Implementation of personalized therapy for lung cancer in Taiwan and strategy to

overcome drug resistance

楊泮池 Pan-Chyr Yang MD, PhD

National Taiwan University Institute of Biomedical Sciences

Academia Sinica

Implementation of Personalized Therapy of Lung Cancer in Taiwan

Lung adenocarcinoma is endemic in East Asia

Translational lung cancer research in Taiwan

Implementation of personalized therapy

Strategy to overcome drug resistanceMultidisciplinary approach for lung cancer therapy

Epidemiology of Lung Cancer in Never Smokers

(Sun S et al, Nature Rev Cancer 2007)

7th in all cancers

Epidemiology of Lung Cancer in Never Smokers

(Sun S et al, Nature Rev Cancer 2007)

7th in all cancersFemale Lung Cancer in TaiwanFemale Lung Cancer in TaiwanNo. 1 Cause of Cancer DeathNo. 1 Cause of Cancer Death

AdenocarcinomaAdenocarcinoma 70%70%NeverNever--smokers smokers 93%93%

Early Metastasis of Lung Adenocarcinoma

Female, nonsmoker, adenocaDiagnosis late, operable < 30%Poor treatment outcomeEarly metastasis

Early Metastasis of Lung Adenocarcinoma54yr old male, non-smoker

Early Relapse in Stage I Lung Adenocarcinoma

Mr. Tseng, 67 year-old Adenocarcinoma IBTumor recur 6 months after operation

March 2007

Oct 2007

NSCLC is a Heterogeneous Disease

CT

Pathology Specimens

Histopathology: Adenoca, SCC, Large Cell, etc.

NSCLC

Not All Tumors

are the Same

Modified from Fred R. Hirsch

Molecular scope and

Classification

K-rasEGFR

B-raf

METHER2ALK

Others

Caucasians East Asia

The Driver Pathways of Lung Adenocarcinoma- East and West are Different -

東西方人肺癌不同

MET3-5%

HER23%

B-raf1%

Others20%K-ras

30%

EGFR10%MET

3-5%HER23%

ALK3-5%

B-raf3%

Others40%

K-ras5-10%

ALK5%

EGFR50~60%

EGFR50-55%

Oncogenic Pathways of Lung Adenocarcinoma in Smokers and Never Smokers

(Sun S et al, Nature Rev Cancer 2007)

Program Overview 11

National Science CouncilAnnual Budget: NT$90~100 Billions

NSTPBP (National Science & Technology Program for Biotechnology and Pharmaceuticals)                              

2000~2010: NT$9.8 Billions

NRPGM (National Research Program for Genomic Medicine)2002~2010: NT$13.5 Billions

NRPB (National Research Program for Biopharmaceuticals)2011~2016: NT$2.1~2.2 Billions/Year

Government Fund for Science & Technology

2011 Advisory Committee Meeting NRPB Introduction 12

Functions of Each Groups

Research GroupPreclinical

Development GroupLead Optimization

IND Enabling Studies

Industrial Bridging & International Collaboration (IBIC) Group

Resource Centers

Ethical, Legal and Social Issues (ELSI) Group

Clinical GroupTranslational Medicine

Clinical Trials

1. Structural Determination of Genes & Proteins2. Animal Models for Human Diseases3. CGMP Biologics Pilot Plant & GLP Tox Studies

4. Chemical Synthesis5. Chemical & Bio-Specimen Banks6. Translational Medicine Resource Center

R&D on Biomarkers/Drug Targets/New Drugs/New Medical Devices

Translational Research/Product Development

PreclinicalStudies Clinical Trials

Productsto Market

- Improvement of PK, PD, &formulation- Animal toxicity and safety tests

Screening, identification & confirmation of biomarkers, targets, new drugs, new bio-medical devices

IND/IDEapplications

- Early, Phase I, II, III Clinical trials

- Clinical valuation

- Synthesis & improvement of potential targets- Design & modification of new medical devices

