State of the Art: Treatment Options in Advanced Genitourinary Cancers David I. Quinn MBBS (Hons) PhD FRACP Associate Professor of Medicine Chief, Section of GU Medical Oncology Division of Cancer Medicine & Blood Diseases Medical Director, Norris Cancer Hospital & Clinics Co-Leader, Developmental Therapuetics Program Kenneth J. Norris Comprehensive Cancer Center Keck School of Medicine, University of Southern California David Quinn has received honoraria and served on advisory boards for Genomic Health, Pfizer, Novartis, Glaxo Smith Kline and Genentech Learning Objectives After reading and reviewing this material, the participant should be better able to: • List the major potentially practice changing data elements in the field of GU cancer to 2010 – Assess their merit – As applicable apply their content to clinical practice • Understand the implications of how practice changing and other material presented that may impact clinical practice in GU oncology in the coming years Genitourinary Cancers - ASCO 2010: Key prostate cancer abstracts Intergroup randomized phase III study of androgen deprivation therapy (ADT) plus radiation therapy (RT) in locally advanced prostate cancer CRA4504 Impact of radiotherapy (RT) combined with androgen deprivation (ADT) versus ADT alone for local control in clinically locally advanced prostate cancer 4505 A randomized phase III trial of denosumab versus zoledronic acid in patients with bone metastases from castration-resistant prostate cancer LBA 4507 Cabazitaxel or mitoxantrone with prednisone in patients with metastatic castration resistant prostate cancer (mCRPC) previously treated with docetaxel: Final results of a multinational phase III trial (TROPIC).4508 A randomized, double-blind, placebo-controlled phase III trial comparing docetaxel, prednisone, and placebo with docetaxel, prednisone, and bevacizumab in men with metastatic castration-resistant prostate cancer (mCRPC):Survival results of CALGB 90401. LBA4511 Genitourinary Cancers - ASCO 2010: Key prostate cancer abstracts Intergroup randomized phase III study of androgen deprivation therapy (ADT) plus radiation therapy (RT) in locally advanced prostate cancer CRA4504 Impact of radiotherapy (RT) combined with androgen deprivation (ADT) versus ADT alone for local control in clinically locally advanced prostate cancer 4505 A randomized phase III trial of denosumab versus zoledronic acid in patients with bone metastases from castration-resistant prostate cancer LBA 4507 Cabazitaxel or mitoxantrone with prednisone in patients with metastatic castration resistant prostate cancer (mCRPC) previously treated with docetaxel: Final results of a multinational phase III trial (TROPIC).4508 Locally advanced prostate cancer Advanced prostate cancer: bone metastases and osteoclast inhibition Castrate resistant prostate cancer A randomized, double-blind, placebo-controlled phase III trial comparing docetaxel, prednisone, and placebo with docetaxel, prednisone, and bevacizumab in men with metastatic castration-resistant prostate cancer (mCRPC):Survival results of CALGB 90401. LBA4511 ASCO 2010: Germ Cell, Renal Cell Cancer and Urothelial Cancer Highlights A randomized phase III study comparing standard dose BEP with sequential high-dose cisplatin, etoposide, ifosfamide (VIP) plus stem cell support in males with poor prognosis germ cell cancer: An intergroup study of EORTC, GTCSG, and Grupo Germinal (EORTC 30974) 4512. The high-dose aldesleukin (HD IL-2) “SELECT” trial in patients with metastatic renal cell carcinoma.4514 Can the combination of temsirolimus and bevacizumab improve the treatment of metastatic renal cell carcinoma (mRCC)? Results of the randomized TORAVA phase II trial. 4516 Randomized phase III trial comparing adjuvant paclitaxel/gemcitabine/ cisplatin (PGC) to observation in patients with resected invasive bladder cancer: Results of the Spanish Oncology Genitourinary Group (SOGUG) 99/01 study. LBA4518 Randomized phase II/III trial comparing gemcitabine/carboplatin (GC) and methotrexate/carboplatin/vinblastine (M-CAVI) in patients (pts) with advanced urothelial cancer unfit for cisplatin-based chemotherapy (CHT): Phase III results of EORTC study 30986. LBA4519 ASCO 2010: Germ Cell, Renal Cell Cancer and Urothelial Cancer Highlights A randomized phase III study comparing standard dose BEP with sequential high-dose cisplatin, etoposide, ifosfamide (VIP) plus stem cell support in males with poor prognosis germ cell cancer: An intergroup study of EORTC, GTCSG, and Grupo Germinal (EORTC 30974) 4512. The high-dose aldesleukin (HD IL-2) “SELECT” trial in patients with metastatic renal cell carcinoma.4514 Can the combination of temsirolimus and bevacizumab improve the treatment of metastatic renal cell carcinoma (mRCC)? Results of the randomized TORAVA phase II trial. 