Immune checkpoint inhibition in melanoma

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Hugh Carr
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1 Immune checkpoint inhibition in melanoma John Haanen ESMO Preceptorship Zürich 217

2 Disclosures I have provided consultation, attended advisory boards, and/or provided lectures for: Pfizer, MSD, BMS, IPSEN, Roche/Genentech, NEON Therapeutics, Novartis for which NKI received honoraria Through my work NKI received grant support from BMS, MSD, Novartis I declare no conflict of interest

3 Immune Checkpoint inhibitors Immune checkpoints play an important role in immune tolerance Cancer hijacks many of these peripheral tolerance mechanism to escape the immune system Inhibition of a single immune checkpoint can be enough to break this cancer induced tolerance (anti-ctla4, anti-pd- 1/PD-L1) Combination of these inhibitors appear more powerful

4 Melanoma has become from a disease that gave cancer a bad name to a model disease for I-O Current I-O treatment options for melanoma Stage IIII disease Neo-adjuvant/adjuvant trials Unresectable stage IIIc and stage IV disease

6 EORTC 1871/CA184-29: Study Design Randomized, double-blind, phase 3 study evaluating the efficacy and safety of ipilimumab in the adjuvant setting for high-risk melanoma High-risk, stage III, completely resected melanoma R N = 475 INDUCTION Ipilimumab 1 mg/kg Q3W 4 MAINTENANCE Ipilimumab 1 mg/kg Q12W up to 3 years N = 951 N = 476 INDUCTION Placebo Q3W 4 MAINTENANCE Placebo Q12W up to 3 years Week 1 Week 12 Week 24 Stratification factors Stage (IIIA vs IIIB vs IIIC 1-3 positive lymph nodes vs IIIC 4 positive lymph nodes) Regions (North America, European countries, and Australia) Enrollment Period: June 28 to July 211 Treatment up to a maximum of 3 years, or until disease progression, intolerable toxicity, or withdrawal Q3W = every 3 weeks; Q12W = every 12 weeks; R = randomization.

7 Baseline Patient Characteristics Ipilimumab (n = 475) Placebo (n = 476) Median age, years Male, % ECOG PS /1, % 94/6 94/6 Stage, % IIIA IIIB IIIC with 1-3 positive LN IIIC with 4 positive LN vs 2-3 vs 4 positive LN, % 46 vs 34 vs 2 46 vs 33 vs 21 LN involvement, % Microscopic Macroscopic Ulceration of primary, % ECOG PS = Eastern Cooperative Oncology Group performance status; LN = lymph node.

8 Patients Alive and Without Recurrence (%) RFS (per IRC) Ipilimumab Placebo Events/patients 264/ /476 HR (95% CI) a.76 (.64,.89) Log-rank P value a.8 Median RFS, months (95% CI) 41% 3% 27.6 (19.3, 37.2) 17.1 (13.6, 21.6) a Stratified by stage provided at randomization. CI = confidence interval O N Number of patients at risk Years Ipilimumab Placebo

9 OS Patients Alive (%) Ipilimumab Placebo Deaths/patients 162/ /476 HR (95.1% CI) a.72 (.58,.88) Log-rank P value a.1 65% 54% a Stratified by stage provided at randomization O N Number of patients at risk Years Ipilimumab Placebo

10 Patient Disposition and Treatment Ipilimumab (n = 471) Placebo (n = 474) Discontinuation, % 1 1 Reasons for discontinuation, % Normal completion (received study drug for entire 3 years) Disease recurrence AE related to study drug Other reasons a Median doses, per patient, n Receiving 1 maintenance dose, % Receiving 7 doses (1 year of therapy), % a Includes AE unrelated to study drug, both related and unrelated to study drug, patient request, poor/noncompliance, death, pregnancy, patient no longer eligible, other.

