Second-line treatment for advanced NSCLC

Second-line treatment for advanced NSCLC Silvia Novello silvia.novello@unito.it UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

DISCLOSURE OF INTEREST Speaker Bureau: Eli Lilly, MSD, BI, BMS, Roche, AZ UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

Life was so boring simple and back disappointing in 2008 back in 2008 UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

Di Maio M, EJC 2010

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY In 2018, second line therapy is no longer as simple We must now take into consideration: 1.Tumor histology 2.Molecular phenotype (EGFR, ALK, ROS1, etc), 3.Frontline chemo components (i.e. bevacizumab) 4. IO in First Line 5. Maintenance therapy (continuation, switch) 6. Others (adequacy of tumor tissue, third party reimbursement, guidelines, pathways, etc)

.even worse than this Country First Author (yr) Patients With Second-Line Treatment Brazil # Younes 2011 40.4% Canada # Sacher 2015 31.3% Europe Bischoff 2010 29.2% France Carpentier 2016 41.2% Germany Zietemann 2011 52.5% Japan Asahina 2012 69% US * Davis 2015 20% # Only consisted of patients with stage IV NSCLC; Countries included France, Germany, Portugal, Finland, Denmark, the United Kingdom, Sweden, the Netherlands, Israel, Romania, and Peru.; * only squamous ca Davis Jet al, PlosONE 2017

BUT this will change in the future

.not only an increase in N

Di Maio M, JCO 2009

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Clinical Lung Cancer 2014

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Median Age: 59-68 Second Line Candidates: Larger proportion of Male pt characteristics Adenocarcinoma was the most common NSCLC (33% in Brazil to 77% in Japan) Never Smoker#: highest proportion in Japanese cohort (range from 7.5% Germany, to 34%) PS*: most patients having a Karnofsky Performance Status of 70 or better or an ECOG score of 0 or 1 *only in 5 trials; # in 8 trials Davis Jet al, PlosONE 2017

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Second line therapy Outside Clinical Trials (N=464, 86% of pts progressing after first line) Gridelli C et al, JCancerRes ClinOncol. 2014 De Marinis Fet al, ClinicalLungCancer2014

Distribution of Second line treatment in advanced NSCLC Davis Jet al, PlosONE 2017 UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

Guidelines [ESMO-AIOM] UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Treatment Options Post-platinum Progression: Docetaxel Docetaxel was the first treatment to be approved for NSCLC patients with disease progression following first-line chemotherapy 1 1.0 Patients receiving docetaxel 75 mg/m 2 had OS of 7.5 months, compared with 4.6 months for those receiving BSC 2 Docetaxel-treated patients had a significantly higher 1-year survival rate compared with patients receiving vinorelbine or ifosfamide (32% vs. 19%; p=.025) 3 Cumulative probability 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Docetaxel 75 mg/m 2 (n=55) BSC (n=49) 0.0 0 6 12 18 Survival (months) 1. Sanofi Aventis. Taxotere (docetaxel) prescribing information. Nov 2014 2. Shepherd FA et al. J Clin Oncol 2000;18:2095-103 3. Fossella FV et al. J Clin Oncol 2000;18:2354-62

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Treatment Options Post-platinum Progression: Pemetrexed in nonsquamous NSCLC Pemetrexed was approved for patients progressing after chemotherapy after it demonstrated non-inferiority vs. docetaxel, but with a better toxicity profile 1-3 In patients with nonsquamous histology, pemetrexed treatment resulted in a median OS of 9.3 months, compared with 8.0 months for docetaxel 4 Pemetrexed is only suitable for patients with nonsquamous histology 1 Survival distribution function 0 6 12 18 24 30 Survival (months) The increased use of pemetrexed in first-line treatment means docetaxel remains an option as subsequent therapy for patients of all histologies 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Pemetrexed Docetaxel Adjusted HR 0.78 (95% CI 0.61 1.00) 1. Eli Lilly and Company. Alimta (pemetrexed) prescribing information. Sep 2013 2. Hanna N et al. J Clin Oncol 2004;22:1589-97 3. Weiss GJ et al. J Clin Oncol 2006;24:4405-11 4. Scagliotti G et al. Oncologist 2009;14:253-63

