Optimizing Survival in Advanced Prostate Cancer. Welcome!

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1 Optimizing Survival in Advanced Prostate Cancer Welcome!

2 Optimizing Survival in Advanced Prostate Cancer Cora N. Sternberg Rome, Italy

3 Programme Understanding the heterogeneity of prostate cancer Jack Schalken Radboud UMC, Nijmegen, The Netherlands Tailoring mcrpc therapies to optimize survival: where do we stand? Nicolas Mottet Université Jean Monnet, Saint-Etienne, France CHAARTED results and its implications for the future? Cora N. Sternberg San Camillo and Forlanini Hospitals, Rome, Italy Co-chairs: Nicolas Mottet and Cora N. Sternberg

4 Questions & answers

5

6 Disclosures The views expressed in the following presentations are those of the individual authors and do not necessarily reflect the views of Sanofi. Sanofi does not recommend the use of its products in any manner inconsistent with that described in the full prescribing information available in your country. Before prescribing the product always refer to the prescribing information in the summary of product characteristics available in your country.

7 Programme Understanding the heterogeneity of prostate cancer Jack Schalken Radboud UMC, Nijmegen, The Netherlands Tailoring mcrpc therapies to optimize survival: where do we stand? Nicolas Mottet Université Jean Monnet, Saint-Etienne, France CHAARTED results and its implications for the future? Cora N. Sternberg San Camillo and Forlanini Hospitals, Rome, Italy Co-chairs: Nicolas Mottet and Cora N. Sternberg

8 Understanding the heterogeneity of prostate cancer Jack Schalken Radboud UMC Nijmegen, The Netherlands

9 Disclosures Speaker honoraria Sanofi, Astellas, Pierre Fabre Consultant Hologic Founder and shareholder NovioGendix BV Founder and shareholder Oncodrone BV

10 Intro: let s start with some facts Cancer is a complex disease Cancer is caused by an accumulation of genetic changes in stem(-like) cells Stromal cells can play an important role in the control or promotion of cancer cells Cancer has a clonal origin Cancer progression is associated with the development of subclones Therapy results in resistant subclones Subclonal diversity is the basis for cancer heterogeneity Cancer heterogeneity is the number one challenge

11 Cancer is a complex disease Trastuzumab Trastuzumab Metastatic HER2 + BrCa Adjuvant HER2 + BrCa 1978 (CSH, RNA tumor viruses) 1989 (Nobel Prize) CML-bcr-abl + Imatinib 1983/ ties HIV causes AIDS HIV test AZT AIDS as a chronic disease AIDS: acquired immunodeficiency syndrome; AZT: azidothymidine; BrCa: breast cancer; CSH: Cold Spring Harbor; HIV: human immunodeficiency virus

12 Cancer is caused by an accumulation of genetic changes in stem(-like) cells Available at last accessed January 2015

13 Subclonal evolution Yates LR & Campbell PF. Nat Rev Gen, 2012; 13: MRCA: most common recent ancestor

14 Another schematic representation Based on Greaves M & Maley CC. Nature, 2012; 481:

15 Heterogeneity vs time Luebeck EG. Nature, 2010; 467:

16 ETS gene fusions; heterogeneous in primary PCa, homogeneous in metastases Kumar-Sinha C et al. Nat Rev Cancer, 2008; 8: PCa: prostate cancer

17 Tracking the clonal origin of PCa 47-year old men diagnosed with Gleason 8 PCa Died 17 years later due to mcrpc Genetic analysis of metastases and primary: lethal clone arose from a small low grade (Gleason 6) focus present at diagnosis and harboring PTEN and p53 mutations Haffner MC et al. J Clin Invest, 2013; 123:

