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Prostate Cancer Epidemiology: Estimated 2010 Total Active Disease: 773,000 Stages I-III: 508,000 Metastatic (M+): 183,000 Asymptomatic M+ CRPC Symptomatic M+ CRPC Castrate Sensitive*: 80,000 US Census, SEER 2007, NODB- IMPAC Market Research Castrate Resistant*: 103,000 *Estimated based on physician reported percentages among 200 community oncologists and urologists.(2005).
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Life After Traditional Androgen Deprivation Failure Other Hormonal Therapy Chemo Therapy Immunotherapy
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Rationale For Immunotherapy CancerCancer Cellular dysfunctionCellular dysfunction Resistance to or escape from host defensesResistance to or escape from host defenses Active immunotherapyActive immunotherapy Suitable target antigenSuitable target antigen Effective presentation of antigenEffective presentation of antigen Mobilization of immune cascadeMobilization of immune cascade
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Antigen Presenting Cells (APCs) Dendritic cells (DCs) are antigen-presenting cells that process and present MHC-peptide complexes to activate a T-lymphocyte response
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Dendritic cell TCR MHC class I MHC class II CD8 CD4 CD80 CD86 CD28 CD54 CD11/CD18 Peptide CD154 CD40 T-cell CTLA4
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sipuleucel-T (Provenge ® ) sipuleucel-T is an autologous active cellular immunotherapy that activates the immune system against prostate cancer
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Sipuleucel-T: Patient-Specific Therapy Day 1 Leukapheresis Day 2-3 sipuleucel-T is manufactured Day 3-4 Patient is infused Apheresis Center DendreonDoctor’s Office COMPLETE COURSE OF THERAPY: Weeks 0, 2, 4
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Primary Endpoint (Trial 9901) Time to Disease Progression Study 1 Percent without ProgressionWeeks
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Secondary Endpoint - Survival Clinically Significant and Statistically Persuasive Overall Survival Benefit 34% 11% Median benefit 4.5 months
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Vote of FDA Expert Panel 17 – 0 for safety 17 – 0 for safety 13 – 4 for substantial evidence of efficacy 13 – 4 for substantial evidence of efficacy FDA Requires More Data (<2% Event) FDA Requires More Data (<2% Event)
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Randomized Phase 3 IMPACT Trial (IMmunotherapy Prostate AdenoCarcinoma Treatment) Primary endpoint:Overall Survival Secondary endpoint: Time to Objective Disease Progression Asymptomatic or Minimally Symptomatic Metastatic Castrate Resistant Prostate Cancer (N=512) Asymptomatic or Minimally Symptomatic Metastatic Castrate Resistant Prostate Cancer (N=512) Placebo Q 2 weeks x 3 Sipuleucel-T Q 2 weeks x 3 PROGRESSIONPROGRESSION PROGRESSIONPROGRESSION 2:1 SURVIVALSURVIVAL SURVIVALSURVIVAL Treated at Physician discretion and/or Salvage Protocol Treated at Physician discretion
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Eligibility Criteria Metastatic castrate resistant prostate cancer Life expectancy of at least 6 months Serum PSA ≥ 5.0 ng/mL Castrate level of testosterone (< 50 ng/dL) achieved via medical or surgical castration Adequate hematologic, renal, and liver function Negative serology for HIV 1 & 2, HTLV-1, and Hepatitis B & C
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Patient Demographics and Baseline Characteristics Sipuleucel-T (N = 341) Placebo (N = 171) Age, median yrs (range) 72 (49 – 91)70 (40 – 89) Race, white (%) 89.491.2 ECOG status, 0 (%) 82.181.3 Gleason Score ≤ 7 (%)75.4 Disease localization Bone only (%)50.743.3 Soft tissue only (%)7.08.2 Bone & soft tissue (%)41.948.5 >10 bone mets (%)42.842.7 Bisphosphonate use 48.148.0 Prior docetaxel (%) 15.512.3
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Baseline Median Laboratory Values Sipuleucel-T (N = 341) Placebo (N = 171) Serum PSA, ng/mL 51.747.2 Serum PAP, U/L 2.73.2 Alk. Phosphatase, U/L 99.0109.0 Hemoglobin, g/dL 12.912.7 LDH, U/L 194.0193.0 WBC, 10 3 /µL 6.26.0
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IMPACT Overall Survival: Primary Endpoint Intent-to-Treat Population P = 0.032 (Cox model) HR = 0.775 [95% CI: 0.614, 0.979] Median Survival Benefit = 4.1 Mos.
