Emerging Therapies for Triple Negative Breast Cancer

Transcription

1 Emerging Therapies for Triple Negative Breast Cancer Joseph A. Sparano, MD Professor of Medicine & Women s Health Albert Einstein College of Medicine Associate Chairman, Department of Oncology Montefiore Medical Center Bronx, New York

2 Overview Clinical Features Biology and Disease Classification Cytotoxic Therapy PARP Inhibitors Biological Agents Immune Checkpoint Blockade Clinical Trials & Novel Approaches

3 Triple-Negative Disease Compared with Other Phenotypes in the California Cancer Registry Study Bauer et al. Cancer 2007: 109; 721 Parise et al. The Breast Journal 2009: 15: 593 Population-based study 6370 with triple-negative disease compared with 44,704 other cases (12% of all cases) TNBC more likely to be associated with Younger age (<40): OR 1.53 Non-Hispanic black race (OR 1.77) or Hispanic ethnicity (OR 1.23) Higher grade (72% grade 3) More advanced stage (66% >/= stage II vs. 50% ER+HER2-) Poorer 5 year RFI irrespective of stage TNBC: 76% (similar to 76% for HER2-Pos) HR-Pos, HER2-Neg: 94% Greater propensity for lung and brain mets

4 Annual Hazard Rate of Recurrence by Breast Cancer Subtype in E1199: Node-Positive & High-Risk Node Negative Breast Cancer Treated with AC-Taxane Chemotherapy Plus Endocrine Therapy ER+/PR+ HER2+ TN Years Since Randomization

5 Biology and Disease Classification

6 Breast cancer intrinsic subtypes by gene expression profiling Luminal A Luminal B ERBB2+ Basal NormL Perou et al. Nature 2000; Parker et al. JCO, 2009

7 Terminal Duct Lobular Unit (TDLU) Luminal Epithelial Cells Low molecular wt CK 7, 8, 18 and 19 Mucin, BCL2, Hormone Receptors Basal Cells (Myoepithelial cells) High molecular wt CK 5, 6, 14 and 17 SMA, Calponin, p63, P-caderin Perou C, et al. Nature 460: , 2000 Smalley M. Ashworth A. Nat. Cancer Reviews 2003;3,

8 Intrinsic Subtype Frequencies by ER/PgR Cutoffs within TNBC Across 3 Adjuvant Trials: GIECAM 9906, MA5, MA12 ER/PR <1% (n=283) ER/PR <10% (n=331) Cheang et al. ASCO 2012, abstract 1008

9 Biologic Basis for Poorer Outcome for Triple Negative and/or Basal Disease Genomic instability Impaired DNA damage repair ATM Kinase CK1, claspin, EF1 macrophage activation motility survival after colonization (ID genes) Tommiska et al. Oncogene 2007 Nov 5 Epub Verlinden et al. Cancer Res 2007; 67: 6574 Gupta et al. PNAS 2007; 104: 19506

10 XBP1 promotes TNBC by controlling the HIF1alpha pathway Unfolded protein response (UPR) adaptive response to hypoxia Mediated by endoplasmic reticulum (ER)- localized membrane sensor (IRE1) and its substrate (XBP1) XBP1 gene expression signature highly correlated with HIF1-alpha and hypoxia signatures, and associated with a poor prognosis XBP1 drives tumorigenicity by complexing with HIF1-alpha and regulating expression of HIF1- alpha targets via recruitment of RNA polymerase II Knockdown of of XBP1 enhances effectiveness of cytotoxic therapy in an MDA 231 xenograft model Chen et al. Nature 2014

11 BRCA Mutations & TNBC Up to 20% of unselected patients Up to 50% of patients with a strong family history 50% of mutation carriers don t have a strong family history Gonzalez-Angulo et al. JCO 2011 Bayraktar et al. BCRT 2011

12 BRCA1-Deficient Cells are Hypersensitive to Cisplatin BRCA-deficient cell line HCC1937 BRCA Proficient - MCF-7 (ER-pos) & MDA-MB-231 (ER/PR-Neg) Tassone P et al. Br J Cancer 2003; 88:

