Nuevos Agentes en el Manejo de Cáncer Colorectal: Dónde

Incorporalos?

Prof. Dr. Paulo M. Hoff Instituto do Câncer do Estado de São

Paulo - ICESP Faculdade de Medicina

Universidade de São Paulo (USP)

Conflicts of interest

•  Scientific consultant:

–  Roche, Astra-Zeneca

•  Research support:

–  Roche, Astra-Zeneca, Novartis, Sanofi-

Aventis, Pfizer, CNPq

•  All honoraria received by me from

pharmaceutical companies is donated to

filantropic institutions

Treatment options for advanced colorectal cancer in 2012

•  Six different classes/ 13 drugs available: –  Fluoropyrimidines •  5-FU, FUDR, Capecitabine, UFT, S-1

–  Platins •  Oxaliplatin

–  Topoisomerase I inhibitors •  Irinotecan

–  Direct TS inhibitors •  Raltitrexed

–  Anti-VEGF •  Bevacizumab, regorafenib, aflibercept

–  Anti-EGFR •  Cetuximab, Panitumumab

Disponibilidade de todos os agentes citotóxicos relacionados com a sobrevida

Grothey A. ASCO GI 2006. General Session. Grothey A and Sargent D. J Clin Oncol. 2005;23:9441-9442.

Pacientes com 3 drogas (%)

0

SG M

ed

iana

(m

ese

s)

10 20 30 40 50 60 70 80

13 14 15

16

17 18 19

20 21 22

12

New concepts in CRC

•  Maintenance therapy vs treatment breaks

•  Sequential therapy

•  Molecular targeted treatments

•  Individualization of therapy

•  Neo-adjuvant therapy

•  Conversion therapy

•  “Continuum of care” – Strategic planning

Molecular events and cancer

Signal Transduction

Autocrine growth factor secretion

Matrix metalloproteinase secretion

Changes in oncogenes and tumor suppressor genes

Angiogenesis

Deregulation of growth factors and receptors

VEGF Pathway as a Target

Impact of Bevacizumab

•  Increased PFS with all tested regimens

•  Increased RR and OS with fluoropirimidines

alone and with irinotecan based regimens

•  Did not increase RR nor OS with oxaliplatin

based regimens in first line (only second)

•  May be benefitial even after first PD

BEV + standard first-line CT (either oxaliplatin or

irinotecan-based) (n=820)

Randomise 1:1

Standard second-line CT (oxaliplatin or irinotecan-based)

until PD

BEV (2.5 mg/kg/wk) + standard second-line CT

(oxaliplatin or irinotecan-based) until PD

PD

ML18147 study design (phase III)

CT switch: Oxaliplatin → Irinotecan

Irinotecan → Oxaliplatin

Study conducted in 220 centres in Europe and Saudi Arabia

Primary endpoint •  Overall survival (OS) from randomisation

Secondary endpoints included

•  Progression-free survival (PFS) •  Best overall response rate •  Safety

Stratification factors •  First-line CT (oxaliplatin-based, irinotecan-based) •  First-line PFS (≤9 months, >9 months) •  Time from last BEV dose (≤42 days, >42 days) •  ECOG PS at baseline (0/1, 2)

Arnold ASCO 2012

PFS: ITT population P

FS e

stim

ate

Time (months)

1.0

0.8

0.6

0.4

0.2

0

0 6 12 18 24 30 36 42

No. at risk CT 410 119 20 6 4 0 0 0 BEV + CT 409 189 45 12 5 2 2 0

CT (n=410) BEV + CT (n=409)

4.1 mo 5.7 mo

Unstratifieda HR: 0.68 (95% CI: (0.59–0.78) p<0.0001 (log-rank test)

Stratifiedb HR: 0.67 (95% CI: 0.58–0.78) p<0.0001 (log-rank test)

aPrimary analysis method; bStratified by first-line CT (oxaliplatin-based, irinotecan-based), first-line PFS (≤9 months, >9 months), time from last dose of BEV (≤42 days, >42 days), ECOG performance status at baseline (0, ≥1)

Arnold ASCO 2012

OS: ITT population O

S e

stim

ate

Time (months)

1.0

0.8

0.6

0.4

0.2

0

0 6 12 18 24 30 36 42 48

No. at risk CT 410 293 162 51 24 7 3 2 0 BEV + CT 409 328 188 64 29 13 4 1 0

CT (n=410) BEV + CT (n=409)

9.8 mo 11.2 mo

Unstratifieda HR: 0.81 (95% CI: 0.69–0.94) p=0.0062 (log-rank test)

