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TRIPLE-NEGATIVE BREAST CANCERNeoadjuvant and Adjuvant Chemotherapy Considerations for Triple-Negative Breast CancerDaniel G. Stover, MD, Caitlin F. Bell, and Sara M. Tolaney, MD, MPH

LUNG AND HEAD & NECK CANCERFibroblast Growth Factor Receptor (FGFR) as a Therapeutic Target in Lung and Head and Neck CancerYoung Kwang Chae, MD, MPH, MBA, Sachin G. Pai, MD, Peng Sun, MD, PhD, Ricardo Costa, MD, Maria Matsangou, MD, Mark Agulnik, MD, and Francis Giles, MD

PRECISION MEDICINEProtein Pathway Activation Mapping for Multi-Omic Based Precision MedicineMariaelena Pierobon, MD, Leena Gandhi, MD, Massimo Cristofanilli, MD, Debu Tripathy, MD, and Emanuel F. Petricoin III, PhD

CHRONIC LYMPHOCYTIC LEUKEMIAManagement of Patients With Relapsed Chronic Lymphocytic Leukemia Polina Shindiapina, MD, PhD, and Farrukh T. Awan, MD

A m e r i c a n

J o u r n a l

H e m a t o l o g y /

O n c o l o g y ®

A Peer-Reviewed Resource

for Oncology Education

ajho

www.AJHO.com ISSN 1939-6163 (print) ISSN 2334-0274 (online)

Volume 12 Number 3 3.16

METASTATIC COLORECTAL CANCER CME-certified enduring materials sponsored by Physicians’ Education Resource®, LLC

Advances in the Treatment of Metastatic Colorectal Cancer

Lung CancerCONGRESS®

17th AnnualInternational Program Directors

Program Director

David R. Gandara, MDUC Davis Comprehensive Cancer CenterSacramento, CA

Roy S. Herbst, MD, PhDYale School of MedicineNew Haven, CT

Joyce A. O’Shaughnessy, MDThe US Oncology Network Dallas, TX

AUGUST 4-6, 2016 HYAT T REGENCY HUNTINGTON BEACHHUNTINGTON BEACH, CA

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17th AnnualInternational Program Directors

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Table of Contents

TRIPLE-NEGATIVE BREAST CANCER

Neoadjuvant and Adjuvant Chemotherapy Considerations for Triple-Negative Breast CancerDaniel G. Stover, MD, Caitlin F. Bell, and Sara M. Tolaney, MD, MPHChemotherapy remains the standard of care for triple-negative breast cancer because no targeted thera-pies have been proven to be effective for it. Platinum agents in the neoadjuvant setting, poly ADP ribose polymerase inhibitors, immune checkpoint inhibitors, and biomarkers as potential treatment regimens are evaluated for viability.

LUNG AND HEAD & NECK CANCER

Fibroblast Growth Factor Receptor (FGFR) as a Therapeutic Target in Lung and Head and Neck CancerYoung Kwang Chae, MD, MPH, MBA, Sachin G. Pai, MD, Peng Sun, MD, PhD, Ricardo Costa, MD, Maria Matsangou, MD, Mark Agulnik, MD, and Francis Giles, MD The potential roles of FGFR in lung and head and neck cancers, as well as the current landscape of therapies in development that target the FGFR pathway, are discussed through this summary of FGFR inhibitor clinical trials.

PRECISION MEDICINE

Protein Pathway Activation Mapping for Multi-Omic Based Precision MedicineMariaelena Pierobon, MD, Leena Gandhi, MD, Massimo Cristofanilli, MD, Debu Tripathy, MD, and Emanuel F. Petricoin III, PhDWill precision cancer therapy fulfill its promise through the addition of functional protein activation mapping of tumors along with genomic analysis?

CHRONIC LYMPHOCYTIC LEUKEMIA

Management of Patients With Relapsed Chronic Lymphocytic Leukemia Polina Shindiapina, MD, PhD, and Farrukh T. Awan, MDTherapeutic options for chronic lymphocytic leukemia (CLL) have been expanding, boosting overall response and progression-free survival rates. But, a cure remains elusive. This review focuses on recent exploration of chemotherapeutic and targeted therapy options directed against relapsed CLL.

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CME

CME-certified enduring materials sponsored by Physicians’ Education Resource®, LLCMETASTATIC COLORECTAL CANCER

Advances in the Treatment of Metastatic Colorectal CancerTreatment of colorectal cancer (CRC), including metastatic CRC, continues to evolve at a rapid pace. John Marshall, MD, Chief, Division of Hematology/Oncology, Georgetown University Hospital, and Director, Ruesch Center for the Cure of GI Cancers, Washington, DC, shares his insights on recent advancements in the treatment of CRC and their significance.

31

Patrick I. Borgen, MDChairman, Department of Surgery Maimonides Medical CenterDirector, Brooklyn Breast Cancer ProgramBrooklyn, NY

Julie R. Brahmer, MDAssociate Professor, Oncology Johns Hopkins University School of

MedicineSidney Kimmel Comprehensive Cancer

CenterBaltimore, MD

J. Michael Dixon, MD, OBEProfessor of Surgery and Consultant

SurgeonClinical Director, Breakthrough Research

UnitEdinburgh Breast UnitEdinburgh, UK

David R. Gandara, MDProfessor of MedicineDirector, Thoracic Oncology ProgramSenior Advisor to the DirectorDivision of Hematology/OncologyUC Davis Comprehensive Cancer CenterSacramento, CA

Andre Goy, MD, MSChairman and DirectorChief of LymphomaDirector, Clinical and Translational Cancer ResearchJohn Theurer Cancer Center at Hackensack University Medical CenterHackensack, NJ

Omid Hamid, MDChief, Translational Research and ImmunotherapyDirector, Melanoma TherapeuticsThe Angeles Clinic and Research InstituteLos Angeles, CA

Roy S. Herbst, MD, PhDEnsign Professor of Medicine (Medical

Oncology)Professor of PharmacologyChief of Medical OncologyAssociate Director for Translational ResearchYale Cancer CenterYale School of Medicine New Haven, CT

Thomas J. Lynch, Jr, MDCEO and ChairmanMassachusetts General Physicians

OrganizationMassachusetts General HospitalBoston, MA

Maurie Markman, MDPresident, Medicine and ScienceNational Director, Medical OncologyCancer Treatment Centers of AmericaPhiladelphia, PA

John L. Marshall, MDChief, Hematology and Oncology Director, Otto J. Ruesch Center for the

Cure of Gastrointestinal CancersLombardi Comprehensive Cancer CenterGeorgetown University Medical CenterWashington, DC

Hyman B. Muss, MDProfessor of OncologyUniversity of North CarolinaDirector of Geriatric OncologyLineberger Comprehensive Cancer CenterChapel Hill, NC

Joyce A. O’Shaughnessy, MDCo-Director, Breast Cancer ResearchBaylor Charles A. Sammons Cancer

Center Texas Oncology The US Oncology NetworkDallas, TX

Daniel P. Petrylak, MDProfessor of Medicine (Medical Oncology) and of UrologyCo-Director, Signal Transduction Research

ProgramYale Cancer Center and Smilow Cancer

HospitalNew Haven, CT

Heather A. Wakelee, MDAssociate Professor, Medicine (Oncology)Stanford University Medical CenterStanford, CA

Jeffrey S. Weber, MD, PhDSenior Member and DirectorDonald A. Adam Comprehensive Melanoma Research CenterMoffitt Cancer CenterTampa, FL

PER® Executive Board/AJHO Editorial Board

4 www.ajho.com MARCH 2016

Virtually every great discovery in human history began with one person asking a question. “Is the earth truly flat?” “Why did that Apple fall downwards from that tree?” “Why is there lightning, and what can it do?”

That spirit of inquisitiveness lives on today in the pages of American Journal of Hematology/Oncology, where, each month, our physician authors raise incisive questions about new techniques that may ulti-mately guide the cancer treatments of tomorrow.

This issue kicks off with “Neoadjuvant and Adjuvant Chemotherapy Considerations for Triple-Neg-ative Breast Cancer.” Despite recent strides in adjuvant chemotherapy regimens, the prognosis for patients with triple-negative breast cancer (TNBC) continues to lag behind. Chemotherapy remains the standard of care because no targeted therapies have been proven to be effective for TNBC. The authors review the viability of platinum agents in the neoadjuvant setting, poly ADP ribose polymerase inhibitors, immune checkpoint inhibitors, and biomarkers as potential treatment regimens.

“Fibroblast Growth Factor Receptor (FGFR) as a Therapeutic Target in Lung and Head and Neck Cancer” looks at the FGFR aberration, which has been identified in various cancers, and speculates on the potential roles of FGFR in treating head and neck and lung cancers. The author also examines therapies that are currently in development to target the FGFR pathway through a discussion of FGFR inhibitor clinical trials.

Our third story, “Protein Pathway Activation Mapping for Multi-Omic-Based Precision Medicine, presents two clinical case studies that illustrate the clinical potential for utilizing functional proteomics data into the precision medicine workflow. The authors focus on high-throughput proteomic platforms able to capture changes within signaling networks such as the Reverse Phase Protein Microarray, a widely used proteomic platform for signaling network mapping of biological samples.

Management of chronic lymphocytic leukemia (CLL) has improved significantly in recent years, with chemoimmunotherapy emerging as a commonly used treatment of patients with CLL, using fludara-bine, cyclophosphamide, and rituximab (FCR) or bendamustine and rituximab (BR). But, significant morbidity has been associated with the utilization of these drugs. In “ Management of Patients With Relapsed Chronic Lymphocytic Leukemia,” the authors discuss recent explorations of chemothera-peutic and targeted therapy options directed against relapsed CLL, summarize factors that may predict resistance to therapy, and highlight future directions.

In this month’s CME section from Physicians’ Education Resource Group, we present an interview with John Marshall, MD, Chief, Division of Hematology/Oncology, Georgetown University Hospital, and Director, Ruesch Center for the Cure of GI Cancers. The treatment of colorectal cancer (CRC), including metastatic CRC, continues to evolve at a rapid pace, and Dr. Marshall has been a prime mover and shaker in the development of new regimens. In this conversation, he shares his thoughts on recent advancements in CRC treatment.

We hope you find this issue thought-provoking and educational. We welcome your opinions on the content, as well as your suggestions for topics to cover in future issues, and your participation as authors and peer reviewers is welcomed, as well.

Michael J. Hennessy, Sr

Chairman and Chief Executive Officer

Chairman’s Letter

The content of this publication is for general information purposes only. The reader is encouraged to confirm the information presented with other sources. American Journal of Hema-tology/Oncology 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. American Journal of Hematology/Oncology reserves the right to alter or correct any error or omission in the information it provides in this publication, without any obligations. American Journal of Hematology/Oncology 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 American Journal of Hematology/Oncology.

VOL. 12, NO. 3 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY® 5

EDITORIAL STAFF

Last year, ASCO cited transformation in the treatment of chronic lymphocytic leukemia (CLL) as a hallmark achievement. As you will read in this issue of AJHO, there is good reason for this designation. Newer immunotherapy drugs obinutuzumab and ofatumumab delay progression of first-line CLL by more than one year when combined with chemotherapy, and may be better options for older patients in comparison with standard CLL therapies. Coupled with novel oral targeted therapies such as ibrutinib and idelasib for relapsed disease, these drugs have truly changed the therapeutic landscape.

It is estimated that there are slightly less than 120,000 individuals in the U.S. living with CLL, many of whom are older individuals, making more effective and less toxic therapies particularly welcome. Nearly 19,000 new cases of CLL are expected this year, and while survival rates vary, this can, in many cases, be considered a chronic disease, as the 5-year survival rate is about 80%, with a trend toward improvement in the last few years. We have learned more about the biology of CLL, with prognostic indices such as IGHV mutation status, fluorescence in situ hybridization, ZAP-70, CD38, and β2-microglobulin increasingly being used for decision-making. Newer pharmacological approach-es have emerged through our understanding of signaling pathway components such as Bruton’s tyrosine kinase (BTK) and specific PI3K isoforms, as well as newer targetable receptors such as CD23 that added to the CD20-based antibodies in existence for some time. Novel drugs targeting Bcl-2 and older immunomodulatory drugs such as lenalidomide also hold potential for refractory disease.

Cancer therapies often come in large quantum leaps for a particu-lar disease, as we witnessed at the turn of the century for breast and colorectal cancers, followed by significant advances in lung cancer, then in melanoma, and more recently for multiple myeloma and CLL. We hope to see this trend continue—with more effective and better- tolerated drugs—as evidenced by how we manage CLL all the way from

diagnosis through frontline therapies and beyond.CORPORATE OFFICERS Chairman and CEOMichael J. Hennessy, Sr

Vice Chairman Jack Lepping

President Mike Hennessy, Jr

Chief Operating Officer and Chief Financial Officer Neil Glasser, CPA/CFE

Executive Vice President and General Manager John Maglione

Vice President, Digital Media Jung Kim

Chief Creative Officer Jeff Brown

Human Resource Director Shari Lundenberg

Debu Tripathy, MD Editor-in-Chief

From the Editor Editor-in-ChiefDebu Tripathy, MD

Professor and Chair Department of Breast Medical Oncology The University of Texas MD Anderson Cancer Center Houston, TX

Associate EditorJason J. Luke, MD, FACP

Assistant Professor of MedicineUniversity of ChicagoChicago, IL

Managing EditorHoward Whitman [email protected] Art Director Nicole Martino

Editorial OfficesPhysicians’ Education Resource®, LLC666 Plainsboro Road, Ste 356Plainsboro, NJ 08536(609) 378-3701

PresidentPhil Talamo, CHCP

Medical DirectorMichael Perlmutter, PharmD, MS

· BREAST CANCER ·


Neoadjuvant and Adjuvant Chemotherapy Considerations for Triple-Negative Breast Cancer

Daniel G. Stover, MD, Caitlin F. Bell, and Sara M. Tolaney, MD, MPH

Introduction: Defining the SubtypeTriple-negative breast cancers (TNBC), defined by the absence of estrogen (ER), progesterone (PR), and HER2 receptors, ac-count for approximately 15% of all breast cancers.1 This subtype is more common in African-American women, younger women, and BRCA1 mutation carriers.1,2 They are disproportionately as-sociated with early recurrences, particularly in the first 5 years after diagnosis, with recurrences that are more commonly viscer-al or CNS rather than bone.3,4 Hormone receptor-positive breast

cancer recurs at a rate of 3% to 5% per year over a patient’s lifetime, while TNBC recurs at a rate of 10% to 15% per year for 3 years before declining.2,5 In an analysis of nearly 45,000 women with a first primary breast cancer who were registered in the California Cancer Registry, TNBC had a 5-year survival rate of 77% compared to 93% for other subtypes.6

There is growing interest in molecular classification of breast cancers as we move towards precision medicine for this disease.7 Genomic analyses of TNBC, including sequencing of several hundred primary TNBCs, revealed frequent mutation in TP53 but few recurrent targetable mutations.8,9 Mutations in DNA repair pathways are more common in TNBC relative to other breast cancer subtypes. There is particular interest in BRCA1 mu-tation carriers, since about 70% of breast cancers that develop in this group are triple-negative.10 However, BRCA1 mutation carri-ers remain a minority among all TNBC, with 10% to 25% ger-mline or somatic BRCA1 mutation in most series11,12 (Figure 1).

Gene expression is the most widely studied classification ap-proach, stratifying breast cancers into 5 ‘intrinsic’ subtypes: lu-minal A, luminal B, HER2-like, basal-like, and normal-like.13,14 These intrinsic subtypes have been associated with long-term prognosis and predict response to neoadjuvant chemotherapy.14 More than 70% of TNBC are basal-like, defined primarily by high proliferation-related markers as well as by increased expres-sion of cytokeratins 5 and 17, EGFR, and the proto-oncogene c-kit. Each of the additional intrinsic subtypes is represented in lower frequency among TNBCs, while 15% to 40% of bas-al-like tumors are not triple-negative by immunohistochemistry15 (Figure 1). More recent expression analysis of several hundred TNBC yielded a classification system for TNBC subpopulations based on 6 equally represented categories: basal-like 1, basal-like 2, mesenchymal-like, mesenchymal stem-like, luminal AR, and immunomodulatory.16 This classification system correlates with pathologic response to neoadjuvant chemotherapy and may offer guidance on targeted therapies for subgroups within TNBC.17

Standard Chemotherapy Regimens in the Neoadjuvant and Adjuvant SettingsThe goals of neoadjuvant chemotherapy include improving the

Abstract

Triple-negative breast cancers (TNBC) are an immuno-

histochemically defined subset of breast cancer that is

negative for the estrogen receptor (ER), progesterone

receptor (PR), and HER2, and represent a heterogeneous

group of tumors based on expression profiling. Despite

strides made in adjuvant chemotherapy regimens and in

overall survival for patients with breast cancer, progno-

sis for patients with TNBC continues to lag behind those

with ER+ or HER2+ tumors. Chemotherapy remains the

standard of care for TNBC because no targeted therapies

have been proven to be effective for this subtype. There

is growing interest in the use of platinum agents in the

neoadjuvant setting for TNBC but we await data from on-

going, randomized, adjuvant trials to understand if these

agents have an impact on long-term outcomes. Patients

with BRCA-mutant TNBC are a special subgroup who

may benefit more from platinums and, potentially, from

poly ADP ribose polymerase (PARP) inhibitors. Immune

checkpoint inhibitors are promising in many cancer types

and are investigational in combination with chemothera-

py in the neoadjuvant setting. Growing attempts to devel-

op biomarkers to guide therapy within TNBC may lead to

more effective regimens or to novel therapeutic targets.

Key words: Triple-negative breast cancer, chemotherapy,

platinum, BRCA



likelihood of breast-conserving surgery as well as assessing re-sponse to systemic therapy.18 Given a lack of targeted therapy options in the adjuvant setting, most women with TNBC will be considered for chemotherapy at some point in their care. Neoad-juvant chemotherapy also provides important prognostic infor-mation: those women with no histologic evidence of residual in-vasive cancer in either breast or axillary lymph nodes (pathologic complete response [pCR]) have significantly improved long-term outcomes relative to women with residual disease (RD).19 Howev-er, in a meta-analysis by Cortazar and colleagues, improvements in pCR were not associated with similar improvements in overall survival (OS) across breast cancers, suggesting that neoadjuvant chemotherapy outcomes are not an appropriate surrogate for long-term outcome for all breast cancer subtypes.19

Among neoadjuvant regimens, sequential anthracycline-tax-ane chemotherapy represents a commonly used standard of care. The National Surgical Adjuvant Breast and Bowel Project (NS-ABP)-30 study suggested that, in the adjuvant setting, sequential therapy showed a small, but significantly improved disease-free survival (DFS) compared to concurrent regimens.20 There is strong interest in whether adding agents to existing regimens or developing new regimens can both improve rates of pCR and improve long-term outcomes.

