Nuovi inibitori irreversibili di EGFR Cesare Gridelli Division of Medical Oncology “S.G. Moscati” Hospital – Avellino (Italy) cgridelli@libero.it

NEGATIVE TRIAL 1 N= 440 patients Stratification -Race -Exon 19 v 21

Ramalingam SS et al. WCLC 2015 Comparison of the Efficacy of Dacomitinib v Erlotinib for NSCLC Pts with Del 19/21 121 EGFR Mutant Patients Retrospectively analysed from ARCHER 1028 (Ramalingam S JCO 2012) and ARCHER 1009 (Ramalingam S Lancet Oncol 2014) OS PFS PFS OS Dacomitinib (N=66) Erlotinib (N=55) Events(%) 51 (77.3%) 44 (80.0%) 39 (59.1%) 32 (58.2%) Median (95% CI) in Mons 10.9 (7.4-17.4) 9.6 (7.4-11.3) 26.6 (20.1-29.0) 24.1 (17.9-39.4) Un-stratified HR (95% CI) 0.815 (0.542-1.224) 0.958 (0.596-1.538) P-value (1-sided) 0.160 0.431 Ramalingam SS et al. WCLC 2015

ARCHER 1050: Randomized Phase III Study Dacomitinib vs Gefitinib Dacomitinib 45mg qd Advanced NSCLC Adenocarcinoma EGFR exon 19/21 mut+ First-line treatment PS 0-1 Primary endpoint in PFS 14.8 vs 9.5 months 1 Gefitinib 250mg qd 1 N= 440 patients Stratification -Race -Exon 19 v 21

Acquired resistance in EGFR Mut+ NSCLC Mechanisms of acquired resistance to EGFR TKIs Acquired resistance to EGFR TKIs in metastatic setting is inevitable The average PFS is 8–13 months Activation of other receptor tyrosine kinases? (eg. ERBB2 amplification) FAS/NFB activation? Epithelial-mesenchymal transition? (AXL, Slug activation?) Loss or spliced variant of BIM? Other? (eg. CRKL or ERK amplification) ~30–40% ~60% second-site EGFR mutations (mostly T790M) Can we add this slide instead of the previous one (more clear than previous one concerning the figure ?). Perhaps you can redraw the figure ? ~1% BRAF mutations ~5% small-cell cancer transformations ~5% PIK3CA mutations -5–10% MET amplification Ohashi et al, J Clin Oncol 2013

Adequacy and Complications of re-biopsy 126 patients referred for repeat biopsy with NSCLC resistant to conventional chemotherapy or EGFR Tki 94 patients (31 men, 63 women) selected for rebiopsy (75%) (25% of case it was not possible) Technical success rate for biopsy was 100% (80% suitable for mutational analyses). Postprocedural complications occurred in 13 (14%) patients Of 126 patients evaluated for re-biopsy, 94 were eligible for this procedure: specimens resulted adequate for mutational analysis in 75 cases (80%), while post-procedural complications occurred in 13 (14%) of patients, thus proving that lung re-biopsies may be a feasible and adequate procedure in approximately 4/5 of patients, when performed by employing rigorous computed tomography (CT) criteria. Yoon HJ et al, Radiology 2012

3rd Generation Irreversible EGFR TKIs Under Development: AZD9291 Selectively targets mutated EGFR, including T790M Phase I dose escalation study in patients with EGFR Mut+ disease and PD on EGFR TKI Encouraging activity : 61 % response rate months in 127 pts T790M+ 21 % response rate in 61 pts T790M- No DLTs Recommended dose: 80 mg daily In the Ref N°3: « ECCCO » Is it possible to put on one slide CO-1686 as you done and on the right of the slide the waterfall plot of the study (see, next slide N°15) and same thing for AZD9291 (waterfall plot slide N°16) (it might be more visuel) ? Janne et al. N Engl J Med 2015; 372: 1689–1699

ZD9291: clinical development Phase II extension – further assessment of efficacy and tolerability of AZD9291 80 mg QD in patients with T790M+ NSCLC AURA Confirmatory global Phase II – assessment of efficacy and tolerability of AZD9291 80 mg QD in patients with T790M+ NSCLC AURA 2 Phase III – efficacy and safety of AZD9291 vs platinum-based doublet chemotherapy in second-line patients with T790M+, advanced/metastatic NSCLC who have progressed following prior therapy with an EGFR-TKI AURA 3 FLAURA Phase III – efficacy and safety of AZD9291 vs gefitinib or erlotinib in first-line patients with EGFR M+, advanced/metastatic NSCLC

