Combination Therapies Based on PD-1 or PD-L1 Blockade

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1 Combination Therapies Based on PD-1 or PD-L1 Blockade Melanoma Bridge Naples, Italy December 4, 214 Mario Sznol- Yale University (in Absentia)

2 Summary of Anti-PD-1/PD-L1 Activity in Metastatic Melanoma Nivolumab Treatment-Naive Nivolumab (post ipilimumab) Nivolumab (prior Rx, not ipi) Pembrolizumab Ipi-Naive Objective Response Rates Median Duration of Response Median PFS Median Survival 1/2/3 year survival 4% (CR = 7.6%) NR 5.1 months NR 73%/x/x 26-32% NR NA NA 7%/x/x 32% 23 months 4 months 17 months 63%/48%/42% 4% NR 5.6 months NR 74%/x/x Pembrolizumab (post ipilimumab) 21-28% NR months 6mth 34-38% NR 65%/x/x

3 Possible Mechanisms for Innate Resistance to PD-1/PD-L1 Blockade No tumor antigen specific T-cells in tumor microenvironment Don t exist or; Blocked from entry into tumor Insufficient tumor antigen specific T-cells in tumor microenvironment Dysfunctional tumor antigen specific T-cells in tumor microenvironment Other checkpoints present in addition to PD1-PD-L1 pathway Dysfunction driven by checkpoints other than PD1-PD-L1 pathway Other mechanisms of T cell suppression IDO, TGF-beta, Treg, etc. Loss of tumor antigen presentation Innate tumor cell resistance to immune mediated killing

4 Combinations Based on PD-1/PD-L1 Blockade Multiple combinations supported by animal models Vaccines Cytokines (IL-15, IL-21, IFN-alfa, ) Immune checkpoints CTLA-4 LAG-3, TIM-3, B7-H3? Co-stimulatory agents 4-1BB, OX4, CD27,. Adoptive Cell Transfer Inhibitors of infiltrating suppressive MDSC and type 2 macrophages Enzyme based suppression- IDO Treg inhibition Targeted agents Chemotherapy Radiation therapy Anti-angiogenesis agents HDAC Inhibitors No human data yet to reliably predict best combination for individual patient

5 Synergistic Activity with Anti-PD-1 and Anti- CTLA-4 Antibodies Combination of Non-Efficacious Doses of anti-pd1 and anti-ctla-4 Antibodies is Efficacious in Mouse Model median tumor volume mm3 Dosing Control actla-4 MAb apd-1 MAb Combination apd-1 + actla days Provided by Alan Korman, BMS Rationale: Different roles in T cell Differentiation- Compensatory upregulation Anti-CTLA4 elimination of tumor Treg Anti-CTLA4 induced tumor T cell infiltration

6 Phase 1 CA29-4 Cohorts Cohort 1 (N = 14) Nivo.3 + Ipi 3 Q3W x 4 Q3W Nivo.3 x 4 Nivo.3 + Ipi 3 Q12W x 8 Concurrent Therapy Cohort 2 (N = 17) Cohort 3 (N = 6) Cohort 2a (N = 16) Nivo 1 + Ipi 3 Nivo 3 + Ipi 3 Nivo 3 + Ipi 1 Q3W x 4 Q3W x 4 Q3W x 4 Nivo 1 Q3W x 4 Nivo 1 + Ipi 3 Nivo 3 Q3W x 4 Nivo 3 + Ipi 3 Nivo 3 Q3W x 4 Nivo 3 + Ipi 1 Q12W x 8 Q12W x 8 Q12W x 8 Cohort 8 (N = 41) Nivo 1 + Ipi 3 Q3W x 4 Nivo 3 Q2W x 48 Sequenced Therapy Cohort 6 (N = 17) Cohort 7 (N = 16) Prior standard ipilimumab therapy 4 12 weeks from last dose Nivo 1 Nivo 3 Q2W x 48 Q2W x 48 All dose units are mg/kg. Results from Cohorts 6 and 7 (sequenced treatment cohorts ipilimumab followed by nivolumab) were reported previously (Kluger et al. ESMO 214) Ipi = ipilimumab; Nivo = nivolumab; Q2W = every 2 weeks; Q3W = every 3 weeks; Q12W = every 12 weeks 6

