1. Which chemotherapy in BRCA mutated patients? S.C. Cecere INT Fondazione “G.Pascale” Napoli

2. Chemotherapy for patients with BRCA1 and BRCA2 mutated ovarian cancer (BMOC) Outline of talk: Clinical behaviour of BMOC Efficacy of individual cytotoxic agents in BMOC  single agents  combinations How should BMOC patients be treated at present?  first line  recurrent sensitive and resistant disease  Conclusions

3. Chemotherapy for patients with BRCA1 and BRCA2 mutated ovarian cancer (BMOC) Outline of talk: Clinical behaviour of BMOC Efficacy of individual cytotoxic agents in BMOC  single agents  combinations How should BMOC patients be treated at present?  first line  recurrent sensitive and resistant disease  Conclusions

4. 1 Bolton et al JAMA 2012 2 Dorst et al Cancer Cell 2011 3 Sun et al PLoS One 2014 Clinical behaviour of BMOC -Platinum sensitivity and improved survival - HRD and inability to repair platinum- induced DSBs  Lack of data linking BRCA1/2 mutation genotype to clinical phenotype  Waiting for MITO22 results

5. Chemotherapy for patients with BRCA1 and BRCA2 mutated ovarian cancer (BMOC) Outline of talk: Clinical behaviour of BMOC Efficacy of individual cytotoxic agents in BMOC  single agents  combinations How should BMOC patients be treated at present?  first line  recurrent sensitive and resistant disease  Conclusions

6. Efficacy of platinum based therapy in BMOC Response rateCommentAuthor First line87%-96% (n= 105) 71% (p=0.002) in sporadic OC No difference between BRCA1 and BRCA2 Venken et al 1 Tan et al 2 Recurrent 2nd- 3° line 65-100% (n=67) Mostly platinum sensitive Only one cohort of 10 pts had primary platinum resistant disease with 8 reponders (80%) Alsop et al 3 Tan et al 2 1. Venken et al Ann Onc2011 2. Tan et al Jco 2008 3. Alsop et al JCO2012 Platinum based therapy more active in BRCA mutated than in sporadic patients

7. Efficacy of Pegylated liposomal doxorubicin (PLD)- based treatment in BMOC Response rate (RECIST or Ca125) Median PFS (months) CommentAuthor 68% (n= 40) 15.8 mo PLD plus platinum in 22 Mostly platinum sensistive (31) RR for PD/platinum in NH of 49%; mPFS of 8 mo (p=0.009) Safra et al 1 56% (n= 23) 6.3 mo Single agent PLD RR for PD/platinum in NH of 19%; mPFS of 4 mo (p=0.004 ) Non correlation with platinum sensitivity Adams et al 2 39% (n=33) 7.1 mo Single agent PLD Patients had 0-12 months of PFI Part of randomized trial vs olaparib wich had a RR of 59% and mPFS of 8.8 mo Kaye et al 3 1. Safra et al Mol Canc Ther 2011 2. Adams et al Gyn Onc 2011 3. Kaye et al J Clin Oncol 2012

8. Efficacy of Pegylated Liposomal doxorubicin (PLD) –based treatment in BMOC Safra et al Mol Canc Ther 2011 BRCA mutations carrier vs Non Hereditary mPFS 15.84 m vs 8.05 m (p=0,009) m OS 56.84 m vs 22,6 m (p=0,002) CR+PR 68,4% vs 49% (p=0,023) 246 pz PFS OS

9. Adams et al Gyn Onc 2011 6.3 vs 4 mo 22,2 vs 12 mo

10. Kaye et al J Clin Onc 2012 ORR  Olaparib 59%  PLD 39% mPFS  Olaparib 200 mg 6.5 m (95% CI, 5.5 a 10.1 m)  Olaparib 400 mg 8.8 m (95% CI, 5.4 to 9.2 m)  PLD 7.1 m (95% CI, 3.7 to 10.7m) BRCA mutated r elapsed EOC PFI between 0 -12 months Efficacy of PLD is comparable to Olaparib

11. Efficacy of PLD – based treatment in BMOC Possible reasons for that:  PLD mechanism of action linked to the defective mechanism of repair of DSB after topo II inhibition in HRD cells  Data from experimental studies Immunophenotypic changes of BRCA1and wild-type (WT) ovarian cancer cells after treatment with PLD Amplification of immuno-modulatory effects, particularly in BRCA1 mutated tumors Upregulation of MHC 1 and Fas ligand expression, with an higher Intra tumoral recuitment of citotoxic T cells 2 Typgen et al Gyn Onc 2005 Mantia Smaldone et al Gyn Oncol 2014  3 studies (two retrospective) indicate excellent responses to Pegylated Liposomal Doxorubicin (PLD) in BMOC compared to unselected cases ( RR 7-25%; med PFS 4-5 months )