AURA2: Phase II, open-label, single-arm study Primary objective To investigate the efficacy of AZD9291 by assessment of ORR (RECIST 1.1 BICR) Patients with confirmed EGFRm locally advanced or metastatic NSCLC who have progressed following prior therapy with an approved EGFR-TKI Key inclusion criteria Aged ≥18 (≥20 in Japan) Confirmation of tumor EGFR mutation associated with EGFR-TKI At least one lesion suitable for accurate repeated measurements WHO performance status 0 or 1 Acceptable organ function Stable brain metastases allowed Central T790M mutation testing* of biopsy sample collected following confirmed disease progression T790M positive (n=210) AZD9291 80 mg once daily T790M negative Not eligible for enrollment *The EGFR T790M mutation status of the patient’s tumor was prospectively determined by the designated central laboratory using the cobas™ EGFR Mutation Test (Roche Molecular Systems) by biopsy taken after confirmation of disease progression on the most recent treatment regimen BICR, blinded independent central review; EGFR, epidermal growth factor receptor; EGFRm, EGFR-TKI-sensitizing mutation; NSCLC, non-small cell lung cancer; ORR, objective response rate; RECIST, Response Evaluation Criteria In Solid Tumors; TKI, tyrosine kinase inhibitor; WHO, World Health Organization

Tumor response (independent central review) 100 80 Best percentage change from baseline in target lesion – all patients 60 40 20 -20 -40 -60 Complete response Partial response Stable disease Progressive disease Not evaluable -80 -100 Confirmed objective response Total ORR† 71% (95% CI 64, 77) Complete response,‡ n (%) Partial response,‡ n (%) Stable disease ≥6 weeks,§ n (%) Progressive disease, n (%) 2 (1) 139 (70) 41 (21) 15 (8) DCR 92% (95% CI 87, 95) Tables 11.2.1.1.1, 11.2.1.2.1, 11.2.1.4.1 Figure 11.2.1.5.5 Mitsudomi T et al. WCLC 2015

Duration of response and progression-free survival 1.0 0.9 0.8 0.7 0.5 0.4 0.3 0.2 0.0 Probability of response 12 9 6 3 Month 0.6 0.1 Number of patients at month: AZD9291 80 mg 141 123 43 Censored observations Number of patients at risk: 1.0 0.9 0.8 0.7 0.5 0.4 0.3 0.2 0.0 Probability of progression-free survival 12 9 6 3 Month 0.6 0.1 AZD9291 80 mg 210 172 115 15 Censored observations KM-based estimated† Total‡ Median DoR,¶ months (95% CI) 7.8 (7.1, NC) Maturity: 27% Remaining in response, % (95% CI) 6 months 9 months 75 (65, 82) NC (NC, NC) Range of DoR, months 1.3–8.4 KM-based estimated† Total§ Median PFS,** months (95% CI)†† 8.6 (8.3, 9.7) Maturity: 38% Remaining alive and progression free, % (95% CI) 6 months 9 months 70 (63, 76) 48 (36, 58) Median follow-up for PFS 6.7 months Tables 11.2.1.6.3, 11.2.1.6.4, 11.2.1.3.1, 11.2.1.3.2 Figure 11.2.1.6.5 Mitsudomi T et al. WCLC 2015

AURA 3 TRIAL: AZD9291 vs Chemotherapy in II line in patients with EGFR activating mutation and T790M+ R A N D O M I Z E AZD9291 (80 mg daily) Advanced NSCLC Adenocarcinoma EGFR mut+ EGFR T790M+ Second-line treatment PS 0-1 1 Chemotherapy CDDP+Alimta 1 Primary Endpoint Estimated Enrollment: PFS 410 Study Start Date: August 2014 Accrual Completed Estimated Primary Completion Date: April 2016 (Final data collection date for primary outcome measure)

ASTRIS TRIAL

Best percentage change in target lesion size – all patients ZD9291 in 1-line EGFR M+ (19/21): Response in first-line cohorts by dose 100 90 80 Best percentage change in target lesion size – all patients 70 60 50 40 D 30 20 10 -10 -20 -30 D -40 -50 D -60 D -70 -80 80 mg D D -90 -100 160 mg 80 mg N=30 160 mg Total N=60 Confirmed objective response rate 67% (95% CI 47, 83) 83% (95% CI 65, 94) 75% (95% CI 62, 85) Disease control rate 93% (95% CI, 78, 99) 100% (95% CI 88, 100) 97% (95% CI 89, 100) Best objective response Complete response Partial response Stable disease Progressive disease 20 8 2 2* 23 5 43 13 Ramalingam S et al. WCLC 2015

