Making the TRK to Precision Medicine in Cancer The Promise of Targeting TRK Fusions in Lung, Breast, GI, and Other Tumors

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1 Making the TRK to Precision Medicine in Cancer The Promise of Targeting TRK Fusions in Lung, Breast, GI, and Other Tumors Not an official event of the 2018 ASCO Annual Meeting. Not sponsored, endorsed, or accredited by ASCO, CancerLinQ, or the Conquer Cancer Foundation.

2 Disclosures George D. Demetri, MD, has a financial interest/relationship or affiliation in the form of: Consultant for: Bayer Corporation; Bessor Pharma LLC; Blueprint Medicines; Caris Life Sciences; Champions Oncology; Daiichi Sankyo, Inc.; Eli Lilly and Company; EMD Serono, Inc.; Epizyme; G1 Therapeutics; Ignyta; Janssen Oncology; Loxo Oncology; Merrimack Pharmaceuticals; Mirati Therapeutics; Novartis Pharmaceuticals Corporation; Pfizer Inc.; PharmaMar; Polaris Pharmaceuticals, Inc.; Sanofi-Aventis U.S. LLC. (Oncology); WIRB Copernicus Group; and ZIOPHARM Oncology, Inc. Grant/Research Support from: AbbVie Inc.; Adaptimmune; Bayer Corporation; Epizyme; Ignyta; Janssen Oncology Global Services, LLC (Oncology); Loxo Oncology; Novartis Pharmaceuticals Corporation; and Pfizer Inc. Equity in Bessor Pharma LLC; Blueprint Medicines, Caris Life Sciences Inc.; Champions Oncology; G1 Therapeutics; and Merrimack Pharmaceuticals. Blueprint Medicines and Merrimack Pharmaceuticals where Dr. George Demetri serves as a Member of the Board of Directors for Blueprint Medicines and Merrimack Pharmaceuticals. George D. Demetri, MD, does intend to discuss either non-fda-approved or investigational use for the following products/devices: larotrectinib, entrectinib, LOXO-195, ropotrectinib, and other investigational TRK fusion inhibitors with tumor-agnostic activity. This CME activity is jointly provided by Medical Learning Institute, Inc. and PVI, PeerView Institute for Medical Education. This activity is supported by educational grants from Bayer US and LOXO Oncology, and Genentech.

3 Disclosures Alexander Drilon, MD, has a financial interest/relationship or affiliation in the form of: Consultant and/or Advisor for: AstraZeneca; BeiGene; Blueprint Medicines; F. Hoffmann-La Roche/Genentech, Inc.; Helsinn Therapeutics (US) Inc.; Ignyta; Loxo Oncology; Pfizer, Inc.; Takeda Pharmaceutical Company Limited and TP Therapeutics, Inc. Alexander Drilon, MD, does intend to discuss either non-fda-approved or investigational use for the following products/devices: larotrectinib, entrectinib, LOXO-195, ropotrectinib, and other investigational TRK fusion inhibitors with tumoragnostic activity. Anna F. Farago, MD, PhD, has a financial interest/relationship or affiliation in the form of: Consultant and/or Advisor for: AbbVie Inc.; AbbVie/ Stemcentrx; Loxo Oncology; PharmaMar; and Takeda. Honorarium from Foundation Medicine Research funding (to institution) from: AbbVie Inc.; AbbVie/Stemcentrx; AstraZeneca; Bristol-Myers Squibb; Ignyta; Loxo Oncology; Merck; Novartis; and PharmaMar. Anna F. Farago, MD, PhD, does intend to discuss either non-fda-approved or investigational use for the following products/devices: larotrectinib, entrectinib, LOXO-195, ropotrectinib, and other investigational TRK fusion inhibitors with tumor-agnostic activity. This CME activity is jointly provided by Medical Learning Institute, Inc. and PVI, PeerView Institute for Medical Education. This activity is supported by educational grants from Bayer US and LOXO Oncology, and Genentech.

4 Disclosures CME Reviewer Siyang Leng, MD Columbia University Medical Center New York, New York Siyang Leng, MD, has no financial interests/relationships or affiliations in relation to this activity. Medical Director Carmine Deluca PVI, PeerView Institute for Medical Education Carmine Deluca has no financial interests/relationships or affiliations in relation to this activity. The associates of Medical Learning Institute, Inc., the accredited provider for this activity, and PVI, PeerView Institute for Medical Education do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this CME activity during the past 12 months. This CME activity is jointly provided by Medical Learning Institute, Inc. and PVI, PeerView Institute for Medical Education. This activity is supported by educational grants from Bayer US and LOXO Oncology, and Genentech.

