Immunotherapy for Breast Cancer Clinical Development

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1 Immunotherapy for Breast Cancer Clinical Development Laurence Buisseret, MD, PhD Breast Cancer Translational Research Laboratory Institut Jules Bordet Université Libre de Bruxelles (ULB) ESMO preceptorship on Immuno-Oncology November 3, 2017

2 Rationale to develop immunotherapy in BC TIL levels Immune gene signatures Responses in early phases trials Features of BC Mutation Load PD-L1 expression

3 Tumor-infiltrating lymphocytes (TIL) in breast cancer Increased TIL levels in HER2+ and TNBC Luen et al. Breast Savas et al. Nature 2016

4 Increasing lymphocytic infiltration was associated with excellent prognosis in TNBC

5 Clinical significance of TIL levels in BC TIL have prognostic and predictive value in early stage BC, particularly in HER2+ and TNBC Savas et al. Nature 2016

6 Clinical significance of mutation load TIL can recognize somatic mutations and are correlated to the density of predicted mutant epitopes Total mutations and survival BC has a moderate mutational load Higher mutation load in TNBC and HER2+ BC Schumacher et al. Science 2015 Scott D. Brown et al. Genome Res. 2014

7 PD-L1 expression in early stage BC PD-L1 positivity Age <50y vs >=50 Histo grade 3 vs 1-2 Ki-67 > =20% vs <20% ER neg vs ER pos PR neg vs PR pos TIL hi vs TIL int TIL neg TLS pos vs TLS neg PD-1 pos vs PD-1 neg N= Odds ratio (95%CI) PD-L1 CD3 CD20 BC subtype N (%) PD-L1 positivity Lum A 54 (49.5) 5 (9.3) Lum B 24 (22) 10 (41.7) HER2+ 17 (15.6) 5 (29.4) TNBC 14 (12.8) 6 (42.9) PD-L1 IHC expression on N = 110 (%) Tumor cells 6 (5.5) Immune cells 22 (20) Stromal cells 4 (3.6) Any cells 26 (23.6) PD-L1 positivity : 1% expression on tumor or immune or stromal cells Buisseret et al. Oncoimmunology 2017.

8 PD-L1 expression in metastatic BC PD-L1 PD-L1 IHC expression on N = 111 (%) Tumor cells 3(2.7) Immune cells 12 (10.8) Stromal cells 9 (8.1) Any cells 17(15.3) PD-L1 positivity : 1% expression on tumor or immune or stromal cells Adenopathy 111 metastases from 11 sites including skin (40), ipsilateral breastrelapse(23), liver (12), soft tissues(7), pleura (6), bone(6), brain (5), peritoneum(3), colon (1), lung(1), nodes(7) BC subtype PD-L1 positivity (%) Luminal A 0/15 (0) Luminal B 4/34 (11.7) HER2+ 2/21 (9.5) TNBC 10/28 (35.7) Solinas et al. In preparation.

9 TNBC : the candidate for immunotherapy Worse prognosis than other BC subtype Limited treatment options Cancer immunotherapy represents a promising treatment approach for TNBC Higher TIL levels associated with a better outcome Higher mutation rate immunogenic neoantigens Higher PD-L1 expression inhibit T-cell antitumor responses

10 Strategies to modulate the immune system in breast cancer Active: priming of the immune system Passive: delivery of compounds that may use immune system Antigenspecific Non antigenspecific Monoclonal antibodies Adoptive cell transfer Peptide vaccine DC-vaccine DNA-vaccine Whole cell vaccine Checkpoint inhibitors Cytokines Trastuzumab Pertuzumab CAR T cells Cancer vaccines Immune modulators Targeted antibodies Cellular immunotherapy

11 Summary of status of BC immunotherapy Robert H. Vonderheide et al. Clin Cancer Research 2017

12 PD-1 blockade in breast cancer Single agent activity Synergistic combinations Neoadjuvant/Adjuvant setting Biomarkers of response