- Optimization of leads & device models- Prototype development- Pilot-scale manufacturing

- Validation in clinical samples, efficacy

evaluation in vitro/vivo

NDAPMA

Launch & Post-MarketSurveillance

The Research Projects needs to cross at least 2~3 stages within 3 years

Current Status of NRPB Projects

Target Identification Target Validation HTS/Screening Hit to Lead Lead to Candidate Preclinical Develop IND/Phase I Clinical Trial 

211 (150+61)211 (150+61)

62 (26+36)62 (26+36)

34 (18+16)34 (18+16)

Research Projects

Clinical TrialsVsensorNTU

Licensing Fee: 98M

8 (2+6)8 (2+6)

Academia/Industry CollaborationIntegrin v 3 AntagonistsMPT0E028

22NHRI Integrated Drug TeamAnti‐Viral Compounds: BPR2P SeriesBlocker for IKK /TSC1 Interaction

77

NHRI Integrated Drug TeamTKI Inhibitors (EGFR, Aurora)Cytotoxic AgentsDPP4 InhibitorAnti‐HCV NS5A Inhibitor 

44Preclinical Development ProjectsCB1 Receptor AntagonistIL‐20 Monoclonal Ab (RA)VEGFR‐3 InhibitorTargeted Delivery Therapy for HCC

DrugChemical: 73Biologics: 34Medical Device: 19Biomarker: 42Botanical: 14Others: 29

IND Filing by mid‐2013IND Filing by end of 2013

DrugChemical: 15Biologics: 5Medical Device: 9Biomarker: 20Botanical: 1Others: 12

DrugChemical: 12Biologics: 3

Medical Device: 15Biomarker: 0Botanical: 2Others: 2

Translational Medicine Projects

Services:Resource Center Projects: 29Industrial BridgingELSI

102.09.22 14

肺癌臨床試驗聯盟

Lung Cancer Consortium

癌症早期臨床試驗聯盟

Oncology Phase I Consortium

婦科癌症研究聯盟

GYN Oncology Group

血脂和動脈粥樣硬化聯盟

Lipid and Atherosclerosis Consortium 

乳癌臨床試驗合作聯盟

Breast Cancer Consortium

法布瑞氏症臨床試驗聯盟

Fabry Disease  Consortium

高血壓相關疾病聯盟

Hypertension Associated Cardiac Disease Consortium

小兒感染症聯盟

Pediatric Infectious Diseases Alliance

慢性阻塞性肺病聯盟

COPD Consortium

胃腸疾病與幽門桿菌合作聯盟

Gastrointestinal Disease And Helicobacter Consortium

精神疾病臨床試驗聯盟

Mental Disorders Consortium

肝炎及肝癌臨床試驗聯盟

LiverNet Consortium

Taiwan Clinical Trial Consortium (TCTC): http://tc2.ntu.edu.tw/

Taiwan Clinical Trial Consortium (TCTC)

台大醫學院生物化學暨分子生物學研究所

SCIENCE Vol 333, 22 JULY 2011,  459‐462

Cell Death

Lung Cancer Invasion Cell Line ModelN

o. In

vade

d C

ells

0

500

1000

1500

CL1 CL1-1 CL1-2 CL1-3 CL1-4 CL1-5 (Chen JJW et al. Cancer Res 2001)

Medium 1

Medium 2Membrane Invasion Culture

Cancer Invasion and metastasis

P53‐MDM2‐Slug Pathway and Lung Cancer Metastasis

SlugSlug

MDM2MDM2wtp53

Cellular stress (e.g. UV)

MG132

Proteasomal Degradation

wtp53 MDM2MDM2

UbUb

UbUb

E-cadherin

mtp53mtp53

MDM2MDM2

p73

(Wang SP, Nature Cell Biol 2009)

CRMP‐1/LCRMP‐1 Isoforms and Cancer Metastasis

(Pan SH et al, J Clin Invest 2011)