11 Phase III trials in the adjuvant setting for stage III and IV disease A Phase 3, Randomized, Double-blind Study of Adjuvant Immunotherapy With Nivolumab Versus Ipilimumab After Complete Resection of Stage IIIb/c or Stage IV Melanoma in Subjects Who Are at High Risk for Recurrence (CheckMate-238) Adjuvant Immunotherapy With Anti-PD-1 Monoclonal Antibody Pembrolizumab Versus Placebo After Complete Resection of High-risk Stage III Melanoma: A Randomized, Double- Blind Phase 3 Trial of the EORTC Melanoma Group (KEYNOTE-54) A Phase III Randomized Trial Comparing Physician/Patient Choice of Either High Dose Interferon or Ipilimumab to Pembrolizumab in Patients With High Risk Resected Melanoma

12 Adjuvant Therapy With Nivolumab Versus Ipilimumab After Complete Resection of Stage III/IV Melanoma: A Randomized, Double-blind, Phase 3 Trial (CheckMate 238) Jeffrey Weber, 1 Mario Mandala, 2 Michele Del Vecchio, 3 Helen Gogas, 4 Ana M. Arance, 5 C. Lance Cowey, 6 Stéphane Dalle, 7 Michael Schenker, 8 Vanna Chiarion-Sileni, 9 Ivan Marquez-Rodas, 1 Jean-Jacques Grob, 11 Marcus Butler, 12 Mark R. Middleton, 13 Michele Maio, 14 Victoria Atkinson, 15 Paola Queirolo, 16 Veerle de Pril, 17 Anila Qureshi, 17 James Larkin, 18 * Paolo A. Ascierto 19 * 1 NYU Perlmutter Cancer Center, New York, New York, USA; 2 Papa Giovanni XIII Hospital, Bergamo, Italy; 3 Medical Oncology, National Cancer Institute, Milan, Italy; 4 University of Athens, Athens, Greece; 5 Hospital Clínic de Barcelona, Barcelona, Spain; 6 Texas Oncology-Baylor Cancer Center, Dallas, Texas, USA; 7 Hospices Civils de Lyon, Pierre Bénite, France; 8 Oncology Center Sf Nectarie Ltd., Craiova, Romania; 9 Oncology Institute of Veneto IRCCS, Padua, Italy; 1 General University Hospital Gregorio Marañón, Madrid, Spain; 11 Hôpital de la Timone, Marseille, France; 12 Princess Margaret Cancer Centre, Toronto, Ontario, Canada; 13 Churchill Hospital, Oxford, United Kingdom; 14 Center for Immuno-Oncology, University Hospital of Siena, Istituto Toscano Tumori, Siena, Italy; 15 Gallipoli Medical Research Foundation and Princess Alexandra Hospital, Woolloongabba, and University of Queensland, Greenslopes, Queensland, Australia; 16 IRCCS San Martino-IST, Genova, Italy; 17 Bristol-Myers Squibb, Princeton, New Jersey, USA; 18 Royal Marsden NHS Foundation Trust, London, UK; 19 Istituto Nazionale Tumori Fondazione Pascale, Naples, Italy; *Contributed equally to this study.

13 CA29-238: CA29-67: Study Design Patients with high-risk, completely resected stage IIIB/IIIC or stage IV melanoma Stratified by: 1:1 n = 453 n = 453 1) Disease stage: IIIB/C vs IV M1a-M1b vs IV M1c 2) PD-L1 status at a 5% cutoff in tumor cells NIVO 3 mg/kg IV Q2W and IPI placebo IV Q3W for 4 doses then Q12W from week 24 IPI 1 mg/kg IV Q3W for 4 doses then Q12W from week 24 and NIVO placebo IV Q2W Follow-up Maximum treatment duration of 1 year Enrollment period: March 3, 215 to November 3, 215

14 Study Overview Primary endpoint RFS: time from randomization until first recurrence (local, regional, or distant metastasis), new primary melanoma, or death Secondary endpoints OS Safety and tolerability RFS by PD-L1 tumor expression HRQoL Current interim analysis Primary endpoint (RFS), safety, and HRQoL DMFS (exploratory) Duration of follow-up: minimum 18 months; 36 events DMFS = distant metastasis-free survival; HRQoL = health-related quality of life

