Recent Advances in Lung Cancer: Updates from ASCO 2016

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1 Recent Advances in Lung Cancer: Updates from ASCO 2016 Charu Aggarwal, MD, MPH Assistant Professor of Medicine Division of Hematology-Oncology Abramson Cancer Center University of Pennsylvania 6/23/2016

2 Outline What is new in SCLC Is BID radiation better for LS-SCLC? Is there finally something new for relapsed refractory ES-SCLC? What about immunotherapy for SCLC? Adjuvant chemotherapy for NSCLC Are all chemotherapy regimens the same? ALK Positive NSCLC Should we change our current first line? How do we sequence new therapies? Immunotherapy for NSCLC Front line Immunotherapy (+/- immunotherapy or chemo)

3 Outline What is new in SCLC Is BID radiation better for LS-SCLC? Is there finally something new for relapsed refractory ES-SCLC? What about immunotherapy for SCLC? Adjuvant chemotherapy for NSCLC Are all chemotherapy regimens the same? ALK Positive NSCLC Should we change our current first line? How do we sequence new therapies? Immunotherapy for NSCLC Front line Immunotherapy (+/- immunotherapy or chemo)

4 Role of RT in LS-SCLC SCLC is highly chemo/rt sensitive Gy was the prior standard 45 Gy BID has been shown to be better than 45 Gy once daily Improved OS Improved Local Control Practically, < 25% sites use BID XRT Turrisi et al, NEJM 1999 Jan 28;340(4):265-71

5 CONVERT trial<br />Concurrent ONce-daily VErsus twice-daily RadioTherapy: A 2-arm randomised controlled trial of concurrent chemo-radiotherapy comparing twice-daily and once-daily radiotherapy schedules in patients with limited-stage small cell lung cancer and good performance status Presented By Corinne Faivre-Finn at 2016 ASCO Annual Meeting

6 CONVERT Trial Presented By Corinne Faivre-Finn at 2016 ASCO Annual Meeting

7 CONVERT Trial: OVERALL SURVIVAL Presented By Corinne Faivre-Finn at 2016 ASCO Annual Meeting

8 Is BID radiation better for LS-SCLC? Survival in both arms was better than previously reported Radiation related toxicities lower than expected OD NOT superior to BID Either regimen can be used for LS-SCLC in combination with chemotherapy

9 Future Directions: CALGB R A N D O M I Z E 45 Gy 3 wks 1.5 Gy BID CDDP VP Gy 7 wks 2.0 Gy QD CDDP VP Gy 5 wks Con boost CDDP VP-16 CDDP VP-16 CDDP VP-16 CDDP VP-16 CDDP VP-16 CDDP VP-16 CDDP VP-16 CDDP VP-16 CDDP VP-16 CDDP VP-16 PCI

10 Outline What is new in SCLC Is BID radiation better for LS-SCLC? Is there finally something new for relapsed refractory ES-SCLC? What about immunotherapy for SCLC? Adjuvant chemotherapy for NSCLC Are all chemotherapy regimens the same? ALK Positive NSCLC Should we change our current first line? How do we sequence new therapies? Immunotherapy for NSCLC Front line Immunotherapy (+/- immunotherapy or chemo)

11 Abstr# LBA8505 (Rudin): DLL-3 and Rovalpituzumab Teserine (Rova-T)<br /> Presented By Martin Edelman at 2016 ASCO Annual Meeting

12 Confirmed Responses Comparable in 2nd & 3rd Line Presented By Charles Rudin at 2016 ASCO Annual Meeting

13 Favorable Comparison vs. Existing 2L and 3L CTX Presented By Charles Rudin at 2016 ASCO Annual Meeting

14 Outline What is new in SCLC Is BID radiation better for LS-SCLC? Is there finally something new for relapsed refractory ES-SCLC? What about immunotherapy for SCLC? Adjuvant chemotherapy for NSCLC Are all chemotherapy regimens the same? ALK Positive NSCLC Should we change our current first line? How do we sequence new therapies? Immunotherapy for NSCLC Front line Immunotherapy (+/- immunotherapy or chemo)

15 Nivolumab +/- Ipilimumab in Recurrent SCLC:<br />CheckMate 032 Study Design Presented By Scott Antonia at 2016 ASCO Annual Meeting

16 Nivolumab +/- Ipilimumab in Recurrent SCLC: Summary of Response Presented By Scott Antonia at 2016 ASCO Annual Meeting

17 Checkmate 032 Grade 3-4 AEs 13-30% Higher AEs in combination arms Durable objective responses Tumor responses seen regardless of platinum sensitivity or PDL-1 expression Nivo-1 and Ipi-3 have been selected for the Phase III trial

18 Outline What is new in SCLC Is BID radiation better for LS-SCLC? Is there finally something new for relapsed refractory ES-SCLC? What about immunotherapy for SCLC? Adjuvant chemotherapy for NSCLC Are all chemotherapy regimens the same? ALK Positive NSCLC Should we change our current first line? How do we sequence new therapies? Immunotherapy for NSCLC Front line Immunotherapy (+/- immunotherapy or chemo)

