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Myeloproliferative Neoplasms

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1 Myeloproliferative Neoplasms
Hematology Highlights Las Vegas, NV, USA – February 27, 2014, 2014 Ruben A. Mesa, MD Professor & Chairman, Division of Hematology & Medical Oncology Deputy Director, Mayo Clinic Cancer Center Mayo Clinic – Arizona, USA ©2011 MFMER |

2 Myeloproliferative Neoplasms Hematology Highlights 2014
Burden and Biology of MPNs JAK2 Inhibition in 2014 JAK2 Inhibition and beyond

3 The Natural History of MPNs
Diagnosis WHO 2008 Essential Thrombocythemia Polycythemia Vera Early/ Pre-fibrotic Primary Myelofibrosis Classic Primary MF Post ET/PV MF MPN Blast Phase ©2011 MFMER |

4 ©2011 MFMER |

5 Calreticulin (CALR) Within ER
- chaperone ensuring quality control of glycoprotein folding - calcium homeostasis Outside ER - found in cytoplasmic, cell surface and extracellular compartments - roles in: proliferation apoptosis phagocytosis immunogenic cell death

6 CALR mutations in JAK2 negative ET and MF

7 Burden of Myelofibrosis
Burden of ET/PV Et & PV Associated Symptoms Macrovascular Risk Microvascular Symptoms MF Associated Symptoms MPN Associated Symptoms Splenomegaly Anemia/ Cytopenis Burden of Myelofibrosis

8 Myelofibrosis and Cytopenias (N=364)
N.B. Varying times NL Hg Men 13.5 g/dL Women 12 g/dL Emanuel et. al. JCO 2012 ©2011 MFMER |

9 Myelofibrosis and Splenomegaly
Why does Splenomegaly Matter in MF? Mechanical discomfort Pain Possible splenic infarction Early satiety adding to cachexia Splenic sequestration and exacerbation of cytopenias May delay engraftment in setting of allogeneic stem cell transplant Cervantes et. al. Blood 2009 (N=1054 PMF) Emanuel et. al. JCO 2012 (N=329 MF) ©2011 MFMER |

10 MPN Symptom Burden by Quartiles 1858 MPN-SAF Respondents
TSS <8 Q2 TSS 8 -17 Q3 TSS Q4 TSS >32 Parameter P value of Comparison Age 0.24 Gender F>M <0.001 MPN Diagnosis Subtype of MF 0.86 IPSET (ET Risk) 0.18 PV Risk (PV) 0.30 DIPSS (MF Risk) Quartile 1 (Q1): 0-24% Quartile 2 (Q2): 25-49% Quartile 3 (Q3): 50-74% Quartile 4 (Q4): % Percentile MPN-SAF TSS

11 ET (N=775) PV (N=654) MF (N=423) Q1 – 30% Q2 – 26% Q3 – 24% Q4 – 20%

12 New Response Criteria for MPNs
ET2 PV2 MF1 Complete response Partial response Clinical improvement Stable disease No response Relapse Other responses Molecular Cytogenetic and molecular 1. Tefferi A et al. Blood. 2013;122: Barosi G et al. Blood. 2013;121:

13 New Response Criteria for MF: Complete Response1
Required criteria: for all response categories, benefit must last for ≥12 wks to qualify as a response Bone marrow: Age-adjusted normocellularity; <5% blasts; ≤Grade 1 MF; and Peripheral blood: Hemoglobin ≥ 100 g/L and <UNL; Neutrophils ≥ 1 x 109/L and <UNL; Platelets ≥ 100 x 109/L and <UNL; <2% immature myeloid cells; and Clinical: Resolution of disease symptoms Spleen and liver not palpable No evidence of EMH EMH: extramedullary hematopoiesis 1. Tefferi A et al. Blood. 2013;122:

14 New Response Criteria for MF: Other Categories1
Clinical improvement Achievement of anemia, spleen, or symptoms response without progressive disease or increase in severity of anemia, thrombocytopenia, or neutropenia Anemia response Transfusion-independent pts: a ≥20 g/L increase in Hb level Transfusion-dependent pts: becoming transfusion independent Spleen response Baseline splenomegaly that is palpable at 5-10 cm, below the LCM, becomes not palpable, OR Baseline splenomegaly that is palpable at >10 cm, below the LCM, decreases by ≥50% Baseline splenomegaly that is palpable at <5 cm, below the LCM, is not eligible for spleen response Symptoms response A ≥50% reduction in the MPN-SAF TSS CI: clinical improvement; LCM: left costal margin. 1. Tefferi A et al. Blood. 2013;122:

15 Myeloproliferative Neoplasms Hematology Highlights 2014
Burden and Biology of MPNs JAK2 Inhibition in 2014 JAK2 Inhibition and beyond

16 JAK Inhibitors and Status of Development Myelofibrosis as lead indications
* * * * No Longer in Development For MPNs * Now Testing in PV ©2011 MFMER |

17 Patient Disposition – 3 Year FU Comfort I
Ruxolitinib (n = 155) Placebo (n = 151) Placebo Ruxolitinib (n=111) Median exposure, weeks 145 37 105 Still on treatment, n (%) 77 (49.7) 57 (51.4) Crossed over, n (%) 111 (73.5) Discontinued, n (%) 78 (50.3) 40 (26.5) 54 (48.6) Primary reasons for discontinuation, n (%)* Death 15 (19.2) 7 (17.5) 11 (20.4) Adverse event 9 (22.5) 8 (14.8) Consent withdrawn 12 (15.4) Disease progression 18 (23.1) 13 (32.5) 15 (27.8) All patients originally randomized to placebo crossed over or discontinued within 3 months of the primary analysis Median time to crossover: 41.1 weeks ASH 2013 * Percentages are calculated based on the number of patients who discontinued within the respective treatment group.

18 Mean Daily Dose of Ruxolitinib Over Time
ASH 2013 25 20 15 10 5 Mean Daily Dose (mg, BID) ± SEM 8 16 24 32 72 104 136 144 48 88 120 64 56 96 128 40 80 112 Weeks 20 mg BID starting dose 15 mg BID starting dose 98 62 20 mg BID 49 15 mg BID Number of patients 100 55 77 69 33 26 73 30 93 35 Approximately 70% of patients had dose adjustments during the first 12 weeks of therapy By week 24, patients originally randomized to RUX 15 mg BID and 20 mg BID were titrated to a mean dose of ~10 mg BID and mg BID, respectively

19 Percentage Change in Spleen Size
ASH 2013 Mean reductions in spleen volume and palpable spleen length with ruxolitinib were stable over time Ruxolitinib Placebo Weeks Mean Percentage Change from Baseline 148 139 120 107 100 84 132 35 73 n = 12 24 48 72 96 144 4 8 153 152 150 141 130 110 102 147 136 109 47 90 79 Spleen Volume Spleen Length

20 Improvements in EORTC QLQ-C30 Over Time
ASH 2013 Global Health Status/QoL Fatigue 10 -10 -15 -25 -35 5 -5 -20 -30 20 10 -5 -15 15 5 -10 Mean Change From Baseline Mean Change From Baseline 12 24 36 48 60 72 84 96 108 120 132 144 12 24 36 48 60 72 84 96 108 120 132 144 Weeks RUX PBO Weeks Arrows indicate improvement Role Functioning Physical Functioning 25 10 -5 -15 -25 15 5 -10 -20 20 Mean Change From Baseline Weeks 15 5 -5 -10 10 Mean Change From Baseline 12 24 36 48 60 72 84 96 108 120 132 144 12 24 36 48 60 72 84 96 108 120 132 144 Weeks

21 Overall Survival ASH 2013 HR=0.69 (95% CI: 0.46, 1.03); P=0.067
Overall survival favored patients originally randomized to ruxolitinib compared with patients originally randomized to placebo 153 144 129 114 105 Placebo 154 149 134 119 107 100 92 85 8 95 88 79 38 82 68 28 155 148 143 131 124 115 111 108 1 Ruxolitinib Number of patients at risk 145 137 125 122 112 101 45 106 84 19 Randomized to Placebo  Ruxolitinib Randomized to Ruxolitinib 1.0 0.8 0.6 0.4 0.2 24 40 56 72 104 120 136 168 176 Probability Weeks 16 32 48 64 80 96 128 152 160 4 22 54 99 13 35 73 97 HR=0.69 (95% CI: 0.46, 1.03); P=0.067 No. of deaths: Ruxolitinib=42; Placebo=54 Median follow-up: 149 weeks Percent of at-risk placebo who crossed over or discontinued * *By week 80, all patients originally randomized to placebo discontinued or crossed over to ruxolitinib therapy 21

