Patient Selection: The Search for Immunotherapy Biomarkers Mark A. Socinski, MD Executive Medical Director Florida Hospital Cancer Institute Orlando, Florida
Patient Selection Clinical smoking status Histologic Molecular - EGFR mutants Biomarkers - PD-L1 - Mutational load
Available PD-L1 Assays, Platforms, and Scoring PD-L1 Drug Nivolumab Pembrolizumab Atezolizumab Durvalumab Clone and source IVD class III partner Scoring method 28-8 Abcam 22c3 Dako SP142 Spring Bio SP263 Spring Bio Dako Dako Ventana Ventana % cells with membrane staining at any intensity % cells with membrane staining at any intensity Thresholds 1%, 5%, or 10% >1% 1% to 49% >50% Method Pathologist/ subjective Pathologist/ subjective TC = Tumor cell IC = Immune cell Combine both percentage and subjective intensity TC3 = TC>50% IC3 = IC>10% TC2/IC2 = TC or IC >5% TC1/IC1 = TC or IC >1% Pathologist/ subjective % cells with membrane staining at any intensity >25% Pathologist/ subjective
Available PD-L1 Assays, Platforms, and Scoring PD-L1 Drug Nivolumab Pembrolizumab Atezolizumab Durvalumab Clone and source IVD class III partner Scoring method 28-8 Abcam 22c3 Dako SP142 Spring Bio SP263 Spring Bio Dako Dako Ventana Ventana % cells with membrane staining at any intensity % cells with membrane staining at any intensity Thresholds 1%, 5%, or 10% >1% 1% to 49% >50% Method Pathologist/ subjective Pathologist/ subjective FDA- Approved TC = Tumor cell IC = Immune cell Combine both percentage and subjective intensity TC3 = TC>50% IC3 = IC>10% TC2/IC2 = TC or IC >5% TC1/IC1 = TC or IC >1% Pathologist/ subjective % cells with membrane staining at any intensity >25% Pathologist/ subjective
Expression of PD-L1 Is Heterogeneous and Varies With Antibody Used H&E E1L3N SP142 Negative 1 mm Positive Immunofluorescence shows stroma and epithelial staining are often concordant and adjacent Green = Cytokeratin Blue = Nuclei Red = PD-L1 (SP142) Unpublished Data: J McLaughlin, K Schalper, R. Herbst, and D Rimm (Yale Pathology).
PD-L1 Immunohistochemistry (IHC): Expression Heterogeneity and Potential for Sampling Error Biopsy Core 1 18 g needle = 800 µm Biopsy Core 2
PREVALENCE of PD-L1 Expression in NSCLC From CheckMate 017, KEYNOTE-001, and POPLAR Clinical Trials Trial/ IHC Antibody Drug Histology Cells Scored for PD-L1 Expression 1%, % (n) 5%, % (n) 10%, % (n) 50%, % (n) CheckMate 017/ Dako 28-8 Ab Nivolumab 1 Squamous Tumor 44 (119) 30 (81) 25 (69) Keynote001/ Merck 22C3 Ab Pembrolizumab 2 NSCLC Tumor 38 (310) 23 (191) POPLAR/ Spring Bioscience SP142 Ab Atezolizumab (MPDL3280A) 3 NSCLC Tumor and/or immune Cells 68 (195) 37 (105) 16 (47) 1. Brahmer J, et al. N Engl J Med. 2015;373(2):123-135. 2. Garon EB, et al. N Engl J Med. 2015;372(21):2018-2028. 3. Spira AI, et al. J Clin Oncol. 2015;33(suppl): Abstract 8010.
PD-L1 IHC Biomarker: Challenges Focal PD-L1 expression in some tumors may be missed in small biopsy specimens, such as needle biopsies PD-L1 expression among multiple tumor lesions from individual patients can vary over time and by anatomic site PD-L1 expression in tumor biopsies collected months or years earlier might not accurately reflect PD-L1 status at the time of treatment initiation; therapies given after biopsy but before administration of PD-1 pathway blockade (radiation therapy, chemotherapy, or kinase inhibitors) may alter PD-L1 expression PD-L1 epitopes detected by some antibodies are potentially unstable with prolonged specimen fixation or inadequate tissue handling before fixation (see NCI guidelines for tissue handling) Antibodies used for PD-L1 detection have different affinities and specifications PD-L1 protein expression can be membranous and/or cytoplasmic; however, only membranous PD-L1 is functionally relevant, by contacting PD-1+ T cells PD-L1 can be expressed by multiple cell types within the tumor microenvironment, which poses challenges for scoring and interpretation Topalian SL, et al. Nat Rev Cancer. 2016;16(5):275-287.