There are many potential regimens for standard chemother-apy for TNBC in the adjuvant setting, although the sequential, dose-dense anthracycline-taxane combination remains a com-mon regimen for moderate-to-high risk TNBC.20 The epirubi-cin-based regimen, including 5-fluorouracil, epirubicin, and cy-clophosphamide (FEC) followed by paclitaxel or docetaxel, are also acceptable regimens for patients with moderate-to-high-risk triple-negative disease.21 Docetaxel plus cyclophosphamide (TC) is used in the United States and appears to be at least as effective as adriamycin plus cyclophosphamide (AC) for many patients; but this trial included a very small number of hormone recep-tor-negative patients.22 The combination of cyclophosphamide, methotrexate, and fluorouracil (CMF) may be an alternative with less short-term and long-term toxicity but longer duration of therapy.23,24

The Role of Platinum Chemotherapy in TNBCInterest in platinum agents emerged from data suggesting a high frequency of DNA repair defects in TNBC that may render TN-BCs particularly susceptible to cross-linking agents8, as well as evidence of high response rates in the metastatic setting.25-27 The TNT trial prospectively randomized patients with metastatic or recurrent, locally advanced TNBC to either first-line carboplatin or docetaxel.28 Overall response rates at 18 months were similar, with 31.4% for carboplatin and 35.6% for docetaxel, indicating that platinum is a viable first-line option but not superior to taxane therapy. A nonrandomized, phase II trial of single-agent platinum in metastatic TNBC demonstrated a slightly lower re-

sponse rate of 25.6% across patients who had received 0-1 lines of chemotherapy for their metastatic disease.26

The GeparSixto and CALGB/Alliance 40603 trials prospec-tively examined the addition of platinum to neoadjuvant che-motherapy regimens in TNBC. GeparSixto randomized patients with TNBC to receive paclitaxel, liposomal doxorubicin, and bevacizumab with or without carboplatin.29 Along similar lines, in CALGB/Alliance 40603, patients with TNBC received pacli-taxel weekly for 12 weeks followed by doxorubicin plus cyclophos-phamide every two weeks for 4 cycles, and were randomized to receive concurrent carboplatin every 3 weeks for 4 cycles and/or bevacizumab every 2 weeks for 9 cycles.30 The dose and schedule of platinum differed between trials: in GeparSixto, carboplatin area under the curve (AUC) of 1.5 was dosed weekly with lipo-somal doxorubicin and paclitaxel for 18 weeks, while in 40603, carboplatin AUC=6 was given every 3 weeks with weekly pacli-taxel for a total of 12 weeks. Both trials demonstrated improved rates of pCR with the addition of carboplatin. In GeparSixto, the addition of carboplatin improved pCR rates (breast/axilla) from 36.9% to 53.2% and the BRCA carriers demonstrated an increase in pCR by 25% (P = .005).29,31 CALGB/Alliance 40603 demonstrated an increase in pCR with the addition of carbo-platin for breast/axilla (54% vs 41%; P = .0029).30 Long-term outcomes data recently presented at San Antonio Breast Cancer Symposium, however, were divergent; there was improved DFS

Proportional representation of the overlap among triple-nega-tive, basal-like, and BRCA1-mutant breast cancers. Most TNBC are basal-like (BLBC) and vice versa. While most BRCA1-mu-tant breast cancers are both TNBC and BLBC, only a small proportion of total TNBCs or BLBCs are BRCA1-mutant. Venn diagram created with BioVenn.53

FIGURE 1. Overlap of Triple-Negative, Basal-like, and BRCA1-Mutant Breast Cancers.

· BREAST CANCER ·


with the addition of carboplatin in GeparSixto (HR, 0.56; 95% CI, 0.33-0.96; median follow-up 35 months) while CALGB/Al-liance 40603 did not demonstrate improved event-free survival with addition of carboplatin (HR, 0.84; 95% CI, 0.58-1.22; me-dian follow-up 39 months).32,33

The data for the addition of platinum to standard chemother-apy in the neoadjuvant setting are encouraging, but both studies were underpowered for long-term outcome end points, making it challenging to conclusively interpret benefit. One difference between the trials is that patients in the CALGB/Alliance study received an alkylating agent (cyclophosphamide) in addition to an anthracycline and taxane (with or without carboplatin), while in GeparSixto patients did not receive an alkylator. Differenc-es in platinum dosing (weekly in GeparSixto vs every 3 weeks in 40603) or duration (18 vs 12 weeks, respectively) could also have had an impact. In addition, the improvements in pCR were associated with added toxicities, such as increased grade 3-4 neutropenia and thrombocytopenia, as well as required dosing adjustments of paclitaxel in the CALGB/Alliance trial.30 It re-mains unclear how to incorporate platinum, and it is not known whether platinum could be used to substitute for anthracycline, taxane, or an alkylator rather than added to the current regi-mens.

Several ongoing phase III studies may provide additional insight regarding platinum. In the pre-operative setting, the ADAPT trial will evaluate nab-paclitaxel in combination with either carboplatin or gemcitabine for patients with TNBC.34 The NRG BR003 study of adjuvant doxorubicin plus cyclophospha-mide followed by weekly paclitaxel with or without carboplatin for node-positive or high-risk TNBC may provide additional in-sight on long-term outcomes, as well as on potential differences between neoadjuvant versus adjuvant setting. EA1131 is a ran-domized trial of 4 cycles of platinum chemotherapy versus obser-vation for TNBC with residual disease after neoadjuvant chemo-therapy. Given the complicating factors of toxicity and dosing, as well as unclear long-term benefit, platinum is not ready to be included in current standard neoadjuvant or adjuvant chemo-therapy regimens for all patients with TNBC.

PARP Inhibitors in TNBCInhibitors of poly ADP ribose polymerase (PARP)1, a base ex-cision repair enzyme, result in synthetic lethality in the context of altered BRCA1 or 2. PARP1 inhibitors have been explored in TNBC, which often have BRCA defects or deficiencies in other DNA repair participants.35 In the I-SPY 2 study, patients with tri-ple-negative and HR+ disease received veliparib and carboplatin in combination with paclitaxel as part of neoadjuvant therapy. The pCR rate for patients with TNBC in the arm with the PARP inhibitor plus carboplatin was 52% with the addition of velipa-rib/platinum versus 26% for patients receiving therapy not con-

taining platinum or PARP, respectively.36 Based on the success of this phase II trial, there is an ongoing phase III clinical trial in which patients with TNBC are randomized to receive velipa-rib/carboplatin/paclitaxel, carboplatin/paclitaxel, or paclitaxel alone, all to be followed by doxorubicin/cyclophosphamide in the neoadjuvant setting (NCT02032277).

Another recent trial enrolled patients with TNBC or BRCA mutation and randomized those with residual disease after neo-adjuvant therapy to either single-agent cisplatin or cisplatin in combination with rucaparib following preoperative chemothera-py. The addition of the PARP1 inhibitor did not affect the toxic-ity of the chemotherapy, but it also did not significantly improve 1-year DFS.37 Despite no definitive study showing improvement in DFS and/or OS using PARP inhibitors, the neoadjuvant or adjuvant settings ongoing studies may give us further insight into the role of PARP inhibitors.

Vascular Endothelial Growth Factor Inhibitors in TNBCTNBCs demonstrate high intratumor levels of VEGF, leading to investigation of bevacizumab, a VEGF-directed monoclonal antibody, in this group.38 The NSABP B-40 trial evaluated addi-tional chemotherapeutic agents (gemcitabine or capecitabine) to anthracycline/taxane neoadjuvant regimens, as well as the role of neoadjuvant bevacizumab in HER2-negative breast cancers.39 The addition of either gemcitabine or capecitabine was not as-sociated with improved outcomes.39 Adding bevacizumab was associated with increased OS (HR, 0.65; 95% CI, 0.49-0.88; P = .004) but not DFS (HR, 0.8; 95% CI, 0.63-1.01; P = .06) with significantly more frequent grade 3-4 neutropenia, hand-foot syn-drome, and hypertension.39 In the GeparQuinto study, the ad-dition of bevacizumab to neoadjuvant epirubicin/cyclophospha-mide followed by docetaxel demonstrated increased pCR rates for TNBCs (39.3% vs 27.9%), but no significant improvement in DFS or OS.40

Bevacizumab has also been explored in the adjuvant setting for TNBC. BEATRICE was an open-label, multicenter, phase III tri-al with in patients with TNBC who were randomized to receive 4 cycles of standard chemotherapy with or without bevacizumab.41 The DFS (82.7% vs 83.7%) and OS (HR, 0.84; 95% CI, 0.64-1.12; P = 0.23) were not significantly different with the addition of bevacizumab. There was also a slight increase in cardiac events in patients receiving bevacizumab concomitantly with anthracy-clines.41 Given the added toxicities and lack of benefit in the adjuvant setting (ECOG 5103 and BEATRICE), bevacizumab is unlikely to have a role in the treatment of TNBC.

The Special Case of BRCA-Mutant TNBCs: Platinum and PARPThere is growing evidence that patients with BRCA mutations may have a distinct biology and disproportionately benefit from



platinums both in the neoadjuvant and adjuvant settings. In pa-tients who develop breast cancer with an underlying BRCA mu-tation, 70% are classified as triple-negative and basal-like on in-trinsic expression profiling.15 In the neoadjuvant setting, a study of 107 women with breast cancer and BRCA1 mutation, treated with 4 cycles of cisplatin, had a pCR of 61%.42 The TBCR009 study, a nonrandomized, phase II trial using single-agent plat-inum in metastatic TNBC, had a response rate of 54.2% in BRCA-mutated patients versus only 19.7% in those with wild-type BRCA.26 A study of neoadjuvant in TNBC suggested that biomarkers to platinum response were BRCA1 mutation, low BRCA1 expression, and high BRCA1 methylation.27 In the met-astatic setting, subgroup analysis of patients in the TNT trial re-ceiving carboplatin with BRCA 1/2 mutations had significant improvement in progression-free survival.28

These data suggest that platinums are likely beneficial in pa-tients with BRCA-mutant breast cancer. The ongoing INFORM trial (TBCRC 031) randomizes BRCA carriers to either 4 cycles of AC or 4 cycles of cisplatin followed by definitive breast surgery. Eventual results of this trial will examine pCR, long-term clinical response rate, and comparative toxicities of the 2 regimens and may provide more insight into how to incorporate platinum in this special subgroup.

While PARP inhibitors have not yet demonstrated a clear role in unselected TNBCs, their role in BRCA-mutant patients is of intense interest based on promising data in the metastatic setting.27-29 A phase II trial enrolled women who had advanced, recurrent BRCA-mutated cancer and assigned them to receive either continuous maximum dose or lower dose olaparib. The overall response rate was higher for those on maximum dosing (41% vs 22%) with an acceptable toxicity profile.43 The ongoing OlympiA study, which evaluates 1 year of adjuvant PARP inhib-itor in patients with BRCA-mutant breast cancer, may give us further insight into the role of PARP inhibitors in this special patient population.

Looking Ahead: Better Biomarkers and Intriguing ImmunotherapyThe development of specific biomarkers may help identify a sub-set of patients with TNBC who benefit from platinum beyond BRCA-mutant patients. In the CALGB/Alliance trial, the overall pCR rate did not differ between basal-like (54%) and the relative-ly small number of nonbasal-like cancers (52%).30 A single-arm neoadjuvant phase II study of gemcitabine, carboplatin, and ini-parib for TNBC found that a high homologous recombination deficiency (HRD) score predicted favorable pathologic response to cisplatin therapy.44 Expression of various immune signatures that reflected tumor-infiltrating lymphocytes was associated with higher pCR rates, but was not specific to basal-like subtypes.30 Continued investigation of biomarkers that indicate DNA repair

deficiency and predict platinum responsiveness is ongoing.45,46 Recent impressive results of immune checkpoint inhibitors in

melanoma and non-small cell lung cancer have led to evaluation of this class of agents across tumor types. In breast cancer, most work to date has focused on TNBC given greater frequency of tumor infiltrating lymphocytes (TILs) and an association of TILs with both response to neoadjuvant chemotherapy and long-term outcomes.47-49 Three early-phase studies of immune checkpoint inhibitors demonstrated promising response rates of 8.3% to 19% in patients with metastatic disease.50-52 This has led to the initiation of multiple studies of checkpoint inhibitors in combi-nation with chemotherapy in the neoadjuvant setting for TNBC: pembrolizumab plus nab-paclitaxel with or without carboplatin followed by pembrolizumab + doxorubicin + cyclophosphamide (KEYNOTE-173; NCT02622074); MEDI4736 with weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide for stage I-III TNBC (NCT02489448); and MEDI4736 with tax-ane-anthracycline (GeparNuevo; NCT02685059).

ConclusionsThe standard of care for neoadjuvant and adjuvant therapy in TNBC remains chemotherapy. While platinums show promise with increased pCR rates in the neoadjuvant setting, lack of consistent data regarding long-term outcomes limits widespread incorporation into routine care. PARP inhibitors have shown some promise, particularly in BRCA-mutant breast cancer, and several ongoing trials will clarify the role of this class of agents in TNBC. Although bevacizumab may be associated with increased pCR in TNBC, the lack of benefit in the adjuvant setting cou-pled with increased toxicity have not led to widespread adoption. Patients with BRCA mutations may have additional benefit from platinum, but when and how to incorporate therapy remains un-clear. Progress in predictive biomarkers, as well as incorporation of immunotherapy may be practice-changing in the future.

Affilations: Daniel G. Stover, MD and Sara M. Tolaney are from Department of Medical Oncology, Dana-Farber Cancer Insti-tute, Boston, MA. Caitlin F. Bell is from Vanderbilt University School of Medicine, Nashville, TN.Disclosures: None.Address correspondence to: Sara M. Tolaney, MD, MPH, De-partment of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA, 02215. Email: [email protected]

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2. Boyle P. Triple-negative breast cancer: epidemiological considerations and recommendations. Ann Oncol. 2012;23(suppl 6):vi7-vi12.3. Lin NU, Vanderplas A, Hughes ME, et al. Clinicopathologic features, patterns of recurrence, and survival among women with triple-negative breast cancer in the National Comprehensive Cancer Network. Cancer. 2012;118(22):5463-5472. doi: 10.1002/cncr.27581.4. Chikarmane SA, Tirumani SH, Howard SA, Jagannathan JP, DiPiro PJ. Metastatic patterns of breast cancer subtypes: what radiologists should know in the era of personalized cancer medicine. Clin Radiol. 2015;70(1):1-10. doi: 10.1016/j.crad.2014.08.015.5. Dent R, Trudeau M, Pritchard KI, et al. Triple-negative breast cancer: clinical features and patterns of recurrence. Clin Cancer Res. . 2007;13(15 pt 1):4429-4434.6. Bauer KR, Brown M, Cress RD, Parise CA, Caggiano V. Descriptive analysis of estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, and HER2-negative invasive breast cancer, the so-called triple-negative phenotype: a population-based study from the California cancer Registry. Cancer. 2007;109(9):1721-1728.7. Stover DG, Wagle N. Precision medicine in breast cancer: genes, genomes, and the future of genomically driven treatments. Curr Oncol Rep. 2015;17(4):438. doi: 10.1007/s11912-015-0438-0.8. Cancer Genome Atlas Network. Comprehensive molecular portraits of human breast tumours. Nature. 2012;490(7418):61-70. doi: 10.1038/nature11412.9. Shah SP, Roth A, Goya R, et al. The clonal and mutational evolution spectrum of primary triple-negative breast cancers. Nature. 2012;486(7403):395-399. doi: 10.1038/nature10933.10. Foulkes WD, Metcalfe K, Sun P, et al. Estrogen receptor status in BRCA1- and BRCA2-related breast cancer: the influence of age, grade, and histological type. Clin Cancer Res. 2004;10(6):2029-2034.11. Gonzalez-Angulo AM, Timms KM, Liu S, et al. Incidence and outcome of BRCA mutations in unselected patients with triple receptor-negative breast cancer. Clin Cancer Res. 2011;17(5):1082-1089. doi: 10.1158/1078-0432.CCR-10-256012. Hartman AR, Kaldate RR, Sailer LM, et al. Prevalence of BRCA mutations in an unselected population of triple-negative breast cancer. Cancer. 2012;118(11):2787-2795. doi: 10.1002/cncr.26576.13. Perou CM, Sorlie T, Eisen MB, et al. Molecular portraits of human breast tumours. Nature. 2000;406(6797):747-752.14. Parker JS, Mullins M, Cheang MC, et al. Supervised risk predictor of breast cancer based on intrinsic subtypes. J Clin Oncol. 2009;27(8):1160-1167. doi: 10.1200/JCO.2008.18.1370.15. Mayer IA, Abramson VG, Lehmann BD, Pietenpol JA. New strategies for triple-negative breast cancer--deciphering

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28. Tutt A EP, Kilburn L, Gilett C, et al. The TNT trial: A randomized phase III trial of carboplatin (C) compared with docetaxel (D) for patients with metastatic or recurrent locally advanced triple negative or BRCA1/2 breast cancer (CRUK/07/012). 2014 San Antonio Breast Cancer Symposium; December 9-13, 2014; San Antonio, TX.29. von Minckwitz G, Schneeweiss A, Loibl S, et al. Neoadjuvant carboplatin in patients with triple-negative and HER2-positive early breast cancer (GeparSixto; GBG 66): a randomised phase 2 trial. Lancet Oncol. 2014;15(7):747-756. doi: 10.1016/S1470-2045(14)70160-3.30. Sikov WM, Berry DA, Perou CM, et al. Impact of the addition of carboplatin and/or bevacizumab to neoadjuvant once-per-week paclitaxel followed by dose-dense doxorubicin and cyclophosphamide on pathologic complete response rates in stage II to III triple-negative breast cancer: CALGB 40603 (Alliance). J Clin Oncol. 2015;33(1):13-21. doi: 10.1200/JCO.2014.57.0572.31. von Minckwitz G, Hahnen E, Fasching PA, et al. Pathological complete response (pCR) rates after carboplatin-containing neoadjuvant chemotherapy in patients with germline BRCA (gBRCA) mutation and triple-negative breast cancer (TNBC): results from GeparSixto. ASCO Meeting Abstracts. 2014;32(suppl 15):1005.32. Sikov W, Berry D, Perou C, et al. Event-free and overall survival following neoadjuvant weekly paclitaxel and dose-dense AC +/- carboplatin and/or bevacizumab in triple-negative breast cancer: Outcomes from CALGB 40603 (Alliance). San Antonio Breast Cancer Symposium. December 9, 2015.33. von Minckwitz G, Loibl S, Schneeweiss A, et al. Early survival analysis of the randomized phase II trial investigating the addition of carboplatin to neoadjuvant therapy for triple-negative and HER2-positive early breast cancer (GeparSixto). San Antonio Breast Cancer Symposium. December 9, 2015.34. Hofmann D, Nitz U, Gluz O, et al. WSG ADAPT - adjuvant dynamic marker-adjusted personalized therapy trial optimizing risk assessment and therapy response prediction in early breast cancer: study protocol for a prospective, multi-center, controlled, non-blinded, randomized, investigator initiated phase II/III trial. Trials. 2013;14:261. doi: 10.1186/1745-6215-14-261.35. Lord CJ, Ashworth A. Mechanisms of resistance to therapies targeting BRCA-mutant cancers. Nature Med. 2013;19(11):1381-1388. doi: 10.1038/nm.3369.36. Rugo HS, Olopade O, DeMichele A, et al. Veliparib/carboplatin plus standard neoadjuvant therapy for high-risk breast cancer: first efficacy results from the I-SPY 2 trial. SABCS. 2013.37. Dwadasi S, Tong Y, Walsh T, et al. Cisplatin with or without rucaparib after preoperative chemotherapy in patients with triple-negative breast cancer (TNBC): Hoosier Oncology Group BRE09-146. J Clin Oncol. 2014;32(suppl): Abstract 1019 (5s).