22 Overall Survival: Rank-Preserving Structural Failure Time (RPSFT) Analysis
ASH 2013 1.0 0.8 0.6 0.4 0.2 8 24 40 56 72 88 104 120 136 168 176 Probability Weeks 16 32 48 64 80 96 112 128 152 144 160 HR=0.36 (95% CI: 0.204, 1.035) Placebo  Ruxolitinib Ruxolitinib Placebo-RPSFT RPSFT is a recognized method to estimate HR after adjusting for crossover1-5 Hazard ratio of 0.36 is consistent with the hypothesis that ITT analysis underestimates the survival benefit of ruxolitinib relative to “true placebo” (1) Robins J, Tsiatis A. Commun Stat Theory Methods. 1991;20: ; (2) Demetri GD, et al. Clin Cancer Res. 2012;18: ; (3) National Institute for Health and Care Excellence (NICE). NICE technology appraisal guidance Issued September 23, 2009; (4) Sternberg CN, et al. Eur J Cancer. 2013;49: ; (5) National Institute for Health and Care Excellence (NICE). NICE technology appraisal guidance Issued February 2011. 22

23 Mean Platelet Count and Hemoglobin Level Over Time
ASH 2013 Platelet Count Hemoglobin 370 115 Ruxolitinib Placebo Ruxolitinib Placebo 110 320 105 270 Mean Platelets (x109/L) Mean Hemoglobin (g/L) 100 220 95 170 90 120 85 12 24 36 48 60 72 84 96 108 120 132 144 12 24 36 48 60 72 84 96 108 120 132 144 Weeks Weeks Number of patients Number of patients RUX 155 144 143 136 124 112 110 107 104 100 94 88 79 155 145 143 136 124 113 110 107 104 100 94 88 79 PBO 151 128 112 82 37 151 132 113 83 37

24 Incidence of New Onset All Grade Non-hematologic Adverse Events Regardless of Causality
ASH 2013 Incidence (%) Ruxolitinib 0–<12 months (n=155) 12–<24 months (n=130) 24–<36 months (n=103) ≥36 months (n=82) Fatigue 29.0 15.2 15.3 7.7 Diarrhea 27.8 6.7 10.8 3.9 Ecchymosis 21.2 10.4 5.7 Peripheral edema 21.3 8.4 12.6 Dyspnea 19.2 10.2 2.9 3.3 Dizziness 18.1 3.0 3.5 Pain in extremity 18.0 6.2 4.2 Headache 16.6 5.1 2.7 Nausea 6.8 5.9 Constipation 14.5 8.6 10.1 9.0 Abdominal pain 13.8 3.6 Insomnia 3.7 Vomiting 13.7 2.8 2.4 5.5 Pyrexia 13.5 7.3 8.5 Cough 13.1 13.3 4.0 6.0 Arthralgia 11.8 5.8 6.6 6.3 Upper respiratory tract infection 11.1 3.2 There was no change in the rate, distribution, or severity of nonhematologic adverse events in the ruxolitinib group with longer-term treatment; most nonhematologic adverse events were grade 1 or 2 Percentage of patients for each event was based on the effective sample size of the time interval (number of patients at risk at the beginning of the interval minus half of the censored patients during the time interval). Adverse event is included if the incidence was >10% at any yearly interval.

25 Incidence of New Onset Grade 3 or 4 Non-hematologic Adverse Events Regardless of Causality
ASH 2013 Incidence (%) Ruxolitinib 0–<12 months (n=155) 12–<24 months (n=130) 24–<36 months (n=103) ≥36 months (n=82) Fatigue 6.2 0.9 3.3 Pneumonia 5.6 3.6 3.5 Abdominal pain 4.2 3.2 Arthralgia 2.1 Diarrhea Dyspnea 2.2 2.5 Pain in extremity 1.1 Hyperuricemia 1.4 Fall GI hemorrhage Septic shock Muscular weakness Hypoxia Sepsis 0.7 1.7 Epistaxis Renal failure acute 2.4 Abdominal pain upper Myocardial infarction 4.8 Percentage of patients for each event was based on the effective sample size of the time interval (number of patients at risk at the beginning of the interval minus half of the censored patients during the time interval). Adverse event is included if the incidence was ≥2 patients at any yearly interval.

