Clinical Activity of the Oral ALK Inhibitor, Clinical Activity of the Oral ALK Inhibitor, Crizotinib (PF-02341066), in Patients with Crizotinib (PF-02341066), in Patients with ALKALK-positive Non-small Cell Lung Cancer-positive Non-small Cell Lung Cancer

Bang Y,1 Kwak EL,2 Shaw A,2 Camidge DR,3 Iafrate AJ,2 Maki RG,4 Solomon B,5 Ou SI,6 Salgia R,7 Clark J2

1Seoul National University, Seoul, Korea; 2Massachusetts General Hospital, Boston, MA, USA; 3University of Colorado Cancer Center, Aurora, CO, USA; 4Memorial Sloan-Kettering Cancer Center, New York, NY, USA; 5Peter MacCallum Cancer Centre, East Melbourne, Australia; 6University of California at Irvine, Irvine, CA, USA; 7University of Chicago Cancer Center,

Chicago, IL, USA

Abstract 3ASCO Annual Meeting 2010

Potential Oncogenic “Drivers” in Potential Oncogenic “Drivers” in Non-small Cell Lung Cancer (NSCLC)Non-small Cell Lung Cancer (NSCLC)

ALK (~5%)

OtherOther

AdenocarcinomaAdenocarcinoma

Massachusetts General Hospital, data on file. [AT Shaw, personal communication]

Massachusetts General Hospital, data on file. [AT Shaw, personal communication]

ALK = anaplastic lymphoma kinase; EGFR = epidermal growth factor receptor; Her2 = human epidermal growth factor receptor 2; PIK3CA = phosphoinositide-3-kinase, catalytic, alpha polypeptide

ALKALK Pathway Pathway

1. Inamura K et al. J Thorac Oncol 2008;3:13–17 2. Soda M et al. Proc Natl Acad Sci U S A 2008;105:19893–19897

Figure based on: Chiarle R et al. Nat Rev Cancer 2008;8(1):11–23; Mossé YP et al. Clin Cancer Res 2009;15(18):5609–5614; and Data on file. Pfizer Inc.

*Subcellular localization of the ALK fusion gene, while likely to occur inthe cytoplasm, is not confirmed.1,2

TranslocationOr

ALK ALK fusion protein*

Tumor cellproliferation

Inversion

Cell survival

PI3KPI3K

BADBAD

AKTAKT

STAT3/5STAT3/5

mTORmTOR

S6KS6K

RASRAS

MEKMEK

ErKErK

PLC-PLC-YY

PIPPIP22

IPIP33

Soda M et al. Nature 2007;448:561–567Reprinted by permission from

Macmillan Publishers Ltd: Nature, © 2007

EML4–ALKEML4–ALK is a Potent “Oncogenic” Driver is a Potent “Oncogenic” DriverEML4–ALKEML4–ALK is a Potent “Oncogenic” Driver is a Potent “Oncogenic” Driver

3T3

Nudemice

Tumor/ injection 0/8 0/8 0/8 8/8 0/8 8/8 2/2

Vector EML4 ALK EML4–ALK K589M NPM–ALK v-Ras

Inhibition of ALK leads to dramatic in vivo tumor regression

EML4 = echinoderm microtubule-associated protein-like 4; NPM = nucleophosmin

~250 kb ~300 kb

t(2;5) ALK genebreakpoint region

2p23 regionTelomere Centromere

3’ 5’

FISH Assay for FISH Assay for ALKALK Rearrangement* Rearrangement*

Break-apart FISH assay for ALK-fusion genes1

ALK 29.3

EML4 42.3

ALK break-apart FISH assay[Courtesy John Iafrate, Massachusetts General Hospital]

1Shaw AT et al. J Clin Oncol 2009;27:4247–4253

1Shaw AT et al. J Clin Oncol 2009;27:4247–4253

q36.1

q36.3q37.2

q34

q32.1

q32.3

q33.2

q31.3

q24.3

q24.1

q23.2q22.2q22.1

q21.2q14.3

q14.1

q12.3q12.1

p12

p13.2p14

p16.1

p16.3

p22.1

p23.2

p22.3

p24.1

p24.3

p25.2

q36.1

q36.3q37.2

q34

q32.1

q32.3

q33.2

q31.3

q24.3

q24.1

q23.2q22.2q22.1

q21.2q14.3

q14.1

q12.3q12.1

p12

p13.2p14

p16.1

p16.3

p22.1

p23.2

p22.3

p24.1

p24.3

p25.2

Split signalNon-split signal

*Assay is positive if rearrangements can be detected in ≥15% of cellsFISH = fluorescence in situ hybridization

