May 2013, Vol 2, No 3
Highlights From the American Association for Cancer Research Annual MeetingUncategorized
The American Association for Cancer Research (AACR) 2013 Annual Meeting was held in Washington, DC, April 6-10, 2013. Following are selected highlights of early studies presented at the meeting. The hope is that these encouraging preliminary findings will be confirmed by larger studies and lead to advances in cancer care.
Antibody-Drug Conjugate Encouraging in Platinum-Resistant Ovarian Cancer
T-DM1 was the first antibody-drug conjugate to gain FDA approval for the treatment of HER2-positive metastatic breast cancer. Preliminary study suggests that a second antibody-drug conjugate is active in platinum-resistant ovarian cancer, and if the encouraging early results are confirmed by clinical trials, this would fulfill an unmet need for a difficult-to-treat cancer with limited treatment options.
The antibody-drug conjugate DMUC5754A includes a monoclonal antibody that recognizes the MUC16 protein expressed by ovarian cancer cells and is linked to a potent antimitotic toxin called MMAE. The antibody targets MUC16, and the toxin is released selectively into tumor cells that express MUC16, limiting the effects of the toxin on healthy tissues and organs.
MMAE is so potent that it could not be delivered directly to patients, explained lead author Joyce Liu, MD, MPH, Dana-Farber Cancer Institute, Boston, MA.
The phase 1 study evaluated the safety, pharmacokinetics, and pharmacodynamics of DMUC5754A in 44 women with advanced, recurrent, platinum-resistant ovarian cancer. Among these heavily pretreated patients, there were 1 complete response and 4 partial responses. All 5 responses were observed in patients with high expression of MUC16 in their tumor cells.
The maximum tolerated dose was identified as 2.4 mg/kg, and the antibody-drug conjugate was given every 3 weeks. Dose-limiting toxicities included 1 grade 4 neutropenia and 1 grade 4 uric acid increase, occurring at a higher dose level. Grade 3 adverse events included fatigue in 9% of patients and neutropenia in 9%. Fatigue was the most common adverse event at all dose levels, occurring in 57% of patients. Nausea, vomiting, decreased appetite, diarrhea, and peripheral neuropathy were also reported.
“If the activity of this drug is confirmed in additional trials, this will represent a real step forward in finding new, effective treatments for advanced ovarian cancer,” Liu said.
Liu J, Moore K, Birrer M, et al. Targeting MUC16 with the antibody-drug conjugate (ADC) DMUC5754A in patients with platinum-resistant ovarian cancer: a phase I study of safety and pharmacokinetics. Presented at: American Association for Cancer Research 2013 Annual Meeting; April 6-10, 2013; Washington, DC. Abstract LB-290.
Genetically Engineered T Cells Show Promising Activity in Pediatric Leukemia
A small preliminary study suggests that a unique immunotherapy called “anti-CD19 chimeric antigen receptor (CAR) T-cell therapy” can achieve complete remission in children with acute lymphocytic leukemia (ALL) who relapse after bone marrow transplantation (BMT).
“Childhood ALL is the most common malignancy in pediatric patients. The majority of children can achieve remission, but this comes with the price of long therapy, toxicity, and cost, with no guarantee of long-term cure. Children who relapse have limited therapeutic options, and new therapies are sorely needed,” stated lead author of the study Daniel W. Lee III, MD, assistant clinical investigator in the Pediatric Oncology Branch of the National Cancer Institute, Bethesda, MD.
Anti-CD19 CAR T-cell therapy is a new way to treat childhood cancer, he continued. This therapy uses the patient’s own immune cells that have been collected and then modified and expanded in the laboratory to attach to the CD19 protein expressed by leukemia cells.
Activation of the T cells for immunity requires 2 signals, Lee explained. Leukemia cells do not generate the second signal required, and therefore the leukemia is not controlled. “Genetically engineered T cells get around this by being designed specifically to recognize the CD19 antigen. When they are reinfused into the patient, the receptor fires 2 signals and activates the T cells to kill the target tumor tissue,” he added.
At AACR, Lee reported results in the first 4 patients treated with anti-CD19 CAR T-cell therapy. Three patients had ALL and had received BMT, and 1 patient had B-cell lymphoma. All patients received fludarabine and cyclophosphamide prior to receiving the CAR T cells. One ALL patient had a complete response, and a second ALL patient had a transient complete response, with minimal residual disease remaining. The B-cell lymphoma patient did not respond.
The side effects were temporary and not seen in every patient, Lee continued. They included fever and low blood counts and were easily managed in the hospital.
“Graft-versus-host disease is a side effect of concern in patients treated with BMT. We saw no evidence of this in the first 3 ALL patients we treated who had undergone previous BMT,” he said.
“Anti-CD19 CAR T cells represent a new way to attack childhood leukemia. Preliminary evidence suggests that we can induce complete remission in patients refractory to other therapies,” Lee stated.
