Treatment Algorithm and Therapy Management in mrcc. Manuela Schmidinger Medical University of Vienna Austria

Treatment Algorithm and Therapy Management in mrcc Manuela Schmidinger Medical University of Vienna Austria

A Paradigm Shift in the Treatment of mrcc 1. Sunitinib 2. Sorafenib 3. Bevacizumab+IFN-alpha 4. Temsirolimus 5. Pazopanib 6. Everolimus 7. Axitinib

Trials Conducted in First-Line Agent tested in 1 st -line ORR (%) vs comparator PFS (months) vs comparator OS (months) Sunitinib 1,2 47 vs 12 11 vs 5 26.4 vs 21.8 Bev + IFN 3 31 vs 12 10.2 vs 5.4 23.3 vs 21.3 Bev + IFN 4 26 vs 13 8.5 vs 5.2 18.3 vs 17.4 Sorafenib 5 5.2 vs 8.4 5.7 vs 5.6 na Pazopanib 6 32 vs 4 a 11.1 vs 2.8 a 22.9 b Temsirolimus 7c 8.6 vs 4.8 3.8 vs 1.9 10.9 vs 7.3 Pazopanib vs Sunitinib 8 31 vs 25 8.4 vs 9.5 28.4 vs 29.3 1.Motzer et al. NEJM 2007; 356: 115 124; 2. Motzer et al. J Clin Oncol 2009; 27: 3584 3590; 3. Escudier et al. Lancet 2007; 370: 2103 2111; 4. Rini et al. J Clin Oncol 2008; 26: 5422 5428; 5. Escudier et al. J Clin Oncol 2009; 27: 1280 1289; 6. Sternberg et al. J Clin Oncol 2010; 28: 1061 1068; 7. Hudes et al. NEJM 2007; 356: 2271 2281; 8. Motzer et al. ESMO 2012; Abstract LBA8_PR (Oral presentation) a first-line patients only; b total population; c temsirolimus monotherapy group; na: not applicable

Trials Conducted after Cytokine Failure Agent n ORR % PFS months HR Sorafenib 1 451 10 5.5 vs 2.8 0.44 Pazopanib 2 135 29 7.4 vs 4.2 0.54 Sunitinib 3 106 34 8.3 --- Axitinib 4 251-12.1 0.464 Escudier B et al., New Engl J Med 2007; Sternberg C et al., J Clin Oncol 2010; Motzer RJ et al., Lancet 2008 3.Motzer RJ et al., JAMA 2006; 4.Rini B et al., Lancet 2011

Trials Conducted after anti-vegf-failure n ORR% PFS OS Everolimus 416 1 vs 0 4.9 vs 1.9 14.8 vs 14.4 vs Placebo 1 Axitinib versus Sorafenib 2 Temsirolimus vs Sorafenib 3 741 19.4 vs 9.4 6.8 vs 4.7 20.1 vs 19.2 512 8 and 8 4.28 vs 3.91 12.24 vs 16.64 Statistically significant difference 1. Motzer RJ et al., Lancet 2008; 2. Rini B et al., Lancet 2011; 3.Hutson T et al., ESMO 2012

Treatment guidelines for clear cell mrcc: ESMO 2012 Setting Treatment group Standard recommendation Level of evidence Longterm survival First-line Favourable or intermediate risk Sunitinib Bevacizumab + IFN-α Pazopanib* I, A I, A II, B Poor risk Temsirolimus I, B Second-line Post-cytokines Axitinib Sorafenib Pazopanib * I, A I, A II, A Post-TKI Axitinib Everolimus I, B II, A Third-line Post two TKIs Everolimus II, A *Conditionally approved Escudier B et al. Ann Oncol 2012;23(suppl 7):vii65-vii71

Relevance of Two versus One Treatment Options for Patients with Favourable- Intermediate Risk For the patients: the more options, the better For the treating physician: Awareness of potential differences between agents Responsibility to choose the individually best treatment The need to use it well in order to optimize the outcome because only one agent will be reimbursed

Sunitinib, Pazopanib What Do Randomized Trials Tell Us?

PISCES Study Pazopanib versus sunitinib patient preference study in treatment naïve advanced or metastatic renal cell carcinoma

Study Design of PICSES Randomisation n=169 No prior tx Measurable or non-measurable Disease Any histology ECOG 0 or 1 Pazopanib 800 mg once daily, 10 weeks Sunitinib 50 mg 4/2, 10 weeks Period 1 Sunitinib 50 mg 4/2, 10 weeks Pazopanib 800 mg once daily, 10 weeks 2-week washout Period 2 Double-blind 0 10 12 22 Patient choice of treatment to progression Off study 1:1 randomisation Time (weeks) Both drugs were over-encapsulated Patients on sunitinib received placebo during 2-week off-period 1. ClinicalTrials.gov. NCT01064310.

