Nanotechnology essentially restructures molecules to make materials lighter, stronger, more penetrating or absorbant, among many innovative qualities. In cancer research, it offers a unique opportunity to study and interact with normal and cancer cells in real time, at the molecular and cellular scales, and during the various stages of the cancer process. For cancer researchers, a special interest lies in ligand-targeted therapeutic nanoparticles (TNP), which are expected to selectively deliver drugs and especially cytotoxic agents specifically to tumor cells and enhance intracellular drug accumulation. Targeting can be achieved by various mechanisms. For example, nanoparticles with numerous targeting ligands can provide multi-valent binding to the surface of tumor cells with high receptor density (as opposed to low receptor density on normal cells) or nanoparticle agents can enhance permeability and retention (EPR) effect to exit blood vessels in the tumor, to target surface receptors on tumor cells, and to enter tumor cells by endocytosis before releasing their drug payloads. In this presentation we shall look at nanotechnology in drug development with a focus on anticancers and the advantages of nanoparticles as therapeutic platform technology. Approved nanotech based drugs and their clinical trials will be discussed. Two specific clinical trial case studies will be focused on along at some length with a mention of some ongoing clinical trials of nanotherapeutics. We shall also take a look at the future direction of nanotechnology based therapeutics.

1. NANOTECHNOLOGY
IN CLINICAL
TRIALS
Dr. Bhaswat S. Chakraborty
Sr. VP & Chair, R&D Core Committee
Cadila Pharmaceuticals Ltd., Ahmedabad

2. CONTENTS
 Nanotechnology in drug development
 Advantage of nanoparticles as therapeutic
platform technology
 Approved nanotech based drugs
 Clinical trials of nanotech based drugs
 Case Study 1: Myocet (liposome-encapsulated
doxorubicin)
 Case Study 2: Abraxane (Albumin bound
Paclitaxel)
 Some ongoing CTs of nanotherapeutics
 Future directions
 Concluding remarks

3. Comparing a nanoparticle to an
ant is like comparing that ant to
a four-kilometer strip of a 12-
lane highway!

4. SO SMALL!! ANY RISKS?
WHAT BENEFITS?
 Essentially, nanotechnology restructures
molecules make materials lighter, stronger or
more penetrating or absorbant, among many
innovative qualities; thus:
 Are they toxic? Are we poisoning ourselves (since
they are foreign to the body)?
 Have there been extensive basic research of “nano-
toxicity”?
 True estimation of benefits
 Do the benefits outweigh the risks?
 How would one regulate the nanotherapeutics?
 Etc.

5. NANOTHERAPEUTICS
 Nanotechnology is knowledge and control of material
particles in ~1–100 nm range
 Nanotherapeutics (applied nanotechnology to
therapeutics) is the use of precisely engineered
materials at nanoscale to develop novel therapeutics
and diagnostics
 Nanomaterials have unique physicochemical properties
 e.g.,ultra small size, large surface area / mass ratio, and
high reactivity
 different from bulk materials of the same composition
 can be used to overcome limitations found in traditional
therapeutic and diagnostic agents

6. MANY ADVANTAGES &
APPLICATIONS
 Nanotechnology allows improvement in basic
properties
 e.g
solubility, diffusivity, t1/2, drug release characteristics,
immunogenicity
 Nano-therapeutics and -diagnostics in last 2 decades:
 developed for cancer, diabetes, pain, asthma, allergy,
infections, and so on
 Often provide more effective and/or more convenient
RoA, lower therapeutic toxicity, maximize product life
cycle, & reduce costs
 Allow targeted delivery and controlled release
 (In diagnostic applications) allow detection on the
molecular scale:
 fragments of viruses, precancerous cells, & disease markers
that cannot be detected with traditional diagnostics

7. APPROVED
NANOTHERAPEUTICS
 Currently >150 companies are developing nanoscale
therapeutics
 Internationally >36 nano-therapeutic products have
been approved for clinical use
 Total sales exceeding $12 billion
 Liposomal drugs and polymer–drug conjugates
 are the two dominant classes, accounting for more than 80%
of total
 Other platforms include:
 nanoemulsions, dendrimers, and inorganic nanoparticles
 Polymerosomes, micelles, gold nano particles
 Nano-shells (gold-silica)
Personal research and Zhang et al (2008) Clin Pharmacol Therap 83, 761-769