13 TNBC Subtypes 21 publicaly available gene expression breast cancer datasets, 587 TNBCs Basal-like 1 (BL1): Cell-cycle, proliferation and DNA damage response genes Basal-like 2 (BL2): Growth factor signaling (EGF, MET, Wnt/β-catenin, IGF1R) Immunomodulatory (IM): Immune cell & cytokine signaling (overlap with medullary signature) Mesenchymal (M): Cell motility and differentiation (Wnt, ALK, TGF-β) Mesenchymal stem-like (MSL): Similar to M, but increased growth factors signaling, low proliferation, enrichment of stem cell genes Luminal androgen receptor (LAR): Enriched in hormonally-regulated pathways, androgen receptor signaling. Displays luminal expression patterns (molecular apocrine carcinomas) Copyright 2011, American Society for Clinical Investigation Lehmann BD, et al. Journal of Clinical Investigation, 2011

14 Are the Subtypes Clinically Relevant? Maybe Basal Cisplatin LAR Bicalutamide Mesenchymal-like Src inhibition

15 Cytotoxic Therapy

16 Schema Study Design: Multi-center, randomized open-label Phase III Trial N = 519 Study Population: Stage IV TNBC ECOG PS 0 1 Stable CNS metastases allowed 0-2 prior chemotherapies for mtnbc R Gem/Carbo (GC) (N= 258) Gemcitabine 1000 mg/m 2 IV d 1, 8 Carboplatin AUC2 IV d 1, 8 21-day cycles Crossover allowed to GCI following Disease Progression* (central review) Randomization stratified by prior chemo in the metastatic setting: 1 st -line (no prior therapy) 2 nd /3 rd -line (1-2 prior therapies) Gem/Carbo + Iniparib (GCI) (N= 261) Gemcitabine mg/m2 IV d 1, 8 Carboplatin - AUC2 IV d 1, 8 Iniparib mg/kg IV d 1,4,8,11 21-day cycles *Prospective central radiology review of progression required prior to crossover 96% (n=152) of progressing patients crossed over to GCI at time of primary analysis NCT

17 Probability of Progression Free Survival Probability of Survival Efficacy Endpoints ITT population PFS Median PFS, mos (95% CI) GC (N=258) 4.1 (3.1, 4.6) GCI (N=261) 5.1 (4.2, 5.8) HR (95% CI) 0.79 (0.65, 0.98) p-value Pre-specified alpha = OS GC (N=258) GCI (N=261) Median OS, mos (95% CI) (9.2, 12.1) (10.6, 12.9) HR (95% CI) 0.88 (0.69, 1.12) p-value 0.28 Pre-specified alpha = Months Since Study Entry No. at risk GC GCI No. at risk Months GC GCI

18 Relation Between BRCA Mutation Status and Response to Neoadjuvant Platinum Trial Characteristics Regimen No. pcr Byrski BRCA1+mut carriers Not-platinum-based (16%) BRCA1+mut carriers CDDP 75mg/m 2 x (83%) Silver Sporadic TNBC (not BRCA1+mut carriers) CDDP 75mg/m 2 x (15%) BRCA1mut carriers CDDP 75mg/m 2 x4 2 2 (100%) Ryan Sporadic TNBCs (not BRCA1+mut carriers) CDDP 75mg/m2 x4 + bevacizumab 15 mg/kg q3wk x (16%) Byrski, JCO 2009; Silver JCO 2009: Baselga ESMO 2010; Isakoff SABCS 2010

19 PrECOG 0105 Schema PI: Melinda Telli, MD Newly Diagnosed Stage I-IIIA (T 1cm by MRI) Triple-negative (ER/PR 5%) or BRCA1/2 mutation Carboplatin AUC 2 D 1, 8 Gemcitabine 1000 mg/m 2 D 1, 8 Iniparib 5.6 mg/kg D 1, 4, 8, 11 Every 21 days x 6 cycles n = 80 Definitive Surgery Assess Pathologic Response Primary Endpoint: Pathologic complete response (pcr) [no invasive disease in breast + axilla] Secondary Endpoint: Correlation of gene expression profiles & gene copy number with response

