAFi + Immunotherapyof Combinations of BRAFi + Immunotherapy
Oncogenic BRAF-induced production of immune suppressive factors (IL-6, IL-10, VEGF) is inhibited with a MEK inhibitor (Sumimoto et al, 2006)
Vemurafenib increases melanosomal antigen expression and T cell recognition (Boni et al, 2010)
Human T cells exposed to vemurafenib are fully functional (Comin-Anduix et al, 2010)
Goel, Haluska et al. Oncogene. 2009
BRAFV600E mutation
Days
0 5 10 15 20 25
% T
umor
-Fre
e A
nim
als
0
20
40
60
80
100
Vehicle Control (n = 14)
PLX4032 (n = 14)
pmel-1 ACT (n = 19)
pmel-1 ACT+PLX4032 (n = 19)
3 replicated experiments, p < 0.0001 by log rank test
pERK
ERK
VC 1 155
Tubulin
PLX4032 (µM)
CRAF
MEK1/2
ERK
P
P
BRAF
PLX4032
MAPK signaling
Koya et al, 2012.
Pre-clinical Evidence Supporting the Feasibility of Pre-clinical Evidence Supporting the Feasibility of Combinations of BRAFi + Immunotherapy (cont.)Combinations of BRAFi + Immunotherapy (cont.)
PLX4720 treatment leads to a decreased frequency of immune cells in BRAFV600E/PTEN-/- melanomas and this cannot be restored by CTLA-4 blockade
Addition of anti-CTLA-4 mAb treatment to PLX4720 treatment does not further improve tumor growth control
Pre-clinical Evidence Against the Feasibility of Pre-clinical Evidence Against the Feasibility of Combinations of BRAFi + ImmunotherapyCombinations of BRAFi + Immunotherapy
Hooijkaas et al, 2012.
Clinical Evidence Supporting the Feasibility of Clinical Evidence Supporting the Feasibility of Combinations of BRAFi + ImmunotherapyCombinations of BRAFi + Immunotherapy
CD8+ T cell infiltration in regressing melanoma lesions after BRAFi therapy
T cells from patients treated with dabrafenib are fully functional
Wilmott et al, 2012; Hong et al, 2012.
Results of Diagnostic and Radiotherapy Simulation Results of Diagnostic and Radiotherapy Simulation Imaging Throughout the Disease CourseImaging Throughout the Disease Course
Postow et al, 2012.
Postow et al, 2012.
NY-ESO-1 Expression and Antibody Response NY-ESO-1 Expression and Antibody Response to Ipilimumab and Radiotherapyto Ipilimumab and Radiotherapy
Results of Flow Cytometry of Results of Flow Cytometry of Peripheral Blood Mononuclear CellsPeripheral Blood Mononuclear Cells
Postow et al, 2012.
Key TakeawaysKey Takeaways
Checkpoint blockade is an effective treatment with durable responses
New and promising immune modulators are in clinical development
Combination therapy will be necessary for immunotherapy to achieve full potential (other immune modulators, vaccines, radiation, chemotherapy, targeted therapy, antiangiogenic therapy)
Case Study: MelanomaCase Study: Melanoma
Antoni Ribas, MD, PhDUniversity of California, Los Angeles
Case Study 1Case Study 1
A 55-yr-old man is diagnosed with melanoma, and further examination reveals metastatic disease
Discussion
– What factors should be considered when selecting frontline therapy for this patient?
– What indications would lead to your recommendation of a specific treatment?
– Under what circumstances might you suggest this patient participate in a clinical trial?
Case Study 1: Follow-UpCase Study 1: Follow-Up The patient is treated with ipilimumab; after 12 wks
of therapy, he has not responded and new hepatic lesions are observed
– How might this patient’s progression affect your recommended treatment strategy?
– At what point might you consider alternative therapeutic approaches?
– What factors might affect your treatment decisions?
NCCN, 2013.
Case Study 1: Follow-Up (cont.)Case Study 1: Follow-Up (cont.)
The patient has remained on ipilimumab and has begun to suffer from a grade 2 rash and diarrhea
– What concomitant medications can be used to reduce the severity of this AE?
– Can dose reductions/omissions be used for these AEs?
– How might this affect your recommended treatment strategy?
NCCN, 2013.
Case Study 2Case Study 2 A 61-yr-old woman is diagnosed with metastatic
melanoma and receives alkylating agents as frontline therapy. After 20 wks, there has been no measurable response. Testing of the tumor tissue reveals a V600E mutation. The patient wishes to discuss treatment options for refractory disease, including the possibility of clinical trial enrollment.
– What factors might help to determine an alternative treatment strategy?
– Which late-stage trials might be most promising for patients with this mutation?
– What other molecular approaches might help to direct potential therapies?
NCCN, 2013.
Immuno-Oncology: Immuno-Oncology: Non-Small Cell Lung CancerNon-Small Cell Lung Cancer
John Powderly II, MD, CPICarolina BioOncology Institute, PLLCCancer Therapy & Research Center
BackgroundBackground
NSCLC remains the leading cause of cancer-related mortality in the US and worldwide
NSCLC long considered non-immunogenic, that is, unable to induce immune destruction
However, there is evidence to suggest that the immune system can recognize NSCLC:
– Tumor-infiltrating lymphocytes have been identified in NSCLC patients, and correlates with survival
– T cells reactive to tumor associated antigens can be found in patients with NSCLC
NSCLC = non-small cell lung cancer.
Background (cont.)Background (cont.)
Why have prior attempts to modulate the immune system in NSCLC patients failed to show consistent benefit?
– Not the right immunotherapy
– Need for combination therapy to fully enable immune attack- e.g. immunotherapy with other immunotherapy, chemotherapy and/or radiation
Problem of immune tolerance- lack of immune attack despite recognition (e.g. immune checkpoints)
Newer therapies, including immune checkpoint inhibitors and novel vaccines are beginning to show promise in NSCLC
Clinical Significance of Tumor-Infiltrating Clinical Significance of Tumor-Infiltrating Lymphocytes in Lung Neoplasms Lymphocytes in Lung Neoplasms
Resected Squamous CellLung Cancer, Stage I–IIIap = .03
Ruffini et al, 2009.
