Anthony W. Tolcher,1 Stanislaw Mikulski,2 Wells A. Messersmith,3 Eunice L. Kwak,4 Darlene Gibbon,5 John F. Boylan,2 Zhi X. Xu,2 Mark DeMario,2 Jennifer J. Wheler6

1START (South Texas Accelerated Research Therapeutics), San Antonio, TX; 2Hoffmann- La Roche, Inc., Nutley, NJ; 3University of Colorado Cancer CenterAurora, CO; 4Massachusetts General Hospital, Boston, MA; 5The Cancer Institute of New Jersey, New Brunswick, NJ; 6UT M.D. Anderson Cancer Center, HoustonTX, USA

A phase I study of RO4929097, a novel γ-secretase inhibitor, in patients with advanced solid tumors

Background

• The Notch signaling pathway is involved in cell fate decisions during normal development, and has a pro-oncogenic function in several solid tumors1

• γ-secretase is a large intramembrane protease complex which is a key mediator in the Notch signaling pathway2

• By preventing Notch activation, it is anticipated that γ-secretase inhibitors may inhibit tumor growth

• RO4929097 is a potent, selective, small molecule γ-secretase inhibitor3

• A phase I study was performed to evaluate the safety, pharmacokinetics and activity of RO4929097 in patients with refractory, advanced solid tumors

1. Koch U, Radtke F. Cell Mol Life Sci 2007;64:2746-62

2. Huppert et al. Nature 2000;405:966-703. Luistro L, et al. Cancer Res 2009;69:7672-80

RO4929097: in vitro activity

• RO4929097 IC50 for γ-secretase is 4 nmol/L, with >100-fold selectivity in panel of 75 other proteins

• After RO4929097 exposure, the phenotype of NSCLC A549 tumor cells becomes more differentiated, similar to primary bronchial epithelial cells

DMSO control 100nM 500nM Primary bronchial epithelial cells

Luistro, L et al. Cancer Res 2009;69:7672-80

RO4929097: in vivo activity

• Activity in 7 of 8 human tumor xenografts (10 mg/kg qd dosing)

• Sustained inhibitory activity after 7 or 14 days dosing supports intermittent dosing regimens in the clinic

Tumor Type Tumor growth inhibition (%)

LOVO (colon) 83

BxPC3 (pancreatic) 82

HCT-116 (colon) 76

A549 (NSCLC) 70

AsPC-1 (pancreatic) 58

MiaPaCa-2 (pancreatic)

53

Calu-6 (NSCLC) 42

H460a (NSCLC) 8

Luistro, L et al. Cancer Res 2009;69:7672-80

Study objectives

Primary objectives

•Determine maximum tolerated doses (MTD) for two schedules

•Recommend phase II doses

•Characterize safety and tolerability profile

Secondary objectives

•Pharmacokinetics

•Pharmacodynamics

�molecular biomarkers in plasma, tumor, surrogate tissues

•Anti-tumor activity

Study design

• Phase I, non-randomized, 2-arm, open-label, multicenter study

• RO4929097 given orally in two different schedules:

Schedule A: 3 days on/4 days off wks 1 & 2, q3 wks (1st 2 cycles) then continuous administration

Schedule B: days 1-7 q3 wks

1Day 8 15

Schedule A

Schedule B

29 36 43

Continuous starting week 7

50

Assessments

•Standard safety assessments (NCI-CTC)

•PK samples cycle 1 (1st and last dosing days) and cycle 2 (day 1)

•CYP3A4 induction (midazolam DDI substudy)

•Effects of γ-secretase inhibition on:

– Aβ-40 (plasma)

– Hes-1 and MYC expression (hair follicles)

– Hes-1, MYC, ICN-1 and additional biomarkers (tumor tissue)

– Soluble markers angiogenesis/cytokines

•Tumor assessments (RECIST) every 6 weeks by CT or MRI

•PET-CT evaluation at baseline, cycles 1 and 2

Patient demographics

N=94*

Age, median (range), years 60 (26-87)

Sex (male/female), % 46/54

ECOG (0/1/2), % 28/70/2

Tumor type, %

MelanomaColorectalSarcomaOvarianNeuroendocrineHormone-refractory prostateOther

20 1311107732

Median no. prior regimens (range)

3 (0-12)

*Schedule A (n=47); Schedule B (n=47)

Dose-limiting toxicities

•DLTs observed in 4 patients:– Hypophosphatemia (transient grade 3): schedule B 27 mg (n=2)

– Asthenia (transient grade 3): schedule A 80 mg (n=1)

– Pruritus (grade 3): schedule B 60 mg (n=1)

•DLTs have not precluded dose escalation on either schedule

•RO4929097 dose range used to date:‒ Schedule A: 3-270 mg

‒ Schedule B: 3-135 mg

•Maximum tolerated doses:– Schedule A: not reached (PK-related stopping of dose escalation)

– Schedule B: not reached (PK-related stopping of dose escalation)

Safety summary

• RO4929097 is well tolerated

• Skin and gastrointestinal events and fatigue are the most common treatment-related toxicities

• Most (95%) treatment-related events are grade 1/2 severity

• No grade 4 events have been reported

• Discontinuations for related events occur rarely (2%)

• Dose adjustments in any cycle are also uncommon (11%)

Common treatment-related AEs (≥10%)

Event

Incidence [no. patients (%)]

Overall (n=94)

By NCI CTC grade

By schedule

1 2 3

Schedule A

(n=47)

Schedule B

(n=47)

