The NCI Comparative Program: Clinical Trials in Pet with Cancer and Insight for Humans

Amy LeBlanc, DVM DACVIM (Oncology) Director, Comparative Oncology Program NIH/NCI/CCR

14th Joint Meeting of the Board of Scientific Advisors & National Cancer Advisory Board December 3, 2019 The State of Comparative Oncology in North America

The NCI Comparative Oncology Trials Consortium

Integration of Comparative Intramural + Extramural NCI – Oncology within the Comparative Oncology Program Cooperative Group Focus on Cancer Drug Structures Development and Translational (Children’s Oncology Tumor Biology Group; NCI-CTEP, NeXT)

Increasing support from Pharma to 10 Veterinary Colleges conduct early phase studies with formal membership with novel and integration to NCI cancer Comprehensive Cancer Study of gene- therapeutics Centers environment Several with informal or Comparative Cancer Genomics and cancer- associated risk NIH or other National individual interactions Breen Lab – NCSU Funding/Philanthropy factors TGen for Comparative Other cooperative Broad Institute Oncology Research veterinary clinical trial Ostrander Laboratory- NIH/NHGRI groups (private practice and academic-led) Spontaneous cancer in dogs: why is it relevant?

Approximately 78 million dogs in US households - Over 1 million will develop cancer each year Many cancers are similar to those that occur in people: - Non-Hodgkin’s lymphoma, , , soft tissue , muscle-invasive , brain tumors Owners are increasingly interested in more advanced therapeutics and access to clinical trials for their pets - Surgery, chemotherapy, radiation therapy, small molecule RTK inhibitors, canine-specific immunotherapies Why consider a comparative oncology approach to cancer drug development?

Greater synteny between /human vs. Comparable genetic rodent/human etiopathogenesis Similar gene expression alterations in cancer Comparable signal Similar druggable targets identified transduction pathways Similar angiogenic and apoptotic pathways Recapitulates heterogeneity in human tumors Spontaneous tumors, Recurrence, , resistance to therapy outbred population common GMP quality material not always necessary Lower relative cost Pre-IND work highly valuable, particularly for early efficacy signals Population less heavily Higher patient performance status, more accurate pretreated AE assessment and less acquired resistance Similar imaging and treatment modalities used Body size of Opportunity for repeated tissue and fluid companion species sampling One patient, many opportunities

 Large-volume biologic samples collected routinely via validated SOPs during comparative oncology clinical trials  Access to canine-specific assays and reagents through the COTC Pharmacodynamic (PD) Core laboratory (Colorado State University) A Comparative and Integrated Approach to Cancer Drug Development COTC001: Evaluation of RGD targeted delivery of phage expressing TNF-α in tumor bearing dogs

Phase I study of TNFα adeno- Green: anti-CD31 Red: anti-phage expression cassette with RGD motif targeting αvβ3 integrin receptors on tumor neo-vessels. Co-localization of RGD-TNF particles was present within tumor vascular endothelium, but not in the tumor cells or blood vessels in normal tissues. hTNFα levels increased in post- treatment tumor biopsies compared to pre-treatment tumor biopsies.

Informed phase I trials in people. Paoloni et al, PLOS One, 2009 Comparative oncology’s challenge: to move past observations and into action

The comparative approach impacts 1 human health

Data-driven research and discovery bridges human 2 and canine oncology

Naturally-occurring cancers in pet dogs are a novel model 3 system for human cancers

8 Canine Osteosarcoma • >10,000 middle-old age, large and giant breed dogs in the US/year vs. ~ 1000 pediatric/AYA cases • Median Survival Time: 10-14 months - majority develop metastatic disease • Shares many clinical and molecular features with pediatric osteosarcoma • Canine model recognized as a key component of discovery process for new therapies for children

Paoloni M., et al BMC Genomics 2009

Images courtesy of Nicola Mason/UPenn and Kristen Weishaar/CSU  In-depth genomic profiling of human OS allows generation and selection of appropriate PDX models, and rational testing of therapeutic strategy

 Companion strategy in dogs can identify translationally-relevant canine OS subtypes for targeted recruitment into clinical trials A Comparative Approach to Osteosarcoma Drug Development: Translational studies of agents designed to improve outcomes for dogs and humans

Localized Primary Minimal Residual Distant Gross Canine OS Trials Disease Metastasis

Minimal residual disease studies • Comparative Oncology Trials Consortium • Prioritize agents for human MRD/adjuvant based studies of metastatic progression

12 Months

Enrolled ~450 canine patients on 3 trials over ~3.5 years

Therapeutic approaches include: Early Phase Trials Novel biologics/vaccines Later Phase Trials Rapalog inhibition of mTOR Metabolic targeting of metastatic cells