Time (yrs)
Cancer Self-Tolerance BlockadeCancer Self-Tolerance Blockade Endogenous immune response to cancer is observed in patients,
however it is ineffective
– Tolerance: Cancer is viewed as self
– Tumors exploit mechanisms to suppress the host immune response
• Immune checkpoints (CTLA-4, PD-1) abort immune responses
– Co-opted by tumors to evade immune destruction
– “Tumor adaptive immune resistance”
• Immune checkpoint inhibitors may block self-tolerance of cancer, and enable antitumor immune destruction
Topalian et al, 2011.
Normal T Cell Activation and AttackNormal T Cell Activation and Attack
Dendritic cell
MHC
B7
TCR
CD28
T cell
Ribas, 2012.
T cell
MHCTCR
Cancer Cell
Effector phasePriming phase
Lymph node
Peripheral tissue
Release of :
- Perforin/ granzyme
- Cytokines
T cell proliferation
PD-L1
Immune Checkpoints – CTLA4 & PD1Immune Checkpoints – CTLA4 & PD1
Dendritic cell
MHC
B7
TCR
CD28
CTLA4
T cell
Ribas, 2012.
T cell
MHCTCR
PD-1
Cancer Cell
Antibody Antibody Antibody
B7
Effector phasePriming phase
Lymph node
Peripheral tissue
Inhibitory signals
Negative regulation
Self-Tolerance BlockadeSelf-Tolerance BlockadeDrugs in DevelopmentDrugs in Development
Anti-CTLA-4
– Ipilimumab (fully human IgG1, Medarex/BMS)
– Tremelimumab (fully human IgG2, Pfizer/Medimmune)
Anti-PD-1
– MDX-1106/BMS-936558 (fully human IgG4, Medarex/BMS)
– CT-011 (humanized IgG1, Curetech/Teva)
– MK-3475 (humanized IgG4, Merck)
– AMP-224 (B7-DC/IgG1fusion protein, Amplimmune/GSK)
Anti-PD-L1
– MDX-1105/BMS-936559 (fully human IgG4, Medarex/BMS)
– MPDL3280A (Genentech/Roche)
Pierard et al, 2012; Brahmer et al, 2010; Topalian et al, 2012; Paradoll et al, 2012b.
Ipilimumab in Combination With Paclitaxel Ipilimumab in Combination With Paclitaxel and Carboplatin as First-Line Treatment and Carboplatin as First-Line Treatment in Lung Cancer: Phase II Trial CA184-041in Lung Cancer: Phase II Trial CA184-041
Ipilimumab 10 mg/kg, Paclitaxel 175 mg/m2, Carboplatin AUC = 6
– Randomized 3 Arms 1:1:1
• Concurrent Ipilimumab + Paclitaxel/Carboplatin
• Phased Ipilimumab + Paclitaxel/Carboplatin
• Placebo Control + Paclitaxel/Carboplatin
Stratified by 2 Cohorts
– Stage IIIB/IV NSCLC, n = 203
– Extensive Disease SCLC (ED-SCLC), n = 128
Eligibility: ECOG 0–1; ECOG 0–2; at least 1 measurable lesion, no prior lung cancer therapy, no prior auto-immune disease, no active brain mets
ECOG = European Cooperative Oncology Group.Lynch et al, 2011; Reck et al, 2011.
CA184-041: Study SchemaCA184-041: Study SchemaStage IIIB/IV NSCLC CohortStage IIIB/IV NSCLC Cohort
p = placebo; c = chemotherapy (Pac/Carbo) Ipi (10 mg IV).Lynch et al, 2011.
CA184-041: Stage IIIB/IV NSCLung irPFSCA184-041: Stage IIIB/IV NSCLung irPFS
Lynch et al, 2012.
Time (mos)
CA184-041: Stage IIIB/IV NSCLungCA184-041: Stage IIIB/IV NSCLung Overall Survival Overall Survival
Lynch et al, 2012.
Time (mos)
CA184-041: Stage IIIB/IV NSCLungCA184-041: Stage IIIB/IV NSCLungSummary ConclusionsSummary Conclusions
Phased Concurrent Control
Median irPFS 5.7 mos 5.5 mos 4.6 mos
Median PFS 5.1 mos 4.1 mos 4.2 mos
irBORR 32% 21% 18%
BORR 32% 21% 14%
Median OS 12.2 mos 9.7 mos 8.3 mos
Grade 3/4 irAEs 15% 20% 6%
Any Grade 4 AEs 12% 27% 11%
Treatment-Related Deaths 0 1 patient 1 patient
Lynch et al, 2012.
CA184-041: Stage IIIB/IV NSCLC CohortCA184-041: Stage IIIB/IV NSCLC CohortActivity of Phased-IPI by Baseline HistologyActivity of Phased-IPI by Baseline Histology
Lynch et al, 2011.
CA184-041: Stage IIIB/IV NSCLC CohortCA184-041: Stage IIIB/IV NSCLC CohortOverall Survival Squamous SubsetOverall Survival Squamous Subset
Lynch et al, 2011.
CA184-041: Stage IIIB/IV NSCLC CohortCA184-041: Stage IIIB/IV NSCLC CohortMost Common (> 15% Any Arm) Adverse EventsMost Common (> 15% Any Arm) Adverse Events
Lynch et al, 2011.
Ongoing Lung Cancer Ipilimumab TrialsOngoing Lung Cancer Ipilimumab Trials
NSCLC
– CA184-104: Randomized, Multi-Center, Double-Blind, Phase III Trial Comparing Efficacy of Ipilimumab in Addition to Paclitaxel and Carboplatin in Subjects With Stage IV/Recurrent NSCLC (NCT01285609) Global 920 Patients
– CA184-124: Randomized, Open-Label, Phase II Safety and Efficacy Trial of Ipilimumab Vs. Pemetrexed in Subjects With Recurrent/Stage IV Non-Squamous, NSCLC Who Have Not Progressed After Four Cycles of Platinum-Based First-Line Chemotherapy (NCT01471197) Global 200 Patients
SCLC
– CA184-156: Extensive-Disease SCLC Subjects Comparing Ipilimumab Plus Etoposide and Platinum Therapy to Etoposide and Platinum Therapy Alone (NCT01450761) Global 912 Patients
– The Addition of Ipilimumab to Carboplatin and Etoposide Chemotherapy for Extensive Stage SCLC (NCT01331525) Europe
Clinicaltrials.gov, 2012.
