INDIVIDUALIZED THERAPY OF METASTATIC BREAST CANCER Lance A. Liotta MD PhD

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1 INDIVIDUALIZED THERAPY OF METASTATIC BREAST CANCER Lance A. Liotta MD PhD A vision for Combining proteomic mapping with genomic analysis of the metastatic lesion

2 57 year old women TNBC locally recurrent to chest wall distant metastasis (lung and bone) Initial diagnosis: 2011 Infiltrating ductal breast cancer Characteristics of the primary tumor: Her2 ++ by IHC Her2 - by FISH ER NEG PR NEG. Previous Therapies: SD pcr: preoperative AC/T; PD: bortezomib/cyclophosphamide/ PD: BEZ235 (PI3K/mTOR inhibitor) CASE STUDY There are only a few proven standards of care in metastatic breast cancer management, and inclusion of patients in.. trials must be a priority. Cardoso et al. Clinical Practice Guidelines, Annals of Oncology 2012 Patient judged eligible for a clinical research trial (SIDE OUT TRIAL) combining proteomics and genomics to individualize therapy : Target lesion for biopsy: chest wall

3 Options for therapy of recurrent and metastatic breast cancer are limited, and too often do not improve the PFS Therapy strategies are usually based on a profile of the primary tumor, not the metastasis. (Recurrent/Metastatic) Combining bevacizumab with docetaxel and trastuzumab did not significantly improve investigator assessed PFS Improved treatment may be facilitated by biomarker-led understanding of subgroup molecular targets, which may predict benefit from currently approved agents, and newer targeted drugs.

4 Lung Ecosytem SEED and SOIL Growth factors, extracellular matrix composition, hypoxia/vascular, immune microenvironment, are completely different in the target organ of metastasis, compared to the primary breast Bone Ecosytem

5 Cancer Clonal Selection in Breast Cancer Metastasis Subclones are selected out based on selective pressures: A. Survival in a secondary tissue or organ during metastasis B. Survival in the face of therapy Some clones remain dormant while others dominate depending on the selective pressures in the tissue microenvironment. Mel Greaves and Maley 2012 Darwin s notebook

6 CONCEPT 1. Map the signaling network of the metastatic tumor cells to understand which growth or survival pathways are functionally in use in the tissue microenvironment. 2. Combine this information with genomic analysis to sort out which of the many genetic defects are true drivers. 3. Use this integrated knowledge to recommend therapies. Genomics LCM Proteomics Biopsy of Metastatic Lesion Molecular Profiling Select Therapy

7 Solving the Problem of how to map phosphoprotein signal networks in small numbers of biopsy cells Multiple samples/array, highly precise One antibody probe/array Built in controls, standards, calibrators, and samples on same array 380 validated endpoints: 2000 to 4000 cells required to measure more than 100 endpoints Phosphorylation reveals the activity state

8 A Pilot Study Utilizing Molecular Profiling by IHC, FISH, DNA Microarray, and Reverse Phase Protein Microarray (RPMA) of Patients Tumors to Find Potential Targets and Select Treatments for Patients with Metastatic Breast Cancer 1.CARIS/MPI Target NOW based profiling for IHC and DNA Array for Therapeutic Selection 1.Functional pathway activation analysis on FDA approved kinase-targeted therapeutics by Reverse Phase Protein Microarrays Sponsor: Side-Out Foundation Byant Dunetz Participants: CARIS Molecular Profiling Institute George Mason University Dr. Stephen Anthony Spokane WA Co-PI: Gayle S. Jameson Co-PI : Dr. Nicholas Robert Nicholas James Robert. Gayle Jameson

9 SIDE OUT TRIAL Breast Cancer Metastasis Sponsor: Side-Out Foundation Byant Dunetz Participants: CARIS Molecular Profiling Institute George Mason University Mariaelena Pierobon Patient is consented and screened for the study Patient eligibility verified by medical monitor Metastasis biopsy performed Stephen Anthony Spokane WA Co-PI: Gayle S. Jameson Co-PI : Dr. Nicholas Robert IHC, FISH, Microarray analyses, and LCM - RPMA Yes Treat patients according to MP Findings. Target Found? No Treat patient with clinician's choice

10 Primary Objective of the Study 1. To compare progression free survival (PFS) using therapy selected by molecular profiling (period B) with PFS for the most recent therapy on which the patient has just progressed (period A) PFS (TTP) prior therapy last PFS selected by Mol. Prof. Period A Period B If PFS B /PFS A ratio 1.3 then MP selected therapy was defined as having benefit for patient Robert Temple, Clinical measurement in drug evaluation. Edited by Wu Ningano and G.T. Thicker John Wiley and Sons Ltd. 1995; Von Hoff, D.D. Clin Can Res. 4: 1079, 1999: Dhani et al. Clin Cancer Res. 15: , 2009

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12 ASCO 2013

13 A Pilot Study Utilizing Molecular Profiling to Find Potential Targets and Select Individualized Treatments for Patients with Metastatic Breast Cancer ASCO 2013

14 Molecular Profiling yielded a treatment recommendation different from that recommended by the physician in all patients

15 Side Out Trial Conclusions 1. Three US sites enrolled 25 evaluable patients who were treated based on molecular profiling data. N= 25 was determined (exact single-stage design for phase II studies, type I error rate of 5% [onesided], power of 90%). Molecular Profiling selected therapy would warrant further investigation if 35% of the pts demonstrate a PFS ratio of Clinical benefit for the pt is defined by PFS ratio (PFS on MP selected therapy/pfs on prior therapy) is 1.3, (JCO,28: :2010). Ten pts (40%) met or exceeded the PFS ratio of pts continue on treatment for 199, 254 and 816 days. 3. SIXTY percent of pts LCM samples had activation of drug targets determined by RPMA in 3 major clusters: pan-her-akt; EGFR/SRC/ERK/mTOR; IGFR/RAF/MEK/PLK1.

16 METASTATIC BrCA PATIENT PROGRESSING AFTER 1-3 Rd LINE SIDEOUT II 9 SITES Target: PATIENTS Open BIOPSY OF METASTATIC LESION TGEN CARIS GMU WHOLE EXOME WHOLE RNAseq MULTIPLEXED IHC TREATMENT RECOMMENDATION COMMITTEE PROTEIN PATHWAY ACTIVATION MAPPING MOLECULAR RATIONALE FOR INDIVIDUALIZING THERAPY

17 CASE STUDY DATA: Integration of Proteomics and Genomics reveals potential functional drivers of the metastasis Protein pathway activation mapping Notable Findings POS phosphorylation pegfr Y1068 POS phosphorylation pakt S473 POS phophorylation perk T202/Y204 POS phosphorylation psrc Y527 POS PTEN Total protein Ki % ER NEG PR NEG NEG Phosphorylation of ERB2 Genomic Results Notable Findings Overexpressed: SRC, DCK, EGF Amplified: GRB2 Chr 17 Log2fc Candidate therapies recommended Gemcitabine: High expression of DCK associated with benefit Dasatinib: Activated and Overexpressed SRC + downstream ERK Erlotinib: Activated (dimer) EGFR + downstream AKT /ERK: POS PTEN GRB2 associates with pegfr activates MAPK/ERK