1. Novel approaches in endocrine sensitive breast cancer
Giorgio Mustacchi
Eminente Docente di Oncologia Medica, Università di Trieste

2. President Barack Obama January 30, 2015
“And that’s why we’re here today. Because something called precision medicine … gives us one of the greatest opportunities for new medical breakthroughs that we have ever seen.”
President Barack Obama January 30, 2015 2

3. Personalized Medicine
The National Cancer Institute (NCI) has defined personalized medicine …“as a form of medicine that uses information about a person’s genes, proteins and environment to prevent, diagnose and treat disease”
American Cancer Society 2014
Li T J Clin Oncol 2013
National Cancer Institute. Dictionary of cancer terms
Grullich C Onkologie 2012

4. Personalized Medicine
Personalized medicine has changed the paradigms in oncology, because it is now based on understanding molecular carcinogenesis, pharmacogenomics, and individual genetic differences that determine the response to chemotherapeutics
American Cancer Society 2014
Li T J Clin Oncol 2013
National Cancer Institute. Dictionary of cancer terms
Grullich C Onkologie 2012

5. A New Taxonomy of Cancer From organs to molecules
Garraway LA. Genomics-driven oncology: framework for an emerging paradigm. Journal of Clinical Oncology, 31(15), (2013).

6. Cancer Genomes Are Dynamic
WGS is a snapshot
Certain mutations reflect paternal and/or maternal germline variation
Additional somatic mutations accumulate through life
“Driver” mutations cause cancer, “passenger” mutations are carried along
Additional drivers evolve and diversify the cancer
Some alter aggressiveness…
…which may be treatable
Others may alter treatment response, leading to relapse
Cancer genomes are not static.
In cancer, one snapshot is not enough.
Relapse
Germline
Somatic
Cancer
(Metastasis)
Review the main themes that underlie the huge potential of cancer genome sequencing:
Cancer is a disease of the genome. Every cancer is different, containing a unique combination of germline and somatic mutations that together give rise to the specific properties of the individual cancer. Our particular focus is therefore on whole genome sequencing, which has opened the possibility for the first time to determine comprehensive, ultimately near-complete catalogues of genomic variation, whether germline or somatic; and to use sequencing both for discovery and routine screening. In the last few years, attention of substitutions has expanded to include comprehensive studies on all other types of variant as well as they are all important as candidates for biological effects and disease mutation. Near-complete ascertainment of all changes in a cancer creates a new and unrivalled opportunity for understanding the mechanism of cancer onset, progression, sensitivity to chemotherapy as well as providing new biomarkers for diagnosis and prognosis. In the near future we anticipate a revolution in healthcare and personalised cancer treatment with accurate, high throughput, low cost sequencing at the heart of clinical practice.
Cancer
(Primary)
Treatment

7. Intratumoral & Intermetastatic Clonal Heterogeneity Heterogeneity within single patient
Intratumor Heterogeneity Revealed by multiregion Sequencing
n engl j med 366;10 march 8, 2012
Background
Intratumor heterogeneity may foster tumor evolution and adaptation and hinder
personalized-medicine strategies that depend on results from single tumor-biopsy
samples.
Methods
To examine intratumor heterogeneity, we performed exome sequencing, chromosome
aberration analysis, and ploidy profiling on multiple spatially separated samples obtained
from primary renal carcinomas and associated metastatic sites. We characterized
the consequences of intratumor heterogeneity using immunohistochemical analysis,
mutation functional analysis, and profiling of messenger RNA expression.
Results
Phylogenetic reconstruction revealed branched evolutionary tumor growth, with 63 to
69% of all somatic mutations not detectable across every tumor region.
Allelic composition and
ploidy profiling analysis revealed extensive intratumor heterogeneity, with 26 of 30 tumor
samples from four tumors harboring divergent allelic-imbalance profiles and with
ploidy heterogeneity in two of four tumors.
Conclusions
Intratumor heterogeneity can lead to underestimation of the tumor genomics landscape
portrayed from single tumor-biopsy samples and may present major challenges to
personalized-medicine and biomarker development. Intratumor heterogeneity, associated
with heterogeneous protein function, may foster tumor adaptation and therapeutic
failure through Darwinian selection.
Biopsy samples were obtained before
the initiation of 6 weeks of treatment with everolimus.
After a 1-week washout period in which
patients did not receive everolimus, a nephrectomy
was performed. Everolimus treatment was continued
after recovery from surgery until tumor progression.
**************
Take home messages
•Tumours are composed of multiple, genetically diverse clones
–Additional mutations are accumulated over time
–At diagnosis, tumours are already mosaics!
•Which sample should be used for biomarker testing?
–Primary vs metastasis vs CTCs
Gerlinger M, Rowan AJ, Horswell S et al. Intratumor heterogeneity and branched evolution revealed by multiregion sequencing. The New England Journal of Medicine, 366(10), (2012).