18 Therapy-induced heterogeneity The androgen-receptor (AR) pathway AR splice variants 2 AR overexpression 2 AR mutants 2 PI3K/AKT/ERK/mTOR Androgen production by adrenal glands and prostate tumor 2 AR PI3K/AKT/ERK/mTOR T/DHT NUCLEUS Upregulation of AR cofactors 1,2 Signalling cross-talk 1,2 1. Heinlein CA & Chang C. Endocr Rev, 2004; 25: ; 2. Hu R et al. Expert Rev Endocrinol Metab, 2010; 5: DHT: dihydrotestosterone; ERK: extracellular signal-regulated kinase; mtor: mammalian target of rapamycin; PI3K: phosphatidylinositol-3 kinase; T: testosterone

19 Primary resistance Charles HUGGINS Nobel Prize [ ] The first series of patients with PCa treated by orchiectomy comprised 21 patients with far advanced metastases; only four of them survived for more than 12 years. Despite regressions of great magnitude, it is obvious that there were many failures of endocrine therapy to control the disease but, on the whole, the life span had been extended by the novel treatments and there had been a decrease of man-pain hours [ ] Available at last accessed January 2015

20 Co-existence of AR-positive and AR-negative tumor cells in a same patient AR-negative cells AR-positive cells Tumor with mixed features of neuroendocrine PCa and prostate adenocarcinoma Beltran H et al. Cancer Discov, 2011; 1:

21 AR-negative disease progression with ABI 75-year old, previously progressed on ADT, bicalutamide and dexamethasone Prostate biopsy: AR-positive cancer Development AR-negative liver metastases with ABI despite good PSA response Biopsy x 2 Pezaro CJ et al. Eur Urol, 2014; 65: ABI: abiraterone; ADT: androgen deprivation therapy; PSA: prostate-specific antigen

22 AR splice variants (ARv) AR-FL AR-45 AR-V7 AR-V1 AR-V4 AR-V3 AR-V567 AR-FL: full-length androgen receptor DBD: DNA-binding domain ENZ: enzalutamide LBD: ligand-binding domain NTD: N-terminal domain U: unique N- or C-terminal sequence ADT induces constitutively active splice variants which drive development of CRPC 1-2 ARv567 (43%) and ARv7 (24%) are the most prevalent 3 : Both lack ligand-binding domain AR-V7 also lacks hinge domain Inhibition of ARv7 transcription by FOXO1 (potent AR suppressor) 4-5 May contribute to resistance to ENZ 6 and ABI 7 Taxanes inhibit nuclear translocation of ARv567, not ARv Guo Z et al. Int J Biol Sci, 2011; 7: ; 2. Lu C & Luo J. Transl Androl Urol, 2013; 2: ; 3. Sun S et al. J Clin Invest, 2010; 120: ; 4. Mediwala SN et al. Prostate, 2013; 73: ; 5. Bohrer LR et al. Prostate, 2013; 73: ; 6. Li Y et al. Cancer Res, 2013; 73: 483-9; 7. Mostaghel EA et al. Clin Cancer Res, 2011; 17: ; 8. Thadani-Mulero M et al. Cancer Res, 2014; 74:

23 Best PSA response (% change) Best PSA response (% change) PSA response according to ARv7 status Patients previously receiving chemotherapy, ABI or ENZ were included ENZ ABI * * * AR-V7 positive AR-V7 negative * * * * AR-V7 positive AR-V7 negative PSA response rate: AR-V7 positive: 0% (95% CI: 0 26%) AR-V7 negative: 52.6% (95% CI: 29 76%) p=0.004 PSA response rate: AR-V7 positive: 0% (95% CI: 0 46%) AR-V7 negative: 68.0% (95% CI: 46 85%) p=0.004 Prospective biomarker study of 62 patients receiving ENZ or ABI Antonarakis et al. NEJM, 2014; 371: CI: confidence interval

