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Although a variety of cytotoxic agents have been actively investigated for the treatment of patients with CRPC, most agents tested have demonstrated only
marginal efficacy and, at best, have extended survival only 10–12 months.
Mike Shelley, et al. Cochrane Database Syst Rev 2008
Mitoxantrone with prednisone is the only other cytotoxic regimen indicated for CRPC based on a palliative benefit
(improvement in the McGill-Melzack bone pain score) rather than a prolongation of OS.
Mitoxantrone
Kantoff PW et al J Clin Oncol 1999;17: 2506–2513.
Tannock IF et al. J Clin Oncol 1996;14:1756 –1764.
Berthold DR et al Ann Oncol 2008;19:1749 –1753.
Rosenberg JE et al Cancer 2007;110:556 –563.
PSA response, as defined above, occurs in approximately 20%– 30% of patients treated with mitoxantrone in the first-line setting and in 15% of patients treated in the second- line setting following docetaxel
FDA Regulatory Approvals in Metastatic CRPC
• Estramustine-1981 Ancient History
• Strontium89-1993 Reduction in new onset of painful bone lesions after XRT + isotope
• Mitoxantrone + prednisone-1996 Reduction in pain
• Samarium153-1997 Reduction in bone pain
• Zoledronic acid-2002 Skeletal related event reduction
• Docetaxel + prednisone-2004 Prolonged survival
• Sipuleucel-T-2010 Prolonged Survival
• Cabazitaxel + prednisone-2010 Prolonged Survival
• Denosumab-2010 Skeletal related event reduction
• Abiraterone + prednisone-2011 Prolonged Survival
• 2012: MDV3100 and radium-223 chloride Prolonged Survival
Two randomised phase 3 trials have demonstrated a significant improvement in overall survival (OS)
for docetaxel- based chemotherapy, compared with the
mitoxantrone-prednisone combination
Petrylak DP et al NEJM 2004; 351: 1513–20.
30 months
Tannock IF et al NEJM 2004; 351: 1502–12
Docetaxel given at the dose of 75 mg/m2 every 21 d is the sole regimen approved by the FDA and EMA for the treatment of mCRPC
Treatment for docetaxel-resistant CRPC is becoming a major unmet need
for patients with advanced prostate cancer because no standard treatment
exists for this clinical situation
Berthold DR et al J Clin Oncol 2005;23:8247– 8252.
SECOND LINE CHEMOTHERAPYOPTIONS
• DOCETAXEL RE-CHALLENGE
• NEW TAXANES :CABAZITAXEL
• NEW CHEMOTHERAPEUTIC AGENTS:
• EPOTHILONES,, NEW PLATINUM- BASED REGIMENS,
• NONTAXANE HALICHONDRIN B ANALOG MICROTUBULE INHIBITOR,
NEW CHEMOTHERAPEUTIC AGENTS
NEW TAXANES: CABAZITAXEL, NAB-PACLITAXEL
EPOTHILONES:IXABEPILONE,PATUPILONE,SAGOPILONE
PLATINUM CHEMOTHERAPY DRUGS:SATRAPLATIN
NONTAXANE HALICHONDRIN B ANALOG MICROTUBULE INHIBITOR: ERIBULIN MESYLATE (E7389)
METRONOMIC CHEMOTHERAPY
Cabazitaxel: a next generation taxane
Both extracted from needles of the European Yew treeTaxus baccata
XY
X Y
Docetaxel
Cabazitaxel
-OH
-OCH3 -OCH3
-OCCH3
O
99th AACR annual meeting, San Diego, April 2008 (abstract #3227)
These 2 radicals confer very specific properties to cabazitaxel
Cabazitaxel: selected to overcome taxane resistance
• Some patients do not answer to Docetaxel (acquired or constitutional resistance). This may be due to various mechanisms:
affinity for multidrug resistant (MDR) membrane-associated P-glycoprotein (PgP) efflux pump,
alterations of tubulin, overexpression Bcl-2, Aurora-A …
• Cabazitaxel: Poor affinity for the PgP efflux
pump
greater penetration of the blood brain barrier compared with docetaxel and paclitaxel
Active in vitro and in vivo on tumors resistant to Docetaxel
Mita AC et al, Clin Cancer Res. 2009, 15, 723-730
Taxane
H
R
• Docetaxel and paclitaxel have a strong affinity for the PgP pump
• If the PgP pump is surexpressed, it drives drug out of tumour cell
• Preclinical data Activity against tumor cells and tumor models that are
resistant to, or not sensitive tocurrently available taxanes¹,²
As potent as docetaxel against sensitive cell lines and tumor models¹,²
• Phase I studies Dose-limiting toxicity was neutropenia Antitumor activity in mCRPC including docetaxel-
resistant disease3
Cabazitaxel: preclinical & clinical data
¹ Attard G, Greystoke A, Kaye S, De Bono J. Pathol Biol (Paris). 2006;54(2):72-84.² Pivot X, Koralewski P, Hidalgo JL, et al. Ann Oncol. 2008;19(9):1547-1552.3 Mita AC, Denis LJ, Rowinsky EK, de bono JS et al. Clin Can Res. 2009; Jan 15;15(2):723-30.
