Why did the antibodies fail in adjuvant treatment?
Heinz-Josef Lenz
Associate Director, Clinical Research
Kathryn Balakrishnan Chair for Cancer Research
Co-Director, USC Center for Molecular Pathways and Drug Discovery
Co-Leader GI Oncology Program
USC/Norris Comprehensive Cancer Center
Why Treatment Failures in Adjuvant Therapy
• Tumor Biology (Genetic Make Up)
– What do we know?
• Host Response (Host Genome/ Microenvironment)
– What do we know?
Tumor Biology (PETACC)Tumor Biology (PETACC)Multivariate Analysis in whole Multivariate Analysis in whole
populationpopulationMarkers
Stage II Stage III
HR§ p value* HR§ p value*
T Stage (T4 vs T3) 2.8 0.0001 1.6 0.0006
N Stage (N2 vs N1) N/A N/A 2.2 <0.0001
Histologic Grade (3-4 vs 1-2)
0.6 0.55 1.4 0.07
Age (>60 vs ≤60) 1.8 0.026 1.1 0.3
MSI (High vs Stable) 0.3 0.027 0.7 0.12
p53 (High) 0.7 0.27 1.3 0.015
SMAD4 (any loss) 1.0 0.9 1.6 0.0002
Treatment, Sex, Site, KRAS, BRAF,TS, 18qLOH (Stage II: HR 1.4, p=0.33), hTERT: not significant* p values from the Wald test in a multiivariate Cox regression§ HR = hazard ratio Tejpar ASCO 2010
Bertagnolli, M. M. et al. J Clin Oncol; 27:1814-1821 2009
Influence of MSI: Prognostic relevance in mutant BRAF
22% (16%-29%)
18% (13%-24%)
12% ( 9% -16%)
Kaplan-Meier Estimates (95% CI) of Recurrence Risk at 3 years
Tumor Biology: Tumor Biology: Gene Expression Signature in Gene Expression Signature in
QUASAR QUASAR
Comparison of High vs. Low Recurrence Risk Groups using Cox Model: HR = 1.47 (p=0.046)
Years
Recurrence Risk Group
High
Intermediate
Low
Pro
po
rtio
n E
ven
t F
ree
0.0
0.2
0.4
0.6
0.8
1.0
0 1 2 3 4 5
Recurrence Risk Group
Range of RS
Proportion of patients
Low <30 43.7%
Intermediate
30-40 30.7%
High ≥41 25.6%
Kerr et al ASCO 2010
Why an active therapy in advanced disease is not active in the adjuvant setting?
Cytotoxic agents such as Irinotecan failedMonocloncal Antibodies targeting EGFR
and VEGF failed
Is this TRUE in Other Cancers? Or is this Colon Cancer Specific?
Disease-free Survival: Stage II and Stage III Patients
Data cut-off: June 2006
HR [95% CI] p-value
Stage II 0.84 [0.62–1.14] 0.258
Stage III 0.78 [0.65–0.93] 0.005
FOLFOX4 stage II
LV5FU2 stage II
FOLFOX4 stage III
LV5FU2 stage III
Months
Pro
bab
ilit
y
1.0
0.8
0.6
0.4
0.2
0
0.9
0.7
0.5
0.3
0.1
0 6 12 18 24 6030 36 42 48 54 66 72
3.8%
7.5%
p=0.258
p=0.005
Benefits of Adjuvant Tamoxifen (5 yrs, ER+)Benefits of Adjuvant Tamoxifen (5 yrs, ER+)
EBCTG Lancet 2005
Hazard Ratio 0.59 (SE 0.03) Hazard Ratio 0.66 (SE 0.04)
Summary of Trastuzumab AdjuvantTrial DFS Benefits
Study FU, yrs N
HERA1 3,387
2 3,401
NSABP B-31/NCCTG 9891
2 3,351
4 3,968
BCIRG 006 3 3,222
FinHer 3 231
0 1 2In favor of T In favor of Obs.
HR
0.54
0.64
0.48
0.48
0.61
0.42
Interactions between Tumor and Normal Cells
1. Interactions between tumor cells and normal cells result in alterations in several important tumor cell characteristics other than proliferation
2. Response to Growth Factors are differentially expressed in different organs determining homing of cancer cells
3. Growth conditions may significantly affect chemosensitivity of tumor cells and metastases in different organs differ in their response to therapy
Fidler, 1986;Liotta, 1986; Cavanaugh and Nicolson, 1991a; Fodstad et al., 1988b; Hoffmann, 19921.
Toggle Switch Dormancy to Macroscopic
Tumor
Klauber-DeMore, N. et al. Biological behavior of human breast cancer micrometastases. Clin. Cancer
Res. 7 (2001), pp. 2434-2439. Folkman, J. et al. Cancer: looking outside the genome. Nat.
Rev. Mol. Cell Biol. 1 (2000), pp. 76-79. Hanahan, D. and Folkman, J. Patterns and emerging
mechanisms of the angiogenic switch during tumorigenesis.Cell 86 (1996), pp. 353-364.
