Emerging Therapies for Triple NegativeEmerging Therapies for Triple NegativeEmerging Therapies for Triple Negative Emerging Therapies for Triple Negative Breast CancerBreast Cancer

Joseph A. Sparano, MDJoseph A. Sparano, MDDirector Breast Evaluation CenterDirector Breast Evaluation CenterDirector, Breast Evaluation Center Director, Breast Evaluation Center MontefioreMontefiore--Einstein Cancer CenterEinstein Cancer Center

Professor of Medicine & Women’s HealthProfessor of Medicine & Women’s HealthAlb t Ei t i C ll f M di iAlb t Ei t i C ll f M di iAlbert Einstein College of MedicineAlbert Einstein College of Medicine

Bronx, New YorkBronx, New York

Overview • Presentation and prognosisp g• Outcomes with standard therapy• Biological agents• Biological agents

– Bevacizumab, cetuximabDNA d• DNA damage– Inducers of DNA damage (alkylators, platinums)– Inhibitors of DNA repair (gemcitabine)

• PARP inhibitors• Other agents

2

Triple-Negative Disease Compared with Other Ph t i th C lif i C R i t St dPhenotypes in the California Cancer Registry Study

Bauer et al. Cancer 2007: 109; 721

• Population-based study– 6370 with “triple-negative” disease compared with

44 704 “ th ” (12% f ll )44,704 “other” cases (12% of all cases)• Findings – more likely to be associated with

– Younger age (<40): OR 1 53– Younger age (<40): OR 1.53– Non-Hispanic black (OR 1.77) or Hispanic (OR 1.23)– Higher grade (72% grade 3)g g ( g )– Poorer 5 year RFI irrespective of stage

• TNBC: 76% (similar to 76% for HER2-Pos)• HR-Pos, HER2-Neg: 94%

Nomenclature: Basal-like and T i l N i

N ll i l

Triple-Negative15-40% of basal are not triple-negative

~ ER+, PR+, or

Not all triple-negative are

basal-like10 20% of

Basal-likeand

triple-negative ER+, PR+, or HER2+ on clinical

assays

~ 10-20% of triple-negative

have a non-basal genomic

IHC Array

basal genomic profile

-Terms are not synonymous-Terms are often used interchangeably- 20-30% discordance across several studies

Seal MD et al. Cancer J 2010; 16: 12-16

- 20-30% discordance across several studies

TNBC comprised of diverse molecular subtypes

0.3Preliminary*

0.2

0.25

y in

pan

el

0.15

ve fr

eque

ncy

0.05

0.1

Rel

ativ

0basal claudinLow ERBB2 luminalA luminalB normalLike

* Validation ongoingAffymetrix gene expression profiling of FFPE samples Intrinsic subtypes assigned using Sorlie et al, PNAS, 2003 data set and claudin-low classifier (Prat et al., BCR, 2010) [courtesy of J. Theilhaber and D. Bergstrom, Sanofi]

BLBC/TNBC Shares Clinical and Pathologic Features with BRCA-1-Related Breast Cancers

Ch t i ti H dit BRCA1 Basal-like/Triple-

Features with BRCA-1-Related Breast Cancers

Characteristics Hereditary BRCA1 pnegative1,2,3

ER/PR/HER2 status Negative NegativeTP53 status Mutant MutantTP53 status Mutant Mutant

BRCA1 status Mutational inactivation* Diminished expression*

Gene-expression pattern Basal-like Basal-like

Tumor histology Poorly differentiated Poorly differentiated Tumor histology (high grade) (high grade)Chemosensitivity to DNA-damaging agents Highly sensitive Highly sensitive

3Sorlie et al. Proc Natl Acad Sci U S A 2001;98:10869-744 Miyoshi et al. Int J Clin Oncol 2008;13:395-400

*BRCA1 dysfunction due to germline mutations, promoter methylation, or overexpression of HMG or ID44