Nausea 25 (27) 19 6 0 11 (23) 14 (30)

Skin (rash,eczema, pruritus)

22 (24)

14 5 3 5 (11) 17 (36)

Fatigue 17 (18) 5 12 0 9 (19) 8 (17)

Diarrhea 15 (16) 10 4 1 6 (12) 9 (19)

Hypophosphatemia

14 (15) 0 9 5 3 (6) 11 (23)

Emesis 11 (12) 7 4 0 3 (6) 8 (17)

Pharmacokinetics

• Exposure increased with dose in both schedules • Exposure reaches/exceeds effective levels in

xenograft model at doses ≥6 mg

3 6 12 18 27 40 60 90 135

20000

15000

10000

5000

0

45000

40000

30000

25000

35000

30mg/kg nude mouse efficacy exposure (~5200 ng*hr/mL)

10mg/kg nude mouse efficacy exposure (~1700 ng*hr/mL)

Schedule B

AU

C0

-24

(n

g*h

r/m

L)

Dose (mg)

C1D1

C1D7

C2D1

Schedule A

3 6 12 24 36 54 80 120 180 270

40000

30000

20000

10000

0

80000

70000

60000

50000

Dose (mg)

AU

C0

-24

(n

g*h

r/m

L)

P4503A4: auto-induction potential

• Exposure increases with dose on day 1 of both schedules

• At high doses, exposure decreases after repeated dosing

• After ‘drug holidays’ in both schedules, exposure returns to day 1 levels generally on day 1 of cycle 2 in most patients

• Auto-induction of P4503A4 is considered the most likely reason for decreased exposure after repeated dosing

• Preclinical study indicated that RO4929097 is 3A4 substrate and inducer

• Importantly, exposure reaches/exceeds effective levels estimated from xenograft model at doses ≥6 mg, including dose cohorts that demonstrated auto-induction

Pharmacodynamics: plasma Aβ40

• Increase in Aß40 levels 0-4 hrs postdose, followed by decrease towards baseline by 24 hrs

• At higher doses, decrease below baseline is durable up to 24 hrs postdose

• Data consistent with dose-dependent modulation of γ-secretase proteolytic activity

0 5 10 15 20

-20

60

40

20

0

Schedule A%

ch

an

ge

fro

m B

L

ABeta % change from BL, Sch A

3

12

246

270

180

80120

5436

Time (hour)

Dose (mg)

0 5 10 15 20

-20

60

40

20

0

80

100

Schedule B

% c

ha

ng

e f

rom

BL

ABeta % change from BL, Sch B

18

12

3

40

60

90

135

6

27

Time (hour)

Dose (mg)

Activity: clinical benefit summary

• Tumor types most commonly among clinical benefit population

– Melanoma (6 of 19 patients)

– Sarcoma (3 of 10 patients)

– Ovarian (3 of 9 patients)

– 11 patients (12%) had FDG-PET response (EORTC criteria) in cycle 1 or 2

No. of patients (%)

Duration of therapy

Schedule A (n=47)

Schedule B (n=47)

Total (n=94)

≥4 cycles (3 months)

12 (25) 14 (30) 26 (28)

≥8 cycles (6 months)

3 (6) 4 (9) 7 (7)

Patient / tumor / disease burden

Schedule

Dose Best Response

25F, epithelial sarcoma, soft tissue and pulm mets

B 6 mgMixed response, overall –12% RECIST; 6 cycles total

69F, melanoma, in transit mets

B 18 mg

Near 100% PET response, Clinical flattening of in

transit lesions; 16 cycles total

39M, melanoma, widespread cutaneous mets

B 27 mg-27% (RECIST), measurable

disease; 6 cycles total

76F, neuroendocrine colon peritoneal and nodal disease

B 40 mg RECIST PR; 10 cycles total

51F, sarcoma cervical paraspinal

B 60 mg

Prolonged SD, 10 cyclesPD, 2 mo. on last prestudy

Rx

54M, chondrosarcoma, peritoneal & soft tissue mets

A 80 mg

Prolonged SD (10 cycles total) + C2 PET – 31%,

PD < 3mo. on last prestudy Rx

Antitumor Activity: patient details

Case study: PET scansMay 5 2008

PretreatmentJune 11 2008

Post C2

Jan 6 2009 May 19 2009

Case study: CT scans

Conclusions

• RO4929097 is safe and well tolerated with prolonged administration on two intermittent dosing schedules

• Day 1 drug exposures increase with dose for both schedules, but decreases at later time-points with repeated dosing at higher dose levels consistent with auto-induction

• Aβ40 data suggest RO4929097 modulates γ-secretase activity at all doses

• Encouraging signs of anti-tumor activity (RECIST responses and prolonged SD), including melanoma and sarcoma

Next steps

• In the present study, cohort expansions and paired tumor biopsies are currently ongoing to define phase II doses

• Phase II study in 2nd/3rd line NSCLC initiated

• A collaboration with CTEP, US NCI is ongoing; over 30 clinical studies are currently planned

Acknowledgements

START Cancer Institute of New JerseyAmita Patnaik Cecilia Thomas

Kyri Papadopoulos Jacalyn Neceskas

MD Anderson Univ. ColoradoRozelle Kurzrock Sarah Eppers

Chetna Wathood Stacy Grolnic

Massachusetts General HospitalGeoffrey Shapiro

Donald Lawrence

Trial sponsored by Hoffmann La-RocheStacey Ukrainskyj

Karen Wang

Our Patients and their families

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