8. Zhang et al (2008) Clin Pharmacol Therap 83, 761-769

9. Examples of nanotechnologies and targeting nanocarriers

10. NANOTHERAPEUTICS IN
CLINICAL TRIALS
 Drug-encapsulated liposomes and polymer–drug
conjugates (such as PEGylated drugs) were/are also the
main candidates in clinical trials
 PEG-ylated products
 PEG enhances the PK of many nanoparticle formulations
 It is highly hydrated flexible polymer chain & reduces
plasma protein adsorption and biofouling of nanoparticles
 It reduces renal clearance of relatively smaller drug
molecules, and thus prolongs drug circulation t1/2
 Itis non-toxic and non-immunogenic
 Examples:
 PEG–naloxol for treating opioid-induced constipation, PEG–
arginine deaminase for hepatocellular carcinoma, PEG–uricase) for
hyperuricemia & PEG-GCSF for neutropenia.
Personal research and Zhang et al (2008) Clin Pharmacol Therap 83, 761-769

11. Zhang et al (2008) Clin Pharmacol Therap 83, 761-769

12. CASE STUDY 1: ELAN’S MYOCET
(LIPOSOME-ENCAPSULATED
DOXORUBICIN)
 Myocet (liposome-encapsulated doxorubicin) was
developed to obtain an effective but less cardiotoxic
parenteral dosage form of doxorubicin
 using liposome nanotechnology
 Presented as a three-vial system; Myocet doxorubicin
HCl, Myocet liposomes and Myocet buffer
 Constituted liposomes are:
 stable pluri-lamellar liposomes
 with an aqueous core
 comprised of egg phosphatidylcholine (EPC) and cholesterol
 drug is entrapped into liposomes during the constitution of
the ready to use liposomal formulation.

13. Phospholipid bilayer
Aqueous core
(hydrophilic)
EXTRAVASATION AND RELEASE OF
Liposomes contain an
LIPOSOMAL DRUG CARGO IN TUMOR
internal aqueous core
surrounded by a INTERSTITIAL FLUID
phospholipid bilayer. The
internal aqueous core, which
is used for drug
encapsulation, is suited for
the delivery of hydrophilic
drugs, and the phospholipid
bilayer allows for the
delivery of hydrophobic
drugs

14. CLINICAL TRIAL: MYOCET +
CYCLOPHOSPHAMIDE (MC) VS CONVENTIONAL
DOXORUBICIN + CYCLOPHOSPHAMIDE (AC)
 RCT, two arms
 297 patients with metastatic breast cancer
 no prior chemotherapy for advanced disease
 48 centers
 142 patients were randomized to receive MC
 155 patients were randomized to receive AC
 Primary end point:
 cardiotoxicityin all treated patients & objective tumor
response rate (primary efficacy parameter)
 Secondary end point:
 time to disease progression, time to treatment failure, and
overall survival
Batist G et al. JCO 2001;19:1444-1454

15. LIFETIME DOSE OF DOXORUBICIN TO A CARDIAC EVENT
Batist G et al. JCO 2001;19:1444-1454 MC=Myocet in combination with cyclophosphamide
AC=Conventional doxorubicin with cyclophosphamide
©2001 by American Society of Clinical Oncology

16. OBJECTIVE RESPONSE TO TREATMENT
MC AC
No. % No. %
Total randomized 142 155
Objective response
Complete response 7 5 9 6
Partial response 54 38 57 37
Stable disease 41 29 38 25
Progressive disease 28 20 37 24
Not assessable 12 8 14 9
Response rate (CR + PR) 61/142 43 66/155 43
95% CI 35-52 35-51
No prior doxorubicin 54/128 42 63/140 45
Prior doxorubicin 7/14 50 3/15 20
Cochran-Mantel-Haenszel statistic
General association χ2 P value .95
Relative risk (MC/AC) 1.01
95% one-sided lower bound 0.81
Stratified difference in response rate (MC 1
– AC)
95% CI for difference (–10, 12)

17. TIME TO TREATMENT FAILURE
MC=Myocet in combination with cyclophosphamide
AC=Conventional doxorubicin with cyclophosphamide
Batist G et al. JCO 2001;19:1444-1454
©2001 by American Society of Clinical Oncology