Adaptive Immune Resistance
Tumor
OncogenicPathway
T Cell
TCR
PD-1
MHC + Peptide
PD-L1
Oncogene-Driven PD-L1Expression
Tumor
PD-L1
Adaptive Up-Regulation Of PD-L1 Turns T Cell OFF
Tumor
Interferon g
Immune Resistance: PD-1Immune Resistance: PD-1Innate Immune Resistance
Pardoll, 2012a; Slide from Immuno-Oncology GU presentation by Charles Drake.
T Cell T Cell
B7-H1 (PD-1L) on Cancer Cells In Vitro B7-H1 (PD-1L) on Cancer Cells In Vitro Is Inducible by Gamma InterferonIs Inducible by Gamma Interferon
Haile et al, 2011.
B7-H1 (PD-1L) Expression on NSCLC and B7-H1 (PD-1L) Expression on NSCLC and Relationship With TIL PD-1 ExpressionRelationship With TIL PD-1 Expression
52 resected lung cancers
Fewer TIL in B7-H1+ regionsp = .01
Fewer PD-1+ TIL in B7-H1 regionsp = .02
Concluded: Expression of B7-H1 on tumorcells in local areas reciprocally correlated With # TIL, and may contribute to negative regulation in antitumor immune response
Konishi et al, 2004.
Phase Ia Study of Single-Agent Phase Ia Study of Single-Agent Anti-PD-1 (MDX-1106/BMS-936558/ONO-4538) in Anti-PD-1 (MDX-1106/BMS-936558/ONO-4538) in
Refractory Solid TumorsRefractory Solid Tumors– Fully human IgG4 anti-human PD-1 blocking Ab - No ADCC/CD
– High affinity for PD-1 (KD ~ 3 nM)
– Blocks binding of both PD-L1 (B7-H1) and PD-L2 (B7-DC)
– Among 39 Patients:
• 1 CR (CRC), 2 PRs (Melanoma, RCC), 12 SD > 3 mos, including2 significant mixed responses (NSCLC, Melanoma)
• CR and PR were ongoing 3–21+ mos
– Toxicities: No DLT; MTD not reached
• Grade 3 colitis (1 melanoma patient, after 5 doses)
• Grade 2 hypothyroidism (1 patient)
• Grade 2 polyarticular arthropathies (2 patients, required oral steriods)
– Among 9 patients examined, tumor expression of B7-H1 (PD-1L) showed correlation with likelihood of response
DLT = dose-limiting toxicity.
Brahmer J, et al. J Clin Oncol 2010;28:3167-75
61-yr-old BF stage IV NSCLC (squamous) bilateral lung metastasis, bone mets. Prior treatment carboplatin/vinorelbine/bevacizumab.
May 2007, Rx single dose of MDX-1106, anti-PD-1 mAb (1 mg/kg IV)
8 wks 41% RECIST PR, but 12-wk scans showed new spine mets (mixed response)
Rechallenged MDX-1106, progressed
May 2007 July 2007
MDX-1106 001: Phase I Study of Single-Agent MDX-1106 001: Phase I Study of Single-Agent Anti-PD-1 (MDX-1106) in Refractory Solid Tumors Anti-PD-1 (MDX-1106) in Refractory Solid Tumors
(cont.)(cont.)
RECIST = Response Evaluation Criteria in Solid Tumors.Brahmer et al, 2010.
BMS-936558 (Anti-PD1) Study Design: BMS-936558 (Anti-PD1) Study Design: Phase Ib Multi-dose RegimenPhase Ib Multi-dose Regimen
Topalian et al, NEJM, 2012.
BMS-936558 (Anti-PD-1):BMS-936558 (Anti-PD-1): Expansion Cohorts for NSCLC Expansion Cohorts for NSCLC
Baseline Characteristics Baseline Characteristics
Summary of Key Safety ResultsSummary of Key Safety Results
MTD was not identified at doses up to 10 mg/kg
There was no apparent relationship between drug dose and AE frequency in all treated patients or NSCLC patients
In the total patient population across all tumor types:
Grade 3-4 drug-related AEs occurred in 14% of patients
Grade 1-2 pneumonitis was noted in 6 (2%) patients
Three drug-related deaths occurred in patients with pneumonitis (2 with NSCLC and 1 with CRC)
In NSCLC patients:
Grade 3-4 drug-related AEs occurred in 8% of patients
Grade 1-2 pneumonitis was noted in 4 (3%) patients
The most common grade 3-4 AEs were fatigue, pneumonitis, and elevated AST (2 pts each)
Clinical Activity of BMS-936558 in Clinical Activity of BMS-936558 in NSCLC PatientsNSCLC Patients
Clinical Activity by Histology, Clinical Activity by Histology, Efficacy PopulationEfficacy Population
Safety, Activity, and Immune Correlates Safety, Activity, and Immune Correlates of Anti-PD-1 Antibody (BMS-936558, of Anti-PD-1 Antibody (BMS-936558,
MDX-1106) in Cancer (cont.)MDX-1106) in Cancer (cont.)
Baseline 2 Mos 4 Mos
NSCLC Patient With Immune-Related Pattern of Delayed Response
Topalian et al, 2012.
Pre/ Post BMS 936558 (Jun / Oct Pre/ Post BMS 936558 (Jun / Oct ’’11)11)
- 58 y/o ex smoker with squam NSCLC- 4 prior tx for Stage IV disease- Left flank pain resolved within 2 mos
Anti-PD-1 mAb Lung Cancer ResponseAnti-PD-1 mAb Lung Cancer Response
60-yr-old man
– Diagnosed in 2002
Intermittent responses but eventual progression on multiple prior combination chemotherapies and RT
RX MDX-1106 10 mg/kg
A: Baseline
B: Cycle 2 assessment
Courtesy of Dr. Brahmer and Dr. Topalian, John Hopkins.
Correlation of PD-L1 Expression in Pretreatment Correlation of PD-L1 Expression in Pretreatment Tumor Biopsies with Clinical OutcomesTumor Biopsies with Clinical Outcomes
Ongoing PD-1 Blockade Trials Ongoing PD-1 Blockade Trials That Include Lung CancerThat Include Lung Cancer
CA209-012: Multi-Arm Study of BMS-936558 (MDX-1106, anti-PD-1 mAb) in Combination With3 Platinum-Based Doublet Chemotherapy Regimens in Subjects With Treatment-Naive Stage IIIB/IV NSCLC (NCT01454102) North America, 60 Patients
Phase I Study of Single Agent MK-3475 in Patients With Progressive Locally Advanced or Metastatic Carcinoma, Melanoma, and Non-Small Cell Lung Carcinoma (NCT01295827)
Clinicaltrials.gov, 2012.