Measurable Minimal Residual Disease Disease DOG2 project goals:

 Build out a comprehensive comparative dataset describing the molecular landscape of canine OS  Define molecular subtypes  New druggable targets

 Leverage existing canine OS N = 157 dogs; Median Disease-free Interval (Intent to Treat) biospecimen repository = 173 days (5.8 months)  Tumor:normal; tumor:met; all treatment- Early failures naïve and outcome-linked; same method (DFI < 90 days) of treatment

 n = 72  36 each early failures/elite responders Elite responders  RNAseq, WES, low-pass and deep WGS (DFI > 360 days)  n = 25 tumor:met pairs The National Cancer Institute Comparative Oncology Trials Consortium Define genomic landscape of canine OS with COP biospecimen repository

Prioritize therapeutic A Comparative approaches to study in Approach: Integrate with human canine OS clinical trials OS data (NCI TARGET) Leveraging existing COG input tools and expertise to identify new approaches for pediatric OS

Interrogate with Identify new druggable preclinical (mouse) targets models Prioritization of a lead compound

• Study sponsored by DCTD • 400 & 776 most NSC 743400 promising based on preclinical data • Biomarker: Induction of γH2AX foci formation

1. Can indenoisoquinolines be safely administered to tumor-bearing dogs?

2. What are the comparable toxicity profiles of the three indenoisoquinolines in tumor-bearing animals?

3. What are comparative PK profiles and correlative PD marker(s) for response?

4. Are indenoisoquinolines active in a naturally occurring canine model of non- Hodgkin’s lymphoma? Indenoisoquinolines: novel inhibitors of topoisomerase 1 (TOP1)

TOP1 empirically validated as target by success of camptothecin derivatives (topotecan and irinotecan)

Topoisomerase (Top1) relaxes DNA by generating single-stranded breaks in the DNA backbone, forming cleavage complexes

Top1 inhibition  cytotoxicity: 1. Drug binds reversibly to cleavage complex to slow down DNA re-ligation 2. Upon collision with replication fork or transcription machinery, complex becomes irreversibly “trapped” and induces DS DNA breaks Why develop the indenoisoquinoline class?

Camptothecins (CPTs) Indenoisoquinolines

• Inactivated at physiologic • Stable in blood pH by lactone hydrolysis • Persistent enzyme-DNA • Long infusion times needed cleavage complexes at novel to overcome reversibility of sites compared to CPTs binding • Not/lesser substrates of • Drug efflux ABCG2 ABCG2 substrates • Animal models (mouse, dog) • Murine bone marrow more predictive of toxicity progenitors resistant to profile CPTs

Frederick National Laboratory Indenoisoquinolines: γH2AX as pharmacodynamic (PD) readout

Predose Day 1, 2Hr Day 1, 6Hr Day 6 COTC007b: A multicenter trial, open-label prospective preclinical trial of indenoisoquinolines in pet dogs with lymphoma

Biopsy (2 & 6hr) Biopsy Biopsy Weekly Tumor aspirate Tumor aspirate Tumor aspirate rechecks (2, 4, & 6hr) BM aspirate BM aspirate Tumor 24hr PK curve 24hr PK curve measurements Tumor measurements

CR/PR Cycle 2

SD/PD

Dosed daily IV for 5 days Off study

Dose Cohort (mg/m2/day) NSC 743400 NSC 706744 NSC 725776 1 8 25 3 2 16 50 6 3 24 75 9 4 40 125 15

5 50 150 Frederick National20 Laboratory NSC725776 Enrollment NSC743400 Enrollment

20 70 60 15 50 40 10 mg/m2 Patient Entry 30 Patient Entry 5 20 10 0 0 5/13/08 5/13/09 7/15/08 7/15/09 7/15/10

NSC706744 Enrollment Grade 5 event Grade 4 event 125 Grade 3 event 100

75 9 COTC sites; 84 dogs 50 patient entry enrolled 25 Dose escalation complete: 0 69 dogs treated 8/14/08 8/14/09 8/14/10 Cohort expansion complete: 13 dogs treated Best Overall Response 100 NSC725776 NSC743400 NSC706744 90 NSC725776 NSC743400 NSC706744 3mg/m2 8mg/m2 25mg/m2 80 NSC725776 NSC743400 NSC706744 70 6mg/m2 16mg/m2 50mg/m2

