Targeting NSCLC in the future

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Targeting NSCLC in the future
Lucio Crinò Silvestrini HospitalPerugia, Italy
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Targeting NSCLC in the future approaches to
further optimise treatment strategies

• Will targeted therapies with proven efficacy in
  advanced disease confer benefits in earlier
  disease?
• Will simultaneous inhibition of multiple pathways
  involved in tumorigenesis improve efficacy?
• Can continued tumour control with targeted
  therapies improve outcomes?
• Is it possible to identify patients who derive
  optimal benefit from therapy using biological
  markers?

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E1505 ongoing phase III trial of Avastin as
adjuvant therapy in NSCLC
Cisplatin/vinorelbine or cisplatin/docetaxel or
cisplatin/gemcitabine
Completely resected stage IBIIIA NSCLC
(n1,500)
Avastin 15mg/kg every 3 weeks for up to 1 year
Avastin 15mg/kg every 3 weeks
cisplatin/vinorelbine or cisplatin/docetaxel or
cisplatin/gemcitabine
No PD

• Primary endpoint overall survival (OS)
• Secondary endpoints disease-free survival (DFS)
  and toxicity

If stage IB, tumour must be 4cm Avastin
15mg/kg on day 1 and then every 3 weeks PD
progression of disease
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RADIANT ongoing phase III trial of Tarceva as
adjuvant therapy in NSCLC
Tarceva 150mg/day for 2 years
Four cycles of standard platinum-based chemothera
py (optional)
Stage IBIIIA EGFR-positive complete
resection No radiotherapy (n945)
Stratified by country adjuvant chemotherapy
histology stage smoking status EGFR status
R
Placebo

• Primary endpoint
• DFS (all patients EGFR IHC-positive and/or
  FISH-positive)
• Co-primary endpoints
• USA DFS in FISH-positive
• Europe to be determined based on outcome of
  SATURN

EGFR epidermal growth factor receptor FISH
fluorescent in situ hybridisation IHC
immunohistochemistry
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Targeting NSCLC in the future approaches to
further optimise treatment strategies

• Will targeted therapies with proven efficacy in
  advanced disease confer benefits in earlier
  disease?
• Will simultaneous inhibition of multiple pathways
  involved in tumorigenesis improve efficacy?
• Can continued tumour control with targeted
  therapies improve outcomes?
• Is it possible to identify patients who derive
  optimal benefit from therapy using biological
  markers?

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A number of multitargeted agents are in clinical
development for NSCLC
Not all of the molecular targets inhibited by
these molecules have been shown to be involved
in lung carcinogenesis
HER1 human epidermal growth factor receptor-1
PDGFR platelet-derived growth factor
receptorTKI tyrosine kinase inhibitor VEGFR
vascular endothelial growth factor receptor
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Adverse events (AEs) monoclonal antibodies
versus kinase inhibitors
Overall incidence of US National Cancer
Institute-Common Toxicity Criteria grade 35 AEs
across all indications Overall incidence across
all indications Febrile neutropenia
Source Summary of Product Characteristics
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Potential benefits of combiningsingle-target
agents
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Tarceva and Avastin targeting the tumour and the
vasculature
Avastin
Tarceva
Inhibits tumour cell growth and blocks synthesis
of angiogenic proteins (e.g. VEGF, TGF-?) by
tumour cells
Binding VEGF inhibits endothelial cells from
responding to this angiogenic protein
VEGF TGF-?
Endothelial cells
Tumour
TGF-? transforming growth factor-? VEGF
vascular endothelial growth factor
Herbst, et al. JCO 2005
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Phase II studies demonstrating efficacy of
Avastin with Tarceva in advanced NSCLC
First-line1
Advanced, non-squamous, treatment-naïve NSCLC
(n47)
Avastin Tarceva (up to 6 cycles)
Tarceva Avastin(n39)
Second-line2
Previously treated advanced non-squamous NSCLC
(n120)
Avastin docetaxel or pemetrexed (n40)
Docetaxel or pemetrexed (n41)
1Dingemans, et al. Eur J Cancer Suppl
2007 2Herbst, et al. JCO 2007
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BO20571 (TASK) phase II first-line study to
assess efficacy of Avastin with Tarceva
Tarceva 150mg/day Avastin 15mg/kg every 3 weeks
Stage IIIB/IV enlarged non-squamous NSCLC,
unselected (n200)
Chemotherapy Avastin

• Randomised, multicentre, open-label, phase II
  study
• Primary endpoint progression-free survival (PFS)
• Secondary endpoints safety, quality of life, OS,
  correlation of biomarkers and clinical
  characteristics with outcome
• EGFR IHC, EGFR FISH, EGFR and KRAS mutations,
  pMAPK, pAKT, HER2 IHC and FISH, HER3,
  amphiregulin, TGF-?, EGF, ICAM

ICAM intercellular adhesion molecule
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Targeting NSCLC in the future approaches to
further optimise treatment strategies

• Will targeted therapies with proven efficacy in
  advanced disease confer benefits in earlier
  disease?
• Will simultaneous inhibition of multiple pathways
  involved in tumorigenesis improve efficacy?
• Can continued tumour control with targeted
  therapies improve outcomes?
• Is it possible to identify patients who derive
  optimal benefit from therapy using biological
  markers?