Pending PD-1 Blockade Pending PD-1 Blockade Registration NSCLC Trials Registration NSCLC Trials
An Open-Label Randomized Phase III Trial of BMS-936558 Versus Docetaxel in Previously Treated Advanced or Metastatic Squamous Cell Non-small Cell Lung Cancer (NCT01642004)
An Open-Label Randomized Phase III Trial of BMS-936558 Versus Docetaxel in Previously Treated Advanced or Metastatic Non-squamous Cell Non-small Cell Lung Cancer (NCT016738677)
Safety and Activity of Anti-PD-L1 Antibody Safety and Activity of Anti-PD-L1 Antibody in Patients With Advanced Cancerin Patients With Advanced Cancer
Phase Ia, 207 patients solid tumors stage IV– Rx monotherapy anti-PD-L1 antibody q2wks (3 doses over
6-wk cycles) up to 16 cycles until PD or CR
– Cumulative objective response• Melanoma 17%
• RCC 12%
• NSCLC 10% (75 patients with NSCLC)
– 50% of responders durable > 1 yr
– Immune-related events 39% (rash, hypothryoidism, hepatitis, myasthenia gravis)
– Drug related grade 3–4 AEs 9%
– NSCLC 12% SD; Clinical benefit (CR + PR + SD) = 22%
Brahmer et al, 2012.
Safety and Activity of Anti-PD-L1 Antibody Safety and Activity of Anti-PD-L1 Antibody in Patients With Advanced Cancerin Patients With Advanced Cancer
Brahmer et al, 2012.
Safety and Activity of Anti-PD-L1 Antibody Safety and Activity of Anti-PD-L1 Antibody in Patients With Advanced Cancerin Patients With Advanced Cancer
Brahmer et al, 2012.
Lung Cancer VaccinesLung Cancer Vaccines
GSK1572932A (MAGE-A3) VaccineGSK1572932A (MAGE-A3) Vaccine
MAGE-A3 (melanoma associated antigen A3) genes constitute a family of ‘cancer-germline’ or ‘cancer testis’ genes (testes, placenta, cancers)
30-50% of NSCLCs express MAGE-A3 on their surface (higher expression in squamous cell NSCLC)
GSK1572932A (MAGE-A3) vaccine
• Recombinant protein vaccine combined with immunological adjuvant ASO2B
US NIH, NCT00480025
MAGRIT MAGRIT MMAGE-A3 as AGE-A3 as AAdjuvant Non-djuvant Non-Small Cell LunSmall Cell LunGG Cance CanceRR IImmunommunoTTherapyherapy
Primary endpt: DFS overall and DFS in a gene signature positive population
11,000 patients screened, 10,000 tumors tested, 3,235 tested + MAGE A3, 2270 randomized (Largest lung cancer trial ever)
L-BLP (Stimuvax)L-BLP (Stimuvax)
MUC-1 is a cell surface mucinous glycoprotein overexpressed or aberrantly glycosylated in a number of epithelial malignancies
Aberrant glycosylation appears to expose the core peptide of MUC-1 to immune effector cells
L-BLP-25: MUC-1 vaccine consisting of the BLP 25 peptide, monophosphoryl lipid A adjuvant and liposomal cholesterol, dimyristoyl phosphatidylglycerol (DMPG) and dipalmitoyl phosphatidylcholine (DPPC) to facilitate immune recognition
RPhII of Stimuvax in advanced NSCLC- Subgroup analysis suggested benefit in Stg IIIB (but not SS)
L-BLP25: A Peptide Vaccine Strategy L-BLP25: A Peptide Vaccine Strategy in NSCLCin NSCLC
Randomized Phase IIB 171 Patients Stage IIIB–IV Canada & UK
Post hoc subgroup Analysis IIIB(65 patients)
p Value non-significant But trend favorable. Led to phase III trial with stage III patients ongoing.
BSC = best supportive care.Sangha et al, 2007.
Survival Time (mos)
START Phase III Trial: L-BLP-25 inSTART Phase III Trial: L-BLP-25 inUn-resectable, Stage III NSCLCUn-resectable, Stage III NSCLC
•Unresectable, stage III
NSCLC
•Stable or responding
disease after chemoradio-
therapy
•PS 0-1
(Adjusted N=1476)
R
A
N
D
O
M
I
Z
E
L-BLP-25 930 μg
q7d x 8 cycles
Placebo
q7d x 8 cycles
• Primary endpoint: survival
• Secondary endpoints: TTP; TTSP; 1-, 2-, and 3-year survival; and safety
L-BLP-25 930 μg
q6w
Placebo
q6w
Maintenance until
progressionEligibility Criteria
TTSP=time to symptom progression.
US NIH, NCT01015443
Belagenpumatucel-L (Lucanix)Belagenpumatucel-L (Lucanix)
One mechanism used by tumors to escape immune surveillance is secretion of transforming growth factor beta (TGF-β) which:
– Inhibits T and B cell activation
– Inhibits dendritic cell maturation and antigen presentation
– Inhibits NK and lymphokine activated (LAK) cells
– Induces immunosuppressive FoxP3 Treg cells
Lucanix- allogeneic whole tumor vaccine consisting of four irradiated NSCLC tumor cell lines modified to block TGF- β2 secretion
PhII (primarily IIIb/IV), n=75, 3 doses tolerated well with encouraging survival
Lucanix Phase III NSCLC trialLucanix Phase III NSCLC trial
Stage III-IV NSCLC
without POD after
1-6 cycles of 1st line
platinum based chemo
(n=1322)
Lucanix
18 monthly inj
2 quarterly inj
+ BSC
Placebo
+ BSC
Survival
• Primary endpoint:
– Overall survival
• Secondary endpoints:
– Safety
– PFS
– OR
– QOL
Randomization
* 420/ 506 accrued as of 2-09-2012US NIH, NCT00676507.