Stratifiedb HR: 0.83 (95% CI: 0.71–0.97) p=0.0211 (log-rank test)

aPrimary analysis method; bStratified by first-line CT (oxaliplatin-based, irinotecan-based), first-line PFS (≤9 months, >9 months), time from last dose of BEV (≤42 days, >42 days), ECOG performance status at baseline (0, ≥1)

Median follow-up: CT, 9.6 months (range 0–45.5); BEV + CT, 11.1 months (range 0.3–44.0)

Arnold ASCO 2012

Aflibercept

  Fusion protein of key domains from human VEGF receptors 1 and 2 with human IgG Fc¹

  Blocks all human VEGF-A isoforms, VEGF-B, and placental growth factor (PlGF)²

  High affinity – binds VEGF-A and PlGF more tightly than native receptors

1.  Holash J et al. Proc Natl Acad Sci USA. 2002;99:11393-11398.

2.  Tew WP et al. Clin Cancer Res. 2010;16:358-366.

VELOUR Study Design

Primary endpoint: overall survival Sample size: HR=0.8, 90% power, 2-sided type I error 0.05 Final analysis of OS: analyzed at 863rd death event using a 2-sided nominal significance level of 0.0466 (α spending function)

Metastatic Colorectal Cancer

R A N D O M I Z E

Aflibercept 4 mg/kg IV, day 1 + FOLFIRI q2 weeks

Placebo IV, day 1 + FOLFIRI q2 weeks

1:1 Disease Progression Death

600

600 Stratification factors: •  ECOG PS (0 vs 1 vs 2) •  Prior bevacizumab (Y/N)

Van Cutsem E et al. ESMO/WCGC 2011, Barcelona, Abstract O-0024.

VELOUR Study

Van Cutsem E et al. ESMO/WCGC 2011, Barcelona, Abstract O-0024.

OS PFS

Overall Survival: Stratified by Prior Bevacizumab –

ITT Population

Van Cutsem E et al. ESMO/WCGC 2011, Barcelona, Abstract O-0024.

Safety: Adverse Events

Prior Bevacizumab No Prior Bevacizumab

Safety Population, % of Patients

Placebo/ FOLFIRI (n=172)

Aflibercept/ FOLFIRI (n=171)

Placebo/ FOLFIRI (n=433)

Aflibercept/ FOLFIRI (n=440)

Serious AEs 32 52 33 47

Any AE leading to death 6 6 4 6

Grade 3/4 AEs in >10% of patients in any treatment group

Neutropenia 13 20 25 27

Diarrhea 9 19 7 20

Asthenic conditions 9 16 11 17

Infections and infestations 8 14 7 12

Stomatitis 4 11 5 14

CORRECT: Patients with metastatic colorectal cancer treated with regorafenib or placebo after

failure of standard therapy

•  Multicenter, randomized, double-blind, placebo-controlled, phase III –  Stratification: prior anti-VEGF therapy, time from diagnosis of metastatic disease, geographical region

•  Global trial: 16 countries, 114 centers •  Recruitment: May 2010 to March 2011

2:1

Evaluation with CT scan of abdomen and chest every 8 weeks

Van Cutsem ASCO 2012

Regorafenib significantly improves PFS compared to placebo

Progression-free survival (secondary endpoint)

Van Cutsem ASCO 2012

Overall survival (primary endpoint) Primary endpoint met prespecified stopping criteria at interim analysis

(1-sided p<0.009279 at approximately 74% of events required for final analysis)

Van Cutsem ASCO 2012

Overall response and disease control rates (secondary endpoints)

Best response, % Regorafenib N=505

Placebo N=255

Complete response 0 0

PR 1.0 0.4

SD 42.8 14.5

Progressive disease 49.5 80.0

DCR* 41.0 14.9

*DCR = PR + SD (≥6 weeks after randomization); p<0.000001

Regorafenib significantly improves DCR compared to placebo

Van Cutsem ASCO 2012

Drug-related treatment-emergent adverse events occurring in ≥10% of patients

Adverse event, %

Regorafenib N=500

Placebo N=253

All grades

Grade 3 Grade 4 Grade 5* All grades

Grade 3 Grade 4 Grade 5*

Hand-foot skin reaction 46.6 16.6 0 0 7.5 0.4 0 0

Fatigue 47.4 9.2 0.4 0 28.1 4.7 0.4 0

Hypertension 27.8 7.2 0 0 5.9 0.8 0 0

Diarrhea 33.8 7.0 0.2 0 8.3 0.8 0 0

Rash / desquamation 26.0 5.8 0 0 4.0 0 0 0

Anorexia 30.4 3.2 0 0 15.4 2.8 0 0

Mucositis, oral 27.2 3.0 0 0 3.6 0 0 0

Thrombocytopenia 12.6 2.6 0.2 0 2.0 0.4 0 0

Fever 10.4 0.8 0 0 2.8 0 0 0

Nausea 14.4 0.4 0 0 11.1 0 0 0

Bleeding 11.4 0.4 0 0.4 2.8 0 0 0

Voice changes 29.4 0.2 0 0 5.5 0 0 0

Weight loss 13.8 0 0 0 2.4 0 0 0 * Grade 5 drug-related AEs: 1.0% in regorafenib arm vs 0% in placebo arm