15 Baseline Patient Characteristics NIVO (n = 453) IPI (n = 453) Median age, years Male, % Stage, IIIB+IIIC, % Macroscopic lymph node involvement (% of stage IIIB+IIIC) 6 58 Ulceration (% of stage IIIB+IIIC) Stage IV, % M1c without brain metastases (% stage IV) PD-L1 expression 5%, % BRAF mutation, % LDH ULN, % Most of the patients had cutaneous melanoma (85%), and 4% had acral and 3% had mucosal melanoma All 95 patients are off treatment; median doses were 24 (1-26) in the NIVO group and 4 (1-7) in the IPI group 397 patients completed 1 year of treatment (61% of the NIVO group and 27% of the IPI group)

16 Primary Endpoint: RFS NIVO IPI 1 Events/patients 154/453 26/ Median (95% CI) NR NR (16.6, NR) HR (97.56% CI).65 (.51,.83) Log-rank P value <.1 RFS (%) % 61% 66% 53% NIVO IPI Months Number of patients at risk NIVO IPI

17 Subgroup Analysis of RFS: PD-L1 Expression Level PD-L1 Expression Level <5% PD-L1 Expression Level 5% NIVO IPI NIVO IPI Events/patients 114/ /286 Events/patients 31/152 57/154 Median (95% CI) NR 15.9 (1.4, NR) Median (95% CI) NR NR 1 HR (95% CI).71 (.56,.91) 1 HR (95% CI).5 (.32,.78) % 8 8 RFS (%) % 54% RFS (%) % NIVO IPI 2 1 NIVO IPI Number of patients at risk Months Number of patients at risk Months NIVO NIVO IPI IPI

18 RFS: Prespecified Subgroups Subgroup No. of events/no. of patients NIVO 3 mg/kg IPI 1 mg/kg Unstratified HR (95% CI) Overall Overall 154/453 26/ (.53,.81) Age <65 years 16/ / (.51,.84) 65 years 48/12 59/ (.45,.97) Sex Male 99/ / (.53,.88) Female 55/195 73/ (.44,.89) Stage (CRF) Stage IIIb 41/163 54/ (.44, 1.) Stage IIIc 79/24 19/ (.49,.87) Stage IV M1a-M1b 25/62 35/66.63 (.38, 1.5) Stage IV M1c 8/2 8/21 1. (.37, 2.66) Not reported 1/2 / Stage III: Ulceration Absent 58/21 94/ (.42,.82) Stage III: Lymph node involvement Present 6/153 64/ (.51, 1.4) Not reported 2/15 5/15.39 (.7, 2.) Microscopic 41/125 55/ (.47, 1.7) Macroscopic 72/219 11/ (.46,.84) Not reported 7/25 7/18.6 (.21, 1.72) PD-L1 status <5%/indeterminate 123/3 149/ (.56,.9) 5% 31/152 57/154.5 (.32,.78) BRAF mutation status Mutant 63/187 84/ (.52, 1.) Wild-type 67/197 15/ (.43,.79) Not reported 24/69 17/45.83 (.45, 1.54) Unstratified HR (95% CI) 1 2 NIVO IPI

19 Exploratory Endpoint: DMFS for Stage III Patients NIVO IPI % Events/patients 93/ /366 Median (95% CI) NR NR HR (95% CI).73 (.55,.95) Log-rank P value.24 DMFS (%) % Number of patients at risk NIVO IPI NIVO IPI Months

20 Treatment-Related Select Adverse Events NIVO (n = 452) IPI (n = 453) AE, n (%) Any grade Grade 3/4 Any grade Grade 3/4 Skin 21 (44.5) 5 (1.1) 271 (59.8) 27 (6.) Gastrointestinal 114 (25.2) 9 (2.) 219 (48.3) 76 (16.8) Hepatic 41 (9.1) 8 (1.8) 96 (21.2) 49 (1.8) Pulmonary 6 (1.3) 11 (2.4) 4 (.9) Renal 6 (1.3) 7 (1.5) Hypersensitivity/infusion reaction 11 (2.4) 1 (.2) 9 (2.) Endocrine Adrenal disorder 6 (1.3) 2 (.4) 13 (2.9) 4 (.9) Diabetes 2 (.4) 1 (.2) 1 (.2) Pituitary disorder 8 (1.8) 2 (.4) 56 (12.4) 13 (2.9) Thyroid disorder 92 (2.4) 3 (.7) 57 (12.6) 4 (.9) Median time to onset of treatment-related select AEs was generally shorter for patients receiving IPI (range weeks) than for those receiving NIVO (range weeks)