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Avastin-based therapy the standard of care for
eligible patients
In Avastin-eligible patients the standard of care
is
Avastin-based therapy for 46 cycles
PD
Avastin
Continued tumour control with active treatment
PD progression of disease
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Maintenance therapy in first-line NSCLC can we
add to standard care?
Avastin-based therapy for 46 cycles
PD
Avastin
Tarceva
Continued tumour control with active treatment
Can we improve patient outcomes by adding Tarceva
to Avastin?
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Ongoing phase III trial of first-lineAvastin
with or without Tarceva (ATLAS)
Avastin 15mg/kg Tarceva150mg/day
PD
Off study
Chemotherapy- naïve stage IIIB/IV non-squamous
NSCLC (n1,150)
Avastin 15mg/kg plus chemotherapy
Non-PD
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Avastin 15mg/kg placebo
(n800)
Tarceva150mg/day
PD
PD or significant toxicity
Off study

• Study start date December 2005
• Primary endpoint PFS
• Secondary endpoints safety of Avastin during the
  chemotherapy phase by chemotherapy regimen
  safety of Avastin plus Tarceva

Specified regimens carboplatin/paclitaxel,
cisplatin/gemcitabine, carboplatin/docetaxel
AVF3671g study protocol
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Patients receiving first-line chemotherapy alone
. . . the standard approach in patients not
eligible for Avastin-based therapy is
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Maintenance therapy in first-line NSCLC can we
add to standard care?
Tarceva
PD
Can we improve patient outcomes by using Tarceva
to prolong the benefits of first-line
chemotherapy?
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SATURN (Sequential Tarceva in unresectable NSCLC)
Chemotherapy-naïve stage IIIB/IV NSCLC planned
(n1,700)
Tumour samples (mandatory)
Stratify by EGFRIHC status
Tarceva 150mg/day
PD
Four cycles of first-line standard platinum-based
doublet
Non-PD (n850)
11 rand
Placebo
PD
PD
rand randomised Cut-off is 10 of tumour
cells with any membranous staining for EGFR
protein
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Ongoing phase III trial of second-line Tarceva
with or without Avastin (BeTa Lung)
Tarceva 150mg/day placebo (n325)
PD
Previously treated advanced NSCLC (n650)
Tarceva 150mg/day Avastin 15mg/kg every 3
weeks (n325)
PD

• Multicentre, placebo-controlled, double-blind,
  randomised study
• Primary endpoint OS
• Secondary endpoints include PFS, objective
  response rate, duration of response, safety and
  pharmacokinetics

No crossover will be permitted
OSI3364g study protocol
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Targeting NSCLC in the future approaches to
further optimise treatment strategies

• Will targeted therapies with proven efficacy in
  advanced disease confer benefits in earlier
  disease?
• Will simultaneous inhibition of multiple pathways
  involved in tumorigenesis improve efficacy?
• Can continued tumour control with targeted
  therapies improve outcomes?
• Is it possible to identify patients who derive
  optimal benefit from therapy using biological
  markers?

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Extensive biomarker programme for Avastin in
advanced NSCLC
AVAiL
BO21015
ATLAS
Biomarkers are being investigated as part
of various ongoingNSCLC trials
Avastin
E1505
INNOVATIONS
TASK
BeTa Lung
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Identifying a biomarker for Tarceva extensive
trial programme
RADIANTn945
EGFR IHC/FISH-positive patients
Adjuvant
EURTAC(monotherapy) n146
EGFR mutation-positive patients
Stratified by EGFR IHC status plus other
biomarker analyses
SATURN(maintenance) n1,700
First-line
FAST-ACT(intercalated)n154
EGFR IHC/FISH, MAPK/pAKT IHC, EGFR and KRAS
mutations
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Targeting NSCLC in the future

• Avastin and Tarceva have demonstrated activity in
  the advanced disease setting
• strong rationale to evaluate their role
  inearlier disease
• Continued tumour control with Tarceva in the
  maintenance setting may improve patient outcomes
• Combining single-targeted agents may exploit
  complementary modes of action
• To date, no validated predictive markers for
  Avastin or Tarceva therapy
• ongoing biomarkers programme