EGFR Pathway as a Target

Targeting the EGFR pathway: K-Ras mutations

Adapted from Roberts Der. Oncogene 2007

K-Ras mutation: • CRC (30–50%) • Pancreatic cancer (90%) • Papillary thyroid cancer (60%) • NSCLC (30%)

EGFR overexpression: •  CRC (27–77%) • Pancreatic cancer (30–50%) • Lung cancer (40–80%) • NSCLC (14–91%)

EGFR mutation: • NSCLC (10%) • Glioblastoma (20%)

MAPK

MEK

B-Raf*

K-Ras*

TGF-α

Grb2

Sos

*Mutated in human cancers NSCLC = non-small cell lung cancer TGF = transforming growth factor

EGFR*

Cetuximab and Panitumumab

•  Similar activity but different epitopes in EGFR

•  Only active against wild-type K-Ras, with

question remaining in G13D mutation

•  Increase RR with almost all regimens tested

•  Questions remaining regarding OS, particularly

when combined with oxaliplatin

R

CAIRO 2: Chemotherapy + Bevacizumab and Cetuximab

Capecitabina (2 g/m2, D1-14) Oxaliplatina (130 mg/m2, D1)

Bevacizumabe (7,5 mg/kg, D1)

Capecitabina, Oxaliplatina Bevacizumabe e Cetuximabe (400 mg/m2 na semana 1 e

250 mg/m2 semanal)

Punt, et al. N Engl J Med. 2009 Feb 5;360(6):563-72

Previously Untreated CRC Pts

N=736

CAIRO2: PFS

Punt, et al. N Engl J Med. 2009 Feb 5;360(6):563-72

Bevacizumab + XELOX: 10.7 months (9.7-12.5) Bevacizumab + XELOX + cetuximab: 9.6 months (8.5-10.7)

Hazard ratio for progression: 1.21 p value 0.018

0 6 12 18 24 30 Months from randomization

0.0

0.2

0.4

0.6

0.8

1.0

Pro

gre

ssio

n f

ree

surv

ival

pro

bab

ilit

y

How to choose the First-Line?

" Cure

" Extend Survival

" Extend Progression Free Survival

" Relieve symptoms

" Improve quality-of-life

Treatment Goals:

" Extent and Number of Metastatic Sites

" Resectability

" Symptomatic?

" Treatening Vital Organs?

" Need for a Quick Response

" Histology

Tumor Characteristics:

" Performance Status

–  Baseline

–  Tumor related

" Chronological and Physiological Age

" Comorbidities

" Patient wishes!

Patient Characteristics:

$

Treatment Options for mCRC Resectable  Disease   Poten/aly  Resectable   “Agressive”  

Unresectable  Disease  “Indolent”  Unresectable  Disease  

mFOLFOX  (Peri  or  post  surgery)    

FOLFOXIRI  or  FOLFOX/FOLFIRI  +/-­‐  cetuximab*  or  panitumumab*    

FOLFIRI/FOLFOX  +/-­‐  Bevacizumab    

5-­‐FU/LV  or  capecitabine  +/-­‐  Bevacizumab  

Depend  on  first-­‐line   FOLFOX  +/-­‐  Bevacizumab  or  FOLFIRI  +/-­‐  aflibercept  

mFOLFOX  ou  XELOX  +/-­‐  Bevacizumab  

Irinotecan  +  cetuximab*  or  panitumumab*  

Irinotecan  or  FOLFIRI  +/-­‐  aflibercept  

Regorafenib   Irinotecan  +  cetuximab*  or  panitumumab*  

Regorafenib  

* Wild-Type K-Ras

Seculo XIX 1980s 2000

Histology Single gene predictors Multi-gene predictors (?)

Seculo XXI

DNA arrays SNP analysis Multiplex PCR

Proteomics

What Did We Learn?

•  Plan for a sequence of regimens

•  Continuing antiangiogenics likely a good thing

•  Not all patients nor colorectal cancers are equal.

–  Not from the start and they may change as they are treated.

Plan accordingly

•  Biomarker studies are an essential component in large

randomized trials