clinical benefits with tarceva combination therapy in pancreatic cancer malcolm j. moore princess...
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Clinical benefits with Tarceva combination therapy in
pancreatic cancer
Malcolm J. MoorePrincess Margaret Hospital,
University of Toronto
Burden of disease in pancreatic cancer
The incidence of pancreatic cancer is rising
Screening or early detection not developed
Vast majority of patients will die less than a year after diagnosis
– fourth-leading cause of cancer-related deaths
– overall survival is shortest of any solid tumour
The disease is debilitating and there is a need to improve patient symptoms and QoL as well as survival
Trends in the incidence of pancreatic cancer*
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1983 1985 1987 1989 1991 1993 1995 1997
Hong Kong
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1978 1982 1986 1990 1994 1998
Mumbai, India
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1958 1968 1978 1988 1998
Sweden
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1983 1985 1987 1989 1991 1993 1995 1997
Kuwait
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1968 1973 1978 1983 1988 1993
Singapore Chinese
0123456789
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1978 1982 1986 1990 1994
Ontario, Canada
Parkin DM et al, Cancer Incidence in Five Continents, Vol. I to VIII IARC CancerBase No. 7, Lyon, 2005
*Age standardised rates, per 100,000
Pancreatic cancer: a major therapeutic challenge
Most patients are not able to have surgery
Gemcitabine has been the standard of care for patients with advanced disease
1
Little progress in improving clinical outcomes over the last decade
Treatment options remain limited
1Burris H, et al. J Clin Oncol 1997;15:2403–13
Gemcitabine registration study in advanced pancreatic cancer
Burris H, et al. J Clin Oncol 1997;15:2403–13
Gemcitabinen=63
5-FUn=63 p value
Clinical benefit response† (%) 24 5 0.002
Median survival (months) 5.7 4.4 0.002
Time to progression (months) 2.1 0.9 0.001
6-month survival (%) 46 31
1-year survival (%) 18 2
Partial response (%) 5.4 0
Stable disease (%) 39.3 19
†Composite of measurements of pain (analgesic consumption and pain intensity),Karnofsky performance status, and weight
Survival
Phase III combination chemotherapy trials have been negative
Gemcitabine vs gemcitabine + 5-FU Berlin J et al. J Clin Oncol 2002;20:3270–5
Gemcitabine vs gemcitabine + irinotecan Rocha Lima CM et al. J Clin Oncol 2004;22:3776–83
Gemcitabine vs gemcitabine + oxaliplatin Louvet C et al. J Clin Oncol 2005
Gemcitabine vs gemcitabine + pemetrexedOettle H et al. Ann Oncol. 2005;16:1639–45
Gemcitabine vs gemcitabine + exatecanO’Reilly EM et al. Proc ASCO 2004;22:14S (Abs. 4006)
Phase III trials of targeted agents also negative
Ras-farnesyltransferase inhibitors
Gemcitabine vs gemcitabine + tipifarnibVan Cutsem E et al. J Clin Oncol 2004;22:1430–8
Matrix metalloproteinase inhibitors
Gemcitabine vs gemcitabine + marimastatBramhall SR et al. Br J Cancer 2002;87:161–7
Gemcitabine vs BAY 12–9566Moore MJ et al. J Clin Oncol 2003;21:3296–302
Gastrin vaccine
Gemcitabine vs gemcitabine + G17DT– Shapiro J, et al. J Clin Oncol 2005;23(Suppl. 16
Pt I):310 (Abs. 4012)
Rationale for targeting HER1/EGFR in pancreatic cancer
HER1/EGFR overexpression is common1,2
