Month: November 2015

ONIVYDE® in Combination with 5-FU and Leucovorin Improves Overall Survival in Metastatic Pancreatic Carcinoma

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SUMMARY: The FDA on October 22, 2015 approved ONIVYDE® (Irinotecan liposome injection) administered in combination with Fluorouracil (5-FU) and Leucovorin , for the treatment of patients with metastatic adenocarcinoma of the Pancreas, whose disease has progressed following GEMZAR® (Gemcitabine) based therapy. The American Cancer Society estimates that in 2015, close to 49,000 people will be diagnosed with pancreatic cancer in the United States and over 40,000 people will die of the disease. Some important risk factors for Pancreatic cancer include increasing age, obesity, smoking history, genetic predisposition, exposure to certain dyes and chemicals, heavy alcohol use and pancreatitis. The best chance for long term survival is complete surgical resection, although this may not be feasible in a majority of the patients, as they present with advanced disease at the time of diagnosis. Based on the National Cancer Data Base, the 5 year observed survival rate for patients diagnosed with exocrine cancer of the Pancreas is 14% for those with Stage IA disease and 1% for those with Stage IV disease.

ONIVYDE® is a novel nanoliposomal encapsulation of Irinotecan, a topoisomerase 1 inhibitor. It is designed to optimize the delivery of Irinotecan, by extending the duration of circulation of the drug in the body and preferentially activating the drug within the tumor tissues, to achieve higher levels of the active cytotoxic drug metabolite, SN-38. This approach reduces the toxicity of Irinotecan to normal tissues while maintaining or increasing its anti-tumor efficacy.

NAPOLI-1 is an open-label phase III study in which 417 patients with Gemcitabine-refractory metastatic Pancreatic adenocarcinoma were randomly assigned in a 1:1:1 ratio to receive either ONIVYDE® monotherapy, ONIVYDE® plus 5-FluoroUracil (5-FU) and Leucovorin or 5-FU with Leucovorin (control group). Sixty one percent (61%) of patients had cancer in the head of the Pancreas and 68% had liver metastases. Treatment consisted of ONIVYDE® 120 mg/m2 IV over 90 minutes every 3 weeks in Group A, ONIVYDE® 80 mg/m2 IV given over 90 minutes followed by 5-FU 2400 mg/m2 given over 46 hours and racemic Leucovorin 400 mg/m2 IV given over 30 minutes every 2 weeks in Group B and 5-FU 2000 mg/m2 IV given over 24 hours plus racemic Leucovorin 200 mg/m2 IV given over 30 minutes weekly for 4 weeks followed by 2 weeks of rest in Group C (Control group).

Each of the two ONIVYDE® containing groups was compared with the 5FU/Leucovorin control group. The primary study endpoint was Overall Survival and secondary endpoints included Progression Free Survival (PFS) and Overall Response Rate (ORR). The combination of ONIVYDE®, 5-FU and Leucovorin resulted in a median OS of 6.1 months compared with 4.2 months with 5-FU and Leucovorin alone (HR = 0.67; P=0.012). The median PFS was 3.1 months for the ONIVYDE® combination compared with 1.5 months with 5-FU and Leucovorin alone (HR= 0.55; P=0.0001). The ORR was low in both treatment groups (7.7% vs 0.8%). ONIVYDE® montherapy was not superior, compared with 5-FU and Leucovorin and was associated with more side effects compared to the combination regimen. In an expanded, pre-specified analyses, patients who received at least 80% of the target dose in the first 6 weeks experienced an even greater Overall Survival benefit (43% improvement) with ONIVYDE® combination, compared with 5-FU and Leucovorin alone (8.9 months vs 5.1 months, HR=0.57, P=0.011).

The most common grade 3/4 adverse events with ONIVYDE® plus 5-FU and Leucovorin were neutropenia, fatigue, diarrhea and vomiting. The authors concluded that a combination of ONIVYDE® plus 5-FU and Leucovorin significantly improved Overall Survival compared to 5-FU and Leucovorin with manageable toxicities. Expanded analyses of Napoli-1: Phase 3 study of MM-398 (nal-IRI), with or without 5-fluorouracil and leucovorin, versus 5-fluorouracil and leucovorin, in metastatic pancreatic cancer (mPAC) previously treated with gemcitabine-based therapy. Chen L, Von Hoff DD, Li C, et al. J Clin Oncol 33, 2015 (suppl 3; abstr 234)

Targeting CD38 with Daratumumab Monotherapy in Multiple Myeloma

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SUMMARY: The FDA recently assigned a priority review designation to Daratumumab, as a treatment for patients with double refractory Myeloma. Multiple Myeloma is a clonal disorder of plasma cells in the bone marrow and the American Cancer Society estimates that in the United States, close to 27,000 new cases will be diagnosed in 2015 and 11,240 will die of the disease. The choice of first line therapy for patients with Myeloma may depend on transplant eligibility, comorbid conditions, cytogenetics and patient performance status. Following progression on first line therapy, single agent therapy with KYPROLIS® (Carfilzomib) has an Objective Response Rate of 24%, with a median duration of response of 7.4 months, in patient groups refractory to both VELCADE® (Bortezomib) and REVLIMID® (Lenalidomide). POMALYST® (Pomalidomide) in combination with Dexamethasone is superior to high dose Dexamethasone alone, with a significant improvement in the Progression Free Survival and Overall Survival, in patients with relapsed and refractory Multiple Myeloma. More recently, data became available for three triplet regimens in patients with relapsed Myeloma – 1) The addition of KYPROLIS® to REVLIMID® and Dexamethasone resulted in significant improvement in Progression Free Survival, when compared with REVLIMID® and Dexamethasone alone, in patients with relapsed Multiple Myeloma 2) A combination of FARYDAK® (Panobinostat), a histone deacetylase (HDAC) inhibitor, VELCADE® and Dexamethasone significantly improves Progression Free Survival in patients with relapsed and refractory Multiple Myeloma when compared to VELCADE® and Dexamethasone 3) Elotuzumab (HuLuc63), a monoclonal antibody that binds to the Signal Lymphocyte Activation Molecule – SLAMF7 protein (CS1, CD319), when added to REVLIMID® and Dexamethasone, reduced the risk of disease progression by 30% in patients with Relapsed/Refractory Multiple Myeloma, when compared with REVLIMID® and Dexamethasone.