7 Baseline Characteristics Cohorts 1 3 (N = 53)* Cohort 8 (N = 41)* Median age, years (range) 57 (22 79) 55 (22 8) Male, n (%) 6 44 ECOG performance status, n (%) 1 Not reported Lactate dehydrogenase level, n (%) Upper limit of the normal range >Upper limit of the normal range Systemic cancer therapy, n (%) Immunotherapy BRAF inhibitor Number of prior systemic cancer therapies, n (%) *All treated patients JUNE 214 data analysis. ECOG = Eastern Cooperative Oncology Group. 7

8 Activity Summary Cohort(s) Nivo (mg/kg) + Ipi (mg/kg) N b ORR, a % CR, % Aggregate Clinical Activity Rate, % 8% Tumor Burden Reduction at 36 Weeks, c % a d All Concurrent Cohorts a Per modified World Health Organization (mwho) criteria, [CR+PR]/Nx1. b Number of response-evaluable patients. c Best overall response. d Cohort 8 using the phase 2/3 trial dose schedule, started November 213. JUNE 214 data analysis 8

9 Maximum Response in Target Lesions Maximum Response From Baseline in Target Lesion (%) Patient Patients Cohorts % patients had 8% reduction in target lesion Cohort 8 29% patients had 8% reduction in target lesion JUNE 214 data analysis. April 214 data analysis 9

10 Metastatic melanoma from anal mucosal primary, Cohort 2: response to ipilimumab 3 mg/kg + nivolumab 1 mg/kg; Received a single dose of combination due to early onset uveitisresponded to high dose steroids

11 Metastatic melanoma from anal mucosal primary, Cohort 2: response to ipilimumab 3 mg/kg + nivolumab 1 mg/kg; Received a single dose of combination due to early onset uveitisresponded to high dose steroids

Sienkiewicz, Dina, L CT NP 256 LightSpeed VCT Unit#: MR2263994 CT CHEST ABDOMEN PELVIS W IV CONTRAST Acc#: E11726672 6.

12 Metastatic melanoma from anal primary Relapse after approx. 2 years, re-induction with 4 combination doses to near CR; No recurrence of uveitis Sienkiewicz, Dina, L Unit#: MR Acc#: E DOB: 1/7/1967 F/46 YEAR H Yale New Haven Hospital Sienkiewicz, Dina, L CT NP 256 LightSpeed VCT Unit#: MR CT CHEST ABDOMEN PELVIS W IV CONTRAST Acc#: E CHEST - ABDOMEN - PELVIS WITHOUT AND/OR WITH DOB: 1/7/1967 6/5/214 1:42:41 PM F/46 YEAR Tech: DM H Yale New Haven Hospital CT NP 256 LightSpeed VCT CT CHEST ABDOMEN PELVIS W IV CONTRAST 6.1 CHEST - ABDOMEN - PELVIS WITHOUT AND/OR WITH 8/16/214 1:53:26 AM Tech: mt R L R L FFS Tilt: KVp: W: 4 C: 4 Z: 1.53 HELICAL MODE /1:42:41 PM ORAL OMNI & 85CC OMNI 35 F cm NI: 135 ASIR: SS2 FFS THK: 5 Tilt: XY: 8.6 KVp: Compressed 8:1 W: 49 C: 39 Z: 1.22 IM: 22 SE: 61 HELICAL MODE /1:53:26 AM Page: 22 of 51 ORAL OMNI & 85CC OMNI 35 F cm NI: 135 ASIR: SS2 THK: 5 XY: Compressed 8:1 IM: 25 SE: 61 Page: 25 of 54

13 Cohort 8, Ipilimumab + nivolumab, response at 12 weeks Prior therapy with HD-IL2, multiple resections, Vemurafenib, and RT; LDH > 2 at baseline; LDH nearly normal within 3 weeks