12. Mantia Smaldone et al Gyn Oncol 2014 Is there a scope for PLD/immuno-modulatory agent combination in BMOC?

13. Efficacy of Paclitaxel in BMOC Conflicting Pre-clinical data Sensitivity of BRCA mutated cancer cell to taxanes correlates inversely with sensitivity to platinum 1 Inibition of BRCA-1 expression in ovarian cancer cells reduces anti- tumor activity of taxanes 2 Data indicate that a low expression of BRCA1 confers increased sensitivity to paclitaxel 3 1.Tagliaferri et al J Ov Res 2009 2. Quinn et al Gyn Onc 2009 3.Zhou et al. Oncogen 2003

14. Efficacy of Paclitaxel in BMOC Similar PFS after weekly paclitaxel in BMOC and non Hereditary OC 5 Clinical data…also CONFLICTING 4.Quinn et al Clin Can Res 2007 5. Safra et al Int j Gyn Canc 2014 6.Tan et al. Eu Jun Canc 2013 Higher BRCA1 expression levels not increase survival following taxane- contaning chemo 4 46% of RR in 26 BMOC treated with weekly paclitaxel (60% platinum sensitive 27% platinum resistant) 6 No conclusive evidence of the impact of BRCA mutation on response to paclitaxel

15. Trabectedin is a minor groove DNA binding agent derived from marine organism Schöffski, et al. Eur J Cancer 2011 Efficacy of Trabectedin-based treatment in BMOCTrabectedin

16. Schöffski, et al. Eur J Cancer 2011 Very high sensitivity to Trabectedin of HRD tumor cells Trabectedin sensitivity of different cell lines isogenic (colony assay) Preclinical data suggest enhanced efficacy in HDR cells

17. MITO 15 trial Phase II study on Trabectedin (Yondelis®) in BRCA1 and BRCA2 mutation carrier ad BRCA ness phenotype advanced ovarian cancer patients - Relapsed partially sensitive (PFI 6-12 months) ovarian cancer patients preteated with >2 lines platinum-based CT - BRCA mutated or BRCAness phenotype - Relapsed resistant (PFI <6 months) OC patients pretreated with at least 2 lines platinum-based CT Trabectedin 1.3 mg/m2 1.3 mg/m2i.v. every 21 days untill PD and/or unacceptable toxicity Translational sub-study: Assess germline mutations of BRCA 1 and 2 Evaluate activity of trabectedin according to BRCA and single nucleotide polymorphisms (SNPs) in DNA repair genes (XPD, XPG and ERCC1) mutations Lorusso D et al. ESMO 2014 Abstract 886PD.

18. MITO-15 results Lorusso D et al. ESMO 2014 Abstract 886PD. According to BRCA mutational status Overall population

19. 26-30 September 2014, Madrid, Spain esmo.org 5 SNPs involved in NER machinery ( ERCC1 C118T, ERCC1 C8092, XPG ASP1104HIS, XPD ASP312ASN, XPD LYS751GLN) were evaluated in 75 patients. Response to Trabectedin according to mutations of single nucleotide polymorphisms (SNPs) in DNA repair genes (XPD, XPG and ERCC1) SNPsCR+PR+ SD (%)PD (%)P value ERCC1 C118T WT (26) MUT (49) 16 (61.5) 33 (67.3) 8 (30.7) 14 (28.5) 0.8 ERCC1 C8092 WT (37) MUT (38) 23 (61.3) 26 (69.3) 12 (32.4) 10 (26.3) 0.6 XPG ASP1104HIS WT (47) MUT (28) 30 (63.8) 19 (67.8) 15 (32) 7 (25) 0.6 XPD ASP312ASN WT (26) MUT (49) 15 (57.6) 34 (69.4) 9 (34.6) 13 (26.5) 0.4 XPD LYS751GLN WT (29) MUT (46) 16 (55) 33 (72) 11 (38) 11 (24) 0.2 Lorusso D et al. ESMO 2014 Abstract 886PD. In this clinical study NER polymorphisms did not correlate with responses to trabectedin

20. Monk et al. Gyn Oncol 2014 OVA-301 trial In OVA-301 trial the association of BRCA1/XPG mutations with response rate, PFS, and OS has been investigated.  Overall 41/264 of patients analyzed had BRCA mut and 17 /264 had XPG mut Relapsed ovarian cancer cancer R Trabectedin 1.1 mg/m² 3 h i.v. every 3 weeks + PLD 30 mg/m² every 3 weeks Trabectedin 1.1 mg/m² 3 h i.v. every 3 weeks + PLD 30 mg/m² every 3 weeks PLD 50 mg/m 2 every 4 weeks N= 672 213 partially sensitive pts XPG is a component of TC-NER (trascription-coupled Nucleotide Excision Repair of DSB)