Talactoferrin Alfa (TLF)Talactoferrin Alfa (TLF)
Recombinant human lactoferrin with immunomodulatory properties
After ingestion, TLF acts of GI epithelium to release chemokines which recruit immature dendritic cells to gut-associated lymphoid tissue where they undergo maturation/ activation
– Initiate both active immunity (via NK cells) and adaptive immunity by antigen presentation to CD8+ T cells that seek out tumor
Encouraging survival data in RPhII trials as monotherapy and with chemotherapy
Parikh et al, 2011; Digumarti, 2011
FORTIS-M (LF-0207)FORTIS-M (LF-0207)
742 patients
enrolled
Stage IIIB/IV
NSCLC who have
failed two or more
prior regimens
ECOG PS 0-2
R
A
N
D
O
M
I
Z
E
TLF 1.5 g BID
12 wks on, 2 wks off
up to 5 cycles
+ BSC
Placebo BID
12 wks on, 2 wks off
up to 5 cycles
+ BSC
2:1
Primary Endpoint: Overall Survival
Secondary Endpoints: 6-month & 1-year survival rate, PFS, ORR, Disease Stabilization Rate (PR+CR+SD), TLF
safety and tolerability
Stratifications: Prior regimens (2 vs ≥3), ECOG PS, Geographical region
US NIH, NCT00707304
FORTIS-C (LF-0208)FORTIS-C (LF-0208)
1,100 patients previously untreated
Stage IIIB/IV NSCLC
ECOG PS 0-1
TLF 1.5g BID+ Carboplatin (AUC 6) + Paclitaxel (200mg/m2)
q3 weeks for 6 cycles
Placebo BID+ Carboplatin (AUC 6) + Paclitaxel (200mg/m2)q3 weeks for 6 cycles
TLF until disease progression
(up to 18 months)
Placebo until disease progression (up to 18
months)
Co-Primary Endpoints: PFS & OSSecondary Endpoints: Objective Response Rate, Duration of Response, Safety
Stratifications: gender; disease stage; geographical region
1:1
RANDOMIZE
US NIH, NCT00706862
Additional Immunotherapies Being Evaluated in Additional Immunotherapies Being Evaluated in NSCLC & SCLCNSCLC & SCLC
NSCLC
– TG4010 (modified vaccine virus Ankara expressing MUC, IL-2, Transgene/Novartis)
• Phase IIB/III (NCT01383148)
– EGF (conjugated to an immunoadjuvant, “Cuban Vaccine”)
• Phase III (NCT01444118)
– Reolysin (naturally occurring unmodified oncolytic virus)
• Phase I/II (NCT00861627; NCT00998192)
SCLC
– -SVV1 (Seneca Valley Virus; replication competent picovirus with selective tropism for tumors with neuroendocrine features)
• Phase II (NCT01017601)
– Autologous dendritic cell-adenovirus p53 vaccine +/- tretinoin
• Phase II (NCT00618891)
Key TakeawaysKey Takeaways
Tumor infiltrating lymphocytes in lung cancer predict improved survival
Lung cancer can be immunogenic, withself-tolerance blockade drugs
– Anti-CTLA4 (randomized phase II durable responses)
– Anti-PD1/PDL1 (early phase IB durable responses)
– Phase III trials launched
Phase III Vaccine trials close to completing accrual
Case Study: Case Study: Non-Small Cell Lung CancerNon-Small Cell Lung Cancer
John Powderly II, MD, CPICarolina BioOncology Institute, PLLCCancer Therapy & Research Center
Case Study: Diagnostic Work-UpCase Study: Diagnostic Work-Up
69-yr-old Caucasian man, prior smoker, presenting with cough and night sweats
– 1/06 CT Chest: RUL necrotic mass 5.7 x 5.9 cm (? abscess vs. cancer)
– 1/06 Bronchoscopy RUL lung biopsy (Bx): Poorly differentiated adenocarcinoma with extensive tumor necrosis
– PET: RUL mass SUV 14.7; precarinal LN SUV 4.0
– CT brain: Neg
RUL = right upper lobe; LN = lymph node; SUV = standardized uptake value.
Initial TreatmentInitial Treatment 1/06 bronchoscopy, R thoracotomy, RUL lobectomy,
mediastinal lymphadenectomy
Path:
– 5 cm SCC, high grade, 0 of 18 LNs
• Incidental lymphoid follicular hyperplasia in level 10 LNs
– pT3pN0, initial stage IIB
– Patient declined chemotherapy
ICU = intensive care unit.NCCN, 2012b.
Surveillance and RelapseSurveillance and Relapse Surveillance q6mos CT scan
• 9/07 CT scan: New R adrenal nodule 2.4 cm
• 1/08 PET/CT scan: R adrenal mass larger 5.4 x 3.8 cm, SUV 10
1/08 Bx R adrenal mass: Poorly differentiated, non-small cell, mixed adenocarcinomatous with squamoid features
Stage IV with solitary R adrenal mass (oligometastatic)
NCCN, 2012b.
Stage IV MetastectomyStage IV Metastectomy
4/08 R adrenalectomy, Path: 4.5 cm lung carcinoma poorly differentiated (EGFR PCR wild-type)
– Rendered surgical no evidence of disease
8/08 Started chemotherapy. Carboplatin/Paclitaxel/Bevacizumab x 4 cycles, with maintenance bevacizumab until progression.
PCR = polymerase chain reaction.NCCN, 2012b.
Second Recurrance Second Recurrance
2/09 CT scan: Enlarging contralateral L adrenal mass5.5 cm
2/09 Brain MRI: Negative
3/09 Informed consent for phase I clinical trial with MDX-1106 (anti-PD-1 mAb)
3/09 First dose MDX-1106 (3 mg/kg) IV q2wks
Baseline ANA 1:40, + Rheumatoid Factor = 19, CRP = 23
CTC = circulating tumor cell; CRP = C-reactive protein. NCCN, 2012b.
Immunotherapy ResponseImmunotherapy Response
5/09 CT scan: Decreased L adrenal mass 3.0 x 2.8 cm (PR)
5/09 Hospitalization COPD exacerbation, Rx azithromycin, methylprednisolone, then prednisone taper (MDX-1106 delayed until 2 wks after last dose of prednisone)
6/09 Resumed MDX-1106
7/09 CT scan: Further decrease L adrenal mass 2.7 x 2.9 cm
NCCN, 2011.