20 Results ITT population Pathologic Response (n=80) Target: lower bound of 90% exact binomial CI pcr rate exceeds 25% 87.5% power to detect 15% absolute improvement from 25% to 40% in pcr rate (binomial test with 1- sided alpha level of 5%) All patients ******* BRCA 1/2 wild-type BRCA 1/2 mutant TN & BRCA 1/2 mutant n = 80 n = 61 n = 19 n = 16 pcr [RCB 0]; n (%) 29 (36%) 20 (33%) 9* (47%) 9* (56%) 90% CI RCB 0/1; n (%) 45 (56%) 31 (51%) 14 (74%) 12 (75%) 90% CI * One BRCA1 carrier had bilateral TNBC & achieved pcr in both breasts

21 Homologous Recombination Deficiency (HRD) Assay Goal: To detect a genomic HR deficiency footprint in a tumor caused by various defects in the HR pathway Potential to identify non-brca1/2 mutation carriers with BRCA-like cancers who may benefit from DNA repair targeted treatment strategies Assay development: Association of genomic patterns of loss of heterozygosity (LOH) & HR deficiency assessed in ovarian cancer Major Finding: LOH regions of intermediate size were observed more frequently in tumors with defective BRCA1 or BRCA2 HRD Score = Count of the # of LOH regions of intermediate size (> 15 Mb and < whole chromosome) observed in the tumor genome Abkevich V, et al. British Journal of Cancer, 2012

22 Rate of Favorable Response (RCB 0/1) by HRD Score BRCA1/2 mutant responders BRCA1/2 intact responders Non-responders p = HRD score Telli ML, Timms K, Hartmann A-R, Ford JM, et al. SABCS 2012; abstract PD09-04

23 Antitubulins Bind to Different Sites on Tubulin Vincas binds to (+) ends and along sides Paclitaxel, docetaxel, and epothilone B bind to subunits at inside surface Eribulin binds to (+) ends Vinorelbine Paclitaxel Docetaxel Ixabepilone Eribulin Catharanthus roseus Rosy periwinkle Myxobacteria Sorangium cellulosum Marine sponge Halichondria okidai Taxus brevifolia Paciific yew tree Taxus baccata European yew tree

24 PFS Probability PFS Probability E2100: Weekly paclitaxel alone or plus bevacizumab as first-line therapy for metastatic breast cancer outcomes by ER/PR expression PFS by Treatment ER Negative, PgR Negative PB P P < Medians: 4.7, 8.6 ER/PR Negative P P+B All 17% 34% Measurable (79%) 17% 41% Months PFS by Treatment ER Positive, PgR Positive ER and/or PR Positive PB P P < Medians: 7, 14.1 P P+B All 23% 37% Measurable (46%) 30% 51% Months 31

25 Phase III Trials of Capecitabine With or Without Ixabepilone in Anthracycline and Taxane Pretreated or Resistant Advanced Breast Cancer Eligibility criteria: Locally advanced or metastatic breast cancer CA Trial: Anthracyclinepretreated or resistant Taxane-resistant CA Trial: Anthracyclinepretreated Taxane-pretreated R A N D O M I Z E Resistance criteria for CA : Progression / recurrence: (Neo)adjuvant: < 6 months anthracycline, < 12 months taxane Metastatic: < 3 months anthracycline, < 4 months taxane Ixabepilone 40 mg/m 2 day 1 q3w Capecitabine 2000 mg/m 2 days 1-14 q3w Capecitabine 2500 mg/m 2 days 1-14 q3w Thomas ES, et al. J Clin Oncol. 2007;25: ; Sparano J, et al. J Clin Oncol. 2010;28:

26 Capecitabine ± Ixabepilone in Triple Negative MBC Pooled triple negative subgroup (n = 443) Efficacy Ixa + Cape (n = 191) Cape (n = 208) ORR 31% 15% CR 3% 1% PR 28% 14% Median PFS 4.2 mo 1.7 mo HR 0.63 P value < Median OS 10.3 mos (n = 213) HR 0.87 P value mos (n = 230) Selected Grade 3/4 AEs Ixa + Cape (n = 209) Cape (n = 226) Neutropenia 70% 8% Febrile neutropenia 4% < 1% Leukopenia 63% 5% Peripheral neuropathy Hand-foot syndrome 23% < 1% 14% 16% Fatigue 11% 3% Rugo H, et al. SABCS Abstract 3057.