4516 Randomized phase III trial comparing adjuvant paclitaxel/gemcitabine/ cisplatin (PGC) to observation in patients with resected invasive bladder cancer: Results of the Spanish Oncology Genitourinary Group (SOGUG) 99/01 study. LBA4518 Randomized phase II/III trial comparing gemcitabine/carboplatin (GC) and methotrexate/carboplatin/vinblastine (M-CAVI) in patients (pts) with advanced urothelial cancer unfit for cisplatin-based chemotherapy (CHT): Phase III results of EORTC study 30986. LBA4519 High risk testis cancer Renal cancer: immunotherapy Locally advanced bladder cancer: adjuvant therapy “Unfit” patients with urothelial cancer ASCO 2010: GU Summary Conclusions Take home messages Locally Advanced Prostate Cancer: RT with ADT for 3 years is a standard of care Monotherapy with ADT or RT are NOT Castrate-Resistant Prostate Cancer: Docetaxel needs a date or a mate: still looking! BUT son of docetaxel, Cabazitaxel has a role in second line therapy Options for Osteoclast inhibition broaden: Denosumab Germ Cell Tumors: No role for first line HDCSCT Optimal therapy at relapse: standard chemotherapy or SCT? RCC: Selection can improve HDIL2 outcome but still no biomarker Serial monotherapy: ruling therapeutic paradigm for targeted therapy Urothelial cancer: adjuvant chemotherapy may have a place … In medical unfit patients Gemcitabine/Carboplatin remains a default standard Concurrent mitomycin C and 5FU adds to disease control with RT. Intergroup randomized phase III study of androgen deprivation therapy (ADT) plus radiation therapy (RT) in locally advanced prostate cancer (CaP) (NCICCTG, SWOG, MRC-UK, INT: T94-0110; NCT00002633) Abstract CRA 4504 P. R. Warde, M. D. Mason, M. R. Sydes, M. K. Gospodarowicz, G. P. Swanson, P. Kirkbride, E. Kostashuk, J. Hetherington, K. Ding, W. Parulekar, NCIC CTG PR.3/ MRC PRO7/ SWOG JPR3 investigators; Department of Radiation Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Velindre Hospital, Cardiff, United Kingdom; Clinical Trials Unit, Medical Research Council, London, United Kingdom; University of Texas Health Science Center at San Antonio, San Antonio, TX; Weston Park Hospital, Sheffield, United Kingdom; British Columbia Cancer Agency, Surrey, BC, Canada; Castle Hill Hospital, Hull, United Kingdom; NCIC Clinical Trials Group, Kingston, ON, Canada J Clin Oncol 28:18s, 2010 (suppl; abstr CRA4504) ADT ± EBRT in Locally Advanced/High-Risk Prostate Cancer: Phase III Trial Men with locally advanced/ high-risk prostate cancer (N = 1205) Continuous ADT (n = 602) Continuous ADT + RT (n = 603) Stratified by baseline PSA (< 20 vs 20-50 vs > 50 µg/L), hormonal therapy (orchiectomy vs LHRH analogue + antiandrogen therapy), lymph node staging (clinical vs radiological vs surgical), Gleason score (< 8 vs 8-10), previous hormonal therapy, and treatment center. Warde PR, et al. ASCO 2010. Abstract CRA4504. Eligibility and Patient Characteristics at Baseline • Main inclusion criteria – T3/T4, N0/Nx prostate cancer or – T2 prostate cancer with PSA > 40 µg/L or – T2 prostate cancer with PSA > 20 µg/L and Gleason stage 8-10 Characteristic ADT + RT (n = 603) ADT (n = 5) Median age, yrs 69.7 69.7 T3/T4 prostate cancer, % 88 89 Gleason score ≤ 7, % 81 81 < 20 ng/mL 36 37 20-50 ng/mL 38 38 > 50 ng/mL 26 25 PSA, % Warde PR, et al. ASCO 2010. Abstract CRA4504. ADT ± EBRT: Overall Survival 100 7-yr OS: 74% Patients (%) 80 60 40 Deaths 7-yr OS: 66% 175 ADT ADT + RT 145 HR: 0.77 (95% CI: 0.61-0.98; p = .0331) 20 0 0 Patients at Risk, n ADT 602 ADT + RT 603 3 509 512 Yrs 6 9 213 232 51 60 Warde PR, et al. ASCO 2010. Abstract CRA4504. ADT ± EBRT: DiseaseSpecific Survival 100 7-yr DSS: 90% Patients (%) 80 60 40 Prostate Cancer Deaths 89 ADT ADT + RT 51 7-yr DSS: 79% HR: 0.57 (95% CI: 0.37-0.78; p = .001) 20 0 0 Patients at Risk, n ADT 602 ADT + RT 603 3 509 512 Yrs 6 9 213 232 51 60 Warde PR, et al. ASCO 2010. Abstract CRA4504. Reprinted with permission. ADT ± EBRT: Safety Late Adverse Event, % ADT + RT (n = 595) ADT (n = 596) Grade 1/2 14 8 Grade ≥ 3 1.3 0.7 Grade 1/2 12 5 Grade ≥ 3 0.3 0.5 Grade 1/2 44 42 Grade ≥ 3 2.3 2.3 Diarrhea Rectal bleeding Genitourinary effects Warde PR, et al. ASCO 2010. Abstract CRA4504. ADT ± EBRT: Conclusions • In men with locally advanced or high-risk prostate cancer, addition of EBRT to ADT associated with significant efficacy improvements vs ADT alone – 23% improvement in OS – 43% improvement in disease-specific survival • Late toxicity similarly low with ADT vs ADT plus EBRT • These data suggest combined modality therapy should be standard of care for patients with locally advanced/high-risk prostate cancer Warde PR, et al. ASCO 2010. Abstract CRA4504. Impact of radiotherapy (RT) combined with androgen deprivation (ADT) versus ADT alone for local control in clinically locally advanced prostate cancer. Abstract 