The International Journal of Targeted Therapies in Cancer by Intellisphere, LLC

In advanced prostate cancer...

TREAT fIRST LINE wITh PROVENGE TO

Activate PROVENGEactivated T cells

Resting T cell

PROVENGE activating a T cell

Amplify Prostate cancer cell

Attack Activated T cell attacks prostate cancer

EXTEND SURVIVAL

• PROVENGE extends median survival beyond 2 years1 • Only 1.5% of patients treated with PROVENGE in the pivotal trial discontinued treatment due to adverse events2 — The most common adverse events in PROVENGE trials were chills, fatigue, fever, back pain, nausea, joint ache, and headache2 • PROVENGE is the first and only FDA-approved immunotherapy for advanced prostate cancer • The NCCN recommends PROVENGE as a first-line treatment for men with asymptomatic or minimally symptomatic metastatic castrate resistant prostate cancer (NCCN Category 1 recommendation)3

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• Explore the PROVENGE Interactive Experience • Create a personalized patient educational poster for your office

IndIcatIon: provenge® (sipuleucel-T) is an autologous cellular immunotherapy indicated for the treatment of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer. Important Safety InformatIon: provenge is intended solely for autologous use and is not routinely tested for transmissible infectious diseases. In controlled clinical trials, serious adverse events reported in the provenge group include acute infusion reactions (occurring within 1 day of infusion) and cerebrovascular events. Severe (grade 3) acute infusion reactions were reported in 3.5% of patients in the provenge group. reactions included chills, fever, fatigue, asthenia, dyspnea, hypoxia, bronchospasm, dizziness, headache, hypertension, muscle ache, nausea, and vomiting. no grade 4 or 5 acute infusion reactions were reported in patients in the provenge group. The most common adverse events (incidence ≥15%) reported in the provenge group were chills, fatigue, fever, back pain, nausea, joint ache, and headache. For more information on provenge, please see Brief Summary of prescribing Information on adjacent page.

www.provenge.com

PROVENGE® (sipuleucel-T) Suspension for Intravenous Infusion

Rx Only

BRIEF SUMMARY — See full Prescribing Information for complete product information

INDICATIONS AND USAGE: PROVENGE® (sipuleucel-T) is an autologous cellular immunotherapy indicated for the treatment of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer. DOSAGE AND ADMINISTRATION • For Autologous Use Only. • The recommended course of therapy for PROVENGE is 3 complete doses, given at approximately 2-week intervals. • Premedicate patients with oral acetaminophen and an antihistamine such as diphenhydramine. • Before infusion, confirm that the patient’s identity matches the patient identifiers on the infusion bag. • Do Not Initiate Infusion of Expired Product. • Infuse PROVENGE intravenously over a period of approximately 60 minutes. Do Not Use a Cell Filter. • Interrupt or slow infusion as necessary for acute infusion reactions, depending on the severity of the reaction. (See Dosage and Administration [2] of full Prescribing Information.) CONTRAINDICATIONS: None. WARNINGS AND PRECAUTIONS • PROVENGE is intended solely for autologous use. • Acute infusion reactions (reported within 1 day of infusion) included, but were not limited to, fever, chills, respiratory events (dyspnea, hypoxia, and bronchospasm), nausea, vomiting, fatigue, hypertension, and tachycardia. In controlled clinical trials, 71.2% of patients in the PROVENGE group developed an acute infusion reaction. I n controlled clinical trials, severe (Grade 3) acute infusion reactions were reported in 3.5% of patients in the PROVENGE group. Reactions included chills, fever, fatigue, asthenia, dyspnea, hypoxia, bronchospasm, dizziness, headache, hypertension, muscle ache, nausea, and vomiting. The incidence of severe events was greater following the second infusion (2.1% vs 0.8% following the first infusion), and decreased to 1.3% following the third infusion. Some (1.2%) patients in the PROVENGE group were hospitalized within 1 day of infusion for management of acute infusion reactions. No Grade 4 or 5 acute infusion reactions were reported in patients in the PROVENGE group. Closely monitor patients with cardiac or pulmonary conditions. In the event of an acute infusion reaction, the infusion rate may be decreased, or the infusion stopped, depending on the severity of the reaction. Appropriate medical therapy should be administered as needed. • Handling Precautions for Control of Infectious Disease. PROVENGE is not routinely tested for transmissible infectious diseases. Therefore, patient leukapheresis material and PROVENGE may carry the risk of transmitting infectious diseases to health care professionals handling the product. Universal precautions should be followed. • Concomitant Chemotherapy or Immunosuppressive Therapy. Use of either chemotherapy or immunosuppressive agents (such as systemic corticosteroids) given concurrently with the leukapheresis procedure or PROVENGE has not been studied. PROVENGE is designed to stimulate the immune system, and concurrent use of immunosuppressive agents may alter the efficacy and/or safety of PROVENGE. Therefore, patients should be carefully evaluated to determine whether it is medically appropriate to reduce or discontinue immunosuppressive agents prior to treatment with PROVENGE. • Product Safety Testing. PROVENGE is released for infusion based on the microbial and sterility results from several tests: microbial contamination determination by Gram stain, endotoxin content, and in-process sterility with a 2-day incubation to determine absence of microbial growth. The final (7-day incubation) sterility test results are not available at the time of infusion. If the sterility results become positive for microbial contamination after PROVENGE has been approved for infusion, Dendreon will notify the treating physician. Dendreon will attempt to identify the microorganism, perform antibiotic sensitivity testing on recovered microorganisms, and communicate the results to the treating physician. Dendreon may request additional information from the physician in order to determine the source of contamination. (See Warnings and Precautions [5] of full Prescribing Information.) ADVERSE REACTIONS Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety evaluation of PROVENGE is based on 601 prostate cancer patients in the PROVENGE group who underwent at least 1 leukapheresis procedure in four randomized, controlled clinical trials. The control was non-activated autologous peripheral blood mononuclear cells.

The most common adverse events, reported in patients in the PROVENGE group at a rate ≥15%, were chills, fatigue, fever, back pain, nausea, joint ache, and headache. Severe (Grade 3) and life-threatening (Grade 4) adverse events were reported in 23.6% and 4.0% of patients in the PROVENGE group compared with 25.1% and 3.3% of patients in the control group. Fatal (Grade 5) adverse events were reported in 3.3% of patients in the PROVENGE group compared with 3.6% of patients in the control group. Serious adverse events were reported in 24.0% of patients in the PROVENGE group and 25.1% of patients in the control group. Serious adverse events in the PROVENGE group included acute infusion reactions (see Warnings and Precautions), cerebrovascular events, and single case reports of eosinophilia, rhabdomyolysis, myasthenia gravis, myositis, and tumor flare. PROVENGE was discontinued in 1.5% of patients in Study 1 (PROVENGE group n=341; Control group n=171) due to adverse events. Some patients who required central venous catheters for treatment with PROVENGE developed infections, including sepsis. A small number of these patients discontinued treatment as a result. Monitoring for infectious sequelae in patients with central venous catheters is recommended. Each dose of PROVENGE requires a standard leukapheresis procedure approximately 3 days prior to the infusion. Adverse events that were reported ≤1 day following a leukapheresis procedure in ≥5% of patients in controlled clinical trials included citrate toxicity (14.2%), oral paresthesia (12.6%), paresthesia (11.4%), and fatigue (8.3%). Table 1 provides the frequency and severity of adverse events reported in ≥5% of patients in the PROVENGE group of randomized, controlled trials of men with prostate cancer. The population included 485 patients with metastatic castrate resistant prostate cancer and 116 patients with non-metastatic androgen dependent prostate cancer who were scheduled to receive 3 infusions of PROVENGE at approximately 2-week intervals. The population was age 40 to 91 years (median 70 years), and 90.6% of patients were Caucasian.

Table 1 Incidence of Adverse Events Occurring in ≥5% of Patients Randomized to PROVENGE PROVENGE (N = 601)

Any Adverse Event Chills Fatigue Fever Back pain Nausea Joint ache Headache Citrate toxicity Paresthesia Vomiting Anemia Constipation Pain Paresthesia oral Pain in extremity Dizziness Muscle ache Asthenia Diarrhea Influenza-like illness Musculoskeletal pain Dyspnea Edema peripheral Hot flush Hematuria Muscle spasms

Control* (N = 303)

All Grades n (%)

Grade 3-5 n (%)

All Grades n (%)

591 (98.3) 319 (53.1) 247 (41.1) 188 (31.3) 178 (29.6) 129 (21.5) 118 (19.6) 109 (18.1) 89 (14.8) 85 (14.1) 80 (13.3) 75 (12.5) 74 (12.3) 74 (12.3) 74 (12.3) 73 (12.1) 71 (11.8) 71 (11.8) 65 (10.8) 60 (10.0) 58 (9.7) 54 (9.0) 52 (8.7) 50 (8.3) 49 (8.2) 46 (7.7) 46 (7.7)

186 (30.9) 13 (2.2) 6 (1.0) 6 (1.0) 18 (3.0) 3 (0.5) 11 (1.8) 4 (0.7) 0 (0.0) 1 (0.2) 2 (0.3) 11 (1.8) 1 (0.2) 7 (1.2) 0 (0.0) 5 (0.8) 2 (0.3) 3 (0.5) 6 (1.0) 1 (0.2) 0 (0.0) 3 (0.5) 11 (1.8) 1 (0.2) 2 (0.3) 6 (1.0) 2 (0.3)

291 (96.0) 33 (10.9) 105 (34.7) 29 (9.6) 87 (28.7) 45 (14.9) 62 (20.5) 20 (6.6) 43 (14.2) 43 (14.2) 23 (7.6) 34 (11.2) 40 (13.2) 20 (6.6) 43 (14.2) 40 (13.2) 34 (11.2) 17 (5.6) 20 (6.6) 34 (11.2) 11 (3.6) 31 (10.2) 14 (4.6) 31 (10.2) 29 (9.6) 18 (5.9) 17 (5.6)

Grade 3-5 n (%) 97 (32.0) 0 (0.0) 4 (1.3) 3 (1.0) 9 (3.0) 0 (0.0) 5 (1.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 7 (2.3) 3 (1.0) 3 (1.0) 0 (0.0) 1 (0.3) 0 (0.0) 0 (0.0) 2 (0.7) 3 (1.0) 0 (0.0) 3 (1.0) 3 (1.0) 1 (0.3) 1 (0.3) 3 (1.0) 0 (0.0)

(Table 1 continued on next page.)

Table 1 Incidence of Adverse Events Occurring in â&#x2030;Ľ5% of Patients Randomized to PROVENGE PROVENGE (N = 601)

Hypertension Anorexia Bone pain Upper respiratory tract infection Insomnia Musculoskeletal chest pain Cough Neck pain Weight decreased Urinary tract infection Rash Sweating Tremor

Control* (N = 303)

All Grades n (%)

Grade 3-5 n (%)

All Grades n (%)

Grade 3-5 n (%)

45 (7.5) 39 (6.5) 38 (6.3) 38 (6.3)

3 (0.5) 1 (0.2) 4 (0.7) 0 (0.0)

14 (4.6) 33 (10.9) 22 (7.3) 18 (5.9)

0 (0.0) 3 (1.0) 3 (1.0) 0 (0.0)

37 (6.2) 36 (6.0)

0 (0.0) 2 (0.3)

22 (7.3) 23 (7.6)

1 (0.3) 2 (0.7)

35 (5.8) 34 (5.7) 34 (5.7) 33 (5.5) 31 (5.2) 30 (5.0) 30 (5.0)

0 (0.0) 3 (0.5) 2 (0.3) 1 (0.2) 0 (0.0) 1 (0.2) 0 (0.0)

17 (5.6) 14 (4.6) 24 (7.9) 18 (5.9) 10 (3.3) 3 (1.0) 9 (3.0)

0 (0.0) 2 (0.7) 1 (0.3) 2 (0.7) 0 (0.0) 0 (0.0) 0 (0.0)

*Control was non-activated autologous peripheral blood mononuclear cells.

Cerebrovascular Events. In controlled clinical trials, cerebrovascular events, including hemorrhagic and ischemic strokes, were reported in 3.5% of patients in the PROVENGE group compared with 2.6% of patients in the control group. (See Adverse Reactions [6] of full Prescribing Information.) To report SUSPECTED ADVERSE REACTIONS, contact Dendreon Corporation at 1-877-336-3736 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Dendreon Corporation Seattle, Washington 98101

References: 1. Kantoff PW, Higano CS, Shore ND, et al; for the IMPACT Study Investigators. Sipuleucel-T immunotherapy for castration-resistant prostate cancer. N Engl J Med. 2010;363:411-422. 2. PROVENGE [package insert]. Dendreon Corporation; June 2011. 3. NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer. V.1.2012. National Comprehensive Cancer Network Web site. www.nccn.org. Accessed March 6, 2012.

North American Edition, June 2012

Contents

President Peter Ciszewski pciszewski@onclive.com

Editorial & Production

Clinical Articles Lung Cancer.. ......... 30 ALK Rearrangements as a Therapeutic Target in Advanced Non-Small Cell Lung Cancer

Vice President, Oncology and Managed Markets Lyn Beamesderfer lbeamesderfer@onclive.com Senior Editors Anita T. Shaffer Jason M. Broderick Beth Fand Incollingo Associate Editor Ben Leach Assistant Editor Marissa Murtaugh

Web Editor Silas Inman Assistant Web Editor Stephanie Ogozaly Oncology Special Projects Editor Devera Pine dpine@onclive.com Art Director Leighanne Tillman

D. Ross Camidge, MD, PhD

Cancer Research Moves Beyond the Original “Hallmarks of Cancer” The seminal “hallmarks of cancer” remain central to tumor biology and research, yet it is now generally accepted that additional hallmark capabilities may be involved.

Feature

Clinical Trial Profiles:

MetMAb and ARQ 197 in Non-Small Cell Lung Cancer

Despite its remarkable clinical activity, acquired resistance to crizotinib is predicted to develop in all ALK-positive cases of NSCLC. Multiple mechanisms of intrinsic and acquired resistance to crizotinib in ALK-positive NSCLC have been described, and treatment options in this setting are discussed.

Melanoma.. . . . . . . . . . . . 37 Immunotherapy in Advanced Melanoma Deepika Narasimha, MD, Anthony Jarkowski, III, PharmD, and Nikhil I. Khushalani, MD

The year 2011 witnessed the approval of an anti-CTLA-4 antibody, ipilimumab, and a BRAF-targeted agent, vemurafenib, in advanced melanoma, which has led to a renaissance in melanoma therapeutics. This is an exciting phase for melanoma immunotherapy and holds important implications for clinicians.

BRAF Inhibitors in Melanoma

Antoni Ribas, MD

The BRAFV600E mutation makes up over 90% of the mutations in BRAF, and two BRAF inhibitors with high antitumor activity in patients with BRAF-mutant metastatic melanoma are in clinical use, while other therapies and combinations are under study.

Departments

Executive Vice President, Sales & Marketing Jack Lepping jlepping@onclive.com Vice President, Sales & Marketing Lisa Greene lgreene@onclive.com Vice President, Integrated Special Projects Group David Lepping dlepping@mdmag.com

Directors of Sales Scott Harwood sharwood@onclive.com Erik Lohrmann elohrmann@onclive.com Senior National Accounts Manager Mike Hennessy, Jr mjhennessy@onclive.com National Accounts Manager Robert Goldsmith rgoldsmith@onclive.com

Digital Media Vice President, Digital Media Jung Kim

Director, Digital Content Sean Johnson

Manager, Digital Operations Keli Rising

Operations & Finance Director of Operations Thomas J. Kanzler

Controller Jonathan Fisher, CPA

Director of Circulation John Burke jburke@mdng.com

Assistant Controller Leah Babitz, CPA

Corporate Chairman/Chief Executive Officer/President Mike Hennessy

Vice President/Executive Director of Education Judy V. Lum, MPA

Chief Operating Officer Tighe Blazier

Vice President/Group Creative Director Jeff Brown

Chief Financial Officer Neil Glasser, CPA / CFE

Cancer Therapy....... 50

8 Clinical Trials in Progress

MET Inhibitors in Cancer Therapy

12 Targeted Therapy Updates

Alex A. Adjei, MD, PhD

Interested in contributing? If you’d like to submit an article outline or abstract for consideration in an upcoming issue, please e-mail Devera Pine at dpine@onclive.com. 4 / 6.12

Sales & Marketing

Because of its ubiquitous role in cancer cells, the MET axis has been seen as an attractive target for cancer therapy. Over the last four years, more than 10 anticancer agents targeting different aspects of MET signaling via different mechanisms have been introduced into the clinic.

The International Journal of TargetedTherapies in Cancer

Office Center at Princeton Meadows Bldg 300 • Plainsboro, NJ 08536 (609) 716-7777 The content contained in this publication is for general information purposes only. The reader is encouraged to confirm the information presented with other sources. The International Journal of Targeted Therapy in Cancer makes no representations or warranties of any kind about the completeness, accuracy, timeliness, reliability, or suitability of any of the information, including content or advertisements, contained in this publication and expressly disclaims liability for any errors and omissions that may be presented in this publication. The International Journal of Targeted Therapy in Cancer reserves the right to alter or correct any error or omission in the information it provides in this publication, without any obligations. The International Journal of Targeted Therapy in Cancer further disclaims any and all liability for any direct, indirect, consequential, special, exemplary, or other damages arising from the use or misuse of any material or information presented in this publication. The views expressed in this publication are those of the authors and do not necessarily reflect the opinion or policy of The International Journal of Targeted Therapy in Cancer.

From the Editor

Editorial Board Physician Editor-in-Chief Alex A. Adjei, MD, PhD Professor and Chair, Department of Medicine Katherine Anne Gioia Chair in Cancer Medicine Senior Vice President, Clinical Research Roswell Park Cancer Institute Buffalo, NY

Sagar Lonial, MD Professor, Emory School of Medicine Vice Chair of Clinical Affairs, Department of Hematology and Medical Oncology Director, Translational Research, B-cell Malignancy Program Emory University School of Medicine Atlanta, GA

Edward Chu, MD Chief, Division of Hematology-Oncology University of Pittsburgh School of Medicine Deputy Director, University of Pittsburgh Cancer Institute Pittsburgh, PA

Joyce A. O’Shaughnessy, MD Co-Director, Breast Cancer Research Baylor Charles A. Sammons Cancer Center/Texas Oncology US Oncology Dallas, TX

Roger B. Cohen, MD Professor of Medicine Associate Director of Clinical Research Abramson Cancer Center University of Pennsylvania Philadelphia, PA Robert L. Coleman, MD, FACOG, FACS Professor of Gynecologic Oncology Vice Chair, Clinical Research, Department of Gynecologic Oncology The University of Texas MD Anderson Cancer Center Houston, TX Jorge Eduardo Cortes, MD Chair, CML Section, Department of Leukemia Division of Cancer Medicine The University of Texas MD Anderson Cancer Center Houston, TX Grace Dy, MD Assistant Professor Department of Medicine Roswell Park Cancer Institute Buffalo, NY Ramaswamy Govindan, MD Professor Department of Medicine Oncology Division Washington University School of Medicine St. Louis, MO Axel Grothey, MD Professor of Oncology Consultant, Medical Oncology Mayo Clinic Rochester, MN

Roberto Pili, MD Professor of Oncology Chief, Genitourinary Section Leader, Genitourinary Program, Department of Medicine Roswell Park Cancer Institute Buffalo, NY Igor Puzanov, MD Associate Director of Phase I Drug Development Melanoma/Renal Cancer Program Vanderbilt-Ingram Cancer Center Assistant Professor of Medicine Division of Hematology-Oncology Vanderbilt University Medical Center Nashville, TN Antoni Ribas, MD, PhD Associate Professor, HematologyOncology and Surgical Oncology Assistant Director for Clinical Programs, UCLA Human Gene Medicine Program Director, JCCC Cell and Gene Therapy Core Facility David Geffen School of Medicine University of California, Los Angeles Los Angeles, CA Hope Rugo, MD Clinical Professor, Department of Medicine (Hematology/Oncology) Director, Breast Oncology Clinical Trials Program University of California, San Francisco San Francisco, CA Oliver Sartor, MD Piltz Professor of Cancer Research Departments of Medicine and Urology Tulane University School of Medicine New Orleans, LA

Alex A. Adjei, MD, PhD

Colleagues, Welcome to the inaugural issue of The International Journal of Targeted Therapies in Cancer. This is a quarterly, peer-reviewed journal, aimed at nonacademic oncologists who treat the majority of cancer patients in this country. Advances in genomics and molecular biology have uncovered multiple targets for cancer therapy. Novel molecules targeting specific genetic derangements such as gene mutations, gene amplifications, and gene fusions are in the clinic (vemurafenib, crizotinib). For the first time, successes are increasingly occurring in exploiting host and tumor immunity (ipilumumab, sipuleucel-T) for cancer therapy. These and a number of compounds in clinical trials possess novel mechanisms of action and unusual toxicities. There are novel diagnostic tests being introduced in the clinic. These advances mean there is an explosion in new information that needs to be mastered for effective care of patients. This journal will fill this important niche. The language of molecular biology, genomics, and genetics will be simplified for the nonspecialized, nonacademic oncologist. Novel technologies, pathways and novel drug mechanisms, side effects and their management, as well as optimal administration schedules will be discussed in this journal. Please forward suggestions on potential future topics and your comments for improvement to my attention, and enjoy this inaugural issue!

Jonathan L. Kaufman, MD Assistant Professor Associate Director Fellowship Program Department of Hematology and Medical Oncology Winship Cancer Institute Emory University Atlanta, GA

Interested in joining our editorial board? Contact Devera Pine, Oncology Special Projects Editor, at dpine@onclive.com.

Also available in our family of publications:

—Alex A. Adjei, MD, PhD physician Editor-in-Chief

To reach Dr. Adjei and/or the journal’s editorial staff, please e-mail: dpine@onclive.com.

Bringing New Vision to the Fight Against Cancer

DSNA12100979

“There is nothing impossible to him who will try.” — Alexander the Great

Joining the Fight Chest X-ray with lung cancer tumors color enhanced.

WWW.DAIICHISANKYO.COM

Clinical Trials in Progress The Trials in Progress section is intended to stimulate discussion about ongoing clinical trials and to promote collaboration across the oncology community. Each issue, The International Journal of Targeted Therapies in Cancer will present summaries of ongoing research in a broad range of cancer types.

Pancreatic Cancer Gemcitabine and AMG 479 in metastatic pancreatic cancer This phase III study is examining whether AMG 479 or placebo in combination with gemcitabine is superior as first-line therapy for metastatic adenocarcinoma of the pancreas. AMG 479 is an investigational fully-human, monoclonal antibody that targets type 1 insulin-like growth factor receptor (IGF-1R). Signaling through IGF-1R plays an important role in the regulation of cell growth and survival. The primary outcome measure is overall survival. Secondary outcome measures include progression-free survival, objective response rate, time to disease progression, disease-control rate, and adverse-event rate. The target recruitment is approximately 825 patients, and the investigators aim to complete the study in December 2014. Sponsor: Amgen ClinicalTrials.gov Identifier: NCT01231347

Algenpantucel-L immunotherapy under study for pancreatic cancer This phase III is study is comparing adjuvant standard-of-care treatment (involving gemcitabine alone or with 5-FU chemoradiation) with or without algenpantucel-L immunotherapy in patients with pancreatic cancer who have undergone surgical resection. Algenpantucel-L is composed of irradiated, live, allogeneic human pancreatic cancer cells expressing the enzyme Îą-1,3 galactosyl transferase (Îą-GT), which is the major barrier to xenotransplantation from lower mammals to humans (eg, hyperacute rejection). Up to 2% of circulating human antibodies are directed against the Îą-GT epitope of algenpantucel-L and are the proposed mechanism of initiating the antitumor immune response. The primary outcome measure is overall survival. Investigators will also assess disease-free survival and conduct correlative sci-

8 / 3.12

entific studies to determine the mechanism of any observed antitumor effect. The estimated study completion date is January 2014. Sponsor: NewLink Genetics Corporation ClinicalTrials.gov Identifier: NCT0107298

Renal Cancer Sunitinib or placebo for patients at high risk of recurrent renal cell cancer This phase III study is comparing sunitinib with placebo as adjuvant treatment in patients at high risk of recurrent kidney cancer per modified University of California Los Angeles Integrated Staging System (UISS) criteria after surgery. Subjects are Eastern Cooperative Oncology Group (ECOG) grade 0 to 2 and have predominant clear-cell histology. In addition, they have not undergone prior anticancer treatment but have had their kidney tumor removed with no evidence of macroscopic disease following surgery. Approximately 720 patients will be randomized to sunitinib 50 mg PO or placebo on a 4/2 schedule: 4 weeks on, 2 weeks off for 1 year or until disease recurrence or occurrence of a secondary malignancy, significant toxicity, or withdrawal of consent. The primary outcome measure is disease-free survival. Investigators will also determine overall survival, safety, tolerability, and patient-reported outcomes. Sponsor: Pfizer ClinicalTrials.gov Identifier: NCT00375674

Axitinib (AG-013736) for the treatment of metastatic renal cell cancer This phase III study is designed to determine whether axitinib is superior to sorafenib in delaying tumor progression in patients with metastatic renal cell cancer. Participants are required to have histologically documented metastatic

renal cell cancer with a component of clear cell histology and evidence of measurable disease. They cannot have received prior systemic firstline therapy or must have progressive disease per Response Evaluation Criteria In Solid Tumors (RECIST) - version 1.0 after one prior systemic first-line regimen for metastatic disease containing sunitinib, cytokine(s), or both. Subjects will be randomized to axitinib at a starting dose of 5 mg bid with continuous dosing or sorafenib at a dose of 400 mg bid with continuous dosing. The primary outcome measure is progression-free survival. Secondary outcome measures include overall survival, response rate, safety and tolerability, duration of response, kidney-specific symptoms, and health status. Sponsor: Pfizer ClinicalTrials.gov Identifier: NCT00920816

1Hematologic Malignancies

RAD001 adjuvant therapy in poor-risk lymphoma patients This phase III study is comparing RAD001 (everolimus) adjuvant therapy versus placebo in patients with histologically confirmed stage III-IV diffuse large B-cell lymphoma at the time of their original diagnosis, who have had a complete response to first-line rituximab chemotherapy. Patients with stage II bulky disease, defined as any tumor mass more than 10 cm in longest diameter, are also eligible. All study participants must be considered poor risk, which is defined as International Prognostic Index (IPI) of 3, 4, or 5 at the time of their initial diagnosis. The primary outcome measure is disease-free survival. Secondary outcome measures include overall survival, lymphoma-specific survival, and safety. Investigators aim to recruit 687 patients for their study, which has an estimated primary completion date of May 2014. Sponsor: Novartis ClinicalTrials.gov Identifier: NCT00790036

The International Journal of TargetedTherapies in Cancer

Standard graft–versus–host disease prevention regimen with or without sirolimus for lymphoma prevention This phase III study is examining whether the mammalian target of rapamycin (mTOR) inhibitor sirolimus for graft-versus-host disease (GVHD) prevention is more effective at preventing a lymphoma relapse after transplantation than a standard GVHD prevention regimen without sirolimus. Since mTOR inhibitors have anti-lymphoma activity, the investigators had hypothesized that their use after transplantation may decrease the risk of relapse and thus improve transplantation outcome. About 140 lymphoma patients will be randomized after reduced-intensity allogeneic stem cell transplantation to one of two possible groups for GVHD prophylaxis: a sirolimus-containing regimen (tacrolimus, sirolimus, and methotrexate) or a sirolimus-free regimen (tacrolimus and methotrexate or cyclosporine and mycophenolate mofetil). The primary outcome measure is the overall survival rate at two years. Sponsor: Dana-Farber Cancer Institute ClinicalTrials.gov: Identifier: NCT00928018

Bortezomib/dexamethasone with or without perifosine in multiple myeloma This phase III study is evaluating the efficacy and safety of the novel signal transduction modulator perifosine when added to the combination of bortezomib and dexamethasone in multiple myeloma patients who have relapsed on a prior bortezomib treatment regimen. Participants will be randomized to perifosine or placebo dosed as a single 50-mg pill every day of each cycle. All patients will receive bortezomib dosed at 1.3 mg/m2 on days 1, 4, 8, and 11 every 21 days and dexamethasone administered orally at 20 mg on days 1, 2, 4, 5, 8, 9, 11, and 12 of each 21-day cycle. The primary outcome measure is progression-free survival. Secondary outcome measures include overall survival, overall response rate, and adverse events. Study investigators at 88 sites aim to recruit 450 patients. Sponsor: Keryx / AOI Pharmaceuticals, Inc. ClinicalTrials.gov Identifier: NCT01002248

1Liver Cancer

Sorafenib with or without doxorubicin in advanced liver cancer This phase III study is comparing sorafenib plus doxorubicin versus sorafenib alone in patients with locally advanced or metastatic liver cancer. Participants are stratified according to the extent of disease (locally advanced or metastatic) and then randomized to one of two treatment groups. One group of patients will receive doxorubicin IV on day 1 and oral sorafenib twice daily on days 1 though 21, and treatment is repeated every 21 days for six courses in the absence of disease progression or unacceptable toxicity; after six courses, patients may continue to receive oral sorafenib twice daily in the absence of disease progression or unacceptable toxicity. The other group will be treated with oral sorafenib twice daily on days 1-21, and treatment is repeated every 21 days in the absence of disease progression or unacceptable toxicity. After the completion of treatment, patients in both groups are followed up every three months for one year, and then every six months for two years. The study intends to enroll 480 patients at 290 sites. Sponsor: Cancer and Leukemia Group B ClinicalTrials.gov Identifier: NCT01015833

Glioblastoma Experimental vaccine being tested for glioblastoma This phase III study will investigate the efficacy and safety of the addition of rindopepimut (CDX-110) to temozolomide, the current standard of care, in patients with surgically resected epidermal growth factor receptor variant III (EGFRvIII)-positive glioblastoma. Rindopepimut is an investigational therapeutic vaccine candidate that targets the tumor-specific oncogene EGFRvIII, which confers an enhanced capacity for unregulated tumor growth and which is present in many cancer cell types, but not present at significant levels in normal cells. Expression of EGFRvIII is linked to poor long-

The International Journal of TargetedTherapies in Cancer

term survival irrespective of other factors such as extent of resection and age. The primary outcome measure is overall survival. Secondary outcome measures include progression-free survival and safety and tolerability. An estimated 440 patients are expected to participate in the study, which is projected to be completed in November 2016. Sponsor: Celldex Therapeutics ClinicalTrials.gov Identifier: NCT01480479

Bevacizumab on top of standard treatment for glioblastoma This phase III study is testing the addition of bevacizumab to conventional concurrent chemoradiation and adjuvant temozolomide in patients with newly diagnosed histologically confirmed glioblastoma. Participants are required to have undergone partial or complete surgical resection of tumor within the past three to five weeks and have at least one block of tumor tissue of sufficient size available for analysis of O(6)-methylguanine-DNA methyltransferase (MGMT) status and determination of molecular profile. Patients with recurrent or multifocal malignant glioma or metastases detected below the tentorium or beyond the cranial vault are ineligible. The primary outcome measures are overall survival and progressionfree survival. Treatment-related toxicity is the sole secondary outcome measure. Researchers plan to recruit 942 patients. Sponsor: Radiation Therapy Oncology Group ClinicalTrials.gov Identifier: NCT00884741

3.12 / 9

Targeted Therapy Updates

Analysis of the Cost-Effectiveness of Targeted Therapies in Lung Cancer

to the costs of treating every patient. If it is 1%, you have to add $100,000 up front as the money you spend to find even one patient who is positive.” In the initial modeling, the researchers explored a range of costs, assuming that costs would vary over time. They found that, if all patients with advanced non–small cell lung cancer were screened for ALK, and the assay cost around $1400, screening would be $106,707 per quality-adjusted life-year (QALY) before any drugrelated costs were considered. If the population could be narrowed to only those more likely to test positive, the QALY cost would fall to $4756. However, physicians would miss more than half the patients who would benefit from treatment. “When you start to think like this, the costeffectiveness of these breakthroughs becomes a real problem,” Camidge said. “We can either enrich the population being screened by other means but run the risk of missing some people, or bring down the cost of finding each positive patient, such as by reducing the cost of the individual test or multiplexing the tests so you get more positives (even if in different markers) per dollar spent.”

By Marie Rosenthal, MS A cost-effective method to identify biomarkers that determine which therapies patients should receive is needed for the routine use of targeted oncology therapy in clinical practice. That conclusion was reached in a recent cost-effectiveness analysis of targeted therapies for lung cancer. As a model, the analysis used the biomarker ALK and the targeted therapy crizotinib (Xalkori, Pfizer). As more people were tested who didn’t have the biological abnormality being sought, costs rose, according to the analysis, which was published in the British Journal of Cancer. However, when the researchers controlled costs by applying methods to target patients for screening who were more likely to test positive, they missed a significant proportion of the patients who could have benefited from targeted therapy. D. Ross Camidge, MD, PhD, who performed the analysis with Adam J. Atherly, PhD, said that cost-effectiveness of screening has to be considered when determining the costs of treatment with targeted therapy, and that the high costs of a

“test-everyone” approach may not be feasible in today’s healthcare environment. “The big advances in lung cancer (and many other cancers) have come from not giving one drug to everyone, but developing tests to find out in advance who will get maximal benefit from the drug. If you don’t, the average benefit is very poor. However, the cost of testing now has to be factored into the calculations of determining the cost-effectiveness of any drug used in this way. Bringing down the cost per positive is essential,” explained Camidge, who was involved in early research for the development of crizotinib and helped to develop one of the assays used to test for the ALK gene alteration. “Assuming you only treat those who come up positive on a test, your cost-effectiveness goes down as you screen more people who don’t have the abnormality you are looking for. It increases the up-front costs of finding those positives,” Camidge said. “For a $1000 test, if the group you screen has a 50% hit rate, you have to add $2000

Atherly AJ, Camidge DR. The cost-effectiveness of screening lung cancer patients for targeted drug sensitivity markers. Br J Cancer. 2012; 106(6):1100- 1106. doi:10.1038/bjc.2012.60.

