optimal integration of new treatments for castration resistant prostate cancer
TRANSCRIPT
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Optimal Integration of New Treatments for Castration-Resistant Prostate Cancer
Dr. Sankar Srinivasan, AB, FACPConsultant Oncologist, Apollo HospitalsVisiting Consultant, Ironwood Cancer and Research Center, Phoenix, AZ, USA
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Std Hormonal treatments
Orchiectomy or Zoladex or Lupron
Bicalutamide added for combined hormonal blockade
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Case-1 57-yr-old man – T3a PCa, Gleason 4+4 = 8,
PSA = 8.2 ng/mL
Undergoes radical prostatectomy
Develops PSA recurrence none in prostatic bed
Started on leuprolide + bicalutamide, and responds for 18 months
Then develops rising PSA, despite bicalutamide withdrawal
PSAs: 4.2 → 5.6 → 7.2 ng/mL
Testosterone: 28 ng/dL
Bone scan and CT scan: Negative for metastatic disease
•PSADT = prostate-specific antigen doubling time; CT = computed tomography.
•NCCN, 2011.
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Does this patient meet criteria for CRPC?
How would you manage this patient?
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•HRPC Definition
Practical definition: a consecutive series of increasing PSA levels after a nadir is reached with HT. Must have had a trial of anti-androgen withdrawal and must have castrate levels of testosterone
• Men with HRPC are not treated to cure their disease but simply to improve their quality of life.
• The lack of effective treatments for HRPC leads patients to turn to unproven therapies.
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Overview
Modern approaches to targeting androgens
– COU-AA-301 phase III study: abiraterone
– Other androgen-targeted agents: MDV3100
The evolving role of chemotherapy
– TAX 327 study: weekly vs 3-weekly docetaxel vs mitoxantrone
– TROPIC phase III study: second-line cabazitaxel
Autologous cellular immunotherapy: understanding a new paradigm
– IMPACT phase III study: sipuleucel-T
– TBC-PRO-002 phase II study: ProstVac-VF
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Modern Approaches to Targeting Androgens
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Androgen Receptor Addiction Is a Hard Habit to Break
Hormonal treatments continue to have antitumor activity
High levels of intratumoral androgens despite castration
– Preclinical and clinical evidence of intracrine synthesis
Castration resistance associated with
– AR amplification (increased gene dose)
– AR mutations that increase AR (transcriptional) activity
– ↑ AR (< 2x) expression (ligand driven) in isogenic resistant lines
Identification of oncogenic translocations/fusions driven by androgens + estrogen-response elements (ETS genes; TMPRSS2/ERG in 50% to 70% of prostate cancer)
Attard G, et al. Cancer Cell. 2009;16:458-462.
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Abiraterone Acetate: Androgen Biosynthesis Inhibitor Androgens produced at 3 critical sites lead to tumor
proliferation
– Testes
– Adrenal gland
– Prostate tumor cells
Abiraterone inhibits biosynthesis of androgens that stimulate tumor cell growth
PSA and radiographic responses in phase I/II studies
– Chemotherapy-naive and postchemotherapy patients[1-5]
1. Attard G, et al. J Clin Oncol. 2008;26:4563-4571. 2. Attard G, et al. J Clin Oncol. 2009;27:3742-3748. 3. Reid AH, et al. J Clin Oncol. 2010;28:1489-1495. 4. Ryan C, et al. J Clin Oncol. 2010;28:1481-1488. 5. Danila D, et al. J Clin Oncol. 2010;28:1496-1501.
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COU-AA-301: Phase III Study of Abiraterone Acetate in mCRPC
Patients with mCRPC progressing after 1-2
chemotherapy regimens,
1 of which contained docetaxel
(N = 1195)
Abiraterone acetate 1000 mg/day +Prednisone 5 mg BID
(n = 797)
Placebo +Prednisone 5 mg BID
(n = 398)
Stratified by ECOG PS, worst pain over previous 24 hrs, previous
chemotherapy, type of progression
de Bono J, et al. N Engl J Med. 2011;364:1995-2005.
Randomized 2:1
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AA 797 736 657 520 282 68 2 0
Placebo 398 355 306 210 105 30 3 0
HR: 0.646 (95% CI: 0.54-0.77; P < .0001)
Placebo Median OS: 10.9 mos (95% CI: 10.2-12.0)
0 3 6 9 12 15 18 210
20
40
60
80
100
Survival (%
)
Months
Abiraterone acetate Median OS: 14.8 mos (95% CI: 14.1-15.4)
Median OS with 2 prior chemo:14.0 mos AA vs 10.3 mos placebo
de Bono J, et al. N Engl J Med. 2011;364:1995-2005.Copyright © 2011 Massachusetts Medical Society. All rights reserved.