Patients (%) PISCES Trial: Primary endpoint: Patient preference for study treatments (Primary analysis population) 1 100 90 80 70 60 50 40 30 20 10 0 90% CI (for difference): 37.0-61.5; p<0.001 70% (n=80) 22% (n=25) 8% (n=9) Preferred pazopanib Preferred sunitinib No preference 1. Escudier B, et al. ASCO 2012 oral presentation; abstract 4502.

Summary of all reasons given for patient preference 1 Better quality of life Less fatigue Less taste change Less mucositis/stomatitis Less nausea/vomiting Less hand-foot syndrome Pazopanib preferred (n=80) Sunitinib preferred (n=25) Better appetite Less stomach pain Less diarrhoea Other Less hair colour change 0 10 20 30 40 50 60 70 Number of patients 1. Escudier B, et al. ASCO 2012 oral presentation; abstract 4502.

COMPARZ: Pazopanib vs. Sunitinib Treatment-naïve advanced or metastatic RCC patients Primary endpoint: PFS Secondary endpoint(s): OS, ORR, Safety, QOL R A N D O M I Z E Pazopanib 800 mg daily 1:1 Randomization N = 876 Sunitinib 50 mg 4 wks / 2 wks * Sunitinib PFS no more than 25% better than A/P PFS (e.g. 8.8 vs.11 months at median) / 80% Power to detect non-inferiority Motzer et al., ESMO 2012

COMPARZ: Non-Inferiority Trial Design that aimed to show that pazopanib is not worse than sunitinib by more than a pre-specified small amount (which is deemed clinically acceptable) the non-inferiority margin 1 How is the Non-inferiority margin defined? Protocol-defined criterion: hazard ratio upper bound of a twosided 95% CI of <1.25 European Medicines Agency (CHMP) -defined criterion: hazard ratio upper bound of a two-sided 95% CI of 1.22 for both, the ITT and PP-population 1.Piaggio G et al. JAMA 2012;308:2594 604.

COMPARZ: Progression-free Survival (primary endpoint - independent review) N Median PFS (95% CI) Pazopanib 557 8.4 mo (8.3, 10.9) Sunitinib 553 9.5 mo (8.3, 11.1) HR (95% CI ) 1.047 (0.898,1.220) ORR PAZ: 31% SUN 25% 0.032 Pazopanib Sunitinib Motzer et al., ESMO 2012

Most Common Adverse Events Pazopanib (n = 554) % Sunitinib (n = 548) % Adverse Event a All Grs Gr 3/4 All Grs Gr 3/4 Any event b >99 59/15 >99 57/17 Diarrhea 63 9/0 57 7/<1 Fatigue 55 10/<1 63 17/<1 Hypertension 46 15/<1 41 15/<1 Nausea 45 2/0 46 2/0 Decreased appetite 37 1/0 37 3/0 ALT increased 31 10/2 18 2/<1 Hair color changes 30 0/0 10 <1/0 Hand-foot syndrome 29 6/0 50 11/<1 Taste Alteration 26 <1/0 36 0/0 Thrombocytopenia 10 2/<1 34 12/4 a AE 30% in either arm b 2% of patients in pazopanib arm and 3% of patients in sunitinib arm had grade 5 adverse events.

Instrument Domain Description Treatment difference : mean change from baseline 2 P -value FACIT-F Fatigue/Total score 2.32 <0.001 FKSI-19 Cancer Treatment Satisfaction Questionnaire (CTSQ) Supplementary Quality of Life Questionnaire (SQLQ) Quality of Life Results (first 6 months 1 ) Kidney Symptom Index/Total score 1.41 0.018 Physical 0.78 0.027 Emotional 0.05 0.409 Treatment Side Effects 0.31 0.033 Functional Well Being 0.31 0.098 Expectations of Therapy 1.41 0.284 Feelings about Side Effects 8.50 <0.001 Satisfaction with Therapy 3.21 <0.001 Worst mouth/throat soreness 0.505 <0.0001 Worst foot soreness 0.204 0.0016 Worst hand soreness 0.267 0.0008 Limitations due to mouth/throat soreness 0.94 <0.001 Limitations due to foot soreness 0.65 0.014 1 Pre-specified analysis. HRQoL changes in mean scores over time were analyzed with a repeated measures analysis of covariance (ANCOVA). 2 Yellow Font: favors pazopanib. Blue Font: favors sunitinib. P-value <0.05 is statistically significant

Have COMPARZ and PISCES Identified Pazopanib as the Better TKI? The most obvious conclusion: sunitinib has not been used well in these trials Results are by far below from our own experience

