ESMO E-Learning: The Use of Biomarkers for Treatment ... · The use of biomarkers for treatment...

The use of biomarkers for treatment decisions

in oncology1Timothy A Yap, MD PhD and

2Debra Josephs, MD PhD1The Institute of Cancer Research and Royal Marsden Hospital, London, UK;

2Kings College London, UK

Definition of a biomarker

“Characteristic objectively measured and evaluated as indicator of normal biological processes, pathogenic processes or pharmacologic responses to a therapeutic intervention.”

(US National Institutes of Health Biomarkers Definition Working Group)

Key component of translational research

Biomarkers Definitions Working Group (2001) Clin Pharmacol Ther 69:89-85

Reprinted by permission from Macmillan Publishers Ltd: Yap T A et al. Nat. Rev. Cancer 2010;10: 514–523, copyright (2010)

Need right biomarker for the right drug in the right patient at the right time

Past

Current & future

Biomarker-driven drug treatment

Changing focus of anticancer drug development

Translational research in new drug development

Transfers preclinical research into clinical practice:

Study of the biology of the disease Evaluation of the biological effects of the drugs in animals Study of the biological effects of those drugs in humans

Biomarkers and drug development

Used during different steps of drug development in order to:

Define the target deregulation correlate to tumour development (proof of target)

Verify the interaction between the drug and the target or pathway (proof of principle)

Verify that alteration of a specific target is crucial for a specific tumour in humans (proof of concept)

Verify that the interaction between drug and target is responsible for biological effects (proof of activity)

Define a range of doses (biologically active dose range) Provide rationale for combination therapies (crosstalk and

feedback loops)

Park JW et al. Clin Cancer Res 2004;10:3885-3896

Reprinted by permission from Macmillan Publishers Ltd: Yap TA et al. Nat. Rev. Cancer 2010;10: 514–523, copyright (2010)

Rational framework for assessing the risk of failure of the development of a new agent at any particular stage

Provides basis for making key decisions, such as determining the optimal dose range and schedule of a new compound and whether to continue or terminate a drug development programme

Pharmacological audit trail

Biomarkers classification

Three main categories (US-NCI):

A. Prognostic biomarkers

B. Predictive biomarkers

C. Pharmacodynamic biomarkers

Kellof GJ, et al. Clin Cancer Res 2004;10:3881-3884Sawyers CL, et al. Nature 2008;452:548-552


Correlate with clinical outcome and allow prediction of the natural course of cancer

Guide the therapeutic decision

They include: 1. Biological progression markers 2. Risk biomarkers (or screening biomarkers)


1. Biological progression markers

Measures of tumour activity (CEA, alphaFP, PSA, CA-125, hCG)


2. Risk biomarkers (or screening biomarkers)

Describe risk of cancer occurrence or cancer progression because they are implicated in neoplastic progression and include:

1. Carcinogen exposure2. Genetic predisposition (e.g., BRCA1/2 mutations)3. Over expression of genes (e.g., PTEN, BCR-ABL, HER-2/neu,

RAS, AKT)4. Pharmacogenomic parameters (genetic polymorphisms, DNA

methylation, aneuploidy)5. Environmental factors and lifestyle (e.g., HPV or HBV infection,

tobacco use)6. Multifactorial risk models (e.g., Gail model, Oncotype DX, MammaPrint)

B. Predictive biomarkers

Correlate with probability of clinical response to treatment:

Amplification of HER-2 gene in breast cancer for treatment with anti-HER-2

ER/PgR expression in breast cancer for hormone therapy Presence of Philadelphia chromosome (BCR-ABL fusion gene) in

leukaemia for anti-BCR-ABL Mutations of EGFR in lung tumours for EGFR inhibitors Extended RAS mutation wildtype (exons 2, 3 and 4 of KRAS and

NRAS) in colorectal cancer for EGFR monoclonal antibodies BRAF V600E mutations in melanoma for BRAF inhibitors EML4/ALK translocations in lung cancers for ALK inhibitors

C. Pharmacodynamic biomarkers

Correlated to biological and clinical effects of the drug on the tumour Measured in tumour biopsies or normal tissue including platelet-rich

plasma, hair follicles, circulating tumour cells, saliva, or urine

They could be: Lower expression or activity of a molecular target

(e.g., EGFR expression) Decrease in phosphorylation signal of target (e.g. phosphoSer473 AKT) Induction of metabolism (e.g., interference with cytochrome P-450) Interference with cell growth processes