Median OS with 1 prior chemo 15.4 mos AA vs 11.5 mos placebo
COU-AA-301: Abiraterone Acetate Improves OS in mCRPC
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COU-AA-301: All Secondary Endpoints Achieved Statistical SignificanceEndpoint Characteristic Abiraterone
(n = 797)Placebo (n = 398)
HR(95% CI)
P Value
Time to PSA progression, mos
10.2 6.6 0.58(0.46-0.73)
< .0001
rPFS, mos 5.6 3.6 0.67(0.59-0.78)
< .0001
PSA response rate, %
Total 38.0 10.1 < .0001
Confirmed 29.1 5.5 < .0001
de Bono J, et al. N Engl J Med. 2011;364:1995-2005.Copyright © 2011 Massachusetts Medical Society. All rights reserved.
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COU-AA-301: Adverse Events of Special Interest
Adverse Event, %Abiraterone
(n = 791)Placebo (n = 394)
All Grades Grades 3/4 All Grades Grades 3/4
Fluid retention 30.5 2.3 22.3 1.0
Hypokalemia 17.1 3.8 8.4 0.8
LFT abnormalities 10.4 3.5 8.1 3.0
Hypertension 9.7 1.3 7.9 0.3
Cardiac disorders 13.3 4.1 10.4 2.3
de Bono J, et al. N Engl J Med. 2011;364:1995-2005.
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AR
T
MDV3100: Phase I/II Study in Advanced Prostate Cancer[1]
MDV3100: novel, oral AR antagonist
– Blocks testosterone binding to AR, impedes movement of AR to nucleus, inhibits DNA binding
– Slows tumor growth and causes cell death in cancers resistant to bicalutamide
Phase I/II trial conducted to determine safety, PK, and antitumor activity of MDV3100[2]
– N = 140 patients with progressive CRPC, pre- or postchemotherapy
1. Higano CS, et al. ASCO GU 2011. Abstract 134. 2. Scher HI, et al. Lancet. 2010;375:1437-1446.
Testosterone synthesis
Tumor deathTestosterone
MDV3100
No prednisone required
AR binding blocked
Nuclear translocation impaired
Cell nucleus
DNA binding and activation blocked
T
X X
X3
2
1
– Cohorts treated with sequentially escalating doses of MDV3100 (30-600 mg/day)
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Long-term Follow-up of MDV3100: Antitumor Activity MDV3100 antitumor activity durable both before and
after chemotherapy
Higano CS, et al. ASCO GU 2011. Abstract 134.
Outcome ChemotherapyNaïve
(n = 65)
PostChemotherapy
(n = 75)
≥ 50% PSA decline from baseline, % 62 51
Median time to PSA progression, days
Per protocol* NYR 316
PCCTWG 2 criteria† 281 148
Median time to radiographic progression, days 392 175*≥ 25% increase in PSA from baseline with increase ≥ 5 ng/mL
†≥ 25% increase in PSA from nadir with increase ≥ 2 ng/mL
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Conclusion: Targeting Androgens
Advanced prostate cancer is neither hormone refractory nor androgen independent and remains nuclear steroid receptor driven
– Hormone therapy works after chemotherapy
CYP17 blockade does not cause adrenal insufficiency
Multiple lines of treatment available for advanced prostate cancer
– Sipuleucel-T, docetaxel, abiraterone, cabazitaxel
– The optimal sequence of administration now needs to be defined
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Evolving Role of Chemotherapy in the Management of Castration-Resistant
Metastatic Prostate Cancer
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TAX 327: Weekly vs 3-Weekly Docetaxel vs Mitoxantrone in CRPC—OS
Berthold DR, et al. J Clin Oncol. 2008;26:242-245.Reprinted with permission. © 2008 American Society of Clinical Oncology. All rights reserved.
Proportion A
live
1.0
0.8
0.6
0.4
0.2
00 1 2 3 4 5 6 7
Time (years)
Docetaxel 3-weeklyDocetaxel weeklyMitoxantrone
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Docetaxel-Based Therapy in CRPC:Observations From Long-term Follow-up After 5 yrs of follow-up, 867 deaths (86% of 1006 patients) have
occurred
Median OS difference between every-3-wk docetaxel and mitoxantrone groups remains highly significant (P = .004)
Outcome Every-3-Wk Docetaxel/Prednisone(n = 335)
Weekly Docetaxel/Prednisone(n = 334)
Mitoxantrone/Prednisone(n = 337)
Median OS, mos 18.9 17.4 16.5
3-yr OS, % 18.6 16.8 13.5
Berthold DR, et al. J Clin Oncol. 2008;26:242-245.