14 Yale Ipi/Nivo Cohorts 1-3 N=25 Confirmed PR/CR 1 (4%) 7 ongoing near CR 1 CR ->PD at approx. 2.5 years -> reinduced -> near CR 1 PD in node and then in brain, DOD at approx. 2 years 1 PD DOD at > 4 years after multiple therapies Of 15 PD/unconfirmed OR: Mixed response (early brain met), then later bowel mets now NED with gamma knife RT + surgery Mixed Resp at 12 weeks -> off due to tox (lipase) CR with further ipi alone, single local recurrence resected upr -> off due to LFTs PD on steroids stable PR with further ipi alone 1 prolonged irpr PD reinduction-> alive with PD 1 inevaluable response in brain mets and small systemic DZ (lung/liver) -2 brain mets RX with GK-RT now NED > 1 year 1 irsd PD reinduced at approx 3.5 years 1 SD PD PR to TIL 1 total deaths (6 non-responders) 4 at dose level 1 1 ocular primary Follow-up 2 years 8/1 PR/CR remain in CR/near CR (one required re-induction at 2.5 years) 4 with mixed response or transient response remain with NED with additional ipi alone, ipi + surgery, or GKRT + surgery 1 with SD x 1 year remains progression-free after TIL 2 with waxing and waning disease and slow progression on continued therapy and reinduction Tail of curve at 5% survival?

15 1 9 Overall Survival 1-yr OS 94% 2-yr OS 88% Lowest survival in cohort 1 Dose response for nivo versus patient selection OS (%) Cohort 8 (N=41) 1-yr OS 85% 2-yr OS 79% Cohort 2 (N=17) Cohorts 1 3 (N=53) Died/Treated Median OS (95% CI) Cohort 2 4/17 NR (26.8 NR) Cohorts /53 NR (39.7 NR) 1 Cohort 8 8/41 NR (1.5 NR) Patients at Risk Cohort 2 (Nivo 1 + Ipi 3) Cohorts 1 3 Cohorts 8 (Nivo 1 + Ipi 3) Month Cohort 8 uses the same dosing schedule that is being tested in the phase 3 trial (CA29-67) JUNE 214 data analysis. 15

16 ORR and Tumor Burden Change by BRAF Mutation Status Cohort(s) [N * ] Evaluable Sample, N BRAF WT ORR, n/n (%) BRAF MT 1 3 [53] 51 18/39 (46) 3/12 (25) 8 [41] 39 1/27 (37) 6/12 (5) * Number of patients treated. MT=mutant (BRAFT V6 mutation positive); WT=wild-type (BRAF V6 mutation negative). Maximum Response From Baseline in Target Lesion (%) Cohorts 1 3 Cohort JUNE 214 data analysis. BRAF MT BRAF WT BRAF Unknown 16

17 ORR and Tumor Burden Change by PD-L1 Status Cohort(s) [N * ] Evaluable Sample, N ORR, n/n (%) PD-L1 Positive PD-L1 Negative 1 3 [53] 37 8/14 (57) 8/23 (35) 8 [41] 21 / 8/21 (38) * Number of patients treated. 5% cut-off, tumor cell surface staining. None of the 21 evaluable patient samples was test positive for PD-L1 by 5% tumor cell surface staining cutoff Cohorts 1 3 Cohort 8 Maximum Response From Baseline in Target Lesion (%) PD-L1+ PD-L1- PD-L1 Unknown JUNE 214 data analysis. 17

18 Treatment-Related AEs Reported in 15% of Patients* Patients with an Cohorts 1 3 (N=53) Cohort 8 (N=41) event, % Any Grade Grade 3/4 Grade 5 Any Grade Grade 3/4 Grade 5 All drug-related Rash Pruritus Fatigue Diarrhea Nausea Lipase increased AST increased Pyrexia ALT increased Amylase increased Vitiligo 15 7 Abdominal pain Arthralgia 9 2 *Listing adverse events reported in 15% of patients in cohorts 1 3 or in cohort 8, sorted by any grade frequency in cohort 1 3; One patient died due to grade 5 multi-organ failure related to study treatment in cohort 8 ALT = alanine aminotransferase; AST = aspartate aminotransferase. JUNE 214 data analysis. 18

19 Treatment-Related Immune-Mediated* AEs Patients with an event, % Cohorts 1 3 (N=53) Cohort 2 (N=17) Cohort 8 (N=41) Any Grade Grade 3/4 Any Grade Grade 3/4 Any Grade Grade 3/4 Skin Gastrointestinal Hepatic Endocrine Pulmonary Renal Hypersensitivity /Infusion Reaction Standard safety guidelines available to manage immune-mediated AEs with immune suppressing medication *Immune-mediated adverse events are events with potential immunologic causes and those that require more frequent monitoring or intervention with immune suppression or hormone replacement JUNE 214 data analysis. 19