TTP for EGFR TKI1

1Shaw AT et al. J Clin Oncol 2009;27:4247–4253

ALK(N=12)

EGFR(N=8)

WT/WT* (N=34)

Response rate, % 25 50 35

TTP, months 9 10 8

TTP for chemotherapy1

Platinum-based chemotherapy EGFR TKI

Patients with Patients with ALKALK-positive NSCLC -positive NSCLC Do not Appear to Respond to EGFR TKIsDo not Appear to Respond to EGFR TKIs

ALK(N=10)

EGFR(N=23)

WT/WT* (N=23)

Response rate, % 0 70 13

TTP, months 5 16 6

Months0 12 24 36 48 60

100

80

60

40

20

0EML4–ALK

EGFR

WT/WT

%

Months0 12 24 36 48 60

100

80

60

40

20

0

%

EML4–ALK

EGFRWT/WT

*WT/WT = wild type: no ALK fusion or EGFR mutation

Selectivity findings

• Crizotinib – ALK and c-MET inhibition at clinically relevant dose levels

• Crizotinib – low probability of pharmacologically relevant inhibition of any other kinase at clinically relevant dose levels

Cellular selectivity on 10 of 13 relevant hits

Upstate 102 kinase

13 kinase “hits” <100X selective for

c-MET

Kinase % InhibitionMet(h) 94Tie2(h) 103

TrkA(h) 102

ALK(h) 100

TrkB(h) 100

Abl(T315I)(h) 98

Yes(h) 96

Lck(h) 95

Rse(h) [SKY] 94

Axl(h) 93

Fes(h) 93Lyn(h) 93

Arg(m) 91

Ros(h) 90

CDK2/cyclinE(h) 87

Fms(h) 84EphB4(h) 80Bmx(h) 79

EphB2(h) 77Fgr(h) 73Fyn(h) 68IR(h) 64

CDK7/cyclinH/MAT1(h) 58cSRC(h) 58

IGF-1R(h) 56Aurora-A(h) 54

Syk(h) 52FGFR3(h) 50PKCµ(h) 50BTK(h) 35

CDK1/cyclinB(h) 25p70S6K(h) 24PRK2(h) 22

PAR-1Bα(h) 21PKBß(h) 21Ret(h) 21

GSK3ß(h) 18Flt3(h) 17

MAPK1(h) 17ZAP-70(h) 17

Abl(h) 16c-RAF(h) 16PKD2(h) 15

ROCK-II(h) 14Rsk3(h) 14

GSK3α(h) 11CDK5/p35(h) 10PDGFRα(h) 10

Rsk1(h) 7SGK(h) 6

CHK1(h) 5ErbB4(h) 5Rsk2(h) 5

JNK1α1(h) 4PKBα(h) 4Blk(m) 3

CDK3/cyclinE(h) 3PKCι(h) 3PKCθ(h) 3

CDK2/cyclinA(h) 2PAK2(h) 2PKCßI(h) 2Pim-1(h) 1PKCη(h) 1

SAPK4(h) 1CaMKII(r) 0MKK7ß(h) 0CaMKIV(h) -1CHK2(h) -1CK2(h) -1

JNK2α2(h) -1MKK6(h) -1CK1δ(h) -2PKCα(h) -2

MAPK2(h) -3MEK1(h) -3PKCδ(h) -3PKCε(h) -3Plk3(h) -3

PKCßII(h) -5MSK1(h) -6

PDGFRß(h) -6PKCζ(h) -6

SAPK3(h) -6MAPKAP-K2(h) -7

PKA(h) -7AMPK(r) -9

CDK6/cyclinD3(h) -9CSK(h) -9

SAPK2a(h) -9JNK3(h) -10PKBγ(h) -10IKKα(h) -11NEK2(h) -11 *The cellular kinase activities were

measured using ELISA capture method

KinaseIC50 (nM)mean*

Selectivity ratio

c-MET 8 –

ALK 20 2X

RON298 34X

189 22X

Axl294 34X

322 37X

Tie-2 448 52X

Trk A 580 67X

Trk B 399 46X

Abl 1,159 166X

IRK 2,887 334X

Lck 2,741 283X

Sky >10,000 >1,000X

VEGFR2 >10,000 >1,000X

PDGFR >10,000 >1,000X

Pfizer Inc. Data on file

Crizotinib (PF-02341066)