Provenge May Have Greater OS Than Previously Reported By Anita T. Shaffer A further analysis of clinical trial data for sipuleucel-T (Provenge, Dendreon) suggests that the therapeutic prostate cancer vaccine may have delivered a greater overall survival (OS) benefit than previously described in the study that paved the way for its approval nearly two years ago, according Leonard G. Gomella, MD to a leading researcher. In fact, the analysis indicated that the survival benefit may be significantly higher than the 4.1-month advantage reported in the IMPACT study when the experiences of patients in the control arm who crossed over to a cryopre12 / 3.12

served form of the vaccine are considered, said Leonard G. Gomella, MD, chairman of the Department of Urology and director of Clinical Affairs at the Kimmel Cancer Center, Thomas Jefferson University, in Philadelphia, Pennsylvania. Gomella discussed his hypothesis at the 5th Annual Interdisciplinary Prostate Cancer Congress (IPCC) March 31 in New York City, for which he served as a program director. The research was presented at the 2012 Genitourinary Cancers Symposium sponsored by the American Society of Clinical Oncology (ASCO) in February and at the 2011 ASCO Annual Meeting. Gomella’s comments come amid continuing controversy over sipuleucel-T, including a recent commentary in the Journal of the National Cancer

Institute that maintained previously unpublished data cast doubt on the vaccine’s survival benefit partly because of factors involving patients in the placebo arm. The FDA approved Provenge on April 29, 2010, for the treatment of asymptomatic or minimally symptomatic metastatic castration-resistant, hormone-refractory prostate cancer based on clinical trial data demonstrating that patients who took the vaccine experienced a median OS of 25.8 months versus 21.7 months for those who received a placebo. Sipuleucel-T is custom-manufactured for each patient from antigen-presenting cells that are harvested from the patient through the process of leukapheresis, then cultured to activate immunogenicity, and infused into the patient. The treatment course consists of three intravenous infusions. In his analysis, Gomella looked more closely at participants in the control arms of three randomized, double-blind sipuleucel-T studies. Of 249 people in the control arms, 216 participants who

The International Journal of TargetedTherapies in Cancer

experienced disease progression had the option of receiving APC8015F, an autologous immunotherapy with the same potency as sipuleucel-T that was made for each patient and cryopreserved at the time the placebo was prepared. For the 155 patients from the control arm who received APC8015F, the median OS was 23.6 months from randomization and 20.0 months following disease progression, which compared favorably with the median OS in the sipuleucel-T arms of 25.4 months from randomization and 20.7 months after progression. In contrast, the 61 participants from the control arm who experienced disease progression but did not cross over to APC8015F had a median OS of 12.7 months from randomization and 9.8 months following disease progression. “The survival difference was dramatically different,” Gomella said during his IPCC presentation. “So in a way, the sipuleucel-T trials shot themselves in the foot because the frozen product was included. If you exclude the frozen product, you actually get a much more dramatic and a much more robust response of about 10 to 12 months.” In an interview, Gomella added, “From my viewpoint, the benefit of sipuleucel-T has been understated because many of the patients who received the frozen product who were on the

control arm actually enjoyed a longer survival, decreasing the difference between the control arm and the treatment arm. “In fact, if you look at our analysis of the patients who received a frozen product on the control arm and those who did not receive it, there was a significant survival advantage to those patients who did receive the frozen product,” said Gomella. “It made the difference between the control arm and the actual treatment arm much closer. And if you take out those patients who did not receive the frozen product on the control arm, that survival difference actually approaches 10 to 11 months.” Gomella’s analysis stands in sharp contrast to the contentions of Huber et al, who argue that previously unpublished trial data show worse OS in older versus younger patients in the placebo groups, and that the difference may stem from the study design. Patients on placebo who were younger than age 65 experienced an 11-month median survival advantage when compared with those over age 65 (28.2 months vs 17.2 months, respectively), the authors said. They contend that the placebo intervention itself may have adversely affected older patients in the placebo arm, and therefore enhanced the sipuleucel-T survival advantage.

“Because two-thirds of the cells harvested from placebo patients, but not from the sipuleucel-T arm, were frozen and not reinfused, a detrimental effect of this large repeated cell loss provides a potential alternative explanation for the survival ‘benefit,’” the authors said. In his IPCC presentation, Gomella said researchers are debating the impact of extracting immune cells, but that a study pending publication indicates the “number of immune cells you pull out of the body with leukapheresis is clinically insignificant.” Meanwhile, Dendreon Corporation, the Seattle, Washington, company that developed Sipuleucel-T, is continuing to investigate the vaccine for patients with earlier-stage disease. REFERENCES • Gomella LG, Nabhan C, Whitmore JB, et al. Postprogression treatment with APC8015F may have prolonged survival of subjects in the control arm of sipuleucel-T phase III studies. Poster presented at: 2011 ASCO Annual Meeting; June 3-7, 2011; Chicago, IL. Abstract 4534. • Huber ML, Haynes L, Parker C, et al. Interdisciplinary critique of sipuleucel-T as immunotherapy in castrationresistant prostate cancer [published online ahead of print January 9, 2012]. J Natl Cancer Inst. 2012;104(4):273-279. • Kantoff PW, Higano CS, Shore ND, et al. Sipuleucel-T immunotherapy for castration-resistant prostate cancer. N Engl J Med. 2010;363(5):411-422. • Nabhan C, Gomella LG, DeVries T, et al. An analysis to quantify the overall survival (OS) benefit of sipuleucel-T accounting for the crossover in the control arm of the IMPACT study. J Clin Oncol. 2012;30(suppl 5;abstract 144).

Hypothyroidism Risks With MKIs Examined By Ben Leach A retrospective analysis of the risks of hypothyroidism in patients in Germany who received sunitinib and sorafenib is gaining attention in the field of head and neck cancers, where the drugs are being evaluated for clinical use. A study published in the European Journal of Cancer earlier this year found that 13.7% of patients on sunitinib and 6.3% of those who took Eric J. Sherman, MD sorafenib were treated with thyroid hormone (TH) therapy typically prescribed to treat hypothyroidism. The study, with findings based on prescription data from 2509 patients, is believed to be the largest database examination of the endocrine disorder among

people taking either of the drugs. Both drugs are multikinase inhibitors (MKIs) that the FDA has approved for the treatment of advanced renal cell carcinoma (RCC). Sunitinib (Sutent, Pfizer) also is approved to treat certain gastrointestinal stromal tumors (GISTs) and pancreatic neuroendocrine tumors, while sorafenib (Nexavar, Bayer/Onyx) is additionally indicated for hepatocellular carcinoma. A number of phase II trials are under way studying the efficacy of sunitinib and sorafenib in the treatment of thyroid cancer. In reviewing the study, Eric J. Sherman, MD, said the findings are notable in his field because MKIs represent a promising class of drugs for thyroid patients. “This study is clinically relevant to anyone treating a patient with thyroid cancer,” he said. Using prescription data from more than 80% of

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German pharmacies, investigators started with an index of 6444 patients for whom one of the two anticancer therapies had been prescribed from July 1, 2006, through December 31, 2007. Clinical hypothyroidism requiring TH therapy was defined as thyroidstimulating hormone (TSH) levels >10 mIU/L. Patients who had been prescribed TH before the study period, those who were not registered in the database, and those who received TH within 29 days of the initial index date were excluded. Data for the remaining 2509 patients were examined based on TH prescriptions written during an observation period that began 30 days after the initial index date through August 31, 2009. In all, 178 of 1295 patients taking sunitinib (13.7%) and 77 of 1214 patients taking sorafenib (6.3%) received TH therapy. Incidence rates were 24.2 per 100 person-years for sunitinib patients 3.12 / 13

and 12.1 per 100 person-years for sorafenib patients, with the unadjusted hazard ratio for TH therapy calculated as 2.0 (95% confidence interval [CI], 1.5-2.6) for sunitinib as compared with sorafenib. Sherman said hypothyroidism has been observed in patients, but that the study marks the first time that there are enough concrete data to make the necessary recommendations. The German research team suggested clinicians exercise caution in prescribing TH for cancer patients with slightly increased serumTSH levels who are not displaying symptoms. “If clinical hypothyroidism occurs, it can be treated with TH, which leads to fast and complete correction of increased TSH values and should not restrict the use of sunitinib and sorafenib in malignant diseases in general,” they concluded. The FDA-approved prescribing information (PI) for Sutent includes a recommendation for a baseline laboratory measurement of thyroid function prior to the start of treatment and advice about monitoring patients for signs of such problems. In May 2011, the PI was updated to include reports of higher rates of hypothyroidism compared with placebo among small groups of patients. The PI for soraferib describes hypothyroidism as an “uncommon” adverse drug reaction and does not include it among the most serious reactions. Sherman said that while hypothyroidism does pose a serious risk to the patient, it is also a very treatable condition. TH can be started as soon as hypothyroidism is identified, and dose rates are monitored throughout treatment. If a patient is taken off sorafenib or sunitinib, it is possible for thyroid levels to return to normal. “It’s very easy to treat,” Sherman said. “It’s just one of those things that you want to make sure you don’t miss.” Feldt S, Schüssel K, Quinzler R, et al. Incidence of thyroid hormone therapy in patients treated with sunitinib or sorafenib: a cohort study [published online ahead of print February 28, 2012]. Eur J Cancer. doi:10.1016/j. ejca.2012.01.036.

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Wikimedia Commons

Targeted Therapy Updates

Bone marrow aspirate showing multiple myeloma.

Elotuzumab Responses High in Multiple Myeloma Study By Ben Leach Elotuzumab, a novel targeted therapy that induces cell breakdown and death in certain cancerous cells, demonstrated notable response rates as combination therapy in a phase II study of patients with relapsed or refractory multiple myeloma. The humanized monoclonal antibody, developed by Bristol-Myers Squibb, targets the cell surface glycoprotein CS1, which is expressed in the tumor cells of more than 95% of patients with multiple myeloma but is minimally expressed in normal cells. In the ongoing trial, 73 patients previously treated with one to three prior therapies were enrolled. Patients received lenalidomide and lowdose dexamethasone with either elotuzumab 10 mg/kg or elotuzumab 20 mg/kg. Of the 36 patients in the elotuzumab 10 mg/kg group, 33 (92%) achieved an objective response rate (ORR), while a 100% ORR was achieved in patients who received one prior therapy before treatment. Of the 37 patients in the elotuzumab 20-mg/kg arm, 27 (73%) achieved an ORR, and an ORR of 82% was seen in patients who received only one prior therapy.

After a 14.1-month median follow-up, between 65% and 75% of patients treated with elotuzumab 10 mg/kg combination therapy achieved progression-free survival (PFS). The most common grade 3/4 treatment-emergent adverse events were neutropenia (16%), thrombocytopenia (16%), and lymphopenia (16%). Two phase III trials incorporating elotuzumab are currently under way. The ELOQUENT 1 study is assessing PFS in previously untreated patients who received elotuzumab 10 mg/kg plus lenalidomide and low-dose dexamethasone, while the ELOQUENT 2 study is assessing PFS in patients with relapsed or refractory multiple myeloma receiving the same dosage. Lonial S, Jakubowiak AJ, Jagannath S, et al. A phase 2 study of elotuzumab in combination with lenalidomide and low-dose dexamethasone in patients with relapsed/refractory multiple myeloma. Blood. Presented at the ASH Annual Meeting. 2011;118(21): abstr 303.

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Brivanib Plus Cetuximab Delivers Mixed Results in Colorectal Study By Alice Goodman Adding brivanib alaninate to cetuximab had no survival advantage over cetuximab alone in patients with KRAS wild-type (WT) chemorefractory metastatic colorectal cancer, according to results of a randomized, phase III trial reported at the ASCO 2012 Gastrointestinal Cancers Symposium. However, both progression-free survival (PFS) and overall response rate (ORR) were improved with the addition of brivanib. Biomarker analysis of this trial is ongoing to determine if specific biomarkers can be identified that are associated with Lillian L. Siu, MD preferential benefit from brivanib, explained lead author Lillian L. Siu, MD, a senior staff physician in the Division of Medical Oncology and Hematology at Princess Margaret Hospital, Toronto, Canada. Brivanib, an investigational drug under development by Bristol-Myers Squibb, is a tyrosine kinase inhibitor that targets vascular endothelial growth factor 2 (VEGF) and fibroblast growth factor receptors. Cetuximab (Erbitux, Bristol-Myers Squibb) is an

epidermal growth factor receptor inhibitor (EGFR) that has improved survival in patients with metastatic, chemorefractory KRAS WT colorectal cancer. The NCIC Clinical Trials Group and AGITG CO.20 trial, sponsored through the Canadian Cancer Society and the Australasian Gastro-Intestinal Trials Group, enrolled 750 patients with chemorefractory, KRAS WT, and metastatic colorectal cancer. Participants were randomized 1:1 to receive either brivanib 800 mg/day orally plus a loading dose of intravenous cetuximab 400 mg/m2 on day 1, then 250 mg/m2 per week versus placebo and the same dose of cetuximab. Both arms were well balanced for prognostic factors, including gender, age, and performance status. More than 90% of patients in both arms received more than three prior lines of therapy (as either neoadjuvant, adjuvant, or metastatic therapy); 40% had one prior anti- VEGF therapy. No prior anti-EGFR therapy was allowed. The study failed to meet its primary endpoint of overall survival (OS). Median OS was 8.8 months in the brivanib arm versus 8.1 months in the control arm. Looking at both planned and unplanned subgroup analyses, no difference in OS was seen

between the two arms for any subgroup. Median PFS was 5 months in the brivanib arm versus 3.4 months in the control arm (P <.0001), but no difference between the two arms in relative PFS benefit was observed in any subgroup. According to RECIST criteria, partial response was 13.6% in the experimental arm versus 7.2% in the control arm (P = .004). There were no complete responses in either arm. Fewer patients in the experimental arm received at least 90% of the planned dose intensity of either drug versus the control arm for cetuximab. Study drugs were discontinued more frequently in the experimental arm. Grade 3 or higher nonhematologic adverse events (fatigue, hypertension, gastrointestinal toxicity, and constitutional symptoms) were more frequent in the brivanib arm (78% vs 53%, respectively). Siu said that the on-treatment adverse events were consistent with those reported for each drug as monotherapy. Ninety-seven percent of patients were assessable for quality of life as reflected by time to deterioration on physical function and global subscales; the control arm had better quality of life on these parameters. Siu LL, Shapiro JD, Jonker DJ, et al. Phase III randomized trial of cetuximab (CET) plus either brivanib alaninate (BRIV) or placebo in patients (pts) with metastatic (MET) chemotherapy refractory K-RAS wild-type (WT) colorectal carcinoma (CRC): The NCIC Clinical Trials Group and AGITG CO.20 trial. J Clin Oncol. 2012;30 (suppl 4; abstr 386).

Stage IVB Stomach (lumen) Greater omentum Liver metastasis

Transverse mesocolon

Tumor

Illustration courtesy of the American Society of Clinical Oncology

Stomach metastasis

Mucosa Transverse colon (lumen)

Primary tumor

Submucosa Muscularis propria Serosa

Midsagittal view of stomach & colon

Anterior view of colon

Primary Tumor (T) T4b

Regional Lymph Nodes (N) Metastasis in 1+ nodes

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Anterior view of body

Distant Metastasis (M) Metastasis in 1+ organ 3.12 / 15

ZYTIGA® (abiraterone acetate) in combination with prednisone is indicated for the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC) who have received prior chemotherapy containing docetaxel.

ADRENALS

PROSTATE TUMOR TISSUE

TESTES

Mechanism of action

Important Safety Information Contraindications—ZYTIGA® may cause fetal harm (Pregnancy Category X) and is contraindicated in women who are or may become pregnant. Hypertension, Hypokalemia, and Fluid Retention Due to Mineralocorticoid Excess—Use with caution in patients with a history of cardiovascular disease or with medical conditions that might be compromised by increases in hypertension, hypokalemia, and fluid retention. ZYTIGA® may cause hypertension, hypokalemia, and fluid retention as a consequence of increased mineralocorticoid levels resulting from CYP17 inhibition. Safety has not been established in patients with LVEF < 50% or New York Heart Association (NYHA) Class III or IV heart failure because these patients were excluded from the randomized clinical trial. Control hypertension and correct hypokalemia before and during treatment. Monitor blood pressure, serum potassium, and symptoms of fluid retention at least monthly. Adrenocortical Insufficiency (AI)—AI has been reported in clinical trials in patients receiving ZYTIGA® in combination with prednisone, after an interruption of daily steroids, and/or with concurrent infection or stress. Use caution and monitor for symptoms and signs of AI if prednisone is stopped or withdrawn, if prednisone dose is reduced, or if the patient experiences unusual stress. Symptoms and signs of AI may be masked by adverse reactions associated with mineralocorticoid excess seen in patients treated with ZYTIGA®. Perform appropriate tests, if indicated, to confirm AI.

Increased dosages of corticosteroids may be used before, during, and after stressful situations. Hepatotoxicity—Increases in liver enzymes have led to drug interruption, dose modification, and/or discontinuation. Monitor liver function and modify, withhold, or discontinue ZYTIGA® dosing as recommended (see Prescribing Information for more information). Measure serum transaminases [alanine aminotransferase (ALT) and aspartate aminotransferase (AST)] and bilirubin levels prior to starting treatment with ZYTIGA®, every two weeks for the first three months of treatment, and monthly thereafter. Promptly measure serum total bilirubin, AST, and ALT if clinical symptoms or signs suggestive of hepatotoxicity develop. Elevations of AST, ALT, or bilirubin from the patient’s baseline should prompt more frequent monitoring. If at any time AST or ALT rise above five times the upper limit of normal (ULN) or the bilirubin rises above three times the ULN, interrupt ZYTIGA® treatment and closely monitor liver function. Food Effect—ZYTIGA® must be taken on an empty stomach. Exposure of abiraterone increases up to 10-fold when abiraterone acetate is taken with meals. No food should be eaten for at least two hours before the dose of ZYTIGA® is taken and for at least one hour after the dose of ZYTIGA® is taken. Abiraterone C max and AUC 0-∞ (exposure) were increased up to 17- and 10-fold higher, respectively, when a single dose of abiraterone acetate was administered with a meal compared to a fasted state.

KAPLAN-MEIER SURVIVAL CURVES OF PATIENTS TREATED WITH EITHER ZYTIGA® + PREDNISONE OR PLACEBO + PREDNISONE (INTERIM ANALYSIS) 100

P < 0.0001; HR = 0.646; 95% CI: 0.543, 0.768

% Survival

ZYTIGA®: 14.8 months (median) (95% CI: 14.1, 15.4)

60 Placebo: 10.9 months (median) (95% CI: 10.2, 12.0)

40 20 0 0

68 30

2 3

0 0

Time to Death (Months) ZYTIGA® 797 Placebo 398

736 355

657 306

520 210

282 105

The median duration of treatment with ZYTIGA® was 8 months.

Proven survival benefit At the interim analysis of the phase 3 study,*† ZYTIGA® in combination with prednisone showed a statistically significant improvement in overall survival compared with placebo plus prednisone and resulted in a 35% reduction in the risk of death (hazard ratio [HR] = 0.646; P < 0.0001; 95% confidence interval [CI]: 0.543, 0.768; median survival: 14.8 months vs 10.9 months, respectively) In an updated survival analysis,‡ results were consistent with those from the interim analysis (HR = 0.74; 95% CI: 0.638, 0.859; median survival: 15.8 months vs 11.2 months)

Janssen Biotech, Inc. © Janssen Biotech, Inc. 2012 3/12 08Z12066A

study in patients with metastatic castration-resistant prostate cancer (mCRPC) who had received prior chemotherapy containing docetaxel (N = 1,195). Patients were randomized 2:1 to receive ZYTIGA® 1,000 mg orally once daily + prednisone 5 mg orally twice daily (n = 797) or placebo orally once daily + prednisone 5 mg orally twice daily (n = 398). Patients were using a gonadotropin-releasing hormone (GnRH) agonist or were previously treated with orchiectomy and were at castration levels of testosterone (serum testosterone ≤ 50 ng/dL).1 The primary efficacy endpoint was overall survival. †552 events. ‡775 events. 08Z11121R3

Adverse Reactions—The most common adverse reactions (≥ 5%) are joint swelling or discomfort, hypokalemia, edema, muscle discomfort, hot flush, diarrhea, urinary tract infection, cough, hypertension, arrhythmia, urinary frequency, nocturia, dyspepsia, fractures and upper respiratory tract infection. Drug Interactions—ZYTIGA® is an inhibitor of the hepatic drug-metabolizing enzyme CYP2D6. Avoid coadministration with CYP2D6 substrates that have a narrow therapeutic index. If an alternative cannot be used, exercise caution and consider a dose reduction of the CYP2D6 substrate. Additionally, abiraterone is a substrate of CYP3A4 in vitro. Strong inhibitors and inducers of CYP3A4 should be avoided or used with caution. Use in Specific Populations—The safety of ZYTIGA® in patients with baseline severe hepatic impairment has not been studied. These patients should not receive ZYTIGA®. *Study Design: ZYTIGA®, in combination with prednisone, was evaluated in a phase 3, randomized, double-blind, placebo-controlled, multicenter

Reference: 1. de Bono JS, Logothetis CJ, Molina A, et al. Abiraterone and increased survival in metastatic prostate cancer. N Engl J Med. 2011;364(21):1995-2005.

Please see adjacent pages for brief summary of full Prescribing Information.

www.zytiga.com

ZYTIGA® (abiraterone acetate) Tablets Brief Summary of Prescribing Information. INDICATIONS AND USAGE ZYTIGA in combination with prednisone is indicated for the treatment of patients with metastatic castration-resistant prostate cancer (CRPC) who have received prior chemotherapy containing docetaxel. CONTRAINDICATIONS Pregnancy: ZYTIGA may cause fetal harm when administered to a pregnant woman. ZYTIGA is contraindicated in women who are or may become pregnant. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. WARNINGS AND PRECAUTIONS Hypertension, Hypokalemia and Fluid Retention Due to Mineralocorticoid Excess: Use ZYTIGA with caution in patients with a history of cardiovascular disease. ZYTIGA may cause hypertension, hypokalemia, and fluid retention as a consequence of increased mineralocorticoid levels resulting from CYP17 inhibition [see Adverse Reactions and Clinical Pharmacology (12.1) in full Prescribing Information]. Co-administration of a corticosteroid suppresses adrenocorticotropic hormone (ACTH) drive, resulting in a reduction in the incidence and severity of these adverse reactions. Use caution when treating patients whose underlying medical conditions might be compromised by increases in blood pressure, hypokalemia or fluid retention, e.g., those with heart failure, recent myocardial infarction or ventricular arrhythmia. The safety of ZYTIGA in patients with left ventricular ejection fraction <50% or NYHA Class III or IV heart failure has not been established because these patients were excluded from the randomized clinical trial. Monitor patients for hypertension, hypokalemia, and fluid retention at least once a month. Control hypertension and correct hypokalemia before and during treatment with ZYTIGA. Adrenocortical Insufficiency: Adrenocortical insufficiency has been reported in clinical trials in patients receiving ZYTIGA in combination with prednisone, following interruption of daily steroids and/or with concurrent infection or stress. Use caution and monitor for symptoms and signs of adrenocortical insufficiency, particularly if patients are withdrawn from prednisone, have prednisone dose reductions, or experience unusual stress. Symptoms and signs of adrenocortical insufficiency may be masked by adverse reactions associated with mineralocorticoid excess seen in patients treated with ZYTIGA. If clinically indicated, perform appropriate tests to confirm the diagnosis of adrenocortical insufficiency. Increased dosage of corticosteroids may be indicated before, during and after stressful situations [see Warnings and Precautions]. Hepatotoxicity: Marked increases in liver enzymes leading to drug discontinuation or dosage modification have occurred [see Adverse Reactions]. Measure serum transaminases (ALT and AST) and bilirubin levels prior to starting treatment with ZYTIGA, every two weeks for the first three months of treatment and monthly thereafter. In patients with baseline moderate hepatic impairment receiving a reduced ZYTIGA dose of 250 mg, measure ALT, AST, and bilirubin prior to the start of treatment, every week for the first month, every two weeks for the following two months of treatment and monthly thereafter. Promptly measure serum total bilirubin, AST, and ALT if clinical symptoms or signs suggestive of hepatotoxicity develop. Elevations of AST, ALT, or bilirubin from the patient’s baseline should prompt more frequent monitoring. If at any time AST or ALT rise above five times the ULN, or the bilirubin rises above three times the ULN, interrupt ZYTIGA treatment and closely monitor liver function. Re-treatment with ZYTIGA at a reduced dose level may take place only after return of liver function tests to the patient’s baseline or to AST and ALT less than or equal to 2.5X ULN and total bilirubin less than or equal to 1.5X ULN [see Dosage and Administration (2.2) in full Prescribing Information]. The safety of ZYTIGA re-treatment of patients who develop AST or ALT greater than or equal to 20X ULN and/or bilirubin greater than or equal to 10X ULN is unknown. Food Effect: ZYTIGA must be taken on an empty stomach. No food should be consumed for at least two hours before the dose of ZYTIGA is taken and for at least one hour after the dose of ZYTIGA is taken. Abiraterone Cmax and AUC0-∞ (exposure) were increased up to 17- and 10-fold higher, respectively, when a single dose of abiraterone acetate was administered with a meal compared to a fasted state. The safety of these increased exposures when multiple doses of abiraterone acetate are taken with food has not been assessed [see Dosage and Administration (2.1) and Clinical Pharmacology (12.3) in full Prescribing Information]. ADVERSE REACTIONS The following are discussed in more detail in other sections of the labeling: Hypertension, hypokalemia, and fluid retention due to mineralocorticoid excess [see Warnings and Precautions]. Adrenocortical insufficiency [see Warnings and Precautions]. Hepatotoxicity [see Warnings and Precautions]. Food effect [see Warnings and Precautions]. Clinical Trial Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. In a placebo-controlled, multicenter phase 3 clinical trial of patients with metastatic castration-resistant prostate cancer who were using a gonadotropin-releasing hormone (GnRH) agonist or were previously treated with orchiectomy, ZYTIGA was administered at a dose of 1,000 mg daily in combination with prednisone 5 mg twice daily in the active treatment arm (N = 791). Placebo plus prednisone 5 mg twice daily was given to control patients (N = 394). The median duration of treatment with ZYTIGA was 8 months. The most common adverse drug reactions (≥5%) reported in clinical studies were joint swelling or discomfort, hypokalemia, edema, muscle discomfort, hot flush, diarrhea, urinary tract infection, cough, hypertension, arrhythmia, urinary frequency, nocturia, dyspepsia, fractures and upper respiratory tract infection. The most common adverse drug reactions that resulted in drug discontinuation were aspartate aminotransferase increased, alanine aminotransferase increased, urosepsis and cardiac failure (each in <1% of patients taking ZYTIGA). Adverse reactions and laboratory abnormalities related to mineralocorticoid effects were reported more commonly in patients treated with ZYTIGA than in patients treated with placebo: hypokalemia 28% versus 20%, hypertension 9% versus 7% and fluid retention (edema) 27% versus 18%, respectively (see Table 1). In patients treated with ZYTIGA, grades 3 to 4 hypokalemia occurred in 5% of patients and grades 3 to 4 hypertension was reported in 1% of patients [see Warnings and Precautions].

ZYTIGA® (abiraterone acetate) Tablets Table 1 shows adverse reactions due to ZYTIGA that occurred with either a ≥ 2% absolute increase in frequency compared to placebo, or were events of special interest (mineralocorticoid excess, cardiac adverse reactions, and liver toxicities). Table 1: Adverse Reactions due to ZYTIGA in a Placebo-Controlled Phase 3 Trial ZYTIGA with Placebo with Prednisone Prednisone (N=791) (N=394) System/Organ Class All Grades1 Grade 3-4 All Grades Grade 3-4 Adverse reaction % % % % Musculoskeletal and connective tissue disorders Joint swelling/discomfort2 29.5 4.2 23.4 4.1 Muscle discomfort3 26.2 3.0 23.1 2.3 General disorders Edema4 26.7 1.9 18.3 0.8 Vascular disorders Hot ﬂush 19.0 0.3 16.8 0.3 Hypertension 8.5 1.3 6.9 0.3 Gastrointestinal disorders Diarrhea 17.6 0.6 13.5 1.3 Dyspepsia 6.1 0 3.3 0 Infections and infestations Urinary tract infection 11.5 2.1 7.1 0.5 Upper respiratory tract infection 5.4 0 2.5 0 Respiratory, thoracic and mediastinal disorders Cough 10.6 0 7.6 0 Renal and urinary disorders Urinary frequency 7.2 0.3 5.1 0.3 Nocturia 6.2 0 4.1 0 Injury, poisoning and procedural complications Fractures5 5.9 1.4 2.3 0 Cardiac disorders 7.2 1.1 4.6 1.0 Arrhythmia6 3.8 0.5 2.8 0 Chest pain or chest discomfort 7 8 2.3 1.9 1.0 0.3 Cardiac failure 1

Adverse events graded according to CTCAE version 3.0 Includes terms Arthritis, Arthralgia, Joint swelling, and Joint stiffness Includes terms Muscle spasms, Musculoskeletal pain, Myalgia, Musculoskeletal discomfort, and Musculoskeletal stiffness 4 Includes terms Edema, Edema peripheral, Pitting edema, and Generalized edema 5 Includes all fractures with the exception of pathological fracture 6 Includes terms Arrhythmia, Tachycardia, Atrial fibrillation, Supraventricular tachycardia, Atrial tachycardia, Ventricular tachycardia, Atrial flutter, Bradycardia, Atrioventricular block complete, Conduction disorder, and Bradyarrhythmia 7 Includes terms Angina pectoris, Chest pain, and Angina unstable. Myocardial infarction or ischemia occurred more commonly in the placebo arm than in the ZYTIGA arm (1.3% vs. 1.1% respectively). 8 Includes terms Cardiac failure, Cardiac failure congestive, Left ventricular dysfunction, Cardiogenic shock, Cardiomegaly, Cardiomyopathy, and Ejection fraction decreased Cardiovascular Adverse Reactions: Cardiovascular adverse reactions in the phase 3 trial are shown in Table 1. The majority of arrhythmias were grade 1 or 2. Grade 3-4 arrhythmias occurred at similar rates in the two arms. There was one death associated with arrhythmia and one patient with sudden death in the ZYTIGA arm. No patients had sudden death or arrhythmia associated with death in the placebo arm. Cardiac ischemia or myocardial infarction led to death in 2 patients in the placebo arm and 1 death in the ZYTIGA arm. Cardiac failure resulting in death occurred in 1 patient on both arms. Hepatotoxicity: Drug-associated hepatotoxicity with elevated ALT, AST, and total bilirubin has been reported in patients treated with ZYTIGA. Across all clinical trials, liver function test elevations (ALT or AST increases of > 5X ULN) were reported in 2.3% of patients who received ZYTIGA, typically during the first 3 months after starting treatment. In the phase 3 trial, patients whose baseline ALT or AST were elevated were more likely to experience liver function test elevations than those beginning with normal values. When elevations of either ALT or AST > 5X ULN, or elevations in bilirubin > 3X ULN were observed, ZYTIGA was withheld or discontinued. In two instances marked increases in liver function tests occurred [see Warnings and Precautions]. These two patients with normal baseline hepatic function, experienced ALT or AST elevations 15 to 40X ULN and bilirubin elevations 2 to 6 X ULN. Upon discontinuation of ZYTIGA, both patients had normalization of their liver function tests and one patient was re-treated with ZYTIGA without recurrence of the elevations. In clinical trials, the following patients were excluded: patients with active hepatitis, patients with baseline ALT and/or AST ≥ 2.5X ULN in the absence of liver metastases, and patients with ALT and/or AST > 5X ULN in the presence of liver metastases. Abnormal liver function tests developing in patients participating in clinical trials were managed by treatment interruption, dose modification and/or discontinuation [see Dosage and Administration (2.2) in full Prescribing Information and Warnings and Precautions]. Patients with elevations of ALT or AST > 20X ULN were not re-treated. Other Adverse Reactions: Adrenal insufficiency occurred in two patients on the abiraterone arm of the phase 3 clinical trial (< 1%). Laboratory Abnormalities of Interest: Table 2 shows laboratory values of interest from the phase 3 placebo-controlled clinical trial. Grade 3-4 low serum phosphate (7.2%) and potassium (5.3%) occurred more frequently in the ZYTIGA arm. 2 3

ZYTIGA® (abiraterone acetate) Tablets Table 2: Laboratory Abnormalities of Interest in a Phase 3 Placebo-Controlled Clinical Trial Abiraterone (N=791) Placebo (N=394) All Grades Grade 3-4 All Grades Grade 3-4 Laboratory Abnormality (%) (%) (%) (%) High Triglyceride 62.5 0.4 53.0 0 High AST 30.6 2.1 36.3 1.5 Low Potassium 28.3 5.3 19.8 1.0 Low Phosphorus 23.8 7.2 15.7 5.8 High ALT 11.1 1.4 10.4 0.8 High Total Bilirubin 6.6 0.1 4.6 0 DRUG INTERACTIONS Effects of Abiraterone on Drug Metabolizing Enzymes: ZYTIGA is an inhibitor of the hepatic drug-metabolizing enzyme CYP2D6. In a CYP2D6 drug-drug interaction trial, the Cmax and AUC of dextromethorphan (CYP2D6 substrate) were increased 2.8- and 2.9-fold, respectively, when dextromethorphan was given with abiraterone acetate 1,000 mg daily and prednisone 5 mg twice daily. Avoid co-administration of abiraterone acetate with substrates of CYP2D6 with a narrow therapeutic index (e.g., thioridazine). If alternative treatments cannot be used, exercise caution and consider a dose reduction of the concomitant CYP2D6 substrate drug [see Clinical Pharmacology (12.3) in full Prescribing Information]. Drugs that Inhibit or Induce CYP3A4 Enzymes: Based on in vitro data, ZYTIGA is a substrate of CYP3A4. The effects of strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin, atazanavir, nefazodone, saquinavir, telithromycin, ritonavir, indinavir, nelfinavir, voriconazole) or inducers (e.g., phenytoin, carbamazepine, rifampin, rifabutin, rifapentine, phenobarbital) on the pharmacokinetics of abiraterone have not been evaluated, in vivo. Avoid or use with caution, strong inhibitors and inducers of CYP3A4 during ZYTIGA treatment [see Clinical Pharmacology (12.3) in full Prescribing Information]. USE IN SPECIFIC POPULATIONS Pregnancy: Pregnancy Category X [see Contraindications]. ZYTIGA is contraindicated in women who are or may become pregnant while receiving the drug. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus and the potential risk for pregnancy loss. Women of childbearing potential should be advised to avoid becoming pregnant during treatment with ZYTIGA. Nursing Mothers: ZYTIGA is not indicated for use in women. It is not known if abiraterone acetate is excreted in human milk. Because many drugs are excreted in human milk, and because of the potential for serious adverse reactions in nursing infants from ZYTIGA, a decision should be made to either discontinue nursing, or discontinue the drug taking into account the importance of the drug to the mother. Pediatric Use: ZYTIGA is not indicated in children. Geriatric Use: Of the total number of patients in a phase 3 trial of ZYTIGA, 71% of patients were 65 years and over and 28% were 75 years and over. No overall differences in safety or effectiveness were observed between these elderly patients and younger patients. Patients with Hepatic Impairment: The pharmacokinetics of abiraterone were examined in subjects with baseline mild (n = 8) or moderate (n = 8) hepatic impairment (ChildPugh Class A and B, respectively) and in 8 healthy control subjects with normal hepatic function. The systemic exposure (AUC) of abiraterone after a single oral 1,000 mg dose of ZYTIGA increased by approximately 1.1-fold and 3.6-fold in subjects with mild and moderate baseline hepatic impairment, respectively compared to subjects with normal hepatic function. No dosage adjustment is necessary for patients with baseline mild hepatic impairment. In patients with baseline moderate hepatic impairment (Child-Pugh Class B), reduce the recommended dose of ZYTIGA to 250 mg once daily. If elevations in ALT or AST >5X ULN or total bilirubin >3X ULN occur in patients with baseline moderate hepatic impairment, discontinue ZYTIGA treatment [see Dosage and Administration (2.1) and Clinical Pharmacology (12.3) in full Prescribing Information]. The safety of ZYTIGA in patients with baseline severe hepatic impairment has not been studied. These patients should not receive ZYTIGA. For patients who develop hepatotoxicity during treatment, interruption of treatment and dosage adjustment may be required [see Dosage and Administration (2.2) in full Prescribing Information, Warnings and Precautions, and Clinical Pharmacology (12.3) in full Prescribing Information]. Patients with Renal Impairment: In a dedicated renal impairment trial, the mean PK parameters were comparable between healthy subjects with normal renal function (N=8) and those with end stage renal disease (ESRD) on hemodialysis (N=8) after a single oral 1,000 mg dose of ZYTIGA. No dosage adjustment is necessary for patients with renal impairment [see Dosage and Administration (2.1) and Clinical Pharmacology (12.3) in full Prescribing Information]. OVERDOSAGE: There have been no reports of overdose of ZYTIGA during clinical studies. There is no specific antidote. In the event of an overdose, stop ZYTIGA, undertake general supportive measures, including monitoring for arrhythmias and cardiac failure and assess liver function. Storage and Handling: Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F) [see USP controlled room temperature]. Based on its mechanism of action, ZYTIGA may harm a developing fetus. Therefore, women who are pregnant or women who may be pregnant should not handle ZYTIGA without protection, e.g., gloves [see Use in Specific Populations]. Manufactured by: Patheon Inc. Mississauga, Canada Manufactured for: Janssen Biotech, Inc. Horsham, PA 19044 Issued: December 2011

08Z11205B

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Strategies Targeting the Hallmarks of Cancer EGFR inhibitors

Sustaining proliferative signaling

Aerobic glycolysis inhibitors

Cyclin-dependent kinase inhibitors

Evading growth suppressors

Deregulating cellular energetics

Proapoptotic BH3 mimetics

Immune-activating anti-CTLA4 mAb Avoiding immune destruction

Resisting cell death

Enabling replicative immortality

Genome instability & mutation

PARP inhibitors

Telomerase Inhibitors

Tumorpromoting inflammation Inducing angiogenesis

Inhibitors of VEGF signaling

Selective antiinflammatory drugs

Activating invasion & metastasis

Inhibitors of HGF/c-Met

This figure illustrates some of the many approaches employed in developing therapeutics targeted to the known and emerging hallmarks of cancer. EGFR indicates epidermal growth factor receptor; CTLA4, cytotoxic T lymphocyte-associated antigen 4; mAb, monoclonal antibody; HGF, hepatocyte growth factor; VEGF, vascular endothelial growth factor; PARP, poly-(ADP ribose) polymerase. Source: Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011;144:646-674. Adapted with permission.