The PD-L1 Blueprint Working Group (IASLC-Industry) 39 cases x 4 assays, scored for % tumor cell and % immune cell expression of PD-L1. Three assays showed consistent pattern SP 142 labeled fewer cells 39%- discrepant results Too preliminary for definitive conclusions- ongoing project Hirsch FR, et al. Presented at: American Association of Cancer Research; April 16-20, 2016: New Orleans, Louisiana.
Analytical Evaluation Results: Mean TPS per Case Based on 3 Readers Analytical comparison of TPS by case for each assay Data points represent the mean score from 3 pathologists for each assay on each case No clinical diagnostic cutoff applied Conclusion: 3 of 4 assays are analytically similar for tumor cell staining % Tumor Staining 100 90 80 70 60 50 40 30 20 10 0 22C3 28-8 SP142 SP263 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 Cases TPS, tumor proportion score Hirsch FR, et al. Presented at: American Association of Cancer Research; April 16-20, 2016: New Orleans, Louisiana.
Agreement Between Assays for PD-L1 Expression Based on Specified Cutoffs Total cases: N = 38 Total number of cases expressing PD-L1 specified cutoff for each assay summarized in parentheses Numbers appearing in each Venn diagram segment represent the number of cases with agreement of PD-L1 expression specified cutoff between assays Cases that show agreement with all 4 assays regardless of which matched assay cutoff is employed: n = 19 (red circle) SP142 TC1/IC1 (30/38) Atezo 6 22C3 1% TPS (26/38) Pembro 0 1 0 19 0 28-8 1% TPS (26/38) Nivo 0 0 1 1 5 0 0 0 SP263 25% (20/38) Durva Hirsch FR, et al. Presented at: American Association of Cancer Research; April 16-20, 2016: New Orleans, Louisiana.
1. Garon EB, et al. J Clin Oncol. 2014;32(5s): Abstract 8020. 2. Soria J-C, et al. Eur J Cancer. 2013;49(Suppl 2): Abstract 3408. 3. Hellman MD, et al. Ann Oncol. 2014;25(suppl_4): Abstract 1229PD. Tobacco Exposure and PD-1 Response in NSCLC Chiron M, et al. Eur J Cancer. 2013;49(Suppl 2): Abstract 2201. Smokers or Ex-smokers Never Smokers Pembrolizumab 1 33/129 (26%) 5/60 (8%) MPDL3280A 2 11/43 (26%) 1/10 (10%) Nivolumab 3 20/75 (26%) 0/13 (0%) Govindan R, et al. Cell. 2012;150(6):1121-1134.
Nivolumab Randomized Trials in Second-Line (Refractory) NSCLC CheckMate 17 Squamous NSCLC Stage IIIB/IV squamous NSCLC 1 prior platinum doublet-based chemotherapy ECOG PS 0-1 N = 272 Archived or fresh tissue required for all patients Randomized 1:1 Nivolumab 3 mg/kg IV q2w until PD or unacceptable toxicity N = 135 Docetaxel 75 mg/m 2 IV q3w until PD or unacceptable toxicity N = 137 Patients stratified by region and prior paclitaxel use Endpoints Primary OS Secondary Investigator-assessed ORR Investigator-assessed PFS Correlation between PD-L1 expression and efficacy (ORR, OS, and PFS) Quality of live (LCSS) CheckMate 57 Nonsquamous NSCLC N = 582 Stage IIIB/IV nonsquamous NSCLC ECOG PS 0-1 1 prior PT-DC Prior maintenance therapy with premetrexed, bevacizumab, or erlotinib allowed Randomized 1:1 Nivolumab 3 mg/kg IV q2w until PD or unacceptable toxicity N = 292 Docetaxel 75 mg/m 2 IV q3w until PD or unacceptable toxicity N = 290 Endpoints Primary OS Secondary ORR PFS Efficacy by tumor PD- L1 expression Disease-related symptom improvement rate by week 12 ECOG, Eastern Cooperative Oncology Group; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; PS, performance status
Nivolumab in Squamous NSCLC Brahmer J, et al. N Engl J Med. 2015;373(2):123-135.