(e.g., Ki-67, BCL-2, cytokeratins) Vascularization and metabolism (imaging biomarkers)

Sarker D et al. Biomarkers Med 2007;1:399-417Yap TA et al. Nat. Rev. Cancer 2010; 10: 514–523 (2010)

“Proximal” and “Distal” biomarkers

Proximal: reflect the immediate effect of the drug on its target (e.g., decrease in a protein substrate of phosphorylation downstream the target kinase such as the phosphorylation of the AKT substrate PRAS40 to reflect the effect of an AKT inhibitor on AKT)

Distal: reflect the effect of the drug downstream the molecular target (e.g., Ki-67 expression for reduction in proliferation)

Applications of biomarkers in drug development

1. Target discovery and validation

2. Preclinical studies

3. First-in-human phase I clinical studies

4. Phase II/III studies

1. Applications of biomarkers in drug development: Target discovery and validation

Identify targets for therapy(e.g., HER-2, VEGF, VEGFR, BCR-ABL, BRAF…):

HER-2 amplification in breast cancer for anti-HER-2 therapy

2. Applications of biomarkers in drug development preclinical studies

Selection of animal models and lead compounds to test

Definition of mechanisms of action in vitro and in vivo

Prediction of the effects of drug combinations

3. Applications of biomarkers in drug development: First-in-human Phase I clinical studies

Evaluate safety and tolerability of a novel compound and select optimal dose for subsequent efficacy trials by establishing the biologically effective dose range and maximum tolerated dose (MTD)

Pharmacokinetic studies (what the body does to the drug) should be undertaken

Pharmacodynamic studies (what the drug does to the body) should be conducted in both tumour and normal tissue, such as platelet-rich plasma and hair follicles

Preliminary signals of antitumour activity may be correlated with predictive biomarkers of response in individual patients

3. Application of biomarkers in Phase I clinical studies: Case studies

PARP inhibitors

AKT inhibitors

MEK and BRAF inhibitors

Immune checkpoint inhibitors

PARP-1 is a key enzyme involved in the repair of single-strand DNA breaks

PAR chains are degraded via PARG

RepairedDNA

PARPDNA damage

Binds directly to SSBs

Repair enzymes

PAR

Nicotinamide+pADPr

NAD+

Once bound to damaged DNA, PARP modifies itself producing large branched chains of PAR

Illustration courtesy of AstraZeneca

3. Application of biomarkers in Phase I clinical studies: PARP inhibitors

Pharmacokinetic (PK) and pharmacodynamic (PD) data

Redrawn from: Fong PC et al. N Engl J Med 2009; 361:123-134

0 100

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200 300 400 500 600Olaparib dose (mg)

0 100

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200 300 400 500 600Olaparib dose (mg)

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(μgxhr/ml)

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Anti-PARantibody

Anti-PARP1antibody

Anti-actinantibody

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Yap et al, ASCO 2007

γH2AX

DAPI

PD analysis: Hair follicles for γ-H2AX foci

Reprinted with permission. © 2007 American Society of Clinical Oncology. All rights reserved. Yap T et al. J Clin Oncol; 25(18S), 2007: abst 3529

3. Application of biomarkers in Phase I clinical studies: PARP inhibitors

RECIST efficacy in BRCA1/2 mutated tumours 1st 60 patients 19 BRCA carriers (15 ovarian, 3 breast, 1 prostate) 8 PR ovarian; 1 CR breast; 1 PR prostate; 2 SD

Redrawn from: Fong PC et al. N Engl J Med 2009; 361:123-134

Progressive disease Stable disease Partial response Complete response

Ovarian cancer Partial response Complete response

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3. Application of biomarkers in Phase I clinical studies: AKT inhibitors

Reprinted by permission from Macmillan Publishers Ltd: Yap TA et al. Nat. Rev. Cancer 2009;9: 167-181, copyright (2009)


Yap TA et al., J Clin Oncol 29, 2011:4688-4695. Reprinted with permission. © 2011 American Society of Clinical Oncology. All rights reserved.

Pair tumour biopsy PD biomarker studies

Hair follicle PD biomarker studies


Yap TA et al., J Clin Oncol 29, 2011:4688-4695. Reprinted with permission. © 2011 American Society of Clinical Oncology. All rights reserved.