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The International Journal of TargetedTherapies in Cancer

Cancer Research Moves Beyond the Original “Hallmarks of Cancer” Cover Story

By Jane de Lartigue, PhD

At the turn of the millennium, Douglas Hanahan and Robert Weinberg presented their seminal article on the “hallmarks of cancer,” six alterations in cellular physiology that are essential to the transformation of normal cells into cancerous ones.1 Just over a decade has passed since then, and though the hallmarks remain central to tumor biology and research, it is now generally accepted that the original six hallmarks may not be sufficient for malignant transformation, and that additional hallmark capabilities may be involved.2

The International Journal of TargetedTherapies in Cancer

Impaired Metabolism: Cancer’s Sweet Tooth Research has shown that cancer cells undergo a metabolic switch, a fundamental change in the metabolism of all four major classes of macromolecules (carbohydrates, proteins, lipids, and nucleic acids).3 The Warburg effect4 is the best characterized metabolic change, in which cancer cells switch their means of energy production from oxidative phosphorylation to glycolysis, even in the presence of Oxidative phosphorylation normal levels of A metabolic pathway that uses energy oxygen (thus termed released by the oxidation of nutrients to aerobic glycolysis). produce adenosine triphosphate (ATP). To compensate for the reduced ATP Aerobic glycolysis production efficiency In normal cells, in the absence of with aerobic glyoxygen, energy production switches from colysis, cancer cells oxidative phosphorylation to anaerobic increase uptake of glycolysis, whereby glucose is converted glucose, a phenomeinto pyruvate in order to generate ATP. non that has proved Cancer cells use glycolysis to generate useful for tumor energy even in the presence of oxygen. detection and monitoring, serving as the basis for [18F]fluorodeoxyglucose positron emission tomography (FDGPET). The Warburg effect has since been demonstrated in numerous tumor types, and genes for glycolysis are overexpressed in the majority of cancers examined, leading to the suggestion that altered metabolism should be considered an additional hallmark of cancer.3,5 A variety of therapeutic strategies targeting different points in the glycolytic pathway are being evaluated.3 During the initial stages of tumor growth, the low oxygen environment promotes expression of hypoxiainducible factor (HIF) 1, a major transcription factor that subsequently activates numerous glycolytic enzymes, including pyruvate dehydrogenase kinases (PDKs), lactate dehydrogenase (LDH)6, and glucose-6-phosphate dehydrogenase (G6PD). 3.12 / 21

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A variety of inhibitors targeting these proteins have been developed. The G6PD inhibitor, 6-amino-nicotinamide, has demonstrated antitumor effects in leukemia, glioblastoma, and lung cancer cell lines.3 Salts of dichloroacetate (DCA), which inhibit PDK, are in phase II trials for squamous cell carcinoma of the head and neck.7 EZN-2968 from Enzon Pharmaceuticals (an antisense oligonucleotide inhibitor of HIF1) is in phase I trials for advanced solid tumors.8 LDH inhibitors are among the most promising agents, though they remain in the early stages of development.6 The serine/threonine kinase AKT is also an important driver of the glycolytic phenotype, stimulating ATP generation through multiple mechanisms; the AKT inhibitor MK-2206 (Merck & Co.) is currently undergoing phase II trials in non-small cell lung cancer (NSCLC) and hematological cancers, among others.9 AMP-activated protein kinase (AMPK) couples energy status to growth signals, and as such, a considerable amount of research has focused on determining whether agonists of AMPK could be used to recouple these signals in cancer cells and shut down cell growth. Examples of AMPK agonists that are under evaluation include the commonly used antidiabetic drugs metformin and phenformin.3 Not all tumors use aerobic glycolysis; approximately 30% of tumors are FDGPET–negative. Some tumors use glutamine instead. Drugs targeting glutamine include phenylacetate, which completed phase II trials for brain tumors,10 and the green tea polyphenol EGCG, which may target glutamine metabolism and is in phase I trials for small cell lung carcinoma.11,12 However, previous studies with these agents have reported mediocre results and, as such, efforts are ongoing to develop more specific and potent inhibitors of glutamine. Some researchers take the theory of altered cancer cell metabolism one step further and believe that all other hallmarks of cancer can be linked to altered metabolism, and that, in fact, cancer should be viewed as a metabolic disease.12 This is an important hypothesis because, if true, it could change the way that we treat cancer. Current treatment paradigms are typically based on the premise that cancer is a genetic disease, and that genomic instability (see below) and the accumulation of genetic mutations are the initiating factors in the development of cancer; usually, treatment strategies involve targeting proteins that are overexpressed, or whose expression is lost as a result of a mutation. Potential metabolic therapies include dietary restriction, which naturally lowers glucose levels and has been shown to significantly reduce growth and progression of numerous tumor types (including mammary, brain, pancreas, colon, lung, and prostate). Dietary restriction has the potential to be a broadspectrum, nontoxic therapy that targets multiple signaling pathways at once; however, the strategy of long-term 20% to 40% calorie restriction that has been studied for many years is associated with chronic weight loss (cachexia). Therefore, current American Cancer Society recommendations suggest that cancer patients receiving chemotherapy should increase calorie and protein intake. However, more recent studies have shown that fasting for up to five days, followed by a normal diet, may protect patients against the toxic effects of chemotherapy (by differentially protecting normal cells from chemotherapeutic drugs) without causing cachexia. Numerous clinical trials are examining the impact of dietary restrictions on the risk of various cancers.12,13 Thus, dietary restriction could represent a promising adjuvant to chemo- or radiation therapy.

Genomic Instability: How Do Tumors Accumulate So Many Mutations? In the “chicken-and-egg” question of what is the initiating step in cancer, the majority of researchers still view cancer as a genetic disease, the result of a succession of alterations in the genome of normal cells that drives the

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acquisition of the hallmarks of cancer. However, the Genomic instability ability of genomic “guardAn increased tendency of alterations, ians,” such as the tumor in the form of mutations and suppressor protein p53, to chromosomal rearrangements, to detect and repair DNA damthe genome of cancer cells. age, ensures that rates of spontaneous mutation are usually very low. Genomic instability explains the increased susceptibility of the cancer genome to mutation and is a key characteristic of all cancer cells. Thus, it has been proposed that genomic instability is another hallmark of cancer. Others feel it should be treated as an “enabling characteristic” of all other hallmarks of cancer. We still have a very limited understanding of the molecular mechanisms underlying genomic instability. Different tumors (even different examples of the same tumor type) have different patterns of DNA mutation, which is a key limiting factor to currently available therapeutic strategies that target oncogenic signaling pathways. Identifying the initiating step in genomic instability and targeting that could prove to be an important therapeutic strategy in the future.14,15

Epigenetic Changes: Flipping the Genetic Switch Epigenetic factors, such as DNA methylation and histone modification, ensure the timely expression or silencing of genes. They are particularly important in differentiated cells, silencing the expression of developmental genes and allowing the expression of only tissue-specific and housekeeping genes. Alterations in the patterns of epigenetic modification may Epigenetics lead to inappropriate Biochemical changes to the DNA reactivation of dethat don’t involve an alteration in the velopmental genes, nucleotide sequence (as mutations do), driving cancer. but still affect gene expression or cellular Studies over the phenotype. Epigenetic mechanisms last decade have include the addition of methyl groups to shown the importhe DNA or the packaging of the DNA tance of epigenetic with histone proteins. mechanisms in regulating the expression Epigenome of genes critical to The overall epigenetic state of the DNA cellular transforwithin an individual cell. mation pathways. Combined with the observation that cancer cells have a distinct epigenome compared with normal cells, this has led to the suggestion that epigenetic modulation should be considered another hallmark of cancer.16 Unlike genetic alterations, epigenetic changes are potentially reversible, and it might be possible to “reset” the cancer epigenome with pharmacologic or genetic therapeutic strategies. A number of agents are under evaluation in this respect. Demethylating drugs, which inhibit methylation, include 5-azacitidine (Vidaza, Celgene) and 5-azadeoxycitidine/decitabine (Dacogen, Eisai, Inc). Both citidine analogs are FDA-approved for the treatment of myelodysplastic syndrome, which transforms into acute myeloid leukemia (AML) in one-third of patients. Both are also currently undergoing phase III trials for AML.16-18

The International Journal of TargetedTherapies in Cancer

Table. Key Therapeutics Targeting the “New” Hallmarks Therapeutic Agent

Hallmark Targeted

Manufacturer

Stage of Development/Clinical Trials

Dichloroacetate

Metabolism

Sanford Health

Phase II trial for squamous cell carcinoma of the head and neck in combination with cisplatin and definitive radiation (Clinicaltrials.gov identifier: NCT01386632).

HIF-1–inhibitors (EZN-2968)

Metabolism

Enzon Pharmaceuticals

Phase I trial in adults with advanced solid tumors with liver metastases (Clinicaltrials.gov identifier: NCT01120288).

AKT inhibitors (eg, MK-2206)

AKT inhibitors primarily target the original hallmarks of cancer associated with dysregulated growth of cells; however, they may also target the altered metabolism of cancer cells of the head and neck in combination with cisplatin and definitive radiation (Clinicaltrials.gov identifier: NCT01349933).

Merck & Co., Inc.

Phase II trials in the treatment of recurrent platinum-resistant ovarian, fallopian tube, or peritoneal cancer (Clinicaltrials.gov identifier: NCT01283035), relapsed refractory acute myelogenous leukemia (Clinicaltrials.gov identifier: NCT01253447), relapsed or refractory diffuse large B cell lymphoma (Clinicaltrials.gov identifier: NCT01466868), advanced colorectal carcinoma (Clinicaltrials.gov identifier: NCT01333475), relapsed lymphoma (Clinicaltrials. gov identifier: NCT01258998), relapsed chronic lymphocytic leukemia or small lymphocytic leukemia in combination with bendamustine hydrochloride and rituximab (Clinicaltrials.gov identifier: NCT01369849), stage I, II, and III breast cancer (Clinicaltrials.gov identifier: NCT01319539), advanced gastric or gastroesophageal junction cancer (Clinicaltrials.gov identifier: NCT01260701), advanced breast cancer tumors with PIK3CA mutations and/or PTEN loss (Clinicaltrials.gov identifier: NCT01277757), and other phase I and II trials.

Metformin

Metabolism

Demethylating drugs (5-azacitidine and 5-azadeoxycitidine)

Epigenetic alterations

miRNA-based therapy (anti-miR-122/ miravirsen)

Epigenetic alterations

Santaris Pharma

Completed phase II trials for the treatment of hepatitis C virus and the prevention of associated liver cancer (Clinicaltrials.gov identifier: NCT01200420).

Sipuleucel-T (Provenge)

Immune system evasion

Dendreon Corporation

FDA-approved for the treatment of advanced, hormone-refractory prostate cancer. Also currently undergoing a number of phase II trials in prostate cancer patients in combination with a variety of other agents.

Ipilimumab (Yervoy)

Immune system evasion

Bristol-Myers Squibb

FDA-approved for the treatment of metastatic melanoma. Currently undergoing phase II trials in the neoadjuvant setting in combination with leuprolide acetate in prostate cancer patients (Clinicaltrials.gov identifier: NCT01194271) and a phase I trial in Japanese subjects with non-small cell lung cancer in combination with paclitaxel and carboplatin (Clinicaltrials.gov identifier: NCT01165216).

Daclizumab (Zenapax)

Immune system evasion

Roche

Currently undergoing phase II trials in combination with chemotherapy and stem cell transplant for Hodgkin lymphoma (Clinicaltrials.gov identifier: NCT01468311).

Basiliximab (Simulect)

Immune system evasion

Novartis

Currently undergoing phase II trials for the prevention of graft-versus-host disease after nonmyeloablative allotransplantation for the treatment of blood cancer (Clinicaltrials.gov identifier: NCT00975975).

Phase III trials in early-stage breast cancer (Clinicaltrials.gov identifier: NCT01101438), and a number of phase II trials in patients with breast cancer, (Clinicaltrials.gov identifier: NCT01266486), in combination with chemotherapy in patients with pancreatic cancer (Clinicaltrials.gov identifier: NCT01210911), in combination with paclitaxel in patients with metastatic or recurrent head and neck cancer (Clinicaltrials.gov identifier: NCT01333852), among others. Celgene Eisai, Inc.

Another mechanism of epigenetic control is through microRNAs (miRNAs), small noncoding RNAs that regulate gene expression. Studies have shown that miRNA expression is deregulated in cancer. miRNA-based anticancer therapies are being developed via two different strategies: (1) use of oligonucleotides or virus-based constructs to block the expression of an oncogenic miRNA or substitute for the loss of expression of a tumor-suppressing miRNA; and (2) use of small-molecule drugs to modulate miRNA expression by targeting their transcription or processing. An example of the former is anti-miR-122 (miravirsen, SPC3649, Santaris Pharma), which has completed The International Journal of TargetedTherapies in Cancer

Both 5-azacitidine (Vidaza) and 5-azadeoxycitidine (Dacogen/decitabine) are FDA-approved for the treatment of myelodysplastic syndrome. Also undergoing phase III clinical testing for acute myeloid leukemia (Clinicaltrials.gov identifiers: NCT00260832 and NCT01074047) and a number of phase I/II trials, for example in combination with capecitabine and oxaliplatin for the treatment of metastatic colorectal cancer (Clinicaltrials.gov identifier: NCT01193517) and in minimal residual disease chronic myeloid leukemia (Clinicaltrials.gov identifier: NCT01460498).

phase I and II clinical trials for the treatment of the hepatitis C virus and the prevention of associated liver cancer. Small-molecule inhibitors are in the early stages of development, focusing on miR-21, which is frequently upregulated in cancer.19

The Immune System and Inflammation There has been much debate over the role of the immune system in cancer; it appears to play a dual role in fighting off and in promoting cancer growth. In the early 2000s, researchers developed the “immunoediting” hypothesis, 3.12 / 23

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which suggests that an immune response is initially raised against cancer cells (the “elimination” stage). Subsequently, the surviving cancer cells accumulate mutations that enable them to evade the immune response, a so-called “equilibrium” stage. Eventually, the tumor cells that have acquired the ability to evade the immune system establish themselves as a growing tumor (the “escape” stage).20 As a result, immune evasion is now considered to be an additional hallmark of cancer, while inflammation is thought to be an “enabling characteristic,” supplying molecules that support growth, survival, and angiogenesis, among other cancer hallmarks, into the tumor microenvironment.2,21 A variety of forms of immunotherapy are being explored as possible treatments for cancer. These include vaccines, designed to elicit an immune response to specific tumor antigens, monoclonal antibodies targeting tumor antigens, and small-molecule inhibitors against molecular or cellular mediators of cancer-induced immunosuppression.20 Vaccines offer the advantages of being easy and relatively inexpensive to produce, easy to administer in a clinical setting, and specific to particular tumor types. Vaccines against a number of different tumor antigens are being developed as anticancer treatments.22 The results of many vaccination trials have been disappointing, possibly because they have been conducted in metastatic patients. It is now believed they will be more active in patients with minimal residual tumor burden, such as after preoperative chemotherapy. Sipuleucel-T (Provenge, Dendreon Corporation) is the first FDA-approved cancer vaccine, a dendritic cell vaccine approved for treatment of advanced, hormone-refractory prostate cancer.20,22,23 Ipilimumab (Yervoy, Bristol-Myers Squibb) is a monoclonal antibody against cytotoxic T lymphocyte antigen-4 (CTLA-4) that is FDA-approved for the treatment of metastatic melanoma, and is currently undergoing phase II trials in the neoadjuvant setting in prostate cancer and phase I trials in combination with chemotherapy in non-small cell lung cancer patients, among other trials.20 At a Glance… Cancer cells undergo fundamental changes in their metabolism, with the best characterized being the “Warburg effect.” Since the metabolism of cancer cells is different from normal cells in the body, targeting molecular components of that altered metabolism may offer potential therapeutic strategies. Targeting metabolism as a whole through dietary restriction is also being investigated. Cancer cells develop a succession of alterations to their genome that results in the acquisition of other hallmarks of cancer, a phenomenon termed genomic instability. It is now believed that genomic instability constitutes a hallmark of its own, or indeed may be the initiating “enabling characteristic” that drives the formation of cancer. The reversible modifications that the DNA undergoes, known as epigenetic changes, are different in cancer cells, which may be important in regulating the expression of genes critical to the formation of cancer. It may be possible to “reset” the epigenome of a cancer cell using a variety of pharmacologic or genetic therapies. The immune system appears to play a dual role in cancer, both fighting it off in the early stages and subsequently promoting cancer growth later on in the development of cancer. A number of forms of immunotherapy are being developed as possible cancer treatments, including vaccines, monoclonal antibodies, and small-molecule inhibitors.

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Finally, T regulatory (Treg) cells have been identified as one of the most powerful suppressors of the antitumor immune response. Studies have shown a clear relationship between the ratio of Treg cells to T effector (Teff ; killing) cells and patient prognosis; the fewer Treg cells, the better. Although research is still in its infancy, evidence suggests that inhibition of Treg cells may provide an extremely useful therapeutic strategy, particularly in combination with immunotherapies that activate Teff cells. Treg cell-targeting strategies thus far have focused on monoclonal antibodies or ligand-directed toxins targeted against receptors on the surface of the cells. They include two drugs that target the cell surface molecule CD25: daclizumab (Zenapax, Roche), undergoing clinical trials in patients with Hodgkin lymphoma, and basiliximab, (Simulect, Novartis), in phase I/II clinical trials in patients with Hodgkin and non-Hodgkin lymphoma, cutaneous melanoma, peripheral T cell lymphoma, and breast cancer.24,25 Jane de Lartigue, PhD, is a freelance medical writer and editor based in the United Kingdom.

REFERENCES 1. Hanahan DW, Weinberg RA. The hallmarks of cancer. Cell. 2000;100:57-70. 2. Hanahan, DW, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011;144:646-674. 3. Cairns RA, Harris IS, Mak TW. Regulation of cancer cell metabolism. Nature Rev Cancer. 2011;11(2):85-95. 4. Warburg O. On respiratory impairment in cancer cells. Science. 1956;124;269-270. 5. Hsu PP, Sabatini DM. Cancer cell metabolism: Warburg and beyond. Cell. 2008;134(5):703-707. 6. Granchi C, Bertini S, Macchia M, Minutolo F. Inhibitors of lactate dehydrogenase isoforms and their therapeutic potentials. Curr Med Chem. 2010;17:672-697. 7. ClinicalTrials.gov. Study of DCA (Dichloroacetate) in combination with cisplatin and definitive radiation in head and neck carcinoma, http://clinicaltrials.gov/ct2/show/NCT01386632?term= dichloroacetate&rank=3. Accessed April 18, 2012. 8. ClinicalTrials.gov. A pilot study of EZN-2968, an antisense oligonucleotide inhibitor of HIF1alpha, in adults with advanced solid tumors with liver metastases, http://clinicaltrials.gov/ ct2/show/NCT01120288?term=ezn-2968&rank=1. Accessed April 18, 2012. 9. ClinicalTrials.gov. Assessment of efficacy and safety of perifosine, bortezomib and dexamethasone in multiple myeloma patients, http://clinicaltrials.gov/ct2/show/NCT0100224 8?term=perifosine+phase+III&rank=1. Accessed April 18, 2012. 10. ClinicalTrials.gov. Phenylacetate in treating children with recurrent or progressive brain tumors. http://clinicaltrials.gov/ct2/show/NCT00003241?term=phenylacetate+phase+II&rank=1. Accessed April 18, 2012. 11. ClinicalTrials.gov. Oral green tea extract for small cell lung cancer, http://clinicaltrials.gov/ct2/ show/NCT01317953?term=EGCG&rank=19. Accessed April 18, 2012. 12. Seyfried TN, Shelton LM. Cancer as a metabolic disease. Nutrition & Metabolism. 2010;7:7-22. 13. Lee C, Longo VD. Fasting vs dietary restriction in cellular protection and cancer treatment: from model organisms to patients. Oncogene. 2011;30:3305-3316. 14. Negrini S, Gorgoulis VG, Halazonetis TD. Genomic instability—an evolving hallmark of cancer. Nature Rev Mol Cell Biol. 2010;11:220-228. 15. Martin SA, Hewish M, Lord CJ, Ashworth A. Genomic instability and the selection of treatments for cancer. J Pathol. 2009;220:281-289. 16. Berdasco M, Esteller M. Aberrant epigenetic landscape in cancer: how cellular identity goes awry. Dev Cell. 2010;19(5):698-711. 17. ClinicalTrials.gov. Intravenous (IV) decitabine and oral bexarotene for acutemyelogenous leukemia (AML). http://clinicaltrials.gov/ct2/show/NCT01001143?term=5azadeoxycytidine&rank=3. Accessed April 18, 2012. 18. ClinicalTrials.gov. Trial evaluating induction therapy with idarubicin and etoposide plus sequential or concurrent azacitidine and maintenance therapy with azacitidine. http:// clinicaltrials.gov/ct2/show/NCT01180322?term=5-azacytidine&rank=4. Accessed April 18, 2012. 19. Garzon R, Marucci G, Croce CM. Targeting microRNAs in cancer: rationale, strategies and challenges. Nature Rev Drug Disc. 2010;9:775-789. 20. Schreiber RD, Old LJ, Smyth MJ. Cancer immunoediting: integrating immunity’s roles in cancer suppression and promotion. Science. 2011;331:1565-1570. 21. Colotta FA, Allavena P, Sica A, Garlanda C, Mantovani A. Cancer-related inflammation, the seventh hallmark of cancer: links to genetic instability. Carcinogenesis. 2009;307):1073-1081. 22. Curigliano G. Immunity and autoimmunity: revising the concepts of response to breast cancer. The Breast. 2011;20(suppl 3):S71-S74. 23. Kantoff PW, Higano CS, Shore ND, et al. Sipuleucel-T immunotherapy for castration-resistant prostate cancer. N Engl J Med. 2010;363:411-422. 24. Byrne WL, Mills KHG, Lederer JA, O’Sullivan, GC. Targeting regulatory T Cells in cancer. Cancer Res. 2011;71:6915-6920. 25. Cavallo F, De Giovanni C, Nanni P, Forni G, Lollini P. 2011: the immune hallmarks of cancer. Cancer Immunol Immunother. 2011;60(3):319-326.

The International Journal of TargetedTherapies in Cancer

NOW ENROLLING

Investigating BKM120 in Patients With Metastatic NSCLC and Activated PI3K Pathway (CBKM120D2201) An Open-Label Two-Stage Study to Determine Efﬁcacy and Safety of Orally Administered BKM120 STUDY DESIGN Stage 1

Stage 2

Metastatic NSCLC Patients

Determine PI3K Pathway Activation

Screening

Enrollment

Group 1: Squamous NSCLC pretreated with 1 prior platinum-based chemotherapy line for advanced disease

Group 2: Non-Squamous NSCLC pretreated with 1 or 2 prior antineoplastic therapies for advanced disease

BKM120

Group 1: Squamous NSCLC pretreated with 1 prior platinum-based chemotherapy line for advanced disease

BKM120

Group 2: Non-Squamous NSCLC pretreated with 1 or 2 prior antineoplastic therapies for advanced disease

Docetaxel

BKM120

Docetaxel or Pemetrexed

End of Treatment due to toxicity  Continue tumor assessments  Progression-Free Survival and Survival OR End of Treatment due to progression  Progression-Free Survival and Survival Up to 180 patients will be enrolled Biomarker prescreening can take place before formal eligibility Study population comprises 1 prior treatment for squamous histology and 1-2 prior treatments for non-squamous histology

• Progression-Free Survival

FOR MORE INFORMATION ABOUT STUDY DESIGN OR ENROLLMENT:

SECONDARY ENDPOINTS

• US residents can visit www.clinicaltrials.gov [NCT01297491] • For countries outside of the US, please contact your local Novartis Medical Representative

PRIMARY ENDPOINT

• Objective Response Rate • Time to Response • Duration of Response • Disease Control Rate • Overall Survival • Safety

Novartis Pharmaceuticals Corporation East Hanover, New Jersey 07936 –1080

BKM120 is an investigational compound. Efﬁcacy and safety have not been established. There is no guarantee that BKM120 will become commercially available.

Printed in USA

5/12

ONC-1040996

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Clinical Trial Profiles MetMAb and ARQ 197 in Non–Small Cell Lung Cancer By Tracey Regan

Two novel therapies designed to improve survival outcomes in patients with advanced non–small cell lung cancer (NSCLC) are now being evaluated in multisetting, international phase III trials after showing promise in earlier trials by slowing disease progression in distinct subgroups of study participants. Both MetMAb (onartuzumab; Genentech), a monoclonal antibody, and ARQ 197 (tivantinib; ArQule), a small-molecule inhibitor, are targeted therapies that block signaling pathways in cancer cells. Specifically, they inhibit c-MET, a cell membrane receptor molecule implicated in both tumor progression and metastasis in several cancers, including NSCLC. “It’s an oncogenic pathway that drives cancer growth. The goal is to shut this pathway down,” said David Spigel, MD, director of Lung Cancer David Spigel, MD Research at the Sarah Cannon Research Insti-

26 / 3.12

tute in Nashville, Tennessee, and the principal investigator for the MetMAb trial. The drugs, which are being tested in late-stage patients who have already received one or two lines of standard therapy, represent a paradigm shift in lung cancer treatment. (See “MET Inhibitors in Cancer Therapy,” page 50.) “In addition to surgery and radiation, the historical approach to lung cancer is chemotherapy, a broad, nonspecific approach that damages DNA and has accompanying toxicities,” said Alan Sandler, MD, division chief of Hematology and Medical Oncology at Oregon Health & Science University and one of the principal investigators for the tivantinib trial, along with Giorgio Scagliotti, MD, PhD, of the University of Torino in Italy. “The concept of personalized medicine is to develop targeted therapies that inhibit specific pathways in specific tumors. These Alan Sandler, MD therapies generally don’t affect bone marrow, do not cause hair loss, and, in general, have more benign side effects.” In each trial, the drugs are being tested in combination with another targeted cancer treatment, erlotinib (Tarceva; Genentech). Erlotinib is a receptor tyrosine kinase inhibitor that blocks the signaling pathway of the epidermal growth factor receptor (EGFR), a cell surface receptor implicated in cancer cell growth. MET has been implicated in part in erlotinib resistance. “In these two trials, the combined therapies work to delay and overcome resis-

The International Journal of TargetedTherapies in Cancer

tance in tumors that initially respond to the other drug but then develop a resistance to it. Synergistic effects can be strong drivers of efficacy and patient benefit,” said Reinhard von Roemeling, MD, vice president of Clinical Development Oncology at Daiichi Sankyo, Inc, which is sponsoring the tivantinib trial with ArQule, Inc. “Each drug has anticancer properties, and when Reinhard von Roemeling, MD we combine them there may be at least additive activity. It’s not clear how additive, although there appears to be a benefit in preclinical models,” Spigel noted of the MetMAb/erlotinib combination.

MetMAb Trial MetMAb is being tested in a randomized, double-blind, phase III study that will assign nearly 500 patients who have already been treated with standard chemotherapy for advanced or metastatic disease into two groups. One group will take MetMAb in combination with erlotinib. The other group will take erlotinib with a placebo. The study, which began in January 2012, has an estimated completion date of December 2015. The primary outcome measure is overall survival, while secondary endpoints are progression-free survival, overall response rate, and safety. Based on results in a phase II study with 137 patients, participation in the phase III trial is restricted to patients whose tumors are characterized as either MET diagnostic-positive or expressing high levels of the MET receptor protein on the cell surface. Patients will be classified as MET diagnostic-positive (high MET) or MET diagnostic-negative (low MET) based on the results of tissue studies from a companion diagnostic test that is also part of the phase III study. In the phase II study, the addition of MetMAb to erlotinib tripled the amount of time people with high-MET tumors lived compared with participants who received erlotinib alone. Median overall survival was 12.6 months for the group receiving MetMAb, compared to 3.8 months for erlotinib alone. With MetMAb, the high-MET population also lived twice as long without their cancer progressing or dying from any cause (2.9 months) compared with the control group (1.5 months). Patients with low-MET tumors, however, had worse outcomes when given MetMAb and erlotinib than when they were given erlotinib alone. In general, patients with low-MET tumors have a better prognosis, Spigel said, adding that in the MetMAb/erlotinib trial, survival outcomes for patients with high-MET tumors (and a poor prognosis) were raised to the level of the low-MET group treated with erlotinib alone.

Tivantinib Trial Tivantinib is being tested in a randomized, double-blind, phase III study that assigns nearly 1000 patients with advanced or metastatic nonsquamous lung cancer who have been treated with one or two systemic therapies to one of two groups. One group will take tivantinib with erlotinib; the other will take erlotinib with a placebo. The study began in November 2010 and should be completed in July 2013. The primary outcome measure is overall survival. “Earlier clinical trials established the role of tyrosine kinase small-molecule inhibitors on the EGFR pathway, and now we’re evaluating the impact of inhibiting two pathways on patients with previously treated nonsquamous NSCLC,” Sandler said. “We know that the oncogene c-Met makes the cancer more likely to be metastatic, to grow and divide, and to be more invasive. What we’re hoping for is that by impacting and inhibiting the c-Met and EGFR pathway, patients will live longer and have a better quality of life.” Secondary and exploratory objectives of the trial include a measure of progression-free survival and overall survival in molecular subgroups, includ-

The International Journal of TargetedTherapies in Cancer

ing patients whose tumors show mutations to EGFR or to KRAS (a gene that plays a role in tissue signaling), overexpression of MET, and overexpression of serum hepatocyte growth factor. All participants will be tested for biomarkers. Tivantinib is also being evaluated for safety. Based on the results of a smaller phase II study with 167 participants, the current trial is restricted to patients with nonsquamous cell tumors. “When we looked at the data [in the phase II study] on progression-free survival, the tivantinib arm did better than the control arm, at 3.7 months compared with 2.2 months, which is more than a 50% improvement. But when we looked at the nonsquamous patients compared with the control, the results were even more dramatic—4.4 months compared to 2.3 months,” Sandler said. “We are trying to define the population that will respond best to this combination, and histology may be a way to determine that.”

