Challenges to Drug Development in Academia

1. Challenges to Drug Development in Academia Charles L. Sawyers, M.D. Chair, Human Oncology and Pathogenesis Program (HOPP) Investigator, Howard Hughes Medical Institute Memorial Sloan-Kettering Cancer Center; New York, NY

2. Disclosure I am a co-inventor of the drug MDV3100, now in a phase III clinical trial in prostate cancer, and I own stock in the company Medivation.

3. Two translational tales Dasatinib (Sprycel) in chronic myeloid leukemia: serendipitous marriage of a discovery in academia that reshaped a pharma-driven drug development program 2) MDV3100 in prostate cancer: academia-based target validation and drug screening project that resulted in a biotech/pharma licensing deal for clinical development

4. The Ph Chromosome: t(9;22) Translocation 9 9 q+ 22 Ph ( or 22q-) bcr bcr-abl abl FUSION PROTEINWITH TYROSINEKINASE ACTIVITY Normal CML

5. Imatinib/STI571 (Gleevec) blocks BCR-ABL Goldman JM, Melo JV. NEJM. 344:1084-1086

6. 100 10 1 WBC x 103 0 30 60 90 120 150 Days on Gleevec Blood counts of the first 6 patients who took 300 mg/day of Gleevec

7. Gleevec is not a cure: Small numbers of CML cells are detected in patients who are in “remission.” Patients can relapse while taking Gleevec. Why?

8. A mutation isolated from patients who relapse on Gleevec blocks drug binding to BCR-ABL WILD-TYPE T315I MUTANT (MODEL) (Gorre et al Science, 2001)

9. BCR-ABL Kinase Domain Mutations Associated with Imatinib Resistance T315I/D F311L/I L387F/M L248V L298V M388L G250E V289A H396R/P E453G/K Q252H/R A397P Y253H/F E450G E459K F317L E255K/V P-loop Activation loop S417Y V379I D276G M351T M244V F486S E355G/D T277A E279K F359C/V/D > 50 distinct mutations reported

10. Imatinib resistance mutations impair conformational flexibility of the ABL kinase Location of Mutations P loop Direct contact with drug hinge John Kuriyan, Bhushan Nagar (UC-Berkeley)

11. How do we deal with resistance? Problem: Over 50 different mutations can cause resistance to Gleevec Structural biology prediction: Mutations change the shape of BCR-ABL so that it favors the “open” conformation. Solution: Drugs that target the “open” conformation should work in patients with Gleevec resistance.

12. Dasatinib Gleevec

13. The SRC/ABL inhibitor dasatinib (BMS-354825) is active against all but one of the known mutations in BCR-ABL that confer imatinib resistance BCR/ABL/WT 1.2 M244V G250E 1 Q252H Q252R T315I 0.8 Y253F Y253H E255K 0.6 Normalized cell viability E255V F317L T315I 0.4 wt BCR-ABL F317L M351T 0.2 E355G F359V H396R 0 F486S 0 1 10 50 100 5 Ba /F3 nM BMS-354825 Shah et al Science, 2004

14. BCR-ABL genotype predicts clinical response to dasatinib Talpaz ….Sawyers, NEJM, 2006

15. Chronic Myeloid Leukemia: 2010 • 1) Imatinibhas beenfrontline CML therapy • -75% of patients achieve complete cytogenetic response • -20% relapse within 5 years, usually with mutant BCR-ABL • Dasatinib and nilotinibwere initially approved as 2nd line therapy for imatinib-resistant CML (2006, 2007) • Upfront comparisons show than 2nd generation compounds are superior to imatinib • (Kantarjian et al NEJM 2010; Saglio et al NEJM 2010)

16. Inhibition of androgen receptor (AR) signaling ARE testosterone hormone LHRH agonists AR kinases Anti-androgens Bicalutamide* Flutamide* *Both drugs are partial agonists/antagonists AR P Androgen receptor Cytoplasm nucleus CoR vs Coactivators NCoR/HDAC Pol II P P AR AR Transcription of AR target genes eg PSA Activation of TMPRSS/ERG fusion

17. Typical Response to Hormone Therapy Hormone Therapy Disease Burden Time Discontinue Antiandrogen

18. Primary Mechanism of Resistance to Castration and/or Current Antiandrogens • AR is overexpressed in castration resistant sublines of multiple prostate cancer xenograft models (and in patients) • Forced AR overexpression confers castration-resistance • AR knockdown impairs castration-resistant growth • AR antagonists act as agonists when AR levels are high • (Chen et al Nature Med, 2004)