Nivolumab in Squamous NSCLC Brahmer J, et al. N Engl J Med. 2015;373(2):123-135.
Nivolumab in Nonsquamous NSCLC Brahmer J, et al. N Engl J Med. 2015;373(2):123-135.
Nivolumab: CheckMate 057 Study N Unstratified HR (95% CI) Overall 582 0.75 (0.62, 0.91) Age Categorization (years) <65 339 0.81 (0.62, 1.04) 65 and <75 200 0.63 (0.45, 0.89) 75 43 0.90 (0.43, 1.87) Gender Male 319 0.73 (0.56, 0.96) Female 263 0.78 (0.58, 1.04) Baseline ECOG PS 0 179 0.64 (0.44, 0.93) 1 402 0.80 (0.63, 1.00) Smoking Status Current/Former Smoker 458 0.70 (0.56, 0.86) Never Smoked 118 1.02 (0.64, 1.61) EGFR Mutation Status Positive 82 1.18 (0.69, 2.00) Not Detected 340 0.66 (0.51, 0.86) Not Reported 160 0.74 (0.51, 1.06) All randomized patients (nivolumab, n = 292; docetaxel, n = 290) 0.25 0.5 1.0 2.0 4.0 Nivolumab Docetaxel 3 mg/kg q2w 75 mg/m 2 q3w Patients with EGFR mutation positive NSCLC who received docetaxel had a numerical OS advantage over patients who received nivolumab No nivolumab treatment effect on OS in patients with EGFR mutation positive NSCLC (n = 82): HR = 1.18 (95% CI: 0.69, 2.00) ECOG, Eastern Cooperative Oncology Group; OS, overall survival; PS, performance status; q2w, every 2 weeks; q3w, every 3 weeks Borghaei H, et al. New Engl J Med. 2015; 373(17):1627-1639.
Nivolumab in Nonsquamous NSCLC Borghaei H, et al. N Engl J Med. 2015;373(17):1627-1639.
Pembrolizumab Biomarker Development Pembrolizumab DAKO-22c3 Ab 0 1% to 49% >50% Low High Garon EB, et al. N Engl J Med. 2015 372(21):2018-2028.
KEYNOTE-010 Randomized Study of Pembrolizumab vs Docetaxel in Patients With Previously Treated PD-L1 Positive* NSCLC Patients: Metastatic NSCLC Previously treated (progression after 2 cycles of platinum-doublet OR prior EGFR TKI in mutant) Measurable disease ECOG PS 0-1 Newly obtained formalin-fixed specimens strongly encouraged PD-L1 positive (defined as staining in 1% of tumor cells) Treated and stable CNS metastases R A N D O M I Z A T I O N 1:1:1 N = 1034 Pembrolizumab 2 mg/kg Q3W Pembrolizumab 10 mg/kg Q3W Docetaxel 75 mg/m 2 Primary endpoints: OS, PFS, safety (adverse events and drug continuations) Secondary endpoints: ORR and response duration (RECIST 1.1) *Positive defined as 1% tumor PD-L1 expression determined using a prototype IHC assay (22C3 antibody) Herbst RS, et al. Lancet. 2016;387(10027):1540-1550.