The Need for New Therapies Both studies are being watched closely because few therapies are available for late-stage lung cancer patients. “Half of patients who have already received one or even two therapies don’t make it to another therapy, and the remaining half have the option of chemotherapy or Tarceva. At that point, with single-agent chemotherapy there is a 10% response rate, and with Tarceva alone, approximately a 5% response rate in unselected patients,” Spigel said. The hope for both drugs is that they will be relevant for large populations of patients with NSCLC, the most common type of lung cancer. “Non–small cell lung cancer represents approximately 85% of all lung cancers and of those, nonsquamous tumors comprise 75%,” Sandler said. Approximately half of all people with NSCLC have high levels of the MET protein on the surface of their cancer cells, said Chris Bowden, MD, vice president for Product Development in Clinical Oncology at Genentech, a sponsor of the MetMAb trial with Hoffman-LaRoche. He added that overexpression of Met correlates with poor prognosis, making the tumor type “a good candidate” for Met-targeted medicines. “A lot of great advances recently have affected select groups of patients, as few as 2% to 4% in some cases. The potential here is as high as 50%, and so Chris Bowden, MD that would be a big step forward,” Spigel said.

Role of MET in Cancer MET was first identified in the 1980s when a mutant form was discovered, Bowden said. Further research led to the classification of the gene encoding c-MET as a proto-oncogene, a gene that has the potential to cause cancer if it is mutated or expressed in increased amounts. Researchers liken the MET receptor to a switch. By attaching to the molecule, the targeted therapies help prevent it from turning on. “MET activation plays key roles in enabling cell movement and invasive growth, as is required during embryonic development and in wound healing in adults, but is also frequently found in cancer,” Bowden said. “The MET protein resides on the cell surface and acts as a receptor for HGF (hepatocyte growth factor). When HGF binds to MET, it sets off a series of signals that tell cells to multiply and spread to other parts of the body.” Overactive MET signaling has been observed in a range of cancers, including lung, colorectal, breast, gastric, liver, and bladder tumors, and its activity may also partially explain why some cancers worsen after initially responding to certain targeted therapies, Bowden added. “For these cancers, it is believed that MET signaling can bypass the targeted signaling pathways, allowing cells to grow and spread again.”

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Table. MetMAb and Tivantinib Trials Molecular Markers and Biomarkers The sponsors of both trials said they will closely analyze outcomes among patients belonging to molecular subgroups. “Within the overall study population, there are some patients who may benefit more, and being able to determine who gets more treatment benefit is the goal of personalized medicine,” von Roemeling said of the tivantinib trial. “We will analyze results by several biomarkers. Patients who exhibit overexpression of c-MET by IHC (immunohistochemistry) testing may benefit more. Also, patients with a higher c-Met gene copy number may see a larger benefit. By looking at specific molecules and features of tumors, determining who is most likely to benefit from tivantinib and selecting patients accordingly, the goal is to maximize benefits.” Other molecular markers are being explored in the MetMAb trial, as well as various methods of MET assessment, Spigel said.

Role of Combination Therapy Sponsors of both trials said they expect to test their respective drugs in combination with other therapies. In addition to the ongoing phase III study comparing erlotinib and onartuzumab with erlotinib alone, a number of trials are ongoing or soon to be initiated in the firstline treatment of NSCLC, gastrointestinal malignancies, glioblastoma multiforme, and breast cancer, Bowden said, adding, “The clinical development for onartuzumab includes combinations with approved chemotherapy, antibodies, and small-molecule TKIs (tyrosine kinase inhibitors). Combination trials of onartuzumab with other investigational agents are planned as well.” von Roemeling also indicated that other combinations will be explored. “There may be other ways to make the benefit larger. We need to select targeted therapies and figure out how they will work together to support each other. The combinations might differ for different cancer types,” he said, adding, “If we can give an active drug at earlier stages of the disease, there may also be a better chance to see a bigger benefit. This is the hope.”

Participant Eligibility Patients with nonsquamous histology are eligible for the tivantinib trial, while in the MetMAb trial all histologies are eligible, but patients must be tested for c-MET expression and have overexpression to take part, Sandler said. “From a practical viewpoint there is no way to clinically examine a patient and say he or she is better suited for a particular therapy,” Spigel said, adding that if the trial results are positive, oncologists would use the same eligibility criteria to select patients for treatment. Tracey Regan is a freelance medical writer.

28 / 3.12

A Study of Onartuzumab (MetMAb) in Combination With Erlotinib (Tarceva) in Patients With MET Diagnostic-Positive Non–Small Cell Lung Cancer Who Have Received Chemotherapy for Advanced or Metastatic Disease

A Study of Tivantinib (ARQ 197) Plus Erlotinib (Tarceva) Versus Placebo Plus Erlotinib for the Treatment of Nonsquamous Non– Small Cell Lung Cancer

ClinicalTrials.gov Identifier: NCT01456325.

ClinicalTrials.gov Identifier: NCT01244191.

Primary outcome measure: Overall survival.

Secondary outcome measures: Progressionfree survival, with tumor assessments according to Response Evaluation Criteria in Solid Tumors (RECIST); overall response rate; safety.

Secondary outcome measures: Progression-free survival in the intent-to-treat population; overall survival in subjects with epidermal growth factor receptor wild type non–small-cell lung cancer.

Study start date: January 2012.

Study start date: November 2010.

Estimated completion date: December 2015.

Estimated completion date: July 2013.

Estimated enrollment: 480.

Estimated enrollment: 988.

Patients: Adults age 18 years or older.

Histologically or cytologically confirmed incurable stage IIIb/IV non–small cell lung cancer tumor.

Histologically or cytologically confirmed surgically unresectable locally advanced or metastatic (stage IIIB/IV) nonsquamous non–small-cell lung cancer.

MET diagnostic-positive status tested by immunohistochemistry. Results of epidermal growth factor receptor– activating mutation testing. Radiographic evidence of disease.

Measurable disease and documented disease progression following last prior therapy according to Response Evaluation Criteria in Solid Tumors (RECIST).

Prior treatment with at least one platinum-based line of treatment (for stage IIIb/IV) and no more than one additional line of chemotherapy treatment; the last dose of chemotherapy must have been administered ≥21 days prior to day 1.

Have received one or two prior lines of systemic anticancer therapy for advanced or metastatic disease, one of which must be a platinumdoublet therapy. Patients who received only adjuvant treatment will be eligible only if disease progression occurred <6 months after completion of adjuvant therapy. Prior maintenance therapy is allowed and will be considered as the same line of therapy when continued without discontinuation after initiation of a treatment regimen.

Availability of tissue sample for diagnostic testing is required.

Eastern Cooperative Oncology Group performance status 0-1.

Eastern Cooperative Oncology Group performance status 0 or 1.

Dosages:

Arm A: Onartuzumab (MetMAb), repeating intravenous dose; erlotinib (Tarceva), repeating oral dose.

Arm A: Tivantinib (ARQ 197), 720 mg daily (360mg oral tablets twice a day); erlotinib (Tarceva), 150-mg oral tablets once a day.

Arm B: erlotinib (Tarceva), repeating oral dose; placebo, repeating intravenous dose.

Arm B: Tivantinib (ARQ 197) oral placebo tablets given twice a day; erlotinib (Tarceva), 150-mg oral tablets given once a day.

Adverse effects: Edema is one effect that will be expected and monitored closely.

Adverse effects: Rash, diarrhea, and fatigue are possible side effects.

Adherence: Compliance with oral therapies.

Note to oncologists and lung cancer patients: Staining tumors for MET is not standard and must be done in a central laboratory.

Note to oncologists and lung cancer patients: In the phase II trial, patients in the placebo arm were allowed to cross over at the time of progression, but they are not permitted to do so in the phase III trial.

The International Journal of TargetedTherapies in Cancer

Cabozantinib (XL184) phase 3 trials in castration-resistant prostate cancer (CRPC) for patients with bone metastases CabOzantinib MET Inhibition CRPC Efficacy Trials KEY ELIGIBILITY CRITERIA •Diagnosis of CRPC •Presence of bone metastases •Prior treatment with docetaxel • Prior treatment with abiraterone and/or MDV3100 (enzalutamide) •No limit to the number of prior therapies

COMET-1

COMET-2

PRIMARY ENDPOINT

Overall Survival

Confirmed Pain Response CRPC (N=246)

CRPC (N=960) • Prior docetaxel treatment • Prior abiraterone and/or MDV3100 treatment • No limit to number of prior therapies

Cabozantinib (60 mg qd) Randomization Prednisone

Randomized, double-blind, controlled trial

• Prior docetaxel treatment • Prior abiraterone and/or MDV3100 treatment • No limit to number of prior therapies • Pain related to bone metastases

Cabozantinib (60 mg qd) Randomization Mitoxantrone + Prednisone

Randomized, double-blind, controlled trial

clinical

A R T I C L E S

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Lung Cancer

ALK Rearrangements as a Therapeutic Target in Advanced Non-Small Cell Lung Cancer D. Ross Camidge, MD, PhD Frequency of ALK positivity in non-small cell lung cancer (NSCLC) varies depending on the presence or absence of several key clinical and pathologic factors; groups with a true 0% chance of positivity are hard to define. Only a small proportion of ALK-positive (ALK+) cases manifest intrinsic resistance to crizotinib, a small-molecule inhibitor of ALK recently licensed for treatment of ALK+ NSCLC by the FDA. The majority demonstrate rapid and dramatic responses to this therapy. Although in general crizotinib is well tolerated, several common mild side effects and a few rare severe side effects require specific management. Despite its remarkable clinical activity, acquired resistance to crizotinib is predicted to develop in all ALK+ cases, just as epidermal growth factor receptor (EGFR)-mutant NSCLC develops resistance to treatment with EGFR tyrosine kinase inhibitors. Multiple mechanisms of intrinsic and acquired resistance to crizotinib in ALK+ NSCLC have been described, and treatment options in this setting are discussed. A B S T R A C T

Corresponding Author: D. Ross Camidge, MD, PhD University of Colorado Comprehensive Cancer Center, Anschutz Medical Campus, Aurora, CO; ross.camidge@ucdenver.edu 30 / 3.12

The anaplastic lymphoma kinase (ALK) gene encodes a transmembrane tyrosine kinase receptor involved in a number of developmental processes.1 Oncogenic ALK gene rearrangements are characterized by chromosomal translocations that place one of a series of different 5’ fusion partners and their associated promoter upstream of the 3’ kinase domain of the ALK gene. These rearrangements were originally described in a subset of non-Hodgkin lymphoma2; hence, the new gene was named anaplastic lymphoma kinase. In 2007, an ALK gene rearrangement involving EML4 as the 5’ partner was discovered by looking for cDNAs with the potential to transform cells isolated from a lung adenocarcinoma occurring in a Japanese male smoker.3 Although other 5’ partners for ALK in non-small cell lung cancer (NSCLC), notably KIF5B and TFG, have since been described, EML4-ALK is by far the most common ALK rearrangement seen in NSCLC.4,5 In series dominated by adenocarcinomas, ALK positivity has been reported to occur in approximately 4% of NSCLC.6 Finding ALK-Positive Lung Cancer Patients in all of the initial crizotinib studies were proven to be ALK-positive (ALK+) using the Vysis Break-Apart fluorescence in situ hybridization (FISH) Probe Kit.7,8 With this assay, the FISH probes flank the common breakpoint in ALK and separate when a rearrangement occurs (Figure 1).9 Immunohistochemistry and reverse transcriptase-polymerase chain reaction are also being explored as alternative diagnostic techniques.10,11 Whether insurers will mandate one test over another to cover access to crizotinib is unclear. When considering different testing methodologies, false-positive results will reduce the benefit from the drug. However, the greater fear is of false-negative results that would deny patients with a high chance of benefit from getting access to the drug. Studies directly comparing techniques and the benefit from crizotinib in patients who are ALK+ according to different criteria are planned. In addition to the issue of how to test, the issue of who should be tested is also under discussion. Recognizing that ALK positivity in NSCLC is associated with adenocarcinoma histology, never-smoking status, and absence of other common molecular drivers such as epidermal growth factor receptor (EGFR) and K-ras mutations, clinical enrichment using some or all of these factors has clearly been shown to increase the positivity rate from screening.9 However, no groups with a 0% chance of positivity stand out. Therefore, a policy of only screening an enriched population has to weigh both (1) the cost savings in terms of reducing the absolute numbers of patients screened and the reduced cost per positive found within an enriched population and (2) the number of true positives missed by any preselection approach.12 To illustrate the second of these points, in one recent modeled example, screening only patients who were never-smokers with adenocarcinoma was predicted to result in missing 50% of all possible ALK+ cases in NSCLC.12

The International Journal of TargetedTherapies in Cancer

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clinical

A R T I C L E S

Lung Cancer Figure 1. Break-Apart FISH Probe Kit Used to Detect ALK Positivity rates at 6 and 12 months of 90% and 81%, respectively.13 Crizotinib received accelerated approval in the US in August 2011, but this approval is conditional upon the results of ongoing randomized studies comparing crizotinib with standard first- and second-line chemotherapies in ALK+ NSCLC (PROFILE 1014 and 1007 trials, respectively) (Figure 3). Red and green FISH probes flank the common breakpoint in the native ALK gene. When no rearrangement is present, the probes appear fused together (yellow arrows in panel A). When an ALK rearrangement With regard to safety and tolerability, occurs, the probes separate, either appearing as a classic “split” pattern (red and green arrows in panel B) common side effects include visual disturor a “single red” pattern where red signals outnumber green signals, suggesting that both a rearrangement bance, nausea and vomiting, diarrhea and/ and loss of the 5’ probe (non-kinase encoding) binding site has occurred (red arrows in panel C). Increases or constipation, peripheral edema, dizziness, in both rearranged (double red and green arrows in panel D) and native ALK copy number can occur. Copy anorexia, dysgeusia, alanine transaminase number gain (CNG) of rearranged signals has been associated with acquired resistance to crizotinib, but (ALT) increase, and fatigue.7,8,13 In most casCNG of the native gene is not currently considered of any clinical significance. es, side effects are mild and develop quickly, ALK=anaplastic lymphoma kinase; FISH=fluorescence in situ hybridization. with only peripheral edema worsening over Adapted with permission from Camidge DR, Kono SA, Flacco A, et al. Clin Cancer Res. 2010;16(22):5581-5590. time.13 Severe side effects are rare and include aspartate aminotransferase (AST) and ALT increases, pneumonitis, and neutroTreatment With Crizotinib penia.7,8,13 Although discontinuing dosing with the drug followed by rechalCrizotinib is supplied in 250-mg and 200-mg capsules. The standard starting dose of crizotinib is 250 mg taken twice a day either with or without food. lenge at a lower dose (eg, 200 mg twice daily or 250 mg every day) may allow The activity of crizotinib 250 mg twice daily in ALK+ NSCLC is striking.7,8,13 In treatment after severe neutropenia or transaminitis, permanent drug discontinuation for severe adverse events is occasionally required.7,13 Anecdotally, the phase I study, the objective response rate was 61%, with most patients achieving some degree of tumor shrinkage from the drug (Figure 2).13 Menausea and vomiting are significantly reduced by taking crizotinib after food. Visual disturbances appear to be characteristic. In most cases, visual disturdian progression-free survival was 10 months, with estimated overall survival A.

100

% Decrease or increase from baseline

80 60

Figure 2. Waterfall Plot Showing Activity of Crizotinib in ALK-Positive NSCLC Objective response details (all evaluable patients)

N=116

ORR (95% CI)

61% (52-70)

Median response duration

48 weeks

Median time to response

8 weeks

Disease control rate at 8, 16 weeks

79%, 67%

Updated median PFS: 10 months. 6-month OS rate (from 1st dose) = 90%, 12-month = 81%. ALK=anaplastic lymphoma kinase; CI=confidence interval; NSCLC=nonsmall cell lung cancer; ORR=overall response rate; OS=overall survival; PFS=progression-free survival.

0 -20 -40 -60 -80

-100

Progressive disease Stable disease Partial response Complete response

Camidge DR, Bang Y, Kwak EL, et al. J Clin Oncol. 2011;29(suppl; abstr 2501). Used with permission from Camidge DR.

The International Journal of TargetedTherapies in Cancer

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Lung Cancer Figure 3. Schema of Ongoing Randomized Trials of Crizotinib versus Chemotherapy in ALK-Positive NSCLC First-Line Setting PROFILE 1014: Phase III Study in Previously Untreated NSCLC Protocol Trial Design

Endpoints

Stratification

Study Sites

Multicenter, randomized, open-label

Primary: PFS Secondary: 6- and 12-month OS, ORR, DCR, DR, safety, quality of life, biomarkers, HCRU

ECOG PS (0/1 vs 2) Ethnicity (Asian vs non-Asian) Brain metastases

Worldwide

Key Entry Criteria • Positive for ALK gene • Metastatic non-squamous cell carcinoma of the lung • No prior treatment

ALK=anaplastic lymphoma kinase; DCR=delayed cutaneous reaction; DR=delayed reaction; ECOG= Eastern Cooperative Oncology Group Performance Status Scale; EGFR TKI=epidermal growth factor receptor tyrosine kinase inhibitor; FSFV=first subject first visit; HCRU=health care resource utilization; NSCLC=non-small cell lung cancer; ORR=overall response rate; OS=overall survival; PFS=progression-free survival. www.clinicaltrials.gov (NCT01154140)

N=167 Crizotinib 250 mg twice daily administered on a continuous dosing schedule

Randomize N=334

N=167 Pemetrexed/cisplatin or pemetrexed/carboplatin, Day 1 of a 21-day cycle

Second-Line Setting PROFILE 1007: Phase III Study of PF-02341066 (Crizotinib) versus Pemetrexed or Docetaxel in NSCLC Patients With a Translocation or Inversion Event Involving the ALK Gene Locus Trial Design

Endpoints

Stratification

Study Sites FSFV

Multicenter, randomized, open-label

Primary: PFS Secondary: ORR, DR, DCR, OS, safety, quality of life, biomarkers

ECOG PS (0/1 vs 2) Previous EGFR TKI treatment Brain metastases

Worldwide

Key Entry Criteria • Positive for ALK gene translocation (Abbott) • Brain metastases allowed • 1 prior chemotherapy (platinum-based)

www.clinicaltrials.gov (NCT00932893)

N=159 PF-02341066 250 mg twice daily administered on a continuous dosing schedule

Randomize N=318

N=159 Pemetrexed 500 mg/m2, infused over 10 minutes on day 1 of a 21-day cycle (first choice) or docetaxel, 75 mg/m2, infused over 1 hour on day 1 of a 21-day cycle

bances develop within days of starting the drug and involve brief light trails, flashes, or image persistence occurring at the edges of the visual field, most often when there is a change in the ambient lighting. These visual changes seem to improve over time and appear to be fully reversible on cessation of dosing (Figure 4).13 Recently, rapid-onset hypogonadism in male patients taking crizotinib has been noted, and serum testosterone levels should be routinely checked and replaced as appropriate.14 Disease Progression on Crizotinib All patients treated with crizotinib will eventually manifest acquired resistance. Some patients’ disease will initially progress exclusively within the brain, possibly as a result of low central nervous system (CNS) penetration of crizotinib.15 In such situations, local CNS therapy (eg, radiotherapy) and continuing crizotinib to maintain extracranial control should be considered. Other patients will manifest extracranial resistance to crizotinib. Multiple

32 / 3.12

Ongoing

secondary ALK kinase domain mutations that reduce sensitivity to crizotinib are now being identified in patients.16 ALK copy number gain (CNG)— increases in the number of copies of the rearranged gene in the cancer cell—either alone or in conjunction with kinase domain mutations, is also emerging as an additional mechanism of acquired resistance.17-19 A series of different second oncogenic drivers (coexisting in the same cell with the ALK rearrangement) and separate oncogenic drivers (when these new changes exist in unique clones that no longer demonstrate evidence of the original ALK rearrangement) have also been described in crizotinib-resistant patients. In contrast to ALK mutations and ALK CNG, which preserve the dominance of ALK signaling in the crizotinib-resistant state, these second and separate drivers should, in theory, degrade or destroy the dominance of ALK signaling.16 Examples of these second and/or separate drivers include both EGFR and K-ras mutations, CNG of KIT, and ligand-driven activation of wild type EGFR and HER2.17,18,20 Conservative estimates place the frequency

The International Journal of TargetedTherapies in Cancer

p eer reviewed

clinical

A R T I C L E S

Clinical Pearls of these non-ALK–dominant crizotinib resistance mechanisms in approximately equal balance with ALK mutations and ALK CNG. Therapies in Development New ALK tyrosine kinase inhibitors (TKIs) are in development, with several showing preclinical activity against both ALK CNG and some of the common ALK mutations that may drive clinical resistance to crizotinib therapy.21,22 In addition, experimental heat shock protein 90 (Hsp90) inhibitors such as ganetespib (formerly STA-9090; Synta Pharmaceuticals) and retaspimycin (IPI-504; Infinity Pharmaceuticals) also appear to show clinical activity against crizotinib-naïve ALK+ NSCLC and preclinical activity against some of the common crizotinib resistance mutations in ALK.23,24 A number of these new drugs—including the Hsp90 inhibitors ganetespib and retaspimycin, and the new ALK TKIs LDK378 (Novartis) and AP26113 (ARIAD)—are being explored in ongoing early-phase clinical trials. In theory, adopting a purely ALK-based therapeutic strategy in a non-ALK– dominant resistance setting is unlikely to be significantly effective, and many of the studies exploring new agents in the crizotinib resistance setting are considering mandating post-crizotinib re-biopsies to explore whether the exact mechanism of resistance will indeed affect outcomes.16 In a non-ALK–dominant situation, combination therapy with agents directed against different drivers or nonmolecularly focused cytotoxic chemotherapy may be required. Of note, in the pre-crizotinib setting, preliminary data suggest that pemetrexed, alone or in combination, may be particularly effective in ALK+ NSCLC.25,26 However, whether the different mechanisms of acquired resistance to crizotinib will impact this sensitivity remains unknown. Regardless of the mechanism of resistance, just as isolated CNS progression may be addressed with radiotherapy, isolated extracranial progression (so-called “oligoprogressive disease”) may in some circumstances be suitable for local ablative therapy (eg, with stereotactic body radiation therapy or metastasectomy) with continuation of the crizotinib to preserve control in other nonprogressing sites of disease.13

Figure 4. Patient-Developed Simulation of Characteristic Visual Side Effects Seen With Crizotinib

“Trails” coming off lights in peripheral vision, in low-light conditions Also, at edges of vision in low-light conditions: • Flashes of light, which don’t appear to be connected to a real light source • High-contrast images (eg, stripes) flip registration • Image persistence Camidge DR, Bang Y, Kwak EL, et al. J Clin Oncol. 2011;29(suppl; abstr 2501). Used with permission from Camidge DR.

The International Journal of TargetedTherapies in Cancer

• Most patients with ALK+ NSCLC demonstrate rapid and dramatic responses to therapy with crizotinib, a small-molecule inhibitor of ALK that is taken orally. • In general, crizotinib is well tolerated, allowing protracted use in those who are benefiting. • Acquired resistance to crizotinib is predicted to develop in all ALK+ cases, and treatment options in this setting are being explored.

Summary Crizotinib represents a major breakthrough in the treatment of ALK+ NSCLC. In general, the drug is well tolerated, allowing protracted use in those who are benefiting. Determining whom to test and how to test for an ALK rearrangement in NSCLC continues to be debated. Multiple different mechanisms of resistance to crizotinib have now been described. Optimal treatment in this setting is now being explored and may well depend on the specific resistance mechanism that manifests in individual patients. REFERENCES 1. Webb TR, Slavish J, George RE, et al. Anaplastic lymphoma kinase: role in cancer pathogenesis and smallmolecule inhibitor development for therapy. Expert Rev Anticancer Ther. 2009;9(3):331-356. 2. Le Beau MM, Bitter MA, Larson RA, et al. The t(2;5)(p23;q35): a recurring chromosomal abnormality in Ki-1-positive anaplastic large cell lymphoma. Leukemia. 1989;3(12):866-870. 3. Soda M, Choi YL, Enomoto M, et al. Identification of the transforming EML4-ALK fusion gene in nonsmall-cell lung cancer. Nature. 2007;448(7153):561-566. 4. Rikova K, Guo A, Zeng Q, et al. Global survey of phosphotyrosine signaling identifies oncogenic kinases in lung cancer. Cell. 2007;131(6):1190-1203. 5. Takeuchi K, Choi YL, Togashi Y, et al. KIF5B-ALK, a novel fusion oncokinase identified by an immunohistochemistry-based diagnostic system for ALK-positive lung cancer. Clin Cancer Res. 2009;15(9):3143-3149. 6. Weickhardt AJ, Camidge DR. The therapeutic potential of anaplastic lymphoma kinase inhibitors in lung cancer: rationale and clinical evidence. Clin Invest. 2011;1(8):1119-1126. 7. Kwak EL, Bang YJ, Camidge DR, et al. Anaplastic lymphoma kinase inhibition in non-small-cell lung cancer. N Engl J Med. 2010;363(18):1693-1703. 8. Crinò L, Kim D, Riely GJ, et al. Initial phase II results with crizotinib in advanced ALK-positive non-small cell lung cancer (NSCLC): PROFILE 1005. J Clin Oncol. 2011;29(suppl): abstr 7514. 9. Camidge DR, Kono SA, Flacco A, et al. Optimizing the detection of lung cancer patients harboring anaplastic lymphoma kinase (ALK) gene rearrangements potentially suitable for ALK inhibitor treatment. Clin Cancer Res. 2010;16(22):5581-5590. 10. Camidge DR, Hirsch FR, Varella-Garcia M, Franklin WA. Finding ALK-positive lung cancer: what are we really looking for? J Thorac Oncol. 2011;6(3):411-413. 11. Shaw AT, Solomon B, Kenudson MM. Crizotinib and testing for ALK. J Natl Compr Canc Netw. 2011;9(12):1335-1341. 12. Atherly AJ, Camidge DR. The cost-effectiveness of screening lung cancer patients for targeted drug sensitivity markers. Br J Cancer. 2012;106(6):1100-1106. 13. Camidge DR, Bang Y, Kwak EL, et al. Progression-free survival from a phase I study of crizotinib (PF02341066) in patients with ALK-positive non-small cell lung cancer. J Clin Oncol. 2011;29(suppl): abstr 2501. 14. Weickhardt AJ, Rothman MS, Salian-Mehta S, et al. Rapid onset hypogonadism secondary to crizotinib use in men with metastatic non-small cell lung cancer. Cancer. In press. 15. Costa DB, Kobayashi S, Pandya SS, et al. CSF concentration of the anaplastic lymphoma kinase inhibitor crizotinib. J Clin Oncol. 2011;29(15):e443-e445. 16. Camidge DR, Doebele RC. Treating ALK-positive lung cancer—early successes and future challenges. Nat Rev Clin Oncol. In press. 17. Doebele RC, Pilling AB, Aisner DL, et al. Mechanisms of resistance to crizotinib in patients with ALK gene rearranged non-small cell lung cancer. Clin Cancer Res. 2012;18(5):1472-1482. 18. Katayama R, Shaw AT, Khan TM, et al. Mechanisms of acquired crizotinib resistance in ALK-rearranged lung cancers. Sci Transl Med. 2012;4 (120):120ra17. 19. Katayama R, Khan TM, Benes C, et al. Therapeutic strategies to overcome crizotinib resistance in non-small cell lung cancers harboring the fusion oncogene EML4-ALK. Proc Natl Acad Sci U S A. 2011;108(18):7535-7540. 20. Koivunen JP, Mermel C, Zejnullahu K, et al. EML4-ALK fusion gene and efficacy of an ALK kinase inhibitor in lung cancer. Clin Cancer Res. 2008;14(13):4275-4283. 21. Zhang S, Wang F, Keats J, et al. Crizotinib-resistant mutants of EML4-ALK identified through an accelerated mutagenesis screen. Chem Biol Drug Des. 2011;78(6):999-1005. 22. Heuckmann JM, Hölzel M, Sos ML, et al. ALK mutations conferring differential resistance to structurally diverse ALK inhibitors. Clin Cancer Res. 2011;17(23):7394-7401. 23. Sequist LV, Gettinger S, Senzer NN, et al. Activity of IPI-504, a novel heat-shock protein 90 inhibitor, in patients with molecularly defined non-small-cell lung cancer. J Clin Oncol. 2010;28(33):4953-4960. 24. Wong K, Koczywas M, Goldman JW, et al. An open-label phase II study of the Hsp90 inhibitor ganetespib (STA-9090) as monotherapy in patients with advanced non-small cell lung cancer (NSCLC). J Clin Oncol. 2011;29(suppl): abstr 7500. 25. Camidge DR, Kono SA, Lu X, et al. Anaplastic lymphoma kinase gene rearrangements in non-small cell lung cancer are associated with prolonged progression-free survival on pemetrexed. J Thorac Oncol. 2011;6(4):774-780. 26. Lee JO, Kim TM, Lee SH, et al. Anaplastic lymphoma kinase translocation: a predictive biomarker of pemetrexed in patients with non-small cell lung cancer. J Thorac Oncol. 2011;6(9):1474-1480.

Jakafi™ (JAK-ah-fye)—First and Only FDA-Approved Agent for MYELOFIBROSIS (MF)*

REGULATE REDUCE JAK signaling

splenomegaly and symptoms of MF

JAK2

JAK1

Jakafi

*Intermediate or high-risk MF.

Indications and Usage Jakafi is indicated for treatment of patients with intermediate or high-risk myelofibrosis, including primary myelofibrosis, post–polycythemia vera myelofibrosis and post–essential thrombocythemia myelofibrosis. Important Safety Information • Treatment with Jakafi can cause hematologic adverse reactions, including thrombocytopenia, anemia and neutropenia, which are each dose-related effects, with the most frequent being thrombocytopenia and anemia. A complete blood count must be performed before initiating therapy with Jakafi. Complete blood counts should be monitored as clinically indicated and dosing adjusted as required

• The three most frequent non-hematologic adverse reactions were bruising, dizziness and headache • Patients with platelet counts <200 × 109/L at the start of therapy are more likely to develop thrombocytopenia during treatment. Thrombocytopenia was generally reversible and was usually managed by reducing the dose or temporarily withholding Jakafi. If clinically indicated, platelet transfusions may be administered • Patients developing anemia may require blood transfusions. Dose modifications of Jakafi for patients developing anemia may also be considered • Neutropenia (ANC <0.5 × 109/L) was generally reversible and was managed by temporarily withholding Jakafi • Patients should be assessed for the risk of developing serious bacterial, mycobacterial, fungal and viral infections. Active serious infections should have resolved before starting Jakafi. Physicians should carefully observe patients receiving Jakafi for signs and symptoms of infection (including herpes zoster)

Jakafi demonstrated superior reductions in spleen volume and improvements in symptom scores at Week 241,2,a,b Percent Change in Total Symptom Score (TSS) in Individual Patients From Baseline to Week 24 or Last Observation1,a,b

Percent Change in Spleen Volume in Individual Patients From Baseline to Week 24 or Last Observation1,a

150

20 0 -20 -40

35% Reduction

-60 -80

Upper 50th Percentile

Jakafi (n = 155)

Upper 50th Percentile

100 50 0 -50

-100

IMPROVEMENT WORSENING

Change From Baseline (%)

60 IMPROVEMENT WORSENING

Change From Baseline (%)

50% Improvement Upper 50th Percentile

Placebo (n = 153)

In these charts, each bar represents an individual patient’s response.

Upper 50th Percentile

Jakafi (n = 145)

Placebo (n = 145)

Worsening of TSS is truncated at 150%.

At Week 24, significantly more patients receiving Jakafi vs placebo had — A ≥35% reduction in spleen volume (41.9% vs 0.7%, respectively; P < 0.0001)1,2,a — A ≥50% improvement in TSS (45.9% vs 5.3%, respectively; P < 0.0001)1,2,a,b Reductions in spleen volume and improvements in TSS were seen with Jakafi in both JAK2 V617F-positive patients and JAK2 V617F-negative patients, relative to placebo2

Visit www.jakafi.com/explore for more information on Jakafi and MF, plus valuable educational resources.

and initiate appropriate treatment promptly • A dose modification is recommended when administering Jakafi with strong CYP3A4 inhibitors or in patients with renal or hepatic impairment [see Dosage and Administration]. Patients should be closely monitored and the dose titrated based on safety and efficacy • There are no adequate and well-controlled studies of Jakafi in pregnant women. Use of Jakafi during pregnancy is not recommended and should only be used if the potential benefit justifies the potential risk to the fetus • Women taking Jakafi should not breast-feed. Discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother

a As studied in COMFORT-I, a randomized, double-blind, placebo-controlled phase III study

with 309 total patients (United States, Canada, Australia). The primary endpoint was the proportion of subjects achieving a ≥35% reduction in spleen volume from baseline to Week 24 as measured by magnetic resonance imaging (MRI) or computed tomography (CT) . A secondary endpoint was the proportion of subjects with a ≥50% reduction in TSS from baseline to Week 24 as measured by the daily patient diary, the modified Myelofibrosis Symptom Assessment Form (MFSAF v2.0).1,2

b Symptom scores were captured by a daily patient diary recorded for 25 weeks.

TSS encompasses debilitating symptoms of MF: abdominal discomfort, early satiety, pain under left ribs, pruritus, night sweats and bone/muscle pain. Symptom scores ranged from 0 to 10 with 0 representing symptoms “absent” and 10 representing “worst imaginable” symptoms. These scores were added to create the daily total score, which has a maximum of 60. At baseline, mean TSS was 18.0 in the Jakafi group and 16.5 in the placebo group.1,2

References: 1. Jakafi Prescribing Information. Incyte Corporation. November 2011. 2. Data on file. Incyte Corporation.