19. AR shRNA GFP Lentivirus vector U6 AR RNAi Term. CMV GFP 3’ LTR 5’ LTR AR is required to maintaincastrate resistance in vivo 600 200 * Vector * Vector 150 * * AR shRNA 400 AR shRNA * Tumor volume (mm3) 100 * * 200 * 50 * 0 0 0 24 48 72 0 24 48 72 LAPC4/CR LNCaP/CR Time (days) Growth of castrate resistant xenografts in castrate male mice

20. Primary Mechanism of Resistance to Castration and/or Current Antiandrogens • AR is overexpressed in castration resistant sublines of multiple prostate cancer xenograft models (and in patients) • Forced AR overexpression confers castration-resistance • AR knockdown impairs castration-resistant growth • AR antagonists act as agonists when AR levels are high • (Chen et al Nature Med, 2004) • Second generation anti-androgens must: • be effective in cells expressing high levels of androgen receptor • AND • overcome the problem of antagonist/agonist conversion

21. H - b o n d i n t e r a c t i o n R i g i d i t y N C R S H y d r o p h o b i c F C N N 3 i n t e r a c t i o n R 2 O R 1 Binding affinity to AR Antagonist Activity Hydrophobic interactions with AR Cell-based screen for compounds with greater antagonism and no agonism (“pure antagonists”) Design tools: - Crystal structure - Homology modeling - Binding affinity High AR binding affinity (Ka = 20 nM for human AR) But with agonistic activity Jung et al, J Med Chem, 2010 Samedy Ouk, Michael Jung (UCLA Department of Chemistry)

22. RD162 and MDV3100 do not display agonism in AR overexpressing cells PSA TMPRSS2 …and have more potent antagonist activity Veh Veh Veh Veh Bic RD162 MDV3100 Bic Bic MDV3100 RD162 RD162 MDV3100 Bic RD162 MDV3100 Tran et al, Science 2009

23. RD162 (and MDV3100) are superior to bicalutamide in the castrate-resistant LNCaP-AR xenograft model bicalutamide Immunodeficient SCID castrate male mice. Tumor volume was measured in 3 dimensions. Tran et al, Science 2009

24. Androgen receptor activation and mechanism of antiandrogen action Androgen (R1881) MDV3100 Bicalutamide Revised from Lancet Oncol. 2009 Oct;10(10):981-91.

25. Overlap among AR binding peaks in response to antagonists (determined by AR ChIP-Seq) R1881 (androgen) R1881 42284 42284 R1881+MDV 1793 MDV 451 Bicalutamide R1881+Bicalutamide 18075 31832 peaks found by MACS, p-value <10-5 Ling Cai

26. A Phase 1-2 Multicenter First-in-Man Trial of MDV3100 in Castrate Resistant Prostate Cancer • Dose escalation, 3 patients per cohort, beginning at 30 mg/d to 600 mg/d • After safety was established at 60 mg/d, cohorts were expanded to 24 patients (12 chemo-naïve, 12 chemo failure) • First patient dosed in July, 2007 • 140 men enrolled at 5 centers (MSKCC, OHSU, U Wash, DFCI, MDACC) Scher et al Lancet, 2010

27. Waterfall Plot of Best Percent PSA Change from Baseline Chemotherapy-Naïve (N=65) Post-Chemotherapy (N=75) 51% (38/75) >50% Decline 62% (40/65) >50% Decline

28. Radiographic Changes in Soft Tissue (N=59) and in Bone (N=109) *59 patients with evaluable soft tissue disease as defined by PCWG2 consensusJ Clin Oncol 2008.

29. Time to PSA Progression For Pre-and Post-Chemotherapy Treated Patients Pre (Not reached) Post (186 days)

30. Summary • Castration resistant prostate cancer remains dependent on androgen receptor (AR) function. • Pure AR antagonists like MDV3100 can overcome clinical resistance to partial antagonists (bicalutamide). • MDV3100 likely induces an AR conformation that precludes DNA binding. • MDV3100 development has progressed to a phase III registration trial in castration resistant, chemotherapy resistant prostate cancer

31. Collaborators Bhushan Nagar John Kuriyan (UC Berkeley) Frank Lee (BMS) CML/Abl Inhibitor Project Mike Burgess Chris Tran Mercedes Gorre Neil Shah John Nicoll Liz Haddad Ron Paquette BMS clinical trial Moshe Talpaz Art Decillis Claude Nicaise Eric Bleickardt

32. Michael Jung (Chemistry) Samedy Ouk (Chemistry) Prostate Cancer/Antiandrogen Project Derek Welsbie John Wongvipat Chris Tran Charlie Chen David Hung Medivation Nicola Clegg