The Immunotherapy of Oncology - PDF Free Download

The Immunotherapy of Oncology The 30-year Overnight Success Story M Avery, BIOtech Now 2014

Disclosures: Geoffrey R. Weiss, M.D. None

The History A. Chekov: It has long been noted that the growth of malignant tumors halts for a time when this disease [erysipelas] is present. Coley s Toxins: Strep pyogenes, Serr marcescens. BCG for superficial bladder cancer. Coley WB, AmJMedSci, 1893 Lamm DL, NEJM, 1991

Interleukin-2/LAK Cells NCI Surgery Branch # Patients Cancer Total Responses Melanoma 7 4 Colorectal 9 3 Sarcoma 4 0 Renal Cell 3 3 Lung 1 1 Esophagus 1 0 Total 25 11 (44%) Rosenberg et al., NEJM, 1985

IL-2/LAK Clinical Protocol week 1 2 3 4 L A K High-dose IL-2 600,000 IU/kg Q8hr x 14 doses Lymphocytapheresis Tumor measurements at Week 6 and 12 then every 12 weeks Repeat Q12 weeks Max 3 cycles

High-Dose Interleukin-2 in Renal Cell Carcinoma 255 metastatic RCC patients. 7 clinical trials of high-dose IL-2 alone. 15% overall response in metastatic RCC. Median duration of response: 54 months (3-131+ mos). Interleukin-2 FDA-approved for metastatic RCC in 1992.

High-Dose Interleukin-2 in Metastatic Malignant Melanoma 270 MM patients treated with high-dose interleukin-2 in 8 clinical trials 16% overall response rate in metastatic MM: 24 without progression at 1 year 10 CRs > 3-8 years Interleukin-2 FDA-approved 1998 for MMM

Sipuleucel-T for Advanced Prostate Cancer

Sipuleucel-T for Advanced Prostate Cancer 512 pts. Leukapheresis Wks 0, 2, 4 PMCs (APCs)+ PA2024 PMCs (APCs) Placebo Infusion 341 pts Infusion 171 pts PA2024=PAP/GMCSF Fusion Product Kantoff P et al. 2010 ASCO GU Kantoff P et al. NEJM 2010

Sipuleucel-T for Advanced Prostate Cancer

CTLA-4 BLOCKADE MELANOMA

Ipilimumab vs. Ipi/gp100 vs. gp100 In Metastatic Melanoma Phase III Trial 2 nd Line Therapy 676 patients: Stages III-IV Melanoma Category Med OS ORR 2-year Surv Ipilimumab 10.1 mos 10.9% Ipilimumab + gp100 Hodi FS et al, NEJM 2010 10.0 mos 5.7% 24% gp100 6.4 mos 1.5% 14% HR 0.68 P < 0.003

Hodi FS et al. N Engl J Med 2010; 363:711-723.

Ipilimumab plus Dacarbazine for Metastatic Melanoma Randomized phase III trial ipilimumab 10 mg/kg iv q3wks x 4 dacarbazine 850 mg/m 2 iv q3wks x 4 Untreated MMM Primary endpoint: OS placebo dacarbazine 850 mg/m 2 iv q3wks x 4 dacarbazine given alone weeks 13-22 Robert C, NEJM 2011

Dacarbazine + Ipilimumab Overall Survival, Robert C et al. N Engl J Med 2011;364:2517-2526.

Dacarbazine + Ipilimumab Overall Survival study. Michele Maio et al. JCO 2015;33:1191-1196

Tremilimumab in Metastatic Melanoma 655 Pts No prior Rx Tremilimumab, 15 mg/kg Chemo (Physician Choice) Endpoint Tremilimumab Chemo Med OS 12.6 mos 10.7 mos HR for Death 0.88 P=0.127 Ribas A et al. J Clin Oncol 2013

Immune Checkpoint Inhibitors Nivolumab and Pembrolizumab Nivolumab: Fully human IgG4 antibody, blocks ligand activation of PD-1 receptor. Pembrolizumab: Humanized IgG4 antibody, blocks ligand activation of PD-1 receptor.

Nivolumab in Cancer Treatment Phase I trial. Advanced melanoma, NSCLC, renal cell cancer, CR prostate cancer, colorectal cancer. Nivolumab: 1 mg/kg; 3 mg/kg; 10 mg/kg; i.v, Q2wks. 5 expansion cohorts for each disease. IHC for tumor PDL-1 expression. Topalian SL et al. NEJM 2012.