60 NSC725776 NSC743400 NSC706744 9mg/m2 24mg/m2 75mg/m2 50 NSC725776 NSC743400 NSC706744 40 15mg/m2 40mg/m2 100mg/m2

30 NSC725776 NSC743400 NSC706744 17.5mg/m2 50mg/m2 125mg/m2 20 NSC725776 10 20mg/m2 Patients 0

-10 0901 0202 0902 0401 0210 0403 0501 0204 0205 0301 0217 1002 0405 0215 0502 0615 0211 0503 0609 0207 0601 0212 1603 1602 0413 0613 0209 1604 0607 0614 1003 0602 0506 0406 0608 0101 0507 0612 0605 0213 0411 0604 0504 0407 0206 0611 1601 1607 0404 0214 1606 0216 1608 1609 0402 0302 0509 0203 0610 0510 0412 1001

-20 **1605 **0208 -30 PR -40 Response Assessment (%) Assessment Response -50 -60 -70 -80 -90 -100 NSC725776 NSC743400 NSC706744

NSC725776 3mg/m2 NSC743400 8mg/m2 NSC706744 25mg/m2

NSC725776 6mg/m2 NSC743400 16mg/m2 NSC706744 50mg/m2

NSC706744 75mg/m2 NSC725776 9mg/m2 NSC743400 24mg/m2

NSC725776 15mg/m2 NSC743400 40mg/m2 NSC706744 100mg/m2

NSC725776 17.5mg/m2 NSC743400 50mg/m2 NSC706744 125mg/m2

NSC725776 20mg/m2 (MTD not reached)

Overall response rate (PR or better) 7/23 (30%) 9/23 (39%) 18/23 (78%)

Response at the MTD 2/6 (33%) N/A 8/11 (73%) Dose vs. Best Clinical Response

NSC725776 NSC743400 80.0 80 60.0 60 40.0 40 20.0 20 0.0 0 0 20 40 60 80 0 5 10 15 20 25

Best Response (% Decrease) Response Best Dose (mg/m2) Dose (mg/m2) (% Decrease) Response Best

120 NSC706744 100 • Evidence of dose response for LMP 80 776 & 400 60 • Early-cohort responders with LMP 40 744 suggest dose-response may be 20 plateaued Decrease) 0 • Non-responders (SD + PD) across Best Best (% Response 0 50 100 150 dose range with LMP 776 & 400 Dose (mg/m2) Red=Previously treated, blue=naïve disease gH2AX at pre-dose, 2 hr, 6 hr, Day 6

12/5/2014 Ji/NCTVL 23 Study Summary

1. Can indenoisoquinolines be safely administered to tumor-bearing animals? • Yes 2. What are the comparable toxicity profiles of the three indenoisoquinolines in tumor-bearing animals? • Toxicity profiles are similar across all 3 agents • No unexpected adverse events 3. What are comparative PK profiles and correlative PD marker(s) for response? • 744 exhibits 10x higher tumor drug accumulation than 766 and 400 • γH2AX signal does not correlate for biologic response for 744 • TOPO-1 inhibition may not be 744’s main mechanism of action

4. Are indenoisoquinolines active in a naturally occurring model of non- Hodgkin’s lymphoma? • 744 overall response rate is 2x that of 776 and 400 What lies ahead for comparative oncology’s role in cancer research and drug development?

. Emphasis on continuing the scientific dialogue on applicability and validity of the dog model of cancer for strategic advancement of novel agents

. Maintain the highest standards for clinical trial design, execution and reporting

. Continue developing portfolio of canine-specific reagents and correlative assays to support trial efforts and enhance human translation

25 Acknowledgements

NIH-NCI Center for Cancer Research -Molecular Imaging Program (Dr. Peter Choyke, Elaine Jagoda, Baris Turkbey, Dagane Daar, Tieu Hoa, Alicia Forest, Phil Eclarinal, Karen Wong) -Genetics Branch (Dr. Paul Meltzer) -Pediatric Oncology Branch (Drs. Javed Khan, Kathy Warren, Rosandra Kaplan, Fernanda Arnaldez) -Radiation Oncology and Biology Branches (Drs. Murali Cherukuri, Kazu Yamamoto) -NeuroOncology Branch (Dr. Mark Gilbert, Dr. Mioara Larion, Victor Ruiz)

NIH-NCI Comparative Oncology Program -Christina Mazcko; Dr. Ling Ren; Dr. Shan Huang; Aswini Cherukuri -Dr. Hongsheng Wang -Christine Tran Hoang -Anusha Kambala

NCI Division for Cancer Treatment & Diagnosis (DCTD) NIH Divisions of Veterinary Resources (DVR) and Radiation Safety (DRS) NIH Imaging Probe Development Center (IPDC)

Dr. Chand Khanna COTC member institutions, investigators, and support staff: past, present and future

26 Thanks for your attention Questions? www.cancer.gov www.cancer.gov/espanol