24 Advances in molecular tools towards the <1 k genome Illumina founded FastTrack services established (genotyping) Genome analyser introduced EveryGenome, CLIA WGS services established HiSeq 2000 introduced FastTrack services sequences first RUO genome Illumina genome network established HiSeq 2500 introduced Year $40M $100M $1.5M $40K $10K $5K $4K First draft of human genome sequence assembly First human genome sequenced First Korean genome sequenced* Actress Glenn Close s genome sequenced* Price per genome Illumina milestones Sequencing milestones First African genome sequenced* First European female genome sequenced* *Performed with an Illumina sequencer Available at last accessed January 2015

25 Personalized care - the short cut Harvest metastases and/or circulating cancer cells Next Generation Sequencing Personalized treatment Patientspecific mutation spectrum Bioinformatics Global Cancer Expert Board Identify druggable driver mutation(s)

26 Targeted Next Generation Sequencing Beltran H et al. Eur Urol, 2013; 63: 920-6

27 Proof of concept demands (complex) clinical trials Bedard PL et al. Nature, 2013; 501:

28 Integral personalized care approach Propagate in vivo and in vitro Step 1: Harvest metastases and/or circulating cancer cells Next Generation Sequencing Personalized treatment Step 2: Patientspecific mutation spectrum Patientderived cancer xenograft months Patientderived cancer organoids weeks Step 3: Test concept Bioinformatics Global Cancer Expert Board Identify druggable driver mutation(s)

29 Patient-derived models Gao D et al. Cell, 2014; 159: CTC: circulating tumor cell; rbc: red blood cell; wbc: white blood cell

30 Increase success rate Targeted therapy early or in a rationalized combination Trastuzumab Trastuzumab Metastatic HER2 + BrCa Adjuvant HER2 + BrCa 1978 (CSH, RNA tumor viruses) 1989 (Nobel Prize) CML-bcr-abl + Imatinib Therapy at driver mutation (<100 patients for registration)

31 Conclusion Cancer heterogeneity is the number one challenge in the treatment of advanced PCa 3D organoid models and Next Generation Sequencing point the way to personalized care Early diagnosis and early therapy, based on the molecular profile of an individual s cancer, is needed to combat the disease

32 Programme Understanding the heterogeneity of prostate cancer Jack Schalken Radboud UMC, Nijmegen, The Netherlands Tailoring mcrpc therapies to optimize survival: where do we stand? Nicolas Mottet Université Jean Monnet, Saint-Etienne, France CHAARTED results and its implications for the future? Cora N. Sternberg San Camillo and Forlanini Hospitals, Rome, Italy Co-chairs: Nicolas Mottet and Cora N. Sternberg

33 Tailoring mcrpc therapies to optimize survival: where do we stand? Nicolas Mottet Department of Urology Saint-Etienne, France

34 Disclosures Nicolas Mottet has consulting agreements with: Astellas BMS Ferring Ipsen Janssen Millennium Novartis Pierre Fabre Sanofi

35 Targets of mcrpc therapies Cell-trafficking Taxanes* Ligand depletion ABI mcrpc AR-targeting ENZ Bone-targeting Radium-223 Immunotherapy Sipuleucel-T *Docetaxel, cabazitaxel ABI: abiraterone; AR: androgen receptor; ENZ: enzalutamide; mcrpc: metastatic castration-resistant prostate cancer

36 Phase III clinical trials in mcrpc Study Agents N Indication HR OS TAX Doc/P vs mito/p 1006 mcrpc IMPACT 2 Sipuleucel-T vs pbo 512 mcrpc (pre-doc) COU-AA COU-AA PREVAIL 5 AFFIRM 6 ABI/P vs P ABI/P vs P ENZ vs pbo ENZ vs pbo (or P) mcrpc (pre-doc) mcrpc (post-doc) mcrpc (pre-doc) mcrpc (post-doc) (est) +4.8 TROPIC 7 Cabazitaxel/P vs mito/p 755 mcrpc (post-doc) ALSYMPCA 8 Radium-223 vs pbo 921 mcrpc Tannock IA et al. NEJM, 2004; 351: ; 2. Kantoff PW et al. NEJM, 2010; 363: ; 3. Ryan CJ et al. Lancet Oncol, 2015; doi: /s (14) ; 4. Fizazi K et al. Lancet Oncol, 2012; 13: ; 5. Beer TM et al. NEJM, 2014; 371: ; 6. Scher HI et al. NEJM, 2012; 367: ; 7. De Bono J et al. Lancet, 2010; 376: ; 8. Parker C et al. NEJM, 2013; 369: Doc: docetaxel; HR: hazard ratio; mito: mitoxantrone; OS: overall survival; P: prednisone; pbo: placebo