De Bono JS et al. Lancet 2010; 376: 1147–54
Primary endpoint: OSSecondary end-points: Progression-freesurvival (PFS), response rate, and safety
Baseline characteristics and treatment history of patients in the intention-to-treat population
De Bono JS et al. Lancet 2010; 376: 1147–54
Baseline characteristics and treatment history of patients in the intention-to-treat population
De Bono JS et al. Lancet 2010; 376: 1147–54
Primary endpoint:Overall survival (updated ITT analysis*)
De Bono JS et al. Lancet 2010; 376: 1147–54
TROPIC Update: at 2 years the same OS (HR 0.70 vs 0.72)
Oudard S, Future Oncology, 2011De Bono JS, The Lancet 2010
OS: 15,1 Vs 12,7 mo
Cut-off Sept 25, 2009)
Intention-to-treat analysis of overall survival in subgroups of patients defined by baseline characteristics.
De Bono JS et al. Lancet 2010; 376: 1147–54
TROPIC Cabazitaxel: Haematological results
De Bono JS et al. Lancet 2010; 376: 1147–54
Higher rate of grade ≥ 3 neutropenia than in TAX 327 but patients enrolled in TROPIC had more advanced disease, were heavily pretreated and had weekly hematological testing
*Prophylactic use of G-CSF was permitted except for cycle 1 of treatment at the discretion of the investigator.
*
The incidence of neutropenia varied significantly by region, with rates of neutropenia in North America exceeding those in the Europe
De Bono JS et al. Lancet 2010; 376: 1147–54
Deaths in patients who received at least one dose of study treatment
30
Conclusions: TROPIC
• Cabazitaxel demonstrated a statistically and clinically significant survival improvement compared with mitoxantrone in study population 15.1 months vs 12.7 months 28% reduced risk of death (HR=0.72, P <.0001) Survival benefit consistent across subgroups
• Secondary endpoints of PFS, RR, and TTP also significantly improved
• Safety profile was manageable Proactive management of side effects recommended
(neutropenia/diarrhea)
Cabazitaxel is the first treatment to show a survival benefit in patients with mCRPC after failure of docetaxel-based therapy
TROPIC post-hoc analyses: impact of cabazitaxel on overall survival at 2 yrs in patients with aggressive
disease
Methods: Patients with poorly differentiated
tumours and/or with visceral metastases
at baseline were analyzed in term of OS
•Aggressive disease was defined as the presence of poorly differentiated tumour histopathology at diagnosis, or presence of visceral metastases.
•Visceral metastases are defined as the presence of lung, liver, adrenal or pancreatic lesions.
Oudard S. at al. ESMO 2012 abs 933P
Overall survival by differentiation at diagnosis
• Patients with poorly differentiated tumour histopathology showed significantly improved OS with CbzP compared with MP
Oudard S. at al. ESMO 2012 abs 933P
Overall survival by duration of hormonal therapy
Cabazitaxel was associated with a significant survival advantage over MP in all subgroups, suggesting that duration of prior hormonal therapy does not affect the OS benefit associated with cabazitaxel
Oudard S. at al. ESMO 2012 abs 933P
Heidenreich A et al European Urology 9 August 2012
In patients likely to poorly respond to abiraterone (eg, high Gleason score, rapid progression to CRPC with primary ADT, or progression during docetaxel therapy), cabazitaxel might be the first option in the second- line setting.
For patients with less-aggressive mCRPC, cabazitaxel and abiraterone are reasonable treatment options.
Journal of Urology 2009; 181, 1672 1677
2 cycles of 150 mg/in2 nab-paclitaxel weekly for 3 weeks during each4-week cycle, followed by radical prostatectomy with bilateral lymphadenectomy.
Journal of Urology 2009; 181, 1672 1677
Post-chemotherapy prostate specific antigen was decreased in 18 of 19 (95%)
Intracytoplasmic vacuolizationoccasional Intranuclear Inclusions.
First-line Therapy : NAB-PACLITAXEL
Kolevska et al 2009: 100 mg/m2 was administered IV QW for 3 weeks of a 4-week cycle. ( 35pts) PSA response was achieved in 9 (25%) Clinical Benefit (response + SD) of 68%.