18. TIME TO PROGRESSION
MC=Myocet in combination with cyclophosphamide
AC=Conventional doxorubicin with cyclophosphamide
Batist G et al. JCO 2001;19:1444-1454
©2001 by American Society of Clinical Oncology

19. OVERALL SURVIVAL
Batist G et al. JCO 2001;19:1444-1454
©2001 by American Society of Clinical Oncology

20. OVERALL RESULTS (CASE STUDY 1)
 Six percent of MC patients versus 21% (including
five cases of CHF) of AC patients developed
cardiotoxicity (P = .0002).
 MC patients also experienced less grade 4
neutropenia.
 Antitumor efficacy of MC versus AC was
comparable:
 objectiveresponse rates, 43% versus 43%
 median time to progression, 5.1% versus 5.5 months
 median time to treatment failure, 4.6 versus 4.4
months
 and median survival, 19 versus 16 months
Conclusion: Myocet reduces cardiotoxicity and grade 4 neutropenia of
doxorubicin and provides comparable antitumor efficacy, when used in
combination with cyclophosphamide as first-line therapy for MBC.

21. CASE STUDY 2: ABRAXIS’ ABRAXANE
(ALBUMIN BOUND PACLITAXEL)
 Abraxane contains paclitaxel complexed with albumin to
form stable; developed to avoid toxic solvent Cremophor®
 Presented as vials containing paclitaxel and human albumin
 as a sterile, lyophilized cake, reconstituted with Sodium
Chloride Injection, USP
 to produce a suspension of 5 mg/mL of albumin-bound particles
 Reconstituted Abraxane is infused @ 260 mg/m2 IV/0.5 hr
 Constituted liposomes are:
 130 nm particles
 stable at high concentrations due to the negative zeta potential
imparted by the albumin moiety with an aqueous core
 In blood, albumin particles disassociate into individual
albumin molecules and then circulate with the paclitaxel still
attached

22.  Some (claimed) advantages of Abraxane over Taxol:
 Allows a higher dose of paclitaxel to be administered with = toxicity
 Increases intratumor paclitaxel concentrations by 33%
 Eliminates solvent-related severe hypersensitivity reactions, including
 anaphylactic reactions and death, permitting administration of paclitaxel
over 30 minutes without premedication;
 Eliminates need for specialized IV tubing required for Cremophor-
containing products (to prevent leaching of plasticizers)
 Results in more rapid clearance from the plasma and predictable, linear PK
 Reduces neutropenia (demonstrated clinically);

23. ABRAXANE: CLINICAL TRIAL
STUDY DESIGN
 Randomized, Phase 3, open label
 Designed to show non-inferiority in RR
 Ifthe primary endpoint of non-inferiority was met, an
analysis for superiority in all patients or in first-line
patients was prospectively planned.
 Sample size: 460 women with metastatic breast cancer
 70 sites: Russia (77%), UK (15%), Canada and US (9%)
 2 Arms: Abraxane 260 mg/m2 as a 30-minute infusion
and Taxol 175 mg/m2 as a 3-hour infusion
 Efficacy outcome:
 1° Endpoint:Response Rate
 2° Endpoints: TTP & Survival
Source: Abraxane® ODAC Briefing Package

24. RESPONSE RATE (ITT)
Abraxane Taxol
260 mg/m2 175 mg/m2
All randomized patients
Response Rate 50/233 (21.5%) 25/227 (11.1%)
95% CI (16.19%-26.73%) (6.94%-15.09%)
P-value 0.003
Taxol Indication: Patients who failed combination chemotherapy or
relapsed within 6 months of adjuvant chemotherapy
Response Rate 20/129 (15.5%) 12/143 (8.4%)
95% CI (9.26%-21.75%) (3.85%-12.94%)