Biomarker-driven case study of responding patient on MK-2206


Reprinted from Yap TA et al., Clin.Cancer Res, 20: 5672-5685, copyright 2014, with permission from AACR

Platelet-rich plasma PD biomarker studies

3. Application of biomarkers in Phase I clinical studies: MEK and BRAF inhibitors

Reprinted from Clin. Cancer Res, copyright 2010, 16(13): 3329-3334, Pratilas C et al., Targeting the Mitogen-Activated Protein Kinase Pathway: Physiological Feedback and Drug response, with permission from AACR

3. Application of biomarkers in Phase I clinical studies: MEK inhibitor

Inhibition of ERK phosphorylation has been proposed as a PD proof-of-mechanism biomarker of MEK inhibitor activity

A phase I study of a MEK inhibitor (AZD6244) was designed in two parts

The first, to determine the maximum tolerated dose, was also used to document a dose-dependent inhibition of ERK phosphorylation in a surrogate tissue (PBMC)

The second part demonstrated consistent inhibition of ERK phosphorylation and reduction in the Ki-67 labelling index, a marker of cell proliferation, when comparing pre- and post-treatment tumour biopsies at all doses

Therefore a lower dose level (50% of the MTD) could be recommended as the tolerable phase II dose

Adjei AA et al., J Clin Oncol. 2008; 26(13): 2139-2146


Inhibition of ERK phosphorylation

Adjei AA et al., J Clin Oncol. 2008; 26(13): 2139-2146 Reprinted with permission.© 2008 American Society of Clinical Oncology. All rights reserved

In peripheral-blood mononuclear cell samples

Pre-treatment Post-treatment

In paired tumour samples Tumor cell nuclei H-score for pERK

ERK phosphorylation

Before study (%inhibition) Day 7-21 (% inhibition)Before dose

(n=50)*After 1 hour

(n=50)Before dose

(n=25)After 1 hour

(n=22)Mean 0 65.4 51.0 69.2

Median 0 66.0 59.0 76.0

Range 0 5-100 3-90 15-97


Reduction in Ki-67 labelling indexPre-treatment Post-treatment

Proportion of tumour cell nuclei staining for Ki-67

Change in target lesion size

Adjei AA et al., J Clin Oncol. 2008; 26(13): 2139-2146, Reprinted with permission. © 2008 American Society of Clinical Oncology. All rights reserved

3. Application of biomarkers in Phase I clinical studies: BRAF inhibitor

Somatic mutations of BRAF kinases are present in approximately 60% melanomas. An activated single substitution V600E accounts for 80% of BRAF mutations in malignant melanoma

Phase I study of PLX4032, an orally available inhibitor of V600E mutated BRAF

Patients with melanoma with BRAF V600E mutation were overrepresented because of selective activity of PLX4032 against such tumours in preclinical testing

PLX4032 induced complete or partial tumour regression in 81% of patients who had melanoma with the V600E BRAF mutation proving this as an excellent predictive biomarker

Flaherty KT et al., N Engl J Med 2010; 363:809-19; Bollag G et al., Nature 2010; 467:596–599


Anti-tumour response in patients with melanoma carrying V600E BRAF mutation

Flaherty KT et al., N Engl J Med 2010;363:809-19, Copyright © 2010 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society Bollag G et al., Nature 2010; 467: 596–599


A cohort of patients had paired tumour biopsies collected before treatment and following two weeks of treatment, to evaluate pathway inhibition

Phosphorylated-ERK (pERK) levels were determined by immunohistochemistry (IHC) to monitor ERK pathway activity. To monitor proliferation, Ki67 levels were also measured

Levels of pERK and Ki67 were decreased in most biopsies following two weeks of dosing, even in patients with modest drug exposure

However, only patients exposed to plasma levels of PLX4032 higher than 300 μM/h experienced tumour regression. In these patients, pathway analysis typically showed >80% inhibition of cytoplasmic pERK indicating that near-complete inhibition of ERK signaling may be needed for significant tumour response

Flaherty KT et al., N Engl J Med 2010;363:809-19; Bollag G et al., Nature 2010; 467: 596–599


IHC of pERK, Cyclin D1 and Ki67 in paired tumour biopsies

Flaherty KT et al., N Engl J Med 2010;363:809-19, Copyright © 2010 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society Reprinted by permission from Macmillan Publishers Ltd: Bollag G et al., Nature 2010; 467: 596–599 copyright (2010)


Correlation of reduction in cytoplasmic pERK with tumour responses

Reprinted by permission from Macmillan Publishers Ltd: Bollag G et al., Nature 2010; 467: 596–599 copyright (2010)


