Development of new targeted

therapies for the treatment of cancer

Frederic de Sauvage, PhD

Vice President Molecular Oncology
Genentech
Background
Background
 Education and Professional Experience

1985-1990 Ph.D. in Molecular Biology

Catholic University of Louvain

1990-1992 Postdoctoral Fellow (Advisor: Dr. David V. Goeddel)

Department of Molecular Biology
Genentech, Inc.

1992-1996 Research Scientist

Department of Molecular Biology
Genentech, Inc.
…

2013-Present Staff Scientist

Vice President Research-Molecular Oncology
Genentech, Inc.
 Topics of Interest during my career

Hematopoeisis Skin Intestine

The 1990s The 2000s The 2010s

 Stages of Drug Discovery & Development

DISCOVERY
DISCOVERY

Identify the Find Optimize

Target the Lead the Lead

years
years 33 1.5
1.5 22

Early
Early Development
Development Development
Development

Early FDA
Develop. Phase I Phase II Phase III Approval
Support

15
15 years
years
years
years 1.5
1.5 1.5
1.5 1.5
1.5 2.5
2.5 1.5
1.5 total
total

Source: Tuft’s Center for Study of Drug Development; Kola, I., Nature Reviews Drug Discovery 3, 711, 2004.
Small Molecules vs. Biologics/Antibodies

Trastuzumab

diseased
diseased cell
cell

Vismodegib
 Small Molecules vs. Antibodies

Target must be outside

the cell
Can target Protein-Protein
interactions

Trastuzumab

diseased
diseased cell
cell

Many more targets inside the cell
than on the cell surface
Vismodegib
Target can be in or outside the cell
Difficult to target protein-protein interactions.
Well defined pockets such as catalytic sites, ion channels
are preffered
 Small Molecules vs. Antibodies

injectable

• Long Half Life

• $$$ to produce
Trastuzumab • More Specific
oral

diseased
diseased cell
cell

Vismodegib • Short Half Life

• $ to produce
Many more targets inside the cell • Less Specific
than on the cell surface
 What goes wrong in cancer cells?

Normal Cells (Cerebellar Granule Cells i.e.)

 What goes wrong in cancer cells?

Normal Cells (Cerebellar Granule Cells ie)

What goes wrong in cancer cells?

Tumor
Unregulated Proliferation

Lose the ability to die

What goes wrong in cancer cells?

Tumor
Unregulated Proliferation

Lose the ability to die

What goes wrong in cancer cells?

Tumor
Unregulated Proliferation

Lose the ability to die

What Happened???
Cancer arises from DNA mutations

DNA Mutations from:

-Heredity

-Environment

-Spontaneous errors during

DNA replication
Cancer development requires
accumulation of multiple mutations

We have many mechanisms to

protect us from developing
cancer.

Several mutations are needed to

disable all the protection
mechanisms

It takes a long time for all these

mutations to accumulate.

Cancer incidence increases with

age!
Cancer incidence in the US (2015)

Breast Cancer
231,840 cases

Lung cancer
221,200 cases

Prostate
220,800 cases

Colorectal
132,700 cases

Melanoma
73,670 cases

Non-Hodgkin lymphoma
71,850 cases

Hematological malignancies
54,270 cases

Kidney & renal pelvis

38,270 cases

Pancreatic
24,120 cases

American Cancer Society 2015 www.cancer.gov

 Thousands of cancer genomes have
been sequenced

• Driven by dramatic improvement in sequencing technology

• Led to the identification of most mutations that drive cancer
• Targeting the signaling pathways disrupted by these mutations
has been a successful approach for the treatment of cancer
The Hallmarks of Cancer

Hanahan and Weinberg, Cell 2011

 Accumulation of detrimental DNA
mutations drives tumor progression

Accumulation of Different driver mutations drives colorectal cancer progression

Different mutations drive heterogeneity
within a tumor type

Different driver mutations lead to NSCLC

 Oncogenes and Tumor Suppressor genes

Oncogene: example KRAS

— Mutation causing activation or over-expression of a
proto-oncogene promotes cancer
— The overactive version is called an oncogene
— Can be achieved by mutations, amplifications,
translocations

Tumor suppressor: example p53

— Mutation causing loss of tumor suppressor promotes
cancer
— Requires the loss of both alleles (Knudsen two-hit
hypothesis)
 Oncogenes and tumor suppressors
Activation of an oncogene

Often requires very specific

mutation (Gly12Val in Ras)

Inactivation of tumor suppressor

Most premature stop codons or

frameshifts inactivate gene
 Topics of Interest during my career

Hematopoeisis Skin Intestine

The 1990s The 2000s The 2010s

 Developmental Pathways Involved in Somatic Stem
Cells: Normal Tissue Repair and Homeostasis
Hematopoietic
Hematopoietic Stem
Stem Cell
Cell Mammary
Mammary Stem
Stem Cell
Cell