1Perou et al. Nature. 2000; 406:747-7522Cleator et al.Lancet Oncol 2007;8:235-44

Timing of Recurrence in Triple Negative Disease vs. Other Phenotypes

Dent et al. Clin Can Res 2007; 13: 4429

DFS and OS After Adjuvant AC-Taxane Therapy: Results by Breast Cancer Subtype

in All Treatment Arms in Trial E1199Sparano et al. NEJM 2008

5 year DFS 5 year OS5 year DFS 5 year OSHR-Pos, HER2-Neg 83% 91%Triple Negative 69% 77%Triple Negative 69% 77%HER2-Positive * 78% 86%

* No adjuvant trastuzumab

8

J Clin Oncol 2009; 27: 1177-11839

Treatment No. TNBC Non-TNBCTNBC

Single agent taxane 166 12% 2%

FAC/FAC/AC 308 20% 5%

T-FAC/T-FEC 588 28% 17%

10

DNA Damage/Repair

11

BRCA1-Deficient Cells are H iti t Ci l tiHypersensitive to Cisplatin

• BRCA1 deficient cells have defect in DNA DShave defect in DNA DS repair

BRCA1 d fi i t ll• BRCA1 deficient cells were more sensitive to cisplatin compared to other cell lines

• BRCA1 loss increases sensitivity to DNA damaging agents like cisplatin

HCC1937, BRCA-deficient cell line

MCF 7 h itip

Tassone P et al. Br J Cancer 2003; 88:1285-1291

MCF-7, hormone-sensitive

MDA-MB230, hormone-insensitive

pCR Rates after Single Agent Cytotoxic Neoadjuvant Therapy

in Triple Negative Diseasein Triple Negative Disease Reference Agent No. PCRGarber et al Cisplatin 75 mg/m2 22 5 (22%)Garber et al.JCO 2009

Cisplatin 75 mg/m2q 3 wks x 4

22 5 (22%)

MartinASCO 2010

Doxorubicin 75 mg/m2q 3wks x 4

20 2 (10%)

Docetaxel 100 mg/m2 q 3 wks x 4

28 8 (27%)

13

pCR in BRCA1-Associated Breast Cancer R i i N dj t Ch thReceiving Neoadjuvant Chemotherapy

J Clin Oncol. 2010; 28:375-9. Epub 2009 Dec 14.

• Registry of 6,903 patients • 102 BRCA1 founder mutation and received neoadjuvant

chemotherapy• 24 (24%) has a pCR

CMF 1 f 14 (7%)– CMF: 1 of 14 (7%)– AT (docetaxel): 2 of 25 (8%)– AC of FAC: 11 of 51 (22%)AC of FAC: 11 of 51 (22%)– Cisplatin: 10 of 12 (83%)

14

N Eng J Med 2009; 3060: 2055-2065 15

J Clin Oncol 1997; 15: 1858-1869

16

J Clin Oncol 1997; 15: 1858-186917

J Clin Oncol 1999; 17: 3374-338818

J Clin Oncol 1999; 17: 3374-338819

ASCO 2009, abstract 522 20

21

22

tAnGo Treatment Schema

E

C T

vs.

E G

C T

P lit l 175 / 2 d1E i bi i 90 / 2 Paclitaxel 175mg/m2 d1 Gemcitabine 1250mg/m2 d1&8 Q 21/7, P-then-G seq admin d1

Epirubicin 90mg/m2

Cyclophosphamide 600mg/m2

Q 21/7

Disease-Free Survival (DFS)No significant difference between treatments

HR=1.0 (95% CI 0.8-1.2)

J Clin Oncol 2010; 328: 3256-326325

Other Adjuvant Strategies in TNBC

• BEATRICE (N=2581)– Adjuvant chemotherapy +/- bevacizumabAdjuvant chemotherapy / bevacizumab

• TITAN (N=1800)– AC →plus weekly paclitaxel x 12 vs ixabepilone x 4AC →plus weekly paclitaxel x 12 vs. ixabepilone x 4

• PACS08 (N=2500)FEC100 x 3 →+ docetaxel x 3 vs ixabepilone x 3– FEC100 x 3 →+ docetaxel x 3 vs. ixabepilone x 3

26

Biological Agents+/- Taxanes

or DNA Damaging Agentsor DNA Damaging Agents

27

E2100: Weekly paclitaxel alone or plus bevacizumab as first-line therapy for metastatic breast cancer – outcomes by ER/PR expression