Durable Partial Response (cont.)Durable Partial Response (cont.)
February 2009 September 2009
Durable Partial ResponseDurable Partial Response
2/11 Completed 2 yrs of bi-wkly MDX-1106
8/12 Remains with durable PR, with only measurable disease at L adrenal nodule 2.0 cm
Circulating Tumor Cell Count Circulating Tumor Cell Count Correlated With Tumor ResponseCorrelated With Tumor Response
R adrenal metastectomy
Carbo/Paclitaxel/Bevacizumab
L adrenal metastasis
MDX-1106 Anti-PD-1 mAb durable response
ANA 1:40CRP 8.7RF 19
Pre-Immunotherapy baseline ANA 1:40, CRP 23, RF 19
RF = rheumatoid factor.
Evaluation and Prognostic Significance Evaluation and Prognostic Significance of CTCs in Patients With NSCLCof CTCs in Patients With NSCLC
101 patients Stage III–IV
Krebs et al, 2011.
Time From Baseline Blood Draw (months)
Ove
rall
Sur
viva
l (%
)
0 2 4 6 8 10 12 14 16 18 20
20
4
0
60
80
10
0
p < .001
CTC / 7.5 mL N (%) Median OS in at Baseline Mo. (95% CI) < 5 CTC 92 (91%) 8.1 (7.8 to 8.4)≥ 5 CTC 9 (9%) 4.3 (2.8 to 5.8)
B7-H1 (PDL1) Profiling ofB7-H1 (PDL1) Profiling ofCirculating Tumor CellsCirculating Tumor Cells
Carolina BioOncology Institute and BioCytics Inc.
Immuno-Oncology: Immuno-Oncology: Other Tumor TypesOther Tumor Types
Mary L. Disis, MDUniversity of Washington School of Medicine
Immune response detected?
Antigens identified?
Immunity associated with prognosis?
Spontaneous tumor regression?
TIL that can kill tumor?
There Is Evidence of Immunogenicity in Nearly
Every Tumor Type
What Defines anWhat Defines anImmunogenic Tumor?Immunogenic Tumor?
Finn, 2003
Therapeutic Adjuvant
Why Has it Been So Difficult to Develop Why Has it Been So Difficult to Develop Immune-Based Therapies That Work?Immune-Based Therapies That Work?
Successes with:– Combination therapy– Targeted populations– Low burden disease
EFS = event-free survival.Yu et al, 2010.
Anti-GD2 Antibody With GM-CSF, IL-2, Anti-GD2 Antibody With GM-CSF, IL-2, and Isotretinoin for Neuroblastoma, and Isotretinoin for Neuroblastoma,
Phase IIIPhase III
Monoclonal antibody targeting a tumor-associated ganglioside-GD2 with enhanced activity when administered with IL-2 (increases T cells) and GM-CSF (increases innate immune cells)
226 high risk neuroblastoma patients post induction and transplant, randomized 1:1, standard therapy (isoretinoin) or anti-GD2, IL-2, GM-CSF + isoretinoin
Immunotherapy superior for EFS: 67% vs. 46% at 2 yrs, p = .01
Immunotherapy superior for OS: 86% vs. 76% at 2 yrs, p = .02
52% with grade 3–5 toxicity about 25% with capillary leak syndrome
TLR-9 = toll-like receptor 9; PFS = progression-free survival, FOXP3 = forkhead box protein P3; T-reg = regulatory T cells. Brody et al, 2010.
In Situ TLR-9 With Radiotherapy inIn Situ TLR-9 With Radiotherapy inLow Grade B Cell Lymphoma, Phase IILow Grade B Cell Lymphoma, Phase II
Treg Fold Induction
5.5x 4.5x 5.0x 0.9x 1.5x 1.3xCD25
Patient 14 Patient 13 Patient 9 Patient 3 Patient 15 Patient 11
Treg inducers Treg noninducers
Time (weeks)Log (PFS or censored
follow-up [weeks])
Patient No.
Time of Best Response (weeks)
Radiation
PF-3512676
Clinical response assessment
p=0.041
p=0.001
p=0.03
Sampson et al, 2010; Camp et al, 2005.
EGFRvIII Vaccination in GlioblastomaEGFRvIII Vaccination in Glioblastoma
EGFRvIII = epidermal growth factor receptor variant III.
Before Vaccination At Recurrence
Positive Negative
Positive Negative
Positive Negative
Positive Positive (< 1%)
Positive Negative
Positive Negative
Positive Negative
Positive Negative
Positive Negative
Positive Positive
Positive Negative
EGFRvIII Immunohistochemistry Before and After Vaccination
Percent negative after vaccine is 82% (95% CI, 48%–97%) or nine of 11; binomial test p < .001
Inclusion Criteria• ≥ 18 yrs old• Newly diagnosed glioblastoma• Attempted surgical resection followed by conventional chemoradiation• Documented EGFRvIII positive tumor• No evidence of progressive disease from the post-operative period to the post-chemoradiation period• Candidate for, and agrees to receive, adjuvant (maintenance) temozolomide therapy
ESTIMATED ENROLLMENT: 440
Randomized Phase III Trial RecruitingRandomized Phase III Trial Recruiting
US NIH, NCT01480479. KLH = keyhole limpet hemocyanin.
LE = low expressor; OE = overexpressor; DTH = delayed-type hypersensitivity; HER2 = human epidermal growth factor receptor 2.Mittendorf et al, 2011; Benavides et al, 2009.
All Patients
HER2 Low Expressing
HER2 Vaccination in Early Stage HER2 Vaccination in Early Stage Breast Cancer (node +)Breast Cancer (node +)
Time (mos)
Time (mos)
Inclusion Criteria:• ≥ 18 yrs old• Pathological diagnosis of invasive adenocarcinoma of the breast• Breast cancer completely excised• Node + disease• Primary tumor stage T1–3• HER2- (HER2 1+ by IHC or HER2 2+ by IHC/FISH)• HLA-A2 or HLA-A3 haplotype• Completed NCCN approved neo-adjuvant/adjuvant chemotherapy or both• Completed radiation therapy• No evidence of disease
ESTIMATED ENROLLMENT: 700
Randomized Phase III Trial RecruitingRandomized Phase III Trial Recruiting
WFI = water for injection; NCCN = National Comprehensive Cancer Network; IHC = immunohistochemistry;FISH = fluorescence in-situ hybridization; HLA = human leukocyte antigen. US NIH, NCT01479244.