5 Visit us at Watch for the ondemand version in the coming weeks Download the slides and Practice Aids Apply for CME credit Join the conversation on Need more information? Send an to

6 Tonight s Agenda 1. TRK 101: A look at the biology behind gene fusions and the rationale for therapeutic targeting 2. TRK testing: Perspectives on how and when to test, and what techniques to consider 3. TRK evidence: An up-to-date assessment of the data that supports the continued development of TRK inhibitors as a tumor-agnostic approach to cancer management 4. Your questions and our answers on TRK fusions in cancer

7 Introduction: Oncogenic Fusions in TRK as the Vanguard in a Tumor- Agnostic Approach to Treating Cancer George D. Demetri, MD Dana-Farber Cancer Institute Ludwig Center at Harvard Harvard Medical School Boston, Massachusetts

8 How Do Physicians Know What Disease to Treat in Any Given Patient? Accurate DIAGNOSIS is a key component of clinical medicine Tools for making the most specific diagnosis have evolved 500 BC observation

9 How Do Physicians Know What Disease to Treat in Any Given Patient? Accurate DIAGNOSIS is a key component of clinical medicine Tools for making the most specific diagnosis have evolved 1200 AD observation and sensory analytics Visual Taste

10 How Do Physicians Know What Disease to Treat in Any Given Patient? Accurate DIAGNOSIS is a key component of clinical medicine Tools for making the most specific diagnosis have evolved 18th century Laboratory analytics Microscopes

11 Hundreds Of Different Key Lessons: 1. Question authority (pathologists) 2. Technology is key 3. Patterns change with tools Subtypes

12 How Does the Most Accurate Diagnosis Impact Treatment? Cancer represents thousands of different diseases The instability in the genome of cancer cells means that each patient s cancer has different mutational patterns, and these patterns evolve over time Identifying drivers from inconsequential gene variants or passenger mutations is a challenge still for most cancers!

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14 What Determines the Value of the Most Accurate Diagnosis? A highly effective new therapy targeted to a specific diagnosis The ability to provide an improved prognosis Avoidance of ineffective, toxic, and/or expensive therapies

15 The Old Landscape of Clinical Trials in Oncology: Target-Specific Smart Drug Trials From One targeted drug One molecularly-defined cancer 1997: Rituximab for B-cell lymphomas 1998: Trastuzumab for HER2+ breast cancer 2001: Imatinib for chronic myeloid leukemia 2002: Imatinib for gastrointestinal stromal tumors Change in practice with 1 FDA approval for 1 cancer in 1 clinical setting

16 Evolving Smarter Clinical Trials in Oncology: Target-Specific Basket Trial One targeted drug (imatinib) One trial testing a basket of cancers linked to targets of targeted drug (imatinib): 40 different cancers 186 patients 5 new FDA approvals granted on October 19, 2006 for five new cancers 1 with this one drug (imatinib) already FDAapproved for two other cancers (CML and GIST) 1. Heinrich MC et al. Clin Cancer Res. 2008;14:

17 Evolving Smarter Clinical Trials in Oncology: Immuno-oncology MSI-High/MMR-D Basket Trial One mechanismbased immuno-oncology drug (pembrolizumab)

18 Evolving Smarter Clinical Trials in Oncology: Immuno-oncology MSI-High/MMR-D Basket Trial One mechanismbased immuno-oncology drug (pembrolizumab) Synthesis of 5 trials testing a basket of cancers linked by DNA-repair aberrancies (MSI-HI or mismatch repair deficient) 11 different types of cancer 149 patients Disease-agnostic FDA approval granted on May 30, 2017 for any solid tumor following failure of prior therapy and with no satisfactory Rx options

19 TRK Fusions Represent the Next Level of Therapeutic Targeting in Solid Tumors Impossible to detect unless you look for them Diagnosis is critical, as there are now highly effective new therapies in late-stage development targeted to this very specific diagnosis Fusions are found across multiple cancer types (therefore disease agnostic ) New agents targeting TRK fusions have induced high rates of durable disease control even in the setting of bulky metastatic disease after failure of prior chemotherapies

20 Sarcomas Are a Model for the Complexity of Cancers Soft tissue sarcoma (90% of all sarcomas) Bone sarcoma (10%)

21 Soft Tissue Sarcoma Is Not a Single Disease Does it matter to make a more specific diagnosis?

22 Philadelphia Chromosome and BCR-ABL Fusion: The Grandparent of Oncogenic Kinase Fusions Accessed May 30, 2018.

23 Philadelphia Chromosome and BCR-ABL Fusion: The Grandparent of Oncogenic Kinase Fusions 1 9q+22qt(9;22)(q34;q11) Ph BCR-ABL gene BCR ABL

24 Fusions of Kinase Genes Are Often Drivers of Cancers

25 Introduction to Neurotrophins and TRKs 1 Sympathetic nervous system development is orchestrated by neurotrophins (NTs) and respective neurotrophin receptors 3 neurotrophin receptors are encoded by 3 distinct genes NTRK1 TRKA NTRK2 TRKB NTRK3 TRKC Normal function of TRK in adults TRKA Pain, thermoregulation TRKB Movement, memory, mood, appetite, body weight TRKC Proprioception Receptors and ligands are commonly dysregulated in multiple tumor types 1. Amatu A et al. ESMO Open. 2016;1:e