1.0

PFS by TreatmentER Negative, PgR Negative

PBP P P+B

ER/PR Negative

0.4

0.6

0.8

PFS

Prob

abili

ty

PP < 0.0001

Medians: 4.7, 8.6

All 17% 34%Measurable

(79%)17% 41%

0.0

0.2

Months

P

0 6 12 18 24 30

(79%)

P P+B

ER and/or PR Positive

0.8

1.0

PFS by TreatmentER Positive, PgR Positive

y

PBP

Months P P+BAll 23% 37%

Measurable(46%)

30% 51%

0.2

0.4

0.6

PFS

Prob

abili

ty P < 0.0001

Medians: 7, 14.1

(46%)

28

0.0

Months

0 6 12 18 24 30

BALI-1 Trial Schema

Cetuximab/cisplatin (n = 115)Cetuximab 400 mg/m2 initial 250 mg/m2 weeklyCi l ti 75 / 2 d1 3 k

Eligibility (N = 173)

Metatstatic triple-Cisplatin 75 mg/m2 d1 q3wk up to 6 cycles

p

negative breast

cancer (mTNBC) 2:1R≤1 prior chemotherapy

for metastatic disease

allowed

Cisplatin (n = 58)*Cisplatin 75 mg/m2 d1 q3wk up to 6 cycles

* Crossover allowed: 31 patients receiving cisplatin alone switched to cetuximab/cisplatin after first disease progression cisplatin after first disease progression.

Baselga J et al. Proc SABCS 2010;Abstract PD01-01.

Response Rates

Cetuximab + Cisplatin

Best ResponseCisplatin(n = 115)

Alone(n = 58)

Overall response (ORR)* 20.0% 10.3%

Complete response (CR)

Partial response (PR)

1.7%

18.3%

1.7%

8.6%

S bl d % 3 0%Stable disease 41.7% 31.0%

Progressive disease 29.6% 53.4%

Odds ratio (95% CI) 2 13 (0 81 5 59) Odds ratio (95% CI)

p-value

2.13 (0.81-5.59)

0.11

*ORR > 20% was a prespecified criterion to demonstrate superiority of t i b i l ti i l ti l

Baselga J et al. Proc SABCS 2010;Abstract PD01-01.

cetuximab + cisplatin over cisplatin alone.

Progression-Free Survival (PFS)

1.0l

Cetuximab + cisplatin Cisplatin

0.9

0.8

0 7free s

urv

ival + cisplatin

n = 115Cisplatinn = 58

Number of Events 92 47

Median PFS, months [95% CI]

3.7[2 8 4 3]

1.5[1 4 2 8]0.7

0.6

0.5

rog

ress

ion

-f months [95% CI] [2.8-4.3] [1.4-2.8]

HR [95% CI] p-value

0.67 [0.47-0.97]0.03

0.4

0.3

0.2

ab

ilit

y o

f p

r

0.1

0.0219630 51

Pro

b

Cetuximab + cisplatinCisplatin

With permission from Baselga J et al. Proc SABCS 2010;Abstract PD01-01.

Months

Overall Survival (OS)

1.0 Cetuximab + cisplatin Cisplatin

0.9

0.8

0.7urv

ival

+ cisplatinn = 115

Cisplatinn = 58

Number of Events 82 42

Median OS, months [95% CI]

12.9[9 6 15 6]

9.4[6 7 14 2]

0.6

0.5

of

overa

ll s months [95% CI] [9.6-15.6] [6.7-14.2]

HR [95% CI] p-value

0.82 [0.56-1.20]0.31

0.4

0.3

0.2Pro

bab

ilit

y

0.1

0.07242128151219630 03

Cetuximab + cisplatinCisplatin

With permission from Baselga J et al. Proc SABCS 2010;Abstract PD01-01.