Please see Brief Summary of Full Prescribing Information on the following page.

JAK targeted to make a difference

Table 2: Worst Hematology Laboratory Abnormalities in the Placebo-controlled Studya Jakafi Placebo (N=155) (N=151) Laboratory All All b Grade 3 Grade 4 Grades Grade 3 Grade 4 Parameter Grades BRIEF SUMMARY: For Full Prescribing Information, see package insert. (%) (%) (%) (%) (%) (%) INDICATIONS AND USAGE Jakafi is indicated for treatment of patients with intermediate or high-risk Thrombocytopenia 69.7 9.0 3.9 30.5 1.3 0 myelofibrosis, including primary myelofibrosis, post-polycythemia vera myelofibrosis and post-essential Anemia 96.1 34.2 11.0 86.8 15.9 3.3 thrombocythemia myelofibrosis. Neutropenia 18.7 5.2 1.9 4.0 0.7 1.3 CONTRAINDICATIONS None. WARNINGS AND PRECAUTIONS Thrombocytopenia, Anemia and Neutropenia Treatment a Presented values are worst Grade values regardless of baseline b National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0 with Jakafi can cause hematologic adverse reactions, including thrombocytopenia, anemia and neutropenia. A complete blood count must be performed before initiating therapy with Jakafi [see Dosage and Additional Data from the Placebo-controlled Study 25.2% of patients treated with Jakafi and 7.3% of Administration (2.1) in Full Prescribing Information]. Patients with platelet counts of less than 200 X 109/L patients treated with placebo developed newly occurring or worsening Grade 1 abnormalities in alanine transat the start of therapy are more likely to develop thrombocytopenia during treatment. Thrombocytopenia was aminase (ALT). The incidence of greater than or equal to Grade 2 elevations was 1.9% for Jakafi with 1.3% Grade 3 and no Grade 4 ALT elevations. 17.4% of patients treated with Jakafi and 6.0% of patients treated generally reversible and was usually managed by reducing the dose or temporarily withholding Jakafi. If with placebo developed newly occurring or worsening Grade 1 abnormalities in aspartate transaminase clinically indicated, platelet transfusions may be administered [see Dosage and Administration (2.2) in Full (AST). The incidence of Grade 2 AST elevations was 0.6% for Jakafi with no Grade 3 or 4 AST elevations. Prescribing Information, and Adverse Reactions]. Patients developing anemia may require blood trans- 16.8% of patients treated with Jakafi and 0.7% of patients treated with placebo developed newly occurring or fusions. Dose modifications of Jakafi for patients developing anemia may also be considered. Neutropenia worsening Grade 1 elevations in cholesterol. The incidence of Grade 2 cholesterol elevations was 0.6% for (ANC less than 0.5 X 109/L) was generally reversible and was managed by temporarily withholding Jakafi Jakafi with no Grade 3 or 4 cholesterol elevations. [see Adverse Reactions]. Complete blood counts should be monitored as clinically indicated and dosing DRUG INTERACTIONS Drugs That Inhibit or Induce Cytochrome P450 Enzymes Ruxolitinib adjusted as required [see Dosage and Administration (2.2) in Full Prescribing Information, and Adverse is predominantly metabolized by CYP3A4. Strong CYP3A4 inhibitors: The C max and AUC of ruxolitinib Reactions]. Infections Patients should be assessed for the risk of developing serious bacterial, mycobac- increased 33% and 91%, respectively, with Jakafi administration (10 mg single dose) following ketoconazole terial, fungal and viral infections. Active serious infections should have resolved before starting therapy with 200 mg twice daily for four days, compared to receiving Jakafi alone in healthy subjects. The half-life was also Jakafi. Physicians should carefully observe patients receiving Jakafi for signs and symptoms of infection and prolonged from 3.7 to 6.0 hours with concurrent use of ketoconazole. The change in the pharmacodynamic initiate appropriate treatment promptly. Herpes Zoster Physicians should inform patients about early signs marker, pSTAT3 inhibition, was consistent with the corresponding ruxolitinib AUC following concurrent adminand symptoms of herpes zoster and advise patients to seek treatment as early as possible [see Adverse istration with ketoconazole. When administering Jakafi with strong CYP3A4 inhibitors a dose reduction is Reactions]. recommended [see Dosage and Administration (2.4) in Full Prescribing Information]. Patients should be ADVERSE REACTIONS Clinical Trials Experience Because clinical trials are conducted under closely monitored and the dose titrated based on safety and efficacy. Mild or moderate CYP3A4 inhibitors: widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly There was an 8% and 27% increase in the Cmax and AUC of ruxolitinib, respectively, with Jakafi administration compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The (10 mg single dose) following erythromycin, a moderate CYP3A4 inhibitor, at 500 mg twice daily for 4 days, safety of Jakafi was assessed in 617 patients in six clinical studies with a median duration of follow-up of 10.9 compared to receiving Jakafi alone in healthy subjects. The change in the pharmacodynamic marker, pSTAT3 months, including 301 patients with myelofibrosis in two Phase 3 studies. In these two Phase 3 studies, inhibition was consistent with the corresponding exposure information. No dose adjustment is recommended patients had a median duration of exposure to Jakafi of 9.5 months (range 0.5 to 17 months), with 88.7% of when Jakafi is coadministered with mild or moderate CYP3A4 inhibitors (eg, erythromycin). CYP3A4 patients treated for more than 6 months and 24.6% treated for more than 12 months. One hundred and inducers: The Cmax and AUC of ruxolitinib decreased 32% and 61%, respectively, with Jakafi administration eleven (111) patients started treatment at 15 mg twice daily and 190 patients started at 20 mg twice daily. In (50 mg single dose) following rifampin 600 mg once daily for 10 days, compared to receiving Jakafi alone in a double-blind, randomized, placebo-controlled study of Jakafi, 155 patients were treated with Jakafi. The healthy subjects. In addition, the relative exposure to ruxolitinib’s active metabolites increased approximately most frequent adverse drug reactions were thrombocytopenia and anemia [see Table 2]. Thrombocytopenia, 100%. This increase may partially explain the reported disproportionate 10% reduction in the pharmacoanemia and neutropenia are dose related effects. The three most frequent non-hematologic adverse reactions dynamic marker pSTAT3 inhibition. No dose adjustment is recommended when Jakafi is coadministered with were bruising, dizziness and headache [see Table 1]. Discontinuation for adverse events, regardless of a CYP3A4 inducer. Patients should be closely monitored and the dose titrated based on safety and efficacy. causality, was observed in 11.0% of patients treated with Jakafi and 10.6% of patients treated with placebo. USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C: There are no adequate Following interruption or discontinuation of Jakafi, symptoms of myelofibrosis generally return to and well-controlled studies of Jakafi in pregnant women. In embryofetal toxicity studies, treatment with pretreatment levels over a period of approximately 1 week. There have been isolated cases of patients discon- ruxolitinib resulted in an increase in late resorptions and reduced fetal weights at maternally toxic doses. tinuing Jakafi during acute intercurrent illnesses after which the patient’s clinical course continued to worsen; Jakafi should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. however, it has not been established whether discontinuation of therapy contributed to the clinical course in Ruxolitinib was administered orally to pregnant rats or rabbits during the period of organogenesis, at doses these patients. When discontinuing therapy for reasons other than thrombocytopenia, gradual tapering of the of 15, 30 or 60 mg/kg/day in rats and 10, 30 or 60 mg/kg/day in rabbits. There was no evidence of teratodose of Jakafi may be considered [see Dosage and Administration (2.6) in Full Prescribing Information]. genicity. However, decreases of approximately 9% in fetal weights were noted in rats at the highest and maternally toxic dose of 60 mg/kg/day. This dose results in an exposure (AUC) that is approximately 2 times Table 1 presents the most common adverse reactions occurring in patients who received Jakafi in the doublethe clinical exposure at the maximum recommended dose of 25 mg twice daily. In rabbits, lower fetal weights blind, placebo-controlled study during randomized treatment. of approximately 8% and increased late resorptions were noted at the highest and maternally toxic dose of Table 1: Adverse Reactions Occurring in Patients on Jakafi in the Double-blind, Placebo-controlled 60 mg/kg/day. This dose is approximately 7% the clinical exposure at the maximum recommended dose. In Study During Randomized Treatment a pre- and post-natal development study in rats, pregnant animals were dosed with ruxolitinib from implanJakafi Placebo tation through lactation at doses up to 30 mg/kg/day. There were no drug-related adverse findings in pups for (N=155) (N=151) fertility indices or for maternal or embryofetal survival, growth and development parameters at the highest Adverse All All dose evaluated (34% the clinical exposure at the maximum recommended dose of 25 mg twice daily). Reactions Gradesa Grade 3 Grade 4 Grades Grade 3 Grade 4 Nursing Mothers It is not known whether ruxolitinib is excreted in human milk. Ruxolitinib and/or its metabolites were excreted in the milk of lactating rats with a concentration that was 13-fold the maternal (%) (%) (%) (%) (%) (%) plasma. Because many drugs are excreted in human milk and because of the potential for serious adverse Bruisingb 23.2 0.6 0 14.6 0 0 reactions in nursing infants from Jakafi, a decision should be made to discontinue nursing or to discontinue Dizzinessc 18.1 0.6 0 7.3 0 0 the drug, taking into account the importance of the drug to the mother. Pediatric Use The safety and effecHeadache 14.8 0 0 5.3 0 0 tiveness of Jakafi in pediatric patients have not been established. Geriatric Use Of the total number of Urinary Tract Infectionsd 9.0 0 0 5.3 0.7 0.7 myelofibrosis patients in clinical studies with Jakafi, 51.9% were 65 years of age and older. No overall differWeight Gaine 7.1 0.6 0 1.3 0.7 0 ences in safety or effectiveness of Jakafi were observed between these patients and younger patients. Renal Impairment The safety and pharmacokinetics of single dose Jakafi (25 mg) were evaluated in a study in Flatulence 5.2 0 0 0.7 0 0 healthy subjects [CrCl 72-164 mL/min (N=8)] and in subjects with mild [CrCl 53-83 mL/min (N=8)], Herpes Zosterf 1.9 0 0 0.7 0 0 moderate [CrCl 38-57 mL/min (N=8)], or severe renal impairment [CrCl 15-51 mL/min (N=8)]. Eight (8) a National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 3.0 b includes contusion, ecchymosis, hematoma, injection site hematoma, periorbital hematoma, vessel puncture site additional subjects with end stage renal disease requiring hemodialysis were also enrolled. The pharmacokinetics of ruxolitinib was similar in subjects with various degrees of renal impairment and in those with hematoma, increased tendency to bruise, petechiae, purpura c includes dizziness, postural dizziness, vertigo, balance disorder, Meniere’s Disease, labyrinthitis normal renal function. However, plasma AUC values of ruxolitinib metabolites increased with increasing d includes urinary tract infection, cystitis, urosepsis, urinary tract infection bacterial, kidney infection, pyuria, bacteria severity of renal impairment. This was most marked in the subjects with end stage renal disease requiring urine, bacteria urine identified, nitrite urine present hemodialysis. The change in the pharmacodynamic marker, pSTAT3 inhibition, was consistent with the e includes weight increased, abnormal weight gain corresponding increase in metabolite exposure. Ruxolitinib is not removed by dialysis; however, the removal f includes herpes zoster and post-herpetic neuralgia of some active metabolites by dialysis cannot be ruled out. When administering Jakafi to patients with Description of Selected Adverse Drug Reactions Anemia In the two Phase 3 clinical studies, median moderate (CrCl 30-59 mL/min) or severe renal impairment (CrCl 15-29 mL/min) with a platelet count time to onset of first CTCAE Grade 2 or higher anemia was approximately 6 weeks. One patient (0.3%) between 100 X 109/L and 150 X 109/L and patients with end stage renal disease on dialysis a dose reduction discontinued treatment because of anemia. In patients receiving Jakafi, mean decreases in hemoglobin is recommended [see Dosage and Administration (2.5) in Full Prescribing Information]. Hepatic reached a nadir of approximately 1.5 to 2.0 g/dL below baseline after 8 to 12 weeks of therapy and then Impairment The safety and pharmacokinetics of single dose Jakafi (25 mg) were evaluated in a study in gradually recovered to reach a new steady state that was approximately 1.0 g/dL below baseline. This pattern healthy subjects (N=8) and in subjects with mild [Child-Pugh A (N=8)], moderate [Child-Pugh B (N=8)], or was observed in patients regardless of whether they had received transfusions during therapy. In the severe hepatic impairment [Child-Pugh C (N=8)]. The mean AUC for ruxolitinib was increased by 87%, 28% randomized, placebo-controlled study, 60% of patients treated with Jakafi and 38% of patients receiving and 65%, respectively, in patients with mild, moderate and severe hepatic impairment compared to patients placebo received red blood cell transfusions during randomized treatment. Among transfused patients, the with normal hepatic function. The terminal elimination half-life was prolonged in patients with hepatic median number of units transfused per month was 1.2 in patients treated with Jakafi and 1.7 in placebo impairment compared to healthy controls (4.1-5.0 hours versus 2.8 hours). The change in the pharmacotreated patients. Thrombocytopenia In the two Phase 3 clinical studies, in patients who developed Grade 3 dynamic marker, pSTAT3 inhibition, was consistent with the corresponding increase in ruxolitinib exposure or 4 thrombocytopenia, the median time to onset was approximately 8 weeks. Thrombocytopenia was except in the severe (Child-Pugh C) hepatic impairment cohort where the pharmacodynamic activity was generally reversible with dose reduction or dose interruption. The median time to recovery of platelet counts more prolonged in some subjects than expected based on plasma concentrations of ruxolitinib. When above 50 X 109/L was 14 days. Platelet transfusions were administered to 4.7% of patients receiving Jakafi administering Jakafi to patients with any degree of hepatic impairment and with a platelet count between and to 4.0% of patients receiving control regimens. Discontinuation of treatment because of thrombo- 100 X 109/L and 150 X 109/L, a dose reduction is recommended [see Dosage and Administration (2.5) in cytopenia occurred in 0.7% of patients receiving Jakafi and 0.9% of patients receiving control regimens. Full Prescribing Information]. Patients with a platelet count of 100 X 109/L to 200 X 109/L before starting Jakafi had a higher frequency of Grade 3 or 4 thrombocytopenia compared to patients with a platelet count greater than 200 X 109/L (16.5% Jakafi is a trademark of Incyte Corporation. All rights reserved. versus 7.2%). Neutropenia In the two Phase 3 clinical studies, 1.0% of patients reduced or stopped Jakafi U.S. Patent No. 7,598,257 because of neutropenia. Table 2 provides the frequency and severity of clinical hematology abnormalities © 2011 Incyte Corporation. All rights reserved. reported for patients receiving treatment with Jakafi or placebo in the placebo-controlled study. Issued: November 2011 RUX-1040

p eer reviewed

clinical

A R T I C L E S

Melanoma

Immunotherapy in Advanced Melanoma Deepika Narasimha, MD1, Anthony Jarkowski, III, PharmD2, and Nikhil I. Khushalani*, MD1,3

Metastatic melanoma has historically been one of the most therapeutically challenging malignancies, with poor 5-year survival. Until recently, dacarbazine and high-dose interleukin-2 were the only agents approved by the FDA for metastatic melanoma. The year 2011 witnessed the approval of an anti-CTLA-4 antibody, ipilimumab, and a BRAF-targeted agent, vemurafenib, in advanced melanoma, which has led to a renaissance in melanoma therapeutics. This is an exciting phase for melanoma immunotherapy and holds important implications for clinicians, due to novel paradigms of treatment, assessment of response, and management of immune-related toxicities. This review seeks to summarize the data on approved immunotherapeutic options in metastatic melanoma, with a special focus on ipilimumab. A B S T R A C T

The incidence of cutaneous melanoma has been steadily rising in the United States, especially in Caucasian women under 40 years of age, in whom an increase of 50% occurred from 1980 until 2004. Approximately 9200 deaths from melanoma are estimated in 2012.1 Thickness of the primary tumor, ulceration, and nodal metastatic status are the most important determinants of prognosis for localized disease, for which surgery remains the mainstay of therapy. A selected subset of oligometastatic stage IV patients also may benefit from surgical resection. Metastatic melanoma has a dismal prognosis, with a median survival of 7 months and a 5-year survival rate of 15%.2,3 Until recently, therapeutic options centered on dacarbazine (DTIC), the only FDA-approved chemotherapeutic agent for metastatic melanoma since 1975.4 An active regimen that was commonly used until recently is carboplatin and paclitaxel, with response rates ranging from 11% to 26%.5-7 In 2011, ipilimumab and vemurafenib gained regulatory approval in the United States for the treatment of advanced melanoma based on positive randomized trials, ushering in a new era in melanoma therapy. This in turn has initiated a cascade of clinical trials that hopefully will build on this improvement and improve the outlook for this disease. This review will summarize the role of immunotherapy in advanced melanoma, with a focus on the use of ipilimumab in the community practice setting.

Immunotherapy Options in Advanced Melanoma Melanoma is a highly immunogenic tumor. Clinical observations of a higher incidence in organ transplant recipients, as well as rare spontaneous tumor regressions, have led to investigations into harnessing the immune system in therapy against melanoma. It is well known that melanomas exhibiting a brisk lymphocytic infiltrate have a better prognosis than those lacking this, and that melanomas are often associated with areas of histologic regression that correlate with lymphocytic infiltration.8 Several biologic agents, vaccines, and checkpoint agents have been tested in clinical trials. 1. Department of Medicine, State University of New York, Buffalo, NY 2. Department of Pharmacy, Roswell Park Cancer Institute, Buffalo, NY 3. Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY

Corresponding Author: Nikhil I. Khushalani, MD Associate Professor of Oncology, Roswell Park Cancer Institute, Department of Medicine, Elm & Carlton Streets, Buffalo, New York; nikhil.khushalani@roswellpark.org The International Journal of TargetedTherapies in Cancer

Interleukin-2 (IL-2) IL-2 is a glycoprotein that binds to IL-2 receptors on T-cells and augments lymphocyte mitogenesis and cytotoxicity. It is essential for T-cell immunity and exerts its anticancer activity by acting as a growth factor for T lymphocytes, increasing interferon-gamma production, stimulating antigenindependent natural killer cells, and facilitating movement of lymphocytes to sites of malignancy.9-11 It was first identified in 1976, and received FDA approval in 1998 for the treatment of metastatic melanoma based on its ability to produce durable, complete responses in this disease.12-14

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Published OnlineFirst April 5, 2011; DOI:10.1158/1078-0432.CCR-10-2232

Melanoma CTLA-4

Figure. CTLA-4 modulation of T-cell activation A

TAA MHC

AP–2 Y Golgi Y CTLA– 4 Y containing Y vesicles Y Y T cell Y AP–1 receptor Y CD 28

T cell

Nucleus

Nucleus NF–κB

PI3K

Bcl–XL

Increased transcription

Bcl–2 APC

Increased survival and proliferation

Cell membrane

CTLA-4

Y ARF–1 Y PLD

AP–2

PP2A MHC

TAA

SHP2

Y Y

Y Y Y Y

TCR

CTLA– 4 containing vesicles

Golgi

Blockade of CD28 mediated signaling

Nucleus

CD 28

NF–κB PI3K

T cell

Attempts at intensifying biological therapy with the addition of chemotherapy or the use of other immunotherapeutic agents (so-called “bio-chemotherapy”) has resulted in improved ORR, but without survival benefit and with greater toxicity.17 Phenotypic and laboratory parameters have been shown to be associated with antitumor response to IL-2.18 A prospective tissue collection trial (High-dose IL-2 SELECT Study) is currently under way, aiming to identify genotypic and tumor-specific predictors of response to IL-2 in melanoma (NCT01288963). This effort is critical, as IL-2-related toxicity has restricted its use to carefully selected patients in highly specialized centers of care. These effects mainly stem from vasodilation and the capillary leak syndrome, resulting in significant hemodynamic consequences.19 Appropriate patient selection, with the exclusion of high-risk patients with pre-existing cardiopulmonary comorbidities and poor performance status, is essential to enhance the safety of this treatment regimen. Skeptics may argue about the lack of evidence supporting a survival benefit from IL-2 in melanoma and the absence of a randomized controlled phase III clinical trial with this toxic biologic agent. However, the persistent “tail” of the Kaplan-Meier survival curve in nearly every published study of this drug attests to its distinct benefit, albeit in a small subset of patients in whom the disease would typically be fatal.

Nucleus

Ipilimumab

Ipilimumab is a human monoclonal antibody specific for the cytotoxic T-lymphocyte antigen-4 (CTLA-4) that was approved by the PD–L2 PP2A FDA for the treatment of unresectable or metastatic melanoma in APC Decreased survival PD–1 SHP2 March 2011. A key co-stimulatory signal for effective T-cell activaand proliferation tion is the binding of CD80 or CD86 on antigen-presenting cells Cell membrane Cell membrane (APCs) to CD28 on T-cells. CTLA-4 is a cell surface molecule closely © 2011 American Association for Cancer Research (A) T-cell activation; (B) T-cell inactivation. related to CD28, with a greater binding affinity towards CD80 and Reprinted by permission from the American Association for Cancer Research: Salama AK, CD86. This prevents co-stimulation, and thereby acts as a negative Hodi FS.T-cell Cytotoxic antigen-4. Clin requires Cancer Res. 2011;17:4622-4628. 1. A, T-cell activation. primingT-lymphocyte-associated in response to a specific antigenic epitope coordination of multiple signals. The initial signal is created full-length peptide is processed and presented on the surface of an APC. The resulting fragments, or tumor-associated antigens (TAA), are bound to of T-cell activation (Figure). Ipilimumab binds to CTLA-4 regulator molecules present on the surface of the APC. This MHC/TAA complex then allows for detection and binding of the TAA by the TCR. A second and its interaction with CD80 or CD86, thereby augmenting ulatory signal, however, is necessary to complete T-cell activation and expansion. The binding of CD28 on the T cell with B7 on the APC createsblocks this d signal, which leads to activation of the PI3K/AKT pathway, upregulation of the antiapoptotic proteins Bcl-2 and Bcl-XL, and an increase in the nuclear T-cell activation and proliferation.20 The Cytokine Working Group described its findings for a patient dataiption factor NF-kB. This collectively leads to increased cellular proliferation, cytokine production, and prolonged survival. Initially, regulatory proteins LA-4 are primarily inactive and remain complexed AP-2 withinmelanoma the intracellularwho compartment. B, Upregulation base of 270 patients with with metastatic were entered into of CTLA-4 andItmaintenance is important for clinicians to understand the mechanism of action of une tolerance. TCR activation induces upregulation of CTLA-4 via a number of mechanisms. ARF-1 and PLD bind to enhance the exocytosis of eightasclinical assessing the efficacyofand toxicity of high-dose ipilimumab, as adverse events from this agent follow similar principles. 4–containing vesicles they exittrials the Golgi apparatus. Phosphorylation the cytoplasmic tailthe of CTLA-4 preventsIL-2 binding of AP-2, which normally 13 ns to promote receptor internalization, resulting in an increase in CTLA-4 surface expression. CTLA-4 is then capable of directly competing with CD28 regimen. The presence of autoimmune disease is considered a contraindication to The overall response rate (ORR) was 16% (95% confidence interding of B7. CTLA-4 may also exert a direct negative effect on CD28 signaling, mediated by the binding of the phosphatases PP2A and SHP-2. Additional ipilimumab therapy, and these patients have been excluded from trials inval [CI], 12%-21%); there were 17 complete responses (CR; 6%) and 26 parory molecules, including PD-1, are also important in limiting T-cell activation and may also inhibit TCR-mediated signaling via blockade of specific tream effectors. The resultant decrease in prosurvival signaling serves to limit T-cell activation and expansion. volving this agent. At baseline, a complete blood count, serum chemistries tial responses (10%). Of the responders, 28% (including 59% who achieved (including liver function tests), and thyroid profile are recommended. In CR) were progression-free at a median follow-up period of 62 months. our practice, we also obtain additional endocrine markers for a pituitary In an attempt to improve responses to IL-2, Schwartzentruber et al ranprofile, domized patients with advanced melanoma to receive IL-2 with or without aacrjournals.org Clin Cancer Res; 17(14) July including 15, 2011 serum 4623 adrenocorticotropic hormone, follicle-stimulating hormone, luteinizing hormone, cortisol, and testosterone levels. a synthetic peptide vaccine, gp100, based on prior encouraging data from Ipilimumab is administered intravenously at a dose of 3 mg/kg over 90 their group.15,16 Although the combination arm significantly improved ORR minutes every three weeks for a total of four doses. Because ipilimumab (16% vsDownloaded 6%; P = .03) from and progression-free survival (PFS; 2.2 months vs 1.6 clincancerres.aacrjournals.org on May 11, 2012 © 2011 AmericaninAssociation for Cancer Research contains only human protein sequences, infusion reactions are rare and months; PCopyright = .008), the improvement overall survival (OS; 17.8 months vs premedications are not required. Prior to each subsequent dose, clinical 11.1 months; P = .06) was not statistically significant.16 Bcl–XL

Bcl–2

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Melanoma questions evaluating immune-mediated symptoms and laboratory value checks that include liver and thyroid functions are recommended. Other parameters should be rechecked based on clinical symptomatology.

Early Experience With Ipilimumab Initial experience with ipilimumab highlighted low, though durable, ORR and the development of immune-related adverse events (irAEs) that appeared to correlate with response.21,22 It demonstrated promising activity as monotherapy in phase II trials in advanced melanoma, giving impetus to larger-scale testing.23-25 A recent report from the National Cancer Institute provides the longest followup data on 177 patients treated in three trials with ipilimumab alone or in combination with gp-100 peptides or IL-2.26 The ORR ranged from 13% to 25%, with complete response rate from 6% to17%. Nearly all patients with CR (14/15) have had a durable duration of response ongoing at 54+ to 99+ months. The 5-year survival rate was 13% to 25%, which highlights the delayed kinetics of response that clinicians in practice should appreciate with the use of this and similar drugs. The Response Evaluation Criteria In Solid Tumors (RECIST), which are utilized to assess objective response in therapeutic trials of cytotoxic drugs, may not be suitable for immunotherapy trials. The infiltration of the tumor by cytotoxic T-cells may result in no change in the size of the tumor, or, paradoxically, an initial increase in the tumor size (which may equate progressive disease at the initial timepoint of response assessment per RECIST). With the recent reporting of long-term follow-up and the noted improved survival (vs historical controls) from the initial ipilimumab trials, it is clear that measurable response may be delayed as compared with conventional chemotherapy. Hence, in the absence of obvious clinical deterioration at the time of first evaluation after ipilimumab, continuing observation is reasonable, even in the presence of radiographic progression. Wolchok and colleagues have proposed a new set of immune-related response criteria (irRC) to assess response in patients treated with immunotherapy.27 These criteria are based on total tumor burden, which is calculated by summation of the product of the perpendicular diameters of measurable index lesions and new lesions. However, one should be mindful of the fact that the irRC criteria can potentially overestimate response to therapy and lead to unnecessary prolongation of nonbeneficial, toxic treatment.

Phase III Trials of Ipilimumab Previously treated melanoma In a randomized phase III trial, 676 HLA-A*0201-positive patients with unresectable stage III or IV melanoma whose disease had progressed on one prior therapy were randomly assigned in a 1:1:3 ratio to receive either ipilimumab (n = 137), gp100 vaccine (n = 136), or a combination of the two (n = 403).28 Most patients had M1c disease (73%) or an elevated lactate dehydrogenase (LDH) level (38%), both adverse prognostic factors. Twentythree percent of patients had previously received IL-2. Ipilimumab dosed at 3 mg/kg was administered intravenously with or without gp100 every

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three weeks for up to four treatments, and patients were eligible for reinduction at progression if they had experienced an initial benefit to therapy. In this trial, ipilimumab plus gp 100 significantly improved OS compared to gp100 (10 months vs 6.4 months; P < .001), and this was independent of age, sex, baseline LDH levels, metastatic stage, and previous IL-2 therapy. A similar improvement was noted in the ipilimumab-alone arm as well. PFS was similar in all three groups at week 12, but the curves separated thereafter, favoring the ipilimumab arms. This observation underscores the fact that responses to ipilimumab may be delayed, as the 2-year survival in the gp 100 group was 14% compared with 22% to 24% in the two ipilimumab arms. The ipilimumab-only arm had the highest response rate (11%), and 60% of these responses were durable at 2 years. Although this trial was conducted in patients who had failed prior therapy, the FDA approved ipilimumab for the first-line and beyond setting based on preliminary results from a concurrent trial in treatment-naïve patients discussed below.29 Therapy-naïve metastatic melanoma Robert et al29 randomized 502 patients to combination ipilimumab (dosed at 10 mg/kg) plus dacarbazine every three weeks versus dacarbazine in a phase III trial for therapy-naïve patients with advanced melanoma. Patients with stable disease received ipilimumab every 12 weeks as maintenance therapy. The 10-mg/kg dose of ipilimumab was chosen based on a randomized phase II study that reported a dose-response relationship for the drug.24 The combination improved OS compared with dacarbazine alone (11.2 months vs 9.1 months), a benefit that spanned all subgroups of patients, including those with M1c disease. However, only 37% of patients in the combination arm completed all four induction cycles, and hepatotoxicity was higher than anticipated. Elevated transaminase levels occurred in a third of patients, with approximately 15% of those being grade 3 or higher, likely due to the addition of dacarbazine. Given this, the use of this combination is not recommended. It is difficult to directly compare the two randomized trials due to inherent differences in study population, dose of ipilimumab, and the partner drug. Although a dose-response relationship has been suggested with ipilimumab, this may come at the cost of greater toxicity, as demonstrated in the randomized phase II study by Wolchok et al.24 In that trial, the ORR was 11%, 4%, and 0% for patients receiving ipilimumab dosed at 10 mg/kg, 3 mg/kg, and 0.3 mg/kg every three weeks, respectively. The respective rates of grades 3 and 4 toxicity were 25%, 7%, and 0%. Until additional data from ongoing clinical trials are available, the use of ipilimumab should be only at the FDA-approved dose of 3 mg/kg every three weeks. In the absence of significant toxicity, it is reasonable to consider reinduction for patients whose disease progresses after an initial response, or following a prolonged period of stability.

Ipilimumab-Related Toxicity and Management As CTLA-4 blockade overcomes tolerance to “self” antigens, adversity from ipilimumab is similarly immune-mediated. Although the types of autoimmune toxicity are predictable, their onset and duration vary considerably. The most common side effects include diarrhea, rash, and endocrine-related adverse

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Melanoma Clinical Pearls immune events.30 Diarrhea and colitis have been reported in 10% to 35% of study patients and are the most commonly seen grade 3/4 toxicities in the majority of clinical trials. Most patients with colitis present within two weeks of starting treatment, although time of onset varies considerably. Colitis can be potentially life-threatening and should be treated with bowel rest, supportive care, high-dose steroids, and/or infliximab.31 The use of budesonide to prevent colitis in patients receiving ipilimumab was studied in a phase II clinical trial. Prophylactic use of budesonide did not affect the rate of grade 2 or higher diarrhea, which occurred in 33% of patients who received budesonide and in 35% of patients who did not receive it.23 Hepatitis or transaminitis has been reported in 2% to 20% of patients treated with ipilimumab. Ipilimumab should be discontinued for > grade 3 hepatotoxicity (AST or ALT > 5 X ULN; bilirubin > 3 X ULN), and a prolonged course of oral corticosteroids may be warranted.25,32 Hypophysitis, adrenal insufficiency, and thyroid dysfunction are the most commonly reported endocrine immune events associated with ipilimumab therapy. Dysfunction of the adrenal axis is often an irreversible adverse event that requires long-term replacement corticosteroid therapy. Virtually every organ can be affected by ipilimumab-associated inflammation, and education of the provider and patient is paramount in its safe administration. The immune-related toxicity of ipilimumab requires prompt diagnosis and intervention, as this can become life-threatening. The algorithms outlined in the FDA-approved Risk Evaluation and Mitigation Strategy (REMS) for ipilimumab are an invaluable source of information for healthcare providers. General guidelines suggest the use of steroids for moderate to severe irAEs (prednisone at 1-2 mg/kg/day or equivalent), with a slow taper over four to six weeks or longer, if necessary. Lower doses (prednisone at 0.5 mg/kg/day or equivalent) can be considered for lesser degrees of toxicity. Ipilimumab therapy is an “all or none” phenomenon. Dose reductions during a course are not undertaken, and the following circumstances mandate permanent discontinuation of ipilimumab: 1. Severe or life-threatening toxicity 2. Inability to wean corticosteroid dose to 7.5 mg prednisone or equivalent per day 3. Inability to complete the entire course of ipilimumab within 16 weeks from the first dose

Ipilimumab Activity in Brain Metastases From Melanoma Melanoma has a high propensity for brain metastases. Most therapeutic trials typically exclude this poor-prognosis cohort of patients. In a multicenter phase II trial of two cohorts of melanoma patients with brain metastases (cohort A: asymptomatic and not on steroids at study entry; cohort B: symptomatic and on stable steroid dosing at entry), ipilimumab dosed at 10 mg/ kg every three weeks was shown to have similar level of activity in the brain and non-central nervous system lesions.33 The global disease-control rate at 12 weeks was 18% in cohort A versus 5% in cohort B, while the median OS was 7 months and 3.7 months, respectively. These intriguing data suggest that ipilimumab may have activity in some patients with small, asymptomatic brain metastases from melanoma, and further investigation is warranted.

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• Immunotherapy offers the best chance for long-term disease control in patients with advanced melanoma. • High-dose IL-2 should be offered to eligible patients through centers of specialized care. • Response to ipilimumab may be delayed, and traditional RECIST criteria may not be universally applicable. • Prompt recognition of irAEs secondary to ipilimumab is necessary in order to institute corrective measures, including high-dose corticosteroids.