26 BM Morphology in a Ruxolitinib-Treated Patient: A Case Demonstrating Improvement on Ruxolitinib
ASH 2013 24 Mo Post Ruxolitinib Grade 2 48 Mo Post Ruxolitinib Grade 0 Baseline Biopsy Grade 3 Kvasnicka HM, et al. ASCO (abstr 7030). Permission to use images from Kvasnicka, HM

27 Dynamics of BM Changes Following Ruxolitinib Treatment at 48 Mo
ASH 2013 Kvasnicka, et al. ASH Abstract 4055.

28 JAK1 & 2 Inhibitors in MPNs – Efficacy Summary – As of ASH 2013
Yes No Occasional Not Reported Yet Ongoing Trials Myelofibrosis Polycythemia Vera Essential Thrombocythemia Spleen Const. Sympt. Anemia Survival Counts Vasc Events Ruxolitinib - Approved P III P II SAR – PH III JAKARTA (HOLD) Pacritinib- PIII Ongoing (Persist MF) CYT387 LY P I NS-018 BMS PH II INCB039110 (JAK1 Alone) PI CEP701 ©2011 MFMER |

29 JAK1 & 2 Inhibitors in MPN – Toxicity ASH 2013
Hematological Toxicities Gastrointestinal/ Renal Neurological Anemia ANC PLT Nausea Diarr-hea LFTs Or CR Lipase Head-ache Dizzy NeuroP/ Parathia Ruxolitinib - Approved 23% 7% 11% 2% 0.6% SAR – PIII Ongoing (MF) 41% 6% 0% 5% 1% W. E. % ? Pacritinib- 18% CYT387 PII Ongoing (MF) 10% 20% INCB (JAK1) – PI/II MF 28% 27% BMS 3% LY 8% Renal <10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100% Toxicity Color – Represents All Grades ( Grade ¾ Toxicity - Percentage in Table Above) ©2011 MFMER |

30 Myeloproliferative Neoplasms Hematology Highlights 2014
Burden and Biology of MPNs JAK2 Inhibition in 2014 JAK2 Inhibition and beyond

31 MPNs – Plateau vs. Decline
Clinical Status ET – Possible Plateau Asymptomatic Thrombocytosis No Vascular Events ET – Possible Plateau 2 Symptomatic Thrombocytosis Sinus Venous Thrombosis PV – Possible Plateau 2 Symptomatic Erythrocytosis No Vascular Events MF on Successful JAK2 Rx Improving Weight Decreased Spleen Improved Survival Post PV MF 6 Months worsening Fatigue 10 kg weight loss Massive spleen Time ©2011 MFMER |

32 MPNs – Cumulative Benefits
Clinical Status Ruxolitinib Improved Survival Improved Spleen Burden Improved Symptom Burden Time ©2011 MFMER |

33 Clinical Status MPNs – Cumulative Benefits Single Agent Trials JAK2 Inhibitors Compared to Ruxo STUDY (JAK2/FLT3 Inhibitor) Pacritinib (SB1518) (PH III vs. BAT) NCT ? Other Benefit -Less cytopenias -Improved activity STUDY (JAK2/JAK1 Inhibitor) Momelotinib (CYT387) (PH III vs. Ruxo) NCT Improved Survival Improved Spleen Burden STUDY (JAK2/FLT3 Inhibitor) NS-018 (PH I/II) NCT Improved Symptom Burden STUDY (JAK2 Inhibitor – Also ET and PV) LY (PH I/II) NCT Time ©2011 MFMER |

34 MPNs – Cumulative Benefits Ruxolitinib + drug X for Anemia
Clinical Status STUDY COMBINATION (JAK2 PLUS Androgen) Ruxolitinib Plus Danazol Mayo Clinic (AZ) and Mt. Sinai Trial: NCT Improved Anemia Burden STUDY COMBINATION(JAK2 PLUS Hypomethylation) Ruxolitinib Plus Azacitidine MDACC Trial: NCT Improved Survival STUDY COMBINATION (JAK2 PLUS IMID) Ruxolitinib Plus Lenalidomide NCT Improved Spleen Burden STUDY COMBINATION (JAK2 PLUS IMID) Ruxolitinib Plus Pomalidomide Germany (ULM): NCT Improved Symptom Burden Time ©2011 MFMER |