Amato et al. 2012 in combination with leuprolide and bicalutamide(46 pts)
After two years of therapy, tumor regression was achieved in 78% of patients with a median reduction of PSA level of >90%.
EPOTHILONES (1)
The epothilones represent a novel class of cytotoxic agents that stabilizes microtubules, leading to cell cycle arrest at the G2/M phase of the cell cycle and triggering death, especially in rapidly growing cellsLee FY et al Clin Cancer Res 2001;7:1429 –1437
Detailed structural studies have identified a taxane binding site on the -tubulin surface localized on the luminal (inner) surface of microtubules.
Nogales E et al. Nature 1995;375:424–427
EPOTHILONES (2)
Epothilones also circumvent the overexpression of the multidrug resistance genes or proteins such as MDR-1 and MRP-1Goodin S et al. J Clin Oncol 2004;22:2015–2025.
These agents have also been shown to inhibit tumor growth in taxane-resistant cell lines, suggesting a lack of crossresistance between the two drug classes
Lee FY et al. Cancer Chemother Pharmacol 2009;63:201–212.
Altmann KH. Curr Pharm Des 2005;11:1595–1613 Sepp-Lorenzino L et al. Prostate Cancer
ProstaticDis 1999;2:41–52.
SAGOPILONE
Beer TM et al.British Journal of Cancer (2012) 107, 808–813.
Chemotherapy-naıve patients with metastatic CRPC:
Sagopilone (one cycle: 16 mgm2 intravenously over
3 h q3w) plus prednisone (5 mg twice daily)
PSA response rate was 37%.Median overall PFS was 6.4 months.
The most commonly reported adverse events:Peripheral Neuropathy (94.3%), Fatigue (54.7%)
and pain in the extremities (47.2%).
Satraplatin
• Third-generation Platinum complex that exhibits in vitro cytotoxicity comparable to cisplatin
• Orally available• Exhibits activity in cisplatin-resistent cell lines
– the DNA-adducts of satraplatin are not recognized by mismatch repair mechanism that acts on cis and carboplatin
• Based on favorable profiles and preclinical data of activity in HRPC cell lines, phase II studies were undertaken
Sternberg. BJU Int;96: 990-4, 2005
Sternberg CN et al Oncology 2005;68:2–9
•Target accrual was 350 patients, but only 50 enrolled due to production
•Primary endpoints included overall survival and time to pain progression
•Secondary endpoints included pain intensity, response rate, time to overall disease progression, ORR, duration of responses, QOL, and safety
EORTC 30972
Satraplatin
• Toxicities were low with more frequent hematologic toxicities observed in the combination arm
• Based on the results of the phase II studies and the EORTC study, a large Phase III trial was planned to extend the results of the EORTC study and determine the OS benefit– Termed SPARC (Satraplatin and Prednisone Against
Refractory Cancer)
Sternberg CN et al. Oncology; 68: 2-9, 2005
SPARC
Sternberg CN et al JCO 2009;5431-38
•Primary endpoints were OS and PFS
•Secondary Endpoints were Time to Pain Progression,PFS
Oh WK et al. Cancer 2007;109:477–86
Platinum chemotherapy drugs historically have been considered inactivein CRPC, although a review of the data suggested otherwise.
Carboplatin, in particular, induced very high response rates when it was combined with estramustine and a taxane, but it also appeared to have activity in patients who progressed after docetaxel
CARBO (AUC=5) +ETOPOSIDE 8O MG/MQ FOR 3 DAYS,Q21
PSA decline > 50% was achieved in nine patients (23%).Median PFS was 2.1 months (range 0.6–9.6)Median OS was 19 months (range 2.1–27.7).
Is a synthetic analog of the marine sponge-derived natural product, halichondrin B, which may overcome resistance to docetaxel.Inhibits microtubule dynamics by suppressing microtubule polymerization and sequesters tubulin into nonfunctional aggregatesThe median age of patients was 71 years and median number of cycles was 4.
PSA decreases of 50% were achieved in 22.4% and 8.5% of taxane-naive and taxane-pretreated patients
Grade 3/4 adverse event was neutropenia, seen in 22.4% of chemo-naive and 40% of taxane-pretreated men and peripheral neuropathy occurred in none of the taxane-naive patients and 6.0% of taxane-pretreated patients.
A confirmed PSA decrease of ≥50% from baseline was observed in 9 of 28 patients (32%).
Median PFS and OS were 3 months and 21 months respectively
500mg/m2 CTX i.v. bolus on day 1 and, from day 2, 50mg/day CTX p.o. plus 200mg/twice a day CXB p.o.
and 1 mg/day DEX p.o. until disease progression
Fontana A et al. Clin Cancer Res 2009;15(15) August 1, 2009
Twenty-eight patients (68%docetaxel-resistant)
Median Age 74.5 yrs