The Emerging Role of Immunotherapy in Cancer Care Renato V. La Rocca, MD, FACP Norton Cancer Institute Louisville, Kentucky

The Emerging Role of Immunotherapy in Cancer Care 2015 Renato V. La Rocca, MD, FACP Norton Cancer Institute Louisville, Kentucky

Renato V. La Rocca, MD, FACP I have no conflicts to disclose with respect to this presentation

The Emerging Role of Immunotherapy in Cancer Care 2015 Learning Objectives: 1. Discuss the emerging role of immunotherapy in cancer care 2. Describe two new targeted therapies for cancer approved in the last 24 months 3. Define the terms prognostic marker and predictive marker

Improved Survival Remains a Challenge in Some Advanced Cancers 5-year Survival in Advanced Cancers (%) 1 5-year survival remains poor for many patients with advanced metastatic solid tumors 1 In the United States, it is estimated that 2 : A total of 589,430 deaths due to cancer will occur in 2015 Lung 4.0 Melanoma 16.1 Colorectal 12.9 Kidney and Renal Pelvis 12.1 Bladder 5.5 There is an ongoing need for new treatments and therapeutic modalities for patients with advanced cancers 3 1. Surveillance, Epidemiology and End Results (SEER) Program. Available at: http://seer.cancer.gov. Accessed March 26, 2015. 2. Siegel RL et al. CA Cancer J Clin. 2015;65(1):5-29. 3. Rosenberg SA. Sci Transl Med. 2012;4(127ps8):1-5.

Hallmarks of cancer As normal cells progressively evolve to a neoplastic state, they can acquire a succession of hallmark capabilities 1 : Resisting cell death Inducing angiogenesis Activating invasion and metastasis Enabling replicative immortality 8 hallmarks of cancer 1 Sustaining proliferative signaling Deregulating cellular energetics* Evading growth suppressors Avoiding immune destruction* *Emerging hallmarks For Immuno-Oncology therapies (I-O therapies) to work, they generally incorporate an understanding of the mechanisms of tumor escape. 2,3 I-O therapies seek to modulate the immune system to promote antitumor activity, and counteract this hallmark. 4 1. Hanahan D, Weinberg RA. Cell. 2011; 144(5) 646-674. 2. Pardoll DM. Nat Rev Cancer. 2012;12:252-264 5 3. Kirkwood JM, et al. CA Cancer J Clin. 2012; 62:309-335 4. Mellman I, et al. Nature. 2011;480:480-489

Immuno oncology Is an Evolving Cancer Treatment Modality Immuno oncology is a fundamentally different approach to fighting cancer that harnesses the body s own immune system 1 Chemotherapy/ Targeted therapy Radiation Surgery Immuno-Oncology Through I-O research, therapies are being investigated in an attempt to utilize the body's own immune system to fight cancer 1-3 1. Murphy JF. Oncology. 2010;4:67-80. 2. Kirkwood JM et al. CA Cancer J Clin. 2012;62(5):309-335. 3. Borghaei H et al. Eur J Pharmacol. 2009;625(1-3):41-54.

Components of the immune system Tumorassociated antigens are abnormal cell substances/proteins (tumor antigens) which can be recognized and responded to by the immune system 1 Antigen-presenting cells take up antigens from infected or malignant cells and processes them into shorter peptide segments 2 present antigen to T cells to mobilize an immune response 2 T cells 1 have T-cell receptors, which can recognize tumor-associated antigens play a major role in killing infected or malignant cells when activated help perpetuate ongoing immune responses 1. Pardoll DM. Nat Rev Cancer. 2012;12:252-264 2. Janeway CA, et al. Immunobiology: The Immune System in Health and Disease. 6th ed. New York, NY: Garland Science; 2004

Components of the immune system B cells 1 Antibodies NK cells 1 display B-cell receptors, which can bind free floating antigens in the blood or lymph once activated, B cells differentiate to become plasma cells which can secrete large quantities of antibodies against a specific antigen 1 are secreted by activated B cells, called plasma cells 1 tag antigen-containing cells for attack by other parts of the immune system, or neutralize their targets directly by blocking important mechanisms 1 1. Janeway CA, et al. Immunobiology: The Immune System in Health and Disease. 6th ed. New York, NY: Garland Science; 2004 can recognize infected or malignant cells innately without contact with an antigenpresenting cell or antibody (this allows NK cells to launch rapid responses against stressed cells) can also attack based on recognition of antibodies on a cell surface