Lee DW III, Shah N, Stetler-Stevenson M, et al. Autologous-collected anti-CD19 chimeric antigen receptor (CAR) T cells for acute lymphocytic leukemia (ALL) and non-Hodgkin’s lymphoma (NHL) in children who have previously undergone allogeneic stem cell transplantation (HSCT). Presented at: American Association for Cancer Research 2013 Annual Meeting; April 6-10, 2013; Washington, DC. Abstract LB-138.
Genetic Analysis Identifies 4 Subsets of Squamous Cell Carcinoma of the Head and Neck
Comprehensive genetic analysis by The Cancer Genome Atlas (TCGA) identified 4 different subtypes of squamous cell carcinoma of the head and neck (SCCHN). The analysis included 279 patients with previously untreated SCCHN. This is the 8th tumor type analysis of TCGA to be presented.
“Our study will likely become a landmark research tool for SCCHN for many years as we gradually unlock the secrets of this massive data set,” said David N. Hayes, MD, MPH, a medical oncologist who is associate professor at the University of North Carolina in Chapel Hill.
SCCHN is the 5th most common cancer worldwide and the 6th most common type in the United States. Forty-five thousand new cases are diagnosed each year. Smoking is a risk factor, as is the epidemic of human papilloma virus (HPV). Among the 279 patients included in the study, 80% had tobacco-related disease and 13% were HPV-positive.
“We need to understand the mutations or individual alterations in the 15 most significant mutated genes in SCCHN,” Hayes said.
In the study, significant mutations were found in the following genes: CDKN2A, TP53, PIK3CA, NOTCH1, HRAS, and NFE2L2.
Looking at all gene expression subtypes of SCCHN, tumors organize themselves into 4 groups that tend to go along with differences in mutation patterns and chromosomal alterations, Hayes explained.
The 4 subtypes are:
- Atypical subtype with no amplification of EGFR, HPV positive, and a high rate of PI3 kinase mutations (PIK3CA);
- Classical subtype, also seen in squamous cell lung cancer, associated with 2 key mutations: KEAP1 and NFE2L2;
- Mesenchymal subtype, mostly FGR1 and FGR mutations;
- Basal subtype, highly associated with SOX2 amplifications and overexpression.
Some of these alterations overlap with squamous cell carcinoma of the lung, which is also a tobacco-related cancer. “We frequently see altered genomes in other tobacco-related cancers. One of the striking findings we observed was a high degree of similarity to other squamous tumors, including lung squamous cell carcinoma. Lessons learned from studying the similarities and differences between tumors, such as copy number alterations, will be an angle to pursue to better understand altered pathways in cancer. The idea that they share properties that go beyond the type of cancer means that this could be studied at a model systems level.”
Other key observations of this study include:
- HPV-positive and other patients have infrequent EGFR gene amplification
- HPV-positive tumors have a high rate of PIK3CA gene mutations
- HPV-infected patients almost never have p5 alterations
- In HPV-negative patients, druggable mutations include EGFR, FGR, and CNCCC21
“We have made a lot of observations, but this also makes things more complicated. We are able to recognize patterns, and some of these patterns may turn out to be druggable, or actionable, in the future,” Hayes stated.
“This is robust information that gives us data on mutational analysis and copy numbers, expression, promoter methylation, and other aspects of SCCHN. This data set confirms other publications indicating that there is a clear difference between HPV-positive patients who usually have a better prognosis and are easier to treat than HPV-negative patients. HPV-negative patients have many more mutations than HPV-positive patients,” stated Giuseppe Giaccone, MD, PhD, Georgetown University Medical Center’s Lombardi Comprehensive Cancer Center, Washington, DC. Giaccone moderated a press conference where these data were presented.
Hayes DN, Grandis J, El-Naggar AK, et al. Comprehensive genomic characterization of squamous cell carcinoma of the head and neck in the Cancer Genome Atlas. Presented at: American Association for Cancer Research 2013 Annual Meeting; April 6-10, 2013; Washington, DC.
Intermittent Vemurafenib May Overcome Resistance
Vemurafenib is a relatively new effective option for the treatment of melanoma; unfortunately, most patients who respond will develop resistance. Studies by researchers at Novartis suggest that an intermittent dosing strategy may be able to overcome resistance that occurs with standard continuous dosing.
“We were excited about the translational science that led to approval of the BRAF inhibitor vemurafenib, which extends survival in these patients. But most patients relapse with lethal drug-resistant disease,” explained Darrin Stuart, PhD, Novartis Institutes for Biomedical Research, Emeryville, CA, who presented results of early animal and human studies.
In a previous study, Stuart and colleagues implanted xenografts of BRAF-expressing tumors in mice and found that the tumors developed resistance to vemurafenib. But possibly more important was the observation that the tumors were dependent on the drug for their proliferation. When drug treatment was withdrawn, the tumors stopped growing and regressed.