Tanaka F. et al. Ann. Oncol. 2011 p<0.0001 P<0.001 UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Relative expre. levels Relative expre. levels P<0.001 Ceppi et al. Cancer 2006 TS (N=965) 649 AC, 316 SCCA 5 Monica V. et al. Clin. Cancer Res. 2009 4 3 2 TS relative mrna levels 1 0 Gandara D. et al. Proc. ASCO 2010 ADC SCC non-ne LCC LCNEC SCLC

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Treatment Options Post-platinum Progression: Erlotinib The EGFR TKI erlotinib is approved for use in unselected patients with disease progression after first-line chemotherapy 1 However, erlotinib was inferior to docetaxel for OS and PFS in patients without an EGFR mutation; other options may be preferred in this setting 2,3 Erlotinib is not recommended for patients with a poor classification following proteomic testing in patients with WT or unknown EGFR status 3,4 Overall survival (%) 100 90 80 70 60 50 40 30 20 10 0 Cox model adjusted HR 0.73 (95% CI 0.53-1.00) Erlotinib Docetaxel 0 2 4 6 8 10 12 14 16 18 20 Survival (months) 1. Astellas Pharma and Genentech. Tarceva (erlotinib) prescribing information. June 2015 2. Garassino MC et al. Lancet Oncol 2013;14:981-8 3. NCCN Clinical Practice Guidelines for Non-Small Cell Lung Cancer, V.6.2015 4. Gregorc V et al. Lancet Oncol 2014;15:713-21

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Revisiting ancient history: Phase III trials in 2 nd line NSCLC Erlotinib 1,2 Docetaxel 3,4 Pemetrexed 5 Outcome 150mg/day 75mg/m 2 500mg/m 2 Response rate (%) 8.9 7.1 8.8 9.1 Median duration of 7.9 5.3 9.1 4.6 response (months) 1-year survival rate (%) 31 30 37 30 Median survival in PS 0/1 patients with 1 prior regimen (months) Median survival (months) *Results cannot be compared directly because of different patient populations 9.42 9.15 9.45 6.7 5.7 7.9 8.3 1 Shepherd F, et al. N Engl J Med 2005;353:123 32; 2 OSI and Roche data on file; 3 Shepherd F, et al. J Clin Oncol 2000;18:2095 103; 4 Fossella F, et al. J Clin Oncol 2000;18:2354 62; 5 Hanna N, et al. J Clin Oncol 2004;22:1589 97

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

SQUAMOUS and NON-SQUAMOUS Carcinoma: rooms for improvements SQUAMOUS and NON-SQUAMOUS UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY HYPERPLASIA DYSPLASIA CARCINOMA Air Space Cellular proliferation through independent growth signaling Gene Methylation Mutations Translocations Bronchial Epithelium Promotion of survival signals and evasion of apoptosis Limitless potential for replication Vascular recruitment and endothelial cell growth INVASIVE CARCINOMA Tissue invasion and metastasis Adapted from Weinberg RA. SciAm. 1996;275:62-70.

1:1 - Stage IV NSCLC after one platinum- based chemo +/- maintenance - Prior Bev allowed - All histologies - PS 0 or 1 R A N D O M I Z E Ramucirumab 10 mg/kg + Docetaxel 75 mg/m 2 q3wks N=628 Placebo + Docetaxel 75 mg/m 2 q3wks N=625 Treatment until disease progression or unacceptable toxicity Stratification factors: ECOG PS 0 vs 1 Gender Prior maintenance East-Asia vs. ROW Primary endpoint: Overall Survival Secondary endpoints: PFS, ORR, safety, patient-reported outcomes