Immune system pathways Under normal conditions, there are a number of immune activation and inhibition pathways that modulate the immune response and protect healthy tissues from collateral damage during an immune response. 1,7 Tumor evasion of the immune system may be associated with an imbalance in immune activation and inhibition. 1-5 IMMUNE SYSTEM PATHWAYS Tumors may down-regulate co-stimulatory pathways. 2-3 Co-stimulatory receptors include: CD28 CD40 OX40 CD137 Tumors may up-regulate immune checkpoints (inhibitory signaling pathways). 2,3,5,6 Checkpoint pathway molecules include: LAG-3 CTLA-4 B7-H3 PD-1 1. Baruah P, et al. Immunobiology. 2012;217(7):669-675 2. Hemon P, et al. J Immunol. 2011,186:5173-5183 3. Pardoll DM. Nat Rev Cancer. 2012;12:252-264 4. Kirkwood JM, et al. CA Cancer J Clin. 2012;62:309-335 5. Zang X, et al. PNAS. 2007;104(49):19458-19463 6. Leitner J. Eur J Immunol. 2009;39:1754-1764. 7. Janeway CA, et al. Immunobiology: The Immune System in Health and Disease. 6 th ed. New York, NY: Garland Science; 2004 9

Immuno-Oncology: Immune System Activating Pathways Natural Killer Cell T Cell CD40L CD137 CD137 SLAMF7 CD28 OX40 Activating pathways enable cytotoxic activity by binding to receptors or ligands on APCs; they can also be expressed or preferentially upregulated by tumor cells 1-4 Several activating receptors are thought to be involved in regulating NK Cell activity, including CD137 and SLAMF7 1,2 T-cell activity may be regulated by pathways, including CD40, CD137, CD28, and OX40 3,4 APC, antigen-presenting cell; NK, natural killer. 1. Long EO et al. Annu Rev Immunol. 2013;13:227 258. 2. Benson DM Jr et al. J Clin Oncol. 2012;30:2013-2015. 3. Pardoll DM. Nat Rev Cancer. 2012;12(4):252-264. 4. Kirkwood JM, et al. CA Cancer J Clin. 2012;62(5):309-335. 10

Immuno-Oncology: Immune System Inhibitory Pathways Natural Killer Cell T Cell LAG-3 KIR CTLA-4 B7-H3 receptor* PD-1 Tumors may enhance inhibitory pathways to block NK cell and T-cell activation 1-3 Several inhibitory receptors are thought to be involved in regulating NK cell activity, including inhibitory KIRs 2,3 T-cell activity may be negatively regulated by pathways including LAG-3, CTLA-4, B7-H3, and PD-1 2 *Defined receptors are not yet known and precise mechanism of T-cell inhibition by B7-H3 is currently unknown. KIR, killer-cell immunoglobulin-like receptor; NK, natural killer. 1. Long EO et al. Annu Rev Immunol. 2013;31:227-258. 2. Pardoll DM. Nat Rev Cancer. 2012;12(4):252-264. 3. Kirkwood JM et al. CA Cancer J Clin. 2012;62(5):309-335. 11

Immune Surveillance: Identification and Elimination of Cancer Cells by the Immune System 1-5 Priming/ T-cell activation Antibody production Priming APC activation NK cell trafficking & tumor killing Antigen release Activated T-cell migration to tumor and tumor killing Tumor cells APC, antigen-presenting cell; NK, natural killer. 1. Abbas AK et al. Cellular and Molecular Immunology. 7th ed. Philadelphia, PA: Elsevier Saunders;2012. 2. Mellman I et al. Nature. 2011;480:480-489. 3. Boudreau JE et al. Mol Ther. 2011;19(5):841-853. 4. Janeway CA Jr et al. Immunobiology: The Immune System in Health and Disease. 5th ed. New York, NY: Garland Science; 2001. 5. Pardoll DM. Nat Rev Cancer. 2012;12:252-264. 12

