TCOS, Shanghai, May 20 2010

Cancer Biomarkers: Opportunities and Challenges

Cancer Biomarkers: Opportunities and Challenges

Ann-Lii Cheng M.D., Ph.D.

Department of Oncology and Department of Internal Medicine, National Taiwan University Hospital;

Taipei, Taiwan.

Cancer Biomarkers- the opportunities

• A new era in which physicians no longer make treatment choices that are based on population-based statistics but rather on the specific characteristics of individual patients and their tumors.

Dalton W Science 2006

First-line study of gefitinib vs carboplatin / paclitaxel in patients with advanced non-small cell lung cancer (IPASS)

EGFR mutation-positive EGFR wild-type

Pro

bab

ilit

y o

f P

FS

1.0

0.8

0.6

0.4

0.2

0P

rob

abil

ity

of

PF

S

1.0

0.8

0.6

0.4

0.2

00 4 8 12 16 20 24 0 4 8 12 16 20 24

Months Months

132 108 71 31 11 3 0129 103 37 7 2 1 0

At risk:GefitinibC/P

91 21 4 2 1 0 085 58 14 1 0 0 0

Gefitinib (n=132)Carboplatin/paclitaxel (n=129)

HR (95% CI) = 0.48 (0.36, 0.64)p<0.0001

Gefitinib (n=91)Carboplatin/paclitaxel (n=85)

HR (95% CI) = 2.85 (2.05, 3.98)p<0.0001

Mok et. al. ESMO 2008

First-line treatment of mCRC with FOLFOX cetuximab (OPUS Study)

K-Ras mutant K-Ras wild-type

Progression-free time (months)

Kap

lan

-Mei

er

esti

ma

te

0 2 4 6 8 10 12 0 2 4 6 8 10 12

Cetuximab + FOLFOX

FOLFOX

Cetuximab + FOLFOX

FOLFOX

HR=1.83; p=0.0192 FOLFOX: 8.6 m Cetuximab + FOLFOX: 5.5 m

Progression-free time (months)

1.0

0.8

0.6

0.4

0.2

0

1.0

0.8

0.6

0.4

0.2

0

HR=0.57; p=0.016 FOLFOX: 7.2 mCetuximab + FOLFOX: 7.7 m

Bokemeyer C, et al. JCO 2009

Cancer Biomarkers- the challenges

• Clinically a must in an increasing number of cancer types.

• Cost, workload, and workflow.

• Technic issues – reliability of methods

• Ethnic and geographic issues – how far can data be extrapolated from area to area ?

Non-Small cell lung cancerColorectal cancer

Breast cancerGastric cancer

Renal cell carcinomaGI stromal tumor

LeukemiaLymphomaMelanoma

Basal cell carcinomaMedulloblastoma

…………

Non-Small cell lung cancerColorectal cancer

Breast cancerGastric cancer

Renal cell carcinomaGI stromal tumor

LeukemiaLymphomaMelanoma

Basal cell carcinomaMedulloblastoma

…………

Reliability of Biomarkers on Surgically Resected Tumor Specimens

1. Ischemia during operation – unknown in most specimens

2. Unknown processing of specimens

Warm ischemia

Specimen aging

Comparison of Biopsy vs. Hepatectomy HCC Tissues

Study design:• 46 paired HCC tissues (‘03~’08)

– Biopsy taken within 3 months before hepatectomy

– Hepatectomy• IHC studies:

– p-Akt (S473): rabbit antibody (Santa Cruz)– p-ERK1/2 (T202/Y204): rabbit antibody

(Santa Cruz)

~ Shao YY et al: AACR 2010, Abstract 3759.

Comparison of Biopsy vs. Hepatectomy HCC Tissues

• Poor correlation• Higher expression in biopsy tissues

phospho-Aktphospho-Aktphospho-ERKphospho-ERK

~ Shao YY et al: AACR 2010, Abstract 3759.

p-ERKBiopsy tissue Hepatectomy tissue

Tissue Ischemia Affects Gene Expression within Minutes Following CRC Excision

─ Microarray analysis

Spruessel A, et al. BioTechniques 2004;36:1030-1037

Tissue Ischemia Affects Protein Expression within Minutes Following CRC Excision

─ SELDI-TOF MS analysis

Spruessel A, et al. BioTechniques 2004;36:1030-1037

Slide Aging Affects Immunohistochemistry

HER2 ER E-Cadherin

Mirlacher M, et al. Mod Pathol, 2004;17:1414-1420

Figure 2. Influence of slide aging on the fraction of positive cases. For each antibody, the frequency of positive cases is shown as separate bars for old (O) and fresh (F) sections.

Slide Aging Affects Immunohistochemistry

Mirlacher M, et al. Mod Pathol, 2004;17:1414-1420

Slide Aging Affect p53 Immunostaining of Breast Cancer Tissues

Jacob TW et al J, Natl Cancer Inst 1996;88:1054-09

The Problems of Genomic Biomarkers- minimal reproducibility

• Numerous gene signatures have been reported.