Overall Survival (%) ITT population 100 80 60 40 20 0 RAM+DOC PL+DOC Censored Median (95% CI) Censoring Rate RAM+DOC 10.5 (9.5-11.2) 31.8% PL+DOC 9.1 (8.4-10.0) 27.0% RAM+DOC vs PL+DOC: Stratified HR (95% CI) = 0.886 (0.75-0.98) Stratified log-rank P =.023 Number at risk RAM+DOC PL+DOC 0 3 6 9 12 15 18 21 24 27 30 33 628 625 527 501 415 386 329 306 231 197 Survival Time (months) 156 129 103 86 70 56 45 36 23 23 11 9 2 0 36 0 0

Progression-Free Survival (%) ITT population, Investigator Assessment 100 80 60 40 20 0 RAM+DOC PL+DOC Censored Median (95% CI) Censoring Rate RAM+DOC 4.5 (4.2-5.4) 11.1% PL+DOC 3.0 (2.8-3.9) 6.7% RAM+DOC vs PL+DOC: Stratified HR (95% CI) = 0.76 (0.68-0.86) Stratified log-rank P = 0.0001 Number at risk RAM+DOC PL+DOC 0 3 6 9 12 15 18 21 24 27 30 33 628 625 383 301 204 172 120 95 Survival Time (months) 59 37 38 17 11 9 7 4 3 3 3 2 0 0 0 0 36 0 0

Response a, n (%) Ramucirumab + Docetaxel (n=628) Placebo + Docetaxel (n=625) CR 3 (0.5) 2 (0.3) p value Ramucirumab improved ORR and DCR in nonsquamous and squamous histologies PR 141 (22.5) 83 (13.3) SD 258 (41.1) 244 (39.0) PD 128 (20.4) 206 (33.0) Unknown 98 (15.6) 90 (14.4) ORR (95% CI) 144 (22.9) (19.7-26.4) 85 (13.6) (11.0-16.5) <.001 DCR (95% CI) 402 (64.0) (60.1-67.8) 329 (52.6) (48.6-56.6) <.001

QoL was measured using LCSS and ASBI A similar increase in symptom burden was observed in both treatment arms Addition of ramucirumab had no detrimental effect on QoL Mean ASBI Total Score Mean LCSS Total Score 100 80 60 40 20 0 n = 100 80 60 40 20 0 n = * * * * * * * * * Ramucirumab * Placebo * * * * * * * * * * * * * * 0 2 3 4 5 6 7 8 9 10 Sum 30-day vis follow-up 484 491 422 433 353 300 326 266 261 217 233 196 178 144 167 120 127 102 111 86 366 367 296 305 * * * * * * * * * * * * * * * * * * Cycle * * * * * * 0 2 3 4 5 6 7 8 9 10 Sum 30-day vis follow-up 493 501 457 443 358 306 338 274 270 218 240 199 181 149 171 125 129 102 112 87 375 372 300 311

REVEL: Patient Disposition Screened (N=1825) Randomized (ITT) Population N=1253 Excluded (n=572) Patients not receiving treatment (n=4) RAM+DOC (N=628) RAM+DOC (N=627) * wt 33% mutant 2.4% unknown 64% PL+DOC (N=625) PL+DOC (N=618) * wt 31.5% mutant 2.9% unknown 65% Patients not receiving treatment (n=4) Reasons for discontinuation (N=613) PD 341 Adverse event 94 Subject decision 90 Investigator decision 37 Death due to adverse events 30 Death from study disease 12 Other 9 On treatment at data cutoff N=11 Safety Population N=1245 Reasons for discontinuation (N=611) PD 429 Adverse event 55 Subject decision 53 Investigator decision 19 Death due to adverse events 31 Death from study disease 14 Other 10 On treatment at data cutoff N=10 *Three PL+DOC arm patients were inadvertently treated with RAM and are therefore considered part of the RAM+DOC arm for the safety analyses, but the PL+DOC arm for the ITT efficacy analysis.