Oncogenic BRAF has been demonstrated as an important stimulator of metabolic activity

In preclinical studies, PLX4032 rapidly inhibited fluorodeoxyglucose(FDG) uptake specifically in BRAFV600E mutant melanoma cell lines

Therefore, FDG uptake in patients on the PLX4032 phase I trial was assessed using PET imaging before treatment and following two weeks of dosing

All of the assessable patients treated with PLX4032 experienced major reductions in FDG uptake

Bollag G et al., Nature 2010; 467: 596–599


PET scans for patients taken pre-dose and following 2 weeks of dosing

Reprinted by permission from Macmillan Publishers Ltd: Bollag G et al., Nature 2010; 467: 596–599, copyright (2010)

3. Application of biomarkers in Phase I clinical studies: Immune checkpoint inhibitors

Reprinted by permission from Macmillan Publishers Ltd: Drake, C G et al. Nat Rev Clin Oncol. 2014 Jan; 11(1): 24–37, published on-line 19.3.2013, copyright (2013)

Anti-CTLA-4 antibodies

Anti-PD-1 and anti-PD-L1antibodies

The Immune Synapse

3. Application of biomarkers in Phase I clinical studies: MPDL3280A (anti-PD-L1 antibody)

PD-L1 expression (by tumour cells or tumour-infiltrating immune cells) has emerged as a potential predictive biomarker for PD-1–directed therapy

A urothelial bladder cancer (UBC) expansion cohort of a phase I trial of anti-PD-L1 antibody, MPDL3280A addressed this

Immune cell (but not tumour cell) PD-L1 levels predicted response to MPDL3280A

Results demonstrated that the likelihood of response could be increased by determining the PD-L1 status of tumour-infiltrating immune cells (predictive biomarker)

Powles T et al, Nature, 2014 Nov 27;515(7528):558-62

3. Application of biomarkers in Phase I clinical studies: MPDL3280A (anti-PD-L1)

Immune cell (but not tumour cell) PD-L1 levels predict response to MPDL3280A in UBC

Reprinted by permission from Macmillan Publishers Ltd: Powles T et al., Nature. 2014 Nov 27;515(7528):558-62, copyright (2014)

Positive PD-L1 expression

3. Application of biomarkers in Phase I clinical studies: MPDL3280A (anti-PD-L1)

Immune cell PD-L1 levels predict response to MPDL3280A in UBC

Reprinted by permission from Macmillan Publishers Ltd: Powles T et al., Nature. 2014 Nov 27;515(7528):558-562, copyright (2014)


Novel biomarkers associated with clinical response to PD-1 directed therapy are still required

Part A of the phase 1 study, in all tumour types, analysed other mechanisms associated with clinical response to the anti-PD-L1 antibody, MPDL3280A

PD-L1 expression, T-helper type 1 gene expression, and CTLA4 expression in pre-treatment samples was associated with clinical response to MPDL3280A

RNA isolated from regressing lesions displayed expression patterns indicative of a generalized activation of CD8 and TH1 T-cell responses

This data suggest that MPDL3280A is most effective in patients in which pre-existing immunity is suppressed by PD-L1, and is re-invigorated on antibody treatment

Herbst RS et al., Nature 2014; 515: 563–567


PD-L1 expression in pre-treatment samples was associated with clinical response to MPDL3280A

Reprinted by permission from Macmillan Publishers Ltd: Herbst RS et al., Nature 2014; 515: 563–567 copyright (2014)


Expression of CTLA4 in pre-treatment tumours correlated strongly with response after MPDL3280A

Suggests that CTLA4 may also be a marker of the presence of activated T cells whose functional role as a negative regulator of intra-tumouralT cells appears to be less important than that of PD-L1



RNA isolated from regressing lesions, analysed for the presence of transcripts of immunological importance, displayed expression patterns indicative of a generalised activation of CD8 and TH1 T-cell responses


4. Applications of biomarkers in drug development: Phase II/III clinical studies

Prospective or retrospective collection of tissue samples and performance of molecular analyses to identify mechanisms responsible of biological effects

Could be used as prediction of clinical outcome to identify active drugs for phase III trials

Conclusions

Biomarkers are key components of translational studies, useful in the process of drug development of molecular targeted agents

Biomarkers are useful in the process of dose escalation, definition of schedule and doses for subsequent phase II studies

There is still insufficient knowledge of the dynamic interaction between drug and target to justify a “pharmacodynamically-only” driven strategy.

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