Crizotinib Selectivity ProfileCrizotinib Selectivity Profile

0.0001 0.01 0.1 1 10

Crizotinib: cell growth inhibition and apoptosis induction in H3122 cells

Crizotinib concentration (mM)

125

100

75

50

25

0

–25

–50

% c

on

tro

l

IC50 = 96 nM

Crizotinib: Induction of Apoptosis in Crizotinib: Induction of Apoptosis in ALKALK-positive NSCLC Cells-positive NSCLC Cells

Crizotinib: cell growth inhibition in NSCLC cell lines

1,000

800

600

400

200

0

H19

93H

3122

H23

H17

34H

82H

520

H52

6S

KM

ES

1H

2347

H19

75H

1838

H22

6H

1703

H64

7H

1755

CA

LU6

CA

LU1

H35

8H

1581

H20

87H

1651

HC

C82

7H

CC

2935

H13

55H

1573

H16

50H

1666

H24

05A

549

IC5

0 v

alu

e (n

M)

Crizotinib demonstrated potent growth inhibitory activity against H3122

(ALK fusion) cells

Activated caspase-3

Untreated 50 nM 500 nM

Cell death

Pfizer Inc. Data on fileIC50 = 50% inhibitory concentration*MET amplification

*

Part 2:Molecularly enriched cohorts

(ALK and c-MET)

Enrolling patients with ALK-positive NSCLC after preliminary observation of impressive activity in a few patients

• Data from database April 7, 2010• Data presented for 82 patients, study

ongoing

Part 1:Dose escalation

Crizotinib: First-in-human/Patient TrialCrizotinib: First-in-human/Patient Trial

1 DLT: grade 3 ALTelevation

2 DLTs: grade 3 fatigue

Cohort 1 (n=3)

50 mg QD

Cohort 2 (n=4)

100 mg QD

Cohort 3 (n=8)

200 mg QD

Cohort 4 (n=7)

200 mg BID

Cohort 5 (n=6)

300 mg BID

Cohort 6 (n=9)

250 mg BIDMTD/RP2D

ALT = alanine aminotransferase

Crizotinib Overview of Pharmacokinetics:*Crizotinib Overview of Pharmacokinetics:*All Patients Enrolled in Dose Escalation All Patients Enrolled in Dose Escalation

● t1/2 ~53 hours at 250 mg BID

● No evidence of non-linearity in PK

● No food effect on PK

● Moderate CYP3A4 inhibitor

Ceff = efficacious concentration; CYP = cytochrome P450; t1/2 = terminal elimination half-life; PK = pharmacokinetics*Please refer to (abstract 2596): Pharmacokinetics (PK) of PF-02341066, a dual ALK/c-MET inhibitor after multiple oral doses to advanced cancer patients. (9:00 AM, Monday, June 7)

500

400

300

200

100

0

Med

ian

pla

sma

co

nce

ntr

atio

n,

cyc

le 1

day

15

(ng

/mL

)

0 2 4 6 8

Time (hours)

50 mg QD 200 mg BID

100 mg QD 250 mg BID

200 mg QD 300 mg BID

Target Ceff (ALK)

Clinical and Demographic Features of Clinical and Demographic Features of Patients with Patients with ALKALK-positive NSCLC-positive NSCLC

Clinical and Demographic Features of Clinical and Demographic Features of Patients with Patients with ALKALK-positive NSCLC-positive NSCLC

N=82Mean (range) age, years 51 (25–78)

Gender, male/female 43/39

Performance status,* n (%)

0 24 (29)

1 44 (54)2 13 (16)3 1 (1)

Race, n (%) Caucasian 46 (56)Asian 29 (35)

Smoking history, n (%)

Never smoker 62 (76)Former smoker 19 (23)Current smoker 1 (1)

Histology, n (%) Adenocarcinoma 79 (96)

Squamous 1 (1)