Could generate vaccine in 91% Common solid metastatic tumors Majority vaccinated achieved SD Survival significantly associated with number of vaccines
Autologous Tumor Cell Vaccine With GM-CSF and Autologous Tumor Cell Vaccine With GM-CSF and bi-shRNA Downregulation TGF-Beta (FANG)bi-shRNA Downregulation TGF-Beta (FANG)
Senzer et al, 2012.
bi-shRNA = bifunctional short hairpin ribonucleic acid; TGF = transforming growth factor.
FANG mean TGFβ1 - ELISA (n = 42)
DaysPaired t-test*< .05, **< .01, ***≤ .001
FANG mean TGFβ2 - ELISA (n = 42)
DaysPaired t-test*< .05, **< .01, ***≤ .001
Days Since Procurement
Inclusion Criteria:• ≥ 18 yrs old• Histologically confirmed colorectal carcinoma with synchronous or metachronous liver metastases +/- pulmonary metastases• Maximum total number of metastatic lesions ≤ 6• Candidate for surgical excision +/= ablation with curative intent• Planned resected viable tumor in sufficient quantity ("golf ball size" estimated weight ~ 30 grams) for vaccine processing• ECOG performance status (PS) 0–2• Estimated > 4-mos survival probability
ESTIMATED ENROLLMENT: 60
Randomized Phase II Trial RecruitingRandomized Phase II Trial Recruiting
US NIH, NCT01505166.
….and multiple myeloma, renal, brain
355 Open Cancer Vaccine Trials180 Open Phase II and III Trials
Clinical TrialsClinical Trials Approximately 2,380 open cancer immune therapy trials
1,444 open phase II and III trials
Clinicaltrials.gov, 2012.
Key TakeawaysKey Takeaways
Immunotherapy clinical trials integrate treatment into current standard of care regimens
– Recent studies suggest some of the most common chemotherapeutic agents we use have profound immunologic effects
There are immunotherapy approaches being studied in almost every common cancer, both hematopoietic and solid tumors
Both adults and children with cancer have shown benefit with immune-based therapies in published clinical trials
Most immune therapies are associated with tolerable toxicities (or even rare toxicity in the case of cancer vaccines)
There are numerous immune-based clinical trials, at all stages, open for enrollment in the US
Management of Immunotherapy-Management of Immunotherapy-Related Adverse EventsRelated Adverse Events
Mary L. Disis, MDUniversity of Washington School of Medicine
Disis, 2010a.
Successful Anti-Cancer Immunity Successful Anti-Cancer Immunity Is AutoimmunityIs Autoimmunity
Disis, 2011.
Autoimmunity Associated With Autoimmunity Associated With Clinical Response to Immune TherapyClinical Response to Immune Therapy Prospective observational study of 3,000 patients evaluated clinical factors
associated with favorable outcome
− Vitiligo predictive in multivariate analysis (p = .006 for OS)
Study evaluating the laboratory and clinical characteristics of 374 patients treated with IL-2 to determine biomarkers of response (NCI)
− Thyroid dysfunction (p = .01) and vitiligo (p < .01) were predictors of increased survival
Trial of 198 MM or RCC patients treated with ipilimumab suggested a higher response rate in patients who developed enterocolitis compared to those that did not (p = .0065) (NCI)
Evaluation of 200 stage II/III melanoma patients treated with interferon; development of autoimmunity correlated with longer relapse-free survival (p < .001) as well as OS (p < .001)
− Some immunity was sub-clinical (serologic only) and still demonstrated effect
Autoimmunity Associated With Improved Autoimmunity Associated With Improved Prognosis After IFN Therapy in Melanoma Prognosis After IFN Therapy in Melanoma
0.0 25.0 50.0 75.0 100.0 125.0
Patients with autoimmunity
Patients without autoimmunity
Months from start of treatment
Patients with autoimmunity
Patients without autoimmunity
0.0 20.0 40.0 60.0 80.0 100.0 120.0
Months from start of treatment
• 26% incidence• Clinical and serologic
Gogas et al, 2006; Dafni et al, 2008.
Mellman et al, 2011; Weber, 2008b.
Re
sp
on
se
ra
te t
o i
pil
imu
ma
b
Autoimmunity Associated With Autoimmunity Associated With Clinical Response After IpilimumabClinical Response After Ipilimumab
Attia Study2005
Beck Study2006
Maker Study2005
Patient number (n=)
Phase III Ipi and DTIC (Ipi at 10 mg/kg) 250
Phase-III Ipi monotherapy (3 mg/kg) 131
Phase-II Ipi monotherapy different doses 217 (71 each at 3 mg/kg and 10 mg/kg)
All grade irAE % [Grade 3, 4%]
77.7 [31.6, 10.1]
61.1 [12.2, 2.3]
65 at 3 mg/kg [7] 70 at 10 mg/kg [25]
Dermatologic % [Grade 3, 4%] Pruritus%
Rash
Vitiligo
26.7 [2.0, 0]
22.3 [1.2, 0]
43.5 [1.5, 0]24.4 [0, 0]
19.1 [0.8, 0]
2.3 [0, 0]
45 at 3 mg/kg [1.5]46 at 10 mg/kg [4.2] 21.3 at 3 mg/kg[1.4] 32.4 at 10 mg/kg [2.8] 23.9 at 3 mg/kg [1.4] 22.5 at 10 mg/kg [0]
Gastrointestinal % [Grade 3, 4%] Diarrhoea %
Colitis
32.8 [4.0, 0] 4.5 [1.6, 0.4]
29 [7.6, 0] 27.5 [4.6, 0]
7.6 [5.3, 0]
32 at 3 mg/kg [2.8] 39.4 at 10 mg/kg [15.5] 25.3 at 3 mg/kg [1.4] 39.4 at 10 mg/kg [14.0] 5.6 at 3 mg/kg [1.4]5.6 at 10 mg/kg [2.8]
Endocrine %[Grade 3, 4%] Hypothyroid % Hypopituitarism Hypophysitis Adrenal insufficiencyIncrease thyrotropin Decrease corticotrophin
7.6[2.3, 1.5] 1.5 [0, 0] 2.3 [0.8, 0.8] 1.5 [1.5, 0] 1.5 [0, 0]0.8 [0, 0] 1.5 [0, 0.8]
5.6 at 3 mg/kg [2.8]4.2 at 10 mg/kg [1.5]
Hepatic %[Grade 3, 4%] Increase ALT %Increase AST Hepatitis
29.1 [15.0, 5.7]26.7 [13.8, 3.6] 1.6 [1.2, 0]
3.8[0, 0] 1.5 [0, 0]0.8 [0, 0]0.8 [0, 0]
0 at 3 mg/kg 2.8 at 10 mg/kg [2.8]
MO
RE
CO
MM
ON
LE
SS
CO
MM
ON
DTIC = dacarbazine; Ipi = ipilimumab; ALT = alanine aminotransferase; AST = aspartate aminotransferase.Lemech et al, 2012.