38. Foekens JA, Peters HA, Grebenchtchikov N, et al. High tumor levels of vascular endothelial growth factor predict poor response to systemic therapy in advanced breast cancer. Cancer Res. 2001;61(14):5407-5414.39. Bear HD, Tang G, Rastogi P, et al. Neoadjuvant plus adjuvant bevacizumab in early breast cancer (NSABP B-40 [NRG Oncology]): secondary outcomes of a phase 3, randomised controlled trial. Lancet Oncol. 2015;16(9):1037-1048. doi: 10.1016/S1470-2045(15)00041-8.40. von Minckwitz G, Loibl S, Untch M, et al. Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†. Ann Oncol 2014;25(12):2363-2372. doi: 10.1093/annonc/mdu455.41. Cameron D, Brown J, Dent R, et al. Adjuvant bevacizumab-containing therapy in triple-negative breast cancer (BEATRICE): primary results of a randomised, phase 3 trial. Lancet Oncol. 2013;14(10):933-942. doi: 10.1016/S1470-2045(13)70335-8.42. Byrski T, Huzarski T, Dent R, et al. Pathologic complete response to neoadjuvant cisplatin in BRCA1-positive breast cancer patients. Breast Cancer Res Treat. 2014;147(2):401-405. doi: 10.1007/s10549-014-3100-x.43. Tutt A, Robson M, Garber JE, et al. Oral poly(ADP-ribose) polymerase inhibitor olaparib in patients with BRCA1 or BRCA2 mutations and advanced breast cancer: a proof-of-concept trial. Lancet. 2010;376(9737):235-244. doi: 10.1016/S0140-6736(10)60892-6.44. Telli ML, Jensen KC, Vinayak S, et al. Phase II study of gemcitabine, carboplatin, and iniparib as neoadjuvant therapy for triple-negative and BRCA1/2 mutation-associated breast cancer with sssessment of a tumor-based measure of genomic instability: PrECOG 0105. J Clin Oncol. 2015;33(17):1895-1901. doi: 10.1200/JCO.2014.57.0085.45. Birkbak NJ, Wang ZC, Kim JY, et al. Telomeric allelic imbalance indicates defective DNA repair and sensitivity to DNA-damaging agents. Cancer Discov. 2012;2(4):366-375. doi: 10.1158/2159-8290.CD-11-0206.46. Abkevich V, Timms KM, Hennessy BT, et al. Patterns of genomic loss of heterozygosity predict homologous recombination repair defects in epithelial ovarian cancer. Br J Cancer. 2012;107(10):1776-1782. doi: 10.1038/bjc.2012.451.47. Loi S, Sirtaine N, Piette F, et al. Prognostic and predictive value of tumor-infiltrating lymphocytes in a phase III randomized adjuvant breast cancer trial in node-positive breast cancer comparing the addition of docetaxel to doxorubicin with doxorubicin-based chemotherapy: BIG 02-98. J Clin Oncol. 2013;31(7):860-867. doi: 10.1200/JCO.2011.41.0902.48. Adams S, Gray RJ, Demaria S, et al. Prognostic value of tumor-infiltrating lymphocytes in triple-negative breast cancers from two phase III randomized adjuvant breast cancer trials:

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ECOG 2197 and ECOG 1199. J Clin Oncol. 2014;32(27):2959-2966.49. Denkert C, von Minckwitz G, Brase JC, et al. Tumor-infiltrating lymphocytes and response to neoadjuvant chemotherapy with or without carboplatin in human epidermal growth factor receptor 2-positive and triple-negative primary breast cancers. J Clin Oncol. 2015;33(9):983-991. doi: 10.1200/JCO.2014.58.1967.50. Emens LA, Braiteh FS, Cassier P, et al. Abstract 2859: Inhibition of PD-L1 by MPDL3280A leads to clinical activity in patients with metastatic triple-negative breast cancer (TNBC). Cancer Res. 2015;75(suppl 15):2859.51. Dirix L, Takacs I, Nikolinakos P, et al. Abstract S1-04: Avelumab (MSB0010718C), an anti-PD-L1 antibody, in patients with locally advanced or metastatic breast cancer: A phase Ib JAVELIN solid tumor trial. Cancer Res. 2016;76(suppl 4):S1-S4.52. Nanda R, Chow LQ, Dees EC, et al. Abstract S1-09: A phase Ib study of pembrolizumab (MK-3475) in patients with advanced triple-negative breast cancer. Cancer Res. 2015;75(suppl 9):S1-S9.53. Hulsen T, de Vlieg J, Alkema W. BioVenn - a web application for the comparison and visualization of biological lists using area-proportional Venn diagrams. BMC Genomics. 2008;9:488. doi: 10.1186/1471-2164-9-488.

· LUNG AND HEAD & NECK CANCER ·


Fibroblast Growth Factor Receptor (FGFR) as a Therapeutic Target in Lung and Head and Neck Cancer

Young Kwang Chae, MD, MPH, MBA, Sachin G. Pai, MD, Peng Sun, MD, PhD, Ricardo Costa, MD, Maria Matsangou, MD, Mark Agulnik, MD, and Francis Giles, MD

FGFR PathwayThe fibroblast growth factor/fibroblast growth factor receptor (FGF/FGFR) signaling pathway fundamentally regulates embryo-genesis, adult tissue homeostasis, angiogenesis and wound re-pair.1,2 It also plays important roles in cell functions, including pro-liferation, differentiation, apoptosis and migration.3-5 Deregulated FGF/FGFR activations have been associated with a broad range of developmental disorders and cancer progression. Upon ligand binding, FGFRs activate a cascade of downstream signaling path-ways, such as the mitogen activated protein kinase (MAPK), signal transducer and activator of transcription (STAT), the phospho-inositide-3-kinase (PI3K)/Akt pathways, and DAG-PKC, and IP3-Ca2+ releasing signaling branches via phospholipase Cγ (PLCγ) activation6-9 (Figure 1). The alternatively spliced FGFR isoforms have been shown to result in oncogenic FGFR signaling, which promotes tumorigenesis. In this review, we will focus on the FGFR aberrations in lung and head and neck cancer, and compare them with other tumor types, such as bladder and gastric cancer. We will also discuss the current clinical trials of FGFR inhibitors that include lung and head and neck cancers.

FGFR Aberrations in Lung CancerFGFR1 has been shown to be amplified in 10%–20% of squa-mous non-small-cell lung cancers (SqNSCLC).10-12 Preclinical studies have demonstrated that FGFR1 amplification confers FGFR signaling dependence.10 Treatment of FGFR1-amplified SqNSCLC cell lines with selective FGFR inhibitor PD173074 resulted in cancer cell growth inhibition and apoptosis. In ad-dition to squamous cell, small–cell lung cancer (SCLC) cell lines, as well as xenograft models derived from both cell lines and patient tumors treated with PD173074 have also shown tumor regression with PD173074 treatment through inhibition of both FGFR 1 and 2.10,13 Activating FGFR2 mutations oc-curred in 5% of SqNSCLC14, and 2.2% in non-small cell lung cancers (NSCLC).15 In vivo NSCLC mice model with an FG-FR2-mutated tumors were sensitive to a Pan-FGFR inhibitor.16 In addition, increased FGFR3 cDNA expression was found in lung cancer tissues17 from patients who progressed on prior chemotherapy treatments. Novel FGFR3 fusion genes were also identified in SqNSCLC18. More recently, it has been discov-ered that de-repression of FGFR2 and FGFR3 can cause rapid acquired resistance to EGFR tyrosine kinase inhibitors among NSCLC cell lines.19 These recent findings have suggested a clear role of various FGFRs in lung cancer (henceforth referred to NSCLC unless otherwise specified) progression. Current re-search focus has been more towards FGFR1 amplification, the most common aberration.

FGFR Aberrations in Head and Neck CancerAdvanced-stage head and neck squamous cell carcinoma (HN-SCC) remains a challenging disease with poor outcomes. Over-all survival has improved by about 10% over the past 20 years, despite advances in treatment modalities. The paucity of infor-mation on the dominant oncogenic drivers has been a major challenge to the effective application of targeted therapies in HNSCC. Recurrent FGFR1 amplification is seen in 10% to 17% of head and neck20,21, and high FGFR2 and FGFR3 expres-sion has been found in the majority of HNSCC cell lines.22,23 Higher expression levels of FGFR1, 2, and 3 were also found to

Abstract

Fibroblast growth factor receptor (FGFR) aberrations

have been identified in various types of cancer. Squa-

mous cell carcinomas of the lung and head and neck have

been shown to harbor these genetic alterations in high

frequencies. A number of agents that target the FGFR

signaling pathway are currently in development in vari-

ous tumor types. This review will summarize the potential

roles of FGFR in lung and head and neck cancers, as well

as discuss the current landscape of therapies in develop-

ment that target the FGFR pathway by summarizing the

clinical trials of FGFR inhibitors.

Key words: FGFR; lung cancer; head and neck cancer;

therapeutic target; clinical trial



be contributing to tumor initiation and early-stage progression in HNSCC.20,24 It has been shown that a reduction of FGFR3 levels in HNSCC cell lines led to a 35% decrease in cell prolif-eration and higher radiation sensitivity.23 The FGFR inhibitor PD173074 reduced cell proliferation and increased cell apop-tosis in head and neck cancer in vitro and in vivo.25 An aber-rant FGFR signaling pathway has been implicated in acquired resistance to bevacizumab, an anti-vascular endothelial growth factor antibody.26 Together, these results support that the aber-rant FGFR pathway might be an important oncogenic pathway as well as a mechanism of acquired resistance to therapies in a subset of HNSCCs.

Comparing the FGFR Landscape with Other Cancer Types—Bladder and Gastric CancerThe FGFR pathway has been known to play a critical role in the tumorigenesis of bladder and gastric cancer.27,28 While FGFR1 amplification is frequently reported in lung and head and neck cancers, FGFR2 amplification has been reported in gastric cancer. However, FGFR3 mutation not usually found in head and neck cancers or lung cancers is not an uncommon characteristic of bladder cancer. FGFR3 is frequently activat-ed by mutation and not by amplification in bladder cancer, and represents a potential target for therapy. FGFR3 mutations have been described in approximately 75% of low-grade papil-lary bladder cancers, and FGFR3 overexpression was identified in 42% of muscle-invasive diseases.27,29,30 FGFR1 amplification was also found in 3% of urinary bladder cancers.31 The anti-FG-FR3 monoclonal antibody inhibits in vitro cell growth and in vivo tumor burden for bladder cancer cells with FGFR3 point mutation mutation.32

In gastric cancer, multiple FGFR alterations (except FGFR3 mutation) were detected in patients’ tumor specimens.33 In particular, FGFR2 amplification was observed from 4-7% in different studies, and intratumoral heterogeneity was observed in 24% of FGFR2 amplified cases.34,35 Furthermore, FGFR2 amplification may portend poor prognosis for patients with gastric cancer. Thus, FGFR2 has attracted significant attention as a potential therapeutic target for the development of novel personalized anticancer treatment. Several clinical trial studies have tried to functionally inhibit FGFR aberrancy in gastric cancer patients: small molecule pan FGFR inhibitors AZD4547 (NCT01457846, NCT01795768, and NCT00979134), TKI258 (NCT01719549, NCT01576380, and NCT01921673) and specific humanized monoclonal antibody FPA144 targeting FGFR2 (NCT02318329).

FGFR Inhibitor Clinical Trials in Lung and Head and Neck CancersPrevious studies in other cancers have led to clinical trials using FGFR inhibitors for lung cancer and HNSCC (Table 1). Of

the non-selective multikinase inhibitors, Dovitinib has a wide range of off-target effects including other receptors of the RTK (receptor tyrosine kinase) superfamily, in addition to FGFR3, vascular endothelial growth factor receptor (VEGFRs), FGFR1, platelet-derived growth factor receptor type 3 (PDGFR-3), FMS-like tyrosine kinase 3, stem cell factor receptor (c-KIT), and col-ony-stimulating factor receptor 1 is undergoing early phase clin-ical studies (NCT01831726, NCT01379534, NCT01732107, NCT01719549). In a phase III trial, another multikinase in-hibitor, nintedanib, in combination with docetaxel compared to docetaxel plus placebo, showed a modest improvement in progression-free survival (PFS) 3–4 months versus 2–7 months; with a hazard ratio of 0–79 (P = 0.0019). The benefit was higher for the adenocarcinoma histology, where median overall surviv-al was 6–12 months versus 3–10 months; HR 0–83 (P = 0·0359) favoring the combination group. Lucitanib is another novel dual inhibitor undergoing early-phase clinical trials. It targets FGFR in addition to VEGFRs and has been shown to have anti-angiogenic activity in addition to anti-tumor proliferation effects in preclinical studies (NCT01283945, NCT02109016).36 Ponatinib, another multi-target kinase inhibitor, has also been used against FGFR-driven tumors, and has completed accrual (NCT01761747).

FIGURE 1. The signal transduction network downstream of FGFR along with FGFR alterations.

Following ligand binding and receptor dimerization, the kinase domains transphosphorylate each other, leading to the docking of adaptor proteins and the activation of four key downstream pathways: RAS–RAF–MAPK, PI3K–AKT, signal transducer and activator of transcription (STAT) and phospholipase Cγ (PLCγ).

FIBROBLAST GROWTH FACTOR RECEPTOR (FGFR) AS A THERAPEUTIC TARGET


Other selective FGFR inhibitors such as BGJ398, BAY1163877, AZD4547, and JNJ-42756493 are being evaluat-ed in several cancers harboring FGFR amplification and mu-tation. While several are being tested in lung cancers and var-ious other solid tumors, a few are available for head and neck cancer in early-phase clinical trials as well. BGJ398 is a pan FGFR kinase inhibitor that has been tested in a phase I dose esclation study in patients with advanced solid malignancies harboring either FGFR1 or FGFR2 amplification or FGFR3 mutations (NCT01004224). AZD4547, a novel and selective inhibitor of the FGFR1, 2, and 3 tyrosine kinases37, is investi-

gated in a phase I/II clinical trial, assessing the efficacy, safety, and tolerability of this inhibitor compared with or without pa-clitaxel in patients with recurrent non-small–cell lung cancer (NCT01824901). An ongoing JNJ-42756493 phase I study in-cludes efforts to optimize dose and schedule and to analyze biomarkers. Expansion cohorts are currently enrolling patients with FGFR-aberrant tumors, including lung and breast cancer (NCT01703481). Several other selective FGFR targeted agent candidates are in various stages of clinical trials (NCT01212107, NCT01976741, NCT01752920).

In terms of toxicity profiles, selective FGFR inhibitors have

TABLE 1. Representative Genomically-Driven Clinical Trials of Various FGFR Inhibitors

Agent Phase Clinical trials.gov ID

Histology Inclusion Criteria Status Molecular Eligibility

Lung Cancer Enrollment

Head and Neck Cancer Enrollment

Nonselective FGFR inhibitors

Dovitinib

1 NCT01831726

Advanced and/or metastatic solid cancer or hematologic malignancies

Active, not recruiting

FGFR1-4 mutant tumors (mutations or translocations of FGFR, PDGFR, VEGF, cKIT, FLT3, CSFR1, Trk and RET)

Yes Yes

2 NCT01379534Advanced and/or metastatic endometrial cancer

CompletedFGFR2-mutant or wild-type endometrial cancer

No No

2 NCT01732107

Early-stage urothelial carcinoma of the bladder defined as Ta, T1, or Tis stage


FGFR3-mutant or overexpressed BCG refractory urothelial carcinoma

No No

2 NCT01719549

Metastatic or unresectable adenocarcinoma of stomach or gastroesophageal junction

RecruitingFGFR2-amplified gastric cancer

No No

Lucitanib

½ NCT01283945

Locally advanced or metastatic solid tumour, relapsed or refractory to standard therapy


Expansion cohort in FGFR1-amplified tumors

Yes Yes

2 NCT02109016Advanced/metastatic lung cancer

Recruiting

FGF, vascular endothelial growth factor receptor (VEGF), or platelet derived growth factor (PDGF) related genetic alterations.

Yes No

Ponatinib 2/3 NCT01761747

Lung or head and neck squamous cell cancer with an alteration in FGFR kinase

CompletedAdvanced squamous cell lung cancers with FGFR kinase alterations

Yes Yes

(continued)



Selective FGFR inhibitors

AZD4547

1 NCT00979134

Solid malignant tumor without standard treatment options or resistance to standard therapies


Expansion cohort in FGFR1- or FGFR2 amplified tumors

Yes Not yet

2 NCT01457846Locally advanced or metastatic gastro adenocarcinoma

Completed

Gastric or lower-esophageal cancer, FGFR2-amplified or not,

randomized to AZD4547 or paclitaxel

No No

½ NCT01202591Breast cancer with ER+ receptor

Completed

Estrogen receptor + and FGFR1-amplified breast cancer,

randomized to AZD4547 plus fulvestrant or fulvestrant alone

No No

2/3NCT02154490 Non small cell lung cancers

- stage 3B, 4 and recurrent; squamous cell lung cancer

RecruitingTumors positive for FGFR1, FGFR2, and FGFR3

Yes No

2NCT01795768 Gastric, esophageal, breast

and squamous lung cancersRecruiting

FGFR1- or FGFR2- amplified

Yes No

BGJ3982 NCT02160041

Solid tumor (except with a primary diagnosis of urothelial cell carcinoma, cholangiocarcinoma, endometrial cancer, and glioblastoma multiforme) or hematologic malignancies

RecruitingFGFR Genetic Alterations advanced cancer

Yes Yes

1NCT01004224 Advanced solid tumors Recruiting

FGFR1- or FGFR2-amplified, FGFR3-mutant advanced cancer

Yes Yes

LY2874455 1 NCT01212107

Solid tumors, lymphoma, or chronic lymphocytic leukemia that is advanced and/or metastatic

CompletedAdvanced cancer with FGFR aberrations during dose expansion

Yes Yes

BAY1163877 1NCT01976741

All solid malignancy, once MTD defined – lung and head and neck, and bladder cancer

RecruitingAdvanced cancer with FGFR aberrations during dose expansion

Yes Yes

ARQ 0871

NCT01752920 Advanced solid tumorsRecruiting

Expanded Cohort to include FGFR genetic alterations, including intrahepatic cholangiocarcinoma with FGFR2 gene fusion

Yes Yes

JNJ-42756493

1 NCT01703481Solid malignancy or lymphoma that is metastatic or unresectable

RecruitingExpansion cohort in FGFR1-, FGFR2-, or FGFR4-amplified tumors

Yes Yes

(continued)



been able to overcome toxicity constraints of multi-target kinase inhibition, which often exhibit a wide range of toxicity. In the reported phase I results from the specific FGFR inhibitor JNJ-42756493 trial, the most common treatment-emergent adverse events included hyperphosphatemia (65%), asthenia (55%), dry mouth (45%), nail toxicity (35%), constipation (34%), de-creased appetite (32%), and dysgeusia (31%).38 Dose-dependent elevations in serum phosphate have been noted to be a predict-ed pharmacodynamics effect of selective FGFR inhibition, and guidelines to manage the toxicity have been published.39

Future DirectionsGiven the tolerability of selective FGFR inhibitors with man-ageable side effect profiles, they could be used in combination with other targeted therapies or immunotherapies for improving anti-cancer activity. Given the rationale of FGFR pathway aber-ration for acquired resistance to EGFR directed therapies, FGFR inhibitors may have a role to overcome this resistance if used in combination. Another potential strategy could be to combine with downstream inhibitors, such as either PI3K pathway or RAF/MEK inhibitors. With the approval of anti-programmed cell death protein 1 (anti PD-1) antibody in SqNSCLC, a cancer known to have aberrations in FGFR pathways and anticipated approval of the same antibody in head and neck cancer40, future studies may be designed for the combination of FGFR inhibitors with immunotherapy.

ConclusionThe FGFR signaling pathway has been identified as a major con-tributing factor in the pathogenesis and progression of NSCLC and HNSCC. In addition, this pathway may function as a mech-anism of resistance to anti-EGFR and anti-VEGF treatment. Targeting FGFRs is a promising therapeutic strategy in these cancers. Until now, phase I and II trials with FGFR inhibitors have shown an improvement for the survival of advanced cancer patients. The tolerability profile seems to be acceptable in these clinical trials. However, questions such as what class of agents are the most promising (nonselective vs selective FGFR inhibitors), and whether combination therapies are needed in order to ob-tain meaningful clinical benefit, are still being answered.