37 Which drug for which patient?

38 Sipuleucel-T: greater survival benefit in patients with low disease burden? Median OS, months 22.1 (n=128) Baseline PSA, ng/ml > (n=128) > (n=128) >134.1 (n=128) Sipuleucel-T Control Difference HR (95% CI) 0.51 ( ) 0.74 ( ) 0.81 ( ) 0.84 ( ) Post-hoc analysis of a randomized phase III trial comparing sipuleucel-t vs pbo in 512 patients with mcrpc (IMPACT). Primary endpoint (OS) was met (HR 0.78, 95% CI , p=0.03) Schelhammer PF et al. Urology, 2013; 81: CI: confidence interval; PSA: prostate-specific antigen

39 Is alkaline phosphatase (ALP) a predictor of Radium-223 efficacy? Variable Subgroup N Hazard Ratio HR 95% CI OS Total ALP Current use of bisphosphonates Prior use of Doc <220 U/L 220 U/L Yes No Yes No Baseline ECOG status 0 or Favors Radium-223 Favors pbo Parker C et al. NEJM, 2013; 369: ECOG: Eastern Cooperative Oncology Group

40 Who are the non-responders to ABI? Primaryresistance in 1 out of 4 patients Who are the NON-responders? (defined as patients treated for 4 months) Bone marrow biopsy: - Intense AR nuclear expression - CYP17 expression YES 82% responders (12/13) NO 18% responders (2/12) Efstathiou E et al. J Clin Oncol, 2011; 30: p<0.001 Phase II trial in 62 mcrpc patients treated with ABI + P Transiliac bone marrow biopsies before treatment, at 8 weeks and at end of study

41 % of patients Who are the non-responders to ENZ? 120% 100% 80% 67% 100% Primary resistance Moderate benefit (4-6 months) Prolonged benefit (>6 months) 60% 40% 20% 0% 25% High AR nuclear + CYP17 expression 50% 17% 0% ARv7 presence 40% 33% 9% ERG presence Phase II trial in 60 patients with bone mcrpc treated with ENZ Transiliac bone marrow biopsies before treatment, at 8 weeks and at end of treatment Efstathiou E et al. Eur Urol, 2015; 67: 53-60

42 May duration of response to first ADT help to guide treatment choice? Retrospective analysis in 153 mcrpc patients treated with cabazitaxel + P Subsequent ADT included anti-androgens, DES, estramustine, ketoconazole, ABI, ENZ Angelergues A et al. J Clin Oncol, 2014; 32 (suppl 4): abstract 282 DES: diethylstilbestrol

43 Duration of prior ADT & activity of ABI on rpfs in pre-doc (COU-AA-302) Prior GnRH duration median (37 months) Prior GnRH duration >median (37 months) Lowest quartile of prior GnRH duration ( 20 months) Oudard S et al. J Clin Oncol, 2014; 32 (suppl 4): abstract 14 ADT: androgen deprivation therapy; GnRH: gonadotropin-releasing hormone analogue; rpfs: radiological progression-free survival