27 Eribulin Study 301 Global, randomized, open-label phase III trial (Study 301) Patients (N = 1102) Locally advanced or MBC 3 prior chemotherapy regimens ( 2 for advanced disease) Prior anthracycline and taxane in (neo)adjuvant setting or for locally advanced Stratification: or MBC Eribulin mesylate 1.4 mg/m 2 2- to 5-min IV Day 1 & 8 q21 days Randomization 1:1 Capecitabine 1250 mg/m 2 BID orally Days 1-14, q21 days Co-primary endpoint OS and PFS Secondary endpoints Quality of life ORR Duration of response 1-, 2- and 3-year survival Tumor-related symptom assessments Safety parameters Population PK Kaufman PA, et al. SABCS December 7, Abstract S6-6.

28 Overall Survival By Receptor Status Subgroup HR (95% CI) Eribulin Capecitabine Median (months) Overall (0.770, 1.003) HER2 status Positive (0.688, 1.355) Negative N = (0.715, 0.983) ER status Positive (0.737, 1.093) Negative N = (0.635, 0.955) Triple negative Yes N = (0.545, 0.906) No (0.795, 1.081) ITT population Favors eribulin Favors capecitabine Kaufman PA. et al, SABCS December 7, Abstract S6-6. Kaufman et al, SABCS December 7, 2012

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32 PARP Inhibitors

33 DNA Damage Repair Pathways Type of damage: Singlestrand breaks (SSBs) Doublestrand breaks (DSBs) Bulky adducts O6- alkylguanine Insertions & deletions Repair pathway: Base excision repair Recombination repair HR NHEJ Nucleotideexcision repair Mismatch repair Direct reversal Repair enzymes: PARP ATM BRCA DNA-PK XP, polymerases MSH2, MLH1 AGT

34 Poly (ADP-ribose) Polymerase (PARP) DNA binding domain Automodification domain Catalytic Domain PARP homology domain PARP-1 Nuclear protein 3 functional domains Amino terminal: DNA binding Automodification: autoribosylation (protein-protein interactions) C-terminal: catalytic domain transfer ADP-ribose from NAD+ to protein acceptors, forming padpr (2x higher charge density than DNA) DNA damage PARPs recruited to altered DNA, catalytic activity up to 500-fold padpr localization to DNA and recruitment of proteins (eg, XRCC1) which assemble and activate DNA base excision repair NAD+ and ATP depletion contribute to cell death

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36 History of Poly(ADP-ribose) Polymerase (PARP) as a Therapeutic Target Chambon et al. Nature Cancer Reviews 2010 Discovery of PARP 1963: Nuclear enzymatic activity that synthesizes an adenine containing RNA-like polymer (Chambon et al) : Confirmed by others, identified as PARP (Nishizuka et al) Discovery of PARP Function 1979: PARP activated by DNA strand breaks (Juarez-Salinas et al) 1980: PARP participates in DNA repair (Durkacz et al) 1986: PARP1 hyperactivation leads to NAD+ and ATP depletion after DNA damage & metabolic cell death (parthanotos) (Berger et al) 2000: PARP knockouts confirm role in DNA repair (Shall et al) Discovery of PARP Inhibitors 1980: PARP inhibitors enhance alkylators (Durkacz et al) 2005: PARP inhibitors toxic to BRCA deficient cells (Bryant et al, Farmer et al) Chambon et al. Biochem Biophsyic Res Comm, 1963; Nishizuka et al l. JBC, 1968; Juarez-Salinas, Nature, 1979, Durkacz et al. Nature, 1980; Berger et al, BBRC, 1986; Shall et al. Mut Res, 2000; Bryant et al, Naure 2005, Farmer et al. Nature, 2005; 46

37 PARP Inhibitors All share 3-aminobenzamide ring R1 O NH H 2 N O N Olaparib R2 Benzamide Inhibitors 3-aminobenzamide N N ABT-888 (Veliparib) O H N NH 2 O H N O F N H AG N H BSI-201 (Iniparib) N H CEP-6800

