Lung Cancer Update 2016 BAONS Oncology Care Update
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1 Lung Cancer Update 2016 BAONS Oncology Care Update Matthew Gubens, MD, MS Assistant Professor Chair, Thoracic Oncology Site Committee UCSF Helen Diller Family Comprehensive Cancer Center
2 Disclosures Consulting ARIAD, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Calithera, Clovis, Genentech/Roche, Nektar, Pfizer Research Funding (to institution) Celgene, Genentech/Roche, Merck, Novartis, OncoMed
3 Two themes Targeted therapies 2nd+ generation approaches in old mutations: EGFR, ALK 1st generation approaches in new mutations Immunotherapy Where we re at: PD-1 inhibition in the 2nd line Where we re going: combos, biomarkers and 1st line
4 Two themes Targeted therapies 2nd+ generation approaches in old mutations: EGFR, ALK 1st generation approaches in new mutations Immunotherapy Where we re at: PD-1 inhibition in the 2nd line Where we re going: combos, biomarkers and 1st line
5 Targets Li TH. Genotyping and genomic profiling of NSCLC: Implications for current and future therapies. JCO 2013;31(8):
6 Two themes Targeted therapies 2nd+ generation approaches in old mutations: EGFR, ALK 1st generation approaches in new mutations Immunotherapy Where we re at: PD-1 inhibition in the 2nd line Where we re going: combos, biomarkers and 1st line
7 EGFR 10-30% of NSCLC patients Higher prevalence among: Asians Younger patients Females Never-smokers Adenocarcinoma
8 EGFR 3 approved first line drugs: erlotinib, gefitinib, afatinib 2009 IPASS study (Mok et al in NEJM)
9 EGFR 1 st line use established since but resistance inevitably develops. Sequist, Sci Transl Med, 2011.
10 EGFR resistance: T790M, the gatekeeper
11 EGFR resistance: T790M, the gatekeeper Osimertinib (Tagrisso) Engineered to inhibit EGFR exon 19/L858R AND T790M, but less inhibitory of normal ( wild-type ) EGFR Effectiveness when erlotinib (or others) fail Fewer toxicities (but get baseline TTE and EKG) Janne, NEJM 2015.
12 EGFR take-home points Cancers evolve Biopsy at the beginning to figure out the driver mutation...and biopsy at progression to figure out the resistance mechanism Tagrisso should follow 1st line EGFR agent if T790M found Future directions: Tagrisso first line? 3rd/4th generation drugs?
13 EGFR ALK 10-30% of NSCLC patients Higher prevalence among: Asians Younger patients Females Never-smokers Adenocarcinoma 4-7% of NSCLC patients Higher prevalence among: - Younger patients - Never-smokers Adenocarcinoma
14 ALK 2007 detected as an alteration in NSCLC 2011 crizotinib approved Single-arm ORR 50, 61% Vs docetaxel in the 2 nd line, PFS 7.7 vs 3.0 mos Vs platinum combo in the 1 st line, PFS 10.9 vs 7.0 mos Solomon, NEJM 2014
15 ALK but resistance inevitably develops. Why? Not a great ALK inhibitor, so cancer can overcome Poor brain penetration, so cancer can thrive there Other mutations develop 2 nd generation ALK inhibitors better ALK activity, better CNS acitivity Ceritinib approved 2014 (duration 7.1 mos post-crizotinib) Alectinib approved 2015 (duration 7.5 mos post-crizotinib)
16 ALK resistance But what about 2 nd generation first line? J-ALEX (ASCO 2016), alectinib vs crizotinib Japanese population, PS 0-2, treated/asymptomatic brain mets allowed Planned to enroll 200 pts
17 ALK: J-ALEX
18 ALK: J-ALEX Caveats: Japanese data (ALEX trial pending with rest of world), no publication yet
19 ALK take-home points Cancers evolve Biopsy at the beginning to figure out the driver mutation Use the best drug first? Stay tuned Lovly, ASCO 2016
20 Two themes Targeted therapies 2nd+ generation approaches in old mutations: EGFR, ALK 1st generation approaches in new mutations Immunotherapy Where we re at: PD-1 inhibition in the 2nd line Where we re going: combos, biomarkers and 1st line
21 Targets other than EGFR and ALK Li TH. Genotyping and genomic profiling of NSCLC: Implications for current and future therapies. JCO 2013;31(8):
22 Targets other than EGFR and ALK ASCO 2015 BRAF V600E (more often seen in melanoma), 1-2% Dabrafenib + trametinib ORR 63%, PFS 9.7mo ASCO 2016 MET exon 14 skipping, 3-4% (often older patients, current/former smokers, sarcomatoid) Crizotinib ORR 44%, PFS not yet reached RET rearrangement, 1-2% Cabozantinib ORR 38% Vandetinib ORR 53%
23 Take-home points on other targets You can t treat a mutation you don t know
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25 Take-home points on other targets You can t treat a mutation you don t know Beyond EGFR and ALK, drugs may not be FDA-approved Should we treat?
26 NCCN on emerging targeted agents
27 Take-home points on other targets You can t treat a mutation you don t know Beyond EGFR and ALK, drugs may not be FDA-approved Should we treat? Consider clinical trials! Access to new drugs, data for everyone.