Other 2 (2)

Prior treatment regimens, n (%)

0 5 (6)

1 27 (33)

2 15 (18)

≥3 34 (41)

Not reported 1 (1)*Performance status = Eastern Cooperative Oncology Group

60

40

20

0

–20

–40

–60

–80

–100

Progressive disease

Stable disease

Confirmed partial response

Confirmed complete response

Max

imu

m c

han

ge

in t

um

or

size

(%

)

–30%

Tumor Responses to Crizotinib for Patients Tumor Responses to Crizotinib for Patients with with ALKALK-positive NSCLC-positive NSCLC

*Partial response patients with 100% change have non-target disease present

*

77% of Patients with 77% of Patients with ALKALK-positive NSCLC -positive NSCLC Remain on Crizotinib TreatmentRemain on Crizotinib Treatment

0 3 6 9 12 15 18 21

Treatment duration (months)

N=82; red bars represent discontinued patients

Ind

ivid

ual

pat

ien

ts

• Duration of treatment (median: 5.7 months)

0–3 mo 13 pts>3–6 mo 29 pts>6–9 mo 24 pts>9–12 mo 9 pts>12–18 mo  4 pts>18 mo 3 pts

• Reasons for discontinuation– Related AEs

1– Non-related AEs

1– Unrelated death

2– Other

2– Progression 13

Clinical Activity of Crizotinib in Clinical Activity of Crizotinib in Patients with Patients with ALK-ALK-positive NSCLCpositive NSCLC

● Objective response rate (ORR): 57% (95% CI: 46, 68%)– 63% including 5 as yet unconfirmed PRs– 57% (8/14) for patients with performance status 2 or 3

No. prior regimens*

ORR % (n/N)

0 80 (4/5)

1 52 (14/27)

2 67 (10/15)

≥3 56 (19/34)

* Unknown for 1 patient

● Response duration: 1 to 15 months ● DCR† (CR/PR/SD at 8 weeks): 87% (95% CI: 77, 93%)

†Disease control rate

Median PFS has Not been ReachedMedian PFS has Not been Reached 70% of Patients in Follow-up for PFS70% of Patients in Follow-up for PFS

1.00

0.75

0.50

0.25

0.00

Pro

gre

ssio

n-f

ree

surv

ival

pro

bab

ilit

y

0 2.5 5.0 7.5 10.0 12.5 15.0 17.5Progression-free survival (months)

PFS probability at 6 months: 72% (95% CI: 61, 83%) 

Median follow-up for PFS: 6.4 months (25–75% percentile: 3.5–10 months) 95% Hall–Wellner confidence bands

Treatment-related Adverse Events in Treatment-related Adverse Events in ALKALK-positive NSCLC (≥10%)-positive NSCLC (≥10%)

Adverse eventGrade 1

n (%)Grade 2

n (%)Grade 3

n (%)Grade 4

n (%)Totaln (%)

Nausea 43 (52) 1 (1) 0 0 44 (54)

Diarrhea 38 (46) 1 (1) 0 0 39 (48)

Vomiting 35 (43) 1 (1) 0 0 36 (44)

Visual disturbance* 34 (42) 0 0 0 34 (42)

Constipation 18 (22) 2 (2) 0 0 20 (24)

Peripheral edema 13 (16) 0 0 0 13 (16)

Dizziness 12 (15) 0 0 0 12 (15)

Decreased appetite 11 (13) 0 0 0 11 (13)

Fatigue 8 (10) 0 0 0 8 (10)

*Changes in light/dark accommodation (no abnormalities on ophthalmologic exam)*Changes in light/dark accommodation (no abnormalities on ophthalmologic exam) N=82

Treatment-related Grade 3/4 Adverse Events Treatment-related Grade 3/4 Adverse Events in in ALKALK-positive NSCLC-positive NSCLC

Adverse eventGrade 3

n (%)Grade 4

n (%)

Any adverse event 10 (12) 1 (1)

ALT elevation* 4 (5) 1 (1)

AST elevation 5 (6) 0

Lymphopenia 2 (2) 0

Hypophosphatemia 1 (1) 0

Neutropenia 1 (1) 0

Hypoxia 1 (1) 0

Dyspnea 1 (1) 0

Pulmonary embolism 1 (1) 0

*Based on laboratory data (n=71), ALT increase to grade 1, 52%; to grade 2, 4% (In preclinical toxicology studies, no histologic changes in the liver were observed) 1 patient discontinued for ALT elevation