38 Synthetic Lethality: Selective effect of PARP-1 inhibition on cancer cells with BRCA1 or BRCA2 mutation DNA Damage Base Excision Repair PARP Inhibitor Homologous Recombination BRCA Mutation Cell survival Cancer cell death

39 PARP Inhibitors In Development Compound Other names Phase Olaparib (AZ) KU , AZD2281 III Veliparib (AbbVie) ABT888 III Rucaparib (Clovis) PF , AG I/II Niraparib (Tesaro) MK4827 III BMN-673 (BioMarin) CEP-9722 (Cephalon) E7016 (Eisai) II & III I I

40 PARP Inhibitors - single agent development in BRCA mutation associated breast cancer Best response (ITT) Olaparib 400 bid (n=27) Olaparib 100 bid (n=27) CR 1 (4%) 0 PR 10 (37%) 6 (22%) SD 12 (44%) 12 (44%) PD 4 (15%) 9 (33%) Median PFS 5.7 mo 3.8 mo MRD days Tutt, Lancet 2010

41 Olaparib Not Effective in Sporadic TNBC Olaparib 400 mg po BID Gelmon et al, Lancet Oncol 2011

42 Phase III OLympiAD (OLaparib in Advanced Disease) Metastatic breast cancer & BRCA mutation carrier Prior anthra/taxane 0-2 prior for MBC No prior platinum Physician s choice (capecitabine, vinorelbine, eribulin) Olaparib Primary endpoint: PFS (no cross-over) Secondary: OS, PFS2 Planned sample size: 310 patients Nearly identical studies planned with niraparib (BIG/EORTC) and BMN-673 (Industry-sponsored)

43 Adjuvant Olaparib in Localized Breast Cancer and BRCA Mutation Carriers Post neoadjuvant BRCA TNBC, Non-PathCR Assumptions: - Control arm 3 year EFS ~ 60% Post adjuvant TNBC Node positive disease Node neg & T,> 2cm Assumptions: -Control arm 3 year EFS ~ 75% Randomise 1:1 Double blind N=1320 Olaparib 300 mg BID x 12 months Placebo X 12 months IDFS Distant DFS; OS Adjuvant ER-positive group will be added after pilot safety data with endcorine therapy Primary endpoint: IDFS HR 0.7 (CV=0.81), 90% power, 5% significance level, approx 330 events required assumes consistent treatment effect (HR=0.7) across patient groups N=1320 (25% maturity), assuming 4 years recruitment, IDFS analysis estimated approx 5.5 to 6 years from FSI Study being managed by BIG & NRG/Alliance

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45 Phase I-II Trials of Veliparib in BRCA-Mutation Associated Metastatic Breast Cancer Recommended phase II dosing: Veliparib monotherapy: 400 mg PO BID continuously Veliparib + carboplatin : 150 mg PO BID days carbo AUC5 q3 wks Somlo et al. ASCO 2014; Abstract 1021

46 I-SPY 2 TRIAL Design: Learn, Drop, Graduate, and Replace Agents Over Time Paclitaxel+ Trastuzumab HER 2 (+) Randomize Paclitaxel + Trastuzumab* + New Agent A Paclitaxel + Trastuzumab* + New Agent B Paclitaxel + Trastuzumab* + New Agent C AC Surgery Learn and adapt from each patient as we go along Patient is on Study Paclitaxel Key MRI Residual Disease (Pathology) HER 2 ( ) Randomize Paclitaxel + New Agent C F Paclitaxel + New Agent GH D Paclitaxel + New Agent E AC Surgery

47 I-SPY 2: Veliparib/Carboplatin Graduates in TNBC SIGNATURE Estimated pcr Rate (95% probability interval) Veliparib/ Carbo Concurrent Control Probability Veliparib + Carbo is Superior to Control Predictive Probability of Success in Phase 3 All HER2-33% (22-43%) 22% (10-35%) 92% 55% HR+/HER2-14% (4-27%) 19% (6-35%) 28% 9% HR-/HER2-52% (35-69%) 26% (11-40%) 99% 90% Rugo et. al. SABCS 2013

