Personalised Cancer Medicine in Phase 1 Cancer Research at Rigshospitalet

1. Personalised Cancer Medicinein Phase 1 Cancer Research at Rigshospitalet Ulrik Lassen MD, PH.D Phase 1 Unit

2. Background • New targeted therapy is selected according to specific molecular alterations in the tumors • Determination of HER2-gene expression in breast cancer is a routine due to treatment with trastuzumab (Herceptin). • Analysis af K-ras mutation status is a routine in order to select patients with colorectal cancer for anti-EGFR therapy • Also EGFR and ALK mutations in lung cancer

3. Tumor regression was seen in 30% of patients with mutations, compared to 10% of patients without mutations. There may be an advantage by selecting patients Titel/beskrivelse (Sidehoved/fod)

4. Non-small cell lung cancer - subtyping Erlotinib, gefitinib crizotinib

5. ALK-inhibition in NSCLC • 31 heavily pre-treated patients with NSCLC and ALK re-arrangement tested in a Phase 1 trial. • 20/31 had regression, (including 1 CR; and long-term regression - median 24 weeks) • The fusion gene was first identified in NSCLC in 2007, clinical activity seen in 2009 – and crizotinib was FDA-approved in 2011 Kwak EL et al, N Engl J Med 2010 Mab og TKI

6. Phase 1 trial: • Partial remissionin 81% of patients with Braf-V600E+ melanoma (960 mg BID) • Investigator assessments • Includes confirmed & unconfirmed responses

8. New track for early clinical trials

9. Schedule of assessments:Differential timing of dosing, PD biopsy, and imaging End of Cycle 2 Scans Schedule A: QW FDG PET Tumor Bx RG7212 dosing … Cycle 1 Scr D1 D2 D3 D4 D8 D15 D17 Cycle 2 D1 D2 D4 D8 D15 RG7212 dosing Tumor Bx FDG PET End of Cycle 2 Scans Schedule B: Q3W Both schedules: blood samples taken at multiple time points for PK and PD assessments

10. Titel/beskrivelse (Sidehoved/fod)

11. The most important finding at the moment is the feasibility of performing complex molecular characterization in daily clinical practice. A hundred patients were enrolled in seven months. For some patients, the results of the analyses changes the phase 1 trials and treatments for which they were being considered Titel/beskrivelse (Sidehoved/fod)

12. Also in Denmark? • Patients with good performance status and tumor lesions assessable for biopsy are included in a study of genomic characterization • A collaboration between the Phase 1 Unit, Pathology, Genomic Medicine, Clinical Genetics, Diagnostic Radiology and Bioinformatics • Important for drug development, attracting new studies and allocating patients for studies • We are part of an European network and hope to be able to distribute patients for enrichment of studies in the future

13. Complete genomic profile of phase 1 population Up to 200 patients are referred to the Phase 1 Unit every year. Every patient will be asked for a signed informed Eligible patients are required to fulfill normal criteria for entering early phase studies, including normal organ function and adequate performance status, as well as measurable disease. Most patient fulfill these criteria, and it is anticipated that 500 patients will be eligible during the project period (5 years). Patients will be referred for ultrasound-guided tumor biopsies with 18 Gauge needle. Biopsies snap-frozen/RNA-later and paraffin-embedded as well as verified for their representativeness, tumor cell content, and suitability for molecular analysis at the Department of Pathology

14. Genome-wide technologies and identification of tumor specific genetic changes The Center for Genomic Medicine functions as core facility for array and NGS technologies and covers all necessary high-throughput analyses from microarray-based transcriptome profiling to analysis of SNP arrays (Affymetrix) as well as NGS (Illumina and Roche platforms). The pipeline from biopsy to isolation of DNA and RNA is firmly established as part of our front-line work-up of carcinoma of unknown origin and childhood solid tumours, which are subject to array analysis and exome sequencing, respectively. All samples are handled according to standard operation procedures and quality control parameters according to MIAME and Tumor Analysis Best Practices Working Group www.rhmicroarray.com

16. List of first line therapeutic targets Whole exome ~23,000 genes (research)) First line gene targets are sequenced to a coverage above 500 - 1000x (labelled in RED (n=48)). Second line genes labelled in BLACK (n=117) and whole exome (n=23.000) are sequenced to an average coverage of 50-100x.

17. Status • 1 breast cancer patient with ROS1 mutation: - offered crizotinib • Several patients with either BRCA-mut, low p53 or ATM – allocated to PARP-inhibitors • Several patients with FGF-ligand overexpression -allocated for studies with FGFR-modifying agents • No specific pattern – allocated to other Phase 1 studies

18. The perspectives of gene profiling Enrichment of population for phase 1 studies Attracting more studies and offering personalized therapy for the patients Recruiting patients Referring patients for appropriate studies locally and globally Offering treatment with selected marketed targeted agents