21 Conclusions Nivolumab showed a clinically and statistically significant improvement in RFS vs the active control of high-dose ipilimumab for patients with resected stages IIIB/IIIC and stage IV melanoma at high risk of recurrence (HR =.65, P <.1) 18-month RFS rates were 66% for nivolumab and 53% for ipilimumab Benefit for nivolumab was observed across the majority of prespecified subgroups tested, including PD-L1 and BRAF mutation status Nivolumab has a superior safety profile in comparison with ipilimumab, with fewer grade 3/4 AEs and fewer AEs leading to treatment discontinuation Nivolumab has the potential to be a new standard treatment option for patients with resected stage IIIB, IIIC, and IV melanoma regardless of BRAF mutation

22 New developments in adjuvant and neoadjuvant trials An Open-label, Phase IB Study of NEO-PV-1 + Adjuvant With Nivolumab in Patients With Melanoma, Non-Small Cell Lung Carcinoma or Transitional Cell Carcinoma of the Bladder Phase II Study to Identify the Optimal neoadjuvant Combination Scheme of Ipilimumab and Nivolumab in Stage III Melanoma Patients (OPACIN-neo) A Phase II, Randomised, Open Label Study of Neoadjuvant Dabrafenib, Trametinib and / or Pembrolizumab in BRAF V6 Mutant Resectable Stage IIIB/C Melanoma A Phase 1b Trial of Neoadjuvant CXCR4 antagonist (X4P- 1) Alone and With Pembrolizumab in Patients With Resectable Melanoma

23 Melanoma has become from a disease that gave cancer a bad name to a model disease for I-O Current I-O treatment options for melanoma Stage IIII disease Neo-adjuvant/adjuvant trials Unresectable stage IIIc and stage IV disease

24 Anti-CTLA-4 Ipilimumab: 4 infusions for the induction Pre-treated-pts +/- gp1 HLA-A2 3mg/kg Re-induction possible naive-pts + DTIC 1 mg/kg Maintenance possible Hodi et al 21 NEJM Robert et al NEJM 211

25 Pooled OS Analysis of ipilimumab treated 4846 patients (incl EAP) Median OS (95% CI): 9.5 (9. 1.) 3-year OS rate (95% CI): 21% (2 22%) Schadendorf et al., J Clin Oncol 215

26 Anti-PD1 Demonstrates Broad Antitumor Activity Change From Baseline in Tumor Size, % Melanoma 1 (N=655) KEYNOTE NSCLC 2 (N=262) KEYNOTE H&N 3 (N=132) KEYNOTE Urothelial 4 (N=33) KEYNOTE Gastric 5 (N=39) KEYNOTE-12 1 TNBC 6 (N=32) KEYNOTE-12 1 chl 7 (N=29) KEYNOTE-13 1 Mesothelioma 8 (N=25) KEYNOTE-28 1 Ovarian 9 (N=26) KEYNOTE-28 1 SCLC 1 (N=2) KEYNOTE-28 1 Esophageal 11 (N=23) KEYNOTE Courtesy of G Long 1. Daud A et al. 215 ASCO; 2. Garon EB et al. ESMO 214; 3. Seiwert T et al. 215 ASCO; 4. Plimack E et al. 215 ASCO; 5. Bang YJ et al. 215 ASCO; 6. Nanda R et al. SABCS 214; 7. Moskowitz C et al. 214 ASH Annual Meeting; 8. Alley EA et al. 215 AACR; 9. Varga A et al. 215 ASCO; 1. Ott PA et al. 215 ASCO; 11. Doi T et al. 215 ASCO.