Overall Survival, PD-L1 TPS 50% Stratum Overall Survival, % 100 90 80 70 60 50 40 30 Treatment Arm Median (95% CI), months HR a (95% CI) P Pembro 2 mg/kg 14.9 (10.4-NR) 0.54 (0.38-0.77).0002 Pembro 10 mg/kg 17.3 (11.8-NR) 0.50 (0.36-0.70) <.0001 Docetaxel 8.2 (6.4-10.7) 2 mg/kg vs 10 mg/kg: HR 1.12, 95% CI 0.77-1.62 20 10 0 0 5 10 15 20 25 Time, Months 139 151 152 110 115 90 51 60 38 20 25 19 3 1 1 0 0 0 Herbst RS, et al. Lancet. 2016;387(10027):1540-1550. Analysis cut-off date: September 30, 2015 a Comparison of pembrolizumab vs docetaxel
Overall Survival, % 100 90 80 70 60 50 40 30 Overall Survival, PD-L1 TPS 1% (Total Population) Treatment Arm Median (95% CI), months Rate at 1 year HR a (95% CI) P Pembro 2 mg/kg 10.4 (9.4-11.9) 43.2% 0.71 (0.58-0.88).0008 Pembro 10 mg/kg 12.7 (10.0-17.3) 52.3% 0.61 (0.49-0.75) <.0001 Docetaxel 8.5 (7.5-9.8) 34.6% 2 mg/kg vs 10 mg/kg: HR 1.17, 95% CI 0.94-1.45 20 10 0 0 5 10 15 20 25 Time, months 344 346 343 259 255 212 115 124 79 49 56 33 12 6 1 0 0 0 Herbst RS, et al. Lancet. 2016;387(10027):1540-1550. Analysis cut-off date: September 30, 2015 a Comparison of pembrolizumab vs docetaxel
Overall Survival in Key Subgroups, PD-L1 TPS 1% a Subgroup Overall Sex Male New Histology Squamous Adenocarcinoma No. of Events/ No. of Patients 521/1033 332/634 189/399 Female Age <65 years 317/604 65 years 204/429 ECOG performance status 0 149/348 1 367/678 PD-L1 tumor proportion score 50% 204/442 1% to 49% 317/591 Tumor sample Archival EGFRstatus Mutant Wildtype 266/455 255/578 128/222 333/708 46/86 447/875 Herbst RS, et al. Lancet. 2016;387(10027):1540-1550. Hazard Ratio (95% CI) 0.1 1 10 Favors Pembrolizumab Favors Docetaxel 0.67 (0.56-0.80) 0.65 (0.52-0.81) 0.69 (0.51-0.94) 0.63 (0.50-0.79) 0.76 (0.57-1.02) 0.73 (0.52-1.02) 0.63 (0.51-0.78) 0.53 (0.40-0.70) 0.76 (0.60-0.96) 0.70 (0.54-0.89) 0.64 (0.50-0.83) 0.74 (0.50-1.09) 0.63 (0.50-0.79) 0.88 (0.45-1.70) 0.66 (0.55-0.80) Analysis cut-off date: September 30, 2015 a Data for the pembrolizumab doses were pooled
Overall Response Rate (RECIST v1.1, Central Review) PD-L1 TPS 50% Pembro 2 mg/kg n = 139 Pembro 10 mg/kg n = 151 Docetaxel n = 152 ORR, % (95% CI) 30 (23-39) P<.0001 a 29 (22-37) P<.0001 a 8 (4-13) PD-L1 TPS 1% Pembro 2 mg/kg n = 344 Pembro 10 mg/kg n = 346 Docetaxel n = 343 ORR, % (95% CI) 18 (14-22) P =.0005 a 18 (14-23) P =.0002 a 9 (6-13) Analysis cut-off date: September 30, 2015 a Comparison of pembrolizumab vs docetaxel Herbst RS, et al. Lancet. 2016;387(10027):1540-1550.
NSCLC: Overall Survival in Durvalumab-Treated Patients, by PD-L1 Status PD-L1 25% PD-L1 <25% Rizvi NA, et al. J Clin Oncol. 2015;33(suppl): Abstract 8032.
POPLAR: A Randomized, All-Comer Phase II Study Metastatic or locally advanced NSCLC (2L/3L) Disease progression on a prior platinum therapy N = 287 Stratification Factors: PD-L1 IC expression (0 vs 1 vs 3) a Histology (squamous vs nonsquamous) Prior chemotherapy regimens (1 vs 2) R 1:1 Atezolizumab 1200 mg IV q3w until loss of clinical benefit Docetaxel 75 mg/m 2 IV q3w until disease progression Primary study objective: Estimate OS in PD-L1 selected and ITT populations Secondary study objectives Evaluate PFS, ORR, and DOR in PD-L1 selected and ITT populations Evaluate safety Interim analysis is based on 153 events with a minimum follow-up of 10 months a Archival or fresh tissue required for pre-dose testing DOR, duration of response; ITT, intent to treat Spira AI, et al. J Clin Oncol 2015;33(suppl): Abstract 8010.