4505 N. Mottet, M. Peneau, J. Mazeron, V. Molinie, P. Richaud; Clinique Mutualiste, St. Etienne, France; CHU Fort de France, Fort de France, France; Pitie-Salpetriere Hospital, Paris, France; Hospital Saint Joseph, Paris, France; Radiation Therapy and Oncology Department, Institut Bergonié, Bordeaux, France J Clin Oncol 28:15s, 2010 (suppl; abstr 4505) • • • • • • n=273 French based trial, shorter follow-up than Intergroup trial Locally advanced patients 3 years of LHRH agonist +/- RT Major advantage for combination relative to biochemical, local and distant-metastatic progression-free survival • Data on testosterone recovery not available No difference in overall survival at this time Median PFS: 7.7 vs 1.7 years p < 0.0001 Median Metastases PFS: p < 0.0183 A randomized phase III trial of denosumab versus zoledronic acid in patients with bone metastases from castration-resistant prostate cancer Abstract LBA 4507 K. Fizazi, M. A. Carducci, M. R. Smith, R. Damião, J. E. Brown, L. Karsh, P. Milecki, H. Wang, R. D. Dansey, C. D. Goessl Institut Gustave Roussy, Villejuif, France; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD; Massachusetts General Hospital, Boston, MA; Hospital Universitario Pedro Ernesto, Rio de Janeiro, Brazil; Cancer Research UK Clinical Centre, Leeds, United Kingdom; The Urology Center of Colorado, Denver, CO; Wielkopolskie Centrum Onkologii, Poznan, Poland; Amgen, Thousand Oaks, CA J Clin Oncol 28:18s, 2010 (suppl; abstr LBA4507) Denosumab: Properties and Pivotal Clinical Investigation • High affinity human monoclonal antibody that binds RANKL • Administered via SC injection • Specific: does not bind to TNF-α, TNF-β, TRAIL, or CD40L • Inhibits formation and activation of osteoclasts • Superior to zoledronic acid for preventing/delaying SREs in metastatic breast cancer[1] • Non-inferior to zoledronic acid for preventing/delaying SREs in solid tumors and [2] multiple myeloma 1. Stopeck A, et al. SABCS 2009. Abstract 22. 2. Henry D, et al. ECCO/ESMO 2009. Abstract 20LBA. Denosumab vs Zoledronic Acid in Patients With CRPC and Bone Metastases Prospective, double-blind, placebo-controlled phase III trial Patients with CRPC and bone metastases, no current or previous IV treatment with bisphosphonate (N = 1901) Fizazi K, et al. ASCO 2010. Abstract LBA4507. Denosumab 120 mg SC + Placebo IV q4w (n = 950) Zoledronic Acid 4 mg IV + Placebo SC q4w (n = 951) Denosumab vs Zoledronic Acid: Time to First On-Study SRE HR: 0.82 (95% CI: 0.71-0.95; P = .0002 noninferiority; P = .008 superiority) Proportion of Subjects Without SRE 1.00 0.75 0.50 KM Estimate of Median, Mos 0.25 Denosumab Zoledronic acid 20.7 17.1 0 0 3 Patients at Risk, n Zoledronic acid 951 733 Denosumab 950 758 6 9 12 15 Study Mo 18 21 24 27 544 407 299 207 140 93 582 472 361 259 168 115 64 70 47 39 Fizazi K, et al. ASCO 2010. Abstract LBA4507. Denosumab vs Zoledronic Acid: Safety Adverse Event, % Zoledronic Acid (n = 945) Denosumab (n = 943) Serious adverse events 60 63 Adverse events causing treatment discontinuation 15 17 Anemia 36 36 Back pain 30 32 Decreased appetite 29 28 Nausea 26 29 Fatigue 24 27 Acute-phase reactions (first 3 days) 17.8 8.4 Renal adverse events 16.2 14.7 ONJ 1.3 2.3 Hypocalcemia 5.8 12.8 Most common adverse events Fizazi K, et al. ASCO 2010. Abstract LBA4507. Denosumab vs Zoledronic Acid: Conclusions • Denosumab superior to zoledronic acid in delaying or preventing SREs in patients with CRPC and bone metastases • No significant difference between treatments in survival or disease progression • High incidence of adverse events in both arms – More patients who received zoledronic acid experienced acute phase reaction – More patients who received denosumab experienced hypocalcemia – ONJ rare but occurred in approximately twice as many patients with denosumab vs zoledronic acid • Denosumab potential treatment option for patients with CRPC and bone metastases Fizazi K, et al. ASCO 2010. Abstract LBA4507. CRPC Landscape In Transition Pre-Chemo Tx Emerging Agents Sipiluecel-T Dendreon 2010 1st Line Chemotherapy 2nd Line Chemotherapy Cabazitaxel Sanofi-Aventis 2010 Docetaxel + DN101 Novacea 2010 Ipilimumab + Docetaxel BMS (2015) Docetaxel + Atrasentan SWOG 2013 Docetaxel + Bevazucimab CALGB 2010 Ipilimumab BMS 2015 Docetaxel + ZD4054 AstraZeneca 2012 Docetaxel + Aflibercept Sunitinib Pfizer 2012 TAK 700 & TOKai ???? Docetaxel + Lenalidomide Celgene 2014-15 Regeneron 2012 Ipilimumab BMS 2013 ZD4054 AstraZeneca 2011 Docetaxel + Dasatinib BMS 2012 Docetaxel + OGX011 Teva 2014-15 Abiraterone J&J 2011 MDV3100 Medivation 2014+ Abiraterone J&J 2012 MDV3100 Medivation 2013 (VEGF-TRAP) Approved Agents mCRPC • Leuprolide • Docetaxel • Docetaxel • Goserelin • Mitoxantrone • Mitoxantrone • Bicalutamide • Bisphosphonates • Flutamide • RT • Ketoconazole • DES Ixabepilone