1. The document discusses individualized systemic therapy for non-small cell lung cancer (NSCLC), focusing on biomarkers like ERCC1, BRCA1, and EGFR mutations that can help customize chemotherapy based on a patient's tumor genetics. 2. Clinical trials show that targeting therapies like EGFR tyrosine kinase inhibitors provide significant benefits for NSCLC patients with EGFR mutations, with response rates over 70% in some studies. 3. Ongoing research aims to identify additional biomarkers to further personalize treatment selection and overcome resistance to targeted therapies.

1. I NDIVIDUALIZED SYSTEMIC THERAPY IN NSCLC Vanesa Gregorc MD Scientific Institute San Raffaele University Hospital Department of Oncology Division of Molecular Oncology Clinical research leader Thoracic Oncology Unit

2. Customizing chemo therapy in advanced NSCLC I

3. 1990 -> 2000 To treat or not to treat ? Spesso solo Terapia di supporto (BSC) NSCLC = SCLC <1980 Today 1. Meta-analysis .BMJ. 1995 Oct 7;311(7010):899-909. 2. Loehrer PJ Sr, Semin Oncol. 1988 Jun;15(3 Suppl 3):2-8. Review. 3. L. Einhorn, JCO 2008;26:3485-3486 4. FR Hirsch JTO 2008;3:1468-1481 . SCLC Platinum Etoposide 2 NSCLC Platinum doublets 1 SCLC Platinum Etoposide 2 NSCLC Platinum doublets 1 Squamos 3,4 Non Squamos 3,4 The Evolving Role of Systemic Treatment in Advanced NSCLC

4. J Schiller et al, NEJM 2002 Study arm OS (mo) 1 year (%) PC 7.8 31 GC 8.1 36 DC 7.4 31 PCb 8.1 34

5. 1. J Clin Oncol 20:4285-4291. 2002 by American Society of Clinical Oncology Worst G 3-4 Tox % GemCis N=197 PacCb N=197 VinCis N=198 Neutropenia 38.1 49.9 64.6 Thrombo 36.6 7.7 0.5 Anemia 17.7 6.1 19.2 N/V 6.6 0.5 12.6 P Neuropathy 0 7 3 Constipation 0.5 0 3 Renal 0.5 0 5 Alopecia G 1-2 10.4 52.3 11.1

7. CBDCA + Paclitaxel (6 cycles) CBDCA + Paclitaxel + Bevacizumab (6 cycles) Bevacizumab 15 mg/kg Primary end point: OS CDDP + GEM + Placebo (6 cycles) CDDP + GEM + Bevacizumab (15 mg/kg) Bevacizumab CDDP + GEM + Bevacizumab (7.5 mg/kg) CDDP + GEM + Placebo (6 cycles) Bevacizumab Primary end point: PFS Placebo Placebo ECOG 4549 AVAiL Reck M; 2009; JCO Sandler A; 2006; NEJM 878 IIIB/IV PS 0-1 NSCLC Bevacizumab in patients with adenocarcinoma 1043 IIIB/IV PS 0-1 NSCLC

8. ECOG 4549 AVAiL

9. Bevacizumab Reck M, JCO 2009 Inclusion criteria Exclusion criteria NSCLC non-sq Hemopthysis grade 2 Chemo-naïve Brain metastasis Stage IIIB inoperable, stage IV Uncontrolled hypertension ECOG PS 0–1 History of thrombosis or hemorrhage Anticoagulants 10 days before starting Bevacizumab Central lesions that invade main vessels

10. CDDP + VNR + Cetuximab (6 cycles) Cetuximab CDDP + VNR (6 cycles) Primary end point: OS Pirker R; 2009; The Lancet More patients in the chemotherapy group were censored and started a new treatment without progression 1125 IIIB/IV EGFR IHC+ NSCLC Median OS: 11.3 months vs 10.1 months HR=0.871, p=0.044 Median PFS: 4.8 months for both arms HR=0.943, p=0.39 Cetuximab in patients with adenocarcinoma