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Cabazitaxel: A Novel Tubulin-Targeting Agent Selected to overcome the emergence of taxane resistance
Preclinical data
– Potency equivalent to docetaxel against sensitive cell lines and tumor models
– Evidence of activity against tumor cells/models resistant to currently available taxanes
Early clinical data from phase I studies demonstrated:
– Dose-limiting toxicity: neutropenia
– Activity in patients with metastatic CRPC
– Moved from phase I to phase III development in a series of trials in a variety of epithelial neoplasms
Pivot X, et al. Ann Oncol. 2008;19:1547-1552.Mita AC, et al. Clin Can Res. 2009;15:723
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Cabazitaxel 25 mg/m2 IV q3w + Prednisone 10 mg/day PO for 10 courses
(n = 378)
Mitoxantrone 12 mg/m2 IV q3w + Prednisone 10 mg/day PO for 10 courses
(n = 377)Patients with metastatic
CRPC progressingon docetaxel
(N = 755)
Stratified by ECOG PS(0,1 vs 2) and measurable vs
nonmeasurable disease
TROPIC: Phase III Registration Trial of Second-line Cabazitaxel in CRPC
Primary endpoint: OS
Secondary endpoints: PFS, response rate, safety
de Bono JS, et al. Lancet. 2010;376:1147-1154de Bono JS, et al. Lancet. 2010;376:1147-1154..
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TROPIC: Main Eligibility Criteria
mCRPC patients with documented disease progression
– Measurable by RECIST or
– Nonmeasurable: documented rising PSA levels (≥ 2 consecutive rises in PSA over a reference value taken at least 1 week apart) or appearance of new lesion
Previous treatment with a docetaxel-containing regimen
No previous treatment with mitoxantrone
ECOG PS: 0-2
Normal organ function (CBC and serum chemistries)de Bono JS, et al. Lancet. 2010;376:1147-1154de Bono JS, et al. Lancet. 2010;376:1147-1154..
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TROPIC: Preprotocol Treatment
Previous Treatment Mitoxantrone/Prednisone(n = 377)
Cabazitaxel/Prednisone(n = 378)
Chemotherapy, n (%)
1 regimen 268 (71) 260 (69)
2 regimens 79 (21) 94 (25)
≥ 3 regimens 30 (8) 24 (6)
Docetaxel, n (%)
1 regimen 327 (87) 316 (84)
2 regimens 43 (11) 53 (14)
≥ 3 regimens 7 (2) 9 (2)
Median total previous docetaxel dose, mg/m2 (range)
529.2 (380.9-787.2)
576.6 (408.4-761.2)
Median time from last docetaxel dose to progression, mos (range)
0.70 (0-2.9) 0.80
(0-3.1)
de Bono JS, et al. Lancet. 2010;376:1147-1154de Bono JS, et al. Lancet. 2010;376:1147-1154..
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TROPIC: OS (Updated ITT Analysis)
Survival MP CBZP
Median OS, mos 12.7 15.1
HR 0.72
95% CI 0.61-0.84
P value < .0001
Combined median follow-up: 13.7 mos
de Bono JS, et al. ASCO 2010. Abstract 4508. de Bono JS, et al. Lancet. 2010;376:1147-1154.
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25
Treatment-Emergent Grade 3/4 Adverse Events,* %
Mitoxantrone/Prednisone(n = 371)
Cabazitaxel/Prednisone(n = 371)
Any adverse event 39.4 57.4
Febrile neutropenia 1.3 7.5
Diarrhea 0.3 6.2
Fatigue 3.0 4.9
Back pain 3.0 3.8
TROPIC: Treatment-EmergentGrade 3/4 Adverse Events
*Sorted by ≥ 2% incidence rate for grade ≥ 3 events in the cabazitaxel arm.
de Bono JS, et al. ASCO 2010. Abstract 4508de Bono JS, et al. ASCO 2010. Abstract 4508..
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Cabazitaxel: Evolving Clinical Issues
Following FDA approval, the first wave of patients treated were more heavily pretreated than would be expected over time
– Effect of dose/toxicity
Many important questions remain undefined
– Optimal dose
– Growth factors?