NOTCH [Dontu et al.(2004).Breast Cancer Res.6:R605]

WNT [Li et al.(2003).PNAS100:15853;
Lindvall et al.(2006).JBC281:35081]
HH [Liu et al.(2006).Cancer Res.66:6063]

WNT [Reya et al.(2003).Nature423:409]

NOTCH [Duncan et al.(2005).Nat Immunol.6:314]
Blank et al.(2007) Blood.Oct 3;[Epub ahead of print] Dimri et al. (2005) Breast Cancer Res.7: 171

Gut
Gut Stem
Stem Cell
Cell NOTCH [van Es et al.(2005).Nature435:959] NOTCH [Hitoshi et al.(2002).GenesDev.16:846
WNT [Korinek et al.(1998).Nature Genetics19:379] WNT [Chen and Walsh(2002).Science19.297: 365]
HH [van den Brink et al.(2004).Nature Genetics36:277] HH [Palma et al.(2005).Development132:335

NOTCH [Vauclair et al.(2005).Dev Biol284:184]

WNT [Ito.(2007).Nature447:316]
HH [Nieuwenhuis.(2007).Dev Biol.308:547]
Neural
Neural Stem
Stem Cell
Cell

Skin
Skin Stem
Stem Cell
Cell

Radtke and Clevers (2005).Science307:1904

Perryman and Sylveter.(2006). J. Cell. Mol. Med.10:292
Gage.(2000).Science287:1433
 Vismodegib Timeline

Identify activating SMO

mutations in BCC Vismodegib
(Nature) IND filing NDA filing
1998 2006 2011

1996 Start Collaboration 2009 2012

on Small Molecule
Identify Patched Initiate Pivotal Erivedge Approval
HPI with Curis
as the Hh Receptor BCC trial
Clone human SMO 2003
(Nature)
The Hedgehog Pathway was First
Discovered in Flies: Value of Basic Research
 Hh signaling in development
Ventral neural progenitor specification
Hair follicle

SHH
SHH

Digit specification
(Ptch1,Gli1)

1
2
3 (Shh, Ptch1, Gli)
4
5 (Ptch1, Gli1) Levy et al. 2005
Shh
Cerebellum EGL proliferation and migration
Branching morphogenesis
EGL

PKC
(SHH)

LGL

Shh-LacZ P10 P21

 The Hedgehog Pathway is Associated with
Developmental Disorders

Polydactyly - PHS Holoprocencephaly (Shh)

• Loss of Shh signaling in utero leads to
cyclopia in offspring.

Pallister-Hall Syndrome (Gli3)

Polydactyly
Hypothalamic Harmatomas

Medulloblastoma Basal Cell Carcinoma

Gorlin’s Syndrome (Patched)
Basal Cell Nevus Syndrome (BCNS)
• LOH of Ptch1, high incidence of tumors:
Medulloblastoma
Rhabdomyosarcomas
Basal cell carcinomas
 Hedgehog Pathway Mutations in
Basal Cell Carcinoma
• Most common form of human cancer with an incidence of over a million
cases in the US every year

• Most BCC are easily removed by surgery. In a small percentage of cases,

there is progression to unresectable locally advanced or metastatic tumors

• There was no standard therapy for these advanced forms of BCC

• In the mid-90s, mutations in the Hedgehog (Hh)

pathway were found be the cause of most BCCs
and up to a third of medulloblastoma

Bruce Merryfield,1984 Nobel Prize in Chemistry

 Mutations in PTCH or SMO
lead to BCC, medulloblastoma
Ligand-dependent Loss of Activating
Inactive Receptor Activation PTCH Mutations SMO Mutations

I I
GL GL

• Most/all BCC show Hh pathway activation. Up to 90% have been attributed to

mutations at the PTCH locus with the remaining 10% caused by SMO mutation.

• About 25-30% of medulloblastoma have mutations leading to activation of the Hh

pathway
 The Hedgehog Signaling Pathway

ON OFF
 Mutations in PTCH or SMO
lead to BCC, medulloblastoma
Ligand-dependent Loss of Activating
Inactive Receptor Activation PTCH Mutations SMO Mutations

I I
GL GL

• Most/all BCC show Hh pathway activation. Up to 90% have been attributed to

mutations at the PTCH locus with the remaining 10% caused by SMO mutation.

