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WO 2017/205611 Al 30 November 2017 (30.11.2017) W !P O PCT

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WO 2017/205611 Al 30 November 2017 (30.11.2017) W !P O PCT (12) INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT) (19) World Intellectual Property Organization International Bureau (10) International Publication Number (43) International Publication Date WO 2017/205611 Al 30 November 2017 (30.11.2017) W !P O PCT (51) International Patent Classification: DZ, EC, EE, EG, ES, FI, GB, GD, GE, GH, GM, GT, HN, A61K 31/416 (2006.01) A61K 31/517 (2006.01) HR, HU, ID, IL, IN, IR, IS, JP, KE, KG, KH, KN, KP, KR, KW, KZ, LA, LC, LK, LR, LS, LU, LY, MA, MD, ME, MG, (21) International Application Number: MK, MN, MW, MX, MY, MZ, NA, NG, NI, NO, NZ, OM, PCT/US20 17/034452 PA, PE, PG, PH, PL, PT, QA, RO, RS, RU, RW, SA, SC, (22) International Filing Date: SD, SE, SG, SK, SL, SM, ST, SV, SY,TH, TJ, TM, TN, TR, 25 May 2017 (25.05.2017) TT, TZ, UA, UG, US, UZ, VC, VN, ZA, ZM, ZW. (25) Filing Language: English (84) Designated States (unless otherwise indicated, for every kind of regional protection available): ARIPO (BW, GH, (26) Publication Langi English GM, KE, LR, LS, MW, MZ, NA, RW, SD, SL, ST, SZ, TZ, (30) Priority Data: UG, ZM, ZW), Eurasian (AM, AZ, BY, KG, KZ, RU, TJ, 62/342,126 26 May 2016 (26.05.2016) US TM), European (AL, AT, BE, BG, CH, CY, CZ, DE, DK, EE, ES, FI, FR, GB, GR, HR, HU, IE, IS, IT, LT, LU, LV, (71) Applicant: THE REGENTS OF THE UNIVERSITY OF MC, MK, MT, NL, NO, PL, PT, RO, RS, SE, SI, SK, SM, CALIFORNIA [US/US]; 1111 Franklin Street, Twelfth TR), OAPI (BF, BJ, CF, CG, CI, CM, GA, GN, GQ, GW, Floor, Oakland, CA 94607 (US). KM, ML, MR, NE, SN, TD, TG). (72) Inventors: PIETRAS, Richard, J.; 3464 Lisa Place, Sher man Oaks, CA 91403 (US). JUNG, Michael, E.; 2335 Published: Manning Avenue, Los Angeles, CA 90064 (US). — with international search report (Art. 21(3)) (74) Agent: COLLINS, Daniel, W. et al; Mintz Levin Cohn Ferris Glovsky and Popeo, P.C., 3580 Carmel Mountain Road, Suite 300, San Diego, CA 92130-6768 (US). (81) Designated States (unless otherwise indicated, for every kind of national protection available): AE, AG, AL, AM, AO, AT, AU, AZ, BA, BB, BG, BH, BN, BR, BW, BY, BZ, CA, CH, CL, CN, CO, CR, CU, CZ, DE, DJ, DK, DM, DO, ESTROGEN RECEPTOR MODULATORCOMBINATIONS CROSS-REFERENCE TO RELATED APPLICATIONS [0001] This application claims the benefit ofU.S.Provisional Application No.62/342,126 filed May26, 2016, the contents ofwhichis herebyincorporated herein in its entiretyfor all purposes. BACKGROUNDOFTHE INVENTION [0002] Breast cancer is the most common malignancyin women in NorthAmerica.Eachyear more than 210,000 new cases ofbreast cancer are diagnosed in the US (1-3).In the clinic, endocrine therapyis an important intervention for cancers that express estrogen receptor (ER), and it has proven to be one ofthe most effective treatment strategies for breast cancer (3,4).At diagnosis, about 70% ofbreast cancers contain estrogen receptors and depend on estrogen for growthand progression.Expression ofER in a tumor is predictive ofa clinical response to hormonal therapy.Suchobservations have led to current use ofantiestrogens (suchas fulvestrant, tamoxifen and its relatives, raloxifene, toremifene, lasofoxifene, etc.)and aromatase inhibitors in treating ER-positive breast cancer (2,3).Tamoxifen and its analogues are among the most highly prescribed drugs for initial estrogen-dependent breast cancer.However, theyare not without their drawbacks since theybind to the estrogen receptor in manytissues (bone, uterus, etc.)and can have harmful effects.A substantial proportion ofpatients presenting withlocalized disease, and all ofthe patients withmetastatic breast cancer, become resistant to current endocrine therapies (5, 6).Thus, there is an urgent need to develop alternative therapeutics to overcome endocrine resistance and to improve the long-term survival ofafflicted patients.Despite remarkable improvements in treatment options, development ofendocrine resistance is one reason that breast cancer is the second most frequent cause ofcancer deathin women (5-7).In most cases, the ER is present in resistant tumors, and in manyofthese its activitycontinues to regulate tumor growth. [0003] Classical and nonclassical mechanisms ofestrogen action in breast malignancy. Estrogen modulates gene transcription in breast cancers throughits receptors using different signaling pathways (2,8)(see FIG.1).The classical pathwayinvolves direct DNA binding of liganded receptor to estrogen response elements (EREs)in the promoter regions ofresponsive genes. [0004] The proliferation and survival ofbreast cancers is closelyregulated bygrowthfactor receptors as well as estrogens (E2) and their receptors, estrogen receptor (ER)-αand -β, with ERαgenerally considered most important in tumor progression (5,6,9). ERαhas 6 major functional domains including an N-terminal transactivation domain, an adjacent DNA-binding domain and a C-terminal portion involved in hormone-binding, receptor dimerization and activity ofa second transactivation region.In classical models ofE2 action, E2 binds ER to promote dimerization and phosphorylation ofthe receptor.This allows direct binding ofthe ligand-ER complexwithsteroid receptor coactivators (CoReg)and E2-responsive elements (ERE)in DNA, leading to changes in gene transcription that regulate growth, differentiation, apoptosis and angiogenesis.In addition, there are alternate pathways ofE2 action that involve protein-protein interactions and do not require direct ER binding to DNA.A subset ofER associate with extranuclear sites and interact there withmembrane growthfactor receptors (EGFR, HER2)and other signaling molecules (components ofthe ras-MAPK and PI3K/AKTpathways, Shc, src kinases, JAK/STAT, nitric oxide synthase (NOS), G-proteins).Ofspecial note, growthfactor and extranuclear estrogen receptors appear to form a structured complexfor signal transduction to MAPK and/or PI3K/AKTkinase that interacts, in turn, withnuclear ER and CoReg.Signaling for cell growthinvolves phosphorylation (P)ofnuclear ER and CoReg, and suchphosphorylation can occur in ligand-dependent as well as ligand-independent modes.ERE-dependent and alternate transcription sites maybe activated.Further, E2 is produced locallyin supporting cells bythe action ofaromatase (ARO), and ARO is regulated bybothnulcear and extranuclear ER and growthfactor-mediated signaling.In addition, estrogens mayregulate tumor-associated angiogenesis bydirect interactions withvascular endothelial cells or byindirect stimulation of VEGFsecretion from tumors. [0005] However, it is now clear that the ERαcan regulate genes that lack a canonical ERE, suggesting additional pathways for estrogen action that maybe ofparamount importance in modulating tumor progression.Alternate, nonclassical pathways involve indirect modulation of transcription byER interaction withcomponents ofother transcription complexes (AP-1, nuclear factor-kB)or kinase signaling complexes (MAPK, PI3K/AKTkinase)via protein-protein interactions.Emerging data suggest that interactions ofER withgrowthfactor receptor-kinase signaling pathways mayplaya critical role in promoting estrogen signaling for tumor progression (9).Based on current data in estrogen target cells, nonclassical ER signaling is associated withepithelial proliferation but not other estrogen-responsive events suchas fluid accumulation in uterus (8), while classical ER signaling appears more essential for skeletal development, bone healthand other differentiated cell functions (10). [0006] ER often continues to playa major role in controlling growthofhormone-resistant cancers.In treatment witharomatase inhibitors (AI’s), ER activation byalternate ligands, local E2 production and development ofER hypersensitivityare especiallyproblematic (2,6).In addition, ligand-independent activation ofER occurs in tumors overexpressing growthfactor receptors suchas HER2, withgrowthfactor receptors promoting ER phosphorylation even in the absence ofestrogen (5,9,11).Suchligand-independent mechanisms likelycontribute to resistance to AI’s as well as antiestrogens (12,13).These nonclassical events are mediated byER or adaptor proteins that impact gene expression indirectlybyactivating growth-promoting kinase cascades to regulate transcription.In breast tumors, significant evidence suggests that regulation ofboth proliferation and cell deathpathways occurs, in part, bythe action ofnonclassical kinase- mediated pathways (9,11,14-19).Better understanding and targeting ofthese complexsignaling pathways in tumors withendocrine resistance to bothantiestrogens and AI’s will help in development ofindividualized and improved treatments in the clinic. [0007] Current antiestrogens are competitive antagonists ofestrogen and disrupt ER-induced transcription.However, some antagonists displaypartial estrogenic activityin a tissue- and gene- dependent manner, hence their description as selective estrogen receptor modulators (SERMs). Tamoxifen, a partial agonist that limits effects ofE2 in breast, has been the most widelyused hormone therapyfor the past 20 years, achieving a 39% reduction in disease recurrence and a 31% reduction in mortalityin ER+earlybreast cancer (6,20,21).Althougheffective, tamoxifen has an important drawback- the limited period ofactivitybefore resistance develops (7,20). Further, prolonged treatment withtamoxifen is associated withan increased riskfor endometrial cancer due to significant agonist activityofthe drug in uterus. As long as the ER is present in tumors, growthmaystill be stimulated bysmall amounts ofestrogens or antiestrogens or by ligand-independent actions.The introduction
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