44 Is baseline Gleason score predictive of response to therapies? Study Agent N Gleason HR for OS TAX327 1 Doc/P vs mito/p 1,006 Pre-Doc COU-AA ABI/P vs pbo/p 1,088 PREVAIL 3 ENZ/P vs pbo 1,717 Post-Doc COU-AA ABI/P vs pbo/p 1,195 <7 7 <8 8 <8 8 < Post-hoc analyses of TAX327, COU-AA-301 and COU-AA-302 trials; planned subgroup analyses of PREVAIL 1. Tannock IA et al. NEJM, 2004; 351: ; 2. Fizazi K et al. J Clin Oncol, 2014; 32 (suppl 4): abstract 20; 3. Beer TM et al. NEJM, 2014; 371: (appendix)

45 ARv7 and resistance to ABI or ENZ - clinical or radiological PFS ENZ ABI AR-V7 negative HR 8.5 (95% CI ) p< AR-V7 negative HR 16.5 (95% CI ) p< AR-V7 positive AR-V7 positive US patients prospectively enrolled to receive ENZ (n=31) or ABI (n=31) Antonarakis ES et al. NEJM, 2014; 371:

46 OS ARv7 and resistance to ABI or ENZ - updated OS (all combined) AR-V7 negative Median OS >16.0 months (95% CI 16.0-NR) AR-V7 positive Median OS 9.9 months (95% CI ) HR 5.5 (95% CI ) p< Time (months) 62 US patients prospectively enrolled to receive ENZ (n=31) or ABI (n=31) Antonarakis ES et al. ESMO 2014 (abstract 7980) NR: not reached

47 Primary doc-refractory patients Cabazitaxel Retrospective review of 186 mcrpc patients 33 (17.7%) Doc-refractory* Subsequent therapies: Cabazitaxel AR-targeted agents (ABI or ENZ) Multivariate analysis: significant OS benefit with cabazitaxel vs new AR-targeted agents ABI Retrospective study of 44 patients with mcrpc Treated with Doc ABI 7/44 patients Doc-refractory No PSA, radiological or clinical response to ABI *Doc-refractoriness defined as disease progression occurring within 3 months from Doc initiation and after adequate exposure to Doc (ie cumulative dose of 225 mg/m²) Di Lorenzo G et al. Eur Urol, 2014; 65: 502-7

48 Cross-resistance between these new therapies?

49 Poor response to ABI in patients progressing on ENZ? Loriot 1 (n=38) Noonan 2 (n=30) COU-AA (n=797) Prior ENZ Yes Yes No Median PFS, months Median OS, months PSA 50%* 8% 3% 29% [1-2] trials are retrospective studies conducted in 38 and 30 patients, respectively *PSA response confirmed by a second value 1. Loriot Y et al. Ann Oncol, 2013; 24: ; 2. Noonan KL et al. Ann Oncol, 2013; 24: ; 3. Fizazi K et al. Lancet Oncol, 2012; 13:

50 Poor response to ENZ in patients progressing on ABI? Schrader 1 (n=35) Bianchini 2 (n=39) Thomsen 3 (n=24) Badrising 4 (n=61) AFFIRM 5 (n=800) Prior ABI Yes Yes Yes Yes No Partial response 2.9% 4.3% % Median PFS, months Median OS, months 7.1** PSA 50% 28.6% 12.8%* 16.7% 21% 54%* *PSA response confirmed by a second value; [1-4] trials are retrospective studies 1. Schrader A et al. Eur Urol, 2014; 65: 30-6; 2. Bianchini D et al. Eur J Cancer, 2014; 50: 78-84; 3. Thomsen FB et al. Scand J Urol Nephrol, 2014; 48: ; 4. Badrising S et al. Cancer, 2014; 120: ; 5. Scher HI et al. Lancet Oncol, 2012; 13:

51 Summary Short response to ADT in first-line (and NOT duration of hormonal therapy) is prognostic and possibly predictive of lower response to AR-targeted agents Level of baseline androgen pathway signals predictive of response of AR-targeted agents (feasibility in clinic?) AR-V7 splice variant in CTCs very promising. Validation is needed Key message: one drug fits all is a mistake in mcrpc need for individualized therapy CTCs: circulating tumor cells