19

Biomarkers for NonBiomarkers for Non--SmallSmall--Cell Lung CancerCell Lung Cancer

(Chen HY et al, NEJM 2007; Yu SL et al, Cancer cell 2008)

MicroRNA as Cancer Biomarker

Tissue specificFrequently dysregulated in various diseases and cancersRelatively stable in paraffin-embedded tissue & body fluids, such as serum, plasmaCirculating microRNA as potential cancer biomarkers

(Mitchell PS et al, PNAS 2008; Boeri M et al, PNAS 2011; Lin PY et al, EMBO Molecular Medicine 2011)

DicermiRNA

Mature miRNA

Reduction or deletionAm

plificat

ion or

Overex

pressio

n

miRNA acts as an oncogene miRNA acts as a tumor suppressor

ORF

OncogeneTumor suppressor gene

Tumor ProgressionProliferationInvasionAngiogenesisApoptosis

Tumor suppressor Oncogenic proteins

MicroRNAs as Oncogene and

Tumor Suppressor

MicroRNA for Histology Stratification

Squamous Cell Carcinoma

Positive miR‐205(Lebanony et al, 2009)

miRNA signature: miR‐25, let‐7e, miR‐34c‐5p, miR‐191, miR‐34 (Landi, 2010)

miRNA signature (miR‐25, let‐7e, miR‐34c‐5p, miR‐191, miR‐34a) Poor overall survival  (Landi et al,  2010)

High miR‐146b or miR‐155Poor overall survival 

(Raponi et al,  2009)

Adenocarcinoma miRNA markers ?High miR‐155 & low let‐7aPoor overall survival (Yanaihara et al. 2006)

Histology Risk

(Emily Lin et al, EMBO‐MM2011, BJC 2010)

MicroRNA for Outcome Prediction

Low let‐7a Postoperative survival (Takamizawa et al. 2004)Low let‐7a Postoperative survival (Takamizawa et al. 2004)

K‐RAS  let‐7a complementary site SNPNSCLC risk in smokers (Chin et al. 2008) 

K‐RAS  let‐7a complementary site SNPNSCLC risk in smokers (Chin et al. 2008) 

miRNA singature (miR‐137, miR‐372, miR‐182*, miR‐221 and let‐ 7a)Disease‐free survival ( Yu et al. 2008)miRNA singature (miR‐137, miR‐372, miR‐182*, miR‐221 and let‐ 7a)Disease‐free survival ( Yu et al. 2008)

miRNA singature Postoperative recurrence (Patnaik et al. 2010)miRNA singature Postoperative recurrence (Patnaik et al. 2010)

Serum miRNA signature for outcome(miR‐486, miR‐30d, miR‐1 and miR‐499 Hu et al. 2010) and early diagnosis (Boeri et al 2011)Serum miRNA signature for outcome(miR‐486, miR‐30d, miR‐1 and miR‐499 Hu et al. 2010) and early diagnosis (Boeri et al 2011)

NSCLC

(Emily Lin et al, BJC 2010, EMBO‐MM 2011)

102.09.22 24

MicroRNA‐135b promotes lung cancer metastasis by regulating multiple targets in the Hippo pathway and LZTS1

Tid1‐L Inhibits EGFR Signaling in Lung Adenocarcinoma by Enhancing EGFR Ubiquitinylation and Degradation

Translational Research in Lung Cancer

Lin CW et al., Nat Commun. 2013; 4(1877):3287‐97Chen CY et al., Cancer Res. 2013; 79(13):4009‐19

••TGFTGF--ββ

•Slug/Snail•Slug/Snail

•miR-200/1•miR-200/1 •miR-203•miR-203•miR-34•miR-34

•ZEB1/2•ZEB1/2 •Bmi1•Bmi1

•miR-183•miR-183

••Notch pathwayNotch pathway•GATA3, Jag1,2,

Mam1,2,3

•EMT (Invasion, migration, anchorage independent growth, angiogenesis)