Nivolumab in Cancer Treatment 296 patients. No maximum tolerated dose defined. 3 deaths from pulmonary toxicity. Responses NSCLC Melanoma Renal cell 18% (14/76) 28% (26/94) 27% (9/33) Topalian SL et al. NEJM 2012.

Nivolumab in Cancer Treatment 20/31 responses exceeded 1 year s duration. None of PDL-1 negative tumors had response. 9 of 25 PDL-1 positive tumors had response. Dominant toxicities: Diarrhea (11%), Rash (12%), Pruritis (9%). Topalian SL et al. NEJM 2012.

PD-1/PDL-1 BLOCKADE MELANOMA

Nivolumab vs. DTIC in Metastatic Melanoma Phase III as 1 st Line Therapy No prior Rx, BRAF negative 418 Pts Nivo, 3 mg/kg, iv, Q2wks + Placebo DTIC, 1000 mg/m 2, iv, Q3wks + Placebo Robert C et al. NEJM, 2014

Nivolumab vs. DTIC in Metastatic Melanoma Category Nivo DTIC OS 1 Yr 72.9% 42.1% Med PFS 5.1 mos 2.2 mos ORR 40% 13.9% HR for Death 0.42 P<0.001 Robert C et al. NEJM, 2014

Pembrolizumab in Melanoma KEYNOTE-001 Phase I-II trial with expansion cohort in melanoma. Objectives: assess safety and antitumor activity. 135 patients treated: 1) prior ipilimumab, or 2) < 2 prior regimens for advanced disease. Pembrolizumab administered i.v. over 30 minutes. Cohort 10 mg/kg Q2 wks 10 mg/kg Q3 wks 2 mg/kg Q 3 wks No prior Ipi 42 24 22 Prior Ipi 16 32 --

Pembrolizumab in Melanoma KEYNOTE-001 Safety 135 patients at least 1 dose pembrolizumab. Common symptoms: fatigue, myalgia, headache, fever. 2% serious/life-threatening toxicity. Autoimmune reactions Vitiligo 9% Hypothyroidism 8% Pneumonitis 4% Hamid O, NEJM, 2013

Pembrolizumab in Melanoma KEYNOTE-001 % Response (# patients) Cohort 10 mg/kg Q 2 wks 10 mg/kg Q 3 wks 2 mg/kg Q 3 wks Total No prior ipi 49 % (19) 26% (5) 25% (5) 38% (44) Prior ipi 62% (8) 27% (7) -- Among 135 patients treated, median PFS = 36 weeks. Duration of response 1.9 10.8 + mos. One-year overall survival 81%. Hamid O, NEJM, 2013

KEYNOTE-006 Pembrolizumab vs. Ipilimumab Pembro, 10 mg/kg, iv Q 2 weeks 834 pts Pembro, 10 mg/kg, iv Q 3 weeks St III-IV Unresect. Ipilimumab, 3 mg/kg, iv Q 3 wks x 4 < 1 prior Rx

KEYNOTE-006 Pembrolizumab vs. Ipilimumab The study was closed early due to achievement of PFS and OS endpoints. Results to be presented at AACR Annual Meeting 2015 (April 18-22, 2015).

BMS-936559 Anti-PDL-1 in Metastatic Melanoma Phase I, > 2nd Line 55 Melanoma pts subset 0.3-10 mg/kg, iv, Q2wks, up to 96 weeks. ORR (all doses): 17% Additional 27% SD > 24 weeks. Brahmer JR, NEJM, 2012.

BMS-936559 Anti-PDL-1 in Metastatic Melanoma Brahmer JR et al. NEJM, 2012

MPDL-3280A Anti-PDL-1 in Metastatic Melanoma Phase 1, no prior checkpoint-inhibitor 45 Melanoma pts subset. 0.01-20 mg/kg, Q3wks, iv. ORR, 26% for cohorts > 1 mg/kg. Responses observed in tumors and TIL expressing high levels PDL-1. Herbst RS et al. Nature, 2014

MPDL-3280A Anti-PDL-1 in Metastatic Melanoma

Predictive Biomarkers Ipilimumab activity Increased abs. lymphocyte count. Expression of inducible T-cell costimulator (ICOS). Tumor microenvironment inflammatory genes. Circulating immunosuppressive myeloid-derived suppressor cells. Maintenance of high clonotypes of TCRb chains.

Predictive Biomarkers PD-1/PDL-1 blockade activity Tumor PDL-1 expression: mixed results. Intrapatient tumor heterogeneity of IHC staining. Tumor vs. immune cell expression. High baseline CD8 cell densities at tumor margin.