8. Evolution of Cancer Genomes Primary vs. metastatic tumors
24% of patients with HER2-positive primary breast tumors had HER2-negative metastatic tumors
Niikura N, Liu J, Hayashi N et al. Loss of human epidermal growth factor receptor 2 (HER2) expression in metastatic sites of HER2-overexpressing primary breast tumors. Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 30(6), (2012).

9. Biological roles of oncological predictive biomarkers

10. Some news
Good News
Better knowledge of endocrine-resistance mechanisms
New active Drugs
Bad News
No response-predictive markers so far
No money enough

11. Italian real world 2012-2015 Luminal MBC Endocrine Drugs across disease progression
+ 1,1 % LHRH an
+ 10,6% LHRH an
Cazzaniga, Mustacchi et al, SABCS2016: the AMBRA-GIM13 study: ASCO 2017, submitted

12. Two major axes in endocrine resistance
Growth Factor Receptors/mTOR/PI3K AND Cyclin dependent Kinases 4 & 6 (CDK4/6)
CDK4/6 and cyclin D have a crucial role in the regulation of the G1/S transition through regulation of the phosphorylation state of pRb (Retinoblastoma protein)
When hyperphosphorylated 
allowed transition from G1 to S phase and progression of the cell cycle.

13. ER resistance Crosstalk between ER and critical signalling pathways
epidermal growth factor receptor/human epidermal growth factor receptor 2 (HER2)
extracellular signal-regulating kinase 1/2/mitogen activated protein kinase cascade
phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway/fibroblast growth factor receptor 1/2 [FGFR]/ insulin-like growth factor-1 receptor [IGF-1R]
Johnston SR, et al 2005; Steroid Biochem Mol Biol 95:173–181
Johnston SRD 2010; Clinical Cancer Res 16:1979–1987

14. Cross-talk between GFR and ER is involved in the development of endocrine resistance
EGFR
TGF
HER2 K K
AKT MAPK
Accelerated
tumour growth
Phosphorylation
AF1
AF1
Coactivator E E ER
RNA
POL II
AF2
AF2

15. A new hypothesis (from 1989!)
“It would appear that when considering second-line hormonal therapy the previous effect of first-line hormone therapy is a more direct and accurate means of identifying patients with hormone- sensitive tumours than ER status”
Robertson et al. Eur J Cancer Clin Oncol 1989; 25: 469–75

16. Overcoming endocrine resistance: Tamrad
Randomised phase II trial
Patient population
111 patients with HR+/HER2- metastatic breast cancer with prior exposure to AI treatment (in adjuvant and/or metastatic setting)
Intervention
Tamoxifen/Everolimus (n=57) vs Tamoxifen alone (n=54)
Results
Tamoxifen/everolimus had a higher clinical benefit rate (61%) and longer time to progression (8.6 months) than the group receiving tamoxifen alone (42% and 4.5 months).
Patients with secondary resistance to AI seemed to benefit more from the combination than patients with primary resistance.
Bachelot T, et al 2012; J Clin Oncol 30:2718–2724.