CALGB/SWOG 2014-15 Docetaxel + OGX011 Teva Oral or IV+Oral IV Things change Stuff happens A randomized, double-blind, placebo-controlled phase III trial comparing docetaxel, prednisone, and placebo with docetaxel, prednisone, and bevacizumab in men with metastatic castration-resistant prostate cancer (mCRPC): Survival results of CALGB 90401 Abstract LBA 4511 W. K. Kelly, S. Halabi, M. A. Carducci, D. J. George, J. F. Mahoney, W. M. Stadler, M. J. Morris, P. Kantoff, J. P. Monk III, E. J. Small, Cancer and Leukemia Group B; Yale University School of Medicine, New Haven, CT; Duke University Medical Center, Durham, NC; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD; Carolinas Hematology-Oncology Associates, Charlotte, NC; University of Chicago, Chicago, IL; Memorial Sloan-Kettering Cancer Center, New York, NY; Dana-Farber Cancer Institute, Boston, MA; The Ohio State University, Columbus, OH; University of California, San Francisco, San Francisco, CA J Clin Oncol 28:18s, 2010 (suppl; abstr LBA4511) CALGB 90401: Phase III Trial of Chemotherapy ± Bevacizumab in CRPC Stratified by 24-mo survival probability (< 10%, 10% to 29.9%, ≥ 30%), age (< 65 yrs ≥ 65 yrs), previous history of arterial events Patients with CRPC previously untreated with chemotherapy or biologic agents (N = 1050) Dexamethasone 8 mg PO x 3 doses + Docetaxel 75 mg/m2 on Day 1 of 21-day cycle + Prednisone 10 mg/day PO + Bevacizumab 15 mg/kg IV on Day 1 of 21-day cycle (n = 524) Dexamethasone 8 mg PO x 3 doses + Docetaxel 75 mg/m2 on Day 1 of 21-day cycle + Prednisone 10 mg/day PO + Placebo IV on Day 1 of 21-day cycle (n = 526) Kelly WK, et al. ASCO 2010. Abstract LBA4511. 0.2 0.4 0.6 0.8 Median DP = 21.5 (20.0-23.0) Median DPB=22.6 (21.1-24.5) HR= 0.91 (0.78-1.05) Placebo+Docetaxel Bev+Docetaxel , log-rank p=0.181 0.0 Overall Survival (probability) 1.0 CALGB 90401: Kaplan-Meier Overall Survival Curves by Treatment Arm 0 6 Number of Patients at Risk Placebo+Doce 526 480 Bev+Doce 524 484 12 18 24 30 Time(months) 36 42 390 417 305 327 44 52 22 23 199 217 100 117 CALGB 90401: ProgressionFree Survival Median PFS, Mos (Range) 1.0 Bevacizumab + CT Placebo + CT Probability 0.8 0.6 9.9 (9.1-10.6) 7.5 (6.7-8.0) HR: 0.77 (95% CI: 0.68-0.88) Log rank P < .0001 0.4 0.2 0 0 6 12 18 Patients at Risk, n Placebo + CT 526 303 134 Bev + CT 524 381 194 75 97 Kelly WK, et al. ASCO 2010. Abstract LBA4511. 24 30 Mos 34 44 8 15 36 42 4 5 0 1 CALGB 90401: Endpoints Longer-Term Use of Drug May Fight Ovarian Cancer Bevacizumab Outcome, By ANDREW POLLACK Mos (Range) (n = 524) Published: June 6, 2010 Placebo (n = 526) HR (95% CI) P Value Median OS— The widely22.6 21.5 can help keep 0.91 CHICAGO used cancer drug Avastin ovarian cancer in .181 (21.1-24.5) (0.78-1.05) check, but only if used for a long period(20.0-23.0) of time, researchers reported here on Sunday. Median PFS 9.9 7.5 0.77 < .0001 (9.1-10.6) (6.7-8.0) (0.68-0.88) A prostate cancer study adding Avastin to chemotherapy showed a benefit to the addition in every parameter but overall survival, meaning it won’t be considered by the FDA …. Dr. David I. Quinn, a prostate oncologist at the University of Southern Outcome, % (95% CI) Bevacizumab Placebo P Value California commented: (n = 524) (n = 526) “Improved survival is good in other ≥ 50% decline inprogression-free PSA 69.5 (65.2-73.5) 57.9enough (53.3-62.3) .0002 cancers;response if a prostate 53.2 were(46.8-59.6) a nothing more breast between Objective 42.1than (36.2-48.2) .0113 a man’s legs we would have Avastin approved for prostate cancer by now!” Kelly WK, et al. ASCO 2010. Abstract LBA4511. Bevacizumab Associated With More Severe Toxicities Adverse Event, % Bevacizumab + CT (n = 524) Placebo + CT (n = 526) Grade 3 11 12 Grade 4 24 17 0 0 Grade 3 53 35 Grade 4 11 10 3.8 1.1 Hematologic Death Nonhematologic Death Kelly WK, et al. ASCO 2010. Abstract LBA4511. CALGB 90401: Conclusions • Addition of bevacizumab to docetaxel/prednisone/ dexamethasone did not significantly increase OS of patients with CRPC • Bevacizumab did significantly improve other clinical outcomes – PFS, PSA decline, incidence of measurable disease • Bevacizumab treatment associated with more severe toxicities Kelly WK, et al. ASCO 2010. Abstract LBA4511. Cabazitaxel or mitoxantrone with prednisone in patients with metastatic castration resistant prostate cancer (mCRPC) previously treated with docetaxel: Final results of a multinational phase III trial (TROPIC) Abstract 4508 J. S. De Bono, S. Oudard, M. Ozguroglu, S. Hansen, J. H. Machiels, L. Shen, P. Matthews, A. O. Sartor, for the TROPIC Investigators; Drug Development Unit, Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Sutton, United Kingdom; Hôpital Européen Georges Pompidou, Paris, France; Istanbul University, Istanbul, Turkey; Odense University