LUNG CANCER

Nivolumab Phase II Trial in Metastatic Squamous Lung Cancer CHECKMATE-063 117 patients with metastatic squamous NSCLC. Failed prior Pt-based regimen and > 1 additional regimen. Nivolumab, 3 mg/kg, i.v., Q2wks. Primary endpoint: Objective response rate. Rizvi NA, Lancet Oncol, March 2015

Nivolumab Phase II Trial in Metastatic Squamous Lung Cancer CHECKMATE- 063 ORR: 14.5% (17/117; 95% CI: 8.7-22.2%). CR/PR/SD: 40.5% 13/17 responses ongoing. Med Time to Resp: 3.3 mos Med Duration of Resp: not reached. 2 deaths: Pneumonia, Ischemic stroke. Rizvi NA, Lancet Oncol, March 2015

Nivolumab vs. Docetaxel in Advanced Squamous Lung Cancer: CHECKMATE-017 272 patients 1 Pt doublet Nivolumab, 3 mg/kg, i.v Q2wks Docetaxel, 75 mg/m 2, i.v. Q3wks

Nivolumab vs. Docetaxel in Advanced Squamous Lung Cancer: CHECKMATE-017 Category Nivolumab (n=135) Docetaxel (n=137) Med OS (95% CI) 9.2 mos (7.3-13.3) 6.0 mos (5.1-7.3) P=0.00025 HR 0.59 (0.44-0.79)

RENAL CELL CARCINOMA

Randomized Phase II Trial of Nivolumab in Renal Cell Carcinoma Blinded, randomized, multicenter trial. mrcc with clear cell component. Measurable disease At least 1 prior treatment with anti-angiogenic Rx No CNS metastases, autoimmune disease, prior immune checkpoint Rx, or >3 prior Rxs. 1 o endpoint: dose-related PFS Motzer RJ et al., JCO, Dec 2014.

Randomized Phase II Trial of Nivolumab in Renal Cell Carcinoma Nivolumab, 0.3 mg/kg, i.v., Q3weeks 168 pts Nivolumab, 2 mg/kg, i.v., Q3weeks Nivolumab, 10 mg/kg, i.v., Q3weeks

Randomized Phase II Trial of Nivolumab in Renal Cell Carcinoma Category 0.3 mg/kg 2 mg/kg 10 mg/kg mpfs (80% CI) 2.7 mos (1.9-3.0) 4.0 mos (2.8-4.2) 4.2 mos (2.8-5.5) ORR 12 (20%) 12 (22%) 11 (20%) mos (80% CI) 18.2 mos (16-24) 25.5 mos (20-29) 24.7 mos (15-26)

(A) Progression-free and (B) overall survival by treatment arm (randomly assigned patients). Robert J. Motzer et al. JCO doi:10.1200/jco.2014.59.0703 2014 by American Society of Clinical Oncology

Phase I nivolumab/ipilimumab in metastatic renal cell carcinoma Nivolumab, 3 mg/kg Ipilimumab, 1 mg/kg i.v. Q3wks x 4 44 mrcc patients untreated or prior Rx Nivolumab, 3 mg/kg Ipilimumab, 1 mg/kg i.v. Q3wks x 4 Both arms continue nivolumab Q2wks Hammers HJ, 2014 ASCO Annual Meeting Abstracts.

Phase I nivolumab/ipilimumab in metastatic renal cell carcinoma Category Arm N3 + I1 n=21 Arm N1 + I3 n=23 ORR, n (%) 6 (29) 9 (39) SD, n (%) [duration, wks] 7 (33) [6+ to 25+] 9 (39) [6+to 26.1] DOR, range (wks) 4.1+ 22.1+ 6.1+ 18.3+ PFS, range (wks) 4.7+ 28.1+ 4.3+ 26.1+

LYMPHOMA

Immune Checkpoint Inhibition in Hodgkins Lymphoma chl has a small number of Reed Sternberg (RS) cells on background of extensive but ineffective inflammatory/immune response cells RS cells often have 9p24.1 structural mutations increased gene dosage of PD-1 ligands In EBV+ chl, viral infection also increases expression of PD-1 ligands

PD-1 Blockade with Nivolumab in R/R HL Armand et al, abstract #289, ASH 2014; Ansell et al, NEJM Dec. 2014 Phase I multicenter study R/R HL, prior Rx with brentuximab 78% s/p prior ASCT Dose: 3 mg/kg q2wk until CR, PD or toxicity Response: 20/23 (87%), CR in 17%, 3 SD 6 pts SCT PFS at 24 weeks = 86% 2 pts d/c Rx: MDS, pancreatitis Toxicity: rash 20%, thrombocytopenia 17%

Response in Tumor Burden of HL Patients Receiving Nivolumab Ansell SM et al. N Engl J Med 2014.