26 Timeline: Discovery History of Oncogenic NTRK Genes OncD isolated from CRC sample 1 OncD found to harbor sequence from TPM3 and previously undescribed kinase = TRK 1 NTRK1 gene fusions in papillary thyroid cancer 2 ETV6-NTRK3 in congenital mesoblastic nephroma 3,10 and congenital fibrosarcoma 3,4 ETV6-NTRK3 in secretory breast cancer 2 NTRK1 gene fusions discovered in NSCLC 5 and glioblastoma 2 NTRK2 gene fusions in astrocytoma 2 NTRK1 gene fusions in cholangiocarcinoma 2 NTRK1 gene fusions in Spitz nevi 2 NTRK3 gene fusions in papillary thyroid 2 NTRK1/2/3 gene fusions in pediatric gliomas 6 NTRK1 gene fusions in pediatric spitzoid tumors NTRK1/3 gene fusions in younger papillary 1. Vaishnavi A et al. Cancer Discov. 2014;5: Amatu A et al. ESMO Open thyroid cancer ;1:e Knezevich SR et al. Cancer Res. 1998;58: Knezevich SR et NTRK1 gene fusions in al. Nat Genet. 1998;18: Vaishnavi A et al. Nat Med. 2013;19: myopericytic/hemangiopericytic 6. Wu G et al. Nat Genet. 2014;46: Wu G et al. Mod Pathol. 2016;29: Prasad ML et al. Cancer. 2016;122: Haller F et al. J Pathol. 2016;238: pattern soft tissue sarcoma El Demellawy D et al. Pathology. 2016;48:47-50.

27 Precision Cancer Medicine for GIST: Gene Mutations Matter 1 KIT mutation (80%) SPECIFIC MUTATIONS affect patient outcomes GIST PDGFRA mutation (10% in met, 25% in gastric primary) SDH mutation or deficiency (either SDHA, SDHB, or SDHC) (approx. 10%) BRAF or NF1 mutations; TRK fusions (<2%) KIT exon 11 point mutations confer overall favorable prognosis KIT exon 9 mutations associated with worse prognosis PDGFRA D842V mutation = good risk in primary GIST BUT worse outcomes in metastatic GIST 1. Corless CL, et al. Nat Rev Cancer. 2011;11(12):

28 Next Steps to Understanding TRK Fusions in Cancer Patients What are the various tools used to find TRK fusions? How reliable are these diagnostic tools? Which patients are most likely to harbor TRK fusions? What are the outcomes of patients treated with TRK inhibitors?

29 TRK to the Future: Biomarker Testing and Strategies for Recognizing TRK Fusions in Cancer Anna F. Farago, MD, PhD Massachusetts General Hospital Instructor in Medicine Harvard Medical School Boston, Massachusetts

30 Types of Biomarkers 1 A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention. Diagnostic Type of disease? Prognostic To treat or not? Types of Biomarkers What treatment? Predictive What dose? Pharmacodynamic 1. Courtesy of Gainor J.

31 1. Mitsudomi T et al. Nat Rev Clin Oncol. 2013;10: Genotype-Directed Therapy 1

32 Molecular Classification of Lung Cancer 1 1. Jordan EJ et al. Cancer Discov. 2017;7:

33 Types of Somatic Genomic Alterations in Cancers Alteration Point mutations short insertions or deletions (indels) Common Examples EGFR mutations KRAS mutations BRAF mutations Copy number alterations HER2 amplification MET amplification Gene fusions BCR-ABL ALK fusions TRK fusions

34 Schematic of Gene Fusion Leading to Activation 1, Accessed May 14, Farago AF, Azzoli CG. Transl Lung Cancer Res. 2017;6:

35 Estimated Frequency of TRK Fusions Across Tumor Types 5%-25% 75% Congenital mesoblastic nephroma 1,2 Recurrent papillary thyroid cancer 3 Pontine glioma 4 Spitzoid melanoma 5 Pediatric and young adult soft tissue sarcomas 6 Pan-negative gastrointestinal stromal tumors (GIST) 7 Mammary analogue secretory carcinoma (MASC) of the salivary gland 8 Secretory breast carcinoma 9 Infantile fibrosarcoma Argani P et al. Mod Path. 2000;13: Rubin BP et al. Amer J Path. 1998;153: Leeman-Neill RJ et al. Cancer. 2014;120: Wu G et al. Nat Genet. 2014;46: Wiesner T et al. Nat Commun. 2014;5: Morosini D et al. ASCO Abstract Brenca M, et al. J Path. 2016;238: Bishop JA, et al. Hum Pathol. 2013;44: Tognon C, et al. Cancer Cell. 2002;2: Bourgeois JM, et al. Am J Surg Pathol. 2000;24:

36 Estimated Frequency of TRK Fusions Across Tumor Types (Cont d) 5% CNS Astrocytoma 1 Low-grade glioma 2 Glioblastoma 3 GI Colorectal cancer 2,4 Cholangiocarcinoma 5 Pancreatic cancer 6 Head and neck Squamous cell carcinoma 2 Lung Adenocarcinoma 2,7 Large cell neuroendocrine carcinoma 8 Other Acute myeloid leukemia 9 Breast-invasive carcinoma 2 Melanoma 2 Sarcoma 2 1. Jones DT et al. Nat Genet. 2013;45: Stransky N et al. Nat Commun. 2014;5: Kim J et al. PLoS One. 2014;9:3. 4. DeBraud F et al American Society of Clinical Oncology Annual Meeting (ASCO 2014). Abstract Ross JS et al. Oncologist. 2014;19: Bailey P et al. Nature. 2016;531: Vaishnavi A et al. Nat Med. 2013;19: Fernandez-Cuesta L et al American Association of Cancer Annual Meeting (AACR 2014). Abstract Kralik JM et al. Diag Path. 2011;6:19

37 Methods for Detection of TRK Fusions 1-3 IHC FISH NGS Advantages Disadvantages Rapid results Rapid results Potential for multiplexed testing Less depletion of tissue Fusion partner and position are defined Increased depletion of tissue Fusion partner and position unknown Less well-validated currently Increased depletion of tissue Fusion partner and position unknown Can be difficult to interpret Longer wait time for results; cost 1. Jordan EJ et al. Cancer Discov. 2017;7: Hyman et al. ASCO Abstract LBA Farago AF et al. J Thorac Oncol. 2015;10:

38 Examples of IHC and FISH 1,2 Take-home point: Techniques with faster results, such as IHC/FISH, may be useful in cancers in which the likelihood of a TRK fusion is high 1. Hyman DM et al. ASCO Abstract LBA Farago AF et al. J Thorac Oncol. 2015;10:

39 1. Meyerson M, Getz G. Nat Rev Genet. 2010;11: Next-Generation Sequencing 1

40 Example of Panel of Genes Tested Using an NGS-Based Approach 1 Take home: NGS may be the most efficient method for capturing TRK fusions, particularly useful in settings where pretest probability is low 1. Accessed May 14, 2018.

41 Circulating Tumor Nucleic Acid For Identification of TRK fusions? ctdna testing can be used to assess the landscape of mutations in a tumor, and can be followed over time. For detection of fusions, NGS is most sensitive, particularly if the exact fusion partners and breakpoints are unknown. The sensitivity for detection of TRK fusions in ctdna may be lower than in biopsies and may vary depending on the assay used. Commercial panels may not include all NTRK genes. 1. Farago et al., JCO Precision Oncology, in press

42 Case Study: TRK Fusions in Non-Small Cell Lung Cancer 1 MGH MSKCC Total Frequency, % (95% CI) NSCLC screened 1,804 3,068 4,872 NTRK1 fusion ( ) NTRK2 fusion ( ) NTRK3 fusion ( ) All NTRK fusions ( ) 1. Farago et al., JCO Precision Oncology, in press

43 Case Study: TRK Fusions in Non-Small Cell Lung Cancer (Cont d) 1 1. Farago et al., JCO Precision Oncology, in press Age at diagnosis, median (range) 47.6 ( ) Gender, n (%) Male 6 (55) Female 5 (45) Smoking history in pack years, n (%) >20 8 (73) 0 (0) 3 (27) Pack years, median (range) 0 (0-58) Stage at diagnosis (AJCC 7 th edition), n (%) I II III IV Histology (local assessment) Adenocarcinoma Squamous cell carcinoma Neuroendocrine carcinoma Sites of metastasis, n Lymph nodes Bone Pleura or malignant effusion Lung Liver Brain Adrenal Skin/soft tissue Pericardium Trachea 0 (0) 2 (18) 1 (9) 8 (73) 9 (82) 1 (9) 1 (9)

44 Looking to the Future: Detection of Acquired Resistance Mutations 1 TRK fusion cancers can acquire resistance to TRK inhibitors via mutations that disrupt drug binding These resistance mutations can be detected by direct gene sequencing (NGS) Next-generation TRK inhibitors may overcome some acquired resistance mutations Kinase enzyme Larotrectinib LOXO-195 IC 50 (nmol/l) n IC 50 (nmol/l) n TRKA WT 0.9 ± ± TRKA G595R 69.0 ± 13.4 (77x) ± 0.8 (3.3x) 6 TRKA G667C 45.5 ± 4.6 (51x) ± 1.7 (16x) 3 TRKC WT 2.8 ± <2.5 ± 0 10 TRKC G623R 48 ± 14 (17x) ± 0.5 (0.9x) 10 TRKC G696A 4.5 ± 1.0 (1.6x) 9 <2.5 ± 0 (1x) 9 1. Drilon A et al. Cancer Discov. 2017;7:

45 Take-Home Points NTRK gene fusions predict sensitivity to TRK inhibitors Point mutations and amplification are not predictors of TRK inhibitor sensitivity based on currently available data Look carefully at the NTRK gene alteration Oncogenic NTRK fusions involve a 5 partner and a 3 NTRK gene that contains the TRK kinase domain A multiplexed testing approach using next-generation sequencing is most efficient for identifying TRK fusions if the pretest probability is not high IHC or FISH may be faster and preferred if the likelihood of a TRK fusion is high In common cancer types, there is no defining clinical or pathologic feature of TRK fusion cancers All solid tumors should be screened

46 Why TRK Makes Sense: A Look at the Evidence for TRK Fusion Inhibitors in Multiple Cancer Settings Alexander Drilon, MD Early Drug Development Service Memorial Sloan Kettering Cancer Center New York, New York Photo Pending

47 Many TRK Inhibitors Are Available in the Clinic 1 1. Courtesy of Cocco E, Scaltriti M, and Drilon A. (Do not post or reproduce)

48 Larotrectinib Is the First Selective Pan-TRK Inhibitor in Development 1 Larotrectinib is a highly potent and selective small-molecule inhibitor of TRKA, TRKB, and TRKC (5-11 nm IC 50 in cellular assays) Prolonged responses in adult patients with TRK fusions (recommended phase 2 dose in adults is 100 mg BID) Promising tolerability profile Liquid formulation for pediatric patients 1. Drilon A et al. New Engl J Med. 2018;378:

49 The Larotrectinib Development Program Spans Several Trials 1 Adult phase 1 Aged 18 y Advanced solid tumors n = 8 TRK fusion status determined by local CLIA (or similarly accredited) laboratories Primary endpoints Best objective response rate SCOUT: Pediatric phase 1/2 Aged 21 y Advanced solid tumors n = 12 N = 55 TRK fusion patients RECIST v1.1 per investigator assessment Secondary endpoints Duration of response PFS NAVIGATE: Adult/adolescent phase 2 basket trial Aged 12 y Advanced solid tumors TRK fusion positive n = 35 Safety Dosing Single-agent larotrectinib, administered predominately at 100 mg BID continuously Treatment beyond progression permitted if patient continuing to benefit 1. Drilon A et al. New Engl J Med. 2018;378:

50 17 Unique Cancer Types Were Treated With Larotrectinib 1 Note: Percentages may not total 100 because of rounding 1. Drilon A et al. New Engl J Med. 2018;378:

51 Larotrectinib Has Tumor-Agnostic Activity in NTRK Gene Fusion-Positive Cancers a b Note: One patient not shown here. Patient experienced clinical deterioration and no post-baseline tumor measurements were recorded. a Patient had TRK solvent front resistance mutation (NTRK3 G623R) at baseline due to prior therapy. b Pathologic CR. 1. Drilon A et al. New Engl J Med. 2018;378:

52 Larotrectinib Has Tumor-Agnostic Activity in NTRK Gene Fusion-Positive Cancers 1 Response Investigator Assessment (N = 55) Percent a Central Assessment (N = 55) ORR (95% CI) b 80 (67-90) 75 (61-85) Best response Partial response 64 c 62 Complete response Stable disease 9 13 Progressive disease 11 9 Could not be evaluated 0 4 a Percentages may not total 100 because of rounding. b The best overall response was derived from the responses as assessed at specified time points according to RECIST v1.1. c Data include one patient who had a partial response that was pending confirmation at the time of the database lock. The response was subsequently confirmed and the patient s treatment and response are ongoing. 1. Drilon A et al. New Engl J Med. 2018;378:

53 Response to Larotrectinib Was Brisk and Dramatic in Several Cases 1 14-year-old female with with ETV6-NTRK3 secretory breast carcinoma and prior therapy: 4 lines of chemotherapy and repeated resections Treated with larotrectinib under expanded access 1. Shukla N et al. JCO Precision Oncol

54 Responses to Larotrectinib in TRK Fusion-Positive Cancers Are Durable 1 Median DOR not reached after median follow-up of 8.3 mo (range, to 24.9+) Median PFS not reached after median follow-up of 9.9 mo (range, 0.7 to 25.9+) At 1 y, 71% of responses were ongoing, and 55% of all patients remained progression free 1. Drilon A et al. New Engl J Med. 2018;378:

55 Larotrectinib Is Active Against Intracranial Disease 1 Early Radiographic and and Clinical Clinical Response Response in GBM in With GBM With an EVT6-NTRK3 an Fusion Fusion Baseline Baseline After 2 cycles After 2 cycles 3-year-old female diagnosed at 3-year-old 5 months of age; female failed diagnosed at treatment 5 months with multiple of age; failed treatment with surgical resections, intensive chemotherapy, multiple surgical and focal resections, intensive chemotherapy, radiation and focal radiation Completed Completed 2 cycles 2 cycles of of larotrectinib and larotrectinib ongoing and ongoing Significant improvement in milestones Significant improvement in milestones within within 2 2 weeks of commencing commencing treatment treatment First First TRK fusion TRK GBM fusion patient GBM patient treated treated to to response with a a TRK inhibitor TRK inhibitor 1. Turpin et al, AACR Peds 2018; images care of Dr. David Ziegler;, Sydney Children s hospital; manuscript in submission.

56 Larotrectinib Used as Neoadjuvant Therapy 1 2-year-old female with infantile fibrosarcoma 2 cycles of vincristine/ actinomycin-d/cyclophosphamide progression leg amputation was only alternative option 4 cycles larotrectinib referred for surgery Pathologic complete response with clear margins No functional deficit post-surgery 1. Hyman DM et al. ASCO Abstract LBA2501.

57 Entrectinib: Pan-TRK/ROS1/ALK Inhibitor 1 Orally administered inhibitor of TRKA/B/C, ROS1, and ALK Active against most known resistant mutants, including gatekeeper mutation Chemical structure of entrectinib X-ray crystallography model of entrectinib binding in the kinase pocket of TRKA Signaling pathways of TRK and TRK fusions Biochemical activity of entrectinib Target TRKA TRKB TRKC ROS1 ALK IC 50 (nm) Wei G et al EORTC-NCI-AACR Molecular Targets and Cancer Therapeutics Symposium. Abstract 78.

58 Entrectinib Development Program: Combined Phase 1 Studies 1 ALKA (N = 54) Dosing: Intermittent and continuous NTRK/ROS1/ALK alterations Italy FIH study: Nerviano Medical Sciences in October 2012 Ignyta assumed responsibility in November 2013 STARTRK-1 (N = 65) Dosing: Continuous NTRK/ROS1/ALK alterations US, EU, and Asia Ignyta initiated in July 2014 RP2D: 600 mg PO once daily, continuous Total clinical experience (n = 119 patients) Updated safety and efficacy data Data cut-off: March 7, Drilon A et al. Cancer Discov. 2017;7:

59 Entrectinib Is an Active Drug in NTRK Fusion-Positive Cancers 1 Tumor Reduction, % Best Response in TKI Treatment-Naïve NTRK-Rearranged Tumors (n = 4) Response achieved in 100% of tumors Rapid (within 1 month of treatment) and prolonged (~1 year, ongoing) responses were observed Response achieved in a variety of histologies and fusion types CRC: NTRK1-LMNA Astrocytoma: NTRK1-BCAN NSCLC: NTRK1-SQSTM1 MASC: NTRK3-ETV6 0% -10% -20% -30% -40% -50% -60% -70% -80% -90% -100% CRC Astrocytoma NSCLC MASC RECIST V1.1 3D volumetric assessment (Courtesy of P Brastianos, MD, MGH) SD by RECIST V Drilon A et al. Cancer Discov. 2017;7:

60 Survival, % Entrectinib Vehicle Entrectinib: CNS Activity 1 Entrectinib was designed to cross the blood brain barrier Entrectinib was designed to cross the blood brain barrier Blood/brain Blood/brain Blood/brain ratios ratios ratios Mouse Mouse Mouse Rat Rat Rat Dog Dog Dog Preclinical CNS activity EML4-ALK-rearranged NCI- H228 cells injected EML4-ALK-rearranged EML4-ALK-rearranged intracranially NCI-H228 NCI-H228 cells cells injected injected Treated intracranially intracranially with entrectinib orally treated vs with vehicle entrectinib for 10 orally days treated with entrectinib orally vs vs vehicle vehicle for for days days Preclinical CNS activity 1. Drilon A et al. Cancer Discov. 2017;7: Pretreatment Day Post Implantation, d Vehicle Entrectinib Vehicle Entrectinib Median Survival 33.5 d 56.5 d P <5 x 10e -4

61 Entrectinib: CNS Activity 1 (Cont d) ETV6-NTRK3 Gene-Rearranged gene ETV6-NTRK3 rearranged gene metastatic rearranged Metastatic fibrosarcoma metastatic Fibrosarcoma fibrosarcoma in 20-month old in 20-month in a 20-Month-Old old Baseline Baseline Day 35 Day 35 massive peritumoral edema, midline shift, Massive transtentorial herniation, progressive edema, lethargy midline shift, transtentorial herniation, progressive lethargy massive peritumoral edema, midline decreased shift, tumor and edema, patient with transtentorial herniation, progressive increased lethargyalertness, resumed eating and crawling decreased tumor and edema, patient with Decreased increased alertness, resumed tumor eating and crawling edema, patient with increased alertness, resumed eating and crawling 1. Drilon A et al. AACR Abstract CT007.