52 Programme Understanding the heterogeneity of prostate cancer Jack Schalken Radboud UMC, Nijmegen, The Netherlands Tailoring mcrpc therapies to optimize survival: where do we stand? Nicolas Mottet Université Jean Monnet, Saint-Etienne, France CHAARTED results and its implications for the future? Cora N. Sternberg San Camillo and Forlanini Hospitals, Rome, Italy Co-chairs: Nicolas Mottet and Cora N. Sternberg

53 CHAARTED results and its implications for the future? Cora N. Sternberg, MD, FACP Department of Medical Oncology San Camillo and Forlanini Hospitals Rome, Italy

54 Disclosures Research funding or honoraria: Sanofi Bayer Novartis Astellas Janssen

55 Why CHAARTED? Despite regressions of great magnitude, it is obvious that there are many failures of endocrine therapy to control the disease Charles B. Huggins Nobel Lecture December 13, e/laureates/1966/huggins-lecture.html 55

56 ADT +/- early chemotherapy ADT Regression Re-emergence De novo resistant clones Pro s Attack de novo testosterone independent clones early allow ADT to keep PCa in remission longer Some patients at the time of progression are too frail for chemotherapy Con s ADT will take cells out of cycle and be less responsive to cytotoxics Some patients respond for a long time and never need chemotherapy Need for a randomized phase 3 trial Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2 ADT: androgen deprivation therapy; PCa: prostate cancer

57 E3805 CHAARTED study Newly diagnosed M1 PCa Key stratification Extent of mets (High vs low) Age ( 70 vs < 70 y) R A N D O M I Z E ARM A (n=397) ADT + Docetaxel for 6 cycles ARM B (n=393) ADT Follow for time to progression and overall survival Chemotherapy at investigator s discretion at progression Open-label, multicenter, phase III trial conducted in US Standard dexamethasone premedication but no daily prednisone Docetaxel in combination with prednisone is indicated for the treatment of patients with hormone refractory metastatic prostate cancer High-volume metastatic disease: Visceral and/or 4 bone metastases (with 1 beyond pelvis and vertebral column) Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

58 Key eligibility criteria High-volume metastatic disease: Visceral metastases and/or 4 bone metastases (with at least 1 beyond pelvis and vertebral column) At study initiation, only patients with high-volume disease were to be accrued Study amendment to allow patients with low volume to be enrolled, with stratification on disease volume Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

59 Study endpoints Primary endpoint: OS Secondary endpoints: Rate of PSA <0.2 ng/ml at 6 mo and 12 mo Time to biochemical, radiographic or symptomatic progressive disease (PD) Time to radiographic or symptomatic PD Define adverse event profile and tolerability Quality of life (FACT-P) until 12 mo after randomization Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2 FACT-P: Functional Assessment of Cancer Therapy-Prostate version; PSA: prostate-specific antigen

60 Results (n=790) Accrual in the US from 7/28/ /21/2012 Planned interim analysis at 53% information October 2013: met pre-specified criteria for significance and release of data January 16, 2014 (median follow-up of 29 mo): 136 deaths ADT alone vs 101 deaths ADT + docetaxel Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

61 Patient characteristics (1) ADT + docetaxel (n=397) ADT alone (n=393) n % n % Age (yr) Median Volume of mets Low % % High % % Gleason score % % % % % % PSA (ng/ml) at time of ADT start Median Range 0.4-8, ,056.0 Sweeney C et al. J Clin Oncol 2014; 32 (June 20 suppl): abstract LBA2