17. Overcoming endocrine resistance: Horizon
Multinational randomised phase III trial
Population
1112  aromatase inhibitor naive women with hormone receptor-positive advanced disease
Intervention
Temsirolimus/Letrozole vs Letrozole/placebo
Results
Stopped for futility by the independent data monitoring committee.
Response rate and overall survival were also similar between groups
Wolff AC, et al 2013; J Clin Oncol 31:195–202.

18. Overcoming endocrine resistance: Bolero 2
Phase III study
Population
724 postmenopausal women with hormone receptor (HR) –positive, HER2-negative metastatic breast cancer that had progressed on therapy with a nonsteroidal aromatase inhibitor
Intervention
Combination therapy with exemestane and mTOR inhibitor everolimus vs exemestane
Results
Significantly longer progression-free survival (7.8 months v 3.2 mth) and higher response rate than single-agent exemestane. ( Baselga et al. NEJM 2013

19. BOLERO-2: Trial Design Primary endpoint: PFS (investigator assessment)
Secondary endpoints: OS, ORR, clinical benefit rate, safety
Randomized 2:1; stratified by sensitivity to previous hormonal therapy, presence of visceral metastases
Treatment until disease progression or unacceptable toxicity
Exemestane 25 mg/day +
Everolimus 10 mg/day
(n = 485)
Postmenopausal women with ER-positive advanced breast cancer
who progressed on previous nonsteroidal AI therapy*
(N = 724)
Exemestane 25 mg/day +
Placebo
(n = 239)
*> 50% of patients in each arm with ≥ 3 previous therapies
Hortobagyi GN, et al. SABCS Abstract S3-7; Baselga J et al N Eng J Med 2012;366:

20. Bolero2: great results but no benefit in OS
% RR
9.5 vs 0.4
% CBR
79.6 vs 59
PSF/TTP mos
11.8 vs 4.1
AEs G3/4
55.2 vs 29.4
SAEs
32.6 vs 15.5
Bolero2: great results but no benefit in OS
Bolero2- OS: same old story
Survival Post Progression Similar (20.8 vs 19.3 mos)
Longer SPP = trial underpowered for OS (Sargent, ASCO 2011)
Post PD Chemo: Eve 53%, Placebo 63%
Time from Randomisation to 1st Chemo
11.9 Everolimus vs 6 mos Placebo
Baselga NEJM 2012; Piccart Ann Oncol 2014

21. Randomized Phase II study of PD 0332991
a Cyclin-Dependent Kinase (CDK) 4/6 inhibitor,
in combination with Letrozole vs Letrozole Alone for
First-Line Treatment of ER+, HER2- Advanced Breast Cancer
(Paloma1/TRIO-18)
Study Design
Palbociclib 125 mg QD x 3 weeks, 1 week off; plus Letrozole 2.5 mg QD x 4 weeks R A N D O M I Z T
Study population
Postmenopausal women with ER+ HER2– breast cancer (Cohort 1)
Patients with CCND1 (CyclinD1) amplification and/or loss of p16 (Cohort 2)
1:1
Letrozole 2.5 mg QD x 4 weeks
4-week treatment cycle
Primary Endpoint: PFS
(50% > median PFS from 9 to 13.5 months
Finn et al. Lancet Oncol 2015; 16: 25–35 21

22. PALOMA 2: Phase III Confirmation Study
Multicenter, international, double-blind, randomized phase III trial
Postmenopausal women with ER+/HER2- advanced breast cancer,
no prior treatment for advanced disease,
no AI resistance
(N = 666)
Palbociclib 125 mg QD (3/1 schedule)
+ Letrozole 2.5 mg QD
(n = 444)
Placebo (3/1 schedule)
(n = 222)
Primary endpoint: PFS by investigator
Secondary endpoints: response, OS, safety, biomarkers, pt-reported outcomes
Results Confirmed
Outcome %
Palbo+Letro
Letro+Plac
HR (p value)
PFS
24.8
14.7
0.58 (< ) RR
CBR 42 85 35 70
p=0.03
P<0.0001
G3/4 AEs 76 24
SAEs
19.6
12.6
AI, aromatase inhibitor; ER, estrogen receptor; HER2, human epidermal growth factor receptor 2.
Finn R, et al. ASCO Abstract 507.