Pembrolizumab in chl failing brentuximab C Moskowitz et al, abstract #290, ASH 2014 Phase Ib multicenter trial R/R chl, no prior autoimmune or interstitial lung disease Pembro 10 mg/kg IV q2wk Preliminary report of 15 pts evaluated at week 12

Pembrolizumab in chl Failing Brentuximab C Moskowitz et al, abstract #290, ASH 2014 Median 4 prior Rx s, 67% prior ASCT 1 pt d/c Rx due to toxicity (pneumonitis) Grade 1-2 resp events in 20%, thyroid disorders in 20% ORR @ week 12 = 53%: 3 CR, 5 PR PD in 4 pts, toxicity or 2 years of therapy Conclusion: clinical benefit in pretreated chl

Nivolumab in lymphoid malignancies AM Lesokhin et al, abstract #291, ASH 2014 Phase I multicenter study, pre-planned interim analysis Heavily pretreated pts, including ASCT 3 mg/kg q2wks x 2 yrs, or PD/ toxicity Correlatives: anti-tumor activity and expression of immunomodulatory proteins

Nivolumab in lymphoid malignancies AM Lesokhin et al, abstract #291, ASH 2014 Tumor n CR PR SD % PFS 24 wks DLBCL 11 1 3 3 24 FL 10 1 3 6 68 MF 13 0 2 9 39 MM 27 0 0 18 15 PTCL/ other T 10 0 2 1 30 Toxicity: pneumonitis 11%, 1 death Very few pts with 9p alteration or PD-L1 expression PD-L1 is expressed in FL microenvironment by stroma

The Immunotherapy Timeline Interferona2b 1995 BCG 1970 IL-2 1992 Ipilimumab 2011 Nivolumab 2015 Pembrolizumab 2014

Ipilimumab plus Nivolumab Phase I trial in advanced melanoma. 2-Part study: Concurrent study-no prior ipilimumab. Sequential study- > 3 prior doses of ipilimumab. Endpoints: Safety and efficacy. Wolchok JD, NEJM, 2013

Concurrent Ipilimumab and Nivolumab Cohort Nivolumab (mg/kg) Ipilimumab (mg/kg) 1 0.3 3 2 1 3 2a 3 1 3 3 3 4 10 3 5 10 10 Nivolumab/Ipilimumab i.v every 3 weeks x 4, then nivolumab alone, i.v., every 3 weeks up to 4 doses. Wolchok JD, NEJM, 2013

Concurrent Ipilimumab and Nivolumab Safety 53 patients treated. Cohort 3 (Niv 3/Ipi 3) exceeded acceptable toxicity. Cohort 2 (Niv 1/Ipi 3) = MTD. Serious/life-threatening toxicity in 49% of all patients. Hepatotoxicity 15% Diarrhea/colitis 9% Acute renal insufficiency 6% Wolchok JD, NEJM, 2013

Concurrent Ipilimumab and Nivolumab Niv/Ipi Dose (mg/kg) % Response Rate (#) % > 80 Reduction at 12 weeks (#) Responses ongoing in 19 of 21 patients at 6.1-72.1+ weeks. Wolchok JD, NEJM, 2013

Wolchok JD et al, NEJM, 2013

Sequential Nivolumab and Ipilimumab 33 patients, metastatic melanoma, > 3 prior doses ipilimumab. Cohorts 6 & 7 treated with nivolumab i.v. every 2 weeks up to 48 doses. Cohort Dose (mg/kg) 6 1 7 3 Hodi FS et al. ASCO Annual Meeting Abstract 2013

Sequential Ipilimumab and Nivolumab Safety 33 patients treated. Serious/life-threatening toxicity in 18% of all patients. Lipase elevation 6% Endocrine events 6% Three patients discontinued treatment due to toxicity. Hodi FS et al. ASCO Annual Meeting Abstract 2013

Sequential Nivolumab and Ipilimumab Nivolumab dose (mg/kg) % Response Rate (#) % > 80 Reduction at 8 weeks (#) Some patients who did not respond to prior ipilimumab did respond to nivolumab. Hodi FS et al. ASCO Annual Meeting Abstract 2013