Epigenetics and

Cancer
+

Nilofer Azad, MD
Assistant Professor, Gastrointestinal Oncology/Phase I Program
Sidney Kimmel Comprehensive Cancer Center
October 19, 2010
Simplified Model of Epigenetic Regulation of Gene Expression

CMAJ 2006;174(3):341-8
 How do genes get turned on and off?

Protein
Complex
Protein
Complex
M M M
DNA
Promoter Coding section Non-coding section Coding section of
Gene X

Histone Histone
Gene is transcribed = ON

Gene blocked from being transcribed = OFF

 DNA Methyltransferase
inhibitors
• Two currently FDA approved agents

• 5-azacytidine
(Vidaza)

• 5-aza-2'-deoxycytidine
(decitabine, Dacogen)
 5-azacitidine
• FDA approved in 2004 for myelodysplasia

• Dose: 75 mg/m2 SQ daily x 7 d / 28 d cycle

• Mechanism of action: Incorporated into DNA → suicide

inhibitor of DNMT
Induces global hypomethylation

• Time to clinical response: Average = 4 months

 Histone deacetylase inhibitors
• Three currently FDA approved agents
• Vorinostat (Pan-HDACi)
(SAHA, Zolinza) Oral agent
Approved for cutaneous T-cell lymphoma
• Depsipeptide (Pan-HDACi)
(Istodax) Intravenous agent
Approved for cutaneous T-cell lymphoma
• Valproic acid (weak inhibitor) anti-seizure
LUNG CANCER
 Rationale for double epigenetic
blockage in lung cancer
• Epigenetic gene silencing mediated by DNA
methylation and histone deaceylation is a key
contributor to lung carcinogenesis
• Preclinical studies suggest that combining
DMNTi with HDACi synergistically enhances
expression of silenced tumor suppressor genes
• Clinical studies combining DMNTi and
HDACi have shown remarkable clinical
activity in MDS/AML
• Hypothesis: similar effect in NSCLC
 Trial Schema

MS275
SNDX-275

5-Aza
5-AC

Day
Day 11 8 8 15 15 22 29 29 36 36

• 5AC Dosing = 40 mg/m2 SQ daily on days 1-6 and 8-10

• SNDX-275 dosing = 7 mg PO (fixed dose) days 3 and 10
• Cycle length = 28 days
 Phase I Toxicity Data
Phase I Toxicities

Injection Site Reaction

Nausea / Vomiting
Constipation
Anorexia
Lower Extremity Edema
Hyperglycemia
Low Electrolytes
Fatigue
Neuropathy
Neutropenia
Lymphopenia
Anemia
Thrombocytopenia
0 2 4 6 8 10
Grade 1
Grade 2 Number of Patients
Grade 3
 Updated Response Data
28 Evaluable Patients
• 1 Complete Response –
On treatment for 14 months
• 1 Partial Response
Responded for 8 months – then new SCLC
Still no progression of his NSCLC 9 months off epigenetic therapy
• 8 Stable Disease
One on treatment for 18 months;
Five treated for 4 months
One treated for 3 months then stopped due to schedule
One still being treated (on cycle 12 now)
• 17 Progressive Disease
• 8 Not evaluable (finished less than 1 cycle)
• 5 Actively being treated
Overall Survival

Median OS: 8.2 months

 Images of Patient with
Complete Response

56 year old woman with stage I lung cancer that was resected and treated
with adjuvant chemotherapy.
She progressed after salvage chemotherapy with radiation at relapse.
She had a response after 2 cycles, continued improvement after 4;
14 cycles were given. She had 3 prior therapies for advanced disease.
 Images of patient with
Partial Response

58 year old male treated with 3 prior therapies; Chemotherapy refractory

disease. He completed 8 cycles.
Images of patient with partial response:
liver metastases

Pre-treatment Cycle 2 Cycle 4 Cycle 8

 Hypotheses for biology of the complete
responder
15500

• Fewer number of previous therapies…

15000

14500
• Higher serum level of 5-azacitidine…
2000
5AC Cmax (ng/mL)