Months

PARP InhibitorsPARP Inhibitors

33

History of Poly(ADP-ribose) Polymerase (PARP)as a Therapeutic Targetas a Therapeutic Target

• Discovery of PARP – 1963: Nuclear enzymatic activity that synthesizes an adenine containing RNA-

lik l (Ch b t l)like polymer (Chambon et al)– 1966-67: Confirmed by others, polymer identified as PARP (Nishizuka et al)

• Discovery of PARP Function1979 PARP ti t d b DNA t d b k (J S li t l)– 1979: PARP activated by DNA strand breaks (Juarez-Salinas et al)

– 1980: PARP participates in DNA repair (Durkacz et al)– 1986: PARP1 hyperactivation lead to NAD+ and ATP depletion after DNA

damage promoting metabolic cell death (parthanosis) (David et al)damage, promoting metabolic cell death (parthanosis) (David et al)– 2000: PARP knockouts confirm role in DNA repair (Shail et al)

• Discovery of PARP Inhibitors 1980: PARP inhibitors enhance alkylators (Durkacz et al)– 1980: PARP inhibitors enhance alkylators (Durkacz et al)

– 2005: PARP inhibitors toxic to BRCA deficient cells (Bryant et al, Farmer et al)– 2009: Clinical trials demonstrating PARPi activity in BRCA-deficient breast

cancer and in combination with DNA damaging agents in sporadic TNBC (Tuttcancer and in combination with DNA damaging agents in sporadic TNBC (Tutt et al, O’Shaugnessy et al)

34

Poly (ADP-ribose) Polymerase (PARP)DNA binding

domainCatalytic Domain

PARP homology domain

Automodification domain

PARP-1

• Nuclear protein 3 functional domains• Nuclear protein – 3 functional domains– Amino terminal: DNA binding– Automodification: autoribosylation (protein-protein interactions)– C-terminal: catalytic domain – transfer ADP-ribose from NAD+ to protein

acceptors, forming pADPr (2x higher charge density than DNA)• DNA damage

– PARPs recruited to altered DNA, catalytic activity ↑up to 500-fold– pADPr localization to DNA and recruitment of proteins (eg, XRCC1)

which assemble and activate DNA base excision repair p– NAD+ and ATP depletion contribute to cell death

DNA Damage Repair Pathways

SingleSingle--strand strand breaksbreaks

DoubleDouble--strandstrandbreaksbreaks

Type of damage:

Bulky adducts

O6-alkylguanine

breaksbreaks(SSBs)(SSBs) (DSBs)(DSBs) Insertions

& deletions

Base Base excision excision

repairrepair

RecombinationRecombinationrepairrepair

Repairpathway:

Nucleotide-

Mismatch repair

Direct

PARPPARP

HRHR NHEJNHEJexcision

repairreversal

PARPPARPATMATM

BRCABRCA DNADNA--PKPKRepairenzymes: XP,

polymerasesMSH2,MLH1

AGT

37

PARP-1 Inhibition Increases DNA DS Damage

DNA SSB

XRCC1

Li III

PNK 1

pol β

PARP

Inhibition of PARP-1 prevents recruitment of

LigIII

recruitment of repair factors to repair SSB

ReplicationReplication (S-phase)

DNA DSBDNA DSB

PARP Inhibitors:Mechanisms of Action

S th ti l th lit• Synthetic lethality– BRCA1/2 loss or other HR proteins (eg, RAD51)– PTEN loss

• Inhibit repair of DNA damage– DNA damaging agents (eg, alkylators/platinum)– Topoisomerase I inhibitorsp

• Transcriptional regulation

39

Synthetic Lethality:Selective effect of PARP-1 inhibition on cancer

cells with BRCA1 or BRCA2 mutation

DNA Damage

Base Excision Repair Homologous Recombination

PARP Inhibitor

BRCA Mutation

Cellsurvival

Cancer cell deathsurvival death

BRCA-Deficient Cells are Hypersensitive to PARP InhibitionBRCA-Deficient Cells are Hypersensitive to PARP Inhibition

41Bryant HE et al. Nature 2005;434:913-7

42

PARP Inhibitors

ONH2

NN H

O

R 1

Benzamide Inhibitors3 AB PD128763 Abbott ABT-888 (Veliparib)

NN

R 2Olaparib

3-AB, PD128763 ( p )