•EMT (Invasion, migration, anchorage independent growth, angiogenesis)

•miR-21•miR-21

••Hippo pathwayHippo pathway•LATS2, β-TrCP, NDR2, Mob1B

•TAZ/ YAP•TAZ/ YAP

•miR-135b•miR-135b

•Twist•Twist

•miR-10b•miR-10b

•miR-9•miR-9

•Let-7d•Let-7d

•NF-κB•NF-κB

•miR-22•miR-22

•NF-kB•NF-kB

••HypoxiaHypoxia

•miR-205•miR-205 •miR-124•miR-124•HIF-1α•HIF-1α •miR-138•miR-138

MicroRNA and EMT

•Lin CW, et al. 2013

LUX-Lung 3: a randomized, open-label, Phase III study of afatinib vs cisplatin/pemetrexed as 1st-line treatment for patients with advanced adenocarcinoma of the lung harboring EGFR-activating mutations

J.C.-H. Yang, M. Schuler, N. Yamamoto, K. O’Byrne, V. Hirsh, T. Mok, S.L. Geater, S. Orlov, C.-M. Tsai, M. Boyer, W.-C. Su, J. Bennouna, T. Kato, V. Gorbunova, K.H. Lee, R. Shah, D. Massey, R. Lorence, M. Shahidi, L. Sequist, on behalf of all LUX-Lung 3 investigators

Yang JC, et al.

台灣首次領先歐美核准的新藥

1.台灣成為新藥全球臨床試驗的主要執行者

2.創國內投入跨國新藥臨床試驗人數的新紀錄

TFDA is World’s 1st to approve Afatinib for NSCLC with EGFR Mutation

Taiwan Lung Cancer Clinical Trial Consortium

IPASS: Mok T, Wu YL, Thongprasert S, Yang CH, et al: Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. New Engl J Med. 2009. LUX-Lung 1: Miller VA, Hirsh V, Cadranel J, Chen YM, Park K, Kim SW, Zhou C, Su WC, Wang M, Sun Y, Heo DS, Crino L, Tan EH, Chao TY, Shahidi M, Cong XJ, Lorence RM, Yang JC*. LUX-Lung 1: a phase 2b/3, randomised trial of afatinib plus best supportive care (BSC) versus placebo plus BSC in advanced, metastatic non-small cell lung cancer patients following failure of 1–2 lines of chemotherapy and erlotinib or gefitinib. Lancet Oncology 2012LUX-Lung 2: Yang JC, Shih JY, Su WC, Hsia TC, Tsai CM, Ou SI, Yu CH, Chang GC, Ho CL, Sequist LV, Dudek AZ, Shahidi, M, Cong XJ, Lorence RM, Yang PC, Miller VA. LUX-Lung 2: a phase 2 study of afatinib, an irreversible ErbB Family Blocker, in patients with lung adenocarcinoma harbouringepidermal growth factor receptor mutations. Lancet Oncology 2012 LUX-Lung 3: A randomised, open-label, phase III study of BIBW 2992 vschemotherapy as first-line treatment for patients with stage IIIB or IV adenocarcinoma of the lung harbouring an EGFR activating mutation. Yang JCet al, ASCO 2012

IPASS Study Confirms that EGFR Mutations are useful Predictive Biomarker

(Mok et al and IPASS Study Group NEJM 2009)

102.09.22 31

EML4‐ALK

Lung Cancer

Gene Testing by Reference Lab

EGFR KRAS HER2 BRAF

Gefitnib

Erlotinib

Afatinib

Sorafenib(?)

ChemotherapyTrastuzumab

BIBW2992

Sorafenib(?) Crizotinib

MET

Met 

Inhibitor

ARQ‐197?