Hospital, Odense, Denmark; Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium; sanofi-aventis, Malvern, PA; Tulane University, New Orleans, LA J Clin Oncol 28:15s, 2010 (suppl; abstr 4508) TROPIC: Randomized, Prospective, Open-Label, Multinational Phase III Trial Stratified by ECOG performance score (0,1 vs 2), and measurable vs nonmeasurable disease Patients with metastatic CRPC progressing on docetaxel (N = 755) Mitoxantrone 12 mg/m2 IV q3w + Prednisone 10 mg/day PO for 10 courses (n = 377) Cabazitaxel* 25 mg/m2 IV q3w + Prednisone 10 mg/day PO for 10 courses (n = 378) *Cabazitaxel group premedicated with antihistamine, steroid, and H2 antagonist IV at least 30 min prior to each cabazitaxel dose. Antiemetic prophylaxis administered as necessary in either arm. De Bono JS, et al. ASCO 2010. Abstract 4508. TROPIC: Overall Survival Updated ITT Analysis 100 Median OS, Mos OS (%) 80 HR 60 CBZP 12.7 15.1 0.72 95% CI 0.61-0.84 P value < .0001 28% reduction in risk of death 40 Censored MP CBZP 20 0 MP Combined median follow-up: 13.7 mos 0 6 Patients at Risk, n MP 377 299 CBZP 378 321 12 Mos 195 241 De Bono JS, et al. ASCO 2010. Abstract 4508. 18 24 30 94 137 31 60 9 19 TROPIC: Conclusions • Cabazitaxel/prednisone significantly improved OS vs mitoxantrone/prednisone in metastatic CRPC – Reduced risk of death: 28% (HR: 0.72; P < .0001) • Cabazitaxel/prednisone also significantly improved PFS, response rates, and TTP vs mitoxantrone/prednisone • Associated with acceptable safety profile – Febrile neutropenia and diarrhea more common with cabazitaxel/prednisone vs mitoxantrone/prednisone • Cabazitaxel/prednisone first treatment to demonstrate survival benefit in patients with metastatic CRPC who failed docetaxel-based therapy De Bono JS, et al. ASCO 2010. Abstract 4508. CRPC Landscape In Transition Emerging Agents Pre-Chemo Tx 1st Line Chemotherapy 2nd Line Chemotherapy Docetaxel + DN101 Novacea 2010 Ipilimumab + Docetaxel BMS (2015) Docetaxel + Atrasentan SWOG 2012 Docetaxel + Bevazucimab CALGB 2010 Ipilimumab BMS 2015 Docetaxel + ZD4054 AstraZeneca 2012 Docetaxel + Aflibercept Sunitinib Pfizer 2012 TAK 700 & TOKai ???? Docetaxel + Lenalidomide Celgene 2014-15 Regeneron 2012 Ipilimumab BMS 2013 ZD4054 AstraZeneca 2011 Docetaxel + Dasatinib BMS 2012 Docetaxel + OGX011 Teva 2014-15 Abiraterone J&J 2011 MDV3100 Medivation 2014+ Abiraterone J&J 2012 MDV3100 Medivation 2013 (VEGF-TRAP) Approved Agents mCRPC • Leuprolide • Docetaxel • Docetaxel • Goserelin • Mitoxantrone • Mitoxantrone • Bicalutamide • Bisphosphonates • Flutamide • RT • Ketoconazole • DES Sipiluecel-T Dendreon 2010 Ixabepilone CALGB/SWOG 2014-15 Docetaxel + OGX011 Teva Cabazitaxel Sanofi-Aventis 2010 Oral or IV+Oral IV Treatment options for RCC have been revolutionized in a short period of time… Bevazucimab + IFN5,6 Everolimus7 High dose interleukin-21 Temsirolimus4 Axitinib? Sorafenib2 Sunitinib3 1992-2005 Interferon- 2005 2006 Pazopanib8 AVEO-751? 2007 2008 2009 2010+ ...but this rapid change has left many unanswered questions, including the optimal sequence of therapy 1. Fyfe G et al. J Clin Oncol 13:688-696, 1995 2. Escudier B et al. N Engl J Med 356:125-134,2007 3. Motzer RJ et al. N Engl J Med 356:115-124,2007 4. Hudes G et al. N Engl J Med 356:2271-2281 2007 5. Escudier B et al. Lancet 370:2103-211, 2007 6. Rini BI et al. J Clin Oncol epud Oct, 2008 7. Motzer RJ et al. Lancet 372:449-456 2008 8. Sternberg C et al. ASCO 2009 The high-dose aldesleukin (HD IL-2) "SELECT" trial in patients with metastatic renal cell carcinoma (mRCC). Abstract 4514 D. F. McDermott, M. S. Ghebremichael, S. Signoretti, K. A. Margolin, J. Clark, J. A. Sosman, J. P. Dutcher, T. Logan, R. A. Figlin, M. B. Atkins, Cytokine Working Group; Beth Israel Deaconess Medical Center, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Washington, Seattle, WA; Loyola University Medical Center, Maywood, IL; Vanderbilt University Medical Center, Nashville, TN; Montefiore Medical Center North Division, New York, NY; Indiana University Cancer Center, Indianapolis, IN; City of Hope, Duarte, CA J Clin Oncol 28:15s, 2010 (suppl; abstr 4514) Study Endpoints Primary Endpoint • Response Rate To prospectively determine if the RR to HD IL-2 in mRCC pts with “good” pathologic predictive features was significantly higher that a historical, unselected population Secondary Endpoints The response rate for patients with “poor” pathologic features. If components of other predictive and prognostic models (MSKCC1, UCLA SANI Score2) can help to further define the optimal population to receive HD IL2. New factors that might be associated with response Maximum % Change in Target Lesions Tumor Shrinkage (n=118) PR Response Comparison Response* % Historical rate 14 IL-2 Select Trial (all pts n=120) 28 p=0.016 95% CI=20.537.3% IL-2 Select Trial (clear cell n=115) 30 p=0.0008 