NH N

HNH2

O

NF N

NO

NH

O

BSI-201 (Iniparib)Pfizer AG014699 Cephalon CEP-6800

NHF N

H H

Biomarkers of PARP Inhibitor Effects

• Poly ADP ribose – PAR – Indirect measure of PARP inhibition– ELISA - PBMC

• Gamma H2AX– Reflective of DNA DS breaks

• FLT-PET (3’-[F-18]Fluoro-3’deoxythmidine)C ll l t k f FLT l t d b t li th idi– Cellular uptake of FLT regulated by cytosolic thymidine kinase I

– Key enzyme in pyrimidine salvage pathway of DNAKey enzyme in pyrimidine salvage pathway of DNA replicaiton

– FLT update dependent on cell proliferation

44

45

Phase II Study of BSI Plus Chemotherapy in TNBC: Efficacy Data

Phase II Study of BSI Plus Chemotherapy in TNBC: Efficacy Data TNBC: Efficacy Data TNBC: Efficacy Data

EfficacyEfficacy BSIBSI--201 + gem/201 + gem/carbocarbo((nn=42) =42)

Gem/Gem/carbocarbo((nn=44)=44) pp valuevalue

Response Response

ORR ORR 20(48%)20(48%) 6 (22%)6 (22%) 0.020.02

CBRCBR 26 (62%)26 (62%) 9 (21%)9 (21%) 0.0020.002

Survival Survival n=57 n=57 n=59n=59

mPFSmPFS 6.9 months6.9 months 3.3 months 3.3 months <0.001<0.001

mOSmOS 9.2 months9.2 months 5.7 months5.7 months 0.0050.005

CBR: clinical benefit rate (CR+PR+SD)

46O’Shaughnessy et al., NEJM, 2011

Iniparib* (BSI-201)A novel, investigational, anti-cancer agent

• In triple negative breast cancer cell lines1-4:• Induces cell cycle arrest in the G2/M phaseInduces cell cycle arrest in the G2/M phase• Induces double strand DNA damage H2AX foci but does not inhibit

PARP 1 and 2 at physiologic drug concentrations • Potentiates cell-cycle arrest induced by DNA damaging agents, including

l ti d it biplatinum and gemcitabine • Physiologic targets of iniparib and its metabolites are under

investigation

Clinical Data:• In a randomized phase 2 study, addition of iniparib to

gemcitabine/carboplatin improved CBR ORR PFS and OS in patientsgemcitabine/carboplatin improved CBR, ORR, PFS and OS in patients with mTNBC5

• No potentiation of chemotherapy-related toxicities when iniparib is combined with gemcitabine/carboplatin

*Iniparib is the United States Adopted Name (USAN) for the investigational agent BSI-201.1. Ossovskaya V, et al. SABCS 2010, San Antonio, TX. Poster P5-06-09; 2. Ossovskaya V, et al. AACR 2009, Denver, CO. Abstract 5552; 3. Ossovskaya V, et al. AACR 2011, Orlando, FL. Abstract LB-401; 4. Ji et al. AACR 2011, Orlando, FL. Abstract 4527; 5. O’Shaughnessy J, et al. N Engl J Med 2011; 364:205–214.

Study Design: Multi center randomized open label Phase III Trial

Schema Study Design: Multi-center, randomized open-label Phase III Trial

N = 519

Gem/Carbo (GC)(N= 258)

Gemcitabine 1000 mg/m2 IV d 1, 8Carboplatin AUC2 IV d 1, 8

Study Population:

• Stage IV TNBC• ECOG PS 0–1

Crossover allowed to GCI following

Disease Progression* (central review)

21-day cycles

Gem/Carbo + Iniparib (GCI)

R• Stable CNS metastases allowed• 0-2 prior chemotherapies for mTNBC

• Randomization stratified by prior chemo in the metastatic setting:

( )

(N= 261)

Gemcitabine - 1000 mg/m2 IV d 1, 8Carboplatin - AUC2 IV d 1, 8

Iniparib - 5.6 mg/kg IV d 1,4,8,11

the metastatic setting: • 1st-line (no prior therapy)• 2nd/3rd-line (1-2 prior therapies)

21-day cycles

*Prospective central radiology review of progression required prior to crossover

96% (n=152) of progressing patients crossed over to GCI at time of primary analysis