SummarySummary

● Treatment with crizotinib resulted in impressive clinical activity in patients with ALK-positive advanced NSCLC

– ORR: 57%

– DCR at 8 weeks: 87%

– PFS probability at 6 months: 72%

● Crizotinib was well tolerated

– The most frequent adverse events were mild and moderate gastrointestinal events and mild visual disturbances

ConclusionsConclusions

● These results are an example of rapid clinical development from target identification, to clinical validation, and supports a personalized approach to NSCLC treatment

● For patients with ALK-positive NSCLC, crizotinib may offer a potential new standard of care

Current Crizotinib Clinical TrialsCurrent Crizotinib Clinical Trials

PROFILE 1007: NCT00932893; PROFILE 1005: NCT00932451

Key entry criteria

● Positive for ALK by central laboratory

● 1 prior chemotherapy (platinum-based)

N=318

PROFILE 1007

Crizotinib 250 mg BID (N=250)administered on a continuous

dosing schedule

Key entry criteria

● Positive for ALK by central laboratory

● Progressive disease in Arm B of study A8081007

● >1 prior chemotherapy

PROFILE 1005

RANDOMIZE

N=250

Crizotinib 250 mg BID (n=159)administered on a continuous

dosing schedule

Pemetrexed 500 mg/m2 ordocetaxel 75 mg/m2 (n=159)infused on day 1 of a 21-day cycle

AcknowledgmentsAcknowledgments

Massachusetts General Hospital● John Iafrate,* Jeffrey Clark, Eunice Kwak,

Alice Shaw, Eunice Kwak, Thomas Lynch, Panos Fidias, Jeffrey Engelman, Marguerite Parkman

Dana-Farber Cancer Institute ● Geoffrey Shapiro, Pasi Janne,* James

Butrynski, Leena Gandhi, Andrew Wolanski Suzanne Hitchcock-Bryan, Charles Lee

Beth Israel Deaconess Medical Center● Bruce Dezube, Daniel Costa, Myles Clancy

Memorial Sloan Kettering Cancer Center● Robert Maki, Suresh C. Jhanwar,* Linda

Ahn, Lindsey Burge

Seoul National University● Woo-Ho Kim,* Dong-Wan Kim, Se-Hoon Lee,

Do Youn Oh, Sae-Won Han, Tae-Min Kim

Peter MacCallum Cancer Centre● Benjamin Solomon, Alex Dobrovic,* Stephen

Fox,* Hongdo Do*, Toni-Maree Rogers,* Allison Lamb

University of Colorado● Ross Camidge, Marileila Garcia,* S. Gail

Eckhardt, Wells Messersmith

University of California – Irvine

● Sai-Hong Ou, Antonio Sanchez, Katie Gottbreht

University of Chicago● Ravi Salgia, Mark Ratain, David Geary,

Leonardo Faoro, Rajani KantetiPfizer● James Christensen, Victoria Cohan, Gina

Emory, Paulina Selaru, Martin Shreeve, Jamey Skillings, Sreesha Srinivasa, Patricia Stephenson, Weiwei Tan, Greg Wei, Keith Wilner *Molecular profiling contributor

● We would like to thank all of the participating patients and their families, as well as the global network of investigators, research nurses, study coordinators, and operations staff

● This study was supported by funding from Pfizer Inc. Editorial Support was provided by Jessica Stevens at ACUMED® (Tytherington, UK) with funding from Pfizer Inc.

Permissions for Use of FiguresPermissions for Use of Figures

● Break-apart FISH assay for ALK-fusion genes, slide 5; TTP graphs, slide 6– AT Shaw et al. Clinical features and outcome of patients with non–small-cell

lung cancer who harbor EML4-ALK. J Clin Oncol 2009;27:4247–4253. Reprinted with permission. © 2008 American Society of Clinical Oncology. All rights reserved

● Figure on slide 4– Soda M et al. Identification of the transforming EML4–ALK fusion gene in non-

small-cell lung cancer. Nature 2007;448:561–567. Reprinted by permission from Macmillan Publishers Ltd: Nature, © 2007