DoR and PFS in AZD9291 first-line cohorts (investigator assessed) Duration of response Progression-free survival 1.0 1.0 0.9 0.9 0.8 0.8 0.7 0.7 0.6 0.6 Probability of response 0.5 Probability of response 0.5 0.4 0.4 0.3 0.3 0.2 0.2 AZD9291 80 mg Censored observation AZD9291 80 mg Censored observation 0.1 0.1 AZD9291 160 mg Censored observation AZD9291 160 mg Censored observation 0.0 0.0 Number of patients at month: 3 6 9 12 15 Number of patients at risk: 18 3 6 9 12 15 18 Month Month 80 mg 20 20 17 14 10 5 80 mg 30 26 23 22 19 12 3 160 mg 25 25 21 18 8 160 mg 30 29 27 23 17 80 mg N=20 160 mg N=25 Total N=45 Median DoR,* months (95% CI) 13.6 (11.1, NC) Maturity: 35% NC (9.7, NC) Maturity: 28% NC (12.3, NC) Maturity: 31% Maximum DoR, months 18.0+ 12.6+ Remaining in response,† % (95% CI) 9 months 12 months 89 (64, 97) 76 (46, 90) 78 (56, 90) 69 (45, 84) 83 (68, 92) 71 (53, 83) 80 mg N=30 160 mg Total N=60 Median PFS,‡ months (95% CI) NC (12.3, NC) Maturity: 40% NC (1 1.1, NC) Maturity: 30% NC (13.7, NC) Maturity: 35% Maximum PFS, months 19.2+ 13.8+ Remaining alive and progression-free,† % (95% CI) 9 months 12 months 83 (64, 93) 75 (55, 87) 80 (60, 90) 69 (48, 82) 81 (69, 89) 72 (58, 82) Ramalingam S et al. WCLC 2015

Gefitinib or Erlotinib FLAURA Phase III trial: AZD9291 vs Gefitnib or Erlotinib in I line in patients with EGFR mutation R A N D O M I Z E AZD9291 (80 mg daily) Advanced NSCLC Adenocarcinoma EGFR mut+ First-line treatment PS 0-1 1 1 Gefitinib or Erlotinib Primary Endpoint Estimated Enrollment: PFS 650 Study Start Date: December 2014 Accrual Ongoing Estimated Primary Completion Date: May 2017 (Final data collection date for primary outcome measure)

3 rd generation EGFR TKIs under development: Rociletinib (CO-1686) Selectively targets mutated EGFR, including T790M spares EGFR WT Phase I dose escalation study in EGFR Mut+ T790M+(n=243/458) encouraging activity: 53% response rate Median PFS 8 months AE profile consistent with lack of EGFR WT inhibition T790M negative 37% OR Positive agreement T790M liquid (81%) vs tissue (87%) biopsy Recommended dose: 1000 mg (500 mg BID ) In the Ref N°3: « ECCCO » Is it possible to put on one slide CO-1686 as you done and on the right of the slide the waterfall plot of the study (see, next slide N°15) and same thing for AZD9291 (waterfall plot slide N°16) (it might be more visuel) ? Sequist L et al, ASCO 2015

Dose Optimization of Rociletinib for T790M Mutated NSCLC 100 80 60 40 20 −20 −40 −60 −80 −100 500mg 625mg 750mg Total n 48 114 77 239 ORR (%) 60 54 46 52 DCR (%) 90 84 82 85 + Ongoing 500mg BID HBr 625mg BID HBr 750mg BID HBr SLD change from baseline (%) Grade ≥3 treatment-related AEs observed in >10% of patients, n (%) AE Rociletinib dose 500mg BID (n=119) 625mg BID (n=236) 750mg BID (n=95) Hyperglycemia 20 (17) 56 (24) 34 (36) The risk-benefit profile of rociletinib is optimal at the recommended dose (500 mg BID) Goldman JW et al. WCLC 2015

TIGER-X: Phase 1/2 study of rociletinib in advanced NSCLC 625mg BID 500mg BID Phase 1 (Dose Escalation) Phase 2 Expansion Cohorts (Required Central Tissue T790M Testing) Rociletinib Treatment (free base rociletinib, followed by 500, 625, 750, and 1000mg BID HBr) 750mg BID 2nd-line patients PD upon 1 immediate prior TKI >2nd-line patients PD upon ≥2 TKI or chemotherapy 21-day cycles; escalate to MTD Key outcome measures Safety Tolerability PK profile ORR ORR in centrally confirmed tissue T790M-positive pts (n=48) enrolled at the 500mg BID dosing level was 60% ORR in centrally confirmed tissue T790M-negative pts (n=35) was 37%1 Updated results in centrally confirmed tissue T790M-negative pts are presented As of August 11, 2015, 111 and 482 pts (T790M±) were enrolled on the phase 1 and 2 portions, respectively Wakelee H et al, WCLC 2015

Why do T790M-negative pts respond to rociletinib? Qiagen therascreen and cobas central T790M tests are highly concordant A sample that tests negative by one central test likely to be negative by other Tumor heterogeneity Not all cells express T790M; tissue biopsy samples one small area Plasma test may be more representative, especially with extrathoracic spread Other mechanisms of rociletinib action may be important Rociletinib inhibits IGF-1R and IR kinases IGF-1R/IR may drive resistance to initial EGFR inhibitor therapy In a preclinical study, treatment with a T790M-potent EGFR TKI prevented emergence of the EGFR T790M mutation, resulting in sequential acquisition of non-T790M resistance mechanisms involving IGF-1R and MAPK pathways1 Wakelee H et al, WCLC 2015 1. Cortot A, et al. Cancer Res. 2013;73:834-43.