Affiliations: Young Kwang Chae, MD, MPH, MBA, Sachin G. Pai, MD, Ricardo Costa, MD, Maria Matsangou, MD, and Francis Giles, MD, are from Northwestern Medicine Develop-mental Therapeutics Institute, Northwestern University Fein-berg School of Medicine Division of Hematology and Oncol-ogy, and Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Peng Sun, MD, PhD, is from Robert H. Lurie Comprehensive Cancer Center of Northwestern Uni-versity. Mark Agulnik, MD, is from Northwestern University Feinberg School of Medicine Division of Hematology and On-

cology and Robert H. Lurie Comprehensive Cancer Center of Northwestern University.Disclosures: NoneAddress correspondence to: Young Kwang Chae, MD, MPH, MBA, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave., Suite 1006 Chicago, IL 60611. Phone: 312-926-4248; Fax: 312-695-0370. Email: [email protected]

REFERENCES1. Neilson KM, Friesel R. Ligand-independent activation of fibroblast growth factor receptors by point mutations in the extracellular, transmembrane, and kinase domains. J Biol Chem. 1996;271(40):25049-25057.2. Keegan K, Johnson DE, Williams LT, Hayman MJ. Isolation of an additional member of the fibroblast growth factor receptor family, FGFR-3. Proceedings of the National Academy of Sciences of the United States of America. 1991;88(4):1095-1099.3. Li M, Bernard O. FDC-P1 myeloid cells engineered to express fibroblast growth factor receptor 1 proliferate and differentiate in the presence of fibroblast growth factor and heparin. Proceedings of the National Academy of Sciences of the United States of America. 1992;89(8):3315-3319.4. Becker D, Lee PL, Rodeck U, Herlyn M. Inhibition of the fibroblast growth factor receptor 1 (FGFR-1) gene in human melanocytes and malignant melanomas leads to inhibition of proliferation and signs indicative of differentiation. Oncogene. 1992;7(11):2303-2313.5. Funato N, Moriyama K, Shimokawa H, Kuroda T. Basic fibroblast growth factor induces apoptosis in myofibroblastic cells isolated from rat palatal mucosa. Biochem Biophys Res Commun. 1997;240(1):21-26.6. LaVallee TM, Prudovsky IA, McMahon GA, Hu X, Maciag T. Activation of the MAP kinase pathway by FGF-1 correlates with cell proliferation induction while activation of the Src pathway correlates with migration. J Cell Biol. 1998;141(7):1647-1658.7. Chen Y, Li X, Eswarakumar VP, Seger R, Lonai P. Fibroblast growth factor (FGF) signaling through PI 3-kinase and Akt/PKB is required for embryoid body differentiation. Oncogene. 2000;19(33):3750-3756.8. Hart KC, Robertson SC, Kanemitsu MY, Meyer AN, Tynan JA, Donoghue DJ. Transformation and Stat activation by derivatives of FGFR1, FGFR3, and FGFR4. Oncogene. 2000;19(29):3309-3320.9. Doherty P, Walsh FS. CAM-FGF Receptor Interactions: A Model for Axonal Growth. Mol Cell Neurosci. 1996;8(2/3):99-111.10. Weiss J, Sos ML, Seidel D, et al. Frequent and focal FGFR1 amplification associates with therapeutically tractable FGFR1 dependency in squamous cell lung cancer. Sci Transl Med. 2010;2(62):62ra93. doi: 10.1126/scitranslmed.3001451.



11. Heist RS, Mino-Kenudson M, Sequist LV, et al. FGFR1 amplification in squamous cell carcinoma of the lung. J Thorac Oncol. 2012; (12):1775-80. doi: 10.1097/JTO.0b013e31826aed28.12. Comprehensive genomic characterization of squamous cell lung cancers. Nature. 2012;489(7417):519-525. doi: 10.1038/nature11404.13. Pardo OE, Latigo J, Jeffery RE, et al. The fibroblast growth factor receptor inhibitor PD173074 blocks small cell lung cancer growth in vitro and in vivo. Cancer Res. 2009;69(22):8645-8651. doi: 10.1158/0008-5472.CAN-09-1576.14. Brooks AN, Kilgour E, Smith PD. Molecular pathways: fibroblast growth factor signaling: a new therapeutic opportunity in cancer. Clin Cancer Res. 2012;18(7):1855-1862. doi: 10.1158/1078-0432.CCR-11-0699.15. Behrens C, Lin HY, Lee JJ, et al. Immunohistochemical expression of basic fibroblast growth factor and fibroblast growth factor receptors 1 and 2 in the pathogenesis of lung cancer. Clin Cancer Res. 2008;14(19):6014-6022. doi: 10.1158/1078-0432.CCR-08-0167.16. Tchaicha JH, Akbay EA, Altabef A, et al. Kinase domain activation of FGFR2 yields high-grade lung adenocarcinoma sensitive to a Pan-FGFR inhibitor in a mouse model of NSCLC. Cancer Res. 2014 Sep 1;74(17):4676-4684. doi: 10.1158/0008-5472.CAN-13-3218.17. Ohira T, Akutagawa S, Usuda J, et al. Up-regulated gene expression of angiogenesis factors in post-chemotherapeutic lung cancer tissues determined by cDNA macroarray. Oncol Rep. 2002;9(4):723-728.18. Majewski IJ, Mittempergher L, Davidson NM, et al. Identification of recurrent FGFR3 fusion genes in lung cancer through kinome-centred RNA sequencing. J Pathol. 2013;230(3):270-276. doi: 10.1002/path.4209.19. Ware KE, Marshall ME, Heasley LR, et al. Rapidly acquired resistance to EGFR tyrosine kinase inhibitors in NSCLC cell lines through de-repression of FGFR2 and FGFR3 expression. PloS one. 2010;5(11):e14117. doi: 10.1371/journal.pone.0014117.20. Freier K, Schwaenen C, Sticht C, et al. Recurrent FGFR1 amplification and high FGFR1 protein expression in oral squamous cell carcinoma (OSCC). Oral Onco. 2007;43(1):60-66.21. Boehm D, Vogel W, Franzen A, et al. A new bright-field dual-colour chromogenic and silver in situ hybridization method for the detection of FGFR1 gene copy number status. Virchows Arch. 2014;464(5):547-551. doi: 10.1007/s00428-014-1564-z.22. Marshall ME, Hinz TK, Kono SA, et al. Fibroblast growth factor receptors are components of autocrine signaling networks in head and neck squamous cell carcinoma cells. Clin Cancer Res. 2011;17(15):5016-5025. doi: 10.1158/1078-0432.CCR-11-0050.23. Henson BJ, Gollin SM. Overexpression of KLF13 and FGFR3 in oral cancer cells. Cytogenet Genome Res. 2010;128(4):192-198.

doi: 10.1159/000308303.24. Vairaktaris E, Ragos V, Yapijakis C, et al. FGFR-2 and -3 play an important role in initial stages of oral oncogenesis. Anticancer Res. 2006;26(6B):4217-4221.25. Sweeny L, Liu Z, Lancaster W, Hart J, Hartman YE, Rosenthal EL. Inhibition of fibroblasts reduced head and neck cancer growth by targeting fibroblast growth factor receptor. Laryngoscope. 2012;122(7):1539-1544. doi: 10.1002/lary.23266. 26. Gyanchandani R, Ortega Alves MV, Myers JN, Kim S. A proangiogenic signature is revealed in FGF-mediated bevacizumab-resistant head and neck squamous cell carcinoma. Mol Cancer Res. 2013;11(12):1585-1596. doi: 10.1158/1541-7786.MCR-13-0358.27. Tomlinson DC, Baldo O, Harnden P, Knowles MA. FGFR3 protein expression and its relationship to mutation status and prognostic variables in bladder cancer. J Pathol. 2007;213(1):91-98.28. Murase H, Inokuchi M, Takagi Y, Kato K, Kojima K, Sugihara K. Prognostic significance of the co-overexpression of fibroblast growth factor receptors 1, 2 and 4 in gastric cancer. Mol Clin Oncol. 2014;2(4):509-517.29. Billerey C, Chopin D, Aubriot-Lorton MH, et al. Frequent FGFR3 mutations in papillary non-invasive bladder (pTa) tumors. Am J Pathol. 2001;158(6):1955-1959.30. Mhawech-Fauceglia P, Cheney RT, Fischer G, Beck A, Herrmann FR. Eur J Surg Oncol. 2006;32(2):231-237.31. Simon R, Richter J, Wagner U, et al. High-throughput tissue microarray analysis of 3p25 (RAF1) and 8p12 (FGFR1) copy number alterations in urinary bladder cancer. Cancer Res. 2001;61(11):4514-4519.32. Gust KM, McConkey DJ, Awrey S, et al. Fibroblast growth factor receptor 3 is a rational therapeutic target in bladder cancer. Mol Cancer Ther. 2013;12(7):1245-1254. doi: 10.1158/1535-7163.MCT-12-1150. 33. Shin EY, Lee BH, Yang JH, et al. Up-regulation and co-expression of fibroblast growth factor receptors in human gastric cancer. J Cancer Res Clin Oncol. 2000;126(9):519-528.34. Su X, Zhan P, Gavine PR, et al. FGFR2 amplification has prognostic significance in gastric cancer: results from a large international multicentre study. Br J Cancer. 2014;110(4):967-975. doi: 10.1038/bjc.2013.802. 35. Beenken A, Mohammadi M. The FGF family: biology, pathophysiology and therapy. Nat Rev Drug Discov. 2009;8(3):235-253. doi: 10.1038/nrd2792.36. Bello E, Colella G, Scarlato V, et al. E-3810 is a potent dual inhibitor of VEGFR and FGFR that exerts antitumor activity in multiple preclinical models. Cancer Res. 2011;71(4):1396-1405. doi: 10.1158/0008-5472.CAN-10-2700.37. Gavine PR, Mooney L, Kilgour E, et al. AZD4547: an orally bioavailable, potent, and selective inhibitor of the fibroblast growth factor receptor tyrosine kinase family. Cancer Res. 2012;72(8):2045-2056. doi: 10.1158/0008-5472.CAN-11-3034.



38. Tabernero J, Bahleda R, Dienstmann R, et al. Phase I Dose-Escalation Study of JNJ-42756493, an Oral Pan-Fibroblast Growth Factor Receptor Inhibitor, in Patients With Advanced Solid Tumors. J Clin Oncol. 2015;33(30):3401-3408. doi: 10.1200/JCO.2014.60.734139. Dienstmann R, Rodon J, Prat A, et al. Genomic aberrations in the FGFR pathway: opportunities for targeted therapies in solid tumors. Ann Oncol. 2014;25(3):552-563. doi: 10.1093/annonc/mdt419. 40. CheckMate -141, a Pivotal Phase 3 Opdivo (nivolumab) Head and Neck Cancer Trial, Stopped Early [press release]. January 28, 2016 2016.

· PRECISION MEDICINE ·


Protein Pathway Activation Mapping for Multi-Omic-Based Precision Medicine

Mariaelena Pierobon, MD, Leena Gandhi, MD, Massimo Cristofanilli, MD, Debu Tripathy, MD, and Emanuel F. Petricoin III, PhD

IntroductionMolecular studies mapping malignant lesions of similar anatom-ical origin have led to the understanding that tumors originating from the same organ can be extremely heterogeneous at the mo-lecular level.1 This underpinning molecular heterogeneity is con-sidered one of the underlying causes of high discrepancy in treat-ment success rates across patients with lesions that have similar histopathologic characteristics.2,3 At the same time, broad-scale molecular profiling efforts such as The Cancer Genome Atlas (TCGA) have revealed that tumors originating from different or-gans also share common molecular alterations.4 For these rea-sons, drugs such as trastuzumab (Herceptin®), a monoclonal an-tibody targeting the HER2 protein, is FDA-approved for treating patients with breast or gastric cancer overexpressing the HER2 protein. This approval may be broadened in the near future to other HER2 overexpressing solid tumors and to a subpopulation of patients presenting with HER2 mutations.5-7 Because these molecular characteristics play such a central role in determin-ing the most appropriate therapeutic approach for patients with cancer, upfront molecular profiling is becoming a de facto part of the standard of care work-up for classifying and describing malignant lesions, and true oncogenic drivers are being used as key targets for effective therapy.

Although a number of DNA mutations and chromosomal am-plifications/translocations are recognized molecular ‘drivers’ of many cancers, it is impossible to distinguish in any given tumor which alterations are drivers of the disease and which adjust-ments were necessary in the early stage of the malignancy, but are not any more necessary or sufficient to sustain tumor pro-gression. Despite the development of high-throughput genomic technologies that have opened new opportunities for precision medicine, the results of these analyses can generate unclear data for the treating physician because multiple genomic abnormal-ities are often identified within the same lesion.8 Moreover, different organ sites, with ostensibly the same driving genomic event, often show diverse response rates to the same targeted compound.9 Therefore, the identification of genomic changes in isolation may be only partially sufficient for stratifying patients to the most appropriate line of treatment.

Abstract

The development of precision medicine in oncology is en-

tirely dependent on the ability to obtain accurate molecular

information that can assist physicians in selecting targeted

treatments for cancer patients. To date, most clinical studies

and companion diagnostic efforts utilizing this approach

have relied heavily upon genomic information as the sole

determinant for patient selection. Unfortunately, many of

these genomic alterations are infrequent, occurring in 1 to

5% of cancers, which generates a frustrating dynamic in

patient accrual and the powering of clinical outcome cor-

relations. Moreover, while these rare events can be readily

identified by genomic profiling, it is impossible to know

ahead of time which genomic alterations are true driving

events for any individual patient’s tumor. Analysis of the

functional proteome may provide a synergistic solution,

since these genetic derangements ultimately lead to aber-

rant protein synthesis and activation of signaling networks

responsible for sustaining tumor growth and progression.

Because changes within the signaling architecture—and,

particularly in kinase activity, are the ultimate causal event

of cancer, the signaling network, itself, has become the di-

rect target of the new generation of therapeutic agents. For

these reasons, high-throughput proteomic platforms able

to capture changes within these signaling networks have

received increasing attention in recent years. Among oth-

ers, the Reverse Phase Protein Microarray (RPPA), a widely

used proteomic platform for signaling network mapping of

biological samples, is currently used as a companion diag-

nostic for patient stratification to personalized treatment.

This platform generates high-throughput, multiplex, quan-

titative information starting from a relatively low amount

of biological material such as a fine needle biopsy. In this

article, two clinical case studies are presented that illus-

trate the clinical potential for utilizing functional proteom-

ics data into the precision medicine workflow.

Key words: molecular profiling, heterogeneity, trastuzum-

ab, HER2 mutations, Reverse Phase Protein Microarray

PROTEIN PATHWAY ACTIVATION MAPPING FOR MULTI-OMIC BASED PRECISION MEDICINE


Finally, while genomic alterations play a central role in cancer progression, the overall cellular signaling architecture is com-prised of proteins, and genetic aberrations ultimately exhibit their phenotypic consequences through the action of activated proteins. Moreover, the activation of specific signaling pathways in tumor cells via feedback mechanisms or the activation of cel-lular receptor by their ligands are often independent from ge-nomic alterations. For these reasons, kinase-driven activation via phosphorylation represents the most direct means for measuring pathway activation in tumor cells.10,11 Because derangements in cellular signaling processes are most often the causal aspect of the disease and thus targets for new therapies, molecular analysis of the proteome and phosphoproteome are becoming central-ly important for identifying new predictive biomarkers as well as new therapeutic targets.12 Therefore, there is an urgent need to find more effective tools for exploring the impact of genetic changes on the function of their protein products.

Planar/Suspension Antibody-Based ArraysSo far, planar or suspension antibody-based arrays are the most commonly used platforms for measuring protein kinase signal-ing in clinical samples.13 A major advantage of these platforms is their ability to generate high-throughput, and in most cases, multiplexed data allowing for the concomitant analysis of hun-dreds of analytes across a large number of samples. Although antibody specificity can be challenging from time to time, these methodologies have the advantage of accurately measuring low abundance proteins with detection limit in the range of ng-pg/mL. As recently described by Pierobon and colleagues,14 when compared to other antibody-based assays suitable for the analysis of clinical samples, the Reverse Phase Protein Microarray (RPPA) has distinguished itself for the ability of reproducibly and sen-sitively quantifying the activation level of hundreds of kinases starting from a limited amount of biological material (<10,000 cells) while being able to generate quantitative data from hun-

dreds of patients at once.14,15 As such, this technology captures the linear dynamic range of most targetable kinases and down-stream substrates.16

Because standard curve and internal controls for quality assur-ance can be mounted on each array, this platform is been used as a Clinical Laboratory Improvement Amendments (CLIA)/College of American Pathologists (CAP)-based technology for measuring protein signaling activation of individual tumors and for identifying patients who can benefit from specific targeted treatment (Figure 1).8 Upfront tissue processing techniques such as Laser Capture Microdissection (LCM) have been effectively coupled to the RPPA workflow and found to be an essential and necessary component in generating accurate protein acti-vation-based clinical data, especially when used to guide treat-ment selection.17,18 The use of core needle biopsies, even under Formaldehyde Fixed-Paraffin Embedded (tissue) (FFPE) fixation, is an appropriate process for the optimal preservation of the phosphoproteome, and has been successfully analyzed using an LCM/RPPA workflow.16,19,20

We recently used the RPPA technology to measure the activa-tion of HER2 in patients with inflammatory breast cancer (IBC) and non-small cell lung cancers (NSCLC) harboring HER2 mu-tations by evaluating the level of phosphorylation at the tyro-sine 1248 residue, a well-described site of modification known to control and modulate transmission of downstream signaling (Figure 2).21 In particular, we evaluated whether measuring the activation level of HER2 is clinically relevant and has added value to conventional genomic characterization in terms of out-come prediction. For these case studies, the protein activation level of HER2 in the tested samples was compared to the dis-tribution of activated HER2 in a large cohort of breast cancer samples with known HER2 expression and amplification (data not shown). In brief, activation and dimerization of HER2 with other receptor tyrosine kinases (RTKs), including other members of the HER family, regulate a number of important cellular pro-

FIGURE 1. Graphic representation of the RPPA platform

Panel A illustrates the RPPA array format, including standard curve, internal control for quality assurance, and patient sample. Panel B exemplifies how standard curve can be used to convert experimental values into standardized relative unit of the reference standard.

Panel A Panel B



cesses by modulating different signaling cascades. In particular, HER2 can stimulate cell proliferation by activating the MAP ki-nase pathway. Activation of the AKT/mTOR kinase pathway, on the other hand, regulates cell survival. Because most of the members of the MAP and AKT/mTOR pathways are kinases, their activity depends on the phosphorylation status of each of the pathway components.

HER2 Mutation and Activating Base SubstitutionsAli and colleagues recently reported the first IBC case with HER2 mutation and activating base substitutions.22 The patient had ex-tensive local and distant recurrent disease classified by standard pathologic testing as a triple-negative tumor that had progressed despite several cytotoxic treatment regimens. After the molecular test results and the implementation of HER2 targeted therapy, she showed remarkable symptomatic improvement and clinical

response. RPPA analysis of a tumor biopsy collected from the same lesion showed an HER2 activation level similar to those seen in breast cancer tumors with overexpression/amplification of HER2, a subgroup of patients who routinely benefit from anti-HER2 targeted treatments (Figure 3). These data indicated that a small subgroup of IBC patients with unamplified (by fluo-rescent in situ hybridization [FISH] and immunohistochemistry [IHC]), but mutated HER2 and high levels of HER2 protein ac-tivation, could benefit from anti-HER2 treatment.

HER2 activation was then evaluated in 2 patients with NS-CLC harboring HER2 mutations. Both patients were treated with the small kinase inhibitor targeting HER2, neratinib, in combination with a downstream mTOR inhibitor, temsirolim-us, as part of a phase I study.23 Retrospective analysis by RPPA showed heterogeneity in terms of HER2 phosphorylation/acti-vation across the 2 clinical specimens. In the first sample, the activation level of HER2 was comparable to that in patients with HER2 FISH/IHC-negative breast cancer (Figure 3). As expect-ed, because the drug target was not activated, the patient did not benefit from treatment with the HER2 inhibitor. Indeed, the lack of activation of the receptor indicates that, although a HER2 mutation was present, this genetic event did not result in high levels of activation/phosphorylation of the receptor in this particular lesion. The development of feedback mechanisms in the receptor tyrosine kinases expression and/or turnover as well as the interaction with specific ligands are a few possible explanations for these findings. On the contrary, the activation level of HER2 in the second NSCLC patient analyzed was sim-ilar to activation levels seen in patients with breast cancer with overexpressed/amplified HER2 (Figure 3). Increased activation of HER2 in this patient was associated with clinical response that lasted close to a year, consistent with the benefit seen with other effective targeted therapies against true oncogenic drivers.