27 CheckMate-66 Robert et al., NEJM 215

28 Updated OS results from CheckMate 66 trial in BRAF wt advanced melanoma Decrease of the risk of death 58% vs chemotherapy Atkinson et al. abstract 3774 SMR 215

29 OS after ipilimumab start as 2 nd line treatment

30 Pembrolizumab vs ipilimumab Treatment Arm Median (95% CI), mo Rate at 12 mo HR (95% CI) P Pembrolizumab Q2W NR (NR-NR) 74.1%.63 ( ) <.1 Pembrolizumab Q3W NR (NR-NR) 68.4%.69 (.52-.9) <.1 Ipilimumab NR (12.7-NR) 58.2% Decrease of risk of death of pembrolizumab 31 to 37% vs ipilimumab Robert et al NEJM 215

31 ANALYSIS OF RESPONSE AND SURVIVAL IN PATIENTS WITH IPILIMUMAB- REFRACTORY MELANOMA TREATED WITH PEMBROLIZUMAB IN KEYNOTE-2 A. Daud 1 ; I. Puzanov 2 ; R. Dummer 3 ; D. Schadendorf 4 ; O. Hamid 5 ; C. Robert 6 ; F. S. Hodi 7 ; J. Schachter 8 ; J. A. Sosman 9 ; A. C. Pavlick 1 ; R. Gonzalez 11 ; C. Blank 12 ; L. D. Cranmer 13 ; S. J. O Day 14 ; A. K.Salama 15 ; K. A. Margolin 16 ; J. Yang 17 ; B. Homet Moreno 17 ; N. Ibrahim 17 ; A. Ribas 18 1 University of California, San Francisco, San Francisco, CA, USA; 2 Vanderbilt-Ingram Cancer Center, Nashville, TN, USA; (currently at Roswell Park Cancer Institute, Buffalo, NY, USA; 3 University of Zürich, Zürich, Switzerland; 4 University Hospital Essen, Essen, Germany; 5 The Angeles Clinic and Research Institute, Los Angeles, CA, USA; 6 Gustave Roussy and Paris-Sud University, Villejuif, France; 7 Dana- Farber Cancer Institute, Boston, MA, USA; 8 Ella Lemelbaum Institute of Melanoma, Sheba Medical Center, Tel Hashomer, Israel; 9 Vanderbilt- Ingram Cancer Center, Nashville, TN, USA (currently at Northwestern University Feinberg School of Medicine, Chicago, IL, USA, USA); 1 New York University Cancer Institute, New York, NY, USA; 11 University of Colorado Denver, Aurora, CO, USA; 12 Netherlands Cancer Institute, Amsterdam, Netherlands; 13 currently at University of Washington and Seattle Cancer Care Alliance, Seattle, WA, USA; 14 John Wayne Cancer Institute, Santa Monica, CA, USA; 15 Duke Cancer Institute, Durham, NC, USA; 16 City of Hope, Duarte, CA, USA; 17 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA; 18 University of California, Los Angeles, Los Angeles, CA, USA 31

32 Time to and Duration (RECIST v1.1, INV) of Complete Response to Pembrolizumab Patients with CR, n = 29 Median, mo (range) Time to CR 2.9 ( ) Time from SD to CR (n = 5) 6.9 ( ) Time from PR to CR ( n = 21) 8. ( ) Duration of CR Not reached ( ) Arrows indicate conversion from SD to CR; 5 patients converted from SD and 21 from PR to CR. Median DOR in all treated patients was not reached (range mo to mo). Of 2 patients without PD, 14 discontinued because of AEs (n = 3) or patient/physician decision (n = 11). Data cut-off: February 3, 217.

33 Time to and Duration (RECIST v1.1, INV) of Partial Response to Pembrolizumab Duration (RECIST v1.1, INV) of Stable Disease to Pembrolizumab Patients with PR, n = 7 Median, mo (range) Time to PR 2.9 ( ) Time from SD to PR (n = 28) 2.7 ( ) Duration of PR Not reached (1.9+ to 43.5+) Patients with SD, n = 88 Median, mo (range) a Duration of SD 6.9 (.8+ to 38.8+) Arrows indicate conversion from SD to PR; 28 patients converted from SD to PR. Median DOR in all treated patients was not reached (range mo to mo). Of 42 patients without PD, 29 discontinued because of AEs (n = 15) or physician/patient decision (n = 14). Data cut-off: February 3, 217. Of 25 patients without PD, 24 discontinued because of AEs (n = 11) or patient/physician decision (n = 13). a Duration of SD is from randomization to progression. Data cut-off: February 3, 217.

