colorectal cancer: what’s new and what’s on the horizon
DESCRIPTION
Every summer, the American Society for Clinical Oncology (ASCO) brings together internationally renowned cancer researchers, doctors and medical professionals to discover and discuss the latest in cancer research and patient care. This webinar, scheduled for June 19 2013 is presented by Dr. John Marshall, and will highlight the key colorectal cancer findings from the 2013 meeting and what these advances mean for you.TRANSCRIPT
Save the date for our 10th National Patient Conference
Learn more or register:www.ccalliance.org or 1-877-422-2030
Presented by:
Fight Colorectal CancerMissionFight Colorectal Cancer demands a cure for colon and rectal cancer. We educate and support patients, push for changes in policy that will increase and improve research, and empower survivors to raise their voices against the status quo.
Monthly Patient Webinar Series3rd Wednesday every monthFightColorectalCancer.org Fight CRC Toll-free Answer Line 1.877.427.2111
Join One Million StrongCRCMillionStrong.org
Join us in March 2014 for Call on Congress
Fighting a Smarter War On Colon Cancer:
John L. Marshall, MD
The Biomarker Divide
Tel: (202) 444-0275Fax: (202) 444-1229
http://lombardi.georgetown.edu/GI
Stakeholder Motivation
Stakeholders• FDA• CMS/Payers• NCI/CTEP• PhRMA• Community Onc• Academic Onc• Patients
Priority/Agenda• Safety and Efficacy• Cost Control/Value• Cure Cancer• Markets, ROI• Efficient/Quality Care• Clinical Trial Accrual• Cure/Benefit/Altruism
Gastrointestinal (GI) Cancers Facts
GI cancers represent the most common and fatal cancers in the world
2009: 275,720 new diagnosis of GI Cancers and 135,830 deaths in the US alone
Anal Cancer Colorectal Cancer Esophageal Cancer Gallbladder Cancer Liver Cancer Pancreatic Cancer Small Intestine Cancer Stomach/Gastric Cancer
No two cancers are alike and treatments must be selected based on an individual’s tumor characteristics, by personalized medicine
Breast Cancer Nation
Why Not Brown?
Our Current Model of Colon Cancer
Antoni van Leeuwenhoek (1632-1723)
Invented the microscope around
166810
The view from 35,000 feet
Everything looks the same from up here
12
Management of MCRC: An Evolving Treatment Algorithm
Diagnosis of MCRC
Resectable Unresectable
Adjuvant therapy
Surgery
Neo-adjuvant/Pre-operative
therapy
First-Line
Second-Line
Third-Line
Borderline/PotentiallyResectable
Fourth-Line
Treatment continuum
13
Advances in the Treatment of Colorectal Cancer
2000 2005 2008 2012
Capecitabine
Oxaliplatin
Cetuximab
Irinotecan
5-FU
Panitumumab
Targeted therapies
Bevacizumab
KRASAfliberceptRegorafanib
2012 ESMO Guidelines: Sequence of Treatment by Line
Schmoll et al. Ann Oncol. 2012;23:2479-2516.
15
EGFR: One of Many Signaling Modules in Cancer Cells
Hanahan, Weinberg, Cell 100:57, 2000
16Proliferation MetastasisAngiogenesisApoptosis
Resistance
Shc
PI3-K
RafMEKK-1
MEKMKK-7
JNKERK
Ras
mTOR
Grb2
AKT
Sos-1
What is the Role of the Epidermal Growth Factor Receptor (EGFR) in Cancer?
Cell Membrane
EGFR
Signaling Proteins
Cell Response
to Signaling
17A. Friedman and N. Perrimon, Cell 128, January 26, 2007
Pathway vs. Network signaling
Network
“Chaotic”
Pathway
“Newtonian”
The Nature of the Disease
19
Shc
PI3-K
RafMEKK-1
MEKMKK-7
JNKERK
Ras
mTOR
Grb2
AKT
Sos-1
Proliferation MetastasisAngiogenesisApoptosis Resistance
EGFR
Signaling Proteins
Cell Response
to Signaling
20
Shc
PI3-K
RafMEKK-1
MEKMKK-7
JNKERK
Ras
mTOR
Grb2
AKT
Sos-1
Which Target?
21
Courtesy of I. Serebriiskii and E. Golemis, Fox Chase Cancer Center
Sos-1
Ras
MEKK-1MEK
Shc
PI3-K
Raf
MKK-7
Grb2
AKT
JNK
ERK
22
Courtesy of I. Serebriiskii and E. Golemis, Fox Chase Cancer Center
Sos-1
Ras
MEKK-1MEK
Shc
PI3-K
Raf
MKK-7
Grb2
AKT
JNK
ERK
Where’s the target?
The EGF Receptor Interactome
638 Genes
23
Colon Cancer Has Many Biologic Subsets That Differ in Response to
EGFR-Targeted Agents
BRAF
KRAS
EREG or AREG
PI3K PTEN
EGFR
PIP1
PIP3
Signaling to the nucleus
Low expression of EGFR ligands → decreased response to EGFR targeted agents
Mutant BRAF → decreased response to EGFR-targeted agents
PTEN loss of expression → decreased response to EGFR-targeted agents
Mutant KRAS → decreased response to EGFR-targeted agents
24
Q: Is More Always Better?
25
Correlation Between Survival and Percentage of Patients Receiving Three
Drugs in Phase 3 Trials
3 drugs: 5-FU/LV, irinotecan, oxaliplatin.Grothey A, et al. J Clin Oncol. 2005;23:9441-9442.