12. JMDB: OS Scagliotti G, JCO 2008

13. 1994 Dabhalkar J Clin Invest. ERCC1 in ovarian cancer 2001 Shirota J Clin Oncol. ERCC1 and TS in colorectal cancer 2002 Lord Clin Cancer Res ERCC1 in NSCLC 2003 Rosell Oncogene beta-tubulin III, stathmin, RRM1, COX-2 and GSTP1 in NSCLC 2004 Rosell Clin Cancer Res RRM1 in NSCLC 2004 Taron Hum Mol Genet BRCA1 in NSCLC 2007 Cobo J Clin Oncol ERCC1 in NSCLC prospectively evaluated 2008 Scagliotti J Clin Oncol Adenocarcinoma (TS) prospectively evaluated 2009 ITACA (adjuvant) ongoing 2009 Rosell PLOS One BRCA1 Evolution for application of customized chemotherapy

14. Gazdar A; 2007; NEJM ERCC1 - XPF RRM1 Damage recognition Assembly of the nucleotide excision repair complex Dual incision Damage excision Adduct formation Repair synthesis DNA ligation Repaired DNA RRM1 ERCC1-XPF XPG ERCC1-XPF TFIIH XPG ERCC1

18. It is implicated in transcription coupled nucleotide excision repair It is involved in homologous recombination repair and non homologous end joining It is a regulator of the mitotic spindle assembly: it mediates G2/M arrest in response to agents that disrupt the mitotic spindle It is linked to apoptosis through the c-Jun N-terminal kinase pathway, which is activated in CDDP induced DNA damage The absence of BRCA1 results in high sensitivity to CDDP, its presence increases sensitivity to antimicrotubule agents. BRCA1

19. Rosell R et al; PLOS one; 2009 Customizing chemotherapy by BRCA1 mRNA profiling in advanced NSCLC 123 patients 12 positive for EGFR mutations 111 screened for BRCA1 levels LOW BRCA1 CDDP+Gem (38) INTERMEDIATE BRCA1 CDDP+TXT (40) HIGH BRCA1 TXT (33)

20. Median survival with TXT = Median survival with CDDP + TXT (11 months) Median survival and 2 years survival rate with CDDP + Gem > Median survival and 2 years survival rate with CDDP + Gem in unselected population (10.3 m vs 11 m and 41.2% vs 22%) Rosell R et al; PLOS one; 2009 BRCA1 mRNA and survival LIMITS: no control arm EGFR BRCA1 Low BRCA1 Intermediate BRCA1 High ORR 90% 25% 45.7% 41.9% TTP 13 months 5 months 5 months 8 months

21. Pemetrexed inhibits TS: high levels of TS are responsible for Pemetrexed resistance

22. TS mRNA expression levels in NSCLC subtypes and SCLC Monica V et al. Clin Cancer Res 2009;15:7547-7552

23. Scagliotti GV, JCO 2008 CDDP + Alimta 1.6 1.0 0.5 CDDP + GEM 0.81 [0.70;0.94] 0.68 [0.48;0.97] 1.3 [1.0, 1.50] ADENOCARCINOMA (847 pts) LARGE CELLS (153 pts) SQUAMOUS (473 pts) NSCLC (252 pts) 0.94 [0.84;1.05] OVERALL (1725 pts) Hazard ratio OS according to different histotypes

24. Control: Investigator’s choice (CDDP + VNR; CDDP+GEM; CDDP+DOC) Primary objective : OS Secondary objective : RFS PI: Giorgio Scagliotti ITACA Adjuvant Trial (ongoing)

26. The Evolving Role of Systemic Treatment in Advanced NSCLC 1980 2009 2000 One fits all 2004 2006 2007 2009 EGFR mutation discovered Antivascular agent Phase III study Role of histotype Phase III study EML4/ALK Pharmacogenetics and pharmacogenomics

27. Gefitinib : approved for patients carrying EGFR activating mutations in any line of treatment. Erlotinib : approved for unselected patients after 1 st line therapy. EGFR TKIs

28. Survival in NSCLC: Supportive care and chemotherapy 1991–2010 4.96 7.22 8.66 8.6 BSC 1995-2001 P alone PE Old Cis + no PE New Cis + 3 rd Carbo +3rd +45.5% +11% +17.9% +10.2% -11.4% Carbo+P+ Beva Gefitinib in mEGFR +43% 12.3 13.6 +10% 21.9 +61% CDDP+GEM+Beva 7.77 9.17

29. LREA 19 deletions and 21 L858R represent 85% to 90% of EGFR mutations EGFR mutations are found in 10% of cases in North America and Western Europe EGFR activating mutations and EGFR TKIs