50% 4% 5% 3% 1% 5%

National Accredited Gene Testing Reference Lab for Cancer Personalized TherapyEstablished in 2010, collaborate with NRPB consortium, provide nation‐wide service and > 3,000 cases had been tested1st line TKI covered by NHI since June 2011

Personalized Therapy of Lung Cancer

Source: NTU Center of Genomic Medicine, 2013

First-line EGFR-TKI53 Yr Male, Non-smoker, Adenocarcinoma, EGFR mutant

Nov 12, 2010 Dec 2, 2010

At diagnosis 2 weeks after TKI

102.09.22 33

Are IPASS Population Reliable Predictors?Ethnicity, Gender, Smoking and EGFR Mutations in Lung 

Adenocarcinoma

Source: PIONEER Study Group, J Thoracic Oncol 2013

Methods for ALK translocation detection Fluorescence in situ hybridization (FISH)Immunohistochemistry (IHC)RT-PCR and multiplex RT-PCRDirect sequencingDNA mass and others

FISH

Sequencing

IHC DNA mass

11--13 13 2020

EA13-20AGGACCTAAAGTGTACCGCCGGA

RT-PCR

Crizotinib for ALK (+) Adenocarcinoma

2010-12-30 2011-02-17

49 y/o man, never smoker, diagnosed in 2009/10, 6th line crizotinib

102.09.22 36

World Average~15.8%

NSCLC 5‐Year Survival (all stages, NTUH) 

102.09.22 37

Case No.Survival Rates (%)

1‐Year 2‐Year 3‐Year 4‐Year 5‐Year

AJCC Stage2009

2012

2009

2012

2009

2012

2009

2012

2009

2012

2009

2012

Stage I 69 145 91.2 95.2 82.2 86.9 73.2 80.6 64.3 71.9 61.3 71.0

Stage II 26 33 88.2 81.8 68.2 63.3 56.2 83.8 48.1 53.8 43.9 53.8

Stage III 145 130 64.0 66.8 38.1 46.6 24.7 33.3 17.0 26.7 14.8 22.6

Stage IV 313 312 42.8 63.7 20.8 36.3 11.5 20.7 6.7 16.7 4.2 14.6

Total/Overall

553 620 56.4 72.7 35.0 51.7 24.6 39.1 18.3 33.7 15.8 31.6

Stage III+IV: 83% 71% (2009 2012)World‐wide Overall 5‐Year Survival: 15%

The Survival Rate of NSCLC in NTUH (2009 2012)

Burden of EGFR-TKI Resistance NSCLCEGFR-TKI resistance in NTUH

T790M: 58%C-Met amplification: 21%Both T790M+Met amplification: 10%

Other mechanisms: IGFR, HER3, Slug,HGF, PTEN, BIM polymorphism, small cell transformation, etc.Burden of EGFR-TKI resistance in Taiwan:NSCLC:~10,000/yr , adenocarcinoma: ~6,000/yrEGFR mutations: ~3,000/yr

(Bean J et al. PNAS 2007, Chang TH et al. AJRCCM 2011, Ng KP et al. Nat Med 2012, Sequist LV et al. Sci Transl Med 2011)

C-Met amplification

T790M: Acquired Resistant Mutation

L858R L858R; T790MGow CH , Shih JY et al Plos Med 2005

De Novo L858R+T790M in AdenocarcinomaResistant to First-line Gefitinib

Shih JY, et al.N Engl J Med 2005

Exon 21 Exon 20

L858R T790M

LymphocyteDNA

TumorDNA

Sensitivity and Specificity of EGFR Mutation Detection

Detection limit: < 1% mutant DNA among wild-type backgroundDetection limit of direct sequencing: 20-25%. (Su KY, et al. JCO 2012)

(Su KY, et al. JCO 2012)

EGFR Mutation Frequency and TKI Response

(Su KY et al, 2012)

ArrayCGH CNA Profiles of EGFR Mutation and Wild-type Lung Adenocarcinoma

(Yuan SS et al, JCO 2011)