12
13
14
15
16
17
18
19
20
21
22
0 10 20 30 40 50 60 70 80
Patients with three drugs (%)
Me
dia
n O
S (
mo
nth
s)
TRIBE Study Design
R
508 mCRC pts1st lineunresectablestratified by center PS 0/1-2
adjuvant CT
FOLFIRI+bev(up to 12 cycles)
FOLFOXIRI+bev
(up to 12 cycles)
5-FU/LV +Bev
5-FU/LV +Bev
PD
INDUCTION MAINTENANCE
Toxicity Profile – Safety population
G3/4 adverse events, % patients
FOLFIRI + bevN=254
FOLFOXIRI + bevN=250
p
Nausea 3 3 1.000
Vomiting 3 4 0.492
Diarrhea 11 19 0.012
Stomatitis 4 9 0.048
Neutropenia 20 50 <0.001
Febrile neutropenia 6 9 0.315
Neurotoxicity 0 5 <0.001
Hypertension 2 5 0.157
Venous Thrombosis 6 7 0.593
Arterial Thrombosis 2 1 1.000
Bleeding 1 1 1.000
Secondary endpoint: Response rate (updated) - ITT population
Best Response, %
FOLFIRI + bevN = 256
FOLFOXIRI + bevN = 252
p
Complete Response 3% 5%
Partial Response 50% 60%
Response Rate 53% 65% 0.006
Stable Disease 32% 25%
Progressive Disease 11% 6%
Not Assessed 4% 4%
Median follow up: 32.3 mos
FOLFIRI + bev: N = 256 / Progressed = 226FOLFOXIRI + bev: N = 252 / Progressed = 213
FOLFIRI + bev, median PFS : 9.7 mosFOLFOXIRI + bev, median PFS : 12.1 mos
Unstratified HR: 0.77 [0.64-0.93]p=0.006
Stratified HR: 0.75 [0.62-0.90] p=0.003
Primary endpoint: PFS (updated) – ITT population
FOLFIRI/bev 256 203 94 46 26 14 7 3 0 0
FOLFOXIRI/bev 252 208 125 74 35 21 11 5 2 1
Pro
gre
ssio
n-f
ree
surv
ival
pro
bab
ility
F-up time (months)
FOLFIRI + bev
FOLFOXIRI + bev
Secondary endpoint: OS (preliminary) – ITT population
FOLFIRI/bev 256 233 216 172 109 69 36 15 5 0
FOLFOXIRI/bev 252 234 205 175 119 70 35 15 4 0
Ove
rall
su
rviv
al p
rob
abili
ty
F-up time (months)
FOLFIRI + bev
FOLFOXIRI + bev
Median follow up: 32.3 mos
FOLFIRI + bev: N = 256 / Died = 155FOLFOXIRI + bev: N = 252 / Died = 131
FOLFIRI + bev, median OS : 25.8 mosFOLFOXIRI + bev, median OS : 31.0 mos
Unstratified HR: 0.83 [0.66-1.05]p=0.125
Stratified HR: 0.79 [0.63-1.00] p=0.054
Contrast of Appearance vs.Expression Phenotyping
Microarray Low Risk High Risk
Microscope Low Grade High GradeTreatment
Advice
31
We need to be careful with our conclusions
pmTOR-immunostaining (Ventana)
Critical: Postsurgical ischemia
34
Colon Cancer is more than one disease
kRAS Wild Type kRAS mutant
MSI-High MSS
+ EGFR Agents - EGFR Agents
? No 5FU
50-60% 40-50%
15-20% 80-85%
And of course it is very many more than the 4 sub-groups above
Clinical Research 2.0
Agent HR $ Cost/Month(÷100)
Toxicity(G1+2) * (G3+4) # Patients
QOL/Utility ScorePass/Fail
Imatinib vs IFNCML 0.17 55.90 0.67
Nilotinib vs ImatCML 0.8 76.40 0.17
ImatinibGIST 0.4 55.90 1.22
Erlotinib vs ChemoMut NSCL
0.75 52.80 0.71
ErlotinibPancreas 0.82 52.80 11.9
Bevacizumab 2nd line CRC 0.74 22.90 0.8
Aflibercept2nd line CRC 0.79 ????- 3.0
Value Metric
Finding Value
• Come together• Listen to each other• Respect what we hear• Find the common threads• Weave a new fabric
- provide global healthcare with value
Engaging the 97%• Better education/information• Incentives for patients and providers
– No added incentives for delivering SOC– Honor our “soldiers” in the war on cancer
• Recognized the shared investment in research– Docs, hospitals, NCI, Industry, Payers, Patients
• Target “substantial therapeutic benefit”– “Breakthrough Designation”
• Reduce concept to approval time line• Embrace the emerging markets
Fundamental Shifts In Cancer CareYesterday• Consumption• Individual Practices• Rich Countries• Microscope• Safety and Efficacy• Large trials• 1.4 months• QOL• Patient as a “Subject”• Chaotic Data Collection• Institutional IRBs• National Approvals
Tomorrow• Outcomes• Healthcare Systems• All Countries• Gene Profile• Value• Small trials• “Substantial Improvement”• Patient Reported Outcomes• Patient as a “Partner”• Standard Data Collection• Central/National IRBs• Global Approvals
Questions & Answers
Thank you!
Fight Colorectal CancerAnswer Line 1-877-427-2111FightColorectalCancer.org
Colon Cancer AllianceHelpline: 1-877-422-2030
www.CCAlliance.org [email protected]