• Only marginal overlap of reports– poor study design

lack of a standard technology platform

different ways of tumor collection

different statistical methods

• Only few validated into clinic practice.

Dalton W. science 2006;312:1165-8

Toward Robust Genomic Biomarkers

• Share samples

• Common technology platform

• Ask similar questions

• Use similar criteria for patient enrollment

• Partnership among academic groups, pharmaceutical and biotechnology companies, as well as government agencies.

Dalton W. Science 2006;312:1165-8

Challenges of Cancer Biomarkers- ethnic and geographic issues -

East vs West

Lung cancer

Breast cancer

Hepatocelluar carcinoma

Asian (n=342) Non-Asian (n=1350)

Pro

po

rtio

n s

urv

ivin

g

Time (months)

0.0

1.0

0.8

0.6

0.4

0.2

0 2 4 6 8 10 12 14 16 0 2 4 6 8 10 12 14 16

GefitinibPlacebo

Importance of Ethnicity for MTT ─ the lessons of ISEL trial

EGFR mutation rates in each subgroup

Study CentreNo. of

patients

AdenoCa

(+BAC) (%) M (%)

F (%)

Smokers (%)

n-smokers (%)

Taiwan1 NTUH 62 49 25 61 29 56

Taiwan2 VGH-T 37 67.4 52 72 44 69

Korea3 Seoul NU 90 21 9 33 13 26

Japan4 NCC Tokyo 66 61 53 69 35 68

Japan5 Aichi CCH 59 64 44 70 42 71

HK6 Chinese U 72 32 — — — —

China7 Pek UMCH 76 48.6 32.3 34.8 — —

Italy8* U Chieti 375 10 6 30 7 25

1. Shih et al, IJC 20052. Chou et al, CCR 20053. Han et al, JCO 20054. Takano et al, JCO 2005

5. Mitsudomi et al, JCO 20056. Lung et al, PAACR 20057. Mu et al, CCR 20058. Machetti et al, JCO 2005

*only AdenoCa

EGFR Mutations in NSCLC Patients Born or Domiciled in the USA

• Other ethnicities 14/159 (9%)

• East Asians 12/22 (55%)

Adi Gazdar, 2005

Ethnic Difference in Mutational Pattern of Lung Adenocarcinoma

EGFR mutationKRAS mutation

EML4-ALKBRAF mutation

HER2 mutataionPIK3CA

MET amplificationMEK1 mutation

Unknown

East Asians Other Countries

EGFR mutation

KRAS mutation

EGFR mutation

KRAS mutation

• Incidence of breast cancer has been increasing around the world including Latina America, Middle East and Asia

– Incidence now stabilizing in some Western populations– Incidence continues to increase in many Asian

populations

Trends in Breast Cancer Incidence

Country Incidence Incidence % 1973–77 1993–97 Increase

Japan (Miyagima) 17.5 34.4 97Japan (Osaka) 12.7 28.7 126Singapore (Chinese) 21.9 45.9 110 China (Shanghai) 19.6 27.2 39

Cancer Incidence in Five Continents (Vol. IV, VIII)

Katanoda et al, Jpn J Clin Oncol. 2007 Aug;37(8):638-9

Age-specific Breast Cancer Incidence in Taiwan

0.0

100.0

200.0

300.0

400.0

500.0

600.0

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 8085+年齡

AmericanCaucasion

台灣1994

台灣1998

台灣2002

台灣2005

Population(study period, y)

Patient no.

Luminal A (%)

Luminal B (%)

HER2+/ER- (%)

Basal-like (%)

Unclassified (%)

USA (1993-1996) 496

African American 196

Premenopausal 97 36 9 9 39 6

Postmenopausal 99 59 16 7 14 4

Non-African American 300

Premenopausal 164 51 18 6 16 10

Postmenopausal 136 58 16 6 16 4

Taiwan (2004-2006) 1028

≦50 y 515 66 11 10 9 4

>50 y 513 56 8 14 17 6

Comparison of Molecular Subtypes between American and Taiwanese

High frequency of ER expression in Taiwanese YFBC: validated by Taiwan Cancer Database

TCDB (n=3899)

<35 35-49 ≧50 P value

ER+ 194 (63) 1837 (66) 1868 (57) <0.001

ER- 114 (37) 927 (34) 1399 (43)

PR+ 160 (52) 1744 (63) 1596 (49) <0.001

PR- 148(48) 1020 (37) 1671 (51)

Taiwan Cancer DataBase 2005

0

10

20

30

40

50

60

70

80

90

100

<36 36-50 >50

1st cohort 2nd cohort

Preliminary data

(1992-2000) (2004-2006)

54

74

62

75

5861

Time Trend of Increase Frequency of ER expressions in Young Breast Cancer at NTUH