B Cell Mediated Cytotoxicity B cells 1 Immune cells that bind free-floating antigens in the blood or lymph through B-cell receptors Activated B cells Once activated, B cells differentiate to become plasma cells, which can secrete large quantities of antibodies against a specific antigen 1 Mature B cell Tumorassociated antigens Tumor cells NK cells Natural Killer cells 1,2 Cytotoxic lymphocytes that attack infected or malignant cells based on recognition of antibodies on a cell surface Apoptotic tumor cell NK, natural killer. 1. Janeway CA Jr et al. Immunobiology: The Immune System in Health and Disease. 5th ed. New York, NY: Garland Science; 2001. 2. Vesely MD et al. Annu Rev Immunol. 2011;29:235-271. 13

T Cell Mediated Cytotoxicity Antigen-presenting cells 1,2 Take up antigens from infected or malignant cells and process them into shorter peptide segments APC Inactive T cell Activated T cells T cells 1,2 APCs present antigens to naïve T cells, which can recognize tumor-associated antigens Together with a second, positive co-stimulation signal, T cells become activated Tumorassociated antigens Tumor cells Apoptotic tumor cell and play a major role in killing infected or malignant cells when activated APC, antigen-presenting cell. 1. Mellman I et al. Nature. 2011;480(7378):480-489. 2. Boudreau JE et al. Mol Ther. 2011;19(5):841-853. 14

Immune Evasion in the Tumor Microenvironment The tumor microenvironment, a network of cells and structures that surround a tumor, creates conditions that may foster tumor growth and immune evasion 1,2 Immune cell activity is regulated by multiple activation and inhibition pathways that modulate the duration and level of the immune response 2 Tumors may target these pathways to alter the immune system s response to cancer cells, resulting in tumor evasion of the immune system 3 APC Active T cell Tumorassociated antigens Tumor cells APC, antigen-presenting cell. 1. Gajewski TF et al. Nat Immunol. 2013;14(10):1014-1022. 2. Pardoll DM. Nat Rev Cancer. 2012;12(4):252-264. 3. Vesely MD et al. Annu Rev Immunol. 2011;29:235-271. Inactive T cell 15

Immunotherapies Encompass a Wide Variety of Classes Immunotherapy 1,2 Passive (Designed to act on the tumor) Active (Designed to act on the immune system itself) Antitumor mabs Adoptive Cytokines Therapeutic cancer vaccines I-O therapies Tumor-directed mabs Cell therapies Interleukins Interferons Cell-based Single antigen/ peptide-based Immune effector cell modulators Checkpoint inhibitors Co-stimulatory agonists I-O, immuno-oncology; mab, monoclonal antibody. 1. Finn OJ. Ann Oncol. 2012;23(suppl 8 ):viii6-viii9. 2. Mellman I et al. Nature. 2011;480:480-489. 13

Immunotherapy Agents Interleukin 2 cytokines Has pleiotophic effects on both cytotoxic T cell function as well as Treg cell maintenance High dose promotes CD8+ effector T cell and natural killer (NK) cytolytic activity and promotes differentiationof CD4+ cells into T helper subclasses Lower Dose preferentially expands Treg populations and inhibits the formation of Th17 cells implicated in autoimmunity

Immunotherapy Agents cytokines Interleukin 2 (cont.): High dose achieved durable responses in a small percentage of patients with metastatic renal cell carcinoma and melanoma First example of an immunotherapy that could eliminate cancer cells

Immunotherapy Agents cytokines Interferon alpha 2B: Promotes TH-1-mediated effector cell responses such as IL-12 secretion Used in the past as an adjuvant treatment for high risk melanoma -? impact on long term survival

Immunotherapy Agents cytokines Lenalidomide and Pomalidomide: Mediate an antitumor effect largely via the cereblon-mediated destruction of Ikaros-family proteins which in turn inhibit IL-2 secretion Prolong survival in multiple myeloma

Known molecules involved in inhibition LAG-3 (aka CD223) is an immune checkpoint molecule. 1 It can inhibit T-cell activity and serve as a modulator of T-cell activation. 1,2 APC MHC LAG-3 - - - Inactive T cell CTLA-4 is an immune checkpoint receptor that plays a key role in modulating T-cell function. 1,3 Interaction of CTLA-4 on T cells with its ligand CD80 (aka B7-1) and CD86 on APCs leads to T-cell inhibition. 1,3 IMMUNE SYSTEM PATHWAYS: INHIBITION APC CD80 or CD86 ligand Inactive T cell CTLA-4 receptor --- 1. Pardoll DM. Nat Rev Cancer. 2012;11:252-264 2. Workman CJ and Vignali DAA. Eur. J Immunol. 2003;33:970-979 3. Hastings, WD et al. Eur J Immunol. 2009 September: 39(9): 2492-2501 21