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Overall Survival Summary Survival Percentiles (months) N75%50%25% Sipuleucel-T34115.125.841.3 Placebo17111.021.735.6 4.1 mos % Survival (K-M estimates 24 Mos.36 Mos.48 Mos. Sipuleucel-T52.131.720.5 Placebo41.223.0 8.7% 16.0
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Survival Consistency Between Population Subsets
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Survival Results Confirmed by Multiple Sensitivity Analyses
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Most Common Adverse Events (≥ 5%) Higher Rate in Sipuleucel-T (p ≤ 0.05) Preferred Term Sipuleucel-T N = 338 % Placebo N = 168 % Chills 54.1 12.5 Pyrexia 29.3 13.7 Headache 16.0 4.8 Influenza-like illness 9.8 3.6 Hypertension 7.4 3.0 Hyperhidrosis5.30.6
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Serious Adverse Events* Safety Population Serious Adverse Events* Safety Population SAE Preferred Term Sipuleucel-T N=338 % Placebo N=168 % Any SAE24.023.8 Pyrexia1.80.6 Cerebrovascular accident1.8 Pulmonary embolism1.20.0 Spinal cord compression1.2 Nausea0.91.2 Atrial fibrillation0.90.6 Dehydration0.90.6 Cardiac failure congestive0.61.2 Pneumonia0.61.2 Hematuria0.61.2 Deep vein thrombosis0.31.8 Renal failure acute0.32.4 *Occurring in ≥ 4 patients.
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Consistency Across Phase 3 Studies D9901* (N = 127) D9902A* (N = 98) IMPACT ** (N = 512) Hazard Ratio p-value 0.586 p = 0.010 0.786 p = 0.331 0.775 p = 0.032 Median Survival Benefit (months) 4.53.34.1 36-Month survival (%) sipuleucel-T placebo 34% 11% 32% 21% 32% 23% *Unadjusted Cox model & log rank **Cox model adjusted for PSA and LDH Integrated** (N=737) 0.735 p < 0.001 3.9 33% 20%
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SummarySummary First active immunotherapy to demonstrate improvement in overall survival for cancer Highly favorable benefit to risk profile Short duration of therapy Potential to create new paradigm in treatment of metastatic, castrate resistant prostate cancer
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Time to Objective Disease Progression Secondary endpoint Result –Independent radiologic review –HR=0.951 (95% CI: 0.77,1.17); P=0.628 (log rank) Consistent with other trials in advanced prostate cancer Difficult endpoint to measure reliably and doesn’t correlate with overall survival
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PSA-TRICom Randomized Phase II Study Primary endpoint: Progression Free Survival Secondary endpoint: Overall Survival Asymptomatic or Minimally Symptomatic Metastatic Castrate Resistant Prostate Cancer (N=125) Asymptomatic or Minimally Symptomatic Metastatic Castrate Resistant Prostate Cancer (N=125) Empty Vector + placebo PROSTVAC-VF Tricom + GM PROGRESSIONPROGRESSION PROGRESSIONPROGRESSION 2:1 SURVIVALSURVIVAL SURVIVALSURVIVAL Treated at physician discretion and/or Salvage Protocol Treated at physician discretion
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25 PSA-TRICom Progression-Free Survival
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26 PSA-TRICom Overall Survival
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27 Background-The Development of PROSTVAC-VF-Tricom Vaccinia –Potent immunological priming agent –Derived from wild-type Wyeth strain (used in millions of immunizations) Fowlpox –Minimally/non-cross-reactive with vaccinia Enables boosting Slightly altered PSA transgene Tricom –Lymphocyte function-associated antigen LFA-3 (CD58) –Intercellular adhesion molecule ICAM-1 (CD54) –Costimulatory molecule for the T-cell receptor B7.1 (CD80)
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28 PROSTVAC-PSA-Tricom PrimeBoosts Vaccinia-PSA-Tricom Fowlpox-PSA-Tricom
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Conclusions Poxviral-based immunotherapy is feasible and safe Primary endpoint of prolonged PFS was not met Secondary endpoint of prolonged median OS –8.5 month difference in OS, HR 0.56 (95% CI 0.37-0.85) with p=0.0061 Baseline characteristics of patients in both arms similar Need to validate these findings in large Phase III study with survival endpoint
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