Elevated HER1/EGFR and EGF is associated with3–5 – more aggressive disease – increased tumour size– late clinical stage – poor prognosis – reduced sensitivity to chemotherapy
1Tobita K, et al. Int J Mol Med 2003;11:305–9 2Srivastava A, et al. Hum Pathol 2001;32:1184–89
3Ueda S, et al. Pancreas 2004;29:1–8 4Nicholson R, et al. Eur J Cancer 2001;37:S9–S15
5Xiong H, et al. Semin Oncol 2002;29:31–7HER1/EGFR = human epidermal growth factor receptor
Rationale for Tarceva (erlotinib) in pancreatic cancer
In a preclinical study, Tarceva significantly inhibited cell growth and proliferation in pancreatic cancer cell lines in vitro1
Tarceva has been shown to enhance gemcitabine-induced apoptosis in pancreatic tumour cells2
1Durkin A, et al. Am J Surg 2003;186:431–6; 2Ng SS, et al. Mol Cancer Ther 2002;1:777–83
NCIC CTG PA.3
Double-blind, placebo-controlled, randomised phase III trial comparing gemcitabine +/- Tarceva
First-line treatment for locally advanced or metastatic adenocarcinoma of the pancreas
International study conducted independently by the NCIC CTG (2001-2003)
*1:1 randomisationECOG = Eastern Cooperative Oncology GroupPS = performance status
PA.3: study schema
Stratified by:CentreECOG PS (0/1 vs 2)Stage of disease(locally advanced vsdistant metastases)(n=569)
RANDOM I SE
Gemcitabine 1,000mg/m2 i.v.+
Tarceva 100/150mg/day p.o.(n=285)
Gemcitabine 1,000mg/m2 i.v.+
placebo 100/150mg/day p.o.(n=284)
Moore M, et al. J Clin Oncol 2005;23(Suppl. 16 Pt I):1 (Abs. 1)Genentech: Tarceva® full prescribing information
*
PA.3: key eligibility criteria
Locally advanced or metastatic adenocarcinoma of the pancreas
Age 18 years
PS 0–2
Measurable or non-measurable disease
Prior radiotherapy for local disease allowed
No prior chemotherapy, except for 5-FU or gemcitabine as a radiosensitiser
HER1/EGFR-positive status not required
Moore M, et al. J Clin Oncol 2005;23(Suppl. 16 Pt I):1 (Abs. 1)
PA.3: endpoints Primary
– overall survival Secondary
– progression-free survival (PFS)– quality of life (QoL) (Canada, USA, other selected
countries)– response rate (RR)– duration of response – toxicity– correlate expression of tissue HER1/EGFR levels
with outcomes
Moore M, et al. J Clin Oncol 2005;23(Suppl. 16 Pt I):1 (Abs. 1)
PA.3: statistical considerations
Based on an estimate of a 33% increase in median survival from 6.6 to 8.8 months– 80% power (two-sided 5% significance)– 381 events required– 450 patients with a follow-up of 18 months
(after protocol amendment)
Primary analysis– stratified log-rank test
Moore M, et al. J Clin Oncol 2005;23(Suppl. 16 Pt I):1 (Abs. 1)
Tarceva(n=285)
Placebo(n=284)
Median age (years) 63 64Female/male (%) 52/48 43/57
PS 0/1/2 (%) 30/51/19 30/52/18
Locally advanced/metastatic (%) 24/76 25/75
Pain score 20/>20/unknown (%) 46/51/3 45/53/2
Measurable disease (%) 94 92
USA/Canada/RoW (%) 38/20/42 36/21/43
PA.3: patient characteristics
569 patients randomised
– 521 patients at 100mg or placebo
– 48 patients at 150mg or placebo
Moore M, et al. J Clin Oncol 2005;23(Suppl. 16 Pt I):1 (Abs. 1)
19% reduction in risk of death
PA.3: overall survival (100mg cohort)
19.423.81-year survival (%)
6.0 6.4Median survival (months)
Placebo + gemcitabine
Tarceva + gemcitabine
*HR=0.81 (0.68–0.97), p=0.028
23% increase in survival
1.00
0.75
0.50
0.25
0
Su
rviv
al p
rob
abili
ty
0 6 12 18 24
Survival time (months)
Tarceva (n=261)
Placebo (n=260)
*Hazard ratio (HR) adjusted for PS and extent of disease at baseline