48 Veliparib Phase III Trials in Breast Cancer Phase III Randomized Placebo-Controlled Trial of Carboplatin and Paclitaxel with or without the PARP Inhibitor Veliparib (ABT-888) in Metastatic or Locally Advanced Unresectable BRCA-Associated Breast Cancer Phase III Randomized, Placebo-Controlled, Double-Blind, Study Evaluating Safety and Efficacy of the Addition of Veliparib Plus Carboplatin Versus the Addition of Carboplatin to Standard Neoadjuvant Chemotherapy Versus Standard Neoadjuvant Chemotherapy in Subjects With Early Stage Triple Negative Breast Cancer (TNBC)

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50 Clinical Trials with PARP Inhibitor BMN673 Phase III: Open-Label, Randomized, Parallel, 2-Arm, Study of BMN 673 versus Physician s Choice in Germline BRCA Mutation Subjects with Locally Advanced and/or Metastatic Breast Cancer, Who Have Received No More than 2 Prior Chemotherapy Regimens for Metastatic Disease Phase II: A 2-Stage, 2-Cohort Study of BMN 673 Administered to Germline BRCA Mutation Subjects with Locally Advanced and/or Metastatic Breast Cancer Cohort 1: previously responded to a platinum-containing regimen for metastatic disease with disease progression > 8 weeks following the last dose of platinum Cohort 2: Received > 2 prior chemotherapy regimens and who have had no prior platinum therapy for metastatic disease

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52 Biological Agents

53 BALI-1 Trial Cisplatin Cisplatin + Cetuximab No Response Rate 10.3% 20% P=0.11 Median PFS 1.5 mo. 3.7 mo. HR 0.67, p=0.03 Median OS 9.4 mo mo. HR 0.82, p=0.31 Baselga et al. J Clin Oncol Jul 10;31(20):

54 Median PFS 9.2 vs. 6.7 mo. HR 0.64 (95% CI 0.58, 0.71) ORR: 49% vs. 32%, p< Miles et al. Ann Oncol 2013, 7/25/13 ahead of print

55 R A N D O M I Z E D Confirmatory Study Schema: MERiDiAN MBC, HER2-Negative Chemo-naïve N=480 Paclitaxel 90 mg/m2 weekly x 3 q4 weeks / Bevacizumab 10 mg/kg q2w Stratification VEGF-A (low/high) Adjuvant therapy (yes/no) Hormonal status (ER +/-) Paclitaxel 90mg/m2 weekly x 3 q4 weeks / Placebo 10 mg/kg q2w Co-Primary Endpoints: PFS (All Patients), PFS (VEGF high subset) Secondary Endpoints: OS; ORR; Symptoms/QoL; Safety

56 Immune Checkpoint Blockade

57 Loi et al.. J Clin Oncol 2013; 31: 860

58 Adams et al. JCO 2014

59 Systematic Review & Metaanalysis of TILs and Response to Neoadjuvant Chemotherapy San Antonio Breast Cancer Symposium 2013 Murali Janakiram, MD Methods: 1147 reports in Pubmed, ASCO abstracts ( ), & Embase between 1/91-5/13 7 studies including 1641 patients met inclusion criteria Results: TIL ratio classified as either high or positive was associated with a significantly higher likelihood of achieving a pcr/near pcr after NAC Effect was driven mainly by a difference in in ER negative tumors and Her2 positive tumors Subtype N No of p CR% OR 95% CI studies TIL low TIL high All % 28.6% ER-/PR % 41.3% Her % 23.4% ER/PR % 11.5%

60 Relationship Between TILs and Response to Neaodjuvant Therapy Reference Trials N (Subtype) pcr Rates and TILs Issa-Nummer, PLOSone 2013 Prospective Validation GeparQuinto 313 (HER2-) 14.3% (<60% TILs) 36.6% ( 60% TILs) Denkert, SABCS 2013 Prospective validation GeparSixto 314 (TNBC) TNBC (+Carbo) 45.7% (<60% TILs) 73.8% ( 60% TILs) TNBC (-Carbo) 33.9% (<60% TILs) 42.6% ( 60% TILs) Presented by: Shaveta Vinayak, M.D., M.S.