23. PALOMA-3: Phase III Study Design
Pts with HR+/HER2- MBC; PD after HT;
≤ 1 CHT regimen for advanced BC
(N = 521)
Palbociclib 125 mg QD
3 wks on/1 wk off +
Fulvestrant 500 mg IM Q4W
(n = 347)
Tx to PD, toxicity, or study withdrawal
Placebo 3 wks on/1 wk off +
(n = 174)
Primary endpoint: investigator-assessed PFS
Secondary endpoints:
ORR, CBR (CR, PR, or SD for ≥ 24 wks), OS, pt-reported outcomes, safety
BC, breast cancer; CBR, clinical benefit rate; CR, complete response; HR, hormone receptor; MBC, metastatic breast cancer; PD, disease progression SD, stable disease; Tx, treatment.
Turner NC et al. N Engl J Med 2015 Jul 16;373(3): Cristofanilli M et al. Lancet Oncol. 2016;17(4):
Slide credit: clinicaloptions.com

24. Ribociclib + Letrozole as Initial Therapy for Adv HR+/HER2- MBC (MONALEESA-2)
Stratified by liver/lung metastases (present/absent)
Ribociclib 600 mg/day PO 3 wks on, 1 wk off + Letrozole 2.5 mg/day
(n = 334)
Recurrent or MBC, postmenopausal, no previous systemic therapy for advanced disease, ECOG PS 0/1
(N = 668)
No crossover allowed !
Placebo PO daily 3 wks on, 1 wk off + Letrozole 2.5 mg/day
(n = 334)
Adv, advanced; CBR, clinical benefit rate; ECOG, Eastern Cooperative Oncology Group; HR, hormone receptor; MBC, metastatic breast cancer; PS, performance status; QoL, quality of life.
Joyce O’Shaughnessy, MD:
For patients with breast cancer, the first important results reported at ESMO 2016 with impact on the first-line treatment of metastatic breast cancer (MBC) were for the randomized, first‑line phase III MONALEESA‑2 trial.[37] MONALEESA-2 compared the addition of the CDK4/6 inhibitor ribociclib to the aromatase inhibitor letrozole vs placebo plus letrozole in 668 postmenopausal patients with ER‑positive, HER2-negative MBC and no previous systemic therapy for metastatic disease. Similar to palbociclib in the PALOMA trials,[38,39] ribociclib was administered 3 weeks on and 1 week off. The primary endpoint was PFS.
Primary endpoint: PFS
Secondary endpoint: OS, ORR, CBR, safety, QoL
Hortobagyi GN, et al. N Engl J Med. 2016;375:

25. CDK 4/6 inhibitors experience
Facts
CDK4/6 inhibitors
Impressive increase in PFS in 1st line
Acceptable-Good safety profile
Solid biological rationale
Considerations
Solid biological rational but no predictive markers
No benefit in Overall Survival
Trials not powered for OS + Crossover (but MONALEESA)

26. “drug holiday” could delay it (Lesley, SABCS 2016 P3-03-09)
Wich “ciclib”?
Barroso-Sousa et al. Breast Cancer, June 2016, modified
Seems better
Palbociclib and ribociclib appears cross-resistant, but not always abemaciclib
mTOR inhibitors appears effective (Lenihan, SABCS 2016 P )
RB loss of function appears an irreversible mechanism of palbociclib-resistance and
“drug holiday” could delay it (Lesley, SABCS 2016 P )