Moore M, et al. J Clin Oncol 2005;23(Suppl.16 Pt I):1s (Abs. 1)Genentech: Tarceva® full prescribing information
PA.3: hazard ratios for survival by pretreatment characteristics (100mg cohort)
0 0.50 1.00 1.50 2.00 2.50
Factors n HR 95% CI
HR
Tarceva: placebo* 521 0.81 0.7–1.0
PS 0–1PS 2
43289
0.870.70
0.7–1.10.5–1.1
Locally advancedDistant metastases
124397
0.930.80
0.6–1.30.7–1.0
Pain intensity 20Pain intensity >20
238268
0.721.00
0.6–0.90.8–1.3
HER1/EGFR positiveHER1/EGFR negativeHER1/EGFR unmeasured
7066
385
0.820.750.86
0.5–1.30.5–1.20.7–1.1
MaleFemale
273240
0.741.00
0.6–0.90.8–1.3
Age <65 yearsAge 65 years
274247
0.780.94
0.6–1.00.7–1.2
CaucasianBlackAsian
4561334
0.880.670.61
0.7–1.10.2–2.20.3–1.3
Prior radiosensitisingchemotherapy**No prior radiosensitisingchemotherapy**
42
479
0.62
0.86
0.3–1.2
0.7–1.0
*Stratified by PS and extent of disease**Only chemotherapy given concurrently with radiationtreatment as a radiosensitiser was allowedCI = confidence interval
Moore M, et al. J Clin Oncol 2005;23(Suppl.16 Pt I):1s (Abs. 1)Genentech: Tarceva® full prescribing information
PA.3: survival by HER1/EGFR status (100mg cohort)
HER1/EGFR positive (n=70)HER1/EGFR negative (n=66)
1.00
0.75
0.50
0.25
00 6 12 18 24
Survival time (months)
Su
rviv
al p
rob
abili
ty
1.00
0.75
0.50
0.25
00 6 12 18 24
Survival time (months)
Su
rviv
al p
rob
abili
ty
Tarceva (n=34)
Placebo (n=32)
HR=0.75
95% CI: 0.46–1.23 (p=NS)
Tarceva (n=41)
Placebo (n=29)
HR=0.82
95% CI: 0.50–1.32 (p=NS)
NS = not significantMoore M, et al. J Clin Oncol 2005;23(Suppl.16 Pt I):1s (Abs. 1)
Genentech: Tarceva® full prescribing information
PA.3: progression-free survival (100mg cohort)
*HR adjusted for PS and extent of disease at baseline
30% increase in PFS
1.00
0.75
0.50
0.25
00 6 12 18 24
Survival time (months)
Su
rviv
al p
rob
abili
ty
Tarceva + gemcitabine median = 3.8 months (n=261)
Placebo + gemcitabine median = 3.5 months (n=260)
*HR=0.76 (0.64–0.92), p=0.006
Moore M, et al. J Clin Oncol 2005;23(Suppl.16 Pt I):1s (Abs. 1)
Genentech: Tarceva® full prescribing information
PA.3: tumour response (100mg cohort)Patients (%)
Tarceva/gemcitabine(n=244)
Placebo/gemcitabine(n=241)
Complete response (CR) 0.4 0.8
Partial response (PR) 8.2 7.1
CR + PR 8.6 7.9
Stable disease (SD) 50.4 41.5
CR + PR + SD 59.0 49.4
Progressive disease 22.5 26.1
Not evaluable/missing 18.4 24.5
Median duration (weeks) ofCR + PR (95% CI) 23.9 (16.3–31.9) 23.3 (16.1–32.4)
Moore M, et al. J Clin Oncol 2005;23(Suppl. 16 Pt I):1 (Abs. 1)
PA.3: QoL
Measures
Impact of adding Tarceva to gemcitabine on patient’s self-reported QoL
Changes from baseline in global QoL; function and symptom domains; and single items – EORTC QLQ-C30 questionnaire
Outcomes
No detrimental effects on global QoL compared with gemcitabine alone
No significant differences between treatments for QoL domains, except for diarrhoea, higher score for Tarceva plus gemcitabine
Tarceva/gemcitabine(n=259)
Placebo/gemcitabine(n=256)
Any (%) Grade 3/4 (%) Any (%) Grade 3/4 (%)
Rash 69 5 30 1
Diarrhoea 48 5–6 36 2
Infection* 39 16 30 11
Stomatitis 22 <1 12 0
Fatigue 73 16 70 15 *Includes all MedDRA preferred terms in the Infections and Infestations System Organ Class
PA.3: selected adverse events (100mg cohort)
Moore M, et al. J Clin Oncol 2005;23(Suppl. 16 Pt I):1 (Abs. 1)
PA.3: serious adverse eventsTarceva/
gemcitabine(%) (n=282)