Immunotherapy Agents checkpoint inhibitors CTLA 4 inhibitors: Considered a physiologic brake on CD4+ and CD8+ T cell activation Ipilimumab first check point inhibitor to be FDA approved, based on its ability to prolong survival in metastatic melanoma Also has a survival impact on high risk Stage 3 melanoma

Known molecules involved in inhibition B7-H3 (a member of the B7 family) is thought to be an immune checkpoint pathway. 1 It may inhibit the T-cell response beyond CD80/CD86 T-cell response. 2 Precise mechanism is under investigation. APC - - - B7-H3??? Inactive T cell PD-1 is an immune checkpoint receptor that inhibits the T-cell response and plays a key role in modulating T-cell function. 1 IMMUNE SYSTEM PATHWAYS: INHIBITION T cell Tumor cell - - - PD-1 PD-L1 or PD-L2 1. Pardoll DM. Nat Rev Cancer. 2012;11:252-264 2. Leitner J, et al. Eur J Immunol. 2009;39(7):1754-1764 23

Immunotherapy Agents checkpoint inhibitors PD-1: Expressed on the surface of multiple tissue types and many tumor cell types Its interaction with PD ligand (1 or 2): Directly inhibits apoptosis of the tumor cell Promotes T effector cell exhaustion Serves as a brake on unrestrained cytotoxic T effector cell function

Immunotherapy Agents Nivolumab (Opdivo): PD-1 inhibitors 1. Improved survival and less toxic as compared to docetaxel in chemotherapy pretreated patients with squamous nonsmall cell lung cancer (Checkmate-057-582 patients ASCO 2015 LBA 109) 2. Improved survival (9.2 versus 6 months; p= 0.00025) and less toxic as compared to docetaxel in chemotherapy pretreated patients with nonsquamous nonsmall cell lung cancer (Checkmate-017 264 patients)

Immunotherapy Agents Nivolumab (Opdivo): PD-1 inhibitors 3. Improved progression free survival (PFS) as first line monotherapy or in conjunction with ipilimumab therapy in metastatic melanoma, as compared to ipilimumab alone (Checkmate-067 945 patients)

Immunotherapy Agents PD-1 inhibitors Pembrolizumab (Keytruda): 1. Approved by the FDA in 2014 for the treatment of patients with metastatic melanoma following treatment with BRAF inhibitors and/or ipilimumab (Keynote 001 Lancet 2014;384:1109-1117) 2. Ongoing trials in nonsmall cell lung cancer

Immunotherapy Agents PD-1 inhibitors MPDL3280A (Genentech/Roche): 1. A human mab that targets PD-L1 2. It prevents binding of PD-L1 to its receptor (PD-1 and B7-1), thereby restoring T cell activity and proliferation 3. Effective and relatively safe in several early phase lung cancer trials

Immunotherapy Agents PD-1 inhibitors Tumor types in which these agents may be effective: 1. Metastatic melanoma 2. Nonsmall cell lung cancer 3. Renal cell carcinoma 4. Hodgkin s Disease 5. Hepatocellular carcinoma 6. Triple negative breast cancer 7. Ovarian cancer 8. Certain colorectal cancers

Potential Patterns of Response to I-O Therapy Therapies that affect the immune system may not induce a measurable impact on tumor growth immediately after administration. Potential effects may be seen weeks to months after initial administration. The potential patterns of response to I-O therapies that modulate T-cell activity are 1,2 : Immediate response 3 Lack of tumor shrinkage but a slowing of tumor progression 3 Early but clinically insignificant progression 3 Tumor regression after early radiographical progression that may be caused by T cells infiltrating the tumor site or appearance of new lesions upon imaging 3,4 There is also the potential that patients may not respond to therapy. I-O, immuno-oncology. 1. Hoos A et al. OncoImmunol. 2012;1:334-339. 2. Aarntzen EHJG et al. Cell Mol Life Sci. 2013;70:2237-2257. 3. Wolchok JD et al. Clin Cancer Res. 2009;15:7412-7420. 4. Ribas A et al. Clin Cancer Res. 2009;15:7116-7118. 31