Outcome of Sunitinib-Patients: Single Center Experiences in Large Cancer Centers Center ORR % PFS months OS months Department of Urology Chungnam National University School of Medicine Daejeon 1 52.4 13.4 28.1 Medical University Vienna 2 51 15.7 32.6 Oncology Asan Medical 43 11.8 22.8 Center Seoul 3 1.Hwang E et al., Korean J Urol 2010; 2.Schmidinger M et al., manuscript in preparation 3.Yoo C et al., Jpn J Clin Oncol 2010;

Reasons for Better Outcome in Real World: COMPARZ versus TKI-Experience in Real World PAZ COMPARZ SUN COMPARZ SUN VIENNA Dose reductions% 44 51 28.7 Toxicity-related treatment discont. 24 18 12.5 ORR 31 25 51 PFS 8.4 9.5 15.7 OS 28.4 29.3 32.6 1. Motzer RJ, et al. ESMO 2012, 2. Schmidinger M, et al. Manuscript submitted

Can The Way a Drug is Used and the Trial Design Impact the Primary Endpoint, PFS in a Clinical Study?

COMPARZ Challenges in Non-Inferiority Trials In non-inferiority trials, many problems can bias the ITT analysis towards showing apparent non-inferiority where it did not really exist When the results of the ITT and PP analyses are inconsistent the results should be interpreted based on the more conservative dataset (ie PP analysis for non-inferiority studies) 1 lar c 1..ICH E9 Guidelines. Note for guidance for statistical principles for clinical trials. September 1998 CPMP/ICH/363/96.

COMPARZ: Inconsistent Results in the Primary Endpoint 1,2 - HR: upper bound of 95% CI <1.25 or CHMP requested ( 1.22) ITT: Median PFS met non-inferiority criteria PP: Median PFS did not meet non-inferiority criteria PFS (IRC-Assessed, ITT Population) Pazopanib (N=557) SUTENT N=553) Median PFS, months (95% CI) 8.4 (8.3 10.9) 9.5 (8.3 11.1) HR (95% CI) 1.0466 (0.8982 1.2195) PFS (IRC-Assessed, PP Population) Pazopanib (N=501) SUTENT (N=494) Median PFS, months (95% CI) 8.4 (8.3 10.9) 10.2 (8.3 11.1) HR (95% CI) 1.069 (0.910 1.255) PFS (Investigator-Assessed, ITT Population) Pazopanib (N=557) SUTENT (N=553) Median PFS, months (95% CI) 10.5 (8.3 11.1) 10.2 (8.3 11.1) HR (95% CI) 0.998 (0.863 1.154) 1. GSK. Clinical Study Register. Study 108844. Available at: http://download.gsk-clinicalstudyregister.com/files/ae28e535-6855-4956-8022-084cdeda4d38 (last accessed February 2013). 2. Data on file. Motzer RJ, et al. ESMO 2012, Vienna, Austria. Abstract LBA8_PR, oral presentation.

Summary PISCES and COMPARZ PISCES Patients prefer pazopanib to sunitinib when asked on day 28 of treatment Patient rate their QoL better with pazopanib than sunitinib COMPARZ Primary endpoint: Non-inferiority of pazopanib questionable: PP-PFS 8.4 vs 10.2 months QoL data questionable because assessed on day 28 of treatment Sunitinib has not been used well: 51% dose reductions, 7.6 months treatment duration Timepoint of response assessment unfavoured sunitinib Inclusion of 300 Asian patients unfavoured sunitinib However: fewer HFS, taste alterations, fatigue, thrombocytopenia In contrast: more ALT increase and diarrhoe with pazopanib

Implications for Clinical Practise

Relevance of Two versus One Treatment Options for Patients with Favourable- Intermediate For the patients: the more options, the better For the treating physician: Awareness of potential differences between agents Responsibility to choose the individually best treatment The need to use it well in order to optimize the outcome because only one agent will be reimbursed

Which Agent for Which Patient? If QoL rather than efficacy is your primary treatment goal: pazopanib is a good choice If efficacy=long term survival is your primary treatment goal: sunitinib might still be the better choice

Patient RK: an Ideal Pazopanib-Patient Male patient, age at diagnosis of RCC 66 Nephrectomy 1998 January 2011, at the age of 79, diagnosis of lung and bone metastases, low tumor bulk MSKCC intermediate risk (anemia) Co-morbidities: coronary artery disease, hypertension, ECOG 2 Individual treatment goal: maintaing QoL, should not have any limitations due to disease or treatment

Patient RK Begin Pazopanib 800 mg January 2011 Toxicities Hypertension 2 Fatigue 1 Diarrhoea 2 Nausea 1 Anorexia 1 Best response: SD PFS 23+ months Individual treatment goal achieved: no cancer-related symptoms due to successful treatment No major impairments in QoL