NCT00938652

Efficacy Endpoints – ITT populationPFS GC

(N=258)GCI

(N=261)Median PFS, mos (95% CI)

4.1 (3.1, 4.6)

5.1 (4.2, 5.8)

0 79 (0 65 0 98)

OS GC (N=258)

GCI(N=261)

Median OS, mos (95% CI)

11.1(9.2, 12.1)

11.8(10.6, 12.9)

HR (95% CI) 0 88 (0 69 1 12)1.0

0.9

0.8

urvi

val

1.0

0.9

0.8

Pre-specified alpha = 0.04

HR (95% CI) 0.79 (0.65, 0.98)p-value 0.027

Pre-specified alpha = 0.01

HR (95% CI) 0.88 (0.69, 1.12)p-value 0.28

0.7

0.6

0.5

ogre

ssio

n Fr

ee S 0.7

0.6

0.5ity o

f Sur

viva

l

0.4

0.3

0.2Prob

abili

ty o

f Pro

0.4

0.3

0.2Pr

obab

ili

0 2 4 6 8 10 12 14 16

0.1

0

M th Si St d E t

P

0 2 4 6 8 10 12 14 16

0.1

0

M thMonths Since Study Entry No. at riskGC 258 171 116 63 38 18 6 1 0GCI 261 187 138 83 53 11 2 0 0

No. at riskGC 258 239 214 181 151 99 38 11 0GCI 261 248 230 204 169 111 52 15 0

Months

Overall Response Rate* – ITT Population

Response, n (%) GCN = 258

GCIN = 261N = 258 N = 261

Complete response 4 (1.6) 5 (1.9)Partial response 74(29) 83 (32)Stable disease 89 (35) 99 (38)Stable disease 89 (35) 99 (38)Progressive disease 62 (24) 62 (24)Inevaluable 29 (11) 12 (4.6)

SD > 6 months 14 (5.4) 19 (7.3)

ORR, n (%)(95% CI)

78 (30) (25 36%)

88 (34)(28 40%)(95% CI) (25 36%) (28 40%)

Clinical Benefit Rate, n (%)[CR +PR +SD(> 6 mos)] 92 (36) 107 (41)

50

* Independent central review, RECIST 1.1 + confirmation of response

Exploratory Analysis 1st -line ITT Population

OSPFS

1st -line = 57% of patients (297/519)

HR=1.1 (0.78, 1.56); 129 events

1.0

0.9

0.8al

1.0

0.9

0.8urvi

val

HR=0.88 (0.66, 1.13); 197 eventsGC 12.6 mos (11.9, NE)

GCI 12.4 mos (10.6, NE)

GC 4.6 mos (3.9, 5.7)

GCI 5.6 mos (4.2, 6.9)

0.5

0.7

0.6

ility

of S

urvi

v

0.5

0.7

0.6

ogre

ssio

n Fr

ee S

u

0.4

0.3

0 2Pr

obab

i

0.4

0.3

0 2roba

bilit

y of

Pro

0 2 4 6 8 10 12 14 16

0.2

0.1

0

0.2

0.1

0

Pr

0 2 4 6 8 10 12 14 16

51

Months Months 149 143 130 113 97 70 27 9 0148 141 132 118 99 64 28 6 0

No. at riskGC 149 110 74 44 29 13 5 1 0GCI 148 106 79 51 35 7 2 0 0

Exploratory Analysis 2nd /3rd-line ITT Population d d

PFS OS

2nd / 3rd -line = 43% patients (222/519)

HR=0.65 (0.46, 0.91); 132 events

1.0

0.9

0.8

1.0

0.9

0.8rviv

al

HR=0.67 (0.5, 0.92); 169 events

GC 8.1 mos (6.6, 10)

GCI 10.8 mos (9.7,13.1)

GC 2.9 mos (1.9, 4.1 )

GCI 4.2 mos (3.8, 5.7)