– Cabazitaxel vs docetaxel retreatment
– Upcoming clinical trials
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Ongoing Cabazitaxel Clinical Trials: Phase III PROSELICA Study Cabazitaxel 20 mg/m² vs 25 mg/m² for the treatment of
patients with metastatic castration-resistant prostate cancer and prior treatment with docetaxel
– Both doses administered with prednisone
Primary objective: overall survival
ClinicalTrials.gov. NCT01308580.
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Ongoing Cabazitaxel Clinical Trials: Phase III FIRSTANA Study Cabazitaxel vs docetaxel for the treatment of patients
with metastatic castration-resistant prostate cancer and no prior chemotherapy
– Cabazitaxel 25 mg/m2 and 20 mg/m2 evaluated
– Cabazitaxel and docetaxel both given with prednisone
Primary objective: overall survival
ClinicalTrials.gov. NCT01308567.
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Autologous Cellular Immunotherapy: Understanding
a New Paradigm
•
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Patient’s white blood cells harvested
Short-term culture with protein “cassette”
Shipping
Cells infused back into patient (IV)
GM-CSF
Prostatic acid phosphatase (PAP)
Active Cellular Immunotherapy(Sipuleucel-T)
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Immunotherapy for Prostate Cancer:Mechanism(s) of Action
CD4+ T cell
TCR
CD8 T cell
TCR
Cytokines
Activated CD8+ T cells: traffic to tumor, lyse tumor cells
Class II MHC
Class I MHC
Activated dendriticcell
Tumor antigen Antibodies: circulate in serabind to tumor cells
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IMPACT: Phase III Study
Primary endpoint: OS
Secondary endpoint: TTP
Placebo q2w x 3
Sipuleucel-T q2w x 3
PROGRESSION
Physician’s discretion
Physician’s discretion, including phase II
open-label sipuleucel-T*
study
Kantoff PW, et al. N Engl J Med. 2010;363:411-422.
2:1
Patients with metastatic,
asymptomatic or minimally
symptomatic CRPC, no visceral metastases
(N = 512)
*Prepared using cryopreserved peripheral blood lymphocytes
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•
IMPACT: Baseline Characteristics
Key Inclusion Criteria
– Metastatic and castrate resistant
– Asymptomatic or minimally symptomatic
– Prior chemotherapy permitted
Selected Patient Characteristics
– Median age: 71
– Median PSA: 50 ng/mL
– Hemoglobin: 12.8 g/dL
– Bone-only disease: 50%
– Bone and soft-tissue disease: 44%
Kantoff PW, et al. N Engl J Med. 2010;363:411-422.
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IMPACT Study: OS (ITT Population)
P = .032 (Cox model)HR: 0.775 (95% CI: 0.614-0.979)
Median survival benefit: 4.1 mos
Sipuleucel-T (n = 341)Median survival: 25.8 mos
Placebo (n = 171)Median survival: 21.7 mos
Kantoff PW, et al. N Engl J Med. 2010;363:411-422.Copyright © 2010. Massachusetts Medical Society. All rights reserved.
Patients R
emaining
Alive (%
)
100
75
50
25
0
Survival (Mos)0 6 12 18 24 30 36 42 48 54 60 66
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IMPACT: Results
Clinical Outcomes
– TTP not significantly different between arms
– 1 objective response (in active treatment group)
– Extensive subgroup analyses were inconclusive
Kantoff PW, et al. N Engl J Med. 2010;363:411-422.
Adverse Event, % Sipuleucel-T Placebo
Chills 54 13
Pyrexia 29 14
Headache 16 5
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Another Cancer Vaccine Approach:ProstVac-VF
PSA
LFA-3
ICAM-1
B7-1
Costimulatory Molecules
Target antigen
Plasmid DNA
Vaccinia virusFowlpox virus
rV-PSA-TRICOMrF-PSA-TRICOM
Packaging cell line
Vaccine
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Kantoff PW, et al. J Clin Oncol. 2010;28:1099-1105.Reprinted with permission. © 2008 American Society of Clinical Oncology. All rights reserved.
rV-PSA ->rF-PSA
100
80
60
40
20
00 12 24 36 48 60
Mos
OS
(%
)
HR: 0.56 (95% CI: 0.37-0.85)
ControlProstVac-VF
n4082
Deaths3765
Median OS, mo16.625.1
TBC-PRO-002: Phase II ProstVac-VF Study—OS
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Prospect Phase III Trial: ProstVac ± GM-CSF in Metastatic CRPC
Patients with asymptomatic or minimally symptomatic
metastatic CRPC
(Planned N = 1200)
ProstVac-VF + TRICOM + low-dose adjuvant GM-CSF
Vector placebo +adjuvant placebo
SURVIVAL
No cross-over
ProstVac-VF + TRICOM +
adjuvant placebo
Standard of Care
Primary endpoint: OS
ClinicalTrials.gov. NCT01322490.