Non-Conventional Response and I-O Therapy Apparent progression upon radiographic imaging after initial I-O therapy can actually be a sign of non-conventional response to I-O therapy. This response may occur when T cells infiltrate the tumor site and cause tumors to flare or appearance of new lesions upon imaging. 1,2 I-O therapy Tumor cells T cells infiltrating the tumor site Appearance of new lesions upon imaging I-O, immuno-oncology. 1. Wolchok JD et al. Clin Cancer Res. 2009;15:7412-7420. 2. Ribas A et al. Clin Cancer Res. 2009;15:7116-7118. 32

Differentiating Disease Progression From Non-Conventional Response With I-O Therapy T-cell infiltration can cause tumors to flare or new lesions may appear upon imaging 1 Considerations that may indicate disease progression vs. non-conventional response include 1,2 : Disease Progression Non-Conventional Response Performance status Deterioration of performance Remains stable or improves Systemic symptoms Worsen May or may not improve Symptoms of tumor enlargement Tumor burden Baseline New lesions Present Increase Appear and increase in size May or may not be present Increase followed by response Appear then remain stable and/or subsequently respond Biopsy may reveal Evidence of tumor growth Evidence of T-cell infiltration I-O, immuno-oncology. 1. Wolchok JD et al. Clin Cancer Res. 2009;15(23):7412-7420. 2. Eisenhauer EA et al. Eur J Cancer. 2009;45(2):228-247. 23

Immune-Mediated Adverse Reactions Immune-mediated adverse reactions related to T-cell modulation may affect certain organ systems 1 Nervous system 2 Eyes 1,3 Skin 1,2,4 Respiratory system 1,2 Liver 2,4 Endocrine system 2,4 Gastrointestinal tract 1-4 Hematopoietic cells 5 1. Amos SM et al. Blood. 2011;118(3):499-509. 2. Chow LQ. Am Soc Clin Oncol Educ Book. 2013:280-285. 3. Robinson MR et al. J Immunother. 2004;27(6):478-479. 4. Phan GQ et al. Proc Natl Acad Sci U S A. 2003;100(14):8372-8377. 5. Lin TS et al. J Clin Oncol. 2010;28(29):4500-4506. 34

Clinical Implications of Immune-Mediated ARs Since I-O can increase immune system activity, the potential exists for toxicity against healthy tissues in addition to cancer cells 1 ARs can be serious and potentially fatal 2,3 An AR is any unfavorable medical occurrence temporally associated with the use of a medical treatment 2 Serious ARs are defined as any AR that requires hospitalization, is life-threatening, results in death, or otherwise causes persistent or significant incapacity 3 Remain vigilant throughout and after treatment 4 Educate and encourage patients to monitor for and report symptoms of immune-mediated ARs Not all immune-mediated ARs will require permanent cessation of therapy. Providing optimal care for your patients includes following management algorithms for certain immune-mediated ARs. 4 AR, adverse reaction; I-O, immuno-oncology. 1. Amos SM et al. Blood. 2011;118(3):499-509. 2. NCI. Radiation therapy for cancer. V4.0. US Department of Health and Human Services. 2010. 3. FDA. What is a serious adverse event? http://www.fda.gov/safety/medwatch/howtoreport/ucm053087.htm. Accessed January 28, 2015. 4. Gelao L et al. Toxins. 2014;6:914-933. 35

Cancer Therapy 2015 Prognostic Marker: 1) Used to classify an individual patient s risk of, or time to, cancer death and/or other disease events independent of the effects of treatment. 2) Can also be used to determine the need for further treatment Patients at very low risk of disease events can safely avoid treatment if risks of adverse events outweigh the estimated benefits. Alternatively, high-risk patients may benefit from a more aggressive treatment regimen 3) In some cases, a prognostic marker also predicts treatment response because it is also a therapeutic target (i.e, it is also a predictive marker). For example, estrogen receptor expression provides prognostic information in women with early breast cancer and RCTs have provided evidence that it predicts response to hormonal therapy

Cancer Therapy 2015 Prognostic Marker: Usually an indicator of growth, invasion and metastatic potential Examples: Weight loss Poor performance status Sites of metastases (bone, CNS, etc.) Hormone receptor positivity in breast cancer Weight loss HER 2 over expression in breast cancer