0 5

0.7

0.6

ity o

f Sur

viva

l

0 5

0.8

0.7

0.6

gres

sion

Fre

e Su

r

0.5

0.4

0.3Pr

obab

ili0.5

0.4

0.3

obab

ility

of P

rog

0 2 4 6 8 10 12 14 16

0.2

0.1

0

0.2

0.1

0

Pro

0 2 4 6 8 10 12 14 16Months

109 96 84 68 54 29 11 2 0113 107 98 86 70 47 24 9 0

0 2 4 6 8 10 12 14 16Months

0 2 4 6 8 10 12 14 16

No. at riskGC 109 61 42 19 9 5 1 0 0GCI 113 81 59 32 18 4 0 0 0

Multivariate Analysis - OSEvaluate impact of imbalances in specific baseline characteristics on OS per multivariate analyses as specified in the statistical analysis plan (SAP)Analyses based on : 1. Pre-specified baseline factors: age, disease burden, ECOG PS, line of therapy, race,

time since diagnosis of mTNBC, visceral disease, and elevated alkaline phosphatase2. Pre-specified baseline factors above - but replace time since diagnosis of mTNBC

with Disease Free Interval from primary BC surgery to onset of metastatic diseasep y g y

Treatment Estimates for OS determined using Multivariate Cox Model

ITT Population 1st-line 2nd/3rd-line

HR p HR p HR p

Unadjusted 0.88 0.28 1.1 0.56 0.65 0.012Using pre-specified

baseline factors 0.81 0.08* 0.91 0.62* 0.72 0.07*Using pre specifiedUsing pre-specified

baseline factors with DFI replacement

0.78 0.05* 0.83 0.32* 0.71 0.05*

* p-value is Wald Chi-Square test

Other StrategiesOther Strategies

54

VM Richon et al. Can Lett 2009

Palmieri et al. Clin Cancer Res 2009;15(19):6148–57)56

Effect of HDAC Inhibitor Vorinostat in Human Breast Cancer in Vivo

Ramaswamy et al. Submitted

57

P7703: Vorinostat Induces Hyperacetylation In Vivo

58

Relationship Between GRB7 Expressionand Recurrence in TNBC

Sparano et al. Clin Cancer Res 2011Sparano et al. Clin Cancer Res 2011

246 ti t ith TNBC ( t l IHC) d 0 3 ill d i E2197

5 year 2

•246 patients with TNBC (central IHC) and 0-3 pos axillary nodes in E2197•Treated with adjuvant doxorubicin/cyclophosphamide or dox/docetaxel

GRB7

5 year Recurrence

Rate 95% C.I.

1

rd R

atio

Low 10.5% 7.8%, 14.1%

-10

Log

Haz

a

High 20.4% 16.5%, 25.0% 4 6 8 10-2

GRB7

5959

Results: Estimated Hazard Ratios and 95% C.I. from Joint Models for Recurrence Rates in TNBCfrom Joint Models for Recurrence Rates in TNBC

Model I Model II

Age ≤ 45 vs. >65 0.49 (0.17,1.42) 0.49 (0.17,1.46)Age 45- 65 vs. >65 0.67 (0.25,1.84) 0.63 (0.22,1.78)Nodes 1 vs. 0 2.04 (1.17,3.57) 2.27 (1.32,3.92)Nodes 2-3 vs 0 1 57 (0 65 3 83) 1 96 (0 86 4 47)Nodes 2 3 vs. 0 1.57 (0.65,3.83) 1.96 (0.86,4.47)Grade Poor vs. Mod/Well 1.62 (0.53,4.95) 1.43 (0.51,3.98)Tumor size >2 vs. ≤ 2 cm 1.97 (1.10,3.55) 1.95 (1.09,3.47)

GRB7 x+2 vs. x 3.41 (1.78,6.53)p=0 0002p=0.0002

GRB7 High vs. Low 2.31 (1 30 4 11)

60

(1.30,4.11)p=0.004

Grb7 Adapter ProteinGrb7 Adapter ProteinMember of a family of adapter proteins no enzymatic activity• Member of a family of adapter proteins – no enzymatic activity– calmodulin-binding protein with an SH2 (Src homology 2) domain

that binds to phosphorylated RTKs and other protein targetsrole in signaling (EGFR HER2) motility (ephrins) migration (focal– role in signaling (EGFR, HER2), motility (ephrins), migration (focal adhesion kinase), and cell-matrix/cell-cell interactions (integrins)