Increasing Options: Sequence of Therapy With increasing options for treatment in melanoma, it becomes incumbent to understand the nuances associated with each therapy and aim to streamline an evidence-based approach to the metastatic patient. Immunotherapy offers the only chance for durable disease control and should preferably be the first-line therapy for the patient with advanced, unresectable melanoma in the absence of any obvious contraindication (eg, active autoimmune disease). Tumors from these patients should be tested for the BRAFV600 gene mutation. The following algorithm offers a reasonable approach in decision making: 1. For younger, fit patients without cardiopulmonary comorbidity, highdose IL-2 remains an appropriate first choice, including patients whose tumors harbor the BRAFV600 mutation. 2. Ipilimumab is also a reasonable option for those unfit for, or unwilling to get, high-dose IL-2, or whose disease progresses after IL-2 therapy. 3. Vemurafenib should be considered for patients with BRAFV600 mutation with bulky, symptomatic disease at presentation, or those in whom immunotherapy is contraindicated or has failed (including toxic effects). 4. Cytotoxic chemotherapy can be used in patients with BRAF-wild type melanoma after failure of immunotherapy, or as a possible bridge to immunotherapy in case of symptomatic disease. 5. At any point in therapy, participation in a clinical trial is an accepted standard of care.

Conclusions: “Pandora’s Box” in Immunotherapy The discovery that cancer cells express tumor-specific antigens lent impetus to the development and testing of various therapeutic agents targeted against these antigens. The recent success of anti-CTLA-4 agents in melanoma has spawned renewed clinical interest in cancer immunology. Multiple phase II/III clinical trials testing various combinations of immune agents with other cytotoxic, targeted, and biologic agents are under way, including temozolomide, melphalan, dactinomycin, fotemustine, and bevacizumab, among a few others. The results of these trials are eagerly awaited. Potential agents that might be predicted to synergize with ipilimumab are those targeting other immunological molecules, such as antibodies

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Melanoma blocking PD-1 and agonistic antibodies activating OX40, a co-stimulatory receptor that promotes T-cell survival and expansion. A list of agents under investigation is outlined in the Table. The overarching goal is to obtain a sustained immune response that can facilitate longer survivorship. Importantly, the concurrent search for predictive markers of outcome is essential in order to help target patients who are most likely to benefit from the intervention and to minimize irAEs. Despite the optimism surrounding the newer agents from this “Pandora’s box” of melanoma therapeutics, this disease remains fatal in the vast majority of advanced cases in 2012. Participation in clinical trials should be strongly encouraged—and, in fact, accepted as a standard of care in advanced melanoma.

Table. Selected Immune Agents Under Investigation in Melanoma Class Type

Agent(s)

Cytokines

IL-2, IL-15, IL-21, GM-CSF

Immune Checkpoint Blockade Anti-CTLA-4

Ipilimumab, tremelimumab

Anti-PD-1/PD-L1

MDX-1106, CT-011, MDX-1105

Targeting tumor necrosis factor

BMS 663513

Vaccines

gp 100, MAGE-A3

REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012;62:10-29. 2. Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol. 2009;27:6199-6206. 3. SEER Cancer Statistics Review, 1975-2008, National Cancer Institute. Bethesda, MD, http:// seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission, posted to the SEER website, 2011. Accessed March 30, 2012. 4. Hill GJ, 2nd, Krementz ET, Hill HZ. Dimethyl triazeno imidazole carboxamide and combination therapy for melanoma. IV. Late results after complete response to chemotherapy (Central Oncology Group protocols 7130, 7131, and 7131A). Cancer. 1984;53:1299-1305. 5. Rao RD, Holtan SG, Ingle JN, et al. Combination of paclitaxel and carboplatin as second-line therapy for patients with metastatic melanoma. Cancer. 2006;106:375-382. 6. Hauschild A, Agarwala SS, Trefzer U, et al. Results of a phase III, randomized, placebocontrolled study of sorafenib in combination with carboplatin and paclitaxel as secondline treatment in patients with unresectable stage III or stage IV melanoma. J Clin Oncol. 2009;27:2823-2830. 7. Kim KB, Sosman JA, Fruehauf JP, et al. BEAM: A randomized phase II study evaluating the activity of bevacizumab in combination with carboplatin plus paclitaxel in patients with previously untreated advanced melanoma. J Clin Oncol. 2012;30:34-41. 8. Oble DA, Loewe R, Yu P, Mihm MC, Jr. Focus on TILs: prognostic significance of tumor infiltrating lymphocytes in human melanoma. Cancer Immun. 2009;9:3. 9. Waldmann TA. The biology of interleukin-2 and interleukin-15: implications for cancer therapy and vaccine design. Nat Rev Immunol. 2006;6:595-601. 10. Malek TR. The biology of interleukin-2. Annu Rev Immunol. 2008;26:453-479. 11. Doyle MV, Lee MT, Fong S. Comparison of the biological activities of human recombinant interleukin-2(125) and native interleukin-2. J Biol Response Mod. 1985;4:96-109. 12. Parkinson DR, Abrams JS, Wiernik PH, et al. Interleukin-2 therapy in patients with metastatic malignant melanoma: a phase II study. J Clin Oncol. 1990;8:1650-1656. 13. Atkins MB, Lotze MT, Dutcher JP, et al. High-dose recombinant interleukin 2 therapy for patients with metastatic melanoma: analysis of 270 patients treated between 1985 and 1993. J Clin Oncol. 1999;17:2105-2116.

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14. Tarhini AA, Kirkwood JM, Gooding WE, Cai C, Agarwala SS. Durable complete responses with high-dose bolus interleukin-2 in patients with metastatic melanoma who have experienced progression after biochemotherapy. J Clin Oncol. 2007;25:3802-3807. 15. Rosenberg SA, Yang JC, Schwartzentruber DJ, et al. Immunologic and therapeutic evaluation of a synthetic peptide vaccine for the treatment of patients with metastatic melanoma. Nat Med. 1998;4:321-327. 16. Schwartzentruber DJ, Lawson DH, Richards JM, et al. gp100 peptide vaccine and interleukin-2 in patients with advanced melanoma. N Engl J Med. 2011;364:2119-2127. 17. Hamm C, Verma S, Petrella T, Bak K, Charette M. Biochemotherapy for the treatment of metastatic malignant melanoma: a systematic review. Cancer Treat Rev. 2008;34:145-156. 18. Phan GQ, Attia P, Steinberg SM, White DE, Rosenberg SA. Factors associated with response to high-dose interleukin-2 in patients with metastatic melanoma. J Clin Oncol. 2001;19:3477-3482. 19. Margolin KA, Rayner AA, Hawkins MJ, et al. Interleukin-2 and lymphokine-activated killer cell therapy of solid tumors: analysis of toxicity and management guidelines. J Clin Oncol. 1989;7:486-498. 20. Salama AK, Hodi FS. Cytotoxic T-lymphocyte-associated antigen-4. Clin Cancer Res. 2011;17:4622-4628. 21. Phan GQ, Yang JC, Sherry RM, et al. Cancer regression and autoimmunity induced by cytotoxic T lymphocyte-associated antigen 4 blockade in patients with metastatic melanoma. Proc Natl Acad Sci U S A. 2003;100:8372-8377. 22. Attia P, Phan GQ, Maker AV, et al. Autoimmunity correlates with tumor regression in patients with metastatic melanoma treated with anti-cytotoxic T-lymphocyte antigen-4. J Clin Oncol. 2005;23:6043-6053. 23. Weber J, Thompson JA, Hamid O, et al. A randomized, double-blind, placebo-controlled, phase II study comparing the tolerability and efficacy of ipilimumab administered with or without prophylactic budesonide in patients with unresectable stage III or IV melanoma. Clin Cancer Res. 2009;15:5591-5598. 24. Wolchok JD, Neyns B, Linette G, et al. Ipilimumab monotherapy in patients with pretreated advanced melanoma: a randomised, double-blind, multicentre, phase 2, dose-ranging study. Lancet Oncol. 2010;11:155-164. 25. O’Day SJ, Maio M, Chiarion-Sileni V, et al. Efficacy and safety of ipilimumab monotherapy in patients with pretreated advanced melanoma: a multicenter single-arm phase II study. Ann Oncol. 2010;21:1712-1717. 26. Prieto PA, Yang JC, Sherry RM, et al. CTLA-4 Blockade with Ipilimumab: long-term follow-up of 177 patients with metastatic melanoma. Clin Cancer Res. 2012;18:2039-2047. 27. Wolchok JD, Hoos A, O’Day S, et al. Guidelines for the evaluation of immune therapy activity in solid tumors: immune-related response criteria. Clin Cancer Res. 2009;15:7412-7420. 28. Hodi FS, O’Day SJ, McDermott DF, et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med. 2010;363:711-723. 29. Robert C, Thomas L, Bondarenko I, et al. Ipilimumab plus dacarbazine for previously untreated metastatic melanoma. N Engl J Med. 2011;364:2517-2526. 30. Thumar JR, Kluger HM. Ipilimumab: a promising immunotherapy for melanoma. Oncology (Williston Park). 2010;24:1280-1288. 31. Johnston RL, Lutzky J, Chodhry A, Barkin JS. Cytotoxic T-lymphocyte-associated antigen 4 antibody-induced colitis and its management with infliximab. Dig Dis Sci. 2009;54:2538-2540. 32. Weber J. Review: anti-CTLA-4 antibody ipilimumab: case studies of clinical response and immune-related adverse events. Oncologist. 2007;12:864-872. 33. Margolin K, Ernstoff MS, Hamid O, et al. Ipilimumab in patients with melanoma and brain metastases: an open-label, phase 2 trial [published online ahead of print March 27, 2012]. Lancet Oncol. 2012;13(5):459-465. doi:10.1016/S1470-2045(12)70090-6.

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At diagnosis of metastatic colorectal cancer (mCRC)

Are you getting the full picture? Name: Age: Cancer: Specialty: Biomarker Status:

George 58 mCRC Storyteller

Not an actual patient.

At diagnosis of mCRC, testing a patient’s tumors for biomarkers can help determine predictive and/or prognostic information1 Colorectal cancer is the 3rd leading cause of cancer death in men and women in the U.S.2 Understanding the patient’s biomarker profile helps define the characteristics of the patient’s disease and their overall prognosis.1 Knowing a patient’s biomarker status at diagnosis may help guide clinical decisions.3,4 Understanding the biomarker pathways involved in mCRC tumorigenesis can help inform appropriate treatment planning.3,5,6

KRAS and BRAF signaling are involved with colorectal tumorigenesis and tumor progression3 The KRAS gene may be mutated or wild-type. When KRAS is mutated, it is permanently switched on, whereas wild-type KRAS protein is activated when the EGFR is stimulated.3,5 Increased BRAF signaling may occur due to mutations in the BRAF gene.5 BRAF mutations are limited to those tumors that do not have KRAS exon 2 mutations.7

Testing of biomarkers at diagnosis of mCRC is important for treatment planning3,7*

T E S T

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P L A N

EGFR = epidermal growth factor receptor. *In a CLIA-certified laboratory. References: 1. Tejpar S, Bertagnolli M, Bosman F, et al. Prognostic and predictive biomarkers in resected colon cancer: current status and future perspectives for integrating genomics into biomarker discovery. Oncologist. 2010;15:390-404. 2. American Cancer Society. Cancer Facts & Figures: 2011. http://www.cancer.org/acs/groups/content/@epidemiologysurveillance/ documents/document/acspc-029771.pdf. Accessed March 1, 2012. 3. Monzon FA, Ogino S, Hammond EH, et al. The role of KRAS mutation testing in the management of patients with metastatic colorectal cancer. Arch Pathol Lab Med. 2009;133(10):1600-1606. 4. Grossman AH, Samowitz WS. Epidermal growth factor receptor pathway mutations and colorectal cancer therapy. Arch Pathol Lab Med. 2011;135:1278-1282. 5. Krasinskas AM. EGFR signaling in colorectal carcinoma. Pathol Res Int. 2011;2011:1-6. http://www.hindawi.com/journals/ pri/2011/932932/cta. Accessed January 6, 2012. 6. Linardou H, Briasoulis E, Dahabreh IJ, et al. All about KRAS for clinical oncology practice: gene profile, clinical implications and laboratory recommendations for somatic mutational testing in colorectal cancer. Cancer Treat Rev. 2011;37(3):221-233. 7. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Colon Cancer V.3.2012. © 2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc. Accessed March 15, 2012.

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BRAF Inhibitors in Melanoma Antoni Ribas, MD

The histology of melanoma is dependent upon driver oncogenic mutations in a major signaling pathway, with up to 70% of advanced melanomas having mutually exclusive activating mutations in the mitogen-activated protein kinase (MAPK) pathway. Mutations closely follow different clinical-pathological presentations of melanoma. The BRAFV600E mutation makes up over 90% of the mutations in BRAF, which are present in approximately 50% of all melanomas. The BRAF inhibitor vemurafenib induces high antitumor activity in patients with BRAF-mutant metastatic melanoma and improvement in survival, leading to its approval by the FDA. Similar results have been eported with another BRAF inhibitor, dabrafenib. Resistance to BRAF inhibitors does not follow the common pathways of resistance to other ATP-competitive targeted kinase inhibitors. Instead, so far, mechanisms of resistance can be divided into two major groups: reactivation of the MAPK pathway and MAPK-independent pathways. An understanding of acquired resistance to BRAF inhibitors is already resulting in new combination therapies to prevent or treat some of the resistance mechanisms, and additional novel combinations are under study. A B S T R A C T

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Corresponding Author: Antoni Ribas, MD Department of Medicine, Division of Hematology-Oncology; Jonsson Comprehensive Cancer Center at the University of California, Los Angeles (UCLA), Los Angeles, CA; aribas@mednet.ucla.edu

Biology of MAPK and BRAF Mutations in Melanoma Melanoma has become one of the best examples of a cancer histology dependent upon driver oncogenic mutations in a major signaling pathway. This is because up to 70% of advanced melanomas have mutually exclusive activating mutations in the mitogen-activated protein kinase (MAPK) pathway, resulting in constitutive signaling leading to oncogenic cell proliferation and escape from apoptosis.1 These mutations are not randomly distributed since they closely follow different presentations of melanoma: 1. Mutations in c-Kit: Mutations in the c-Kit receptor tyrosine kinase (RTK) are located in similar exons as in gastrointestinal stromal tumors (GISTs) and are more prevalent in mucosal melanomas and acral lentiginous melanomas.2 These are two subtypes of melanoma that are not related to the carcinogenic effects of ultraviolet light or history of sunburns. Overall, c-Kit mutations are present in less than 2% of melanomas. 2. Mutations in NRAS: RAS mutations in melanoma are preferentially in NRAS, as opposed to other cancers where mutations are more frequent in KRAS or HRAS. They cluster in the RAS hotspot mutation sites, in particular at Q61, and were the first oncogenic driver mutation described in melanomas.3 These mutations tend to appear in melanomas located on intermittently sun-exposed or chronically sunexposed skin. Emergent data suggest that they are more frequent in melanomas in older individuals. Overall, NRAS mutations are present in approximately 20% of melanomas. 3. Mutations in BRAF: The BRAFV600E mutation, which leads to the substitution of valine by glutamic acid at position 600 (V600E) in the BRAF kinase, is the most common point mutation in melanoma, present in approximately 50% of cases.4,5 The BRAFV600E mutation makes up over 90% of the mutations in BRAF, with other amino acid substitutions at this position (V600K, V600D, or V600R) being much less frequent.5 Increasing evidence suggests that the frequency of the BRAFV600E mutation is inversely correlated with age, with a higher incidence in patients between ages 20 to 40 years than patients older than age 60 years. With increasing age, the second most common BRAF mutation, BRAFV600K, is more frequently seen.6 Uncommon mutations at other positions of the BRAF gene often lead to decreased kinase activity, which may still be oncogenic through the transactivation of CRAF. This happens because BRAF usually forms dimers with CRAF, and it has been shown that certain mutations in BRAF or drugs that block BRAF can paradoxically increase the function of CRAF, resulting in increased MAPK signaling.1,5,7

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Wikimedia Commons

Melanoma

Structure of the BRAF protein.

4. Mutations in GNAQ and GNA11: Melanomas arising from the choroidal layer of the eye are clinically distinct from the rest of melanomas in terms of their risk factors (which are mostly unknown), clinical appearance, and natural history. Not surprisingly, these melanomas are driven by different oncogenic mutations in GNAQ and GNA11, which are part of the signaling complex of G-coupled receptors.8,9 These mutations seem to signal through protein kinase C (PKC) and farther downstream through the MAPK pathway, resulting in constitutive oncogenic signaling. BRAF Inhibitors in Clinical Use Two specific BRAF inhibitors with high antitumor activity in patients with BRAF-mutant metastatic melanoma are in clinical use: the FDA-approved vemurafenib10-12 and the experimental agent dabrafenib (formerly GSK2118436).13 They both induce high frequency of tumor responses, specifically in BRAFV600-mutant metastatic melanoma mediated by the inhibition of oncogenic MAPK signaling.14 The most common side effects of the selective BRAF inhibitors are grade 1 and 2 arthralgia and a variety of skin proliferative conditions, in particular a variety of keratotic hyperproliferative lesions. The main grade 3 toxicity with the use of single-agent BRAF inhibitors is the development of secondary cutaneous squamous cell carcinomas, mostly of keratoacanthoma subtype.10-12,15 These nonmelanoma skin cancers frequently appear within the first few weeks of therapy in patients with pre-existing chronic skin sun damage. They are usually treated with local excision and do not require changing the doses or discontinuing therapy with the BRAF inhibitor. The mechanistic basis of their development is the paradoxical MAPK activation with BRAF inhibitors, where the blockade of BRAF within a dimer with CRAF results in increased MAPK signaling through the paradoxical transactivation of CRAF.12,16 Differential toxicities between the two leading BRAF inhibitors are the higher incidence of photosensitivity with vemurafenib and the higher incidence of fevers with dabrafenib.17 The mechanistic bases of these two side effects are yet to be determined.

The International Journal of TargetedTherapies in Cancer

Mechanisms of Acquired Resistance to BRAF Inhibitors Resistance to BRAF inhibitors does not follow the common pathways of resistance to other kinase inhibitors, in that no mutations in the actual target kinase have been described that would make the drug binding ineffective. Notably, no mutations have been described in patient-derived samples that would correspond to the T315I, resulting in resistance to imatinib in chronic myelogenous leukemia,18 or the T790M mutation, resulting in resistance to gefitinib in non-small cell lung cancer.19 Instead, a variety of mechanistically different resistance pathways have been described in subsets of acquired resistant tumor biopsies. These can be divided into two major groups when focusing on mechanisms reported to date in patient-derived samples: 1. Reactivation of the MAPK pathway: Although secondary acquired mutations in BRAF have not yet been identified, several alterations leading to reactivation of oncogenic signaling through the MAPK pathway result in acquired resistance to BRAF inhibitors. Of note, the resistant lesions universally maintain the BRAFV600 mutation. However, there can be other changes in BRAF itself, including amplifications of the mutant BRAFV600 gene20 and truncations in the BRAF protein through alternate splicing, resulting in increased kinase activity due to increased dimerization.21 Secondary mutations upstream or downstream of BRAF would also be predicted to result in resistance, and secondary mutations in NRAS and MEK (MAPK/ERK kinase) have been described in patientderived samples.22,23 However, some patients with a concurrent mutation in BRAFV600 and MEKP124 at baseline can still have responses to clinical BRAF inhibitors.24 Finally, overexpression of the MAPK protein Cot without mutations has been suggested to also lead to acquired resistance.25 Most of these resistance mechanisms could be blocked by downstream inhibition at the level of MEK or ERK (extracellular signal-regulated kinase). 2. MAPK-independent pathways: In some cases of acquired resistance, the BRAF inhibitor continues to demonstrate ability to block oncogenic BRAFV600 signaling,22 and the cell adapts to gain oncogenic signaling from another pathway. This is induced by the overexpression or overactivation of RTKs such as the platelet-derived growth factor receptor beta (PDGFR-Î˛) 22,26 or the insulin-like growth factor 1 receptor (IGF-1R).27 These RTKs provide a MAPK-redundant oncogenic signaling through the PI3K-Akt pathway. In preclinical models, this signaling can be inhibited by drugs that block PI3K, Akt, or TORC,26,28-30 but clinical trials are not yet started.

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Melanoma Clinical Pearls Addressing Acquired Resistance With Combination Therapies Even in cases with reactivation of the MAPK pathway leading to acquired resistance to BRAF inhibitors, sequential administration of a MEK inhibitor does not result in secondary tumor responses,31 which recapitulates data from preclinical models.29 This is probably because there is a continued need to block oncogenic BRAFV600 signaling in a direct way. Also, in agreement with data from preclinical models,32 there is early clinical evidence of secondary responses when adding a MEK inhibitor to continued therapy with a BRAF inhibitor in patients progressing on single-agent BRAF inhibitors.33 The upfront use of combined therapy with a BRAF inhibitor and a MEK inhibitor may provide even greater benefit by preventing the development of MAPK-driven acquired resistance mechanisms (as opposed to treating resistance). The testing of the combination of BRAF and MEK inhibitors as the first oncogene-targeted therapy for BRAF-mutant melanoma has been done with the combination of dabrafenib and the MEK inhibitor trametinib (formerly GSK1120212), with early evidence of improved benefit.33,34 When compared to single-agent BRAF inhibitors, combined therapy with a MEK inhibitor may induce higher antitumor activity through a more profound oncogenic MAPK inhibition, while leading to more durable responses by preventing the MAPK-dependent acquired resistance mechanisms. An additional benefit of this combination is that MEK inhibitors can block paradoxical MAPK activation that results in the development of cutaneous squamous cell carcinomas.12,16 This phenomenon may also be implicated in inflammatory-like toxicities from BRAF inhibitors, such as rash and joint pain. Therefore, the combination of BRAF and MEK inhibitors is a rare example of two agents that when combined have increased antitumor activity with decreased toxicities. Studies combining a BRAF inhibitor with a PI3K or Akt inhibitor to treat or prevent MAPK-independent resistance are likely to start in the clinic given the wealth of supportive preliminary evidence from the laboratory.26,28-30 In addition, several clinical trials are under way combining MEK inhibitors with PI3K or Akt inhibitors, which also test the potential benefit of blocking both signaling pathways in melanoma. These studies will need to be balanced with the risk of increased toxicities when simultaneously blocking the MAPK and the PI3K/Akt pathways. Combining Targeted Therapies and Immunotherapies Most evidence suggests that the high initial rates of tumor responses with BRAF-targeted oncogene pathway inhibitors do not last as long as the rather infrequent but highly durable tumor responses with immunotherapy agents such as interleukin-2 (IL-2) or the anti-CTLA4 antibody ipilimumab.35 The promise of combining these two modes of therapy is to maintain the high frequency of tumor responses achieved with BRAF inhibitors and make them more durable with immunotherapies.36,37 Preclinical studies demonstrated that BRAF inhibitors are not detrimental to human or murine lymphocyte function,38,39 which provides further rationale for the clinical testing of these two strategies. BRAF inhibitors may actually increase the antitumor function of lymphocytes because they may also induce paradoxical activation of the MAPK pathway in activated lymphocytes, as seen in other cells that have strong RAS-GTP activa-

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• The major grade 3 toxicity with single-agent BRAF inhibitors is the development of secondary cutaneous squamous cell carcinomas, which generally appear within the first few weeks of therapy in patients with pre-existing chronic sun skin damage. • There is early clinical evidence of secondary responses when adding a MEK inhibitor to continued therapy with a BRAF inhibitor in patients progressing on single-agent BRAF inhibitors. • Studies combining a BRAF inhibitor with a PI3K or Akt inhibitor to treat or prevent MAPK-independent resistance are likely to start in the clinic, given the wealth of supportive preliminary evidence from the laboratory.

tion.7,40,41 Finally, BRAF inhibitors may increase the direct presentation or cross-presentation of tumor antigens to the immune system.38 Conclusions The treatment of patients with metastatic melanoma has been improved by applying basic biology knowledge in oncogenic signaling and immune regulation to the clinic. This understanding of the means to improve patient care at a molecular level predicts that the advances will continue in the near future. Understanding acquired resistance to BRAF inhibitors is already resulting in new combination therapies that prevent or treat some of the resistance mechanisms. Additional treatment avenues based on the increasing understanding of molecular mechanisms driving this cancer are likely to reach the clinic in the near future. REFERENCES 1. Gray-Schopfer V, Wellbrock C, Marais R. Melanoma biology and new targeted therapy. Nature. 2007;445:851-857. 2. Curtin JA, Fridlyand J, Kageshita T, et al. Distinct sets of genetic alterations in melanoma. N Engl J Med. 2005;353:2135-2147. 3. Padua RA, Barrass N, Currie GA. A novel transforming gene in a human malignant melanoma cell line. Nature. 1984;311:671-673. 4. Davies H, Bignell GR, Cox C, et al. Mutations of the BRAF gene in human cancer. Nature. 2002;417:949-954. 5. Wan PT, Garnett MJ, Roe SM, et al. Mechanism of activation of the RAF-ERK signaling pathway by oncogenic mutations of B-RAF. Cell. 2004;116:855-867. 6. Long GV, Menzies AM, Nagrial AM, et al. Prognostic and clinicopathologic associations of oncogenic BRAF in metastatic melanoma. J Clin Oncol. 2011;29:1239-1246. 7. Heidorn SJ, Milagre C, Whittaker S, et al. Kinase-dead BRAF and oncogenic RAS cooperate to drive tumor progression through CRAF. Cell. 2010;140:209-221. 8. Van Raamsdonk CD, Bezrookove V, Green G, et al. Frequent somatic mutations of GNAQ in uveal melanoma and blue naevi. Nature. 2009;457:599-602. 9. Van Raamsdonk CD, Griewank KG, Crosby MB, et al. Mutations in GNA11 in uveal melanoma. N Engl J Med. 2010;363:2191-2199. 10. Flaherty KT, Puzanov I, Kim KB, et al. Inhibition of mutated, activated BRAF in metastatic melanoma. N Engl J Med. 2010;363:809-819. 11. Sosman JA, Kim KB, Schuchter L, et al. Survival in BRAF V600-mutant advanced melanoma treated with vemurafenib. N Engl J Med. 2012;366:707-714. 12. Su F, Viros A, Milagre C, et al. RAS mutations in cutaneous squamous-cell carcinomas in patients treated with BRAF inhibitors. N Engl J Med. 2012;366:207-215. 13. Wilmott JS, Long GV, Howle JR, et al. Selective BRAF Inhibitors induce marked T-cell infiltration into human metastatic melanoma. Clin Cancer Res. 2012;18:1192-1194. 14. Bollag G, Hirth P, Tsai J, et al. Clinical efficacy of a RAF inhibitor needs broad target blockade in BRAF-mutant melanoma. Nature. 2010;467:596-599. 15. Chapman PB, Hauschild A, Robert C, et al. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med. 2011;364:2507-2516. 16. Oberholzer PA, Kee D, Dziunycz P, et al. RAS mutations are associated with the development of cutaneous squamous cell tumors in patients treated with RAF inhibitors. J Clin Oncol. 2012;30:316-321.

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17. Arkenau HT, Kefford R, Long GV. Targeting BRAF for patients with melanoma. Br J Cancer. 2011;104:392-398. 18. Gorre ME, Mohammed M, Ellwood K, et al. Clinical resistance to STI-571 cancer therapy caused by BCR-ABL gene mutation or amplification. Science. 2001;293:876-880. 19. Pao W, Miller VA, Politi KA, et al. Acquired resistance of lung adenocarcinomas to gefitinib or erlotinib is associated with a second mutation in the EGFR kinase domain. PLoS Medicine. 2005;2:e7.. 20. Shi H, Moriceau G, Kong X, et al. Melanoma whole-exome sequencing identifies (V600E)B-RAF amplification-mediated acquired B-RAF inhibitor resistance. Nature Communications.2012;3:724. 21. Poulikakos PI, Persaud Y, Janakiraman M, et al. RAF inhibitor resistance is mediated by dimerization of aberrantly spliced BRAF(V600E). Nature. 2011;480:387-390. 22. Nazarian R, Shi H, Wang Q, et al. Melanomas acquire resistance to B-RAF(V600E) inhibition by RTK or N-RAS upregulation. Nature. 2010;468:973-977. 23. Wagle N, Emery C, Berger MF, et al. Dissecting therapeutic resistance to RAF inhibition in melanoma by tumor genomic profiling. J Clin Oncol. 2011;29(22):3085-3096. 24. Shi H, Moriceau G, Kong X, et al. Sensitivity of B-RAF/MEK1 double-mutant melanomas to B-RAF inhibitors. Cancer Discovery [in press]; 2012. 25. Johannessen CM, Boehm JS, Kim SY, et al. COT drives resistance to RAF inhibition through MAP kinase pathway reactivation. Nature. 2010;468:968-972. 26. Shi H, Kong X, Ribas A, et al. Combinatorial treatments that overcome PDGFR{beta}driven resistance of melanoma cells to V600EB-RAF inhibition. Cancer Res. 2011;71:50675074. 27. Villanueva J, Vultur A, Lee JT, et al. Acquired resistance to BRAF inhibitors mediated by a RAF kinase switch in melanoma can be overcome by cotargeting MEK and IGF-1R/PI3K. Cancer Cell. 2010;:683-695. 28. Jiang CC, Lai F, Thorne RF, et al. MEK-independent survival of B-RAFV600E melanoma cells selected for resistance to apoptosis induced by the RAF inhibitor PLX4720. Clin Cancer Res. 2010;17:721-730. 29. Atefi M, von Euw E, Attar N, et al. Reversing melanoma cross-resistance to BRAF and MEK inhibitors by co-targeting the AKT/mTOR pathway. PLoS ONE. 6:e28973, 2011. 30. Paraiso KH, Xiang Y, Rebecca VW, et al. PTEN loss confers BRAF inhibitor resistance to melanoma cells through the suppression of BIM expression. Cancer Res. 2011;71:27502760. 31. Kim KB, Lewis KD, Pavlick AC, et al. A Phase II study of the MEK1/MEK2 inhibitor GSK1120212 in metastatic BRAF-V600E or K mutant cutaneous melanoma patients previously treated with or without a BRAF inhibitor. Pigment Cell Melanoma Res. 2011;24:1021. Abstract. 32. Paraiso KH, Fedorenko IV, Cantini LP, et al. Recovery of phospho-ERK activity allows melanoma cells to escape from BRAF inhibitor therapy. Br J Cancer. 2010;102:1724-1730. 33. Flaherty K, Infante JR, Falchook GS, et al. Phase I/II study of BRAFi GSK2118436 + MEKi GSK1120212 in patients with BRAF mutant metastatic melanoma who progressed on a prior BRAFi. Pigment Cell Melanoma Res. 2011. 34. Infante JR, Falchook GS, Lawrence DP, et al. Phase I/II study to assess safety, pharmacokinetics, and efficacy of the oral MEK 1/2 inhibitor GSK1120212 (GSK212) dosed in combination with the oral BRAF inhibitor GSK2118436 (GSK436). J Clin Oncol .2001;29:Abstract CRA8503. 35. Ribas A, Hersey P, Middleton MR, et al. New challenges in endpoints for drug development in advanced melanoma. Clin Cancer Res. 2012;18:336-341. 36. Begley J, Ribas A. Targeted therapies to improve tumor immunotherapy. Clin Cancer Res. 2008;14:4385-4391. 37. Ribas A, Flaherty KT. BRAF targeted therapy changes the treatment paradigm in melanoma. Nature Rev Clin Oncol. 2011;8:426-433. 38. Boni A, Cogdill AP, Dang P, et al. Selective BRAFV600E inhibition enhances T-cell recognition of melanoma without affecting lymphocyte function. Cancer Res. 2010;70:5213-5219. 39. Comin-Anduix B, Chodon T, Sazegar H, et al. The oncogenic BRAF kinase inhibitor PLX4032/RG7204 does not affect the viability or function of human lymphocytes across a wide range of concentrations. Clin Cancer Res. 2010;16:6040-6048. 40. Halaban R, Zhang W, Bacchiocchi A, et al. PLX4032, a selective BRAF(V600E) kinase inhibitor, activates the ERK pathway and enhances cell migration and proliferation of BRAF melanoma cells. Pigment Cell Melanoma Res. 2012;23:190-200. 41. Poulikakos PI, Zhang C, Bollag G, et al. RAF inhibitors transactivate RAF dimers and ERK signalling in cells with wild-type BRAF. Nature. 2011;480:387-390.

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Cancer Therapy

MET Inhibitors in Cancer Therapy Alex A. Adjei, MD, PhD

The MET signaling A B S T R A C T pathway is abnormal in a wide variety of cancers and stimulates cell growth, invasion, and metastasis, as well as promoting resistance to apoptosis. Because of its ubiquitous role in cancer cells, the MET axis has been seen as an attractive target for cancer therapy. Over the last four years, more than 10 anticancer agents targeting different aspects of MET signaling via different mechanisms have been introduced into the clinic. The majority of MET inhibitors are still in late phase I and phase II trials, but at least three compounds, tivantinib, onartuzumab, and cabozantinib, are in phase III trials in lung cancer and medullary thyroid cancer. Ongoing research is aimed at identifying predictive biomarkers that can help identify patients most likely to respond to these compounds. The terminology for this pathway can be confusing. The gene is c-MET, the protein product of the gene is MET.