95% CI=21.438.8% *Using WHO Criteria Response by Baseline Characteristics Tumor type N (%) P-value* Clear Cell (n=115) Non-clear cell (n=5) 32 (100) 0.32 0 (0) MSKCC Risk Group Favorable Intermediate Poor 10 (32%, [17-51%]) 0.08 20 (24%, [15-35%]) 4 (67%, [22-96%]) UCLA Risk Group High (n=8) Intermediate (n=101) Low (n=10) 0 (0%, [0%-37%]) 30 (30%,[21%40%]) 3 (30%,[7%-65%]) 0.22 Response by Pathology Characteristics Histology risk group RR (95% CI) P-value* Good (n=11) 36% (14%-34%) 0.61 Intermediate (n= 84) 26% (17%-37%) Poor (n=24) 33% (16%-55%) CA-9 Score High (>85%) 23% (14%-34%) Low (<85%) 38% (23%-55%) 0.13 Combined Score Good (n=74) 24% (15%-36%) Poor (n=72) 36% (22%-52%) 0.67 Conclusions • The RR for HD IL-2 in this trial was significantly better than the historical experience • Clinical and pathologic features (e.g. SANI score and histology) may identify patients who are unlikely to respond to HD IL-2 • In this trial, analysis of tumor based predictive markers through central pathology review and staining for CAIX was unable to improve the selection criteria for HD IL-2 • Efforts to understand these results are ongoing .. – CAIX SNPs – B7H1, B7H3 – Immune SNPs – etc Randomized phase III trial comparing adjuvant paclitaxel/gemcitabine/cisplatin (PGC) to observation in patients with resected invasive bladder cancer: Results of the Spanish Oncology Genitourinary Group (SOGUG) 99/01 study. Abstract LBA 4518 L. G. Paz-Ares, E. Solsona, E. Esteban, A. Saez, J. Gonzalez-Larriba, A. Anton, M. Hevia, F. de la Rosa, V. Guillem, J. Bellmunt; Hospital Universitario Virgen del Rocío, Seville, Spain; IVO, Valencia, Spain; Hospital Universitario Central de Asturias, Oviedo, Spain; HCULB, Zaragoza, Spain; Hospital Clinico San Carlos, Madrid, Spain; Hospital Miguel Servet, Zaragoza, Spain; Hospital Central de Asturias, Oviedo, Spain; Hospital Doce de Octubre, Madrid, Spain; Hospital Vall d'Hebron, Barcelona, Spain J Clin Oncol 28:15s, 2010 (suppl; abstr 4518) Adjuvant [Post-Operative] Chemotherapy in Invasive Bladder Cancer Meta-analysis Survival Hazard Ratio Single agent cisplatin Studer Sub-total Hazard Ratio=1.02 p=0.945 Skinner Bono Freiha Stockle Otto Sub-total Hazard Ratio=0.71 p=0.010 Total Hazard Ratio=0.75 p=0.019 Cisplatin-based combinations 0 0.5 Chemotherapy better 1 1.5 2 Control better Test for interaction χ2=1.20, p=0.237 Only 283 events in 491 patients 6 small trials! Very wide confidence intervals! Eur Urol. 2005 Aug;48(2):189-199 SOGUG 99/01 Study Design Multicenter Phase III Randomized Open Label Trial Eligibility: • TCC • PostCystectomy • pT3-4 and/or pN+ • PS 0-1 • CrCl > 50 ml/min R A N D O M I Z E Stratification: • PS: 0 v 1 • pN: N0 v N+ PGC x 4 PD Observation Outcome • Median follow-up: - All patients: 29.8 months (1-95) - Alive patients: 51 months (2-95) • Deaths: 69 patients (49%) - PGC arm: 24 (36%) - Observation arm: 45 (61%) • Disease Progression: 76 patients (54%) - PGC arm: 30 (44%) - Observation arm: 54 (73%) Overall Survival - ITT Adjusted - Cox Multivariate HR: 0.378 ( 95% CI: 0.649-0.221) P< 0.0004 Conclusions • Adjuvant Chemotherapy with the PGC regimen resulted in improved outcomes, including overall survival in the current study. • Treatment compliance was high and toxicity was acceptable. • The final sample size of the study limits the robustness of these conclusions. • Meta-analysis of the available trials and further molecularly-tailored studies are warranted. Results of a phase III randomized trial of synchronous chemoradiotherapy (CRT) compared to radiotherapy (RT) alone in muscle-invasive bladder cancer (MIBC) (BC2001 CRUK/01/004). Abstract LBA 4517 N. D. James, S. A. Hussain, E. Hall, P. Jenkins, J. Tremlett, C. Rawlings, C. Hendron, R. Lewis, S. Rogers, R. A. Huddart, on behalf of the BC2001 Investigators; CRUK Institute for Cancer Studies, University of Birmingham, Birmingham, United Kingdom; Cancer Research UK Institute for Cancer Studies, Birmingham, United Kingdom; Institute of Cancer Research Clinical Trials and Statistics Unit, Sutton, United Kingdom; Cheltenham General Hospital, Cheltenham, United Kingdom; Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom; South Devon Healthcare NHS Foundation, Torbay, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Institute of Cancer Research, Sutton, United Kingdom J Clin Oncol 28:15s, 2010 (suppl; abstr 4517) • • • • • n=360 RT +/- concurrent mitomycin and 5FU weeks 1 and 4 Locoregional DFS improved with combined therapy • HR=0.61, 95% CI: 0.42 - 0.90; p = 0.01 Overall survival data awaited Potential concurrent regimen in CDDP unfit patients Randomized phase II/III trial comparing gemcitabine/carboplatin (GC) and methotrexate/carboplatin/vinblastine (M-CAVI) in patients (pts) with advanced urothelial cancer (UC) unfit for cisplatin-based chemotherapy (CHT): Phase