35 MPNs – Cumulative Benefits Ruxolitinib + drug X for Deeper Marrow Changes Impact
Clinical Status STUDY COMBINATION (JAK2 PLUS HDAC Inhibitors) Ruxolitinib Plus Panobinostat Mt. Sinai Trial: NCT UK Trial: NCT Improved Marrow Dysfunction STUDY COMBINATION (JAK2 PLUS LOXL2 Inhibitors) Ruxolitinib Plus GS-6624 NCT Improved Survival STUDY COMBINATION (JAK2 PLUS rhPTX-2 (Anti-fibrosing)) Ruxolitinib Plus PRM -151 Opening Soon Improved Spleen Burden STUDY COMBINATION (JAK2 PLUS PI3 Kinase Inhibitor) Ruxolitinib Plus BKM120 NCT Improved Symptom Burden STUDY COMBINATION (JAK2 PLUS Hedgehog Inhibitor) Ruxolitinib Plus LDE225 NCT

36 MPNs – Cumulative Benefits Single Agent Trials Alternate Targets
Clinical Status MPNs – Cumulative Benefits Single Agent Trials Alternate Targets STUDY (Interferons) Peg Interferon α2b in “Early” MF Cornell Lead: NCT ? Other Benefit -Less cytopenias -Improved activity STUDY (Activin - ActRIIA-IgG1Fc) Sotatercept (ACE 011) MDACC: NCT Improved Survival Improved Spleen Burden STUDY (Telomerase Inhibitor) Imetelstat (GRN163L) Mayo Clinic (Rochester): NCT Improved Symptom Burden STUDY (JAK1 Inhibitor) INCB (PH II) NCT Time

37 Imetelstat: A Telomerase Inhibitor
Telomerase enzyme: Reverse transcriptase comprised of an RNA component (hTR) and a reverse transcriptase catalytic protein subunit (hTERT) Binds to the 3’ strand of DNA and adds TTAGGG nucleotide repeats to offset the loss of telomeric DNA occurring with each replication cycle Not active in somatic cells; transiently upregulated in normal hematopoietic progenitor cells to support controlled proliferation Highly upregulated in malignant progenitor cells, enabling continued and uncontrolled proliferation imetelstat binds to RNA template preventing maintenance of telomeres Imetelstat: (hTERT) Proprietary: 13-mer thio-phosphoramidate oligonucleotide complementary to hTR, with covalently-bound lipid tail to increase cell permeability/tissue distribution Long half-life in bone marrow, spleen, liver (estimated human t½ = 41 hr with doses 7.5 – 11.7 mg/kg); Potent competitive inhibitor of telomerase: IC50 = nM (cell-free) Target: malignant progenitor cell proliferation (hTR) Tefferi et. al. ASH 2013

38 Preliminary efficacy results from Mayo Clinic investigator-sponsored trial of imetelstat in myelofibrosis Geron’s independent efficacy analysis of the first 22 MF patients enrolled in the study Tefferi et. al. ASH 2013 – 10 –

39 Preliminary efficacy results from Mayo Clinic investigator-sponsored trial of imetelstat in myelofibrosis Geron’s independent efficacy analysis of the first 22 MF patients enrolled in the study Tefferi et. al. ASH 2013 – 10 –

40 Change in Spleen Volume at Week 12 by Dose Cohort
Median % Change in Spleen Volume* Percentage Change From Baseline at Week 12 n=7 n=38 n=9 *Only patients with baseline and week 12 data were included. INCB ASH Mascarenhas et. al

41 Improvement in TSS at Week 12 by Dose Cohort
≥50% Reduction in TSS* Median % Change in TSS† n=6 n=34 n=8 Percentage Change From Baseline at Week 12 Percentage of Patients n=9 n=43 n=10 *Patients who discontinued prior to the week 12 visit were considered nonresponders; 20%-33% of patients in each group discontinued prior to week 12. †Only patients with baseline and week 12 data were included. INCB ASH Mascarenhas et. al