ConclusionsAs shown by our data, directly measuring protein signaling ac-tivity in human samples has the unique advantage of provid-ing an ex vivo readout of the in vivo cellular signaling network even in patients presenting with similar genomic characteristics, and provides information on actual drug-target activation in the presence or absence of genomic alterations. This approach could greatly assist in identifying responding patients missed by genomic-only means as well as help credential and prioritize which genomic alterations are truly functional drivers of malig-nant progression. Moreover, pathway activation as well as the activation of proteins like HER2 (regardless of their expression) are much more frequent events than genomic alterations, in-cluding the rare frequency of HER2 mutation.16 The addition of functional proteomic analysis to precision medicine is poised to alter the landscape of clinical trials and routine molecular profiling that rely on genomic analysis alone, because superior

FIGURE 2. HER2 signaling pathway

Graphic representation of HER2 protein kinase-driven signaling cascades. Activation and dimerization of HER with other RTKs, including the epidermal growth factor receptor (EGFR), stimu-late the activation of the MAPK proliferative pathway, including RAS, the mitogen-activated protein kinase (MEK), the extracellu-lar signal-regulated kinase (ERK), and the AKT/mTOR pathway via activation of phosphoinositide 3-kinase (PI3K), protein kinase B, commonly known as, AKT, and mechanistic target of rapamycin (mTOR).

PROTEIN PATHWAY ACTIVATION MAPPING FOR MULTI-OMIC BASED PRECISION MEDICINE


and increased clinical benefit using the addition of proteomics and phosphoproteomics to genomic analysis is beginning to be demonstrated. As shown in the published results from a recent clinical trial where treatment selection was recommended based on integrated proteomic, phosphoproteomic, and genomic data, this ‘multi-omic’ approach can improve progression-free survival in patients with cancer, providing optimism for the impact of this strategy going forward.24

Affiliations: Mariaelena Pierobon, MD, and Emanuel F. Pet-ricoin III, PhD, are from Center for Applied Proteomics and Molecular Medicine, George Mason University, Manassas, VA. Leena Gandhi, MD, is from Department of Medical Oncolo-gy, Thoracic Oncology Section, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA. Massimo Cristofanilli, MD, is from Department of Medicine, Division of Hematology and Oncology, Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL. Debu Tripathy, MD, is from Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.Disclosures: Dr Pierobon has stock options in Theranostics Health Inc. Dr Pierobon is a paid consultant to Perthera Inc. Dr Pierobon is a co-inventor on technologies licensed from Thera-nostics and receives royalty fee distributions under US law. Dr Gandhi is on the scientific advisory boards (SAB) for Pfizer, Ab-bvie, Astra-Zeneca, Genentech/Roche, and Merck. Dr Gandhi receives research funding from Bristol-Myers Squibb. Dr Cristo-fanilli is a consultant for Agendia. Dr Tripathy has no relevant financial relationships to disclose. Dr Petricoin is a co-founder and equity interest holder in Theranostics Health Inc, and re-ceives compensation from them as well as serving on its SAB. Dr Petricoin is a co-founder and equity interest holder in Perthera Inc, and serves as its chief science officer, and on its SAB. Dr Pet-ricoin is a co-inventor of RPPA technology and receives royalty fee distributions under US law.Corresponding Author: Emanuel Petricoin, PhD, Center for Applied Proteomics and Molecular Medicine, George Mason University, Institute for Biomedical Innovation, 10920 George Mason Circle, Room 2006, Manassas, VA 20110. Phone: 703-993-8606; Fax: 703-993-8606. E-mail: [email protected]

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molecular characterization of urothelial bladder carcinoma. Na-ture. 2014;507(7492):315-322. doi: 10.1038/nature12965.4. Kandoth C, McLellan MD, Vandin F, et al. Mutational land-scape and significance across 12 major cancer types. Nature. 2013; 502(7471):333-339. doi: 10.1038/nature12634.5. Gomez-Martín C, Lopez-Rios F, Aparicio J, et al. A critical review of HER2-positive gastric cancer evaluation and treatment: from trastuzumab, and beyond. Cancer Lett. 2014;351(1):30-40. doi: 10.1016/j.canlet.2014.05.019.6. Siena S, Sartore-Bianchi A, Lonardi S, et al. Trastuzumab and lapatinib in HER2-amplified metastatic colorectal cancer patients (mCRC): The HERACLES trial. J Clin Oncol. 2015;33:(suppl) Abstract 3508.7. Bose R, Kavuri SM, Searleman AC, et al. Activating HER2 mutations in HER2 gene amplification negative breast cancer. Cancer Discov. 2013;3(2):224-237. doi: 10.1158/2159-8290.CD-12-0349.8. Arnedos M, Vicier C, Loi S, et al. Precision medicine for meta-static breast cancer-limitations and solutions. Nat Rev Clin Oncol. 2015;12(12):693-704. doi: 10.1038/nrclinonc.2015.123.9. Hyman DM, Puzanov I, Subbiah V, et al. Vemurafenib in mul-tiple nonmelanoma cancers with BRAF V600 mutations. N Engl J Med. 2015;373(8):726-736. doi: 10.1056/NEJMoa1502309.

FIGURE 3. Standard curve and interpolated values (1) in inflammatory breast cancer (IBC), and (2) in non-small cell lung cancer (NSCLC).

Intensity values of the clinical samples are shown in relation-ship to the standard curve. HER2 activation level of a refer-ence population of patients with breast cancer with known HER2 status measured by conventional FISH/IHC (data not shown), along with the presence of standard curves, were used to establish a cut-point that allows to identify patients with high- and low-activation levels of HER2. The blue line indicates the level of the standard curve where HER2-positive and HER2-negative breast cancers are discriminated.



10. Jhaveri TZ, Woo J, Shang X, Park BH, Gabrielson F. AMP- activated kinase (AMPK) regulates activity of HER2 and EGFR in breast cancer. Oncotarget. 2015;6(17):14754-14765.11. Gregory CW, Whang YE, McCall W, et al. Heregulin-in-duced activation of HER2 and HER3 increases androgen re-ceptor transactivation and CWR-R1 human recurrent prostate cancer cell growth. Clin Cancer Res. 2005;11(5):1704-1712.12. Kolch W, Pitt A. Functional proteomics to dissect tyro-sine kinase signalling pathways in cancer. Nat Rev Cancer. 2010;10(9):618-629. doi: 10.1038/nrc2900.13. Pierobon M, Wulfkuhle J, Liotta L, Petricoin F. Applica-tion of molecular technologies for phosphoproteomic analysis of clinical samples. Oncogene. 2015;34(7):805-814. doi: 10.1038/onc.2014.16.14. Pierobon M, Belluco C, Liotta LA, Petricoin EF 3rd. Reverse phase protein microarrays for clinical applications. Methods Mol Biol. 2011;785:3-12. doi: 10.1007/978-1-61779-286-1_1.15. VanMeter A, Signore M, Pierobon M, Espina V, Liotta LA, Petricoin EF 3rd. Reverse-phase protein microarrays: application to biomarker discovery and translational medicine. Expert Rev Mol Diagn. 2007;7(5):625-633.16. Wulfkuhle JD, Berg D, Wolff C, et al. Molecular analysis of HER2 signaling in human breast cancer by functional protein pathway activation mapping. Clin Cancer Res. 2012;18(23):6426-6435. doi: 10.1158/1078-0432.CCR-12-0452.17. Baldelli E, Haura EB, Crinò L, et al. Impact of upfront cellu-lar enrichment by laser capture microdissection on protein and phosphoprotein drug target signaling activation measurements in human lung cancer: implications for personalized medi-cine. Proteomics Clin Appl. 2015;9(9-10):928-937. doi: 10.1002/prca.201400056.18. Mueller C, deCarvalho AC, Mikkelsen T, et al. Glioblas-toma cell enrichment is critical for analysis of phosphorylated drug targets and proteomic-genomic correlations. Cancer Res. 2014;74(3):818-828. doi: 10.1158/0008-5472.CAN-13-2172.19. Pierobon M, Silvestri A, Spira A, et al. Pilot phase I/II per-sonalized therapy trial for metastatic colorectal cancer: evalu-ating the feasibility of protein pathway activation mapping for stratifying patients to therapy with imatinib and panitumumab. J Proteome Res. 2014;13(6):2846-2855. doi: 10.1021/pr401267m.20. Espina V, Mueller C, Edmiston K, Sciro M, Petricoin EF, Liotta LA. Tissue is alive: new technologies are needed to address the problems of protein biomarker pre-analytical variability. Pro-teomics Clin Appl. 2009;3(8):874-882.21. Montgomery RB, Makary E, Schiffman K, Goodell V, Di-sis ML. Endogenous anti-HER2 antibodies block HER2 phos-phorylation and signaling through extracellular signal-regulated kinase. Cancer Res. 2005;65(2):650-656.22. Ali SM, Alpaugh RK, Downing SR, et al. Response of an ERBB2-mutated inflammatory breast carcinoma to human epi-dermal growth factor receptor 2-targeted therapy. J Clin Oncol.

2014;32(25):e88-e91. doi: 10.1200/JCO.2013.49.0599.23. Gandhi L, Bahleda R, Tolaney SM, et al. Phase I study of neratinib in combination with temsirolimus in patients with human epidermal growth factor receptor 2-dependent and oth-er solid tumors. J Clin Oncol. 2014;32(2):68-75. doi: 10.1200/JCO.2012.47.2787.24. Jameson GS, Petricoin EF, Sachdev J, et al. A pilot study utilizing multi-omic molecular profiling to find potential tar-gets and select individualized treatments for patients with pre-viously treated metastatic breast cancer. Breast Cancer Res Treat. 2014;147(3):579-588. doi: 10.1007/s10549-014-3117-1.

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Management of Patients With Relapsed Chronic Lymphocytic Leukemia

Polina Shindiapina, MD, PhD, and Farrukh T. Awan, MD

IntroductionTherapeutic options for chronic lymphocytic leukemia (CLL) have been remarkably expanded in the last few decades. Exten-sion of available options within particular drug classes, such as addition of fludarabine to purine analogs, the development of multiple targeted therapies, from agents such as rituximab and obinutuzumab that target B cells, and the rapid progress of spe-cific inhibitors of the B-cell receptor-dependent signaling cascade have dramatically increased the rates of overall responses and progression-free survival (PFS).1,2 However, sustained remissions are limited and cure remains elusive. Moreover, convention-al chemotherapeutic use is associated with significant toxicity, which is particularly pronounced in patients more than 65 years of age, who constitute the majority of patients with CLL. Choos-ing treatment strategies for patients with relapsed CLL, there-fore, presents a significant challenge. In this review, we focus on recent exploration of chemotherapeutic and targeted therapy options directed against relapsed CLL, summarize factors that may predict resistance to therapy and highlight future directions.

Chemoimmunotherapy for Initial TreatmentRituximab in combination with fludarabine and cyclophos-phamide (FCR) or bendamustine (BR) are among the most commonly used chemoimmunotherapy regimens for the ini-tial treatment of patients with CLL. In younger patients with good performance status and limited comorbid conditions, the FCR300 phase II trial proposed FCR as an effective com-bination therapy and reported an overall response rate (ORR) of 95%, with 72% complete responses (CR) and a median PFS of 6 years.3 The German CLL Study Group (CLL8) trial com-pared FCR with fludarabine and cyclophosphamide (FC) and further established its efficacy.4 In a similar patient population, the CLL10 trial compared FCR to BR and demonstrated im-proved CR and PFS, although with a higher incidence of cyto-penia and infectious complications.5 However, tolerability and toxicity issues were substantial and survival outcomes were not significantly improved in patients more than 65 years of age, in patients with compromised renal function and multiple comor-bid conditions, and in patients with high-risk del(17p) disease.

Abstract

The management of chronic lymphocytic leukemia (CLL)

has improved significantly over the last decade with mul-

tiple new and well-tolerated therapies now available for

the majority of patients. Chemoimmunotherapy, with

fludarabine, cyclophosphamide, and rituximab (FCR) or

bendamustine and rituximab (BR), has been the mainstay

for the treatment of patients with CLL, but their use is

complicated by significant morbidity, especially in older

and frail patients. The majority of patients relapse within

five years of initial chemoimmunotherapy and outcomes

are even worse in patients with short initial remission.

Remission duration also decreases progressively with

subsequent therapies. The advent of novel therapeutics

including CD20-targeting antibodies such as obinutu-

zumab, ofatumumab, and BTK and PI3K inhibitors such

as ibrutinib and idelalisib respectively, offers an exciting

option for patients with comorbid conditions, previously

untreated, relapsed, and high-risk disease. These novel

agents are generally well-tolerated, have already demon-

strated significant activity in all subsets of patients, and

have the potential to replace conventional chemoimmu-

notherapy. However, resistance issues have been identi-

fied with ibrutinib and outcomes are poor for this group

of patients. Moreover, specific side effects such as bleed-

ing issues, colitis, pneumonitis, and transaminitis, limit

prolonged use with kinase inhibitors in a subset of pa-

tients. Newer agents such as acalabrutinib, which targets

BTK, and venetoclax, which targets the anti-apoptotic

molecule bcl-2, have demonstrated extremely promising

activity in early-phase trials. These developments herald

an era of unprecedented progress for the management of

patients with CLL and are already improving the lives of

thousands of people around the world.

Key words: relapsed, chronic lymphocytic leukemia

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This has led to the development and recent approval of multiple targeted therapies that are very effective and well-tolerated for these patients, and include obinutuzumab,6 ofatumumab,7 and ibrutinib.8 While these agents are being used more frequently, data regarding the optimal management of patients relapsing af-ter these therapies are currently lacking.

Chemoimmunotherapy for Relapsed DiseaseThe REACH trial, a multicenter, randomized, phase III trial, compared 6 cycles of FCR with 6 cycles of FC) for treatment of patients with previously treated, relapsed CLL.9 The trial enrolled 552 patients who received previous treatment with single-agent regimens containing either chlorambucil with or without a ste-roid, other nucleoside analogs, or an alkylator-containing com-bination but not an alkylator/nucleoside-analog combination. After a median follow-up of 25 months, patients who received FCR showed a significantly improved PFS by 10 months (P <.001; median 30.6 months for FCR vs 20.6 months for FC). Furthermore, ORR increased from 58% to 69% (P =.034) and CR rate increased from 13% to 24% (P <.001) in patients treated with FCR compared to those who received FC.

Combination of chemotherapy and targeted therapy was further explored in the large LUCID trial, which studied the addition of lumiliximab (L), a chimeric monoclonal antibody that targets CD23, to FCR for treatment of patients with relapsed CLL who were previously treated with 1 or 2 single-agent or combination regimens.10 The study enrolled 615 patients who were randomized to lumiliximab in combination with FCR versus FCR alone. Even though CR, ORR, and PFS were similar between both groups, this study recognized the utility of FCR in the relapsed setting where patients had received prior combination chemoimmunotherapy and demonstrated an ORR of 72% with a CR of 15% and a PFS of 24 months.

Bendamustine in combination with rituximab was evaluated in a phase II trial of 78 patients with relapsed or refractory CLL and reported an ORR of 59%, with 9% CR and a median event-free survival of 15 months.11 However, ORR was 45% in patients with fludarabine-refractory disease and 60% in patients with fludarabine-sensitive disease. About 50% of patients encountered severe (grade 3/4) hematologic toxicities and 13% experienced severe infections. Patients with del(17p) had only a 7% response to therapy.

Although up to 95% of patients with CLL respond to frontline FCR or BR therapy, 30% to 60% of patients fail to achieve CR and therapy results in significant toxicity.4,7,12 Moreover, no current standard exists to treat patients with relapsed disease after frontline chemoimmunotherapy.13 Efforts have been made to identify optimal regimens for treatment of such patients and various salvage therapeutic options have been evaluated in patients relapsing after frontline FCR, including retreatment with FCR, using lenalidomide-based or other intensive

chemotherapy-based regimens.14 Factors such as duration of initial remission were found to have a direct impact on predicted response to salvage therapy, and patients with initial remission of at least 3 years’ duration showed an average post-salvage survival of 63 months versus 13 months in patients who required salvage therapy earlier than 3 years after initial course of FCR. Also affecting the response to salvage therapy were factors such as older patient age, unfavorable cytogenetics (including del[17p]), and factors dependent on the stage of disease at relapse, such as platelet count and β2-microglobulin.14 The negative predictive value of del(17p) status is not surprising, because mechanism of disease response to fludarabine-based regimens has been previously demonstrated to rely on intact p53 function.15 Moreover, the CLL8 trial demonstrated that FCR does not improve OS of patients with del(17p) disease (37% of patients survived at 3-year follow-up after receiving chemotherapy and 38% after chemoimmunotherapy; P =.25).4

Choice of salvage therapy affects response, and survival was reported to be superior in patients treated with FCR-based or lenalidomide-based regimens, compared to alemtuzumab-based or rituximab-based regimens and intensive chemotherapy (median survival of 82 months vs 29 months; P <.001).14 Another recent retrospective study examined patient outcomes with salvage treatment after progression on FCR and showed that bendamustine-rituximab (BR) regimen was most effective when compared to retreatment with FCR, to an alemtuzumab-containing regimen, or to the combination R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone).16 The study showed that BR produced an ORR of 86%, compared to values in the 50% to 60% range after treatment with the alternative regimens. However, patients had similar and dismal PFS of 18 months with BR or FCR and 6 months with alemtuzumab-containing regimens or R-CHOP. Predictably, patients with del(17p) disease showed lower rate of response to salvage therapy, and survival outcomes were worse in patients with disease relapse within 3 years of frontline FCR therapy.

Taken together, these studies indicate that outcomes of patients with relapsed CLL after firstline chemoimmunotherapy are poor, especially in patients who relapse less than 3 years after initial therapy, in those with del(17p), and in those with comorbid conditions. Finding effective and well-tolerated regimens for such patients that could prolong PFS and OS is vitally important and their outcomes appear to have been significantly improved with the advent of B-cell receptor (BCR) pathway inhibitors.