Placebo/gemcitabine(%) (n=280)
Infections (all) Pneumonia Sepsis Infection NOS
16 4 4 2
13 3 3 5
ILD-like* events 2.5 (n=7) 0.4 (n=1)
Nervous system Cerebral ischaemia
5 2
<1 0
Renal insufficiency 1 0
*Pneumonitis, lung infiltration, and acute respiratory distress syndromeNOS = not otherwise specified; ILD = interstitial lung disease
Moore M, et al. J Clin Oncol 2005;23(Suppl. 16 Pt I):1 (Abs. 1)
PA.3: overall survival according to grade of rash
Moore M, et al. J Clin Oncol 2005;23(Suppl. 16 Pt I):1s (Abs. 1)
HR (rash)=0.71, p<0.0001
Grade 0Grade 1Grade 2
1.0
0.8
0.6
0.4
0.2
0
Su
rviv
al p
rob
abili
ty
0 5 10 15 20Time (months)
Grade 0(n=79)
Grade 1(n=108)
Grade 2(n=103)
Median survival (months) 5.29 5.75 10.51
1-year survival (%) 16 11 43
PA3: summary
Primary endpoint was met – improvement in overall survival
The benefit with Tarceva plus gemcitabine is both statistically and clinically meaningful– 23% increase in overall survival– 30% increase in PFS
The addition of Tarceva to gemcitabine was generally well tolerated
Tarceva 100mg/day is the recommended dose in combination with gemcitabine in this setting
Tarceva in pancreatic cancer: summary
Unresectable, locally advanced or metastatic pancreatic cancer is a difficult disease with few treatment options
Tarceva builds on the standard of care by increasing survival with manageable additional toxicity
The Tarceva + gemcitabine platform represents a step forward in the treatment of pancreatic cancer
Tarceva is a simple and convenient once-daily oral agent with manageable toxicity
InvestigatorsS. ACKLANDA. ALVAREZH. ANDERSONF. ARENA S. ARIFC. ARVANITAKISR. ASBURYA. ASIKH. AUP. BEALEJ. BECKR. BELTS. BERRY J. BIAGIE . BIONDIG. BJARNASONL. BLASZKOWSKYH. BLEIBERGJ. BLONDALJ. BOYDF. BRASFIELDJ. BRELLJ. BRIDGEWATERM. BROWNA. BUIUCM. BURNELLH. BURRISC. BUTTSP. BYEFFJ. CEBONM. CHACONH. CHALCHALE. CHEND. CHOIP. CHOW
N. COHENB. COLWELLDB. COMPOSF. COXONC. CRIPPSG. DARSYS. DAVIDSONS. DEL PRETEP. DESIMONEJ. DEVITTM. DIDOLKARA. DISTEFANOP. DUBEJ. EGNERM. ESTEVEZD. FENTOND. FERRYA. FIGERA. FIGUEREDOE. FILIPCZYK-CISARZJ. GALLARDOD. GALLARDOV. GANJUR. GANSLR. GAURG. GEILSJ. GIESBRECHTR. GOELD. GOLDSTEINL. GONZALEZG. GONZALEZ-OSETEM. GOODYEARP. GRAZEE. GREENOG. GROSSA. GROTHEYJ. GURTLERK. HAGANJ. HAINSWORTHD. HALLER J. HAMM
J. HECHTW. HEIMT. HERRMANNP. HESKETHH. HOCHSTERR. HOHLD. IRWINW. ISACOFFG. JEFFREYD. JONKERS. JOVTISL. KALMANI. KATOSA. KATZP. KENNEDYI. KERRR. KERRJ. KNOXW. KOOE . KORBENFELDP. KOZUCHM. KRAHNJ. KUGLERD. LAHERUJ. LANGREHRS. LEBELA. LEEB. LESPERANCER. LIM W. LOFTERSC. LOHRISCHR. LUYUNS. MADAJEWICZA. MAKSYMIUKI. MALIKA. MARAVEYASC. MARTINL. MARTINC. MATHIAST. MAUGHAN
L. MAURERM. MCCRYSTALJ. MEHARCHANDB. MELOSKYM. MICELIM. MIDDLETON D MINTZER M. MOOREM. MULLANER. MUNDISA. MURADP. MURAWAR. MYERSI. OLIFFI. OLVERY. ONGD. OSBORNA. OZAS. PALMERIF. PARNISM. PATRANM. PFREUNDSCHUHB. PIERCEJ. POLIKOFFA. POSTERAROT. PRINCED. PROPPERY. RAHIMN. RAJAP. RATHJ. REYES-VIDALP. ROBERTSONJ. RODGERS. RORKES. ROSEWICZK. ROSSM. RUBINJ. RUBINS
H. RUECKLE-LANZJ. RUSSELLD. SALTERA. SCARFES. SEEBERA. SHANIL. SIUJ. SMITHR. SOOS. SPADAFORAB. STEINR. STEISS. STEMMERA. SULLIVANM. TAYLORM. THOMASP. THOMPSONA. TOMIAKD. TRENTC. TUDOR-ELIADEJ. VALLEM. VARELAM. VEEDERD. VILLAJ. VINHOLESD. WALDEJ. WASSERD. WECKSTEINL. WEINERB. WEINERMANR. WHITTOMS. WILLIAMSONI. WIZNITZERR. WOLFFR. WONGJ. ZALCBERGE. ZERVOSS. ZEUZEMH. ZIMBLER