34 PFS AND OS in All Pembrolizumab-Treated Patients and Those With Best Response of CR, PR, or SD Group Events, n Median, mo (95% CI) Group Events, n Median, mo (95% CI) CR (38.9-NR) CR 29 NR (NR-NR) PR (27.9 -NR) PR 7 NR (NR-NR) 1 SD All treated ( ) 4.2 ( ) 1 SD All treated ( ) 14. ( ) P F S, % % 76% 24% 29% 75% 66% 6% 21% 72% 49% 1% 16% O S, % % 96% 71% 55% 93% 86% 31% 37% 89% 71% 24% 3% No. at risk Time, months No. at risk Time, months NR, not reached. PFS was assessed by RECIST v1.1 per investigator. Data cut-off: February 3, 217.

35 Conclusions Responses to pembrolizumab are durable and associated with prolonged OS in ipilimumab-refractory melanoma Even in these heavily pretreated patients, best response can evolve over time, with late conversions from SD to PR/CR and PR to CR observed No new safety signals with longer term follow-up

36 Keynote 1: phase I study of pembrolizumab in 655 metastatic melanoma patients. Median follow-up of 43 months All Patients Treatment Naive a 1 9 Pts, N Events, n Median (95% CI) 1 9 Pts, N Events, n Median (95% CI) Overall Survival, % (59%) 23.8 mo ( mo) 42% 37% Overall Survival, % (5%) 41.2 mo (27.2 mo-nr) 51% 48% Time, months Time, months No. at risk No. at risk Robert et al EADO 217 a Excludes patients with ocular melanoma. Analysis cutoff date: September 1, 216.

Decision 11% Discontinued for PD: 42% Discontinued for AEs: 25% Range of

37 Pembrolizumab phase 1: Keynote 1 : Median Follow-Up 43 Months for 655 patients Consent withdrawal 5% On treatment: 16% Discontinue for physician Decision 11% Discontinued for PD: 42% Discontinued for AEs: 25% Range of follow-up: months. Analysis cutoff date: September 1, 216. Robert et al EADO 217

Complete Responders: Disposition Median follow-up: 43 months 92 (88%) remained in CR a 15 (16%) patients had CR per irrc by investigator review 14 (13%) remained on pembrolizumab 24 (23%)

38 Complete Responders: Disposition Median follow-up: 43 months 92 (88%) remained in CR a 15 (16%) patients had CR per irrc by investigator review 14 (13%) remained on pembrolizumab 24 (23%) discontinued for AEs (n = 12), PD (n = 2), or other reason (n = 1) 67 (64%) stopped pembrolizumab for observation Robert et al EADO 217 a Patient was alive and without disease progression. Analysis cutoff date: September 1, 216.

39 Complete Responders Who Stopped Pembrolizumab for Observation (N = 67) Median time to CR: 13 mo ( 3-36 mo) 61 (91%) responses were maintained Median response duration: NR (6+ to 56+ mo) Time to PD or last assessment Last dose CR PR PD Time to death Time, months Total bar length represents the time to the last scan. Analysis cutoff date: September 1, 216.

40 Complete Responders Who Stopped Pembrolizumab for Observation (N = 67) 2 patients died; causes unrelated to pembrolizumab (3,6) Only 4 patients experienced PD 2 received commercial pembrolizumab, and had PD (1, 4) 2 received 2 nd course pembrolizumab 1 had PR and is ongoing (2) 1 had PD (5) Time to PD or last assessment Last dose CR Time, months PR PD Time to death Robert et al EADO 217 Total bar length represents the time to the last scan. Analysis cutoff date: September 1, 216.