30. Mutated EGFR represents the genetic lesion to which the tumor is addicted . The acute withdrawal of these signals by EGFR-TKIs triggers oncogenic shock and tumor cell apoptosis. Sharma et al. Nature Reviews Cancer; 2007 Engelman et al. Cl Can Res, 2008 T790M MET amplification in 60-70% tumors

31. WJTOG3405 IPASS Mok TS, NEJM 2009 Mitsudomi T, Lancet Oncol 2010 ORR : 71.2% in patients treated with Gefitinib vs 47.3% in patients treated with CT (p<0.001) Gefitinib standard of care in first line EGFR mut NSCLC patients: Phase III Asiatic studies

32. Gefitinib first line NSCLC Author Study N (EGFR mut +) RR (TKI vs CT) PFS (HR, 95%CI) Mok T NEJM 2009 IPASS 261 71.2% vs 47.3% 0.48 (0.36, 0.64) Lee JS WCLC 2009 First-SIGNAL 42 84.6% vs 37.5% 0.61 (0.31, 1.22) Mitsudomi T Lancet Oncol 2009 WJTOG 3405 198 62.1% vs 32.2% 0.49 (0.34, 0.71) Maemondo M NEJM 2010 NEJGSG002 177 74.5% vs 29% 0.36 (0.25, 0.51)

34. PFS probability 1.0 0.8 0.6 0.4 0.2 0 Erlotinib (n=82) Gem/carbo (n=72) HR=0.16 (0.10–0.26) Log-rank p<0.0001 Time (months) 0 5 10 15 20 25 Patients at risk Erlotinib 82 70 51 20 2 0 GC 72 26 4 0 0 0 13.1 4.6 OPTIMAL: erlotinib versus gem/carb in EGFR mutation+ NSCLC

35. K-RAS mutations are not a selective biomarker due to the absence of clinical benefit with EGFR-TKIs therapy in EGFR wild type. INTEREST BR.21 Should we use K-RAS mutation as biomarkers to exclude NSCLC patients with ANTI-EGFR agents in EGFR wild type patients? 19% (275/1433) patients had available tissue; 18% of samples were positive for K-RAS mutations 28% (206/731) patients had available tissue; 15% of samples were positive for K-RAS mutations (8 pts on placebo, 22 on erlotinib)

36. FISH Predicts Benefit of EGFR-TKIs (?) BR.21 INTEREST EGFR gene copy number is not a predictive biomarker for clinical benefit with EGFR-TKIs therapy in comparison with chemotherapy, but it is a prognostic marker of poorer survival 26% (374/1433) patients had available tissue; 47% of samples were positive for EGFR gene amplification 21% (206/731) patients had available tissue; 38% of samples were positive for EGFR gene amplification

38. Rosell R; Clin Cancer Res; 2011 T790M is present in 35% of patients at baseline

40. PFS OS AFATINIB: LUX-Lung 1

41. Did not receive subsequent systemic treatment Received subsequent systemic treatment AFATINIB: LUX-Lung 1

42. Rosell R; Clin Cancer Res; 2011 Novel EGFR TKIs resistance mechanisms: BRCA1

43. Rosell R; Clin Cancer Res; 2011 PFS in 81 NSCLC patients with EGFR mut, according to BRCA1 mRNA levels

44. Janjigian; JTO; 2011 Retrospective analysis of EGFR TKIs in adjuvant

45. Primary end point: DFS at 2 years Janjigian; JTO; 2011 Schema for a clinical trial of adjuvant EGFR-TKIs

46. “ GOOD” “POOR” TTP: 84 days TTP: 61 days HR: 0.56; 95% CI 0.28-0.89; p=0.002 OS: 207 days OS: 92 days HR: 0.50; 95% CI 0.24-0.78; p=0.0054 Clinical Benefit TTP > 6 m No Clinical Benefit TTP < 1 m Good Profile Poor Profile PROTEOMICS: VeriStrat algorithm

47. Carbone, European Lung Cancer Conference, 2010 ____ indicates median OS unselected patients BR21 with 95% Conf. Int. Median OS = 6.7 months (CI: 5.5 -7.8 ) N = 61 N = 98 N =34 N =170 N =30 N =176 N =266 N =170 ∞ Comparison between different biomarkers

52. Responses to Crizotinib Kwak EL, NEJM 2010 RESPONSES TO CRIZOTINIB

55. Choi YL, NEJM 2010 Secondary mutations within EML4-ALK

63. + +Bevacizumab (selected patients) or Cet u ximab (not yet!)