(TIGER2 like ;pts T790M plasma) Trials enrolling in 2014 TIGER4 (phase 2) (TIGER2 like ;pts T790M plasma)

TIGER 1 PHASE II TRIAL: 1-line Rociletinib vs Erlotinib in patients with EGFR mutation R A N D O M I Z E Rociletinib Advanced NSCLC Adenocarcinoma EGFR mut+ First-line treatment PS 0-1 1250 mg (625 mg BID) 1 Erlotinib 1 Primary Endpoint Estimated Enrollment: PFS 200 Study Start Date: November 2014 Accrual Ongoing Estimated Primary Completion Date: June 2016 (Final data collection date for primary outcome measure)

TIGER 3 TRIAL: Rociletinib vs chemotherapy in pretreated patients with EGFR mutation and T790M+/- R A N D O M I Z E Rocilietinib Advanced NSCLC Adenocarcinoma EGFR mut+ EGFR T790M+ or - Third or more line treatment PS 0-1 1250 mg (625 mg BID) 1 Single agent Chemotherapy (Pem/Gem/Txt/Tax) 1 Primary Endpoint Estimated Enrollment: PFS 600 Study Start Date: February 2015 Accrual Ongoing Estimated Primary Completion Date: March 2017 (Final data collection date for primary outcome measure)

Recommended dose: 800 mg (400 mg BID) Study Design Recommended dose: 800 mg (400 mg BID)

Best Overall Response: Expansion Part HM61713 Best Overall Response: Expansion Part

Progression-Free Survival<br />: Expansion part (T790M+ versus T790M-)

HM61713 PHASE II TRIAL in 2-line for patients with EGFR activating mutation and T790M+ Advanced NSCLC Adenocarcinoma EGFR mut+ EGFR T790M+ Second-line treatment (previous TKI) PS 0-1 HM61713 800 mg (400 mg BID) Primary Endpoint Estimated Enrollment: Response Rate 150 Study Start Date: July 2015 Accrual Ongoing Estimated Primary Completion Date: December 2016 (Final data collection date for primary outcome measure)

AZD9291 T790M+ T790M+ C797S+ T790M+ C797S- Resistance T790M- C797S- NATURE MEDICINE | BRIEF COMMUNICATION Acquired EGFR C797S mutation mediates resistance to AZD9291 in non–small cell lung cancer harboring EGFR T790M Kenneth S Thress, Cloud P Paweletz, Enriqueta Felip, Byoung Chul Cho, Daniel Stetson, Brian Dougherty, Zhongwu Lai, Aleksandra Markovets, Ana Vivancos, Yanan Kuang, Dalia Ercan, Sarah E Matthews, Mireille Cantarini, J Carl Barrett, Pasi A Jänne & Geoffrey R Oxnard Nature Medicine 21, 560–562 (2015) T790M+ C797S+ 6 pts MOLECULAR SUBTYPES OF RESISTANCE AZD9291 Resistance T790M+ C797S- T790M+ 5 pts 15 pts T790M- C797S- Del19+ or Mut21+ 4 pts Cell-free plasma DNA (cfDNA) Firstly next-generation sequencing of cfDNA from 7 patients detecting an acquired EGFR C797S mutation in 1 patient Then droplet digital PCR on serial cfDNA specimens collected from 15 AZD9291-treated patients All positive for the T790M mutation before treatment, but after AZD9291 resistance: 6 cases acquired the C797S mutation 5 cases maintained the T790M mutation but did not acquire the C797S mutation 4 cases lost the T790M mutation despite the presence of the underlying EGFR activating mutation

Mechanisms of Acquired Resistance to AZD9291 in EGFR T790M Positive Lung Cancer 15 (22%) out of 67 patients, had detectable C797S, all with detectable T790M (T790+/C797S+) C797S was more common with EGFR exon 19 del (13/43, 30%) vs those with L858R (2/24, 8%, p=0.06) 32 of 67 (48%) had no detectable T790M in plasma despite presence of the EGFR-TKI-sensitizing mutation, suggesting overgrowth of an alternate resistance mechanism, such as MET or HER2 amplification or BRAF V600E Oxnard G et al. WCLC 2015