Specific BCR Signaling Pathway Inhibitors in Relapsed CLLSpecific inhibitors of B-cell receptor signaling, such as the BTK inhibitor ibrutinib and the phosphoinositide 3-kinase inhib-itor idelalisib (in combination with rituximab), have been ap-proved for treatment of relapsed CLL. Ibrutinib is able to in-hibit BCR-signaling dependent cell division in vitro,5,17 and has

MANAGEMENT OF PATIENTS WITH RELAPSED CHRONIC LYMPHOCYTIC LEUKEMIA


induced substantially higher ORR and PFS in several phase II and phase III studies18,19 in patients with relapsed and refracto-ry CLL.19 In a phase 1b/II study of 85 patients with previously treated CLL, 65% of whom had advanced-stage disease, 33% had de1(17p), 69% had unmutated immunoglobulin variable heavy-chain variable (IGHV) status, and 30% were >70 years of age, and had received a median of 4 previous therapies. Ibruti-nib demonstrated an ORR of 91% (71% partial response [PR] and 20% PR + lymphocytosis) irrespective of the presence of high-risk features. Of note, 73% of elderly patients responded to ibrutinib, 83% of patients who were enrolled in the trial sur-vived at 26 months, and 75% of patients were disease-free at fol-low-up. Ibrutinib was also shown to effectively induce an ORR in 71% and a CR in 13% of 31 elderly patients with previously untreated CLL, 6% of whom had del(17p).20 A phase III trial compared the outcomes of ibrutinib with ofatumumab and eval-uated ORR, PFS, and OS among a cohort of patients with re-lapsed CLL.21 The cohort of interest included patients who were previously treated with a median of 3 prior therapies, most of whom received targeted CD20-directed therapy, and who shared the following characteristics: median age of 67 years, del(17p) in 32%, and del(11q) in 32%. At 6 months, the ibrutinib group had a PFS of 88%. The median PFS was 8 months in the ofa-tumumab group. Similarly, OS was significantly improved with the use of ibrutinib. These responses and improved outcomes were observed across all cohorts of patients, including patients with high-risk disease features.21 A recent 30-month updated fol-low-up of the original phase I/II trial of ibrutinib demonstrated a PFS of 69% and OS of 79%. However, response frequency and durability were inferior in patients with high-risk disease fea-tures: del(17p) patients had a 30-month PFS rate of 48% and an OS rate of 65%.22

Idelalisib, another inhibitor that selectively targets the BCR-signaling cascade by inhibiting PI3-kinase delta, has also been tested in patients with relapsed and resistant CLL and has shown promising efficacy.23 A phase III trial evaluated this regimen for treatment of elderly (median age 71 years) patients with comorbid conditions and high-risk relapsed disease after a median of 3 prior therapies, in comparison with placebo combined with rituximab. The trial randomized 220 patients to each arm. High-risk features included relapsed progressive disease requiring therapy within 24 months, unmutated IGHV in 83%, and del(17p) or TP53 mutations in 42% of patients. Preliminary results after 12-month follow-up showed 81% ORR, compared with 13% in the placebo-rituximab arm (P <.001), with significant improvement in response rates across all risk subgroups. While more adverse events were reported in the idelalisib plus rituximab group compared to the placebo plus rituximab group, mortality was higher in the placebo group, with 6 deaths in the idelalisib plus rituximab cohort and 13 in the placebo plus rituximab cohort.23

More recently, promising data have been reported with newer BTK inhibitors for the treatment of patients with relapsed disease. Prominent among these is acalabrutinib, which demonstrated an ORR of 95% with the remaining 5% of patients experiencing stable disease. Patients with del(17p) had an ORR of 100% and PFS was 100% at 12 months.12

Development of Resistance and Additional Limitations of Tar-geted Kinase InhibitorsReview of a large, 308-patient, single-institution trial at the Ohio State University revealed that only about 10% of patients dis-continued ibrutinib because of disease progression at a median follow-up of 20-months.24 Several studies have helped to identify high-risk patients who are less likely to respond to such regimens and complex karyotype appears to be an independent predictor of resistance to ibrutinib.24,25 Whole-exome sequencing from samples of patients with CLL at the onset of disease resistance to ibrutinib identified a C481S mutation within the ibrutinib binding site of the BTK protein that rendered the affinity inter-action between BTK and ibrutinib potentially reversible.26 The study also found R665W and L845F mutations in PLCγ2 in 2 separate samples of patients with new-onset ibrutinib resistance and identified them as potential gain-of-function mutations that could allow the BCR-dependent signaling cascade to bypass the inhibition imposed by ibrutinib.24,26

Additionally, other limitations of ibrutinib therapy have been identified, including an increased risk of bleeding, especially in patients on concurrent anticoagulation therapy.27 In review of the Ohio State University experience, up to 19% of patients treated with ibrutinib stopped taking the medication because of toxicities.24 Moreover, patients who developed resistance to ibrutinib did poorly, with most requiring alternative therapy within several weeks of stopping ibrutinib and a median survival of 17.6 months. Eighteen patients developed Richter’s transformation with a median survival of only 3.5 months.5 Similarly, idelalisib use is associated with significant pneumonitis, colitis, and transaminitis that result in significant morbidity in a subset of patients.23

Alternative Therapies for Relapsed DiseaseVenetoclaxTargeting of Bcl-2, an anti-apoptotic protein overexpressed in CLL B cells, results in significant apoptosis in vitro and clinical activity in vivo. Venetoclax is a potent, oral Bcl-2 selective inhibi-tor with limited off-target effects on Bcl-xl expressed on platelets. In a large phase I study it demonstrated impressive activity in relapsed or refractory CLL with an ORR of 79% and a 20% CR. Patients with del(17p) disease had an ORR of 71% with a 16% CR.28 Venetoclax use is complicated by serious cytopenia in almost 50% of patients and fulminant tumor lysis syndrome, especially in the presence of high tumor burden and requires

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specific mitigation efforts such as stepwise dose escalation.

LenalidomideLenalidomide is a potent oral immunomodulatory (IMiD) drug in the thalidomide analog class of therapeutics.14-17 These agents, along with newer pleotropic pathway modifiers (PPM) such as CC-122, have the potential to be an option for patients with aggressive, high-risk disease. Lenalidomide has shown promising activity and reasonable tolerability in multiple clinical trials in patients with relapsed disease but its future development is ques-tionable because the pivotal phase III trial in patients with pre-viously untreated disease had to be halted because of increased mortality. However, it remains a reasonable option for patients with relapsed and refractory disease but patients can frequently experience tumor lysis and/or tumor flare.

Chimeric Antigen Receptor – T (CAR-T) CellsCAR-T cells are ex vivo engineered, lentiviral-modified, autol-ogous T cells containing an altered T-cell receptor targeting a surface antigen (eg, CD19) on CLL B cells. The chimeric T-cell receptor contains costimulatory domains that increase affinity and specificity towards the target antigen. Multiple formulations of CAR-T cells have been advanced and promising early results with sustained remissions have been reported.29,30 Infusion of these CAR-T cells can result in severe cytokine-release syndrome that might require aggressive and intensive supportive care. Moreover, therapy results in persistent hypogammaglobulinemia from sustained normal B-cell eradication, with the resultant need for immunoglobulin supplementation and prophylaxis for infectious complications. Further design modifications may be able to overcome some of these issues.

ConclusionWhile highly encouraging and durable responses are observed in patients with recurrent or resistant CLL who are treated with selective kinase inhibitors ibrutinib and idelalisib, there remains a substantial fraction of patients with relapsed CLL and high-risk disease features who fail to achieve sustained PFS with these therapies. This is despite the fact that many patients with conventional high-risk features, such as old age, unmutat-ed IGHV status, presence of del(17p) or mutated TP53, and complex karyotype have been shown to respond to single-agent or combined therapies with kinase inhibitors. Acquisition of mutations within the mediators of BCR-dependent signaling pathway precipitates resistance to ibrutinib. Additional toxic-ities and individualized limitations of targeted kinase inhibi-tors may limit their utility in particular cases of CLL relapse. However, the advent of additional BTK inhibitors, such as acalabrutinib,12 and other BCR pathway inhibitors, such as en-tospletinib,31 along with Bcl-2 inhibitors such as venetoclax,28 portends a bright future for the management of patients with

relapsed CLL and potentially offers better-tolerated and more efficacious options for these patients. Specific considerations for the use of these agents are summarized in Table 1. Together, these considerations highlight the vital importance of enrolling patients with relapsed CLL, especially those with high-risk dis-ease features, into clinical trials to ensure the development of additional potentially curative therapeutic avenues.

Affiliations: Polina Shindiapina, MD, PhD, and Farrukh T. Awan, MD, are with the Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio.Disclosure: Dr Awan is on the advisory boards for Gilead Sci-ences Inc and Novartis Oncology IncAddress correspondence to: Farrukh T Awan, MD, 320 W. 10th Ave., Columbus, OH 43210. Phone: (614) 688-7942; Fax: (614) 293-7256. Email: [email protected]

REFERENCES1. Awan FT. Cure for CLL? Blood.2016;127(3):274. doi: 10.1182/blood-2015-11-678532.2. Awan FT, Byrd JC. New strategies in chronic lymphocytic leukemia: shifting treatment paradigms. Clin Cancer Res. 2014;20(23):5869-5874. doi: 10.1158/1078-0432.CCR-14-1889.3. Tam CS, O’Brien S, Wierda W, et al. Long-term results of

TABLE 1: Therapeutic Regimens for Patients With Relapsed CLL and Special Considerations

Therapeutic Regimens

Therapeutic Considerations

FCR or BR §§ Prolonged (>3 years) first remission

§§ Younger patients (<65 years) with good performance status

§§ Patients with good-risk genetic features, including del13q and mutated IGHV

Ibrutinib §§ Preferred agent for patients with del(17p) disease

§§ Avoid use in patients on concurrent anticoagulation

Idelalisib §§ Promising activity in patients with del(17p) disease and/or unmutated IGHV

§§ Issues with transaminitis, pneumonitis, and colitis

Venetoclax §§ Deeper responses even in patients with high-risk disease

§§ Issues with tumor lysis and cytopenia

MANAGEMENT OF PATIENTS WITH RELAPSED CHRONIC LYMPHOCYTIC LEUKEMIA


the fludarabine, cyclophosphamide, and rituximab regimen as initial therapy of chronic lymphocytic leukemia. Blood. 2008;112(4):975-980. doi: 10.1182/blood-2008-02-140582.4. Hallek M, Fischer K, Fingerle-Rowson G, et al. Addition of rituximab to fludarabine and cyclophosphamide in patients with chronic lymphocytic leukaemia: a randomised, open-label, phase 3 trial. Lancet. 2010;376(9747):1164-1174. doi: 10.1016/S0140-6736(10)61381-5.5. Eichhorst B, Fink AM, Busch R, et al. Frontline chemoim-munotherapy with fludarabine (F), cyclophosphamide (C), and rituximab (R) (FCR) shows superior efficacy in comparison to bendamustine (B) and rituximab (BR) in previously untreated and physically fit patients (pts) with advanced chronic lympho-cytic leukemia (CLL): final analysis of an international, random-ized study of the German CLL Study Group (GCLLSG) (CLL10 Study). American Society of Hematology website. https://ash.confex.com/ash/2014/webprogram/Paper69485.html.6. Goede V, Fischer K, Engelke A, et al. Obinutuzumab as frontline treatment of chronic lymphocytic leukemia: updated results of the CLL11 study. Leukemia. 2015;29(7):1602-1604. doi: 10.1038/leu.2015.14.7. Hillmen P, Robak T, Janssens A, et al. Chlorambucil plus ofatumumab versus chlorambucil alone in previously untreated patients with chronic lymphocytic leukaemia (COMPLEMENT 1): a randomised, multicentre, open-label phase 3 trial. Lancet. 2015;385(9980):1873-1883. doi: 10.1016/S0140-6736(15)60027-7.8. Burger JA, Tedeschi A, Barr PM, et al. Ibrutinib as initial therapy for patients with chronic lymphocytic leukemia. N Engl J Med. 2015;373(25):2425-2437. doi: 10.1056/NEJMoa1509388.9. Robak T, Dmoszynska A, Solal-Céligny P, et al. Rituximab plus fludarabine and cyclophosphamide prolongs progression-free survival compared with fludarabine and cyclophosphamide alone in previously treated chronic lymphocytic leukemia. J Clin Oncol. 2010;28(10):1756-1765. doi: 10.1200/JCO.2009.26.4556.10. Awan FT, Hillmen P, Hellmann A, et al. A randomized, open-label, multicentre, phase 2/3 study to evaluate the safety and efficacy of lumiliximab in combination with fludarabine, cyclophosphamide and rituximab versus fludarabine, cyclophosphamide and rituximab alone in subjects with relapsed chronic lymphocytic leukaemia. Br J Haematol. 2014;167(4):466-477. doi: 10.1111/bjh.13061.11. Fischer K, Cramer P, Busch R, et al. Bendamustine combined with rituximab in patients with relapsed and/or refractory chronic lymphocytic leukemia: a multicenter phase II trial of the German Chronic Lymphocytic Leukemia Study Group. J Clin Oncol. 2011;29(26):3559-3566. doi: 10.1200/JCO.2010.33.8061.12. Byrd JC, Harrington B, O’Brien S, et al. Acalabrutinib (ACP-196) in relapsed chronic lymphocytic leukemia. N Engl J Med. 2016;374(4):323-332. doi: 10.1056/NEJMoa1509981.13. Buhler A, Wendtner CM, Kipps TJ, et al. Lenalidomide treatment and prognostic markers in relapsed or refractory

chronic lymphocytic leukemia: data from the prospective, multicenter phase-II CLL-009 trial. Blood Cancer J. 2016;6:e404. doi: 10.1038/bcj.2016.9.14. Wendtner CM, Hallek M, Fraser GA, et al. Safety and efficacy of different lenalidomide starting doses in patients with relapsed or refractory chronic lymphocytic leukemia: results of an international multicenter double-blinded randomized phase II trial. Leuk Lymphoma. 2016;1-9. 15. Maddocks K, Ruppert AS, Browning R, et al. A dose escalation feasibility study of lenalidomide for treatment of symptomatic, relapsed chronic lymphocytic leukemia. Leuk Res. 2014;38(9):1025-1029. doi: 10.1016/j.leukres.2014.05.011.16. Wendtner CM, Hillmen P, Mahadevan D, et al. Final results of a multicenter phase 1 study of lenalidomide in patients with relapsed or refractory chronic lymphocytic leukemia. Leuk Lymphoma. 2012;53(3):417-423. doi: 10.3109/10428194.2011.618232.17. Awan FT, Johnson AJ, Lapalombella R, et al. Thalidomide and lenalidomide as new therapeutics for the treatment of chronic lymphocytic leukemia. Leuk Lymphoma. 2010;51(1):27-38. doi: 10.3109/10428190903350405.18. Advani RH, Buggy JJ, Sharman JP, et al. Bruton tyrosine kinase inhibitor ibrutinib (PCI-32765) has significant activity in patients with relapsed/refractory B-cell malignancies. J Clin Oncol. 2013;31(1):88-94. doi: 10.1200/JCO.2012.42.7906.19. Byrd JC, Furman RR, Coutre SE, et al Targeting BTK with ibrutinib in relapsed chronic lymphocytic leukemia. N Engl J Med. 2013;369(1):32-42. doi: 10.1056/NEJMoa1215637.20. O’Brien S, Furman RR, Coutre SE, et al. Ibrutinib as initial therapy for elderly patients with chronic lymphocytic leukaemia or small lymphocytic lymphoma: an open-label, multicentre, phase 1b/2 trial. Lancet Oncol. 2014;15(1):48-58. doi: 10.1016/S1470-2045(13)70513-8.21. Byrd JC, Brown JR, O’Brien S, et al. Ibrutinib versus ofatumumab in previously treated chronic lymphoid leukemia. N Engl J Med. 2014;371(3):213-223. doi: 10.1056/NEJMoa1400376.22. Byrd JC, Furman RR, Coutre SE, et al. Three-year follow-up of treatment-naive and previously treated patients with CLL and SLL receiving single-agent ibrutinib. Blood. 2015;125(16):2497-2506. doi: 10.1182/blood-2014-10-606038.23. Furman RR, Sharman JP, Coutre SE, et al. Idelalisib and rituximab in relapsed chronic lymphocytic leukemia. N Engl J Med. 2014;370(11):997-1007. doi: 10.1056/NEJMoa1315226. 24. Maddocks KJ, Ruppert AS, Lozanski G, et al. Etiology of ibrutinib therapy discontinuation and outcomes in patients with chronic lymphocytic leukemia. JAMA Oncol. 2015;1():80-87.25. Thompson PA, O’Brien SM, Wierda WG, et al. Complex karyotype is a stronger predictor than del(17p) for an inferior outcome in relapsed or refractory chronic lymphocytic leukemia patients treated with ibrutinib-based regimens. Cancer. 2015;121():3612-3621.

· LEUKEMIA ·


26. Woyach JA, Furman RR, Liu TM, et al. Resistance mechanisms for the Bruton’s tyrosine kinase inhibitor ibrutinib. N Engl J Med. 2014;370():2286-2294.27. Lipsky AH, Farooqui MZ, Tian X, et al. Incidence and risk factors of bleeding-related adverse events in patients with chronic lymphocytic leukemia treated with ibrutinib. Haematologica. 2015;100(12):1571-1578. doi: 10.3324/haematol.2015.126672.28. Roberts AW, Davids MS, Pagel JM, et al. Targeting BCL2 with venetoclax in relapsed chronic lymphocytic leukemia. N Engl J Med. 2016;374(4):311-322. doi: 10.1056/NEJMoa1513257.29. Porter DL, Levine BL, Kalos M, et al. Chimeric antigen receptor-modified T cells in chronic lymphoid leukemia. N Engl J Med. 2011;365(4):725-733. doi: 10.1056/NEJMoa1513257.30. Gill S, June CH. Going viral: chimeric antigen receptor T-cell therapy for hematological malignancies. Immunol Rev. 2015;263(1):68-89. doi: 10.1111/imr.12243.31. Sharman J, Hawkins M, Kolibaba K, et al. An open-label phase 2 trial of entospletinib (GS-9973), a selective spleen tyrosine kinase inhibitor, in chronic lymphocytic leukemia. Blood. 2015;125(15):2336-2343. doi: 10.1182/blood-2014-08-595934.

CME


Dates of certification: April 1, 2016, to April 1, 2017 Medium: Print with online posttest, evaluation, and request for credit

The American Journal of Hematology/Oncology® Editorial BoardDebu Tripathy, MDProfessor of Medicine and ChairDepartment of Breast Medical OncologyThe University of Texas MD Anderson Cancer CenterHouston, TX Disclosure: Grant/research support from Genentech/Roche, Pfizer, Puma Biotechnology Inc, and Novartis (clinical trial support contracted to the University of Southern California and MD Anderson Cancer Center); consultant for Eisai, Oncoplex Diagnostics, Merck, and Novartis.

FacultyJohn Marshall, MDChief, Division of Hematology/OncologyGeorgetown University HospitalDirector, Ruesch Center for the Cure of GI CancersWashington, DC Disclosure: Grant/Research Support: Genentech, Amgen, Bayer, Cel-gene Corporation; Consultant: Genentech, Amgen, Bayer, Celgene Cor-poration, Indivumed Inc, Caris; Speaker’s Bureau: Genentech, Amgen, Bayer, Celgene Corporation.

Staff/Planner Disclosures and Conflict of Interest ResolutionThe staff of Physicians’ Education Resource®, LLC, (PER®) and the editorial staff of The American Journal of Hematology/Oncology have no relevant financial relationships with commercial interests to disclose.

It is the policy of PER® to ensure the fair balance, independence, objectivity, and scientific objectivity in all of our CME activities. In accordance with Accreditation Council for Continuing Medical Education (ACCME) guidelines, PER® requires everyone who is in a position to control the content of an educational activity, including spouses/partners, to disclose all relevant financial relationships with any commercial interest to participants as part of the activity planning process. PER® has implemented mechanisms to identify and resolve all conflicts of interest prior to the release of this activity.

OverviewThis activity is designed to inform physicians about the latest advances in colorectal cancer (CRC) treatment, including current and investigational management strategies.

Target AudienceThis activity is directed toward medical oncologists, gastroenterologists, primary care physicians, nurses, and nurse practitioners who treat patients with colorectal cancer. Surgical oncologists, radiation oncologists, pathologists, fellows, physician assistants, and other healthcare providers interested in the management of colorectal cancer are also invited to participate.

Learning ObjectivesAfter participating in this CME/CE activity, learners should be better prepared to:• Discuss unmet needs in the management of relapsed metastatic CRC• Describe the role of biomarker testing including molecular profiling

in diagnosis and treatment of CRC• Discuss and apply emerging therapies and data from recent clinical

studies for the treatment of metastatic CRC

Accreditation/Credit DesignationPhysicians’ Education Resource® LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Physicians’ Education Resource® LLC, designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physicians’ Education Resource® LLC is approved by the California Board of Registered Nursing, Provider #16669 for 1.0 Contact Hour.

This activity is funded by PER®.

Instructions for Participation/How to Receive Credit

1. Read the article in its entirety.2. Use the QR code or type

http://www.ajho.com/go/Mar16CME into your Web browser to access the posttest.

3. Complete and pass the posttest with a score of 70% or higher.

4. Complete the evaluation and request for credit. Participants may immediately download a CME/CE certificate upon successful completion of these steps.

Off-Label Disclosure and DisclaimerThis continuing medical and nursing education activity may or may not discuss investigational, unapproved, or off-label uses of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only and is not meant to substitute for the independent medical judgment of a physician or nurse relative to diagnostic, treatment, and management options for a specific patient’s medical condition.

DisclaimerThe opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource®, LLC. Contact information for questions about the activity:

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Advances in the Treatment of Metastatic Colorectal Cancer

CME


Colorectal cancer (CRC) is the third leading cause of cancer-related mortality in the United States and is estimated to account for as many as 49,190 deaths this year.1 In recent years, great strides have been made in early detection and diagnosis of CRC; however, despite in-corporating strategies such as population-based screening, about 35% of patients present with stage IV metastatic disease at the time of diag-nosis. 2,3 Additionally, 20% to 50% of patients presenting with stage II or III disease eventually progress to stage IV at some point during the course of their disease. Prognosis is poor once the disease progresses to stage IV, with a 5-year survival rate of less than 10% despite optimal supportive care with chemotherapy.3 Current therapies for CRC are not curative at advanced stages.4

Given the highly heterogeneous nature of CRC tumors, variable re-sponses to therapy, and the fact that tumors continue to evolve as dis-ease advances, a lot of focus in recent years has been on understanding the molecular characterization of CRC. Originally, CRC tumors were broadly classified as those with microsatellite instability (MSI) caused by defective function of the DNA mismatch repair system and others with microsatellite stable (MSS) but chromosomal instability (CIN).5 Most recently, further sub-classification into different molecular sub-types of CRC has been proposed by the Colorectal Cancer Subtyping Consortium (CRCSC) group.