42 Mean Hemoglobin Levels Over Time by Dose Cohort
100 mg BID 200 mg BID 600 mg QD Mean (±SEM) Hemoglobin (g/dL) Mean (±SEM) Hemoglobin (g/dL) Weeks Weeks All Patients Patients entering the study without transfusion requirements* n, patients n, patients 100 mg BID 200 mg BID 600 mg QD 10 9 8 6 100 mg BID 45 41 43 39 37 200 mg BID 29 21 600 mg QD 7 6 4 24 22 23 21 19 15 5 *Receipt of 2 or more units of red blood cell product transfusions in the 12 weeks prior to day 1. INCB ASH Mascarenhas et. al

43 MPNs – Cumulative Benefits Difficult PV-ET
Clinical Status STUDY (ET and PV) MPD-RC 112 Peg Inf a2a vs. Hydroxyurea (PH III) NCT STUDY (ET and PV) MPD-RC 111 Peg Inf a2a AFTER Hydroxyurea (PH III) NCT Improved Marrow Dysfunction Improved Survival STUDY (PV) AOP Peg Inf a2a vs Hydroxyurea (PH III) NCT Improved Spleen Burden STUDY COMBINATION (PV) Ruxolitinib Vs. Hydroxyurea (RELIEF) NCT Improved Symptom Burden FUTURE STUDY COMBINATION JAK2 Inhibitor Plus PEG INFa 2a/b Improved Vascular Event Risk (?PV)

44 Individualizing MPN Pharmacotherapy
Patient Goals & Input Improving Symptom Burden /HR QOL “Balancing” Spleen/ Cytoses/ Cytopenias Extending Life CURE ©2011 MFMER |

45

46 Acknowledgements ©2011 MFMER | 3133089-46 Argentina Ireland Sweden
Ana Clara Kneese, MD Mary Francis McMullen, MD Andreasson Bjorn, MD Federico Sackmann, MD Israel Elisabeth Ejerblad, MD Australia Martin Ellis, MD Gunnar Birgegard, MD David M Ross  MBBS, PhD Italy Jan Samuelsson, MD Cecily Forsyth Alessandro M. Vannucchi, MD Johanna Ablesson, MD John Seymour, MBBS, PhD Francesco Passamonti, MD Peter Johansson, MD Karen Hall, MD Giovanni Barosi, MD UK Kate Burbury MD Tiziano Barbui, MD Anthony Green, MD Tam Constantine, MD Netherlands Claire N. Harrison, MD Canada Harry Schouten, MD, PhD Deepti Radia, MD  Lynda Foltz, MD Jan Jacques Michiels, MD Uruguay Vikas Gupta, MD Karin Klauke, MD Pablo Muxi, MD China Peter te Boekhorst, MD USA Hsin-An Hou, MD Sonja Zweegman, MD PhD Alison Moliterno, MD Huan-Chau Lin, Stephanie Slot, MD Brady Stein, MD MHS MD Hung Chang, MD Suzan Commandeur, MD Casey O'Connell Ming-Shen Dai, MD New Zealand Catriona Jamieson Yuan-Bin Yu, MD Hilary Blacklock, MD Daniel Rubin, ND Yung-Chen Su, MD Panama Elizabth Hexner Zhijian Xiao, MD Francis Guerra, MD Hala Simm Denmark  Singapore  Jason Gotlib, MD Christen Lykkegaard Andersen, MD Wee Joo Chng, MB ChB Jeff Sloan, PhD Hans Hasselbalch, MD Spain  Jessica Altman, MD France  Ana Kerguelen Fuentes, MD Joseph Prchal, MD Brigitte Dupriez, MD Carlos Besses, MD Kimberly Hickman Jean-Jacques Kiladjian, MD Francisco Cervantes, MD Martin Tallman, MD Jean-Loup Demory MD Dolores Fernandez-Casados Mike Boxer, MD   Magali Demilly, PhD Olatoyosi Odenike, MD Germany Robert Silver, MD Heike L. Pahl, PhD Ross Levine, MD Soo Jin Kim Srdan Verstovsek, MD ©2011 MFMER |


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