DISCLOSURES. Roche/MSD-Merck/Celgene: Research Funding

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2 DISCLOSURES Roche/MSD-Merck/Celgene: Research Funding Roche/Celgene/AstraZeneca/Amgen/MSD/Novartis/Sanofi- Aventis/Pierre Fabré: Advisory Board or Consultant No conflict of interest with respect to this topic I am clinical oncologist (not immunologist unfortunately )

3 OUTLINE i. Definitions and framework ii. Types of neoantigens iii. Types of cancer vaccines iv. Strategies with vaccine effects v. Clinical results and trials ongoing vi. Final remarks

4 Definitions Vaccine: a preparation of microbial antigen, often combined with adjuvants, that is administered to individuals to induce protective immunity against microbial infections Antitumoral vaccines: array of approaches that seek to generate and/or amplify antitumor immunity through tumor antigens, often with APC, or direct modulation of the tumor. Considered active immunotherapy

5 Generation of cancer immunity is a cyclic process self-propagating Tumour cell death releases tumour-derived antigens Killing of tumour cells by T cells 7 Recognition of tumour cells by T cells 1 2 Dendritic cells process tumour-derived antigens The cancer immunity cycle Infiltration of T cells into tumours Adapted from Chen DS, Mellman I. Immunity 2013;39:1 10. T cells are primed and activated by dendritic cells presenting tumour-derived antigens Trafficking of T cells to tumours

6 Melero I. Nat Rev 2014 Vaccine targets

7 Cancer vaccination needs immunization with tumor antigens: non-mutated (TAA, cancer-testis, oncofetal antigens) or mutated-tumor specific antigens (TSA) Butterfield LH. BMJ 2015;350:h988

8 Types of cancer vaccines 1) Peptidebased, MHC I restricted epitopes on TAAs 2) DNA, RNA based 3) AutologousAPCsin TAA based vaccines 4) Tumor cells, engineered with cytokines or adjuvants 5) Viral based vaccines Butterfield LH. BMJ 2015;350:h988

9 Types of cancer vaccines 1) Peptide based, MHC I restricted epitopes on TAAs 2) DNA, RNA based 3) Autologous APCs in TAA based vaccines 4) Tumor cells, engineered with cytokines or adjuvants 5) Viral based vaccines Butterfield LH. BMJ 2015;350:h988

10 Butterfield LH. BMJ 2015;350:h988

11 Vaccines in clinic, a disappointing story. Rosenberg, Nat Med 2004

12 SIPULEUCEL-T (FDA APPROVAL 2010) Autologous APC+ TAA (PAP)+ GM-CSF Collects patient s blood cells Manufacturing Process Overview: Sipuleucel-T (APC8015) Further enrichment of mononuclear cells PA2024 ANTIGEN ADDED 3-4 Days APC activation/antigen processing Final formulation

13 SIPULEUCEL-T (FDA APPROVAL 2010) Autologous APC+ TAA (PAP)+ GM-CSF Collects patient s blood cells Manufacturing Process Overview: Sipuleucel-T (APC8015) Further enrichment of mononuclear cells PA2024 ANTIGEN ADDED 3-4 Days APC activation/antigen processing Final formulation

14 SIPULEUCEL-T Apheresis (APH) Granulocytes Red Blood Cells Platelets Neutrophil Eosinophil Basophil Monocyte B cell T cell Buoyant Density Centrifugation Steps (BDS77 and BDS65) NK cell In vitro culture Final product formulation (FP)

15 SIPULEUCEL-T Apheresis (APH) Buoyant Density Centrifugation Steps (BDS77 and BDS65) PA2024 Monocyte B cell T cell NK cell In vitro culture Final product formulation (FP)

16 SIPULEUCEL-T

17

18 Melero I. Nat Rev 2014 Clinical trials with vaccines

19 Types of cancer vaccines 1) Peptidebased, MHC I restricted epitopes on TAAs 2) DNA, RNA based 3) AutologousAPCsin TAA based vaccines 4) Tumor cells, engineered with cytokines or adjuvants 5) Viral based vaccines Butterfield LH. BMJ 2015;350:h988

20 VACCINE EFFECT: EVERY TUMOR HAS ITS ACHILLES HEEL Sharma Science 2015

21 Damage Associated Mollecular Patterns DAMPs Galluzzi L, Gomes-de Silva LC, Dewittee H, et al. Combinatorial strategies for the induction of immunogenic cell death. Front Immunol. Mar 2015

22 Galluzzi Cancer Immunol Res AACR 2016

23 Targeted therapies: MAPKi in melanoma BRAF mut Dual MAPK pathway inhibition PD-L1 inhibition MAPK Inhibitor-Induced Changes 1,2 Increased melanoma antigen expression Decreased immunosuppressive cytokine production Increased CD8+ T-cell infiltration Increased T-cell clonality a Increased PD-L1 expression Class I MHC upregulation CD8+ T cell per Tumor Cell ND MEKi 1. Frederick D et al. CCR Ebert P et al. Immunity 2016.