irAE Associated With Ipilimumab: irAE Associated With Ipilimumab: Covers All BasesCovers All Bases
IRAEs From lpilimumab in Phase II and III Trials
Perivascular CD8
Hodi et al, 2008; Lemech et al, 2012.
Grade 1, 2:• Topical steroids or topical creams (urea based)• May require anti-pruritic management (diphenhydramine)• Avoid direct contact with sunlight, sunscreen (prophylactic)
Grade Persistent Grade 2 or Grade 3:• Withhold dose• Treat with 4-wk tapering oral steroid (1 mg/kg/day)
Grade 4:• Discontinue drug permanently• Consider IV steroids
Rash ~ 40%Grade 3–4 ~ 2%
irAE Management: Reticular irAE Management: Reticular Erythematous RashErythematous Rash
irAE Management: GI EffectsirAE Management: GI EffectsDiarrhea ~ 40%
Colitis ~ 5%
Grade 1, 2:
Loperamide and close follow-up
Small frequent meals
Bland diet
No lactose containing products
Electrolyte replacement (oral)
Grade Persistent Grade 2:
Treat with slow tapering oral steroid
(1 mg/kg/day)
Oral budesonide (9 mg daily) x8 wks
(last 2 taper)
Consider endoscopy (R/O colitis), rapidprogression can occur
Grade 3, 4:
Endoscopy
HD IV steroids, slow taper
No response to steroids: infliximab (5 mg/kg IV)
Rare case of perforation (1%)
Discontinue drug permanently
HD = high dose; R/O = rule out; GI = gastrointestinal.Lemech et al, 2012; Weber, 2007.
irAE Management: Hepatic EffectsirAE Management: Hepatic Effects
Hepatic ~ 5%
Grade 1: Monitor closely
Grade 2: Withhold drug, w/u non-immune causes LFTs daily x3 Initiate oral steroids if no improvement 48–72 hrs
Grade 3, 4: HD IV steroids, slow taper (over 1 mos) Daily LFTs No response to steroids at 48 hrs: consider mycophenolate mofetil Discontinue drug permanently
ANA = antinuclear antibody; creat = creatinine; LFTs = liver function tests; SMA = smooth muscle antibody; T Bili = total bilirubin.Lemech et al, 2012; Weber, 2007.
Determine baseline LFTs, T Bili at screening
Baseline LFTs. T Bili =
NORMAL
Baseline LFTs. T Bili= grade 1 or 2
Routine monitoring of
LFTs and T Bili
Routine monitoring of
LFTs and T Bili
LFTs and/or T Bili grade
≥2?
LFTs and/or T Bili grade ≥2x
baseline values ?
Trigger point #1 intensified monitoring
Workup for autoimmunity:1. Clinical signs
2. Labs: ANA, SMA, LFTs., T Bili, creat, other3. Check LFTs, T Bili q 3 days
Workup to do non-IRAE causes:1. Imaging to do mets
2. Consider liver biopsy if suggestion of autoimmune etiology
Monitor course:Check labs q 3
days until stable or decreasing, then once per week
Monitor course:Check labs q 3
days until stable or decreasing, then once per week
LFTs >8x ULN?And/or T Bili >5x
ULN?
Monitor course:1. Hold further Ipilimumab
2. Repeat LFTs within 24 hrs
LFTs still rising over 24-48 hrs?
and/or suspect IRAE
Trigger point #2 Therapeuticintervention
Therapeutic intervention(recommended
sequence):1. Admit to hospital2. Check labs daily
3. Steroids (IV)4. Mycophenolate mofetil
5. Tacrolimus6. Infliximab
Yes
Yes
No No
No No
NoNo
Yes
Yes
Endocrine ~ 7%Grade 3–4 < 2%
Symptoms: Headache, visual field changes, nausea, vomiting, hypotension, electrolyte abnormalities
Work-Up: TSH, free T4/T3, ADH, serum cortisol, LH, FSH, prolactin, MRI of the head
Treatment:• Hold drug• Stress does IV steroids• Gonadal and thyroid replacement, may need permanently• Ongoing monitoring• May consider restarting ipilimumab is grade 1–2 after symptoms resolved
ADH = adrenocorticotropic hormone; LH = luteinizing hormone; FSH = follicle stimulating hormone; TSH=thyroid-stimulating hormone; T4= thyroxine; T3= triiodothyronine ;MRI = magnetic resonance imaging.Lemech et al, 2012.
irAE Management: EndocrinopathiesirAE Management: Endocrinopathies
Weber, 2008b.
Treatment
Post-Treatment Initiation (wks)
= First efficacy assessmentSD
PR
CR
Ongoing 57 + wk no new lesions
• When toxicities occur is variable • Early and late
• Prolonged treatment
• May need to treat again
T Cells Continue to Evolve Even T Cells Continue to Evolve Even After Drug Is Cleared After Drug Is Cleared
Evolving Immune Response
Responses as late as 106 wks
Key TakeawaysKey Takeaways
The development of autoimmune phenomenon may be an expected toxicity associated with some immune-based therapies
Autoimmunity may demonstrate immune activation and has been associated with improved outcome in studies of some immune-based treatments
Autoimmunity induced by current immune-based therapies is self-limited once the treatment has been discontinued
• If toxicity not life-threatening, consideration may be given to reinstituting therapy once symptoms have resolved
If the autoimmune toxicities are mild, symptoms can be managed medically while the patients remain on treatment
Autoimmune adverse events may occur at anytime in the course of treatment