28 Two themes Targeted therapies 2nd+ generation approaches in old mutations: EGFR, ALK 1st generation approaches in new mutations Immunotherapy Where we re at: PD-1 inhibition in the 2nd line Where we re going: combos, biomarkers and 1st line
29 Immunotherapy: Not a new idea Cancer Research Institute website
30 Immunotherapy: PD1/PD-L1 (and CTLA4) Ribas A. NEJM 2012
31
32 Immunotherapy- PD1/PD-L1 High rates of somatic mutations in lung cancer may contribute to increased immunogenicity Therapies targeting the PD-L1/PD-1 pathway will alter the treatment of NSCLC 1 Lawrence MS, et al. Nature. 2013;499(7457): Chen DS, et al. CCR
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34 Checkpoint 017: Nivo vs doce in squam NSCLC Opdivo prescribing instructions
35 Checkpoint 057: Nivo vs doce in non-squam NSCLC Paz-Ares, ASCO 2015
36 Checkpoint 057: Nivo vs doce in non-squam NSCLC Paz-Ares, ASCO 2015
37 Checkpoint 057: Nivo vs doce in non-squam NSCLC Paz-Ares, ASCO 2015
38 Checkpoint 057: Nivo vs doce in non-squam NSCLC Response rate Nivo 19% vs docetaxel 12% Median duration of response Nivo 17.2mo vs docetaxel 5.6mo Paz-Ares, ASCO 2015
39 KEYNOTE-010: Pembro vs doce in PD-L1+ NSCLC Overall survival All pts 10.2 vs 12.7 vs 8.5 mo PD-L1>50% pts 14.9 vs 17.3 vs 8.2 mo Herbst, Lancet 2016
40 KEYNOTE-010: Pembro vs doce in PD-L1+ NSCLC Response rate All (PD-L1>1%) 18/18% vs 8% PD-L1>50% 30/29% vs 8% (Nivo all comers: 19 vs 12%) Duration of benefit Not reached at time of study for pembro, 6-8mos for doce (Nivo all comers: 17.2 vs 5.6mo) Herbst, Lancet 2016
41 Safety of PD-1 inhibitors Superior tolerability compared to chemo Immunerelated toxicity is unique: anything -itis Herbst, Lancet 2016
42 PD-1 inhibitor 1 st line take-home points Nivolumab and pembrolizumab with different study strategies, similar benefit and toxicity Nivo approved for all comers 2 nd line Pembro approved for PD-L1+ (>50% yes, likely >1% soon) 2 nd line Nivo q2w and pembro q3w Toxicities DIFFERENT than chemo Majority find it better tolerated...but any organ can be inflamed Low threshold to evaluate CT chest (pneumonitis), thyroid function tests (hypo or hyperthyroiditis), etc Consider use of steroid, other immune modulators
43 Two themes Targeted therapies 2nd+ generation approaches in old mutations: EGFR, ALK 1st generation approaches in new mutations Immunotherapy Where we re at: PD-1 inhibition in the 2nd line Where we re going: combos, biomarkers and 1st line
44 Future of immunotherapy in NSCLC Use PD1 inhibitors before chemo? Press release: Pembro > chemo in the 1st line for PD-L1>50% INCLUDING improvement in OS Press release: Nivo NOT > chemo in the 1st line for PD- L1>5% Show us the data!
45 Future of immunotherapy in NSCLC Use PD1 inhibitors with chemo? Motivation: Cancer cell death release cancer cell antigens improved priming and activation might let PD1 inhibitors work better Caveats: Steroids with some chemos General immunosuppressive state post-chemo Awaiting studies of chemo +/- PD1 inhibitors
46 Future of immunotherapy in NSCLC Use PD1 inhibitors with other immunotherapy? Motivation: PD1 inhibition alone only works in 20% of tumors what about the rest? Caveats: Hard to anticipate results based on pre-clinical models Additive (even synergistic) efficacy possible, but so is additional toxicity Awaiting studies of chemo vs PD1 vs PD1/CTLA4 CTLA4 inhibitor already approved in melanoma (ipilimumab) Await two phase III trials of chemo vs PD1/PD-L1 vs CTLA4
47 Hellmann, ASCO 2016
48 Future of immunotherapy in NSCLC Chen and Mellman, Immunity 2013
49 Future of immunotherapy in NSCLC Chen and Mellman, Immunity 2013
50 Future of immunotherapy take-home points Stay tuned for data next month on 1 st line therapy Stay tuned for data on chemo combos Stay tuned for data on immunotherapy combos Clinical trials are the way forward Special role for immunorefractory patients Careful attention to toxicity Value in medicine
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52 Future of immunotherapy take-home points Stay tuned for data next month on 1 st line therapy Stay tuned for data on chemo combos Stay tuned for data on immunotherapy combos Clinical trials are the way forward Special role for immunorefractory patients Careful attention to toxicity Value in medicine These are expensive drugs...but optimizing them (better combos, better patient selection) may yield superior value by meaningfully improving survival in our patients
53 Thank you!
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