IBCSG data Lancet 2000

ER expression : a poor prognostic factor for DFS among very young patients receiving adjuvant

chemotherapy alone in Western Countries

178 very young (<35 years) breast cancer patients diagnosed at NTUH in 1997-2006

ER expression : a favorable prognostic factor for OS among very young (<35y)

patients in Taiwan

Proceeding ASCO 2009

Hepatocellular Carcinoma— Distinct Geographic Distribution

Risk Factors

Hepatitis B virus

Hepatitis C virus

Alcohol

Tobacco

Oral contraceptives

Aflatoxin

Other and emerging risk factors/cofactors

Estimate Range

22 4~-58

60 12~72

45 8~57

12 0~14

--- 10~50

Limited exposure

< 5 ---

Estimate Range

20 18~-44

63 48~94

20 15~33

40 9~51

--- --- Limited exposure

--- ---

Estimate Range

60 40~90

20 9~56

--- 11~41

22 ---

8 ---

Important exposure

< 5 ---

Bosch FX et al. Gastroenterology 2004;127:S5-16.

Europe and United States (%)

Japan (%) Asia and Africa (%)

Viral Proteins And Signal Transduction Pathways

Axin

APC

Cytokine receptor

Growth factor receptor

Toxins, other stress

AKT PI3K

PTEN

RAS

Raf

MEK

ERK

IKK

NFKBNFKB

Fork-head

BADmTOR

Src

PKC

IkBIkB

SHP2SHP2

GRB2

SHCSOS1

Proteasome

ER stress

Pre-S mutant

HBxHBx

HBxHBx

Cell survival Angiogenesis Metastasis

Cell cycle Cell survival Metabolism DNA damage Metabolism

Cell cycle

Cell survival Cell cycle Protein translation Nutrient response

Protein degradation

Cell survival Cell cycle Angiogenesis Metastasis

GSK3

: Targeted agents in pre-clinical development

: Targeted agents in clinical development

: Dys-regulated in HCC

Wnt

β-catenin

HCV core

HCV core

By Hsu C, Shen YC, Cheng AL

Transcriptome classification of HCC

~ Boyault S et al: Hepatol 2007;45:42. based on120 surgically resected HCC, including transcriptome analysis on 57 HCCs and 3 adenomas, and qRT-PCR validation in additional 63 HCCs

Over-expressionIGF1R Akt p-GSK3β HBV(+) HCV(+)

G1-group (N=11) 64% 75% 78% 8 3G2-group (N=17) 25% 42% 7 4Others (N= 92) 9% 8% 9% 22 23

31

Is HBV-related HCC a more aggressive tumor ?

Is HBV-related HCC associated with molecular changes which affect molecular therapy ?

HBV-related HCC

HCC ─ East vs West

Long-term results after surgical treatment were similar in West and East when clinicopatnologic factors were accounted for.

Pawlik TM et al Liver Transplantation 2004;10(suppl 1) 74-80

Taeck D et al Liver Transplantation 2004;10(suppl 1) 58-63

HBV vs. HCV HCCItalian Liver Cancer group

Survival in patients with advanced HCC. HBV-HCC patients had a lower survival than HCV-HCC patients (p=0.025)

• Patients with HBV-HCC tended to have poor prognosis;

~ Cantarini MC et al: Am J Gastroenterol 2006;101:91-8.

and the difference became statistically significant among patients with advanced HCC

HBV vs. HCV HCC in NTUHSurvival for patients with advanced ds.

• 927 patients receiving supportive care or chemotherapy.

Etiology

Median survival

(M)1 year (%)3 year (%)5 year (%)10 year (%)

HBV

2.5

12.43.40.80.5

HCV

3.4

21.78.52.21.1

B+C

3.4

10.83.11.50

NBNC

2.6

11.23.11.01.0

HCV-HCC patients had better survival than HBV-HCC patients

Chen CH et al. Eur J Cancer. 2006 Oct;42(15):2524-9. Epub 2006 Aug 22

HCV+

HBV+

Sorafenib phase II HCC studyHCV- vs. HBV-related HCC

~ Huitzil-Melendez FD et al: ASCO-2007 GI Symposium Abstract# 173.A retrospective analysis

HCV+ HBV+ P

P’t No. 33 13

Median age 71 66

Race (%)

Caucasians 82 54

Clinical benefit (%) 75 53

PFS (median, M) 6.5 3.5 .27

TTP (median, M) 6.5 4 .05

OS (median, M) 12.4 7.3 .29

Thalidomide phase II HCC studyHCV- vs. HBV-related HCC

P’t No.Median age

Objective response+AFP response (%)

TTP (median)OS (median)

HCV+

3367.5

27.314.1 W32.6 W

HBV+

6153.6

13.18.3 W

21.4 W

~ Hsu C et al: Proc. ASCO 2004: Abs#4198.

P

61< .001

.09

.03

.08

Conclusions─ Cancer biomarkers

• Provide excellent opportunity for personalized care.

• Cost, workload, and workflow remain a problem.

• Technic issues should not be overlooked.

• Significant ethnic and geographic difference exist.

TCOS, Shanghai, May 20 2010

Cancer Biomarkers: Opportunities and Challenges

Cancer Biomarkers: Opportunities and Challenges