• Share region with sequence homology to the Mig-10 C. elegans gene– required for migration of neuronal cells in embryonic developmentrequired for migration of neuronal cells in embryonic development– suggests role for Grb7 in cell migration

• Grb7 present in focal adhesionsbound and phosphorylated by focal adhesion kinase (FAK)– bound and phosphorylated by focal adhesion kinase (FAK)

– critical for cell migration• Grb7 also found in the cytoplasm

interacts with other upstream binding– interacts with other upstream binding partners, including ErbB2

– role in regulation of cell proliferationOncogene 2001 20 6315•Oncogene 2001; 20: 6315

•BMC Structural Biol 2007; 7: 5861

GRB7 Peptide Inhibitor• Inhibits cell migration and proliferation of cell lines with varyingInhibits cell migration and proliferation of cell lines with varying

Her2 expression (SK-BR-3, MDA-MB-361, MDA-MB-231, ZR75-30)• Enhances effects of doxorubicin and trastuzumab in the HER2-

pos cell line (SK-BR-3)• Effective in pancreatic xenograft model

62

•Porter et al. BMC Structural Biology 2007; 7: 58; Tanaka et al. JNCI 2006; 98: 491; Pero et al. Br J Cancer 2007; 96: 1520

Effect of GRB7 Inhibitor (G7-18NATE) on Basal Cell LinesKenny et al. BCRT 2011

MDA-MB-468

MDA-MB-468

Motility

InvasionTranswell Matrigel Assay

MotilityMonoloyer Wound Healing Assay

Kenny et al. AACR 2010 63

Effect of GRB7 Inhibitor (G7-18NATE) on Basal Cell Lines

Proliferation 3D C lt

MDA-MB-468

3D Culture

Kenny et al. CCR 2011

Significantly Higher RNA Expression i TNBC HR HER2 Di (T 10%)in TNBC vs. HR+, HER2- Disease (Top 10%)

Sparano et al. Clin Can Res 2011

• Cell cycle/proliferation/mitosis• Markers: (eg, BUB1, MKI67)

T t ( AURKB PLK1 KIFC1)• Targets (eg, AURKB, PLK1, KIFC1)• DNA repair (CHEK1, RAD45L, TOP2A)• Transcriptional regulation (FOXM1 MYBL2 PTTG1)• Transcriptional regulation (FOXM1, MYBL2, PTTG1)• Invasion (CTSL2, MMP12)• Motility (KIFC2)y ( )• Hypoxia (CA9)• Signaling (DEPDC1)• Ubiquitin-mediated protein catabolism (CDC20)

65Cox proportional hazards model score tests; methods of Korn used to control false discovery rates (J Stat Planning Inference, 124:379-398, 2004)

E2197 Results: Differentially Expressed E2197 Results: Differentially Expressed Genes That are Potential Therapeutic TargetsGenes That are Potential Therapeutic Targets

Gene Function Drugs AURKB Binds microtubule K fibers AZD1152 VX-680AURKB Binds microtubule K fibers

near kinetichoresAZD1152, VX 680, AT9283

PLK1 Regulates G2/M transition BI6727, ON01910KIFC1 Microtubule motor activity ARRY-250, ispinesib,

SB743921 CHK1 Regulates G2/M checkpoint AZD7762 PF0477736CHK1 Regulates G2/M checkpoint AZD7762, PF0477736FOXM1 G1–S and G2–M cell cycle

phase progression; mitotici dl i t it

Siomycin A

spindle integrity

66

Conclusions:Management of TNBC and Emerging TherapiesManagement of TNBC and Emerging Therapies

• Anthracyclines, alkylators, taxanes play important roleAkl l t d l ti t ff ti• Aklylators – dose escalation not effective

• Gemcitabine – no role as adjuvant therapy• Capecitabine no role for adjuvant monotherapy• Capecitabine – no role for adjuvant monotherapy• Biological agents – bevacizumab, EGFR inhibitors • PARP inhibitors – role remains to be defined

– Predictive markers? – What level and/or duration of PARP inhibition is sufficient?– PARPi plus other non-cytotoxic and/or cytotoxic agents?

• Other potential therapeutic targets– HDAC inhibitors– Others 67