25. RATIO OF RESPONSE
(ABRAXANE/TAXOL) + 95% CI

26. TIME TO TUMOUR
PROGRESSION
Source: Abraxane® ODAC Briefing Package

27. PROGRESSION FREE
SURVIVAL
Source: Abraxane® ODAC Briefing Package

28. OVERALL SURVIVAL
Not Significant
Source: Abraxane® ODAC Briefing Package

29. OVERALL RESULTS (CASE STUDY 2)
 Response rates in the Abraxane group were statistically
significantly higher than those in the Taxol group (21.5% vs.
11.3%; P = 0.003)
 Time to tumor progression for all patients was significantly longer
for patients treated with Abraxane (p = 0.002, log rank)
 An ad hoc analysis of PFS for all patients revealed results that
were similar to TTP
 The median survival for patients treated with Abraxane was 10
weeks longer than for patients treated with Taxol but the survival
curves were not statistically different.
 The overall toxicity of Abraxane was comparable to that of Taxol in
some aspects but was lower in neutropenia and hypersensitivity
reactions; however Abraxane has a higher incidence of peripheral
neuropathy, nausea, vomiting, diarrhea and asthenia
Conclusion: In the metastatic breast cancer RCT, Abraxane has a higher
tumor response than Taxol but no other conclusive advantages.

30. SOME ONGOING TRIALS
 At the Center of Nanotechnology for Treatment, (University of
California, San Diego CCNE), Dr. Thomas Kipps has developed a
chemically engineered adenovirus nanoparticle to deliver a
molecule that stimulates the immune system.
 Phase I trial in patients with chronic lymphocytic leukemia
(CLL)
 Calando Pharmaceuticals, founded by Dr. Mark Davis at the
Caltech/UCLA CCNE, is conducting clinical trials with a
cyclodextrin-based nanoparticle that safely encapsulates a small-
interfering RNA (siRNA) agent that shuts down a key enzyme in
cancer cells.
 Phase I trial in patients who have become resistant to other chemotherapies.
 Cerulean Pharma, Inc. is conducting clinical trials of a
cyclodextrin-based polymer conjugated to camptothecin.
 Phase I open-label, dose-escalation study of CRLX101 (formerly named IT-
101)in patients with solid tumor malignancies.

31. SOME ONGOING TRIALS
 At the Center of Nanotechnology for Treatment, (University of
California, San Diego CCNE), Dr. Thomas Kipps has developed a
chemically engineered adenovirus nanoparticle to deliver a
molecule that stimulates the immune system.
 Phase I trial in patients with chronic lymphocytic leukemia
(CLL)
 Calando Pharmaceuticals, founded by Dr. Mark Davis at the
Caltech/UCLA CCNE, is conducting clinical trials with a
cyclodextrin-based nanoparticle that safely encapsulates a small-
interfering RNA (siRNA) agent that shuts down a key enzyme in
cancer cells.
 Phase I trial in patients who have become resistant to other chemotherapies.
 Cerulean Pharma, Inc. is conducting clinical trials of a
cyclodextrin-based polymer conjugated to camptothecin.
 Phase I open-label, dose-escalation study of CRLX101 (formerly named IT-
101)in patients with solid tumor malignancies.

32. FUTURE DIRECTIONS
 Approved nanotherapeutic agents have in some cases improved
the therapeutic index of drugs by increasing drug efficacy &/or
reducing drug toxicity.
 In future, nanoparticle systems may have targeting ligands such
as antibodies, peptides, or receptors which may further improve
their efficacy or reduce their toxicities.
 More complex systems such as multifunctional nanoparticles that
are concurrently capable of targeting, imaging, and therapy are
subject of future research.
 Optimally designed nanoparticles with the physicochemical and
biological properties to achieve each of the desired functions can
be a steady focus.
 Systemic therapies using nanocarriers will require methods that
can overcome non-specific uptake by mononuclear phagocytic cells
and by non-targeted cells.
 ….

33. CONCLUDING REMARKS
 Nanotechnology has had a discernible impact on
therapeutics for last 20 years or so.
 Nano-therapeutics and -diagnostics have been proven
highly successful in cancer, diabetes, pain, asthma,
allergy, infections, and so on.
 Numerous other nano-therapeutivc products are
currently under various stages of clinical development,
including various liposomes, polymeric micelles,
dendrimers, quantum dots, gold nanoparticles, and
ceramic nanoparticles.
 Clinical trials of these agents often show “non-
inferiority” rather than superiority but that is not a
bad news…
 Future seems to be very bright.

34. Acknowledgement:
THANK YOU VERY
MUCH