62 Patient characteristics (2) Prior treatment ADT + docetaxel (n=397) ADT alone (n=393) n % n % No localized Rx % % Primary radiation % % Prostatectomy % % Adjuvant ADT Yes % % Median time from start ADT to randomization Months (range) 1.1 (0-3.9) 1.2 (0-3.9) No ADT prior to 46 12% 45 11% randomization Sweeney C et al. J Clin Oncol 2014; 32 (June 20 suppl): abstract LBA2

63 Primary endpoint: OS HR 0.61 (95% CI ) p= ADT alone Median 44.0 mo ADT + docetaxel Median 57.6 mo Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

64 ADT + docetaxel benefited all subgroups Group N HR 95% CI All patients ( ) Age <70 yr Age 70 yr ( ) ( ) Low-volume disease ( ) High-volume disease ( ) Visceral mets ± bone mets High volume (bone mets only) ( ) ( ) Race - white Race - other ( ) ( ) Gleason score <8 Gleason score ( ) ( ) Prior local therapy - no ( ) Prior local therapy - yes ( ) CAB >30 days - no CAB >30 days - yes ( ) ( ) SRE - no ( ) SRE - yes ( ) Favor ADT + docetaxel Favor ADT Alone Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

65 OS by extent of metastatic disease at start of ADT High volume Low volume HR 0.60 (95% CI ) p= ADT + docetaxel Median 49.2 mo ADT alone Not reached ADT + docetaxel Not reached ADT alone Median 32.2 mo HR 0.63 (95% CI ) p= mo benefit in median OS (from 32.2 to 49.2 mo) for high-volume disease Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

66 Secondary endpoints ADT + Doc (n=397) ADT alone (n=393) p-value HR (95% CI) PSA <0.2 ng/ml at 6 mo 27.5% 14.0% < PSA <0.2 ng/ml at 12 mo 22.7% 11.7% < Median time to CRPC (mo) biochemical, symptoms, or radiographic Median time to clinical progression (mo) symptoms or radiographic < < ( ) 0.49 ( ) Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2 Doc: docetaxel; CRPC: castration-resistant prostate cancer; mo: months

67 Chemotherapy doses ADT + Doc (n=697) Number of cycles n % Total 352* 74% with no dose modifications *Missing data on 45 patients due to case report form change (24 patients), never started therapy (6 patients), data missing (15 patients) Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

68 Therapy after progression ADT + Doc (n=397) n ADT alone (n=393) n Biochem, symptom, radiographic PD Symptom or radiographic PD Docetaxel Cabazitaxel Mitoxantrone and/or platinum Abiraterone/enzalutamide Antiandrogen/ketoconazole Sipuleucel T Radiotherapy /174 (74%) of patients who progressed on ADT received docetaxel Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

69 Non-hematologic toxicity (%) ADT + docetaxel (n=397) Grade Allergic reaction 2 <1 - Fatigue Colitis/diarrhea Stomatitis Neuropathy-motor Neuropathy-sensory Thrombo-embolism <1 1 - Sudden death patient Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

70 Hematologic toxicity (%) ADT + docetaxel (n=397) Grade Anemia 1 <1 - Thrombocytopenia - <1 - Neutropenia Febrile neutropenia Infection with neutropenia Worst grade hematological and nonhematological toxicity per patient 16% 12% 1 patient Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

71 Summary Standard ADT + 6 cycles of docetaxel significantly improved OS compared to standard ADT alone in men with hormone-sensitive PCa The benefit in patients with a high volume of metastases is clear Need to be chemotherapy-fit Longer follow-up is required for patients with low-volume metastatic disease Sweeney C et al. J Clin Oncol, 2014; 32 (June 20 suppl): abstract LBA2