III results of EORTC study 30986 Abstract LBA 4519 M. De Santis, J. Bellmunt, G. Mead, J. M. Kerst, M. G. Leahy, G. Daugaard, T. Gil, J. P. Maroto, S. Marreaud, R. Sylvester; ACR-ITR VIEnna/CEADDP, LBI-ACR VIEnna, and KFJ-Spital, Vienna, Austria; Hospital del Mar, IMIM, Barcelona, Spain; Royal South Hants Hospital, Southhampton, United Kingdom; The Netherlands Cancer Institute, Amsterdam, Netherlands; St. James Hospital, Leeds, United Kingdom; Rigshospitalet, Copenhagen, Denmark; Institut Jules Bordet, Brussels, Belgium; Hospital Santa Creu, Barcelona, Spain; EORTC Headquarters, Brussels, Belgium J Clin Oncol 28:15s, 2010 (suppl; abstr 4519) Phase III results of EORTC study 30986 Treatment plan Treatment 1: Methotrexate / CArboplatin / VInblastine Methotrexate 30 mg/m2 i.v. days 1, 15, 22 Carboplatin dose in mg = 4.5 x (GFR+25) i.v. day 1 Vinblastine 3 mg/m2 i.v. days 1, 15, 22 > Every 4 weeks for at least 2 cycles Treatment 2: Gemcitabine / Carboplatin Gemcitabine Carboplatin 1000 mg/m2 i.v. days 1 and 8 dose in mg = 4.5 x (GFR+25) i.v. day 1 > Every 3 weeks for at least 2 cycles M. De Santis phase III 30986 ASCO 2010 Phase III results of EORTC study 30986 Inclusion criteria (summary) Patients ineligible (unfit) for cisplatin-based chemotherapy: PS (WHO) 2 and /or impaired renal function (30 ml/min < GFR < 60 ml/min) Histologically proven TCC of the urinary tract Unresected lymph nodes (N+), distant metastases (M1, stage IV) or unresectable primary bladder cancer (T3-4) Measurable disease (RECIST criteria V1.0 *) No previous systemic treatment, neither cytotoxic nor biologic * M. De Santis Therasse P et al, J Natl Cancer Instit 2000;92:205-216 phase III 30986 ASCO 2010 Phase III results of EORTC study 30986 Results: Toxicity GC (n=118) n (%) M-CAVI (n=118) n (%) Leukopenia G 3/4 ª 53 (44.9) 55 (46.6) Neutropenia G 3/4 ª 62 (52.5) 75 (63.5) Thrombocytopenia G 3/4 ª 57 (48.3) 23 (19.4) Febrile Neutropenia G 3/4 5 (4.2) 17 (14.4) Infection G 3/4 ª 14 (11.8) 15 (12.7) Severe Acute Toxicity (SAT)* 11 (9.3) 25 (21.2) ªnot a SAT ; *patients with at least 1 SAT M. De Santis phase III 30986 ASCO 2010 Phase III results of EORTC study 30986 Results: Best Overall Response CR+PR GC (n=119) n (%) 49 (41.2) M-CAVI (n=119) n (%) 36 (30.3) 43 25 39 (32.8) 18 (15.1) 4 (3.4) 9 (7.6) 41 (34.5) 17 (14.3) 10 (8.4) 15 (12.6) Confirmed response No change Progression Early death Not assessable The difference in response rate between the two treatment arms is not significant (p=0.08) The difference in confirmed response rate between the two treatment arms is significant (p=0.01) M. De Santis phase III 30986 ASCO 2010 Phase III results of EORTC study 30986 Results: Overall Survival 100 90 80 70 60 % 50 40 30 20 10 0 0 O N 108 119 110 119 M. De Santis HR=0.94 (95%CI: 0.72, 1.22) p=0.64 8.1 months (95%CI: 6.1, 10.3) 9.3 months (95%CI: 7.6, 11.3) (years) 1 2 3 4 5 Number of patients at risk : 37 13 7 3 1 44 15 5 2 2 phase III 30986 6 1 1 7 8 Treatment 1 M-CAVI 1 GC ASCO 2010 What have we learnt? ASCO 2010: GU Summary Conclusions Take home messages Locally Advanced Prostate Cancer: RT with ADT for 3 years is a standard of care Monotherapy with ADT or RT are NOT Castrate-Resistant Prostate Cancer: Docetaxel needs a date or a mate: still looking! BUT son of docetaxel, Cabazitaxel has a role in second line therapy Options for Osteoclast inhibition broaden: Denosumab Germ Cell Tumors: No role for first line HDCSCT Optimal therapy at relapse: standard chemotherapy or SCT? RCC: Selection can improve HDIL2 outcome but still no biomarker Serial monotherapy: ruling therapeutic paradigm for targeted therapy Urothelial cancer: adjuvant chemotherapy may have a place … In medical unfit patients Gemcitabine/Carboplatin remains a default standard Concurrent mitomycin C and 5FU adds to disease control with RT. Prostate Cancer Case Study Post ASCO 2010 64 year old Attorney, controlled HTN PSA screening annually for more than 10 years: PSA 2.3 – 3.0, DRE normal PSA 4.2, falls on ciprofloxacin Follow up 4 months later: PSA 7.8, DRE firmness of left. Biospy: left Gl 3+3=6, right Gleason 4+4=8, PNI Bone scan: multiple bone metastases CT: right iliac and RP LNs How would treat this patient? Prostate Cancer Case Study Post ASCO 2010 64 year old Attorney, controlled HTN PSA screening annually for more than 10 years: PSA 2.3 – 3.0, DRE normal PSA 4.2, falls on ciprofloxacin Follow up 4 months later: PSA 7.8, DRE firmness of left. Biospy: left Gl 3+3=6, right Gleason 4+4=8, PNI Bone scan: multiple bone metastases CT: right iliac and RP LNs How would treat this patient? Androgen deprivation therapy: Continuous or Intermittent? Bone therapy: he starts calcium and vitamin D Would you start bone directed therapy now? Yes or No If you would what is your therapeutic aim? Prostate Cancer Case Study Post ASCO 