20 PD-1/PD-L1 Blockade + anti-ctla-4 Next Steps and Questions Randomized trials versus ipilimumab (69) and versus ipilimumab or nivolumab (67) were completed Concurrent versus sequential Gene expression (Dhodapkar et al, SITC 214) suggest concurrent administration produces unique biological effects Management of adverse events Predictive biomarkers? Biology of acquired resistance? Safe triple combinations? (anti-vegf, others) 2

21 Non-Immunotherapy VEGF/VEGFRi RT Molecular targets ChemoRx Vaccines Cytokines Antigen Presenting Cell or Tumor T-lymphocyte Function (excluding Treg) Peptide-MHC T cell receptor Signal 1 CD8/CD86 (B7.1, B7.2) CD28/CTLA-4 Stimulatory/inhibitory CEACAM-1 and TIM-3 CEACAM-1 inhibitory CD7 CD27 stimulatory LIGHT HVEM stimulatory HVEM BTLA, CD16 inhibitory PD-L1 (B7-H1) PD-1 and CD8 Inhibitory (Th1) PD-L2 (B7-DC) PD1 and? Inhibitory (Th2) or stimulatory OX4L OX4 stimulatory 4-1BBL CD137 stimulatory CD4 CD4L Stimulatory to DC/APC B7-H3? Inhibitory or stimulatory B7-H4? inhibitory PD-1H (Vista)? inhibitory GAL9 TIM-3 inhibitory MHC class II LAG-3 inhibitory B7RP1 ICOS stimulatory MHC class I KIR Inhibitory or stimulatory GITRL GITR stimulatory CD48 2B4 (CD244) inhibitory HLA-G, HLA-E ILT2, ILT4; NKG2a inhibitory MICA/B, ULBP-1, -2, -3, and -4+- NKG2D Inhibitory or stimulatory CD2 CD2R inhibitory CD155 TIGIT/CD226 Inhibitory/stimulatory IDO Treg MDSC Macrophages TGF-beta In our melanoma gene expression database, high levels of: CEACAM-1 B7-H3 CD2 CD155 (PVR)

22 TIM3

23 41BB + anti-pdl1 Hirano et al, Cancer Res, Feb, 25

24 Ipilimumab (anti-ctla-4) Tremelimumab (anti-ctla-4) Bevacizumab IFNs RCC/melanoma IL-21 terminated? IL-2 (proposed) anti-lag3 anti-kir peptide vaccines Oncolytic viruses (Tvec) Anti-OX4 (proposed) Anti-CD27 Anti-CD137 Treg inhibitors - mogamulizumab Adoptive Cell Therapy Dabrafenib +/- Trametinib Vemurafenib +/-Cobimetinib RT PD-1 Pathway Blockade Combinations in Development

25 Response to Ipi-Nivo June 213 July 213 Feb 214 Pt recently progressed on ACT*

26 Conclusions If phase 3 trials confirm early data, anti-pd-1 + anti-ctla4 will become SOC for metastatic melanoma (wtbraf and mbraf) Following for long term survival Toxicity high but manageable (similar to ipi 1 mg/kg) Approaches to improve ipi/nivo not immediately obvious Multiple combinations supported by animal model data But clinical correlative data not yet available to select best regimens for subsets of patients Clinical endpoints for studies may need to evolve 3-year survival rates? Durable CR or near CR?

27 Credits CA29-4 Jedd Wolchok Margaret Callahan Harriet Kluger Michael Atkins John Kirkwood Mary Ruisi Ashok Gupta Alan Korman Many others

Melanoma. Il parere dell esperto. V. Ferraresi. Divisione di Oncologia Medica 1

Melanoma. Il parere dell esperto. V. Ferraresi. Divisione di Oncologia Medica 1 Melanoma Il parere dell esperto V. Ferraresi Divisione di Oncologia Medica 1 MELANOMA and ESMO 2017.what happens? New data and updates ADJUVANT THERAPY with CHECKPOINT INHIBITORS (CA209-238 trial) AND