The MET Signaling Pathway c-MET was cloned in 1984 and described as a new transforming gene distinct from the then-known RAS family of oncogenes.1 Shortly after cMETâ&#x20AC;&#x2122;s initial discovery, its unique high-affinity ligand known as HGF (hepatocyte growth factor, also called scatter factor [SF]), was purified2 and cloned.3 It should be noted that MET is the only known receptor for HGF. The regulatory pathway of MET and HGF governs various cell processes by modulating important signaling cascades in cancer and in normal cells. For example, MET plays a central role in tissue and organ development of embryos, including development of the placenta, liver, and muscle, and the nervous system.4,5 The role of MET in adults is largely restricted to participation in organ regeneration, notably in wound healing, as well as in the pathogenesis of liver, kidney, and heart diseases.6-9 Activation of the MET receptor, usually upon binding of HGF, results in the classic sequence described for receptor tyrosine kinases, including receptor dimerization, phosphorylation of intracellular residues, and initiation of a signal transduction cascade through direct interactions with adaptor proteins, especially GRB2-associated-binding protein 1(GAB1)10, leading to various cellular effects. In addition, the MET pathway interacts with several other cell surface receptors and intracellular pathways, including the HER family (HER1/2/3)11, IGF-1 receptor12, integrins13, and Fas death receptor.14

The Role of the MET Pathway in Cancer

Alex A. Adjei, MD, PhD Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY; alex.adjei@roswellpark.org 50 / 3.12

In experimental cancer models, increased signaling through the MET pathway results in acquisition or reinforcement of all elements of the malignant phenotype. These include tumor cell proliferation, motility, invasiveness, migration, and survival. In addition, endothelial cell proliferation and motility occur, resulting in tumor angiogenesis.15 It should also be noted that MET is expressed not only in tumor cells and endothelial cells, but also in osteoblasts (bone-forming cells) and osteoclasts (boneremoving cells). HGF binds to MET on all of these cell types, giving the MET pathway an important role in multiple autocrine and paracrine loops. Activation of MET in tumor cells appears to be important in the establishment of metastatic bone lesions. At the same time, activation of the MET pathway in osteoblasts and osteoclasts may lead to pathological features of bone metastases, including abnormal bone growth (ie, blastic lesions) or destruction (ie, lytic lesions). Thus, targeting the MET pathway may be a viable strategy in preventing the establishment and progression of metastatic bone lesions. The MET pathway is abnormally regulated in a wide range of human cancers, including the most common epithelial cancers such as breast, colorectal, lung, pancreatic, hepatic, and ovarian cancers.16 Aberrant MET signaling The International Journal of TargetedTherapies in Cancer

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Cancer Therapy Gene Amplification

Figure 1. MET Signaling Pathway and Inhibitory Targets With Agents That Act on These Targets Anti-HGF Antibodies • Rilotumumab • Ficlatuzumab

HGF HGF

HGF

HGF-MET interaction inhibitors HGF binding MET oligomerization MET activation

Anti-MET Antibodies • Onartuzumab

HGF

Selective MET inhibitors • Tivantinib • INCB28060 • EMD 1214063 Non-selective MET inhibitors • Cabozantinib • Foretinib

Tyrosine-kinase inhibitors Met downstream signaling Other pathway signaling

Ras - ERK P13K — AKT-mTOR STAT PLC SRC

MET activation sets into motion a cascade of signaling events. Recruitment of SH2-domaincontaining molecules activate a number of pathways, including the RAS–RAF–MEK–ERK and the PI3-Kinase-AKT axis, leading to cell proliferation, invasion, angiogenesis, and metastasis. Inhibitory approaches target various molecules involved in MET activation and signaling.

results from several molecular mechanisms, including germline or somatic c-MET gene mutation, c-MET chromosomal rearrangement, c-MET amplification, c-MET transcriptional upregulation, or ligand-dependent autocrine or paracrine changes. These mechanisms are described briefly following.

Receptor and Ligand Overexpression Transcriptional upregulation of c-MET resulting in MET overexpression is the predominant mechanism of c-MET activation encountered in cancer and is present in different types of cancer, including sarcoma, hematologic malignancies, glioblastoma, medulloblastoma, mesothelioma, melanoma, and in the majority of, if not all, carcinomas.16 In this setting, MET activation depends on ligand binding, following an autocrine, or, probably more frequently, paracrine secretion of HGF. The molecular mechanisms resulting in MET overexpression remain poorly described. In a minority of cases, gene amplification (described below), may be the basis of high MET expression. In several clinical studies, aberrant MET signaling—in particular, overexpression of MET and/ or HGF—has been correlated with poor clinical outcome, exemplified by rapid dissemination of disease and short survival. Overexpression of MET and HGF are also thought to result in resistance of tumor cells to chemotherapy and radiotherapy.16 The International Journal of TargetedTherapies in Cancer

Gene amplification refers to the production of multiple copies of a particular gene, which typically amplifies the function attributed to the gene. To evaluate gene copy number, fluorescence in situ hybridization (FISH) and real-time polymerase chain reaction (PCR) are most frequently used, with Southern blot, chromogenic in situ hybridization (CISH), comparative genomic hybridization (CGH), and single nucleotide polymorphism (SNP) array technologies as alternative tools. When high gene copy number is documented by one of these techniques, a specific reference DNA sequence known not to be amplified in tumor cells must be used in addition, as a denominator, to differentiate amplification from polysomy. Amplification of oncogenes has been described in many cancers. HER2 amplification in breast cancer, for example, represents the main criterion for selecting patients for trastuzumab therapy. Other examples are EGFR amplification in non-small cell lung cancer (NSCLC) and glioblastoma. Gene amplification is one of the mechanisms resulting in gene copy number increase, which is restricted to a specific section of DNA. Polysomy, in which a specific chromosome is represented more than twice (also known as aneuploidy), is another genetic alteration resulting in multiple copies per cell of the same gene. Polysomy is therefore a biologically different phenomenon from gene amplification.

Gene Mutations

Rarely, the c-MET gene can be affected by somatic or germline point mutations. Sporadic c-MET mutations occurring in the kinase domain have been described to date in ovarian17, head and neck18, childhood liver19, thyroid cancers20, diffuse large B-cell lymphoma21, and gliomas.17-21 In addition, mutations occurring in the juxta-membrane domain of the MET receptor have been demonstrated in gastric, papillary renal cell, mesothelioma22, NSCLC23, small cell lung cancer (SCLC)24, diffuse large B-cell lymphoma21, and melanoma.25 In general, these mutations are rare, typically occurring in 5% or less of these tumors. One exception is in hereditary papillary renal cell carcinoma (RCC), which seems to depend on aberrant MET activity. In this disease, a nonrandom duplication of the allele bearing the mutated MET gene has been described related to trisomy of chromosome 7 in almost all cases.26 Experimental data confirm that these are classic activating mutations.27

MET Inhibitors in the Clinic Several MET pathway inhibitors are currently being studied in the clinic. These agents focus on the serial steps that lead to activation of MET (Figure 1 and Table 1): 1. HGF specific binding to MET can be prevented by competitors that prevent HGF ligand from interacting with the MET receptor, blocking downstream activation of the pathway. Several anti-HGF humanized antibodies are being studied (rilotumumab, ficlatuzumab). 3.12 / 51

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Cancer Therapy Table 1. Selected Examples of Specific MET Inhibitors Drug Name

Drug Target

Stage of Clinical Development

rilotumumab

HGF IgG2 Mab

Phase II: multiple tumors

ficlatuzumab

HGF IgG1 Mab

Phase II: NSCLC

TAK-701

HGF IgG1 Mab

Phase I: solid tumors

onartuzumab

MET IgG1 Mab

Phase III: NSCLC Phase II: several tumors

tivantinib

MET TKI

Phase III: NSCLC Phase II: several solid tumors

EMD1214063 EMD1204831

MET TKI

Phase I: solid tumors

INCB28060

MET TKI

Phase I: solid tumors

Anti-MET Receptor Antibodies

NSCLC indicates non-small cell lung carcinoma.

2. MET receptor activation can be prevented by receptor blockage by specific monoclonal antibodies that bind to and degrade the receptor (eg, onartuzumab). 3. MET receptor activation can also be targeted by selective MET kinase inhibitors such as tivantinib (ARQ197) and PF04217903, which have specific selectivity for MET receptor tyrosine kinase, or nonselective MET kinase inhibitors such as crizotinib (PF02341066), cabozantinib (XL184), and foretinib, which have broad activity against MET and other receptor tyrosine kinases that have also been shown to be important in cancer.

Anti-HGF Monoclonal Antibodies A number of monoclonal antibodies that bind HGF are currently in clinical trials. These include ficlatuzumab, rilotumumab, and TAK701. Ficlatuzumab (previously called AV299) is a humanized antiHGF IgG1 monoclonal antibody that has completed phase I trials as a single agent and in combination with gefitinib. Toxicities are fatigue, peripheral edema, diarrhea, headache, and hematologic toxicity. Phase II trials are ongoing in NSCLC.28 TAK701 is a humanized IgG1 monoclonal antibody that has just completed phase I testing. Toxicities included fatigue, pleural effusion, and abdominal pain. The future development plans of this compound are unclear.28 Rilotumumab (previously called AMG102) is a fully humanized IgG2 monoclonal antibody29 that has undergone phase I and II clinical trials. It is currently under evaluation as monotherapy in phase IB-II trials in ovarian and renal cancer, as well as in combination with antiangiogenic targeted agents in glioma, 52 / 3.12

erlotinib in NSCLC, panitumumab in colorectal cancer, and platinum-based chemotherapy in SCLC, mesothelioma, and gastric cancer, as well as with mitoxantrone in prostate cancer.

Onartuzumab (previously called OA-5D5 or OAM4558g and later, MetMab): Earlier efforts to develop MET-directed antibodies failed due to the tendency of bivalent antibodies to cause receptor dimerization, and therefore activate the MET receptor. This agonistic activity has been prevented by producing a monovalent human IgG1 antibody with murine variable domains. The resulting monoclonal antibody, onartuzumab, has been studied in a number of clinical trials. A randomized phase II trial comparing onartuzumab/erlotinib to erlotinib treatment in second- or thirdline NSCLC has been reported.30 In the intent-to-treat population of approximately 120 patients, there was no evidence of efficacy in adding onartuzumab to erlotinib. Using a prototype immunohistochemistry (IHC) assay to divide patients in the study into two groups according to a prespecified diagnostic cutoff, there were significant improvements in progression-free and overall survival in the patients with high MET expression by IHC. This “MET high” group was defined as 50% or greater of cells on the diagnostic slide with a staining intensity of 2+ or 3+ (Figure 2). Fifty-four percent of patients were in this “MET high” group. A puzzling finding was the fact that the “low MET” patients did worse when they received onartuzumab in combination with erlotinib. The reasons for this finding are unclear. A phase III trial now under way is using this assay to prospectively enroll patients. Thus, with the help of a novel diagnostic assay, a drug that appeared to be negative in the initial analysis was shown to be potentially active and worthy of further study (see “Clinical Trial Profiles: MetMAb and ARQ 197 in Non-Small Cell Lung Cancer” on page 26). Unfortunately, the design of the phase III study will not help confirm or refute the suggestion that “low MET” patients appear to be harmed by a combination of onartuzumab and erlotinib. The benefit from onartuzumab did not seem to be driven by EGFR mutation or FISH status, nor by imbalances in the randomized patient populations.30

Table 2. Selected Examples of Non-Specific MET Tyrosine Kinase Inhibitors Drug Name

Drug Target (in addition to MET)

Stage of Clinical Development

cabozantinib

VEGFR2, Ret, Kit, Flt3, Tie-2

Phase III: medullary thyroid cancer; prostate cancer Phase II: multiple solid tumors

foretinib

VEGFR2, Axl, PDGFR, Kit, Flt3, Tie-2

Phase II: multiple solid tumors

crizotinib

Alk, Ron Axl, Tie-2

Phase III: NSCLC (targeting ALK); Phase I-II: lymphoma (targeting ALK); multiple solid tumors (targeting MET)

NSCLC indicates non-small cell lung carcinoma; PDGFR, platelet-derived growth factor receptor; VEGFR2, vascular endothelial growth factor receptor 2.

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clinical

Figure 2. MET Staining in NSCLC by IHC

A R T I C L E S

Photos courtesy Adjei A.

Scores are from left to right, 1+, 2+, 3+.

NSCLC indicates non-small cell lung cancer; IHC, immunohistochemistry.

Onartuzumab is also now under clinical evaluation in randomized, double-blind phase II trials in combination with paclitaxel and bevacizumab in triple-negative breast cancer and in combination with FOLFOX and bevacizumab in colorectal carcinoma.

Receptor Tyrosine Kinase Inhibitors (TKIs) Various small-molecule inhibitors of the MET receptor tyrosine kinase have been evaluated in the preclinical setting and several have reached the clinic. Some inhibitors are selective, with no other known targets at achievable concentrations in humans, while others inhibit a panel of kinases.

Selective MET TKIs There are a number of selective MET TKIs in the clinic, including EMD 121406, EMD 1204831, INCB028060, and tivantinib.28 Tivantinib (previously called ARQ197): Tivantinib is probably the most advanced oral MET inhibitor under clinical evaluation. Unlike most other TKIs, tivantinib does not compete for ATP binding and hydrolysis, but blocks the MET receptor in its nonphosphorylated, inactive conformation via an as yet undisclosed mechanism.31 Tivantinib was well tolerated in phase I trials, and pharmacodynamic activity, including reduced total MET and MET phosphorylation, was demonstrated in tumor biopsies from 15 of 51 patients. Common toxicities were fatigue, nausea and vomiting, mucositis, palmar-plantar erythrodysesthesia, hypokalemia, and febrile neutropenia.32 A randomized, placebo-controlled, double-blind phase II clinical trial evaluating the combination of erlotinib/tivantinib compared with erlotinib/placebo in second- and third-line NSCLC has recently been published.33 Progression-free survival, the primary endpoint, was similar in both arms. However, a preplanned exploratory survival analysis demonstrated a trend toward benefit from erlotinib/tivantinib in both PFS and OS in nonsquamous histology, as well as in EGFR wild-type NSCLC patients. Interestingly, in the 15 patients with KRAS mutations, there was also significant benefit in PFS and OS, with poor outcomes reported for KRAS-mutated patients in the erlotinib/placebo arm. There was a trend toward benefit in patients with MET-amplified tumors, with the benefit growing in magnitude with increasing copy number in the erlotinib/ tivantinib arm. Consistent with the role of MET in metastases, there was The International Journal of TargetedTherapies in Cancer

a trend toward delayed development of metastases in patients who received erlotinib in combination with tivantinib. Based on these results, a phase III randomized trial comparing erlotinib/tivantinib with erlotinib/placebo in nonsquamous NSCLC was activated and has completed accrual (see â&#x20AC;&#x153;Clinical Trial Profiles: MetMAb and ARQ 197 in Non-Small Cell Lung Cancerâ&#x20AC;? on page 26).

Non-Selective c-MET TKIs A number of non-selective MET inhibitors are in clinical testing (Table 2). These include crizotinib, which has been developed and marketed as an ALK inhibitor and is now being evaluated for its MET inhibitory activity; foretinib; and cabozantinib. The agent most advanced in its development as a multitargeted MET inhibitor is cabozantinib. Cabozantinib (previously called XL184): Cabozantinib is a multikinase inhibitor acting on MET, VEGFR2, AXL, Tie2, KIT, FLT3, and RET. In the phase I dose-escalation study in patients with advanced solid tumors, 85 patients were enrolled, including 37 with medullary thyroid carcinoma (MTC). The maximum tolerated dose was 175 mg daily. Dose-limiting toxicities were grade 3 palmar-plantar erythrodysesthesia, mucositis, and AST, ALT, and lipase elevations and grade 2 mucositis that resulted in dose interruption and reduction. Ten (29%) of 35 patients with MTC with measurable disease had a confirmed partial response. Overall, 18 patients experienced tumor shrinkage of 30% or more, including 17 (49%) of 35 patients with MTC with measurable disease.34 A phase II randomized discontinuation study evaluated the activity of cabozantinib in patients with breast, gastric/gastroesophageal junction, SCLC, NSCLC, ovarian, pancreatic, hepatocellular, and prostate cancers, or melanoma. In the NSCLC cohort of patients who had failed up to three prior systemic treatments, there were two partial responses and eight stable disease among 20 evaluable patients. The overall disease control rate was 50% at 12 weeks, and one patient with prior exposure to sunitinib achieved a 61% decrease in tumor growth. Another patient previously treated with platinum-based chemotherapy and an EGFR inhibitor achieved a 32% reduction in tumor size. Diarrhea, fatigue, asthenia, and pain in the extremities were the most frequently observed adverse events. In the melanoma cohort, one partial response and 11 stable disease were reported in 24 evaluable patients. The disease control rate was 50%. A total of 12 patients with previously-treated hepatocellular cancer (HCC) and a Child-Pugh score 3.12 / 53

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A R T I C L E S

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Cancer Therapy Clinical Pearls of A were enrolled: seven were evaluable. Two of these patients achieved a partial response, and five achieved stable disease. Preliminary results from a subset of patients with castration-resistant prostate cancer (CRPC) have also been presented. Accrual was halted after 168 patients had been enrolled, and the study was unblinded due to high rates of observed clinical activity. Objective tumor shrinkage occurred in 84% of patients. There was an unprecedented complete or partial resolution of bone metastases in most men with metastatic CRPC in this study. These findings support the putative role of MET in bone metastasis development and propagation. Based on these results, in addition to the phase III study of cabozantinib in prostate cancer, there are studies in breast cancer and in multiple myeloma in which the primary outcome measure is bone scan response rate. A phase III study in patients with medullary thyroid carcinoma is ongoing.

Conclusions MET inhibitors remain a very promising class of compounds for cancer therapy. While the preclinical data and knowledge of the biology of MET suggest that inhibiting MET may have a profound effect on cancer therapy, results from clinical trials to date suggest that MET inhibitors as single agents may be important only in a subset of patients. For instance, there were very few responses to foretinib in hereditary papillary RCC (which harbors c-MET mutations), and the few responses that were seen were not clearly connected to c-MET mutation status. This may imply that while many c-MET mutations have been described, a number of them may not be activating mutations that sensitize the tumors to MET inhibitors.28 Currently, the most robust single-agent activity in unselected patients has been seen with the multikinase inhibitors, such as cabozantinib. There is an urgent need to identify biomarkers that may be predictive of singleagent activity with the selective inhibitors. MET mutations, amplification, and receptor, as well as ligand expression are all being evaluated. The phase III study of onartuzumab is selecting patients based on MET expression by IHC. While this biomarker is not yet validated, it appears to be the only marker that will provide definitive information, at the end of the phase III study. There are multiple other clinical trials with MET inhibitors. Results in the coming years will help define their role in cancer therapy. REFERENCES 1. Cooper CS, Park M, Blair D, et al. Molecular cloning of a new transforming gene from a chemically transformed human cell line. Nature. 1984;311: 29-33. 2. Nakamura T, Nawa K, Ichihara A. Partial purification and characterization of hepatocyte growth factor from serum of hepatectomized rats. Biochemical Biophysical Research Communications. 1984;122:1450-1459. 3. Nakamura T, Nishizawa T, Hagiya M, et al. Molecular cloning and expression of human hepatocyte growth factor. Nature. 1989;342: 440-443. 4. Schmidt, C. Bladt F, Goedecke S, et al. Scatter factor/hepatocyte growth factor is essential for liver development. Nature. 1995;373:699-702. 5. Uehara Y, Minowa O, Mori C, et al. Placental defect and embryonic lethality in mice lacking hepatocyte growth factor/scatter factor. Nature. 1995;373: 702-705. 6. Matsumoto K, Nakamura T. Hepatocyte growth factor: renotropic role and potential therapeutics for renal diseases. Kidney Int. 2001;59:2023-2038. 7. Michalopoulos GK, DeFrances MC. Liver regeneration. Science. 1997;276:60-66. 8. Nakamura T, Mizuno S, Matsumoto K, et al. Myocardial protection from ischemia/reperfusion injury by endogenous and exogenous HGF. J Clin Invest. 2000;106:1511-1519. 9. Rabkin R, Fernanza F, Tsao T, et al. Hepatocyte growth factor receptor in acute tubular necrosis. J Am Soc Nephrol. 2001;12:531-540. 10. Weidner KM, Di Cesare S, Sachs M, et al. Interaction between Gab1 and the c-Met receptor tyrosine kinase is responsible for epithelial morphogenesis. Nature. 1996;384:173-176.

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The MET signaling pathway is involved in all of the key processes of cancer growth and dissemination, and has been implicated in resistance of cancer cells to cytotoxic chemotherapy, as well as targeted agents such as EGFR inhibitors and VEGFR inhibitors. • MET inhibitors have therefore been seen as exciting drugs for cancer therapy. • While MET is expressed in a majority of cancers, molecular abnormalities in the MET gene (mutation, translocations, amplification) are rare, suggesting that abnormalities in MET are not oncogenic drivers. Thus, it is unlikely that objective antitumor responses will be seen with the use of MET inhibitors as single agents. • The promise of these compounds is likely to be seen in combination therapies, with patients selected by predictive biomarkers, all of which are currently under investigation. • Unlike the highly selective MET inhibitors, some of the multitargeted MET inhibitors may possess single-agent activity.

11. Bonine-Summers AR, Aakre ME, Brown K, et al. Epidermal growth factor receptor plays a significant role in hepatocyte growth factor mediated biological responses in mammary epithelial cells. Cancer Biol Ther. 2007;6:561-570. 12. Bauer TW, Somcio RJ, Fan F, et al. Regulatory role of c-Met in insulin-like growth factor-I receptormediated migration and invasion of human pancreatic carcinoma cells. Mol Cancer Ther. 2006;5:1676-1682. 13. Trusolino L, Bertotti A, Comoglio PM. A signaling adapter function for alpha6beta4 integrin in the control of HGF-dependent invasive growth. Cell. 2001;107:643-654. 14. Wang X, D Frances MC, Dai Y, et al. A mechanism of cell survival: sequestration of Fas by the HGF receptor Met. Molecular Cell. 2002;9:411-421. 15. Rosen EM, Carley W, Goldberg ID. Scatter factor regulates vascular endothelial cell motility. Cancer Invest. 1990;8:647-650. 16. Sharma N, Adjei AA. In the clinic: ongoing clinical trials evaluating c-MET-inhibiting drugs. Ther Adv Med Oncol. 2011;3(1 suppl):S37-50. 17. Tanyi J, Tory K, Rig J, et al. Evaluation of the tyrosine kinase domain of the Met proto-oncogene in sporadic ovarian carcinomas. Pathol Oncol Res. 1999;5:187-191. 18. Di Renzo MF, Olivero M, Martone T, et al. Somatic mutations of the MET oncogene are selected during metastatic spread of human HNSC carcinomas. Oncogene. 2000;19:1547-1555. 19. Park WS, Dong SM, Kim SY, et al. Somatic mutations in the kinase domain of the Met/hepatocyte growth factor receptor gene in childhood hepatocellular carcinomas. Cancer Res. 1999;59:307-310. 20. Wasenius VM, Hemmer S, Karjalainen-Lindsberg ML, et al. MET receptor tyrosine kinase sequence alterations in differentiated thyroid carcinoma. Am J Surg Pathol. 2005;29:544-549. 21. Tjin EPM, Groen RW, Vogelzang I, et al. Functional analysis of HGF/MET signaling and aberrant HGFactivator expression in diffuse large B-cell lymphoma. Blood. 2006;107:760-768. 22. Jagadeeswaran R, Ma PC, Seiwert TW, et al. Functional analysis of c-Met/hepatocyte growth factor pathway in malignant pleural mesothelioma. Cancer Res.2006;66:352-361. 23. Kong-Beltran M, Seshagiri S, Zha J, et al. Somatic mutations lead to an oncogenic deletion of met in lung cancer. Cancer Res. 2006;66:283-289. 24. Ma PC, Kijima T, Maulik G, et al. c-MET mutational analysis in small cell lung cancer: novel juxtamembrane domain mutations regulating cytoskeletal functions. Cancer Res. 2003;63:6272-6281. 25. Puri N, Ahmed S, Janamanchi V, et al. c-Met is a potentially new therapeutic target for treatment of human melanoma. Clin Cancer Res. 2007;13:2246-2253. 26. Zhuang, Z, Park WS, Pack S, et al. Trisomy 7-harbouring non-random duplication of the mutant MET allele in hereditary papillary renal carcinomas. Nat Genet. 1998;20:66-69. 27. Jeffers M, Schmidt L, Nakaigawa N, et al. Activating mutations for the met tyrosine kinase receptor in human cancer. Proc Natl Acad Sci USA. 1997;94:11445-11450. 28. Peters S, Adjei AA. MET: a promising anticancer therapeutic target. Nat Rev Clin Oncol. 2012. In press. 29. Giordano S. Rilotumumab, a mAb against human hepatocyte growth factor for the treatment of cancer. Curr Opin Mol Ther. 2009;11:448-455. 30. Spigel D. Final efficacy results from OAM4558g, a randomized phase II study evaluating MetMAb or placebo in combination with erlotinib in advanced NSCLC. J Clin Oncol. 2011;29(suppl; abstr 7505). 31. Adjei AA, Schwartz B, Garmey E. Early clinical development of ARQ 197, a selective, non-ATPcompetitive inhibitor targeting MET tyrosine kinase for the treatment of advanced cancers. Oncologist. 2011;16:788-799. 32. Yap TA, Olmos D, Brunetto AT, et al. Phase I trial of a selective c-MET inhibitor ARQ 197 incorporating proof of mechanism pharmacodynamic studies. J Clin Oncol. 2011;29:1271-1279. 33. Sequist LV, von Pawel J, Garmey EG, et al. Randomized phase II study of erlotinib plus tivantinib versus erlotinib plus placebo in previously treated non-small-cell lung cancer. J Clin Oncol. 2011;29:3307-3315. 34. Kurzrock R, Sherman SI, Ball DW, et al. Activity of XL184 (Cabozantinib), an oral tyrosine kinase inhibitor, in patients with medullary thyroid cancer [published online ahead of print May 23, 2011]. J Clin Oncol. 2011;29:2660-2666.

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1 INDICATIONS AND USAGE 1.1 Metastatic Colorectal Cancer (mCRC) Avastin is indicated for the first‑ or second‑line treatment of patients with metastatic carcinoma of the colon or rectum in combination with intravenous 5‑fluorouracil– based chemotherapy. 1.2 Non‑Squamous Non–Small Cell Lung Cancer (NSCLC) Avastin is indicated for the first‑line treatment of unresectable, locally advanced, recurrent or metastatic non–squamous non–small cell lung cancer in combination with carboplatin and paclitaxel.

1.4 Metastatic Renal Cell Carcinoma (mRCC) Avastin is indicated for the treatment of metastatic renal cell carcinoma in combination with interferon alfa. 4 CONTRAINDICATIONS None.

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5 WARNINGS AND PRECAUTIONS 5.1 Gastrointestinal Perforations Serious and sometimes fatal gastrointestinal perforation occurs at a higher incidence in Avastin treated patients compared to controls. The incidence of gastrointestinal perforation ranged from 0.3 to 2.4% across clinical studies. [See Adverse Reactions (6.1).] The typical presentation may include abdominal pain, nausea, emesis, constipation, and fever. Perforation can be complicated by intra‑abdominal abscess and fistula formation. The majority of cases occurred within the first 50 days of initiation of Avastin. Discontinue Avastin in patients with gastrointestinal perforation. [See Boxed Warning, Dosage and Administration (2.4).] 5.2 Surgery and Wound Healing Complications Avastin impairs wound healing in animal models. [See Nonclinical Toxicology (13.2).] In clinical trials, administration of Avastin was not allowed until at least 28 days after surgery. In a controlled clinical trial, the incidence of wound healing complications, including serious and fatal complications, in patients with mCRC who underwent surgery during the course of Avastin treatment was 15% and in patients who did not receive Avastin, was 4%. [See Adverse Reactions (6.1).] Avastin should not be initiated for at least 28 days following surgery and until the surgical wound is fully healed. Discontinue Avastin in patients with wound healing complications requiring medical intervention. The appropriate interval between the last dose of Avastin and elective surgery is unknown; however, the half‑life of Avastin is estimated to be 20 days. Suspend Avastin for at least 28 days prior to elective surgery. Do not administer Avastin until the wound is fully healed. [See Boxed Warning, Dosage and Administration (2.4).] 5.3 Hemorrhage Avastin can result in two distinct patterns of bleeding: minor hemorrhage, most commonly Grade 1 epistaxis; and serious, and in some cases fatal, hemorrhagic events. Severe or fatal hemorrhage, including hemoptysis, gastrointestinal bleeding, hematemesis, CNS hemorrhage, epistaxis, and vaginal bleeding occurred up to five‑fold more frequently in patients receiving Avastin compared to patients receiving only chemotherapy. Across indications, the incidence of Grade ≥ 3 hemorrhagic events among patients receiving Avastin ranged from 1.2 to 4.6%. [See Adverse Reactions (6.1).] Serious or fatal pulmonary hemorrhage occurred in four of 13 (31%) patients with squamous cell histology and two of 53 (4%) patients with non‑squamous non‑small cell lung cancer receiving Avastin and chemotherapy compared to none of the 32 (0%) patients receiving chemotherapy alone. In clinical studies in non–small cell lung cancer where patients with CNS metastases who completed radiation and surgery more than 4 weeks prior to the start of Avastin

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1.3 Glioblastoma Avastin is indicated for the treatment of glioblastoma with progressive disease in adult patients following prior therapy as a single agent. The effectiveness of Avastin in glioblastoma is based on an improvement in objective response rate. There are no data demonstrating an improvement in disease‑related symptoms or increased survival with Avastin. [See Clinical Studies (14.3).]

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Surgery and Wound Healing Complications

Severe or fatal hemorrhage, including hemoptysis, gastrointestinal bleeding, central nervous systems (CNS) hemorrhage, epistaxis, and vaginal bleeding occurred up to five‑fold more frequently in patients receiving Avastin. Do not administer Avastin to patients with serious hemorrhage or recent hemoptysis. [See Dosage and Administration (2.4), Warnings and Precautions (5.3), Adverse Reactions (6.1).]

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Gastrointestinal Perforations The incidence of gastrointestinal perforation, some fatal, in Avastin‑treated patients ranges from 0.3 to 2.4%. Discontinue Avastin in patients with gastrointestinal perforation. [See Dosage and Administration (2.4), Warnings and Precautions (5.1).]

Hemorrhage

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WARNING: GASTROINTESTINAL PERFORATIONS, SURGERY AND WOUND HEALING COMPLICATIONS, and HEMORRHAGE

The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin‑treated patients. Discontinue Avastin in patients with wound dehiscence. The appropriate interval between termination of Avastin and subsequent elective surgery required to reduce the risks of impaired wound healing/wound dehiscence has not been determined. Discontinue at least 28 days prior to elective surgery. Do not initiate Avastin for at least 28 days after surgery and until the surgical wound is fully healed. [See Dosage and Administration (2.4), Warnings and Precautions (5.2), Adverse Reactions (6.1).]

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AVASTIN® (bevacizumab) Solution for intravenous infusion Initial U.S. Approval: 2004

AVASTIN ® (bevacizumab)

AVASTIN® (bevacizumab)

were evaluated with serial CNS imaging, symptomatic Grade 2 CNS hemorrhage was documented in one of 83 Avastin‑treated patients (rate 1.2%, 95% CI 0.06%–5.93%). Intracranial hemorrhage occurred in 8 of 163 patients with previously treated glioblastoma; two patients had Grade 3–4 hemorrhage. Do not administer Avastin to patients with recent history of hemoptysis of ≥ 1/2 teaspoon of red blood. Discontinue Avastin in patients with hemorrhage. [See Boxed Warning, Dosage and Administration (2.4).]