41 How long to treat with anti-pd1? In case of a partial response or stable disease? 41

KEYNOTE-6 (NCT1866319) Study Design Patients Unresectable, stage III or IV melanoma 1 previous therapy, excluding anti CTLA-4, PD-1, or PD-L1 agents Known BRAF mutation status a ECOG PS -1 No active

Stratification Factors ECOG PS ( vs 1) Line of therapy (first vs second) PD-L1 status b (positive vs negative) Primary end points: PFS and OS Secondary end points: ORR, duration of response, safety a

42 KEYNOTE-6 (NCT ) Study Design Patients Unresectable, stage III or IV melanoma 1 previous therapy, excluding anti CTLA-4, PD-1, or PD-L1 agents Known BRAF mutation status a ECOG PS -1 No active brain metastases No serious autoimmune disease R 1:1:1 Pembrolizumab 1 mg/kg intravenous Q2W for 2 years Pembrolizumab 1 mg/kg intravenous Q3W for 2 years Ipilimumab 3 mg/kg intravenous Q3W 4 doses Stratification Factors ECOG PS ( vs 1) Line of therapy (first vs second) PD-L1 status b (positive vs negative) Primary end points: PFS and OS Secondary end points: ORR, duration of response, safety a Prior anti-braf targeted therapy was not required for patients with normal LDH levels and no clinically significant tumor-related symptoms or evidence of rapidly progressing disease. b Defined as 1% staining in tumor and adjacent immune cells as assessed by IHC (22C3 antibody).

43 Keynote 6: Patients Who Completed Protocol-Specified Time on Pembrolizumab a (median follow-up, 9.7 mo) 556 patients received pembrolizumab 14 (19%) completed pembrolizumab 24 (23%) CR 68 (65%) PR 12 (12%) SD 23 ongoing responses 1 PD b 1 received second course of pembrolizumab 64 ongoing responses 4 PD b 3 received second course of pembrolizumab 1 ongoing SD 2 deaths b,c C Robert et al ASCO 217 a Includes patients completing 21.6 months of treatment. b From end of pembrolizumab treatment. c Both deaths were a result of PD. Data cutoff date: Nov 3, 216.

44 PFS (irrc, investigator) from last Pembrolizumab dose in patients who completed protocol-specified time on treatment (n = 14) 1 9 Progression-Free Survival, % Patients who completed protocol-specified time on pembrolizumab, n Estimated PFS, % (95% CI) Median PFS (8-96) NR 12 (98%) patients were alive after a median of 9.7 months after completing pembrolizumab treatment No. at risk Time, months C Robert et al ASCO 217 Data cutoff date: Nov 3, 216.

45 Do we treat for too long? What is the risk? Late Adverse events with anti-pd1? Weber et al J Clin Oncol 217

46 n (%) No Significant increase in AE incidence between 2 and 3 years with anti-pd1 TREATMENT-RELATED AE INCIDENCE OVER TIME Pembrolizumab N = 555 Median FU (months) Any grade % Grade ¾ % Led to death % <1 Led to discontinuation % Data from Ribas et al, AACR 215; Robert et al ASCO 216; Robert et al ASCO 217 Analysis includes all randomized patients who received 1 pembrolizumab dose. a As designated by the investigator. b Because of sepsis. Data cutoff date: Nov 3, 216.

47 When can we stop anti-pd1? Help from PFS curve Ugurel S et al Eur J Cancer 217

48 Keynote 6 PFS Total Population (Median Follow-Up, 33.9 mo) 1 Stop pembro 9 8 Progression-Free Survival, % % 15% 31% 14% Pembrolizumab 2 1 Ipilimumab No. at risk Pembrolizumab Ipilimumab Time, months C Robert et al ASCO 217

49 Conclusion The optimal duration of immunotherapy is presently unknown Encouraging data: documentation of long term benefit after discontinuation in CR or after two years of treatment with anti-pd1 monotherapy (pembrolizumab) Randomized discontinuation trial needed but challenging to organize Practically: decision should be based upon patient s clear information and decision In case discontinuation due to toxicity and when the disease is not progressing, we advise not to rechallenge In case of confirmed CR after at least 6 months of therapy, if patients agree, we propose to stop In case of PR or SD, if patients agree, we propose to stop after 2 years

Immune checkpoint inhibition in melanoma. John Haanen

Immune checkpoint inhibition in melanoma John Haanen ESMO Preceptorship Singapore 217 Immune Checkpoint inhibitors Immune checkpoints play an important role in immune tolerance Cancer hijacks many of these