13 Phase Ib of pembrolizumab in mtnbc KEYNOTE 012 Recurrent or metastatic ER /PR /HER2 breast cancer ECOG PS 0-1 PD-L1 + tumor a No systemic steroid therapy No autoimmune disease (active or history of) No active brain metastases Pembro 10 mg/kg Q2W Complete Response Partial Response or Stable Disease Confirmed Progressive Disease b Discontinuation Permitted Treat for 24 months or until progression or intolerable toxicity Discontinue PD-L1 positivity: 58% of all patients screened had PD-L1-positive tumors Treatment: 10 mg/kg IV Q2W Response assessment: Performed every 8 weeks per RECIST v1.1 a PD-L1 expression was assessed in archival tumor samples using a prototype IHC assay and the 22C3 antibody. Only patients with PD-L1 staining in the stroma or in 1% of tumor cells were eligible for enrollment. b If clinically stable, patients are permitted to remain on pembrolizumab until progressive disease is confirmed on a second scan performed 4 weeks later. If progressive disease is confirmed, pembrolizumab is discontinued. An exception may be granted for patients with clinical stability or improvement after consultation with the sponsor. Nanda R et al. San Antonio Breast Cancer Symposium 2014

14 Phase Ib of pembrolizumab in mtnbc KEYNOTE 012 Patients Evaluable for Response a n = 27 Overall response rate 5 (18.5%) Best overall response Complete response 1 (3.7%) Partial response 4 (14.8%) Stable disease 7 (25.9%) Progressive disease 12 (44.4%) No assessment 3 (11.1%) Nanda R. et al. JCO 2016

15 PD-1 blockade : single agent activity Drug Phase Subtype PD-L1 Nb pts Evaluable Pembrolizumab (anti-pd-1) Atezolizumab (anti-pd-l1) Avelumab (anti-pd-l1) Ib Ib II TNBC PD-L1+ ER+/HER2- PD-L1+ TNBC 1 st line, PD-L1+ > 1 line 1% TC Stroma+ (58% of screened pts) 1% TC Stroma+ (19% of screened pts) > 1 CPS (58% of screened pts) (62% of screened pts) 32 ORR % References KEYNOTE 012 Nandaet al. SABCS 2014 JCO % KEYNOTE 028 Rugoet al. SABCS Ia TNBC 5% IC 115 Ib All TNBC ER+/HER2-1% TC (58%) 5% TC (16%) 10% IC (9%) % 4.7% % % 8.6% 2.8% KEYNOTE 086 Adams et al. AACR 2017 Schmidet al. AACR2017 JAVELIN Dirixet al. SABCS 2015 Adapted from Solinas et al. Targeting immune checkpoints in breast cancer: an update of early results. ESMO open 2017

16 ORR according to PD-L1 expression Phase Ia: Atezolizumab, an anti-pd-l1 antibody, in patients with locally advanced or metastatic TNBC Phase Ib: Avelumab, an anti-pd-l1 antibody, in patients with locally advanced or metastatic BC PD-L1 expression All patients (N=136) TNBC (N=48) 1% TC 3/85(3.5%) 2/33 (6.1%) 5% TC 1/23 (4.3%) 1/13 (7.7%) 25% TC 0/3 (0) 0/2 (0) 10% IC 4/12 (33.3%) 4/9 (44.4%) Dirix L. et al. SABC 2015 Schmid P. et al. AACR 2017

17 Long lasting responses 3 exceptional responders Nanda R. et al. ECCO 2017

18 Metastatic TNBC treated with pembrolizumab Before pembrolizumab After treatment with pembrolizumab Images provided by Géraldine Gebhart

19 Metastatic TNBC treated with pembrolizumab Before treatment 2 months later 4 months later Images provided by Henri Maisonnier

20 Metastatic TNBC treated with pembrolizumab 2 months laterpr 4 months latercr 4years latercr! Images provided by Henri Maisonnier

21 Survival benefit for responders Phase Ia: Atezolizumab, an anti-pd-l1 antibody, in patients with locally advanced or metastatic TNBC Schmid P, et al. AACR 2017

22 Single agent PD-1 blockade in metastatic BC Response rate in the metastatic setting: 5-20% Higher response rate in TNBC PD-L1 positive cases Long-lasting responses in a subset of responders Survival benefit for responders patients Acceptable safety profile in early phases trials in metastatic setting