61 Cancers associated with BRCA1 mutations showed more lymphocytic infiltrate (P for trend <.0001)

62 WHY DOES AN IMMUNE INFILTRATE PREDICT FOR SENSITIVITY TO CHEMOTHERAPY? 1. CHEMOTHERAPY REVERSES IMMUNE TOLERENCE AND INDUCES EFFECTIVE IMMUNE RESPONSE. 2. IMMUNE INFILTRATE IS A MARKER OF AN UNDERLYING DNA REPAIR DEFECT 3. CHEMOTHERAPY KILLS LYMPHOCYTES, DEPRIVING TUMOR CELLS OF GROWTH FACTORS ( lymphocyte addiction ) Presented by: Sridhar Ganesan, MD, PhD

63 Immune Checkpoint Blockage as a Therapeutic Strategy

64 Ribas et al. NEJM 2012

65 B7 Family Expression in Triple Negative Breast Cancer Unpublished data. Courtesy of X. Zang, Albert Einstein College of Medicine.

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67 Topalian et al. NEJM 2012

68 Clinical Trials and Novel Approaches

69 Research & Discovery Clinical Practice Genomic Sequencing vs. Gene Expression Whole Genome Sequencing 100% Genome (22,000 genes) Exons (coding), Introns (non-coding), & Intergenic Regions Proteomics DNA methylation Non-coding RNA Histone modfications Whole Exome Sequencing 1% Genome Coding regions only Targeted Sequencing 0.003% Genome exons potentially actionable mutations Gene Expression Profiling 7 (BCI), 21 (Oncotype), 50 (PAM50), 70 (Mammaprint), others Poor risk proflles identify patients with ER-pos, HER2 neg disease & 0-3 pos nodes who derive greatest chemo benefit Presented by: Joseph A. Sparano, MD

70 Distribution of Mutations in TCGA by Breast Caner Subtype Presented by: Joseph A. Sparano, MD

71 SAFIR 01 Molecular-Driven Study Flow 427 Enrolled 407 MBC Bx 299 Genomics (13%) 55 Genomic-driven Rx Most Activating Mutations are Rare 195 Druggable Lesions Andre F, et al. Lancet Oncol 2014

72 AURORA Initiative Zardavas et al. BJC 2014

73 NCI MATCH Molecularly profile 3000 patients with PD after Rx Multianalyte validated targeted NGS assay in CLIA lab Identify 1000 patients with tumors that have mutations and/or amplifications in pathways targetable by existing agents Assignment to receive targeted agents/regimens Commercial or experimental agents Phase II design for each agent with OR/PFS endpoint Rule based algorithms Level 1: FDA approved different tumor Level 2: Data from clinical trials in similar molecular abnormality Level 3: Plausible preclinical evidence that drug works against a given tumors with a given molecular abnormality Presented by: Joseph A. Sparano, MD

74 Barriers to Clinical Application Technical and Logical Gaps Tissue access & purity (eg, stroma, inflammation) Limited access to novel agents /combinations Tumor Heterogeneity Biological Barriers Tumor heterogeneity» Intra-cellular (multiple mutations)» Inter-cellular (multiple clones)» Stromal and immune effects Driver vs. passenger mutations» Few addictive» Most are uncommon/rare Clonal evolution» Intrinsic/acquired resistance» Need for combinations Driver vs. Passenger B B C A B A C B A B C A C C Drug A Clonal Evolution B

75 Conclusions Treatment of TNBC Predictive biomarkers Evaluate for BRCA mutation NCCN guidelines vs. population screen? Clinical utility of genomic sequencing uncertain Cytotoxic therapy Taxanes & platinum combinations have modest activity in MBC Capecitabine less effective than eribulin in MBC Platinums improve pcr rates as neoadjuvant therapy effect of breast conservation and recurrence unknown PARP Inhibitors Multiple ongoing trials will define role in mutation-associated and sporadic TNBC Biologics Bevacizumab improves response and PFS, not survival predictive biomarkers needed - use limited due to rescinded FDA approval Anti-EGFR directed agents have modest activity & skin/gi toxicity