The group recommended sub-classification that consisted of four biologically distinct consensus molecular subtypes (CMSs) with dis-tinct pathways and key clinical and molecular traits. The first subtype is CMS1. CMS1 (14% prevalence) is enriched for MSI, is BRAF-mu-tant, shows hypermutation, hypermethylation, and immune path-way activation, and occurs mainly as right-side tumors, in older age, and in females. Survival is intermediate with this subtype. The next subtype is CMS2 (41% prevalence). Tumors of this subtype are CIN high, MSS and display strong WNT and myelocytomatosis (MYC) pathway activation, T53 mutation, and amplification/upregulation of epidermal growth factor receptor (EGFR). Better survival is not-ed with this subtype. CMS3 subtype tumors (8% prevalence) are CIN-low, display moderate WNT/MYC pathway activation and display KRAS mutations, PIK3CA mutations, and IGFBP2 over-expression. Similar to CMS1, survival seen is intermediate with this subtype. The last subtype, CMS4 tumors (20% prevalence), are heterogeneous CIN/MSI characterized by stromal invasion linked to transforming growth factor (TGF)-beta signaling activation and NOTCH3/VEGFR2 overexpression and are seen in younger pa-tients at diagnosis. This subtype displays worse survival. Additional efforts are ongoing by the CRCSC group to further improve the granularity of these identified subtypes.6

Efforts are also ongoing in the diagnostic field to help assist with the best treatment decisions for patients, taking into account their prognosis and predicted response to chemotherapeutics, and given the high variability of clinical responses to CRC treatment.7 One of the major treatment challenges in recent years has been identifica-tion of patients with colon cancer stage II and stage III who can ben-

efit from adjuvant treatment. The use of gene expression–based tests, in conjunction with clinicopathological parameters, can potentially improve treatment decisions based on risk assessment.8 The Onco-type DX, a gene expression–based test, has been clinically validated as a prognostic signature for patients with stage II colon cancer in a large clinical study (NSABP C-07). Findings, from this study, showed that the 12-gene Recurrence Score predicts the risk of recurrence in stage II and stage III colon cancer, and also showed that certain stage II and stage IIIA/B patients with low Recurrence Score disease can elect to forego oxaliplatin treatment as a result of their low risk of re-currence and small absolute benefit with oxaliplatin.9,10 Although not routinely used, this test can help identify patients at increased risk for recurrence who might be good candidates for adjuvant therapy.10 An 18-gene signature using fresh frozen tissue was recently identified (ColoPrint). A large phase II clinical trial to validate the ColoPrint test in stage II CRC (PARSC study, NCT00903565) is currently on-going for this test.10,11

Progress has also been made in attempting treatment personal-ization in CRC. Advances in our understanding of metastatic CRC (mCRC) have led to the development of monoclonal antibodies targeting the EGFR, such as panitumumab or cetuximab. Further-more, our understanding of the negative interaction in patients with KRAS-mutant tumors receiving an EGFR-targeted therapy has cre-ated a significant impact on management of patients with mCRC by helping select appropriate patient prior to initiating therapy with these agents.12 Further evidence indicated that testing for the Kirsten ras (KRAS) mutation only may not be sufficiently reliable. Data from randomized trials now suggests presence of other RAS mutations including KRAS exons 3/4 and Neuroblastoma RAS (NRAS) exon 1/2/3/4).13 Recent evidence indicates that RAS mutations in exons 2, 3, and 4 of both KRAS and NRAS may be predictive of resistance to treatment with anti-EGFR monoclonal antibodies (MoAb, cur-rently cetuximab and panitumumab).

The American Society of Clinical Oncology Provisional Clinical Opinion Update 2015 recommends that “all patients with mCRC who are candidates for anti-EGFR antibody therapy should have their tumor tested in a Clinical Laboratory Improvement Amend-ments–certified laboratory for mutations in both KRAS and NRAS exons 2 (codons 12 and 13), 3 (codons 59 and 61), and 4 (codons 117 and 146). The weight of current evidence indicates that anti-EGFR MoAb therapy should only be considered for treatment of patients whose tumor is determined to not have mutations detected after such extended RAS testing.”14

Anti-EGFR treatment marked the first true use of personalized medicine in CRC, and efforts are ongoing for identification of ad-ditional markers.12,15 Moreover, as our understanding of the role of the immune system in the development and progression of cancer continues to evolve, immunology-based therapies are emerging as an effective option. Recent research has shown that cancer cells can use checkpoint mechanisms to escape immune-mediated elimination.

ADVANCES IN THE TREATMENT OF METASTATIC COLORECTAL CANCER


This understanding of how cancer cells can evade immune control and elimination has led to the development of checkpoint inhibitors (ie, a therapeutic class of drugs that inhibit these inhibitory path-ways).

Current drugs in this class include antibody-based therapies that target cytotoxic T-lymphocyte antigen 4 (CTLA4), programmed cell death 1 (PD-1), and programmed cell death ligand 1 (PD-L1). These therapies have demonstrated clinical response, as single agents, and in combinations in melanoma, renal cell carcinoma, non-small cell lung cancer, and numerous other cancer types.16 Early observations have shown greater activity of checkpoint inhibitors in patients with metastatic deficient mismatch repair CRC.17 Several trials are current-ly ongoing to evaluate the efficacy and safety of checkpoint inhibitors in advanced and/or mCRC including pembrolizumab18; a combina-tion of nivolumab, an anti-PD-1 antibody and ipilimumab, a CTLA-4 inhibitor19; and nivolumab in combination with varlilumab (an an-ti-CD27 inhibitor) in patients with advanced refractory solid tumors, including CRC.20

In addition to checkpoint inhibition, vaccines are being explored as a treatment option in advanced/mCRC. There is a current pilot study using GVAX in irradiated autologous CRC cells in patients with stage IV CRC that examines safety as a primary endpoint, in addition to pro-gression-free survival (PFS) and overall survival (OS).21 Peptide vaccines are also being explored in mCRC.22 Dendritic cell (DC) vaccines have also been explored. Several strategies for delivering tumor-associated antigens to DCs via synthetic peptide, tumor RNA, and tumor cell lysates have been developed to stimulate an adequate CTL response. In phase I clinical studies using autologous human DCs pulsed with carcinoembryonic antigen (CEA) peptide in CEA-expressing mCRC, patients have shown modest clinical improvement with dendritic vac-cines. Safety data from these studies suggest that these vaccines are gen-erally safe and well tolerated.23

Treatment of CRC, including mCRC, continues to evolve at a rapid pace. John Marshall, MD, chief, Division of Hematology/Oncology, Georgetown University Hospital, and director, Ruesch Center for the Cure of GI Cancers, Washington, DC, shared his insights on the recent advancements in the treatment of CRC and its significance.

Moderator: What are some of the most pressing, unmet clinical needs in the management of relapsed mCRC?Dr. Marshall: The answer to that is that our first-line therapies are increasingly effective, and while we have more and more treatments for second-line and beyond, each one of those is less and less effec-tive, meaning they have less impact on OS. They accumulate, so each one by themselves is an important step or addition of time, but the biggest unmet need is really understanding what are the sensitivities and resistance patterns of mCRC. The important piece here is that patients still want to be cured of their cancer. While the survival advantage is certainly nice and worth it, our patients want more than just that, and we want more than just that. In reality, the biggest

unmet need for these patients is truly highly effective, potentially cu-rative therapy for all of our cancers, including mCRC.Moderator: In September 2015, the FDA approved oral nucleoside TAS-102 (trifluridine/tipiracil) for the treatment of patients with metastatic colorectal cancer (mCRC) who have previously received fluoropyrimidine-, oxaliplatin- , and irinotecan-based chemotherapy, an anti-VEGF biologic product, and an anti-EGFR monoclonal an-tibody, if RAS wild-type. This approval was based on the phase III RECOURSE trial. Would you be able to tell us a little bit about this combination drug and its efficacy, based on data from the RE-COURSE trial? In your opinion, how will this approval impact the treatment of mCRC?Dr. Marshall: The RECOURSE study is a very important trial. It is a very traditional trial, a very pure trial done in the refractory metastat-ic patient. The trial enrolled colon cancer patients who had received all of the standard therapies, to date, and that included VEGF drugs and EGFR drugs when appropriate—irinotecan, oxaliplatin, and flu-oropyrimidine. The patients were randomized 2:1 against a placebo control arm, and the primary endpoint was OS. The secondary end-points included PFS and toxicity. Basically what the results of this trial showed was that TAS-102 worked. Data from the RECOURSE trial showed that TAS-102, or trifluridine/tipiracil, worked in im-proving OS and PFS in these patients. There weren’t that many pa-tients who had a clinical response, a regression of their cancer.

And the reason this is a very important study is because it brings new medicines to our chess board, as I like to put it. It’s not just a new piece on the chess board; it’s also a new medicine. It’s not an also-ran. Although it is very similar to fluoropyrimidine-like drugs, it has a somewhat different mechanism of action and different pharma-cology. And even in patients who had had prior fluoropyrimidines, there was an improvement observed. And so it’s a new drug, and, of course, it will get significant use in its approved setting, which is as a single agent in the refractory patient. But my guess is that it will also work fairly well in combination with other chemotherapies, if you will, replacing 5FU or capecitabine in other settings. So we would look to other clinical trials in other lines of therapy pretty much any-where a fluoropyrimidine would be used, including CRC, other GI cancers, and other diseases. And my guess is we’ll see some activity in those places, as well.

Moderator: Would you be able to tell us a little bit more about the PARSC trial and the potential impact it will have on CRC treatment?Dr. Marshall: The PARSC study is a study of molecular profile for patients with stage II and stage III colon cancer that will try and predict who will relapse and who won’t. Also, even better, the hope would be that it can predict who will respond to chemotherapy and who won’t. This study is put together by a company called Agendia, and is for the molecular profile ColoPrint. Most of our readers would know about the Oncotype DX molecular profile, and this is meant to be a sort of better version of that.

To elaborate, in stage II and stage III colon cancers, there are really

CME


three types of patients. There are patients who were indeed cured by the surgeon, and therefore don’t need postoperative chemotherapy. There are patients who were not cured by the surgeon but there is residual microscopic cancer still in them, and if we give them chemo-therapy, that will cure them. And then there’s a third group where they have microscopic residual cancer but the chemotherapy won’t cure them. And what we really need is some test that will tell me, as a doctor, that the patient is in one of those three categories. And obvi-ously if they didn’t need chemo, we wouldn’t give it to them. If they needed it, we would absolutely give it to them. And if it wasn’t going to help, the chemo, they’re in the third group. Then we’d try a clinical trial or some other approach. And so that is to me the Holy Grail in oncology, and the PARSC clinical trial and molecular profile is trying to get us closer to that kind of scenario. And while it is not black-and-white—it doesn’t really sort patients into those three groups—it does help with that. So ColoPrint is a test that one can order from Agendia, and it is similar to Oncotype Dx in some ways because they both are gene signature tests that provide information about recur-rence-free survival but different because coloprint utilizes 18-gene prognostic classifier whereas Oncotype DX utilizes 12-gene panel.

Moderator: In your opinion, what progress have we made in further refining and defining molecular subtypes in colon cancer?Dr. Marshall: The more we are looking at molecular profiling of co-lon cancer, the more we are finding that they’re all different. There’s a recent publication by Sabine Tejpar and others that actually was a consensus paper showing that there were at least four, and may-be five, molecular subgroups of colon cancer. Right side is different than left side. Colon cancer in young patients may be different than one in older patients. We certainly know inherited colon cancer is different from all of them. So we’re beginning to sort colon cancer into its different molecular subtypes. So this is more about trying to get to the heart and soul of the different kinds of colon cancers.

Moderator: What role does molecular profiling play in diagnosis and treatment of mCRC currently? And how do you see it evolving in the near future?Dr. Marshall: Today, every patient with colon cancer, especially every patient with mCRC, needs to have molecular profiling done. And the core results that we all have to know about for all our patients are RAS, and we have to remember that it used to be KRAS but we’ve gotten smarter now and understand that it’s more than just KRAS. So it is all-RAS, so that’s one. The second is microsatellite instability or mismatch repair, and the reason you have to know this is not only because of the inherited cancer syndrome piece of it, but now that the new checkpoint inhibitors appear to work very well in this subgroup, we have to know about this for therapeutic reasons. And then the other biomarkers that are a little softer are BRAF. BRAF may predict for resistance and may also help select for certain clinical trials with BRAF inhibitors, but, in the same token, HER2, there’s an increasing recognition that HER2 is out there. But we also know,

back to the evolution of this, that this is a moving target. The more we test, the more we learn.

I’m leading a national collaboration called the Centers of Excel-lence where we are working collaboratively among many cancer cen-ters and community oncologists to test broad molecular profiling—so not just the ones that we know about today but also the ones that we will see in the future and to understand the impact of doing this broad gene testing and protein testing in patients. So I think and I hope that the future will be that we don’t just do these very specific tests, but that we are doing broad tests to better understand the bi-ology and to hopefully find additional better therapeutic approaches than our current standards.

Moderator: Approximately half of the patients with KRAS wild-type tumors do not respond to anti-EGFR treatment. Are there any prom-ising therapies for patients with this type of mCRC?Dr. Marshall: It’s important to distinguish between KRAS and RAS. So this statement is true when you talk about KRAS, but the more we are enriching and doing all-RAS wild-type and then adding in even BRAF wild-type testing, etc, the response rates are improving. So the answer to this is that we’re getting smarter about selecting which pa-tients should receive anti-EGFR therapies. But don’t get me wrong, it’s not like the EGFR therapies are curing people. They are just help-ing to prolong survival, and so that’s, of course, good and important, but it’s not, if you will, curative therapy. So whether you’re RAS wild-type or RAS-mutated, the same holds. I would say that there are many new approaches to the treatment of mCRC.

There are many new targets that have emerged and are being test-ed, but I think it would be premature for me to, if you will, rank or suggest that one is better than another at this point. They are all fairly early in their development and, to my knowledge, no one kind of drug has emerged as being particularly promising. I will say that the approach to attacking stem cells or stem-like cells is very interesting, and there have been some early positive results there, and the defini-tive studies are being done now or about to be done. But other than that, I think there’s not going to be any single answer for a patient. The patients will have their cancers profiled. Certain genetic abnor-malities will emerge that are particular to those individual patients and treatments will be given that way versus the way we’ve sort of done it in the past, where we gave all the patients the same treatment and hoped it works for them. And that’s really the promise and the hope for precision medicine going forward.

Moderator: What are the key takeaways from the phase III ASPEC-CT trial in patients with chemorefractory WT KRAS exon 2 mCRC and its recent subset analysis that showed that patients who received prior bevacizumab-containing regimens may have derived greater benefit with panitumumab versus cetuximab monotherapy?Dr. Marshall: I think the ASPECCT trial tells us that, basically, the two drugs, cetuximab and panitumumab, perform very similarly in the clinic. And the kinds of differences that these subset analyses pull

ADVANCES IN THE TREATMENT OF METASTATIC COLORECTAL CANCER


forward to me are not clinically relevant to us today. The differences are not reproducible and not meaningful enough. So I think this: my general recommendation to folks is to pick one of these agents for whatever reason and use it. They are essentially interchangeable, and there are pros and cons to both of these agents. My personal answer is that I tend to use more panitumumab because of its simpler admin-istration and lower infusion reactions in the region of the country I live in. So that’s my answer, but, yes, I think that they are very similar in how they work.

Moderator: What role do you see checkpoint inhibitors playing in the treatment of mCRC? Dr. Marshall: Every patient today with mCRC, actually with any co-lon cancer, should have their tumor tested for mismatch repair or MIS. If they fall into the roughly 10%-15% of cases that do, then checkpoint inhibitors should be sought. There are several clinical tri-als around the country that you can get access to for this, and many of the companies that have checkpoint inhibitors approved are granting access to these drugs because the impact is so strong. To give a sense of just how strong it is, there is opening up around the country, a frontline mCRC clinical trial that randomizes patients between che-motherapy, traditional chemotherapy, and single-agent checkpoint inhibitors. That’s how much we think of these agents in this disease. It’s a dramatic impact. Every patient should be sought—young, old, family history or not—and if they have mismatch repair or MIS, these drugs should be sought and tried in those patients.

Moderator: Vaccines are among one of the strategies that target the immune system that are currently being investigated. Do you envi-sion these becoming a promising option for patients with mCRC in the future? Why or why not?Dr. Marshall: Vaccines in CRC and other GI cancers have been my research for over 20 years, and in collaboration with the National Cancer Institute, Duke University, and other places, we’ve been working on vaccines for GI cancers. Everyone in the world, including very smart people, said there’s no point. The immune system won’t help treat cancer except in these very rare circumstances. And we’ve been holding out hope that they were wrong. And now that these other kinds of drugs, the checkpoint inhibitors, have come forward and have been dramatically effective in certain cancers, there’s, of course, a fairly significant renewed interest in vaccines. And vaccines clearly work. You can give treatments to patients and create T cells and other immune responses to cancer antigens and other immune stimulatory axes. So that we know we can do. And we believe, those of us who have been doing this a long time, that having done that to patients, at least some patients, that translates into significant im-provement in their disease and how well their disease is controlled and their survival. But that’s been very hard to prove because of not having large randomized trials showing that result.

So now, the reason this is important is that now with the check-point inhibitors, we have the concept of combination therapy. And

so could we give both a vaccine, if you will, to turn on the immune system and wake it up, and a checkpoint inhibitor to kind of “cut the brakes” to keep it from being shut off. And so because now people believe this is worth exploring, the FDA and other investigators and companies have agreed to begin doing some of these combination studies. So we’re very hopeful that this might have a positive impact going forward and expand the number of people who will be candi-dates for immune therapy.

Moderator: How do you envision the treatment of CRC evolving in the coming years, considering there are a lot of developments hap-pening all at the same time?Dr. Marshall: I think what we’re seeing is that patients are living longer. We have not only new medicines, but new surgical approach-es. We have new treatments for liver-specific cancers. We have new radiation techniques, so we just have a lot more tools to manage these patients. And so on one front, in the old days, just a medical oncol-ogist could take care of patients with mCRC. But in today’s world, it increasingly takes a team—surgeons, radiation oncologists, interven-tional radiologists, gastroenterologists, molecular profilers. So it’s not just a simple med onc giving chemo; it’s really a team sport to manage metastatic disease. And the hope is that with this sort of improved collaborative work, we will improve our patients’ outcomes. Not only will we get smarter about molecular testing and finding drugs, but we will understand when to give what drugs to what patients.

For our readers who are interested in learning more about the evolving role of multidisciplinary teams in the treatment of GI cancers, we would like to re-mind them of the School of Gastrointestinal Oncology™ (SOGO™) meeting that is coming up this April. This meeting will provide a multi-module cur-riculum-based program that is focused exclusively on GI tumor management. This intensive one-day interactive program will provide a comprehensive re-view of data on the most important aspects related to the multidisciplinary management of gastrointestinal tumors.