2010 64 year old Attorney, controlled HTN PSA screening annually for more than 10 years: PSA 2.3 – 3.0, DRE normal PSA 4.2, falls on ciprofloxacin Follow up 4 months later: PSA 7.8, DRE firmness of left. Biospy: left Gl 3+3=6, right Gleason 4+4=8, PNI Bone scan: multiple bone metastases CT: right iliac and RP LNs How would treat this patient? Androgen deprivation therapy: A. Continuous or B. Intermittent? Bone therapy: he starts calcium and vitamin D Would you start bone directed therapy now? A. Yes or B. No If you would what is your PRIMARY therapeutic aim? A. Prevent bone loss or B. Prevent further skeletal related events Prostate Cancer Case Study Post ASCO 2010 64 year old Attorney, controlled HTN PSA screening annually for more than 10 years: PSA 2.3 – 3.0, DRE normal PSA 4.2, falls on ciprofloxacin Follow up 4 months later: PSA 7.8, DRE firmness of left. Biospy: left Gl 3+3=6, right Gleason 4+4=8, PNI Bone scan: multiple bone metastases CT: right iliac and RP LNs How would treat this patient? Androgen deprivation therapy: A. Continuous or B. Intermittent? Bone therapy: he starts calcium and vitamin D Would you start bone directed therapy now? A. Yes or B. No If you would what is your PRIMARY therapeutic aim? A. Prevent bone loss or B. Prevent further skeletal related events Which agent would you use? A. Zelodronic acid B. Pamidronate C. oral bisphosphonate D. Denosumab Prostate Cancer Case Study Post ASCO 2010 64 year old Attorney, controlled HTN PSA screening annually for more than 10 years: PSA 2.3 – 3.0, DRE normal PSA 4.2, falls on ciprofloxacin Follow up 4 months later: PSA 7.8, DRE firmness of left. Biospy: left Gl 3+3=6, right Gleason 4+4=8, PNI Bone scan: multiple bone metastases; CT: right iliac and RP LNs He commences Goserelin and Bicalutamide, PSA falls to 0.1. He also commences zelodronic acid yearly. 2 years later his PSA rises to 1.0 and bicalutamide is stopped. Following month PSA is 2.1. Bone scan shows new lesions compared to prior scan. CT scan is stable. Does the patient have disease progression? Yes (A) or No (B) Prostate Cancer Case Study Post ASCO 2010 64 year old Attorney, controlled HTN PSA screening annually for more than 10 years: PSA 2.3 – 3.0, DRE normal PSA 4.2, falls on ciprofloxacin Follow up 4 months later: PSA 7.8, DRE firmness of left. Biospy: left Gl 3+3=6, right Gleason 4+4=8, PNI Bone scan: multiple bone metastases; CT: right iliac and RP LNs He commences Goserelin and Bicalutamide, PSA falls to 0.1. He also commences zelodronic acid yearly. 2 years later his PSA rises to 1.0 and bicalutamide is stopped. Following month PSA is 2.1. Bone scan shows new lesions compared to prior scan. CT scan is stable. He has no symptoms. What therapy would your recommend? A.Ketoconazole and Corticosteroid B.Triple dose bicalutamide C.Clinical trial with abiraterone or TAK-700 or MDV 3100 D.Sipuleucel T (Provenge) E.Docetaxel chemotherapy Prostate Cancer Case Study Post ASCO 2010 64 year old Attorney, controlled HTN Metastatic prostate cancer. He commences Goserelin and Bicalutamide, PSA falls to 0.1. He also commences zelodronic acid yearly. 2 years later his PSA rises to 1.0 and bicalutamide is stopped. Following month PSA is 2.1. Bone scan shows new lesions compared to prior scan. CT scan is stable. He has no symptoms. He opts for Sipuleucel T. Some chills after infusions. 8 weeks after treatment his PSA is 3.7, further new bone lesions on bone scan. CT shows stable disease but he has a left DVT and pulmonary emboli. Starts LMWH. He develops back pain, starts monthly bisphosphonates. What therapy would your recommend? A.Ketoconazole and Corticosteroid B.Triple dose bicalutamide C.Clinical trial with abiraterone or TAK-700 or MDV 3100 D.Sipuleucel T (Provenge) E.Docetaxel chemotherapy Prostate Cancer Case Study Post ASCO 2010 64 year old Attorney, controlled HTN Metastatic prostate cancer. He commences Goserelin and Bicalutamide, PSA falls to 0.1. He also commences zelodronic acid yearly. 2 years later his PSA rises to 1.0 and bicalutamide is stopped. He opts for Sipuleucel T. 8 weeks after treatment his PSA is 3.7, further new bone lesions on bone scan. Left DVT and pulmonary emboli. Starts LMWH. He develops back pain, starts monthly bisphosphonates. He starts docetaxel q3weekly with prednisone. After 10 cycles he is pain free, PSA 0.3, CT and bone scan improved. Therapy is stopped electively. 4 weeks later he has severe back and risb pain. PSA is 26, bone scan shows PD, MRI no spinal cord compression. CT: lung and liver metastases. What therapy would your recommend? A.Restart docetaxel B.Mitoxantrone C.Cabazitaxel D.Oral cyclophosphamide E.Best supportive care Thank You Jaoquim Belmunt, Bernard Escudier, Cora Sternberg, Kevin Kelly, Howard Scher, Primo Lara, Nicholas Vogelzang, Mria DeSantes, Karim Fizazi, Nicholas Nottet