Forest plot PFS UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

SQUAMOUS Carcinoma: rooms for improvements

New treatment opportunities

When number of new strategies make the difference

Previous ESMO Guidelines

Is there a room for targeted therapies (WITHOUT target) in SQUAMOUS carcinoma SC10.04: Second-Line Therapy and Beyond in Squamous Cell NSCLC - Silvia Novello

Lux Lung 8: Study design Stratified by East Asian vs. Non-East Asian SCC of the lung (Stage IIIB/IV) 1 Progressed after 4 cycles of a first-line platinum doublet ECOG PS 0 1 Adequate organ function 1:1 Afatinib 40 mg QD Erlotinib 150 mg QD Primary Endpoint: PFS by Independent Review Key secondary Endpoint: Overall Survival Other secondary Endpoints: ORR, DCR, tumor shrinkage, PRO, safety Dose escalaoon to 50 mg and dose reducoon to 30 or 20 mg permiped Dose reduction to 100 or 50 mg permitted Tumor assessment at baseline, Weeks 8, 12, 16; every 8 weeks thereafter. 1. American Joint Committee on Cancer staging manual 7th edition SoriaJC et al, ASCO 2015

UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Events, % LUX LUNG 8: Safety Afatinib (N=392) Afatinib (n=392) Erlotinib (n=395) Any AE 99.5 97.5 Drug-related AEs 93.4 81.3 AEs leading to dose reduction 26.5 14.2 AEs leading to discontinuations 20.2 17.0 CTCAE grade 3 or higher 57.1 57.4 Serious AEs 44.1 44.1 Drug-related fatal AEs 1.5 1.3 Erlotinib (N=395) AE category, % All Grade 3 Grade 4 All Grade 3 Grade 4 Total with related AEs 93 25 1 81 16 1 Diarrhea 70 10 1 33 2 <1 Rash/acne* 67 6 0 67 10 0 Stomatitis* 29 4 0 9 0 0 Fatigue* 15 2 0 12 2 0 Nausea 13 1 0 7 1 0 Decreased appetite 13 1 0 10 1 0 Paronychia* 11 1 0 4 <1 0 Dry skin 9 1 0 10 0 0 Pruritus 8 <1 0 12 0 0 Vomiting 8 1 0 3 1 0 Dehydration 4 1 1 1 1 0 GossGD IASLC Geneva 2015; SoriaJC et al, ASCO 2015

LUX LUNG 8: Efficacy OS Forest plot PFS PFS SC10.04: Second-Line Therapy and Beyond in Squamous Cell NSCLC - Silvia Novello SoriaJC et al, Lancet Oncol2015

For Patients and Caregivers -A 60-page booklet in English, designed as an information guide for patients with SqCLC -The most frequent key questions from a patient with SqCLC

ADENOCarcinoma ( non-squamous ): rooms for improvements UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

LUME-Lung 1 Study Design Stage IIIB/IV or recurrent NSCLC patients after 1 st line chemotherapy (all histologies) R A N D O M I Z E 1:1 Nintedanib 200mg BID p.o., D2 21, + Docetaxel 75mg/m 2 IV, D1, 21-day cycles (n=655) Placebo BID p.o., D2 21, + Docetaxel 75mg/m 2 IV, D1, 21-day cycles (n=659) PD PD N=1314 Number of docetaxel cycles not restricted Monotherapy allowed after 4 cycles of combination therapy Stratification: ECOG PS (0 vs 1) Prior bevacizumab (yes vs no) Histology (squamous vs nonsquamous) Brain metastases (yes vs no) Primary end point: PFS Next analysis step only allowed if PFS confirmed with all PFS events at time point of OS analysis RECK LBA8011, ASCO 2013

LUME1: PFS TOTAL population ADENOCARCINOMA SQUAMOUS CARCINOMA ReckM et al, Lancet Oncol2014 UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

LUME1: OS Adenocarcinoma <9mo ADENOCARCINOMA Total population ReckM et al, Lancet Oncol2014 UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

LUME1: Safety ReckM et al, Lancet Oncol2014 UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

Forest plot PFS UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY

Take Home Messages UNIVERSITY OF TORINO DEPARTMENT OF ONCOLOGY Chemotherapy is still present in second line NSCLC advanced patients Antiangiogenic compound found a second youth in second line Immunotherapy plays a relevant role in this setting.at least when it has no role in first line Today, even more than yesterday, is crucial to design a treatment algorithm for patients with advanced NSCLC not to waste therapeutic opportunities