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Conclusions
Sipuleucel-T: a current treatment option
– Asymptomatic or minimally symptomatic patients
ProstVac-VF: entering phase III prechemotherapy
Challenges
– Sipuleucel-T: timing with regard to abiraterone
– Integration of immunotherapy with chemotherapy and multiple other agents
– An embarrassment of riches?
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Hormone Refractory Prostate Cancer
Multiple treatment options– Stop oral anti-androgens
– Switch to another anti-androgen
– Steroids
– Ketoconazole
– Megestrol acetate
– Chemotherapy
– ?immunotherapy
– ?Target therapy
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OS Benefit in Recent CRPC Trials
Trial/Agent Approved Disease State Comparator HR P Value
IMPACT[1]
(Sipuleucel-T vaccine)
Chemo-naiveCRPC
Placebo 0.775 .032
TAX327[2]
(Docetaxel)Chemo-naive
CRPC MitoxantronePrednisone
0.76 .009
TROPIC[3]
(Cabazitaxel)Post-
docetaxel CRPC
MitoxantronePrednisone
0.70 < .0001
COU-AA-301[4]
(Abiraterone acetate)Post-
docetaxelCRPC
PlaceboPrednisone
0.646 < .0001
1. Kantoff PW, et al. N Engl J Med. 2010;363:411-422.2. Tannock IF, et al. N Engl J Med. 2004;351:1502-1512.3. de Bono JS, et al. Lancet. 2010;376:1147-1154.4. de Bono J, et al. N Engl J Med. 2011;364:1995-2005.
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Thanks for the attention
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Case Study: Part 2
Same patient – non-mCRPC
Enrolls in phase II study or oral TAK-700 (orteronel)
Has a PSA response lasting 6 months
Then PSA begins to rise: 4.6 → 7.5 → 11.2 ng/mL
Testosterone: 2 ng/dL
CT scan repeated: Remains normal
Bone scan: New lesions left 5th rib and L1 vertebral body
He remains asymptomatic – no bone pain – ECOG 0
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Case Study: Part 2Discussion Question How would you manage this patient now?
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Case Study: Part 3
Same patient – asymptomatic mCRPC
Patient receives 3 infusions of sipuleucel-T
PSA rises after 3 months, and again after 6 months
CT scan: Para aortic lymphadenopathy (up to 3.8 cm)
Bone scan: 2 rib, 2 vertebral, and 1 pelvic bone lesion
Patient reports new rib and back pain (intensity 3/10)
ECOG PS 0
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Case Study: Part 3Discussion Question How would you manage this patient now?
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Case Study: Part 4 Same patient – symptomatic mCRPC
He receives docetaxel q3wks and denosumab q4wks
Obtains PSA response and objective radiologic response
After 8 cycles, stops docetaxel due to grade 3 neuropathy
4 months later, he has further PSA progression
CT: New liver lesions (up to 4 cm) and lung lesions (8 mm)
Bone lesions: Stable
Has persistent grade 2 peripheral neuropathy
ECOG PS 1
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Case Study: Part 4Discussion Question How would you manage this patient now?
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Case Study: Part 1
57-yr-old man – T3a PCa, Gleason 4+4 = 8,PSA = 8.2 ng/mL
Undergoes radical prostatectomy
Develops PSA recurrence with PSADT = 6 months
Started on leuprolide + bicalutamide, and responds for 18 months
Then develops rising PSA, despite bicalutamide withdrawal
PSAs: 4.2 → 5.6 → 7.2 ng/mL
Testosterone: 28 ng/dL
Bone scan and CT scan: Negative for metastatic disease
•PSADT = prostate-specific antigen doubling time; CT = computed tomography.
•NCCN, 2011.
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Case Study: Part 1
57-yr-old man – T3a PCa, Gleason 4+4 = 8,PSA = 8.2 ng/mL
Undergoes radical prostatectomy
Develops PSA recurrence with PSADT = 6 months
Started on leuprolide + bicalutamide, and responds for 18 months
Then develops rising PSA, despite bicalutamide withdrawal
PSAs: 4.2 → 5.6 → 7.2 ng/mL
Testosterone: 28 ng/dL
Bone scan and CT scan: Negative for metastatic disease
•PSADT = prostate-specific antigen doubling time; CT = computed tomography.
•NCCN, 2011.