PD-L1 Expression on TC and IC Is a Potential Predictive Biomarker for Atezolizumab in NSCLC SP142 IHC assay is sensitive and specific for PD-L1 expression on both TC and IC Intrinsic PD-L1 expression in tumor cells (TC) Distinct TC and IC subpopulations exist at each of four cutoff levels a Gettinger SN, et al. J Clin Oncol. 2015;33(suppl): Abstract 3015. PD-L1 expression on TC and IC was independently predictive of response Horn L, et al. J Clin Oncol. 2015;33(suppl): Abstract 8029. Adaptive PD-L1 expression in tumor-infiltrating immune cells (IC) PD-L1 expression levels and TC/IC overlap in POPLAR a TC scored as percentage of tumor cells and IC scored as percentage of tumor area. TC3 or IC3 = TC 50% or IC 10% PD-L1+; TC2/3 or IC2/3 = TC or IC 5% PD-L1+; TC1/2/3 or IC1/2/3 = TC or IC 1% PD-L1+; TC0 and IC0 = TC and IC <1% PD-L1+, respectively Spira AI, et al. J Clin Oncol 2015;33(suppl): Abstract 8010.
MPDL3280 Biomarker Development TC3 or IC3 TC0 and IC0 n = M 24 D 23 M 51 D 41 OS Median, months MPDL3280A Ventana-SP142 Ab HR 95% CI NR 11.1 9.7 9.7 TC3 or IC3 0.47 0.20-1.11 n= OS 1.22 M D 0.69-2.14 24 23 TC2/3 or IC2/3 M 50 D 55 TC1/2/3 or IC1/2/3 M 93 D 102 TC0 and IC0 M 51 D 41 M 144 ITT D 143 Median, months NR 11.1 13 7.4 NR 9.1 9.7 9.7 11.4 9.5 HR 95% CI 0.47 0.20-1.11 0.56 0.33-0.95 0.63 0.42-0.95 1.22 0.69-2.14 0.78 0.59-1.03 Spira AI, et al. J Clin Oncol 2015;33(suppl): Abstract 8010.
1. Garon EB, et al. J Clin Oncol. 2014;32(5s): Abstract 8020. 2. Soria J-C, et al. Eur J Cancer. 2013;49(Suppl 2): Abstract 3408. 3. Hellman MD, et al. Ann Oncol. 2014;25(suppl_4): Abstract 1229PD. Tobacco Exposure and PD-1 Response in NSCLC Chiron M, et al. Eur J Cancer. 2013;49(Suppl 2): Abstract 2201. Smokers or Ex-smokers Never Smokers Pembrolizumab 1 33/129 (26%) 5/60 (8%) MPDL3280A 2 11/43 (26%) 1/10 (10%) Nivolumab 3 20/75 (26%) 0/13 (0%) Govindan R, et al. Cell. 2012;150(6):1121-1134.
Alexandrov LB, et al. Nature. 2013;500(7463):415-421. Mutational Burden
Mutations in Tumor (NSCLC) HR 0.23 (95% CI 0.09-0.58) P value.002 N = 16 N = 18 Rizvi NA, et al. Science. 2015;348(6230):124-128.
Neoepitopes in Lung Cancer TCGA Project Campbell JD, et al. Nat Genet. 2016;48(6):607-616.
Mismatch Repair Deficiency in Colon Cancer PD-1 Blockage in Tumors With Mismatch-Repair Deficiency Le DT, et al. N Engl J Med. 2015;372(26):2509-2520.
Mismatch Repair Deficiency in Colon Cancer PD-1 Blockage in Tumors With Mismatch-Repair Deficiency P =.03 by log-rank test Le DT, et al. N Engl J Med. 2015;372(26):2509-2520.
Immune Therapy Response Signature (IPRES)in Melanoma Hugo W, et al. Cell. 2016;165(1):35-44.
Response to PD-1 Blockade Multifactorial Factors Topalian SL, et al. Nat Rev Cancer. 2016;16(5):275-287.
Biomarkers for PD-1/PD-L1 Inhibitors Evolving area PD-L1 IHC enriches a group of responders to PD-1 blockade Combination of biomarkers may help to identify patients most likely to respond to PD-1 blockade Rational combination strategies should be guided by biomarkers