1. Below a critical point of cancer cell density and endothelial cell density, cancer will not be able to keep its concentration of angiogenic factors high enough leading to destruction of capillaries
2. Factor of 17 was reported between MVD between microscopic and macroscopic disease
3. Switch from dormant to macroscopic disease through balance of pro and anti angiogenic factors.
Experimental models have shown that Dormancy can protect tumor cells from
chemotherapy
(Naumov et al. Breast Cancer Research and Treatment 82: 199–206, 2003)
Aguirre-Ghisos et al 2007
Dormancy Pathways
• Stem Cells
• Angiogenesis
• Mitosis/Apoptosis
• Immunological
The Wnt pathway is critical for maintaining homeostasis of the intestinal crypt
Van de Wetering et al. 2002Barker et al. 2009
Van de Wetering et al. 2002
Stem Cell Markers (LRG5, ALDH, CD44)
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
0 2 4 6 8 10 12 14 16 18
Est
imate
d r
ecu
rrence-
free p
rob
abili
ty
Years since diagnosis of stage II or III colon cancer
Node 1+2 (n=46): 10.7 (7.1, 11.4+)Node 3 (n=50): 11.3+ (4.8, 11.3+)Node 4 (n=88): 5.7 (2.4, 16.8+)Node 5 (n=25): 1.7 (1.0, 5.9)
Median, years (95%CI) Hazard Ratio (95%CI) 1 (Reference) 2.030 (0.821, 5.018) 4.052 (1.769, 9.279) 6.713 (2.710, 16.633)
Combined analysis of risk alleles of CD44 for overall survival
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
0 2 4 6 8 10 12 14
Est
ima
ted
Pro
babi
lity
of S
urv
ival
Years since Diagnosis of Resectable Gastric Cancer
OS: 3.6 yrs OS: 7.3 yrs
CD44 1–2 Favorable alleles (n=55)
CD44 0 Favorable alleles (n=67)
Adjusted P value = 0.019
Winder et al Annals of Oncology 2011
TCF
CBP
CBP
TCF
p300
cyclin D1axin 2HnkdSurvivinS100A4
p300
TCF
ICG-001
c-junfra-1
-catenin
-catenin
-catenin
-catenin-catenin
-catenin
Cytoplasm
Nucleus
Non-differentiationDifferentiation
A Critical Cellular Switch
Teo et al., PNAS 2005
ICG-001
Colon Cancer Stem Cell Models
Miyabayashi T, et al PNAS 104, 5668, 2007
normal Ig
G
1 3 2normal Ig
GB
A* C
Efficacy of CBP/β-catenin Antagonist on Drug-Resistant
Relapsed Primary Colon Tumorgraft
CBP(A22) IP
p300(N15) IP
β-catenin Western Blot
Oxl./PBS
Oxl./C88
Day 47 Mice VDL +/- ICG-001
VDL onlysacrificed day 52
VDL +ICG-001sacrificed day 115
Targeted Agents why did they fail?
• EGFR
• VEGF
Is Target expressed in Is Target expressed in EMT?EMT?
Adapted from Kalluri & Weinberg, J Clin Invest 119: 1420-8, 2009
EGFR SyndecanE-cadherin MUC1Cytokeratin DesmoplakinZO-1 1 (IV) collagenLaminin-1 miR200 familyEntactin
EGFR SyndecanE-cadherin MUC1Cytokeratin DesmoplakinZO-1 1 (IV) collagenLaminin-1 miR200 familyEntactin
FTS binding protein FAP SnailFSP-1 SlugN-cadherin SIP1Vimentin -SMAFibronectin Twist-catenin GoosecoidO-cadherin LEF-1Syndecan-1 FOXC2miR10b miR21
FTS binding protein FAP SnailFSP-1 SlugN-cadherin SIP1Vimentin -SMAFibronectin Twist-catenin GoosecoidO-cadherin LEF-1Syndecan-1 FOXC2miR10b miR21
EGFR expression during EGFR expression during Metastatic ProcessMetastatic Process
High Low High
“EMT status may be a broadly applicable indicator of sensitivity to EGFR inhibitors.” (Barr et al, Clin Exp Metastasis (2008) 25:685–693)
Primary Tumor
Metastasis Established Metastasis
EGFR
EGFR and VEGF gene expression in adjacent normal tissue predict
Recurrence
Schneider et al 2004, Pharmacogenomics
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 2 4 6 8 10 12
Years Since Diagnosis of Stage II or III Colon Cancer
Estim
ate
d P
rob
ab
ility
o
f R
ecu
rre
nce
-Fre
e S
urv
iva
l
VEGF≤ 4.80 (n=41)RR: 1 (reference)Median TTR: 10.7 yrs
VEGF> 4.80 (n=41)RR: 3.29 (95%CI: 1.46-7.43)Median TTR: 4.0 (95%CI:2.0-6.6 )yrs
Adjusted P value =0.004
VEGF mRNA associated with tumor recurrence in stage II and III colon
cancer
VEGF and Il-8 associated recurrence in Stage III disease
(n=121)
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
0 2 4 6 8 10 12 14
Estim
ate
d P
rob
ab
ility o
f B
ein
g R
ecu
rre
nce
-Fre
e
Years Since Diagnosis of Stage III Colon Cancer
Log-rank P value < 0.001
VEGF 936 C/C and IL8 A/A (n=15)
VEGF 936 T/T and IL8 T/T (n=33)
VEGF 936 C/C and IL8 T or VEGF 936 T and IL8 A/A (n=73)
VEGF936 and IL8 Median Years to Recurrence (95%CI) C/C and A/A 1.0 (0.7, 3.9) C/C or A/A 3.4 (2.0, 8.9+) T and T 11.1 (7.1, 12.4+)
Integrin SNPs associated with recurrence in stage III disease)
Conclusions • Cytotoxic Therapies miminal or no benefit in
adjuvant therapy in colon cancer
• Anti-VEGF/EGFR therapies no benefit in adjuvant
• Differences in Tumor Biology/Host interaction responsible for difference in chemosensitivity
• Toggle Switch: Dormancy in Immunotherapy, Angiogenesis and Growth Factors (Stem Cells)
Future Directions • To induce and/or maintain dormancy of
tumor cells • To induce cell death in residual dormant cells
by targeting their survival and drug resistance mechanisms
• To induce differentiation of cancer stem cells • To identify cellular/serum biomarkers of
dormant cancer