72 Rationale for defining high-volume disease?

73 What is extensive disease? 4 lesions 4 lesions <4 lesions Presented by Michael Morris at 2014 ASCO Annual Meeting

74 High-volume disease and survival: different definitions Study Design Definition OS SWOG S8894 Orchiectomy (1998) 1 ± flutamide 1,387 pts with metastatic PCa SWOG S9346 Intermittent vs (2013) 2 continuous ADT Extensive ribs, long bones (± axial skeletal ) or visceral (lung or liver) mets or both Minimal: spine, pelvic bones, or lymph node mets Same as above Extensive disease: median 27.5 mo Minimal disease: Median 51.0 mo Extensive disease: median 4.4 yr 3,040 pts with metastatic PCa MDACC ADT + KA/VE (2008) 3 vs ADT alone 286 pts with metastatic PCa High-volume: 3 bone or visceral mets Low-volume: bone (<3); local/ nodal (±prior curative therapy) Minimal disease: Median 6.9 yr High-volume: median 3.1 yr Minimal disease: Median 7.8 yr 1. Eisenberger M et al. NEJM, 1998; 339: ; 2. Hussain M et al. NEJM, 2013; 368: Millikan RE et al. J Clin Oncol 2008; 26:

75 Other efforts for early chemotherapy in hormone-sensitive PCa

76 GETUG-15 (France) (n=385) Hormone-naive metastatic PCa Poor prognosis (Glass) 21% ADT + docetaxel q3w (9 cycles) vs ADT alone Primary endpoint: OS Clinical PFS (cpfs) and biochemical PFS significantly improved but not OS cpfs OS ADT+ docetaxel (n=192) ADT alone (n=193) Clinical PFS Median cpfs ADT + Doc: 23.5 mo ADT alone: 15.4 mo HR 0.69 (95% CI ) Median OS ADT + Doc: 58.9 mo ADT alone: 54.2 mo HR 1.01 (95% CI ) Gravis G et al. Lancet Oncol, 2013; 14:

77 Comparison to GETUG-15 GETUG-15 CHAARTED n Docetaxel exposure Up to 9 cycles 6 cycles Median follow-up 50 mo 29 mo % high risk 22% 66% OS ADT + docetaxel 58.9 mo 52.7 mo OS ADT 54.2 mo 42.3 mo % deaths at analysis 46% 30% Docetaxel at progression in ADT arm, % 120/193 (62%) 129/174 (74%)

78 STAMPEDE (UK) Patients eligible for STAMPEDE Newly diagnosed M1 patients Randomization All other patients: M0 Randomization A ADT A ADT (+ RT if N0 M0) A Arm A + ZA A Arm A + ZA A Arm A + docetaxel A Arm A + docetaxel A Arm A + ZA + docetaxel A Arm A + ZA + docetaxel A Arm A + ABI A Arm A + ABI A Arm A + RT to prostate T3/4 N0 M0 with PSA >40 ng/ml or Gleason score 8-10; T any, N+, M0 Parker CC et al. BJU Int 2013; 111: (NCT ); James ND et al. Eur Urol 2014; doi: /j.eururo ABI: abiraterone; MO: no metastasis; M1: metastatic disease; RT: radiotherapy; ZA: Zoledronic acid

79 IMPLICATIONS FOR THE FUTURE

80 Advanced PCa - need to carefully evaluate the risk including elderly pts Risk of dying of other causes Health status +++ Comorbidities Dependence Nutritional status Risk of dying of PCa Aggressiveness of the tumor Droz JP et al. Lancet Oncol, 2014; 15: e404-14; Droz JP. BJU Int, 2010; 106: 462-9

81 CHAARTED results and its implications for the future? Need to appropriately tailor therapy Metastatic hormone-sensitive PCa (high volume) major OS benefit with docetaxel The jury is still out for patients with low-volume disease We eagerly await the results of the STAMPEDE trial

82 THANK YOU

83 Closing remarks Nicolas Mottet Saint-Etienne, France

84 Conclusions Prostate cancer is a constant heterogeneous disease Urgent need for individualized classification to individualize treatments Clear predictive factors still lacking CHAARTED could change clinical practice Prostate cancer requires a systematic multidisciplinary discussion

85 THANK YOU