• Epigenetics… 1500

• Responding patient was a previously resected stage I

1000
NSCLC patient
• 500
Analysis of her tumor and mediastinal lymph nodes
found a methylation pattern that predicted she was at
high
0 risk for early recurrence
PD NE SD CR

Response
Gene DNA Hypermethylation Markers Are Better for
Prognosis than Standard Staging

1.00 p16 and H-cadherin P<0.0001

Proportion Disease-Free

Negative (U)
n=79
0.75

Stag
0.50
e1
Positive (M)
N=11
OR = 25
fold
0.25

Molecular Re- Stage

staging 3
0.00

0 1 2 3 4 5
Years After Surgery Brock et al, 2008
 Epigenetic Therapy Study Design: Treatment
Schema

R
A 2
5-Azacitidine 40 mg/m22 SQ Day 1-5, 8-10
N Entinostat 7mg PO Day 3 and 10
D Every 28 days, for 6 cycles
O
Stage IA or IB M Intended Accrual: 172 patients
NSCLC s/p surgery I
with curative intent Z
E Standard Care
1

Intended Accrual: 86 patients

Within 4-8 weeks of

completing surgery
COLON CANCER
 Colorectal Cancer is Common
2009 Estimated U.S. Cancer Deaths
Men Women
Available at: http://www.cancer.org.
294,120 271,530
Lung and bronchus 31% 26% Lung and bronchus
Prostate 10% 15% Breast
Colon and rectum 8% 9% Colon and rectum
Pancreas 6% 6% Pancreas
Leukemia 4% 6% Ovary
Liver/bile duct 4% 4% Non-Hodgkin lymphoma
Esophagus 4% 3% Leukemia
Urinary bladder 3% 3% Uterine corpus
Non-Hodgkin Lymphoma 3% 2% Brain/other nervous system
Kidney 3% 2% Liver/bile duct
All other sites 24% 25% All other sites

Colorectal cancer represents 2nd leading cause of death

Available at: http://www.cancer.org.
Colorectal Cancer Staging Stage I-II

Adenoma
Pre-cancer lesion

Stage I
localized, not through “muscularis” Stage III
(muscle wall in the colon)

Stage II
through muscularis, but no lymph nodes

Stage III
cancer in nodes, but not other organs IV
Stage IV
metastatic (liver, lung, etc)
Disease Stage at Time of
Diagnosis

Stage I 15%
Stage II 20%–30%
Stage III 30%–40%
Stage IV 20%–25%

Hamilton IM, Grem JL. Current Cancer Therapeutics. 3rd ed. 1998;157.
 Risk of recurrence after primary
resection in Stage II and III Colon
Cancer

85% recur within 3

years

85%

Sargent, D. et al. J Clin Oncol; 27:872-877 2009

Copyright © American Society of Clinical Oncology
Metastatic Disease
 History of Treatment for Colorectal Cancer

• ~1960: 5-FU is a cornerstone of first-line therapy; bolus/infusion

• ~1985: Addition of LV (biomodulator) to 5-FU bolus regimens
• 1998: Irinotecan as single agent approved as second-line
• 2000: Irinotecan approved as first-line in CRC (bolus IFL)
• 2001: Capecitabine approved as first-line in CRC in selected pts
• 2002: Oxaliplatin approved as second-line agent (FOLFOX)
• 2004: Oxaliplatin approved as first-line agent in infusional regimen
• 2004: Approval of Cetuximab (Erbitux) & Bevacizumab (Avastin)
• 2006: Approval of Panitumumab (Vectibix)
• 2008: KRAS mutations predict lack of benefit of EGFR mAb’s
 Incremental Survival Advantage in First-Line
Metastatic Colorectal Cancer