Daratumumab is a human IgG1 antibody that targets CD38, a transmembrane glycoprotein abundantly expressed on malignant plasma cells and with low levels of expression on normal lymphoid and myeloid cells. Daratumumab exerts its cytotoxic effect on myeloma cells by multiple mechanisms, including Antibody Dependent Cellular Cytotoxicity (ADCC), complement mediated cytotoxicity and direct apoptosis. Based on the anti-myeloma activity of Daratumumab in preclinical studies, a phase 1–2 clinical trial was conducted which involved patients with relapsed and refractory Myeloma, who were refractory to two or more prior lines of therapy. Patients in this study had received a median of four previous lines of therapy, 79% of the patients had disease that was refractory to their most recent therapy, including proteasome inhibitors and immunomodulators and 76% of the patients had also undergone autologous stem cell transplantation. This trial included a dose-expansion phase in which 30 patients received Daratumumab 8 mg/kg and 42 patients received 16 mg/kg, given once weekly for 8 doses, twice monthly for 8 doses, and monthly for up to 24 months. The primary end point was safety determined by frequency and severity of adverse events. Secondary end points included Objective Response Rate, duration of response, time to disease progression, Progression Free Survival, Overall Survival and pharmacokinetics.

It was noted that in the cohort that received Daratumumab 16 mg/kg, the overall response rate was 36% with a median Progression Free Survival of 5.6 months and 65% of the patients who had a response did not have disease progression at 12 months.

Infusion related reactions were mild and only 1% had grade 3 events. The other most common adverse events were pneumonia and thrombocytopenia. The authors concluded that Daratumumab has significant single agent activity in a very heavily pretreated and refractory Myeloma patient population, with a favorable safety profile. It remains to be seen if Daratumumab will be an important component of the induction, consolidation and maintenance phases, in the Myeloma treatment landscape. Targeting CD38 with Daratumumab Monotherapy in Multiple Myeloma. Lokhorst HM, Plesner T, Laubach JP, et al. N Engl J Med 2015; 373:1207-1219

Molecular Markers Can Predict Response to Neoadjuvant Cisplatin-based Chemotherapy in Muscle Invasive Bladder Cancer

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SUMMARY: The American Cancer Society estimates that in the United States for 2015, about 74,000 new cases of bladder cancer will be diagnosed and approximately 16,000 patients will die of the disease. A third of the patients initially present with locally invasive or metastatic disease. Even though radical cystectomy was considered the standard of care for patients with localized Muscle Invasive Bladder Cancer (MIBC), two large randomized trials and two meta-analysis have shown greater survival benefit with neoadjuvant Cisplatin-based chemotherapy combinations for patients with MIBC, compared to surgery alone. However, not all patients with MIBC benefit from neoadjuvant Cisplatin based therapy, with only 25-50% attaining a pathologic response. The authors in this publication evaluated the role of genetic testing and genetic biomarkers prior to chemotherapy, in order to select the appropriate group of patients who would benefit from neoadjuvant Cisplatin based chemotherapy and thereby exclude those who are unlikely to benefit from chemotherapy.

Muscle Invasive Bladder Cancer (MIBC) patients from two prospective multicenter clinical trials of Cisplatin-based neoadjuvant chemotherapy were included and pretreatment MIBC samples were prospectively collected and this provided the discovery and validation sets. DNA from pre-treatment tumor tissue was sequenced for all coding exons of 287 cancer related genes and was analyzed for presence of base substitutions, indels, copy number alterations and selected rearrangements. The discovery set allowed for improved prognostic strength, by combining existing known high risk genetic markers with other novel risk markers. The validation set validated these markers. This study included data from 34 patients in the discovery cohort and 24 patients in the validation cohort.

It was noted that patients with a pathologic Complete Response had more alterations in the genes compared to those with residual tumor, both in the discovery (P= 0.024) and validation (P=0.018) sets. Further, in the discovery set, alteration in one or more of the three DNA repair genes ATM, RB1, and FANCC predicted pathologic Complete Response (P<0.001; 87% sensitivity, 100% specificity) as well as improved Overall Survival (P=0.007). DNA repair is one of the mechanisms postulated to contribute to Cisplatin chemo-resistance. This test remained predictive for pathologic Complete Response in the validation set (P=0.033), with a trend towards improved Overall Survival (P=0.055).

The authors concluded that defective DNA repair renders tumors sensitive to Cisplatin and genomic alterations in the DNA repair-associated genes ATM, RB1, and FANCC predict response and clinical benefit for MIBC, treated with Cisplatin-based chemotherapy. Defects in DNA Repair Genes Predict Response to Neoadjuvant Cisplatin-based Chemotherapy in Muscle-invasive Bladder Cancer. Plimacka ER, Dunbracka RL, Brennan TA, et al. European Urology 2015;68:959-967