27. Access to cancer drugs in Europe years 2005-2014
Access to cancer drugs varies in Europe and relates to the countries' economic status
There are also significant variations in access between countries of similar economic power
N. Wilking et al. ESMO 2016 Congress

28. Pending problem: Sustainability
Palbociclib : (125 mgs/day x 21 dd) = USD (€ ) / month1
Ribociclib : (600 mgs/day x 21 dd) = USD (€ )/ month2
1 On-line sale
2 On-line sale (accessed May 9th, 2017)
…Lowering price by 75 % resulted in an ICER of CHF73,995/QALY and a 73 % probability of being cost-effective.
Palbociclib plus letrozole cannot be considered cost-effective for the first-line treatment of patients with metastatic breast cancer
in the Swiss healthcare system
Matter-Walstra et al.: J Clin Oncol 2016;34(suppl):abstr 567; Breast Cancer Res Treat2016 Jul;158(1):51-7
Feb 3rd 2017 NICE has rejected Palbociclib  in first draft guidance, because of the monthly price of UK pounds ( € ).
4/5/17: Pfizer will give for 4-6 months the drug for free
Everolimus-Exemestane : € 3.414/month

29. Pending problem: Sustainability EMA and Italy
EMA Authorisation for EU: 9/11/2016
Ibrance has been shown to prolong the “PFS” by an average of 6 to 10 months, which is considered of clear clinical value. ……
The Agency’s Committee therefore decided that Ibrance’s benefits are greater than its risks and recommended that it be approved for use in the EU.
AIFA GU: Determina 20 febbraio 2017
Classe C (nn)

30. Health Expenses Grow More than the Global Economy
Mean Growth rate of GDP and Health Expenditures per Capita
Growth rate of GDP per Capita
Growth rate of Health expenditures per Capita
Health Expenditures
GDP
Courtesy of Prof Jean-Jacques Zambrowski, Paris,2015

31. Pending problem Lack of biomarkers predittive for response and/or resistance
ESR1 mutation predictive of efficay of Fulvestrant alone1
ESR1 mutation unrelevant for Fulvestrant + Palbociclib efficacy1
Sequential treatment with taxanes ? (safety ?)2
Possible role in TNBC (LAR subtype) ?3
1: Fribbens et al. JCO 34: 2961, sep 2016
2:Clark et al.: Cancer Res 2016;76(4 suppl):abstr P6– 13–08
3: Asghar et al. ASCO Meeting Abstracts 2015; 33(15 suppl):abstr

32. FES-PET as a Marker of Hormone Sensitivity in MBC
16α-[18F]-fluoro-17β-estradiol positron emission tomography (FES-PET)
quantifies estrogen receptor expression in tumors
Imaging examples from two patients who underwent both FES and FDG scans prior to therapy. Left panel: Patient A (15-002) had mediastinal lesions appreciated by both FES and FDG. Right panel: Patient B (3-001) also had mediastinal disease clearly seen by FDG-PET, not visible on FES-PET. The core biopsy of a metastatic axillary lesion from Patient A showed ER+ breast cancer, while the needle biopsy of a vertebral lesion from Patient B showed ER- breast cancer.
FES-PET as a Marker of Hormone Sensitivity in MBC
Peterson et al. Mol Imaging Biol, 2014

33. Some final suggestions
About Sustainability
Governement and BigPharma
should completely revise commercial agreements rules
otherwise inequity will grow everywhere
and black market will provide unsafe drugs
About response prediction and treatment best strategy
Targeted imaging
“Drug Holiday”
Cross to mTor inhibitors
Wait for new data and informations

34. In conclusion ER-positive disease is heterogeneous
endocrine resistance is a complex problem - needs highly translational trials to solve.
Targeting mTOR should be limited to populations with acquired AI resistance and should use everolimus, not others in the class.
From a research perspective, we know that careful choice of compounds and combinations based on biologic and
Further pharmacogenomics may shed light on patient differences, and biomarker analysis on most if not all patients in clinical trials of novel targeted agents and combinations is essential.