24 Phase III Study of Atezo + Cobi + Vem in BRAF V600 Mutant Melanoma (NCT ) A Phase III study evaluating atezo + cobi + vem vs placebo + cobi + vem in patients with BRAF V600 mutant advanced melanoma is planned Previously Untreated Advanced Melanoma BRAF V600 mutation ECOG PS 0-1 Measurable disease No significant history of liver disease N = 500 Vem 960mg BID a Cobi 60mg QD b R 28 days Treatment until PD or toxicity Vem 960mg BID a Cobi 60mg QD b Atezo 840mg q2w Vem 720mg BID + Vem Placebo 240mg BID Cobi 60mg QD b Placebo q2w Vem 960mg BID Cobi 60mg QD b Key study objectives Primary: investigator-assessed PFS Secondary: PFS (IRF-assessed), OS, ORR, DOR, Safety, PK a Vemurafenib dose will decrease to 720 mg BID + placebo 240 mg BID beginning day 22 of vem + cobi doublet treatment phase. b Cobimetinib administered on 21 days on/7 days off schedule. IRF, independent review facility; PK, pharmacokinetics.

25 Oncology Immunovirotherapy: T-VEC an HSV-1-derived oncolytic immunotherapy designed to produce local and systemic effects Local effect: virus-induced tumour-cell lysis Systemic effect: antitumour immune response 1 Healthy cells 2 GM-CSF 3 Dendritic cell activated by GM-CSF CD4+ helper T cell 4 T-VEC Tumour cells Tumour cell lysis TDAs TDAs CD8+ cytotoxic T cell Distant dying tumour cell T-VEC replication in tumour tissue 1 3 Tumour cells rupture for an oncolytic effect 1 4 Systemic antitumour immune response 3,5,6 Death of distant cancer cells Hawkins LK, et al. Lancet Oncol 2002;3:17 26; 2. Fukuhara H, Todo T. Curr Cancer Drug Targets 2007;7:149 55; 3. Amgen. Imlygic Summary of Product Characteristics. Section 5.1; 4. Pol JG, et al. Virus Adapt Treat 2012;4:1 21; 5. Melcher A, et al. Mol Ther 2011;19: ; 6. Dranoff G. Oncogene 2003;22: ; 7. Liu BL, et al. Gene Ther 2003;10: ; 8. Andtbacka RHI, et al. J Clin Oncol 2015;33: Proposed mechanism of action for T-VEC. TDA, tumour-derived antigen.

26 Dual Mechanism of Action: Talimogene Laherparepvec + Pembrolizumab Tumor cell PD-L1/PD-L2 Pembrolizumab binding PD1 CD = cluster of differentiation GM-CSF = granulocytemacrophage colony-stimulating factor MHC = major histocompatibility complex PD-1 = programmed death receptor 1 PD-L1 = programmed death ligand 1 TDA = tumor-derived antigen 7. T cell mediated tumor cell death and release of new array of TDAs 6. T cell tumor recognition 5. T cell tumor infiltration Tumor bed TDA Figure adapted from Chen DS, et al. Immunity. 2013;39:1-10. Luke JJ, et al. Oncotarget. 2015;6: Ribas A. N Engl J Med. 2012;366: T cell Immature dendritic cell Systemic Effect 4. T cell proliferation and migration Talimogene laherparepvec Blood vessel Tumor cells 1. Tumor cell lysis GM-CSF TDA Immature dendritic cell Local Effect Pembrolizumab binding PD-L1/PD-L2 Dendritic cell MHC TDA B7 CD28 T cell 2. Dendritic cell maturation + + Mature dendritic cell 3. T cell activation T cell PD1 T cell receptor

27

28

29

30 Schumacher Science 2015

31 Melero Nature Rev Cancer 2015

32 Vaccines future, combinations Butterfield LH. BMJ 2015;350:h988

33 Closing remarks and future perspectives Goal of tumor vaccines is always the same, activation of tumor specific T cells Neoantigens non-mutated (immunogenic but low avidity) or mutated (immunogenic, high avidity but extremely difficult to identify) Several types of vaccines * Classical: peptides, DNA-RNA, APCs, tumor cells, virus * Vaccine effect concept: CT, RT, targeted Tx, virotx Immunomonitoring crutial for tailor therapy In the era of immune checkpoints mabs, vaccination strategies should be investigated inside combos

34 Thank you so much!

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