Why is First-Line TKI Outcome so Important? The longer progression-free survival in first-line, the longer overall survival in later lines 1 31 studies, 10 943 patients: 10% relative risk reduction (RRR) for PFS/TTP was associated with a 6% RRR for OS A 1-month gain in median PFS/TTP was associated with a 1.17- month gain in median OS (95% CI: 0.59,1.76; R(2)=0.28) 1.Delea TE, British Journal of Cancer 2012

Case Patient SN Male patient, 46 years of age at diagnosis of RCC August 2004: Diagnosis of a tumor on the right kidney and lung metastases MSKCC-risk: Hemoglobin 15.4 g/dl, LDH 154 U/L, cca 2+ : 1.2 mmol/l, PFS: ECOG 0, TDM <1year Intermediate Palliative nephrectomy and metastasectomy cc-rcc, pt3a, N0, M0

Case Patient SN February 2005: 5 months after metatsasectomy, diagnosis of new lung metastases Begin cytokine treatment (IL-2, IFN-alpha sc) Best response PR PD November 2005, PFS 9 months Patient is informed about arrival of new drug (sunitinib) in 3 months, willing to wait

Case Patient SN November 2005 to February 2006: No treatment, further progression February 2006: Begin sunitinib (50 mg/4/2) Toxicities: Fatigue Grade 2, resolved with physical activity, Diarrhoea Grade 2 February 2007: CR: sunitinib continued at 37.5 mg January 2009: PD: one new lung lesion, PFS: 35 months

Case Patient SN February 2009: Therapeutic decision Stereotactic radiosurgery and sunitinib continuation at 37.5 mg Staging January 2010: CR sunitinib continuation (37.5 mg) January 2012: PD, new pancreatic lesion Therapeutic decision_ Increase of sunitinib to 50 mg Referred to surgeon, plan to perform metastasectomy Patient requested more time to decide on surgery April 2012: PR October 2012: CR

Treatment Summary and Messages PFS 1st-line cytokine treatment: 9 months After progression on cytokines, initiation of sunitinib: 1st PFS: 35 mo At PD, SU 37.5 continued+stereotactic radiosurgery: 2nd PFS: 24 mo At PD sunitinib increased to 50 mg: 3rd PFS: 12+ mo So far, sunitinib enabled a survival of 7+ years since progression on cytokines Appropriate side effect management allowed long term treatment QoL in a sunitinib-long term survivor: Has learned how to deal with side effects Has lost his fear to die from the disease Is leading an almost normal life

If Only One Agent is Reimbursed: Use it well Inform your patient appropriately about potential side effects Provide prophylactic and supportive measures Whenever a side effect is difficult to manage, e.g. taste changes, consider changing the schedule (4/2 to 2/1) rather than offering dose reductions Inform your patient about the importance of dosing and the dose response relationship Critically question disease progression: frequently, it s a matter of inappropriate dosing rather than resistance

Case Patient WS: Progression as a Matter of Inappropriate Dosing/Compliance Staging Results and Date PR Nov 2009 Jan 2010 May 2010 Jan 2011 Apr 2011 CR Aug 2010 Jul 2011 Oct 2011 Jan 2012 Apr 2012 PD Nov 2010 Jul 2012 Apparent resistance15 mo True resistance 33 months Sunitinib 50 mg Sunitinib 37.5 mg Dose of sunitinib before staging CT Sunitinib 25 mg

Case Patient FH: Progression as a Matter of Inappropriate Dosing PR CR PD SEPT 2010 DEC 2010 Staging Results and Date APR 2011 AUG 2011 DEC 2011 MAR 2012 JUL 2012 DEC 2012 Next Staging March 2012 Apparent resistance 7 mo Ongoing CR after 31 months Sunitinib 50 mg Sunitinib 37.5 mg Dose of sunitinib before staging CT Sunitinib 25 mg

Conclusions The therapeutic landscape of mrcc management has dramatically improved over the last 7 years The more agents we can offer, the better it is for the patient We need to choose the best agent for the individual patient We need to be aware of differences between agents and define the best individual treatment goal We need to offer appropriate therapy management We need to be aware that QoL is individually defined

What is QoL for the Individual Patient? And in the end it's not the years in your life that count; it's the life in your years* Statement of patient EA, 49 years, physician mrcc: that s wrong it s my own task to bring life to my years, from my physician, I expect to bring years to my life Bringing years to the life of a patient=choosing a treatment based on efficacy criteria and using it well For many of our patients, efficacy of an agent largely contributes to QoL! *Abraham Lincoln (1809-1865)