62 Entrectinib Therapy Is Being Explored on an Ongoing Phase 2 Trial Key eligibility criteria Histologically or cytologically confirmed diagnosis of locally advanced or metastatic solid tumor that harbors an NTRK1/2/3, ROS1, or ALK gene rearrangement, identified by evaluating the genetic profile of tumor biopsy samples from a CAP accredited diagnostic lab ECOG PS 2 CNS involvement allowed Ability to swallow entrectinib intact No prior treatment with TRK, ROS1, or ALK inhibitors Possible chemotherapy per MD STARTRK-2 Studies of tumor alterations responsive to targeting receptor kinases Open-label, multicenter, global phase 2 basket study of entrectinib Patients with locally advanced or metastatic solid tumors NTRK1/2/3 (TRKi-naïve) Molecular testing (NGS) for NTRK1/2/3, ROS1, or ALK gene rearrangements Basket assignments by gene rearrangements ROS1 (ROS1i-naïve) ALK (ALKi-naïve)

63 ASCO 2018 Entrectinib in Recurrent Or Refractory Solid Tumors 1 Phase 1 study: N = 16, 15 evaluable for DLT RP2D: 550mg/m 2 daily; STARTRK-NG Antitumor activity was observed in all 3 patients with fusion-positive tumors DCTN1-ALK IMT, TFG-ROS1 IMT, EML4-NTRK3 IFS Entrectinib continues to be investigated in expansion cohorts of patients with extracranial solid tumors or primary CNS tumors 1. Desai AV, et al. ASCO Abstract

64 TRK Inhibition Can Have On-Target Consequences on Normal Tissues 1 Defect in proprioception, impairment of of motor neuron afferents and lost loss of of a population of of dorsal root ganglia neurons (NTRK3 null) null) Lack Lack populations populations of of motor neurons as motor neurons as well well as dorsal root as dorsal root and and trigeminal trigeminal neurons neurons (NTRK2 null) null) Severe sensory and sympathetic (NTRK1 null) neuropathies (NTRK1 null) sympathetic neuropathies Development of obesity caused by hyperphagia and hyperdipsia in mice (NTRK2 mutant) Increased apoptosis of cardiac of cardiac endothelial endothelial cells cells and and decrease decrease in in intramyocardial intramyocardial blood blood vessels vessels (NTRK2 null) (NTRK2 null) Atrial and ventricular septal defects and valvular defects (NTRK3 null) Congenital Congenital insensitivity Insensitivity to pain to with Pain anhidrosis (CIPA) with Anidrosis (CIPA) (NTRK1 mutant) (NTRK1 mutant) Inhibition of of the the ovulation in in mice mice (TRKA inhibition) 1. Courtesy of Cocco E, Scaltriti M, and Drilon A.

65 Larotrectinib Is a Tolerable Targeted Therapeutic 1 Adverse Event a Adverse Events, Regardless of Attribution Treatment-Related Adverse Events Grade 1 Grade 2 Grade 3 Grade 4 All Grades Grade 3 Grade 4 All Grades Percent of Patients With Event Out of Total # of Patients (N = 55) Increased ALT/AST level Fatigue Vomiting Dizziness Nausea Anemia Diarrhea Constipation Cough Increased body weight Dyspnea Headache Pyrexia Arthralgia Back pain Decreased neutrophil count a The adverse events listed here are those that occurred in at least 15% of the patients, regardless of attribution. The relatedness of the treatment to adverse events was determined by the investigators. 1. Drilon A et al. New Engl J Med. 2018;378:

66 Similarly, Entrectinib Tolerable and On-Target Adverse Events Can Occur 1 Adverse Event, n (%) Grade 1 Grade 2 Grade 3 All Grades (n = 119) Fatigue/asthenia 28 (24) 22 (19) 5 (4) 55 (46) Dysgeusia 47 (40) 3 (3) 0 50 (42) Paresthesia 34 (29) (29) Nausea 29 (24) 4 (3) 0 33 (28) Myalgia 23 (19) 4 (3) 0 27 (23) Diarrhea 19 (16) 3 (3) 1 (1) 23 (19) Vomiting 19 (16) 1 (1) 0 20 (17) Arthralgia 12 (10) 6 (5) 1 (1) 19 (16) Dizziness 14 (12) 5 (4) 0 19 (16) Constipation 12 (10) 2 (2) 0 14 (12) Weight increase 4 (3) 6 (5) 2 (2) 12 (10) 1. Drilon A et al. Cancer Discov. 2017;7:

67 Safety Take-Home Points 1,2 1. To date, evidence suggests that emerging TRK inhibitors such as larotrectinib and entrectinib appear to be well-tolerated agents 2. Most events grade 1/2 in nature, although occasional on-target AEs such as dizziness, weight gain, and paresthesias are observed 3. Dose reductions are infrequently required, but may be useful in managing/reversing AEs; dose modification does not appear to impact efficacy 1. Drilon A et al. New Engl J Med. 2018;378: Drilon A et al. Cancer Discov. 2017;7:

68 LOXO-195 Larotrectinib LOXO-195 Is a Next-Generation Agent That Addresses On-Target Resistance 1 LOXO-195 Larotrectinib TRKA G595R TRKA 1 G595R 1 LOXO-195 Treatment LOXO Treatment 1 Tumor Type Fusion Resistance Mutation Colorectal TPM3-NTRK1 Resistance TRKA Resistance G595R Tumor Type Tumor Fusion Type Fusion Mutation Mutation Colorectal LMNA-NTRK1 TRKA G595R Colorectal Colorectal TPM3-NTRK1 TPM3-NTRK1 TRKA G595R TRKA G595R NSCLC TPR-NTRK1 TRKA G595R Colorectal Colorectal LMNA-NTRK1 LMNA-NTRK1 TRKA G595R TRKA G595R Sarcoma TPM3-NTRK1 TRKA G595R NSCLC NSCLC TPR-NTRK1 TPR-NTRK1 TRKA G595R TRKA G595R IFS ETV6-NTRK3 TRKA G623R Sarcoma Sarcoma TPM3-NTRK1 TPM3-NTRK1 TRKA G595R TRKA G595R Cholangiocarcinoma LMNA-NTRK1 TRKA F589L + IFS IFS ETV6-NTRK3 ETV6-NTRK3 GNAS TRKC G623R TRKC Q227H G623R Cholangiocarcinoma TRK solvent carcinoma front mutations GNAS Q227H detected GNAS in Q227H 5 of 6 Cholangio- TRKA F589L + TRKA F589L + LMNA-NTRK1 LMNA-NTRK1 patients with acquired resistance TRK solvent First TRK front 2 patients solvent mutations front successfully detected mutations in treated detected with in 5 of 6 patients LOXO of with 6 patients acquired with resistance acquired resistance First 2 patients First successfully 2 patients treated successfully with treated with LOXO LOXO Drilon A et al. Cancer Discov. 2017;7:

69 LOXO-195 Is in Phase 1/2 Clinical Trial Testing Phase 1: Dose escalation Phase 2 Patients aged 1 month and older Advanced TRK fusion solid tumor Progressed on prior TRK inhibitor therapy or patient was intolerant to any prior kinase inhibitor with anti-trk activity Advanced TRK fusion solid tumor that has progressed on a prior TRK inhibitor Starting dose Age 12+ MTD/recommended phase 2 dose Age 12+ Age <12 Advanced TRK fusion solid tumor where patient was intolerant to a prior TRK inhibitor Parallel enrollment for age <12 at cleared dose levels for age 12+

70 Sequential TRK Inhibitor Use Can Prolong Disease Control Larotrectinib response Larotrectinib treatment post-progression LOXO-195 Excision, ablation, radiation Tissue and/or liquid biopsy

71 Ropotrectinib (TPX-0005): Potent TRK Inhibitor May Overcome Resistance Mutations 1 Ropotrectinib: Designed to bind within the ATP binding boundary with high affinity and target wild type and mutant kinase Efficacy of TPX-0005 against wild type and mutant fusion TRKs in xenograft tumor models The anti-tumor efficacy in the NIH3T3 LMNA-TRKA wild type xenograft model The anti-tumor efficacy in the NIH3T3 LMNA-TRKA G595R xenograft model Potently inhibited wild type and mutant TRKs in vitro and in vivo, especially the solvent front mutations that render common resistances to TRK inhibitors The Effect of TPX-0005 on the Growth of NIH3T3 LMNA-TRKA G667C Tumors Phase 1/2 clinical trial is ongoing for TPX-0005 for cancer patients with solid tumors harboring ALK, ROS1, or NTRK fusion gene (NCT ) 1. Cui JJ et al. EORTC-NCI-AACR Molecular Targets and Cancer Therapeutics Symposium Abstract B184.

72 Summary First-generation TRK inhibitor therapy is active in a histology-agnostic fashion in patients with NTRK gene fusion-positive cancers TRK inhibition is tolerable overall; several adverse events are on-target consequences of TRKA/B/C inhibition Second-generation strategies are currently in development to address on-target resistance to firstgeneration TRK inhibition

73 Please remember to complete and submit your Post-Test and Evaluation for CME credit. Missed anything? Visit us at: Download slides and Practice Aids Watch for the ondemand version of this symposium Join the conversation on Thank you and good evening.