No active drug ~4-6 mo

5-FU/LV 12-14 mo

IFL ~ 15-16 mo

FOLFOX4 ~ 20 mo
Are we
IFL + bevacizumab 20.3 mo
hitting
FOLFOX/FOLFIRI 21.5 mo a wall
FOLFOX/FOLFIRI
with
?
+ biologics current
0 6 12 18 24 drugs?
Median OS (mo)
Therapy for Advanced Colorectal Cancer:
Response rates and survival
First Line Second Line Third Line
- FOLFOX or - FOLFOX or - Irinotecan +
- CAPOX or - FOLIRI or Cetuximab
- FOLFIRI - Irinotecan alone - Cetuximab
+/- Bevacizumab - Irinotecan/Cetuximab - Panitumumab
+/- Bevacizumab

Response Rates in Randomized Trials:

50-60% 15% 10%
Survival Benefit in Randomized Trials:
Yes Yes Yes
 Epigenetics in CRC
• Many genes have silenced expression due to epigenetic
changes
• Targeting epigenetically abnormal tumors may be more
effective than targeting abnormal mutations in genes
• CRC may be uniquely appropriate for this strategy
• A subset of colon cancer have more gene promoter
methylation

Ahuja et al.
Combination Epigenetic Therapy
• First study of epigenetic therapy in CRC
• Primary Objective:
• To determine the preliminary efficacy via tumor
shrinkage rate of the combination of 5-azacitadine
and entinostat in patients with metastatic colorectal
cancer
• Secondary Objective:
• To see what is happening in the tumor itself and
circulating cells in blood before and after treatment
with these drugs
 Study Schema
28 days

C1d1 C1d3 C1d10 C2d1 C2d3 C2d10 C3d1

entinostat entinostat entinostat entinostat

5-aza days 1-5 and 8-10 q cycle 5-aza days 1-5 and 8-10 q cycle

= plasma sampling for research purpose

= tumor sampling for research purpose

 Ongoing and Upcoming Studies
• Lung Cancer
– New schedule
– Adjuvant treatment of early stage disease
• Breast
– Same schedule in triple negative and hormone
resistant metastatic cancer
 Conclusions
• Despite progress, colon cancer is a still leading source of death
• Epigenetic therapy offers a novel way to approach treating
cancer, based on the abnormal gene expression seen in cancers
compared to normal cells
• We are presently enrolling a trial of patients with late-stage
colon cancer an treating them with epigenetic agents, 5-
azacitidine and entinostat
BREAST CANCER
 Epigenetics and breast cancer
• Multiple genes are methylated and thus
silenced in breast cancer1
• ER, RAR beta, cyclin D, Twist,
RASSF1A, and HIN-1
1
Pu RT. Mod Pathol 2003;16(11):1095-101.
Zebularine inhibits growth of
MDA-MB-231 cell lines alone
or in combination

Billam M.
 Clinical studies: Vorinostat in
MBC
• Phase 2
 SKCCC J0785/TBCRC 008
A Multi-Institutional Randomized Phase II Study
Evaluating Response and Surrogate Biomarkers to
Carboplatin and nab-Paclitaxel (CP) with or without
Vorinostat (SAHA) in HER2- Negative Breast
Cancer
Principal Investigator: Vered Stearns, MD
Fellow: Roisin Connolly, MB.BCh
 Study schema
Eligible patients with
locally advanced or
metastatic breast cancer
(up to 60)

Cohort B (up to 30)

Cohort A (up to 30)
Hormone-resistant
Triple-negative
5-AZA + entinostat
5-AZA + entinostat

Disease 5-AZA + etinostat +

Progression at hormonal therapy
Any Time MD discretion
Cohort A or Cohort
B
Event Monitoring
 Conclusions
• Epigenetics is a new way to look at cancer
biology and therapy
• Ongoing trials in major tumor types in the
metastatic setting
• Plans to move therapy into earlier stage
disease may be even more successful
 Acknowledgements
• First and foremost, our patients
• SU2C researchers
• Research support staff at all our institutions