Survival Prediction by DNA Copy Numbers of 6 Genes from Chromosome 7p

(Yuan SS et al, JCO 2011)

M: male; F: female; ADC: adenocarcinoma; SCC: squamous cell carcinoma; WT: wild type; PR: partial response; PD: progressive disease; P: pending 

Cell line

Sex Histology Clinical Information EGFR PTEN p53 KRASGefitinibIC50

CL25 M ADC Before Tarceva, PR  Del 19 Normal C135Y WT ~50nM

CL100 F SCC No chemotherapy;   Del 20 Normal C141S WT 3uM

CL83 M ADC After Iressa, PD  WT Normal WT WT >10uM

CL141 M ADC No chemotherapy  WT Loss R248W WT >10uM

CL152 M SCC No chemotherapy;  WT Loss R248W WT >10uM

CL97 M ADC After Tarceva & chemotherapy  G719A/T790M Normal R273H WT >10uM

CL182 M Mesothelioma No chemotherapy  WT P P P >10uM

CL239 F ADC Alimta+Cisplatin, PD.  WT P P P >10uM

CL272 M ADC No chemotherapy  WT P P P >10uM

CL68 F ADC After Iressa & chemotherapy, PD  Del19/T790M P P WT P

CL298 F ADC After Tarceva & chemotherapy WT P P WT P

CL309 M ADC No chemotherapy L858R P P WT P

A549 M ADC Explants culture of lung carcinoma WT Normal WT G12S >10uM

PC9 F ADC Untreated   Del19 p p WT 10~30 nM

PC9IR F ADC Derived from PC9 Del19 p p WT >10uM

H1975 F ADC Non‐smoker  L858R/T790M Normal WT WT >10uM

H3255 F ADC Non‐smoker Caucasian  L858R p p p ~50nM

Lung Cancer Cell Lines with Different Driver mutations

Design and Synthesis of Tetrahydropyridothieno[2,3-d]pyrimidine Scaffold Based EGFR-TKIs : The Role of Side Chain Chirality and Michael Acceptor Group for Maximal Potency

Inhibited gefitinib-resistant double mutant (DM, T790M/L858R) EGFR kinase at nanomolar concentration and xenograft tumor in nude mice.

(Wu CH et al. NHRI, J Medicinal Chemistry 2010)

Strategy to overcome EGFR-TKI

Afatinib

Repurposing of old drugs!!Trifluoperazine, an antipsychotic agent, inhibits lung cancer

stem cell growth and overcomes drug resistance

(Yeh CT et al, AJRCCM 2012)

Lung Cancer Mortality and LDCT Screening

A relative reduction of 20% mortality from lung cancer

(The National Lung Screening Trial Research Team, NEJM 2011)

44F, Stage IA Nonmucinous Adenocarcinoma

2007_1218

20080304

102.09.22 51Hsiung CA et al., Nature Genetics 2012;44(12):1330‐5

102.09.22 52

發現3個亞洲不吸菸女性肺癌易感基因，為亞洲不吸菸女性的肺癌風險與相關遺傳特性提供有利

證據 Identify New Susceptibility Loci for Non‐Smoking Women in Asia

Hsiung CA et al., Nature Genetics 2012;44(12):1330‐5

VATS for lung cancerIntubated vs Non-intubated

Which do you want ?

Chen JS et al. Ann Surg 2011

Non-intubated Lung Cancer SurgeryA New Advance in NTUH!!

Chen JS et al. Ann Surg 2011

2012-3-13 Before TKIStage IIIa

2012-4-20 After TKIStage Ib

Neoadjuvant Therapy with TKI in EGFR Mutant NSCLC

The unmet clinical demands for management of lung cancer

Biomarker for precision therapy of lung cancer patients

Cumulating burden of drug resistance patients

Strategy to improve PFS and QoL

Etiology of non-smoker lung cancer

Effective tool for prevention and early diagnosis

Can lung cancer become a chronic dis? “YES!”

Thank you for your attention!