21. PFS and OS by BRCA1 Genotypes in Treatment Groups BRCA1 mut BRCA1 wt BRCA1-mutated patients treated with T+PLD showed longer PFS and OS compared to PLD. XPG-mutated patients treated with T+PLD had shorter PFS compared to XPG-wildtype. BRCA1 mut may predict improved outcome to T+PLD treatment XPG mut was associated to less RR, PFS and OS. Possible biomarker of poor outcome in this patients Monk et al. Gynecologic Oncology 133 (2014) Abs 99 Efficacy of trabectedin-based treatment in BMOC

22. Efficacy of other DNA damaging agents of BMOC Cyclophosphamide 1 Low dose oral cyclo (50mg od) in randomised trial of cyclo/veliparib vs cyclo alone in platinum resistant ovarian cancer- no difference in two arms. But 7/36 (19%) responded to cyclo alone including 4/14(28%) with BMOC 1. Kummer et al JCCR 2015 2. Molsevando et al Med Onco2014 3. Osher et al. Clin Path 2011 4. Hyman et al. Gyn Onc 2011 Mitomycin C 2 6/12 response in BMOC (incl. 4/6platinum resistant), to i.v. mitomycin C 10mg q4w. Melphalan 3 Anecdotal evidence of prolonged CR (25yrs) in one patients treated with oral melphalan 8mg od for platinum resistant BMOC Topotecan 4 One retrospective study (n=9) showed no efficacy in BMOC.

23. Chemotherapy for patients with BRCA1 and BRCA2 mutated ovarian cancer (BMOC) Outline of talk: Clinical behaviour of BMOC Efficacy of individual cytotoxic agents in BMOC  single agents  combinations (is there a preferred partner for carboplatin?) How should BMOC patients be treated at present?  first line  recurrent sensitive and resistant disease  Conclusions

24. 1.Safra et al Int J Gyn Canc 2014 BRCA mutation carriers treated with PLD (with or without platinum) or with Gemcitabine+Platinum had improved PFS and lower risk of disease progression vs NH disease  No difference observed for carbo/taxol (5m vs 6 m)

25.  Insufficient evidence to firm recomendation  Carbo/PLD interesting combination instead to carbo/taxol Efficacy of platinum combination BMOC – is there a preferred partner for carboplatin ? Two other studies comparing carbo/PLD and carbo/taxol may also be informative for further restrospective BRCA mutation analysis (CALYPSO – relapsed setting and MITO2- first line)

26. Chemotherapy for patients with BRCA1 and BRCA2 mutated ovarian cancer (BMOC) Outline of talk: Clinical behaviour of BMOC Efficacy of individual cytotoxic agents in BMOC  single agents  combinations How should BMOC patients be treated at present?  first line  Recurrent sensitive and resistant disease  Conclusions

27. What is the optimal chemotherapy for recurrent Platinum sensitive BMOC? First relapse PFI > 12mo carboplatin combinations (preferred partner?? e.g. PLD or gemcitabine) PFI 6-12mo carboplatin combinations or Trabectedin/PLD Second and further relapse PLD Weekly taxol Topotecan PLD/trabectedin or Trabectedin alone( regulatory issues)- MITO23 Rechallenge with platinum Bevacizumab to use or not? And when to use PARPi?

28. What is the optimal chemotherapy for recurrent Platinum resistant BMOC?  PLD is the commended first option in patients who have not previously received – unclear data ABOUT retreat with PLD Other options: weekly paclitaxel Topotecan Gemcitabine,... trabectedin (limited by regulatory issues)  MITO 23 Key point: repeat carboplatin/combination, e.g. with gemcitabine after at least 12 months of PFI (for intervening treatment) in platinum “resistant patients”

29. Platinum resistant BMOC  Prolonging PFI and repeating platinum appriopriate strategy for platinum resistant BMOC ?  Alternating chemo strategy could be devised incorporating single agent PLD and weekly paclitaxel, with/without carboplatin?

30. How maintenance of PARP affect chemo strategy in BMOC? BRCAm platinum sensitive relapse Prior bevacizumab Carbo/comb Olaparib manintenance in responders No prior bevacizumab Gemcitabine (or Taxol), carboplatin and bevacizumab OCEANS Carboplatin/combination, then olaparib maintenance in responders AB Olaparib for subsequent relapseBevacizumab for subsequent Resistant relapse (AURELIA) A= for patients with large volume/symptomatic relapse (ascites) B= for others

31. Take home messages  The impact of BRCA mutation is not uniform  Not all cytotoxic drugs equally effective  Platinum based therapy will continue to be a mainstay in first and subsequent line of treatment of BMOC  Lacking data linking BRCA1/2 mutation genotype to clinical phenotype  More data are needed also for HRD patients

32. Thank you