Warnings and Precautions (5.3).] • Non‑Gastrointestinal Fistula Formation [See Dosage and Administration (2.4), Warnings and Precautions (5.4).] • Arterial Thromboembolic Events [See Dosage and Administration (2.4), Warnings and Precautions (5.5).] • Hypertensive Crisis [See Dosage and Administration (2.4), Warnings and Precautions (5.6).] • Reversible Posterior Leukoencephalopathy Syndrome [See Dosage and Administration (2.4), Warnings and Precautions (5.7).] • Proteinuria [See Dosage and Administration (2.4), Warnings and Precautions (5.8).] • Ovarian Failure [See Warnings and Precautions (5.10), Use in Specific Populations (8.6).] The most common adverse reactions observed in Avastin patients at a rate > 10% and at least twice the control arm rate, are epistaxis, headache, hypertension, rhinitis, proteinuria, taste alteration, dry skin, rectal hemorrhage, lacrimation disorder, back pain and exfoliative dermatitis. Across all studies, Avastin was discontinued in 8.4 to 21% of patients because of adverse reactions.

infections was increased in the PC plus Avastin arm [58 patients (13.6%)] compared to the PC alone arm [29 patients (6.6%)]. In Study 5, one fatal event of neutropenic infection occurred in a patient with previously treated glioblastoma receiving Avastin alone. The incidence of any grade of infection in patients receiving Avastin alone was 55% and the incidence of Grade 3‑5 infection was 10%. Proteinuria Grade 3‑4 proteinuria ranged from 0.7 to 7.4% in Studies 1, 2, 4 and 7. The overall incidence of proteinuria (all grades) was only adequately assessed in Study 7, in which the incidence was 20%. Median onset of proteinuria was 5.6 months (range 15 days to 37 months) after initiation of Avastin. Median time to resolution was 6.1 months (95% CI 2.8 months, 11.3 months). Proteinuria did not resolve in 40% of patients after median follow up of 11.2 months and required permanent discontinuation of Avastin in 30% of the patients who developed proteinuria (Study 7). [See Warnings and Precautions (5.8).] Congestive Heart Failure The incidence of Grade ≥ 3 left ventricular dysfunction was 1.0% in patients receiving Avastin compared to 0.6% in the control arm across indications. In patients with metastatic breast cancer MBC, an indication for which Avastin is not approved, the incidence of Grade 3–4 congestive heart failure (CHF) was increased in patients in the Avastin plus paclitaxel arm (2.2%) as compared to the control arm (0.3%). Among patients receiving prior anthracyclines for MBC, the rate of CHF was 3.8% for patients receiving Avastin as compared to 0.6% for patients receiving paclitaxel alone. The safety of continuation or resumption of Avastin in patients with cardiac dysfunction has not been studied. Ovarian Failure The incidence of new cases of ovarian failure (defined as amenorrhoea lasting 3 or more months, FSH level ≥ 30 mIU/mL and a negative serum β‑HCG pregnancy test)was prospectively evaluated in a subset of 179 women receiving mFOLFOX chemotherapy alone (n = 84 or with Avastin (n = 95). New cases of ovarian failure were identified in 34% (32/95) of women receiving Avastin in combination with chemotherapy compared with 2% (2/84) of women receiving chemotherapy alone [relative risk of 14 (95% CI 4, 53)]. After discontinuation of Avastin treatment, recovery of ovarian function at all time points during the post‑treatment period was demonstrated in 22% (7/32) of the Avastin‑treated women. Recovery of ovarian function is defined as resumption of menses, a positive serum β‑HCG pregnancy test, or a FSH level < 30 mIU/mL during the post‑treatment period. Long term effects of Avastin exposure on fertility are unknown. [See Warnings and Precautions (5.10), Use in Specific Populations (8.6).] Metastatic Colorectal Cancer (mCRC) The data in Table 1 and Table 2 were obtained in Study 1, a randomized, double‑blind, controlled trial comparing chemotherapy plus Avastin with chemotherapy plus placebo. Avastin was administered at 5 mg/kg every 2 weeks. All Grade 3–4 adverse events and selected Grade 1–2 adverse events (hypertension, proteinuria, thromboembolic events) were collected in the entire study population. Severe and life‑threatening (Grade 3–4) adverse events, which occurred at a higher incidence ( ≥ 2%) in patients receiving bolus‑IFL plus Avastin as compared to bolus‑IFL plus placebo, are presented in Table 1. Table 1 NCI‑CTC Grade 3−4 Adverse Events in Study 1 (Occurring at Higher Incidence [≥ 2%] Avastin vs. Control)

5.4 Non‑Gastrointestinal Fistula Formation Serious and sometimes fatal non‑gastrointestinal fistula formation involving tracheo‑esophageal, bronchopleural, biliary, vaginal, renal and bladder sites occurs at a higher incidence in Avastin‑treated patients compared to controls. The incidence of non‑gastrointestinal perforation was ≤ 0.3% in clinical studies. Most events occurred within the first 6 months of Avastin therapy. Discontinue Avastin in patients with fistula formation involving an internal organ. [See Dosage and Administration (2.4).] 5.5 Arterial Thromboembolic Events Serious, sometimes fatal, arterial thromboembolic events (ATE) including cerebral infarction, transient ischemic attacks, myocardial infarction, angina, and a variety of other ATE occurred at a higher incidence in patients receiving Avastin compared to those in the control arm. Across indications, the incidence of Grade ≥ 3 ATE in the Avastin containing arms was 2.6% compared to 0.8% in the control arms. Among patients receiving Avastin in combination with chemotherapy, the risk of developing ATE during therapy was increased in patients with a history of arterial thromboembolism, or age greater than 65 years. [See Use in Specific Populations (8.5).] The safety of resumption of Avastin therapy after resolution of an ATE has not been studied. Discontinue Avastin in patients who experience a severe ATE. [See Dosage and Administration (2.4).] 5.6 Hypertension The incidence of severe hypertension is increased in patients receiving Avastin as compared to controls. Across clinical studies the incidence of Grade 3 or 4 hypertension ranged from 5‑18%. Monitor blood pressure every two to three weeks during treatment with Avastin. Treat with appropriate anti‑hypertensive therapy and monitor blood pressure regularly. Continue to monitor blood pressure at regular intervals in patients with Avastin‑induced or ‑exacerbated hypertension after discontinuation of Avastin. Temporarily suspend Avastin in patients with severe hypertension that is not controlled with medical management. Discontinue Avastin in patients with hypertensive crisis or hypertensive encephalopathy. [See Dosage and Administration (2.4).] 5.7 Reversible Posterior Leukoencephalopathy Syndrome (RPLS) RPLS has been reported with an incidence of < 0.1% in clinical studies. The onset of symptoms occurred from 16 hours to 1 year after initiation of Avastin. RPLS is a neurological disorder which can present with headache, seizure, lethargy, confusion, blindness and other visual and neurologic disturbances. Mild to severe hypertension may be present. Magnetic resonance imaging (MRI) is necessary to confirm the diagnosis of RPLS. Discontinue Avastin in patients developing RPLS. Symptoms usually resolve or improve within days, although some patients have experienced ongoing neurologic sequelae. The safety of reinitiating Avastin therapy in patients previously experiencing RPLS is not known. [See Dosage and Administration (2.4).] 5.8 Proteinuria The incidence and severity of proteinuria is increased in patients receiving Avastin as compared to controls. Nephrotic syndrome occurred in < 1% of patients receiving Avastin in clinical trials, in some instances with fatal outcome. [See Adverse Reactions (6.1).] In a published case series, kidney biopsy of six patients with proteinuria showed findings consistent with thrombotic microangiopathy. Monitor proteinuria by dipstick urine analysis for the development or worsening of proteinuria with serial urinalyses during Avastin therapy. Patients with a 2 + or greater urine dipstick reading should undergo further assessment with a 24‑hour urine collection. Suspend Avastin administration for ≥ 2 grams of proteinuria/24 hours and resume when proteinuria is < 2 gm/24 hours. Discontinue Avastin in patients with nephrotic syndrome. Data from a postmarketing safety study showed poor correlation between UPCR (Urine Protein/Creatinine Ratio) and 24 hour urine protein (Pearson Correlation 0.39 (95% CI 0.17, 0.57). [See Use in Specific Populations (8.5).] The safety of continued Avastin treatment in patients with moderate to severe proteinuria has not been evaluated. [See Dosage and Administration (2.4).] 5.9 Infusion Reactions Infusion reactions reported in the clinical trials and post‑marketing experience include hypertension, hypertensive crises associated with neurologic signs and symptoms, wheezing, oxygen desaturation, Grade 3 hypersensitivity, chest pain, headaches, rigors, and diaphoresis. In clinical studies, infusion reactions with the first dose of Avastin were uncommon (< 3%) and severe reactions occurred in 0.2% of patients. Stop infusion if a severe infusion reaction occurs and administer appropriate medical therapy. [See Dosage and Administration (2.4).] 5.10 Ovarian Failure The incidence of ovarian failure was higher (34% vs. 2%) in premenopausal women receiving Avastin in combination with mFOLFOX chemotherapy as compared to those receiving mFOLFOX chemotherapy alone for adjuvant treatment for colorectal cancer, a use for which Avastin is not approved. Inform females of reproductive potential of the risk of ovarian failure prior to starting treatment with Avastin. [See Adverse Reactions (6.1), Use in Specific Populations (8.6).] 6 ADVERSE REACTIONS The following serious adverse reactions are discussed in greater detail in other sections of the label: • Gastrointestinal Perforations [See Boxed Warning, Dosage and Administration (2.4), Warnings and Precautions (5.1).] • Surgery and Wound Healing Complications [See Boxed Warning, Dosage and Administration (2.4), Warnings and Precautions (5.2).] • Hemorrhage [See Boxed Warning, Dosage and Administration (2.4),

6.1 Clinical Trial Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The data below reflect exposure to Avastin in 3795 patients with CRC, non‑squamous NSCLC, MBC, glioblastoma, or mRCC trials including controlled (Studies 1, 2, 4, and 7) or uncontrolled, single arm (Study 5) treated at the recommended dose and schedule for a median of 8 to 23 doses of Avastin. [See Clinical Studies (14).] Data also reflect exposure to Avastin in 363 patients with metastatic breast cancer (MBC) who received a median of 9.5 doses of Avastin, an indication for which Avastin is not approved. The population was aged 18‑88 years (median 59), 43.2% male and 85.3% white. The population included 1783 first‑ and second‑line mCRC patients who received a median of 10 doses of Avastin, 669 female adjuvant CRC patients who received a median of 23 doses of Avastin, 480 first‑line metastatic NSCLC patients who received a median of 8 doses of Avastin, 163 glioblastoma patients who received a median of 9 doses of Avastin, and 337 mRCC patients who received a median of 16 doses of Avastin. Surgery and Wound Healing Complications The incidence of post‑operative wound healing and/or bleeding complications was increased in patients with mCRC receiving Avastin as compared to patients receiving only chemotherapy. Among patients requiring surgery on or within 60 days of receiving study treatment, wound healing and/or bleeding complications occurred in 15% (6/39) of patients receiving bolus‑IFL plus Avastin as compared to 4% (1/25) of patients who received bolus‑IFL alone. In Study 5, events of post‑operative wound healing complications (craniotomy site wound dehiscence and cerebrospinal fluid leak) occurred in patients with previously treated glioblastoma: 3/84 patients in the Avastin alone arm and 1/79 patients in the Avastin plus irinotecan arm. [See Boxed Warning, Dosage and Administration (2.4), Warnings and Precautions (5.2).] Hemorrhage The incidence of epistaxis was higher (35% vs. 10%) in patients with mCRC receiving bolus‑IFL plus Avastin compared with patients receiving bolus‑IFL plus placebo. All but one of these events were Grade 1 in severity and resolved without medical intervention. Grade 1 or 2 hemorrhagic events were more frequent in patients receiving bolus‑IFL plus Avastin when compared to those receiving bolus‑IFL plus placebo and included gastrointestinal hemorrhage (24% vs. 6%), minor gum bleeding (2% vs. 0), and vaginal hemorrhage (4% vs. 2%). [See Boxed Warning, Dosage and Administration (2.4), Warnings and Precautions (5.3).] Venous Thromboembolic Events The overall incidence of Grade 3–4 venous thromboembolic events in Study 1 was 15.1% in patients receiving bolus‑IFL plus Avastin and 13.6% in patients receiving bolus‑IFL plus placebo. In Study 1, more patients in the Avastin containing arm experienced deep venous thrombosis (34 vs. 19 patients ) and intra‑abdominal venous thrombosis (10 vs. 5 patients). The risk of developing a second thromboembolic event while on Avastin and oral anticoagulants was evaluated in two randomized studies. In Study 1, 53 patients (14%) on the bolus‑IFL plus Avastin arm and 30 patients (8%) on the bolus‑IFL plus placebo arm received full dose warfarin following a venous thromboembolic event (VTE). Among these patients, an additional thromboembolic event occurred in 21% (11/53) of patients receiving bolus‑IFL plus Avastin and 3% (1/30) of patients receiving bolus‑IFL alone. In a second, randomized, 4‑arm study in 1401 patients with mCRC, prospectively evaluating the incidence of VTE (all grades), the overall incidence of first VTE was higher in the Avastin containing arms (13.5%) than the chemotherapy alone arms (9.6%). Among the 116 patients treated with anticoagulants following an initial VTE event (73 in the Avastin plus chemotherapy arms and 43 in the chemotherapy alone arms), the overall incidence of subsequent VTEs was also higher among the Avastin treated patients (31.5% vs. 25.6%). In this subgroup of patients treated with anticoagulants, the overall incidence of bleeding, the majority of which were Grade 1, was higher in the Avastin treated arms than the chemotherapy arms (27.4% vs. 20.9%). [See Dosage and Administration (2.4).] Neutropenia and Infection The incidences of neutropenia and febrile neutropenia are increased in patients receiving Avastin plus chemotherapy compared to chemotherapy alone. In Study 1, the incidence of Grade 3 or 4 neutropenia was increased in mCRC patients receiving IFL plus Avastin (21%) compared to patients receiving IFL alone (14%). In Study 4, the incidence of Grade 4 neutropenia was increased in NSCLC patients receiving paclitaxel/carboplatin (PC) plus Avastin (26.2%) compared with patients receiving PC alone (17.2%). Febrile neutropenia was also increased (5.4% for PC plus Avastin vs. 1.8% for PC alone). There were 19 (4.5%) infections with Grade 3 or 4 neutropenia in the PC plus Avastin arm of which 3 were fatal compared to 9 (2%) neutropenic infections in patients receiving PC alone, of which none were fatal. During the first 6 cycles of treatment, the incidence of serious infections including pneumonia, febrile neutropenia, catheter infections and wound

NCI‑CTC Grade 3‑4 Events Body as a Whole Asthenia Abdominal Pain Pain Cardiovascular Hypertension Deep Vein Thrombosis Intra‑Abdominal Thrombosis Syncope Digestive Diarrhea Constipation Hemic/Lymphatic Leukopenia Neutropeniaa a

Arm 1 IFL ++ Placebo (n = 396) 74%

Arm 2 IFL ++ Avastin (n = 392) 87%

7% 5% 5%

10% 8% 8%

2% 5% 1% 1%

12% 9% 3% 3%

25% 2%

34% 4%

31% 14%

37% 21%

Central laboratories were collected on Days 1 and 21 of each cycle. Neutrophil counts are available in 303 patients in Arm 1 and 276 in Arm 2.

Grade 1–4 adverse events which occurred at a higher incidence ( ≥ 5%) in patients receiving bolus‑IFL plus Avastin as compared to the bolus‑IFL plus placebo arm are presented in Table 2. Grade 1–4 adverse events were collected for the first approximately 100 patients in each of the three treatment arms who were enrolled until enrollment in Arm 3 (5‑FU/LV + Avastin) was discontinued. Table 2 NCI‑CTC Grade 1‑4 Adverse Events in Study 1 (Occurring at Higher Incidence [≥ 5%] in IFL + Avastin vs. IFL) Arm 1 Arm 2 Arm 3 IFL + Placebo IFL + Avastin 5‑FU/LV + Avastin (n = 98) (n = 102) (n = 109) Body as a Whole Pain Abdominal Pain Headache Cardiovascular Hypertension Hypotension Deep Vein Thrombosis Digestive Vomiting Anorexia Constipation Stomatitis Dyspepsia GI Hemorrhage Weight Loss Dry Mouth Colitis Hemic/Lymphatic Thrombocytopenia

55% 55% 19%

61% 61% 26%

62% 50% 26%

14% 7% 3%

23% 15% 9%

34% 7% 6%

47% 30% 29% 18% 15% 6% 10% 2% 1%

52% 43% 40% 32% 24% 24% 15% 7% 6%

47% 35% 29% 30% 17% 19% 16% 4% 1%

AVASTIN® (bevacizumab) Table 2 (cont’d) NCI‑CTC Grade 1‑4 Adverse Events in Study 1 (Occurring at Higher Incidence [≥ 5%] in IFL + Avastin vs. IFL) Arm 1 Arm 2 Arm 3 IFL + Placebo IFL + Avastin 5‑FU/LV + Avastin (n = 98) (n = 102) (n = 109) Nervous Dizziness Respiratory Upper Respiratory Infection Epistaxis Dyspnea Voice Alteration Skin/Appendages Alopecia Skin Ulcer Special Senses Taste Disorder Urogenital Proteinuria

20%

26%

19%

39% 10% 15% 2%

47% 35% 26% 9%

40% 32% 25% 6%

26% 1%

32% 6%

6% 6%

14%

21%

24%

36%

Avastin in Combination with FOLFOX4 in Second‑line mCRC Only Grade 3‑5 non‑hematologic and Grade 4–5 hematologic adverse events related to treatment were collected in Study 2. The most frequent adverse events (selected Grade 3–5 non‑hematologic and Grade 4–5 hematologic adverse events) occurring at a higher incidence ( ≥ 2%) in 287 patients receiving FOLFOX4 plus Avastin compared to 285 patients receiving FOLFOX4 alone were fatigue (19% vs. 13%), diarrhea (18% vs. 13%), sensory neuropathy (17% vs. 9%), nausea (12% vs. 5%), vomiting (11% vs. 4%), dehydration (10% vs. 5%), hypertension (9% vs. 2%), abdominal pain (8% vs. 5%), hemorrhage (5% vs. 1%), other neurological (5% vs. 3%), ileus (4% vs. 1%) and headache (3% vs. 0%). These data are likely to under‑estimate the true adverse event rates due to the reporting mechanisms used in Study 2. Unresectable Non‑Squamous Non‑Small Cell Lung Cancer (NSCLC) Only Grade 3‑5 non‑hematologic and Grade 4‑5 hematologic adverse events were collected in Study 4. Grade 3–5 non‑hematologic and Grade 4–5 hematologic adverse events (occurring at a higher incidence (≥ 2%) in 427 patients receiving PC plus Avastin compared with 441 patients receiving PC alone were neutropenia (27% vs. 17%), fatigue (16% vs. 13%), hypertension (8% vs. 0.7%), infection without neutropenia (7% vs. 3%), venous thrombus/embolism (5% vs. 3%), febrile neutropenia (5% vs. 2%), pneumonitis/ pulmonary infiltrates (5% vs. 3%), infection with Grade 3 or 4 neutropenia (4% vs. 2%), hyponatremia (4% vs. 1%), headache (3% vs. 1%) and proteinuria (3% vs. 0%). Glioblastoma All adverse events were collected in 163 patients enrolled in Study 5 who either received Avastin alone or Avastin plus irinotecan. All patients received prior radiotherapy and temozolomide. Avastin was administered at 10 mg/kg every 2 weeks alone or in combination with irinotecan. Avastin was discontinued due to adverse events in 4.8% of patients treated with Avastin alone. In patients receiving Avastin alone (N = 84), the most frequently reported adverse events of any grade were infection (55%), fatigue (45%), headache (37%), hypertension (30%), epistaxis (19%) and diarrhea (21%). Of these, the incidence of Grade ≥ 3 adverse events was infection (10%), fatigue (4%), headache (4%), hypertension (8%) and diarrhea (1%). Two deaths on study were possibly related to Avastin: one retroperitoneal hemorrhage and one neutropenic infection. In patients receiving Avastin alone or Avastin plus irinotecan (N = 163), the incidence of Avastin‑related adverse events (Grade 1–4) were bleeding/ hemorrhage (40%), epistaxis (26%), CNS hemorrhage (5%), hypertension (32%), venous thromboembolic event (8%), arterial thromboembolic event (6%), wound‑healing complications (6%), proteinuria (4%), gastrointestinal perforation (2%), and RPLS (1%). The incidence of Grade 3–5 events in these 163 patients were bleeding/hemorrhage (2%), CNS hemorrhage (1%), hypertension (5%), venous thromboembolic event (7%), arterial thromboembolic event (3%), wound‑healing complications (3%), proteinuria (1%), and gastrointestinal perforation (2%). Metastatic Renal Cell Carcinoma (mRCC) All grade adverse events were collected in Study 7. Grade 3–5 adverse events occurring at a higher incidence ( ≥ 2%) in 337 patients receiving interferon alfa (IFN‑α) plus Avastin compared to 304 patients receiving IFN‑α plus placebo arm were fatigue (13% vs. 8%), asthenia (10% vs. 7%), proteinuria (7% vs. 0%), hypertension (6% vs. 1%; including hypertension and hypertensive crisis), and hemorrhage (3% vs. 0.3%; including epistaxis, small intestinal hemorrhage, aneurysm ruptured, gastric ulcer hemorrhage, gingival bleeding, haemoptysis, hemorrhage intracranial, large intestinal hemorrhage, respiratory tract hemorrhage, and traumatic hematoma). Grade 1–5 adverse events occurring at a higher incidence ( ≥ 5%) in patients receiving IFN‑α plus Avastin compared to the IFN‑α plus placebo arm are presented in Table 3. Table 3 NCI‑CTC Grades 1−5 Adverse Events in Study 7 (Occurring at Higher Incidence [≥ 5%] in IFN‑α + Avastin vs. IFN‑α + Placebo) System Organ Class/ IFN‑α + Placebo (n = 304) Preferred terma Gastrointestinal disorders Diarrhea 16% General disorders and administration site conditions Fatigue 27% Investigations Weight decreased 15% Metabolism and nutrition disorders Anorexia 31% Musculoskeletal and connective tissue disorders Myalgia 14% Back pain 6% Nervous system disorders Headache 16% Renal and urinary disorders Proteinuria 3% Respiratory, thoracic and mediastinal disorders Epistaxis 4% Dysphonia 0% Vascular disorders Hypertension 9% Adverse events were encoded using MedDRA, Version 10.1.

IFN‑α + Avastin (n = 337) 21% 33% 20% 36% 19% 12% 24% 20% 27% 5% 28%

AVASTIN® (bevacizumab)

The following adverse events were reported at a 5‑fold greater incidence in the IFN‑α plus Avastin arm compared to IFN‑α alone and not represented in Table 3: gingival bleeding (13 patients vs. 1 patient); rhinitis (9 vs.0 ); blurred vision (8 vs. 0); gingivitis (8 vs. 1); gastroesophageal reflux disease (8 vs.1 ); tinnitus (7 vs. 1); tooth abscess (7 vs.0); mouth ulceration (6 vs. 0); acne (5 vs. 0); deafness (5 vs. 0); gastritis (5 vs. 0); gingival pain (5 vs. 0) and pulmonary embolism (5 vs. 1).

In Study 4, patients aged ≥ 65 years receiving carboplatin, paclitaxel, and Avastin had a greater relative risk for proteinuria as compared to younger patients. [See Warnings and Precautions (5.8).]

6.2 Immunogenicity As with all therapeutic proteins, there is a potential for immunogenicity. The incidence of antibody development in patients receiving Avastin has not been adequately determined because the assay sensitivity was inadequate to reliably detect lower titers. Enzyme‑linked immunosorbent assays (ELISAs) were performed on sera from approximately 500 patients treated with Avastin, primarily in combination with chemotherapy. High titer human anti‑Avastin antibodies were not detected. Immunogenicity data are highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody positivity in an assay may be influenced by several factors, including sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to Avastin with the incidence of antibodies to other products may be misleading. 6.3 Postmarketing Experience The following adverse reactions have been identified during post‑approval use of Avastin. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Body as a Whole: Polyserositis Cardiovascular: Pulmonary hypertension, RPLS, Mesenteric venous occlusion Eye disorders (from unapproved intravitreal use for treatment of various ocular disorders): Permanent loss of vision; Endophthalmitis (infectious and sterile); Intraocular inflammation; Retinal detachment; Increased intraocular pressure; Hemorrhage including conjunctival, vitreous hemorrhage or retinal hemorrhage; Vitreous floaters; Ocular hyperemia; Ocular pain or discomfort Gastrointestinal: Gastrointestinal ulcer, Intestinal necrosis, Anastomotic ulceration Hemic and lymphatic: Pancytopenia Musculoskeletal: Osteonecrosis of the jaw Renal: Renal thrombotic microangiopathy (manifested as severe proteinuria) Respiratory: Nasal septum perforation, dysphonia Systemic Events (from unapproved intravitreal use for treatment of various ocular disorders): Arterial thromboembolic events, Hypertension, Gastrointestinal perforation, Hemorrhage

Of the 742 patients enrolled in Genentech‑sponsored clinical studies in which all adverse events were captured, 212 (29%) were age 65 or older and 43 (6%) were age 75 or older. Adverse events of any severity that occurred at a higher incidence in the elderly as compared to younger patients, in addition to those described above, were dyspepsia, gastrointestinal hemorrhage, edema, epistaxis, increased cough, and voice alteration. In an exploratory, pooled analysis of 1745 patients treated in five randomized, controlled studies, there were 618 (35%) patients aged ≥ 65 years and 1127 patients < 65 years of age. The overall incidence of arterial thromboembolic events was increased in all patients receiving Avastin with chemotherapy as compared to those receiving chemotherapy alone, regardless of age. However, the increase in arterial thromboembolic events incidence was greater in patients aged ≥ 65 years (8.5% vs. 2.9%) as compared to those < 65 years (2.1% vs. 1.4%). [See Warnings and Precautions (5.5).] 8.6 Females of Reproductive Potential Avastin increases the risk of ovarian failure and may impair fertility. Inform females of reproductive potential of the risk of ovarian failure prior to starting treatment with Avastin. Long term effects of Avastin exposure on fertility are unknown. In a prospectively designed substudy of 179 premenopausal women randomized to receive chemotherapy with or without Avastin, the incidence of ovarian failure was higher in the Avastin arm (34%) compared to the control arm (2%). After discontinuation of Avastin and chemotherapy, recovery of ovarian function occurred in 22% (7/32) of these Avastin‑treated patients. [See Warnings and Precautions (5.10), Adverse Reactions (6.1).] 10 OVERDOSAGE The highest dose tested in humans (20 mg/kg IV) was associated with headache in nine of 16 patients and with severe headache in three of 16 patients.

7 DRUG INTERACTIONS A drug interaction study was performed in which irinotecan was administered as part of the FOLFIRI regimen with or without Avastin. The results demonstrated no significant effect of bevacizumab on the pharmacokinetics of irinotecan or its active metabolite SN38. In a randomized study in 99 patients with NSCLC, based on limited data, there did not appear to be a difference in the mean exposure of either carboplatin or paclitaxel when each was administered alone or in combination with Avastin. However, 3 of the 8 patients receiving Avastin plus paclitaxel/carboplatin had substantially lower paclitaxel exposure after four cycles of treatment (at Day 63) than those at Day 0, while patients receiving paclitaxel/carboplatin without Avastin had a greater paclitaxel exposure at Day 63 than at Day 0. In Study 7, there was no difference in the mean exposure of interferon alfa administered in combination with Avastin when compared to interferon alfa alone. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category C There are no adequate or well controlled studies of bevacizumab in pregnant women. While it is not known if bevacizumab crosses the placenta, human IgG is known to cross the placenta Reproduction studies in rabbits treated with approximately 1 to 12 times the recommended human dose of bevacizumab demonstrated teratogenicity, including an increased incidence of specific gross and skeletal fetal alterations. Adverse fetal outcomes were observed at all doses tested. Other observed effects included decreases in maternal and fetal body weights and an increased number of fetal resorptions. [See Nonclinical Toxicology (13.3).] Because of the observed teratogenic effects of bevacizumab in animals and of other inhibitors of angiogenesis in humans, bevacizumab should be used during pregnancy only if the potential benefit to the pregnant woman justifies the potential risk to the fetus. 8.3 Nursing Mothers It is not known whether Avastin is secreted in human milk. Human IgG is excreted in human milk, but published data suggest that breast milk antibodies do not enter the neonatal and infant circulation in substantial amounts. Because many drugs are secreted in human milk and because of the potential for serious adverse reactions in nursing infants from bevacizumab, a decision should be made whether to discontinue nursing or discontinue drug, taking into account the half‑life of the bevacizumab (approximately 20 days [range 11–50 days]) and the importance of the drug to the mother. [See Clinical Pharmacology (12.3).] 8.4 Pediatric Use The safety, effectiveness and pharmacokinetic profile of Avastin in pediatric patients have not been established. Antitumor activity was not observed among eight children with relapsed glioblastoma treated with bevacizumab and irinotecan. There is insufficient information to determine the safety and efficacy of Avastin in children with glioblastoma. Juvenile cynomolgus monkeys with open growth plates exhibited physeal dysplasia following 4 to 26 weeks exposure at 0.4 to 20 times the recommended human dose (based on mg/kg and exposure). The incidence and severity of physeal dysplasia were dose‑related and were partially reversible upon cessation of treatment. 8.5 Geriatric Use In Study 1, severe adverse events that occurred at a higher incidence ( ≥ 2%) in patients aged ≥ 65 years as compared to younger patients were asthenia, sepsis, deep thrombophlebitis, hypertension, hypotension, myocardial infarction, congestive heart failure, diarrhea, constipation, anorexia, leukopenia, anemia, dehydration, hypokalemia, and hyponatremia. The effect of Avastin on overall survival was similar in elderly patients as compared to younger patients. In Study 2, patients aged ≥ 65 years receiving Avastin plus FOLFOX4 had a greater relative risk as compared to younger patients for the following adverse events: nausea, emesis, ileus, and fatigue.

Avastin® (bevacizumab) Manufactured by: Genentech, Inc. A Member of the Roche Group 1 DNA Way South San Francisco, CA 94080‑4990

To confront a common threat across approved indications...

Think Avastin

Clinically meaningful activity in 4 distinct tumor types1

Because anti-angiogenesis matters Avastin is designed to directly inhibit the VEGF ligand to specifically inhibit angiogenesis1*

VEGF=vascular endothelial growth factor. *The mechanism of action of Avastin has been elucidated primarily in preclinical models. Its clinical significance is unknown.

Indications

Avastin is indicated for the treatment of metastatic renal cell carcinoma in combination with interferon alfa. Avastin is indicated for the treatment of glioblastoma as a single agent for adult patients with progressive disease following prior therapy. The effectiveness of Avastin in glioblastoma is based on an improvement in objective response rate. There are no data demonstrating an improvement in disease-related symptoms or increased survival with Avastin. Avastin is indicated for the first-line treatment of unresectable, locally advanced, recurrent or metastatic non–squamous non–small cell lung cancer in combination with carboplatin and paclitaxel. Avastin is indicated for the first- or second-line treatment of patients with metastatic carcinoma of the colon or rectum in combination with intravenous 5-fluorouracil– based chemotherapy.

Most common adverse events

Most common adverse reactions observed in Avastin patients at a rate >10% and at least twice the control arm rate were — Epistaxis — Proteinuria — Lacrimation disorder — Headache — Taste alteration — Back pain — Hypertension — Dry skin — Exfoliative dermatitis — Rhinitis — Rectal hemorrhage Across all studies, Avastin was discontinued in 8.4% to 21% of patients because of adverse reactions

Pregnancy warning

Avastin may impair fertility Based on animal data, Avastin may cause fetal harm Advise patients of the potential risk to the fetus during and following Avastin and the need to continue adequate contraception for at least 6 months following the last dose of Avastin For nursing mothers, discontinue nursing or Avastin, taking into account the importance of Avastin to the mother In mRCC, the most common grade 3–5 adverse events in AVOREN, occurring at a ≥2% higher incidence in Avastin-treated patients vs controls, were fatigue (13% vs 8%), asthenia (10% vs 7%), proteinuria (7% vs 0%), hypertension (6% vs 1%), and hemorrhage (3% vs 0.3%) In GBM Study AVF3708g, in patients receiving Avastin alone, the most frequently reported adverse events were infection (55%), fatigue (45%), headache (37%), hypertension (30%), epistaxis (19%), and diarrhea (21%). Of these, the incidence of grade ≥3 adverse events was infection (10%), fatigue (4%), headache (4%), hypertension (8%), and diarrhea (1%). Two deaths were possibly related to Avastin: 1 retroperitoneal hemorrhage and 1 neutropenic infection In GBM patients receiving Avastin alone or Avastin plus irinotecan,† the incidences of Avastin-related adverse events (grade 1–4) were bleeding/hemorrhage (40%), epistaxis (26%), CNS hemorrhage (5%), hypertension (32%), venous thromboembolic events (8%), arterial thromboembolic events (6%), wound healing complications (6%), proteinuria (4%), GI perforation (2%), and RPLS (1%). The incidences of grade 3–5 events in these 163 patients were bleeding/hemorrhage (2%), CNS hemorrhage (1%), hypertension (5%), venous thromboembolic events (7%), arterial thromboembolic events (3%), wound healing complications (3%), proteinuria (1%), and GI perforation (2%). Intracranial hemorrhage occurred in 8 of 163 patients; 2 patients had grade 3–4 hemorrhage In NSCLC, grade 3–5 (nonhematologic) and grade 4–5 (hematologic) adverse events in Study E4599 occurring at a ≥2% higher incidence in Avastin-treated patients vs controls were neutropenia (27% vs 17%), fatigue (16% vs 13%), hypertension (8% vs 0.7%), infection without neutropenia (7% vs 3%), venous thrombus/embolism (5% vs 3%), febrile neutropenia (5% vs 2%), pneumonitis/pulmonary infiltrates (5% vs 3%), infection with grade 3 or 4 neutropenia (4% vs 2%), hyponatremia (4% vs 1%), headache (3% vs 1%), and proteinuria (3% vs 0%) In first-line MCRC, the most common grade 3–4 events in Study 2107, which occurred at a ≥2% higher incidence in the Avastin plus IFL vs IFL groups, were asthenia (10% vs 7%), abdominal pain (8% vs 5%), pain (8% vs 5%), hypertension (12% vs 2%), deep vein thrombosis (9% vs 5%), intra-abdominal thrombosis (3% vs 1%), syncope (3% vs 1%), diarrhea (34% vs 25%), constipation (4% vs 2%), leukopenia (37% vs 31%), and neutropenia (21% vs 14%) In second-line MCRC, the most common grade 3–5 (nonhematologic) and 4–5 (hematologic) events in Study E3200, which occurred at a higher incidence (≥2%) in the Avastin plus FOLFOX4 vs FOLFOX4 groups, were diarrhea (18% vs 13%), nausea (12% vs 5%), vomiting (11% vs 4%), dehydration (10% vs 5%), ileus (4% vs 1%), neuropathy–sensory (17% vs 9%), neurologic–other (5% vs 3%), fatigue (19% vs 13%), abdominal pain (8% vs 5%), headache (3% vs 0%), hypertension (9% vs 2%), and hemorrhage (5% vs 1%)

Boxed WARNINGS

Gastrointestinal (GI) perforation — Serious and sometimes fatal GI perforation occurs at a higher incidence in Avastintreated patients compared to controls — The incidences of GI perforation ranged from 0.3% to 2.4% across clinical studies — Discontinue Avastin in patients with GI perforation Surgery and wound healing complications — The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin-treated patients — Do not initiate Avastin for at least 28 days after surgery and until the surgical wound is fully healed. The appropriate interval between termination of Avastin and subsequent elective surgery required to reduce the risks of impaired wound healing/wound dehiscence has not been determined — Discontinue Avastin at least 28 days prior to elective surgery and in patients with wound healing complications requiring medical intervention Hemorrhage — Severe or fatal hemorrhage, including hemoptysis, GI bleeding, hematemesis, central nervous system hemorrhage, epistaxis, and vaginal bleeding, occurred up to 5-fold more frequently in patients receiving Avastin. Across indications, the incidence of grade ≥3 hemorrhagic events among patients receiving Avastin ranged from 1.2% to 4.6% — Do not administer Avastin to patients with serious hemorrhage or recent hemoptysis (≥1/2 tsp of red blood) — Discontinue Avastin in patients with serious hemorrhage (ie, requiring medical intervention)

Additional serious adverse events

Additional serious and sometimes fatal adverse events with increased incidence in the Avastin-treated arm vs control included — Non-GI fistula formation (≤0.3%) — Arterial thromboembolic events (grade ≥3, 2.6%) — Proteinuria (nephrotic syndrome, <1%) Additional serious adverse events with increased incidence in the Avastin-treated arm vs control included — Hypertension (grade 3–4, 5%–18%) — Reversible posterior leukoencephalopathy syndrome (RPLS) (<0.1%) Infusion reactions with the first dose of Avastin were uncommon (<3%), and severe reactions occurred in 0.2% of patients Inform females of reproductive potential of the risk of ovarian failure prior to starting treatment with Avastin

Avastin is not approved for use in combination with irinotecan.

†

Please see accompanying brief summary of Prescribing Information, including Boxed WARNINGS, for additional important safety information. Reference: 1. Avastin Prescribing Information. Genentech, Inc. December 2011.

AVA0000488301

Printed in USA.

(01/12)