The next step was to determine if the drug-dependency of the tumors was exhibited in humans. Stuart and colleagues collaborated with scientists at The Royal Marsden Hospital in London, United Kingdom, and evaluated 42 patients with vemurafenib-resistant tumors. Of these, 19 patients had CT scans obtained after drug treatment was stopped. Fourteen of 19 scans showed regression in the rate of tumor growth.
Stuart and colleagues then performed another experiment on mice implanted with BRAF-expressing tumor xenografts; this time they treated them with vemurafenib 4 weeks on and 4 weeks off (intermittent strategy) or continuous vemurafenib. None of the tumors in the animals treated intermittently developed resistance.
This suggests that a drug holiday and intermittent treatment could be beneficial in patients taking vemurafenib and might overcome resistance. Stuart was not at liberty to discuss Novartis’ plans for the future but stated that intermittent dosing was a strategy that he hopes researchers will pursue.
Das Thakur M, Fisher R, Salangsang F, et al. Modeling vemurafenib resistance in melanoma reveals a strategy to forestall drug resistance. Presented at: American Association for Cancer Research 2013 Annual Meeting; April 6-10, 2013; Washington, DC. Abstract LB-144.
Drug Combination Potentially Effective in BRCA-Deficient Solid Tumors
Two orally available experimental drugs achieved response in patients with BRCA-deficient solid tumors in a phase 1 study of 31 patients. Responders were patients with BRCA mutations and incurable pancreatic, breast, and ovarian tumors.
“There is definitely a group of responders who appear to benefit from this drug combination. This should be studied in a new, much larger prospective trial,” said lead author Geoffrey Shapiro, MD, PhD, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA.
Among the 31 patients, 16 had BRCA-deficient cancers. Patients received treatment with sapacitabine and seliciclib – 2 drugs developed by Cyclacel. Sapacitabine causes single-strand DNA breaks that are converted to double-strand DNA breaks during replication. The investigators in the phase 1 trial hypothesized that seliciclib would interfere with the repair of damaged DNA and enhance the cytotoxicity of sapacitabine, Shapiro explained.
Patients were treated with sequential administration of both drugs for 10 days on, followed by an 11-day rest period. During the dose-escalation phase of the study, patients without BRCA mutations had stable disease. Two observations during the dose-escalation phase made researchers focus on the patients with BRCA mutations: 1) it was reported that the repair of DNA breaks caused by sapacitabine is depending on the homologous repair pathway, which includes BRCA proteins and is downregulated in their absence; and 2) a partial response was observed in a pancreatic cancer patient who was found to be a BRCA-mutation carrier.
The trial was then limited to patients with BRCA-deficient cancers. Three additional partial responses (PRs) were observed (2 with breast cancer and 1 with ovarian cancer). The PRs have been durable in 3 patients (from 9 to 21 months). These 3 patients are continuing on study.
In total, 6 of the 16 BRCA-mutation carriers benefitted from the drug combination (4 patients with PRs and 2 with stable disease).
Shapiro said that nonresponders were heavily pretreated and too compromised to tolerate a cycle of the combination therapy and were therefore not evaluable.
“Among the BRCA-proficient group, several patients had prolonged stable disease, but the response was not as dramatic as in the BRCA-deficient group,” he said. “Going forward, the combination therapy has the most chance of efficacy in BRCA-deficient patients.”
Sequential administration of the 2 experimental agents was used in the trial. Concurrent administration of sapacitabine and seliciclib will be studied, as will different dosing schedules.
PARP inhibitors are effective in BRCA-deficient patients. Shapiro said the responders in the trial had not been pretreated with a PARP inhibitor. “We need to determine if the combination works in patients pretreated with PARP. Finally, we have some drug classes that address inherited cancers,” Shapiro stated.
Shapiro GI, Hilton J, Cleary JM, et al. Responses to sequential sapacitabine and seliciclib in patients with BRCA-deficient solid tumors. Presented at: American Association for Cancer Research 2013 Annual Meeting; April 6-10, 2013; Washington, DC. Abstract LB-202.
Personalizing Cancer Care, Policy, and the Payer Perspective:
An Interview with Peter F. Hayes of Healthcare Solutions
The Association for Value-Based Cancer Care (AVBCC) held its annual conference on May 2-5, 2013, in Hollywood, Florida. AVBCC is the fastest growing national specialty organization dedicated to improving the care of cancer patients and their quality of life by discussing, considering, and evaluating the value equation as it relates [ Read More ]
Higher HER2 Expression Leads to Better Outcomes With T-DM1 in HER2-Positive Metastatic Breast Cancer
Among women with HER2-positive metastatic breast cancer, those with the highest expression of HER2 had the best outcomes on treatment with T-DM1, according to a biomarker analysis of the phase 3 EMILIA trial presented at the American Association for Cancer Research 2013 Annual Meeting. Further, the analysis found that T-DM1 [ Read More ]