More information about this meeting can be found at: http://www.goto per.com/conferences/SOGO/meetings/1st-Annual-School-of-Gastro intestinal-Oncology

REFERENCES1. American Cancer Society. Cancer facts and figures 2016. ACS website. http://www.cancer.org/acs/groups/content/@research/doc-uments/document/acspc-047079.pdf. Accessed March 8, 2016.2. Hagan S, Orr MC, Doyle B. Targeted therapies in colorectal cancer-an integrative view by PPPM. EPMA J. 2013;4(1):3. doi: 10.1186/1878-5085-4-33. Zacharakis M, Xynos ID, Lazaris A, et al. Predictors of survival in stage IV metastatic colorectal cancer. Anticancer Res. 2010;30(2):653-660.4. Van Cutsem E, Borràs JM, Castells A, et al. Improving out-

CME


comes in colorectal cancer: where do we go from here? Eur J Cancer. 2013;49(11):2476-2485. doi: 10.1016/j.ejca.2013.03.026.5. Dienstmann R, Salazar R, Tabernero J. The evolution of our mo-lecular understanding of colorectal cancer: what we are doing now, what the future holds, and how tumor profiling is just the beginning. Am Soc Clin Oncol Educ Book. 2014:91-99. doi: 10.14694/EdBook_AM.2014.34.91.6. Dienstmann R, Justin Guinney J, Mauro Delorenzi M, et al. Col-orectal Cancer Subtyping Consortium (CRCSC) identification of a consensus of molecular subtypes. J Clin Oncol. 2014; 32:5s(suppl abstr 3511). 7. Gonzalez-Pons M, Cruz-Correa M. Colorectal cancer biomark-ers: where are we now? Biomed Res Int. 2015;2015:149014. doi: 10.1155/2015/149014.8. Sveen A, Nesbakken A, Ågesen TH, et al. Anticipating the clinical use of prognostic gene expression-based tests for colon cancer stage II and III: Is Godot finally arriving? Clin Cancer Res. 2013;19(24):6669-6677. doi: 10.1158/1078-0432.CCR-13-1769.9. Yothers G, O’Connell MJ, Lee M, et al. Validation of the 12-Gene colon cancer recurrence score in NSABP C-07 as a predictor of re-currence in patients with stage II and III colon cancer treated with fluorouracil and leucovorin (FU/LV) and FU/LV plus oxaliplatin. J Clin Oncol. 2013;31(36):4512-4519. doi: 10.1200/JCO.2012.47.3116.10. Johnston PG. Identification of clinically relevant molecular subtypes in colorectal cancer: The dawning of a new era. Oncologist. 2014;19(5):568-73. doi: 10.1634/theoncologist.2014-038.11. A Prospective Study for the Assessment of Recurrence Risk in Stage II Colon Cancer Patients Using ColoPrint (PARSC). Clini-calTrials.gov website. https://clinicaltrials.gov/ct2/show/NCT0090 3565. Accessed March 8, 2016. 12. Heinemann V, Douillard JY, Ducreux M, Peeters M. Targeted therapy in metastatic colorectal cancer -- an example of person-alised medicine in action. Cancer Treat Rev. 2013;39(6):592-601. doi: 10.1016/j.ctrv.2012.12.011.13. Al-Shamsi HO, Alhazzani W, Wolff RA. Extended RAS testing in metastatic colorectal cancer—Refining the predictive molecular biomarkers. J Gastrointest Oncol. 2015;6(3):314-321. doi: 10.3978/ j.issn.2078-6891.2015.016.14. Allegra CJ, Rumble RB, Hamilton SR, et al. Extended RAS gene mutation testing in metastatic colorectal carcinoma to predict response to anti–epidermal growth factor receptor monoclonal an-tibody therapy: American Society of Clinical Oncology Provisional Clinical Opinion Update 2015. J Clin Oncol. 2016;34(2):179-185. doi: 10.1200/JCO.2015.63.9674.15. Siena S, Sartore-Bianchi A, Trusolino L, et al. Therapeutic dual inhibition of HER2 pathway for metastatic colorectal cancer (mCRC): The HERACLES trial. J Clin Oncol. 2015; 33 suppl 3 abstr 565).16. Sharon E, Streicher H, Goncalves P, Chen HX. Immune check-point inhibitors in clinical trials. Chin J Cancer. 2014;33(9):434-444. doi: 10.5732/cjc.014.10122.

17. Le DT, Uram JN, Wang H, et al. PD-1 blockade in tumors with mismatch-repair deficiency. N Engl J Med. 2015;372(26):2509-2520. doi: 10.1056/NEJMoa1500596. 18. Study of pembrolizumab (MK-3475) as monotherapy in par-ticipants with previously-treated locally advanced unresectable or metastatic colorectal cancer (MK-3475-164/KEYNOTE-164). Clini-calTrials.gov website. https://clinicaltrials.gov/ct2/show/NCT024 60198?term=NCT02460198&rank=1. Accessed March 8, 2016. 19. A study of nivolumab and nivolumab plus ipilimumab in recur-rent and metastatic colon cancer (CheckMate 142). ClinicalTrials.gov website. https://clinicaltrials.gov/ct2/show/NCT02060188?ter-m=NCT02060188&rank=1. Accessed March 8, 2016. 20. A Dose Escalation and Cohort Expansion Study of Anti-CD27 (Varlilumab) and Anti-PD-1 (Nivolumab) in Advanced Refractory Solid Tumors. ClinicalTrials.gov website. https://clinicaltrials.gov/ct2/show/NCT02335918?term=NCT02335918&rank=1. Accessed March 8, 2016. 21. GVAX for Colorectal Cancer. ClinicalTrials.gov website. https://clinicaltrials.gov/ct2/show/NCT01952730?term=NCT01952730 &rank=1. Accessed March 8, 2016. 22. Peptide Vaccine in Advanced Pancreatic Ductal Adenocarci-noma or Colorectal adenocarcinoma. ClinicalTrials.gov website. https://clinicaltrials.gov/ct2/show/NCT02600949?term=NCT0 2600949&rank=1. Accessed March 8, 2016. 23. Singh PP, Sharma PK, Krishnan G, Lockhart AC. Immune check-points and immunotherapy for colorectal cancer. Gastroenterol Rep (Oxf). 2015;3(4):289-297. doi: 10.1093/gastro/gov053.

The rapid pace of discovery in the field of oncology presents practicing oncologists with the difficult challenge of implementing novel research findings into clinical practice. To accelerate the translation of academic advances to community-based practice, The American Journal of Hematology/Oncology® aims to provide practical interpretations of the latest advances in medical and hematologic oncology and to help practicing oncologists gain a better understanding of how these advances are changing the treatment landscape for both solid and hematologic malignancies. The editors are pleased to consider manuscripts on a wide range of topics related to the journal’s mission. Articles of interest include:• Original research• Reviews

- State-of-the Art Updates- On the Horizon- Emerging Guidelines

• Editorials and perspectives- Clinical Controversies - Looking Forward- Brief Reports- Pivotal Trials- New Technologies- Meeting Updates - Case Reports- Survivorship Issues- Team Approaches (Allied Health/Care Extenders)

- Pharmacology Updates- Oncology Practice Issues

Detailed descriptions of each category can be found in the Instructions for Authors at www.ajho.com

T h e

TH

E O

FFICIAL J

OU

RN

AL O

F o f

BREAST CANCERClinical Utility of Emerging Molecular Diagnostics in Breast CancerMarie-Kristin von Wahlde, MD, Tomoko Kurita, MD, Tara Sanft, MD, Erin Hofstatter, MD, and Lajos Pusztai, MD, DPhil

OVARIAN CANCERImmunotherapy in Ovarian Cancer—Where Are We Going?Maurie Markman, MD

COLORECTAL CANCERSalvage Therapy and Emerging Agents in Colorectal CancerJennifer Wu, MD

DOUBLE-HIT LYMPHOMACurrent Concepts in Double-Hit LymphomaMitul Gandhi, MD, and Adam M. Petrich, MD

A m e r i c a n

J o u r n a l

H e m a t o l o g y /

O n c o l o g y ®

A Peer-Reviewed Resource

for Oncology Education

ajho

www.AJHO.com ISSN 1939-6163 (print) ISSN 2334-0274 (online)

Volume 12 Number 2 2.16

IMMUNOTHERAPIES IN BREAST CANCER CME-certified enduring materials sponsored by Physicians’ Education Resource®, LLC

Assessing the Clinical Potential for Immunotherapies in the Treatment of Breast Cancer

All manuscripts will undergo peer review, and authors of accepted articles will receive an honorarium and will be required to sign an authorship form disclosing any possible conflicts of interest. To submit an article to The American Journal of Hematology/Oncology® or if you wish to speak to an editor, please e-mail Howard Whitman at [email protected]

Call for Papers

· COMBINATION THERAPIES ·

VOL. 12, NO. 1 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY®

23

Safety and Efficacy of Combination

Targeted Therapy and Radiotherapy

Danielle S. Bitterman, BA, and Kevin L. Du, MD, PhD, MSCI

Introduction

Radiation therapy (RT), together with surgery and chemothera-

py, is one of the primary modalities used in definitive and pallia-

tive cancer treatment. Utilization analyses have revealed that RT

is a part of initial treatment in approximately 30% of patients

with cancer,1 and approximately 50% of patients overall receive

RT.2 In comparing contribution toward cure by treatment mo-

dality, a European Union expert panel determined that cure is

achieved in 49% of patients by surgery, 40% by RT, and 11% by

chemotherapy.3 Given these statistics and in light of advance-

ments expanding the clinical indications of RT, RT will continue

to be an essential modality in the treatment of malignancies in

the future.

Targeted cancer agents that block specific molecular pathways

involved in oncogenesis are rapidly shifting the landscape of can-

cer treatment. While these agents present promising opportu-

nities for the treatment of many malignancies, the majority are

cytostatic, and many impart modest, if any, survival benefit as

monotherapy.4,5 However, there is preclinical evidence that these

agents are radiosensitizing and may improve cure rates when

used in combination with RT.

The radiosensitizing effects of classical chemotherapeutics,

including cisplatin, 5-fluorouracil (5-FU), taxanes, and temo-

zolomide, have been well characterized, and the combination of

such agents with RT has been demonstrated to improve survival

and cure rates across many cancer types in randomized clinical

trials.6-18 Since these agents are nonspecific and radiosensitize

normal tissue, such treatment carries greater toxicity. While this

toxicity is accepted due to the even greater clinical benefit, tar-

geted agents present an exciting opportunity because they may

selectively radiosensitize tumor cells without a concomitant in-

crease in normal tissue toxicity. In this review, we summarize the

currently published clinical trials of commonly used therapies

in combination with RT, with attention to data on efficacy and

toxicity.

Hormone Therapy

Androgen-deprivation therapy (ADT) in combination with RT

for prostate cancer can be viewed as an early targeted biologic

approach. In 1997, the seminal Southwest Oncology Group

(SWOG)/European Organisation for Research and Treatment

of Cancer (EORTC) randomized trial demonstrated improved

survival with the addition of goserelin to definitive RT for locally

advanced prostate cancer.17 Grade 3 or above acute and late tox-

icities were not significantly different with the addition of ADT.

However, combined late grade 1-3 toxicities, including urinary

incontinence and urethral stricture, were significantly increased

in patients treated with ADT. Despite the higher rate of adverse

effects (AEs) of combined therapy, this toxicity was deemed ac-

ceptable, and ADT with RT is currently an accepted standard of

care for locally advanced prostate cancer.

Monoclonal Antibodies

Bevacizumab, a monoclonal antibody against vascular endothe-

lial growth factor A (VEGF-A), is a pioneering targeted agent

that has been studied in large clinical trials.19 A recently pub-

Abstract

Targeted cancer therapies that act on specific drivers

of oncogenesis are rapidly entering clinical use. While

many of these agents are ineffective at improving cure

rates as monotherapy, there is ample preclinical evidence

that they are both chemosensitizing and radiosensitizing,

and can improve cure rates when utilized in combina-

tion treatment regimens. There is therefore a need for

high-quality safety and efficacy data on targeted therapy

in combination with radiation therapy (RT). This article re-

views the currently published clinical trials examining the

combination of RT with commonly used targeted agents,

such as vascular endothelial growth factor inhibitors, en-

dothelial growth factor receptor inhibitors, and inhibitors

of the PI3K/Akt/mTOR pathway. Continued efforts to de-

velop high-quality clinical trial data combining targeted

agents with RT are necessary for patient safety and to

improve clinical outcomes.

Key words: targeted therapies, radiation therapy, vascu-

lar endothelial growth factor inhibitors, PI3K, Akt, mTOR

· COMBINATION THERAPIES ·

24

www.ajho.com

JANUARY 2016

lished phase III trial utilizing bevacizumab with temozolamide and RT in glioblastoma multiforme improved progression-free survival (PFS) and quality-of-life endpoints, but not overall sur-vival (OS).20 The rates of grade ≥3 AEs were increased with the addition of bevacizumab. Interestingly, these toxicities were not primarily radiation-related. Instead, the majority were attribut-able to bevacizumab, and included thromboembolic events, bleeding events, impaired wound healing, gastrointestinal (GI) perforation, and congenital heart failure. Specifically, the rate of cerebral hemorrhage was increased in patients treated with bevacizumab compared with placebo (3.3% vs 2.0%). In rectal cancer, several early trials demonstrated the feasibility of using bevacizumab in combination with chemoradiation, with overall similar rates of AEs compared with historical controls.21-24 How-ever, increased GI bleeding thought to be due to the addition of bevacizumab was also observed in these studies.For example, a phase II study from Canada reported severe preoperative bleeding events in 17% of patients treated with combination bevacizumab and chemoradiation.23 In pancre-atic cancer, two phase II trials evaluating the addition of beva-cizumab to chemoradiation did not improve survival outcomes compared with historical rates.25,26 Several bleeding events were noted with the addition of bevacizumab, but the sites of bleed-ing were outside of the radiation field. Ultimately, further studies are needed to determine the safety and efficacy of bevacizumab with chemoradiation and its application in the treatment of malignancies. Nevertheless, the data appear to support acceptable, though perhaps increased, toxicities of bleeding and thromboembolic events attributable specifically to bevacizumab.

Activating mutations of the EGFR/PI3K/Akt/mTOR path-way are common in cancers and have been implicated in radio-resistance. The epidermal growth factor receptor (EGFR) inhib-itor cetuximab has been found to have potent radiosensitizing properties in preclinical trials.27 In a large, multi-institutional, randomized trial, Bonner et al28 reported an OS benefit when adding cetuximab to RT in locally advanced head and neck squamous cell carcinoma (HNSCC). With the exception of ac-neiform rash and infusion reactions, the incidence of grade ≥3 toxicity did not differ significantly between patient arms. This trial demonstrated the feasibility, safety, and efficacy of adding cetuximab to RT. However, the follow-up study, RTOG 0522, which added cetuximab to cisplatin-based chemoradiation for locally advanced HNSCC, did not show a survival benefit with the addition of cetuximab.29 Indeed, patients who were treated with cetuximab in addition to cisplatin had more interruptions in RT, increased treatment-related death, and increased grade ≥3 AEs, including mucositis and anorexia. Similarly, a recently reported randomized phase III trial for stage IIIA/B non–small-cell lung cancer (NSCLC), RTOG 0617, demonstrated no clinical benefit with the addition of cetuximab

to standard or dose-escalated chemoradiation.30 However, pa-tients receiving cetuximab in addition to chemoradiation experi-enced significantly higher rates of grade ≥3 toxicities compared with those receiving chemoradiation alone (86% vs 70%). Fur-ther, there were more treatment-related deaths with the use of cetuximab (4.2% vs 2.2%). A related EGFR antibody, panitumumab, has been examined in the randomized phase II trials for HNSCC, CONCERT-1,31 and CONCERT-2.32 CONCERT-2 compared panitumumab plus RT to cisplatin-based chemoradiation in patients with locally ad-vanced HNSCC. This study demonstrated inferior local control at 2 years in those receiving panitumumab (51% vs 61%). Toxic-ities were considered to be similar between the groups, with the exception of increased skin toxicity in the panitumumab group (24% vs 11%). CONCERT-1 examined panitumumab plus cis-platin-based chemoradiation compared with chemoradiation alone. This trial demonstrated no additional benefit with the ad-dition of panitumumab. There were more treatment breaks and grade ≥3 AEs in the panitumumab arm, most commonly muco-sal inflammation (55% vs 24%), radiation dermatitis (28% vs 13%), and dysphagia (39% vs 27%). There was one treatment-re-lated death in each arm in this trial. Small-Molecule InhibitorsErlotinib, an EGFR small-molecule inhibitor, has been shown to be well tolerated in combination with: capecitabine and RT in locally advanced pancreatic cancer33; capecitabine, bevacizum-ab, and RT in rectal cancer34; and RT in esophageal cancer.35 A phase II trial combining erlotinib with stereotactic body RT for patients with progressive metastatic NSCLC demonstrated improved PFS and OS compared with historical controls, and was well tolerated, with only two of 24 RT-related grade 3 toxici-ties.36 Similarly, a phase II trial of erlotinib combined with temo-zolomide in addition to RT in glioblastoma multiforme reported better survival than historical controls and an acceptable safety profile.37 However, a randomized phase II trial comparing erlo-tinib plus cisplatin-based chemoradiation with chemoradiation alone in patients with locally advanced HNSCC demonstrated no difference in clinical complete response rates between the two groups.38 The addition of erlotinib did not increase the rate of AEs overall, but patients receiving erlotinib experienced a higher rate of grade 3 rash (13% vs 2%). Sunitinib, a multikinase inhib-itor, has been shown to be well tolerated when combined with ADT and RT in localized high-risk prostate cancer,39 in combina-tion with RT for central nervous system (CNS) malignancies,40 and for oligometastatic disease,41 with good clinical responses in phase I and II studies.41

The proteasome inhibitor bortezomib may radiosensitize tu-mors by blocking DNA repair and has been examined in several phase I and II trials.42 In a phase I/II trial examining the addition of bortezomib to carboplatin, paclitaxel, and RT for stage III NS-

AJHO_CallForPapers_2'16.indd 5 2/22/16 2:43 PM

AUGUST 4-6, 2016Hyatt Regency Huntington BeachHuntington Beach, CA


17th AnnualInternational

The International Lung Cancer Congress® provides current, practical information on the management of lung cancer, as well as a look at the novel agents and strategies that will shape the future of lung cancer therapy. Leading international and national faculty will address critical topics in lung cancer staging, personalized therapy, and the latest clinical data impacting the treatment of lung cancer. Cutting-edge lectures, panel discussions, multidisciplinary tumor boards, and interactive question-and-answer sessions will provide a unique opportunity for participants to engage with faculty as they share their perspectives and personal experiences on the clinical challenges and ongoing controversies in lung cancer management. The meeting also includes a recurring session that highlights clinical research activity of cooperative groups in the United States, Europe, and Asia.

Physicians’ Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.This activity has been approved for AMA PRA Category 1 Credit™. Physicians’ Education Resource®, LLC, is approved by the California Board of Registered Nursing, Provider #16669.PER® complies with the Physician Payments Sunshine Act as part of the Affordable Care Act. Accordingly, we may be required to collect information on transfers of value provided to any covered recipient under the Act.

JULY 22 - 23, 2016Crowne Plaza® Times Square ManhattanNew York, NY


The 15th Annual International Congress on the Future of Breast Cancer® serves as an update on advances in the breast cancer field, with a focus on the clinical implications of breast cancer genetic and phenotypic subtyping. Novel agents, strategies, and improved regimens are changing the future of breast cancer therapy, and these advances and their clinical impact are highlighted throughout the program. Current controversies in the field are also addressed and debated and new data presented, along with information about how to optimally individualize breast cancer therapy. This conference provides a unique opportunity for medical, surgical, and radiation oncologists and other health care professionals to learn from and interact with international leaders in breast cancer in order to increase knowledge, apply new data to practice, and ultimately improve patient outcomes.

CME MOCABIM

ACCREDITED

ChairJoyce A. O’Shaughnessy, MD

Chair, Breast Cancer ResearchCelebrating Women Chair in Breast Cancer ResearchBaylor Charles A. Sammons Cancer CenterTexas OncologyThe US Oncology Network Dallas, TX

Physicians’ Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Physicians’ Education Resource®, LLC designates this live activity for a maximum of 14.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physicians’ Education Resource®, LLC is approved by the California Board of Registered Nursing, Provider #16669 for 14.5 Contact Hours.

This activity is supported by an educational grant from Lilly.

For further information concerning Lilly grant funding visit www.lillygrantoffice.com.

PER® complies with the Physician Payments Sunshine Act as part of the Affordable Care Act. Accordingly, we may be required to collect information on transfers of value provided to any covered recipient under the Act.

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 14.5 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Program DirectorsDavid R. Gandara, MD

Professor of MedicineDivision of Hematology/OncologyDirector, Thoracic Oncology ProgramSenior Advisor to the DirectorUC Davis Comprehensive Cancer CenterSacramento, CA

Roy S. Herbst, MD, PhDEnsign Professor of Medicine (Medical Oncology)Professor of PharmacologyChief of Medical OncologyAssociate Director for Translational ResearchYale Cancer CenterYale School of MedicineNew Haven, CT

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