19 Slide 2 Presented By Heather Wakelee at 2016 ASCO Annual Meeting

20 E1505 OS +/- Bevacizumab E1505 DFS+/- Bevacizumab Presented By Heather Wakelee at 2016 ASCO Annual Meeting

21 ECOG 1505: OS and Toxicity NON SQUAMOUS SQUAMOUS Presented By Heather Wakelee at 2016 ASCO Annual Meeting

22 Are all chemotherapy regimens the same? Validates the use of other platinum based regimens, other than cisplatin-vinorelbine Practice confirming, not practice changing

23 Outline What is new in SCLC Is BID radiation better for LS-SCLC? Is there finally something new for relapsed refractory ES-SCLC? What about immunotherapy for SCLC? Adjuvant chemotherapy for NSCLC Are all chemotherapy regimens the same? ALK Positive NSCLC Should we change our current first line? How do we sequence new therapies? Immunotherapy for NSCLC Front line Immunotherapy (+/- immunotherapy or chemo)

24 Alectinib versus Crizotinib in ALK Inhibitor Naïve ALK-Positive Non-Small Cell Lung Cancer:<br /> Primary Results from the J-ALEX Study Presented By Hiroshi Nokihara at 2016 ASCO Annual Meeting

25 J-ALEX Phase III Study Design Presented By Hiroshi Nokihara at 2016 ASCO Annual Meeting

26 Primary Endpoint: PFS by IRF (ITT Population) Presented By Hiroshi Nokihara at 2016 ASCO Annual Meeting

27 ALEX Trial: Adverse Events >20% (All grades & > Grade 3) Presented By Howard West at 2016 ASCO Annual Meeting

28 Should we change our current first line? Probably YES Caveats N=207 Asian Study High incidence of ILD and higher incidence of CNS mets at baseline in the control arm ALEX study, in western population to be reported in 2017 What to do today? ASCO Clinical Meaningful Outcomes Guidelines:4 months PFS benefit Await formal inclusion under NCCN

29 ALTA: randomized dose evaluation of Brigatinib 90 mg QD (n=112) 180 mg QD (n=110) Confirmed ORR (n, %) 50 (45%) 59 (54%) CNS Mets Confirmed ORR 9 (36%) 12 (67%)

30 Second Generation ALK inhibitors Presented By Shirish Gadgeel at 2016 ASCO Annual Meeting

31 How do we sequence new ALK therapies? Crizotinib Alectinib 3 rd gen/ Lorlatinib Chemo/IO Crizotinib Brigatinib 3 rd gen/ Lorlatinib Chemo/IO

32 Slide 26 Presented By Shirish Gadgeel at 2016 ASCO Annual Meeting

33 How do we sequence new ALK therapies? Crizotinib Alectinib 3 rd gen/ Lorlatinib Chemo/IO Crizotinib Brigatinib 3 rd gen/ Lorlatinib Chemo/IO Alectinib Bx SPECIFIC ALK Inhibitor

34 Outline What is new in SCLC Is BID radiation better for LS-SCLC? Is there finally something new for relapsed refractory ES-SCLC? What about immunotherapy for SCLC? Adjuvant chemotherapy for NSCLC Are all chemotherapy regimens the same? ALK Positive NSCLC Should we change our current first line? How do we sequence new therapies? Immunotherapy for NSCLC Front line Immunotherapy (+/- immunotherapy or chemo)

35 Phase 1 CheckMate 012 Study Design: <br />Nivolumab Plus Ipilimumab in First-line NSCLC Presented By Matthew Hellmann at 2016 ASCO Annual Meeting

36 Presented By Matthew Hellmann at 2016 ASCO Annual Meeting

37 Pembrolizumab Plus Chemotherapy as Front-Line Therapy for Advanced NSCLC: KEYNOTE-021 Cohorts A-C

38 Design Chemotherapy + Pembrolizumab (2mg/kg or 10 mg/kg q3 week) Cohort A: Carbo/ Pac q3 week Cohort B: Carbo/ Pac/ Bev q3 week Cohort C: Carbo/ Pem q3 week Response A (N=25) B (N=25) C (N=24) ALL (N=74) PR n (%) 13 (52%) 12 (48%) 16 (67%) 41 (55%) Results based on PDL-1 staining TPS > 50% 56% 50% 75% 60% TPS > 1% 53% 50% 69% 57% TPS < 1% 44% 40% 75% 54%

39 Response A (N=25) B (N=25) C (N=24) ALL (N=74) PR n (%) 13 (52%) 12 (48%) 16 (67%) 41 (55%) Results based on PDL-1 staining TPS > 50% 56% 50% 75% 60% TPS > 1% 53% 50% 69% 57% TPS < 1% 44% 40% 75% 54%

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41 CONCLUSIONS There have been many exciting developments in the field of lung cancer in the last year alone What is practice changing in ? BID RT = Once Daily RT for LS SCLC Immunotherapy can lead to durable and robust responses in ES SCLC Cisplatin based doublet chemotherapy regimens are essentially equivalent in the adjuvant NSCLC setting Alectinib will become our go to ALK inhibitor for front line therapy Akin to the EGFR MT setting, rebiopsy at progression will be the new standard for ALK rearranged NSCLC Immunotherapy for metastatic NSCLC will move to the first line setting PDL-1 testing at diagnosis will become the new norm

42 Thank you