Cancer therapy 2015 Predictive Marker: 1) Used to classify response to specific treatment options; predictive markers are used to guide the selection of treatment and identify targets for the development of new molecular-targeted therapies. 2) Used to select the most appropriate treatment by identifying patients most likely to respond and avoiding treatment for patients unlikely to respond or those at unacceptably high risk of adverse events. 3) Classify patients according to their predicted response or resistance to a treatment 4) The use of predictive markers clearly has enormous clinical implications to optimize the selection of treatments to those patients most likely to respond and avoid the use of treatment in patients unlikely to respond, or those at high risk of treatment-related adverse events. 5) Non-responders may benefit from the earlier use of alternative therapies or can be identified as a population in need for the development of new treatments

Cancer therapy 2015 Predictive Marker: 1. Such markers are usually within the target of the treatment or the surrounding stroma Or 2. Serve as modulators or epiphenomena related to expression and/or function of the target Examples: Hormone receptor positivity in breast cancer HER 2 overexpression in breast cancer EGFR mutations and ALK gene rearrangements in lung cancer?pd-1 ligand expression in lung cancer

Cancer therapy 2015 Assay Development Analytical validation Assess assay performance, reproducibility, sensitivity and specificity Clinical validation Prospective-retrospective validations (investigators blinded to outcome data) Clinical utility Use of convenience samples and data subject to bias Second prospective-retrospective study Investigators again blinded to outcome) Randomized prospective trial.

Predictors of response to immune-based therapy PD-1 inhibitors: 1. PD-L1 expression efficacy of nivolumab was more significant in pretreated patients with nonsquamous nonsmall cell lung cancer (Checkmate 057). 2. PD-L1 expression was not linked with efficacy outcome in squamous nonsmall cell lung cancer (Checkmate 017) 3. PD-L1 expression in tumors correlates with response to MPDL3280A (a PD-L1 inhibitor) in the POPLAR Study (ASCO 2015, abstract 8010) 4. MMRD (mismatch repair deficiency) correlation with benefit in a phase 2 study of patients with metastatic colorectal cancer and other tumor types with MMRD (ASCO 2015, abstract LBA 100)

Cancer therapy 2015 summary PD-1 inhibitors and PD- L1 inhibitors are emerging as novel immune modulating agents for the treatment of various refractory cancers The side effects associated with these agents are autoimmune in nature (pneumonitis, hepatitis, colitis, dermatitis, thyroiditis, etc) No definitive predictive marker for PD-I inhibitors has emerged as of yet; the role of PD- L1 remains controversial

Immuno oncology Is an Evolving Cancer Treatment Modality Chemotherapy/ Targeted therapy Radiation Surgery Immuno-Oncology

The Conquest of Cancer 1. Knowledge of the molecular phenotype of the cancer 2. Knowledge of the pharmacogenomics of the patient 3. Knowledge of the angiogenic profile/status of the cancer 4. Knowledge of the immunocompetence of the patient 5. Understanding of the comorbities of the patient

The Conquest of Cancer 1. Knowledge of the molecular footprint of the tumor 1. Susceptibility to one or a combination of targeted therapies 2. Needs to be in real time and with the understanding of possible metastatic site heterogeneity

The Conquest of Cancer 2. Knowledge of the pharmacogenomics of the patient 1. Verification that the therapeutic molecule will achieve therapeutic concentrations and will be appropriately metabolized 2. Knowledge of drug/drug interactions during administration of the therapeutic agent

The Conquest of Cancer 3. Knowledge of the angiogenic profile/status of the tumors 1. Determine that in fact the appropriate targeted agent, metabolized appropriately, can effectively arrive at its target at every site

The Conquest of Cancer 4. Knowledge of the immunocompetence of the patient Some tumors co-opt the patient s immune system so as to be able to evade it A perfect vaccine may not work in every patient in light of a different level of immune competency, which in turn can be impact by: 1. Age 2. Exposure to prior immunosuppressive/immune destroying agents

The Conquest of Cancer 5. Understanding of the co-morbities of the patient The perfect treatment, in the perfect context (pharmacogenomics, etc, that arrives to target (appropriate angiogenic profile), but exacerbates two of the four comorbities that the patient has, thus not conferring a survival benefit