• About 25-30% of medulloblastoma have mutations leading to activation of the Hh

pathway
 Common Lead Finding Approaches

Literature/K
High- nown Lead
Throughput-
Screening

Novel Drug
Leads

Computational
Screening
 Corn Lilies, Sheep and Hedgehog

Cyclopia in lambs found to be due to

pregnant ewes ingesting corn lily in
western USA

Chemical identified: “cyclopamine”

Targets Smoothened

No effect in adult sheep

 Desired pre-clinical profile:

Low molecular weight (< 500 g/mol)

Potency (IC50 < 10 nM)
Selectivity (no off-target issues)
Good correlation of in vitro metabolic stability and in vivo
PK
Good oral bioavailability from crystalline suspension
(>30%)
Good knockdown of in vivo tumor PD (Gli)
Efficacy in mouse tumor models (medulloblastoma,
colon, ovarian)
 Small Molecule Inhibitors of the
Hedgehog Pathway

HTS with a 79,000 compound library:

Cell based assay using Gli-Luciferase reporter

Lead Discovery

Mouse (S12) = 55 nM
Human (HEPM) = 12 nM

Hh-Antag

Medicinal Chemistry

Mouse (S12) = 22 nM
Human (HEPM) = 3 nM
Vismodegib
GDC-0449
 Small Molecule Inhibitors of the
Hedgehog Pathway

HTS with a 79,000 compound library:

Cell based assay using Gli-Luciferase reporter

Lead Discovery

Loss of
Mouse (S12) = 55 nM
PTCH Mutations
Human (HEPM) = 12 nM ! " # # $" %$& ' ( ) $* + , - , . " / #
! " #
Hh-Antag

Medicinal Chemistry ) * + ,- .
2 ' +34
/ 01
! ' ('

( " / # ,.,+ ,.0 1

Mouse (S12) = 22 nM # .2 / - 3
Human (HEPM) = 3 nM
$ %& ' ( ) * +, - . / 000
Vismodegib
GDC-0449
! " # $% " &
 Efficacy in a Genetically Engineered
Mouse Model of BCC
K14-CreER x Ptch1fl/fl x p53fl/fl
Placebo Treated

Day 28 Day 44 Day 47 Day 56

6mm 8.5mm 10mm 17.5mm
HPI
! "reduces
Cur-61414 ! #$%&'BCC
( %tumor
)#*++# , ' and
size - . number
/)# Cur-61414 decreases Gli1 levels
4 -56#78%*DEF - 250
+, - =>3( %?. #
! "#$%&' 0##
123/2#45" 6# 200

Gli (normalized)
4 --56#78%-97-: 55-;%78<6-

.,- ! "! #
- 7( %8#6! #*++) #
94&#45: #- 7( %8#
/,- : #*++) # 150
), -
100
*) , - , - /- 0- 1- ) , - ) ( - ) +- 2, - 22- 2+- 23- / ( -
( ) ( 0##
123/2#45; #- 7( %8# 50
*/ , - 6<#*++)#
94&#45! #- 7( %8#" 6#
*. , - *++)# 0
*+, -
Placebo Cur-61414
=#>?-' @
-AB%
#<C%7<-

E. Epstein, J. Tang, T. Tang

 Hh Pathway Antagonists activity in
Ptch-Mutant Medulloblastoma
Passage in vivo
Ptch+/-, p53-/- WT WT
Spontaneous
tumor

Passage into flank Passage into flank

Use MRI to detect tumor

3000
3000
Vehicle
Vehicle
Tumor Volume (mm3)

Hh-Antag
CUR-0199691
Hh-Antag
100mg/kgqdqdpopo
100mg/kg
2000
2000

1000
1000

00
00 25
25 50
50 75
75 100
100
Days
Days

• Total regression of medullo allograft following 28 days of treatment.

• The effect is durable for at least 60 days following cessation of treatment.
 Different phases of clinical trials

• Phase I:

• Phase II:

• Phase III:
 Different phases of clinical trials

• Phase I:

First stage of testing in human subjects to assess the safety, tolerability,

pharmacokinetics, and pharmacodynamics of a drug

• Phase II:

Designed to assess if the drug has the expected clinical activity

• Phase III:

Designed to provide a definitive assessment of how effective the drug is,

in comparison with current Standard of Care treatment.
 Multiple components impact the
unique PK profile of vismodegib

Nonlinear absorption High plasma

Very low clearance
due to low solubility protein binding

Free drug in intestinal Free drug in circulation Clearance of free drug

lumen

Steady state PK with daily dosing Daily dosing required to maintain

effective free drug despite long half-life

Target exposure
 Most common adverse events

MedDRA preferred term All adverse Grade 1 Grade 2 Grade 3/4

events (%) mild (%) moderate (%) severe (%)

Muscle spasms 68 48 16 4

Alopecia 64 49 14 0

Dysgeusia 51 28 23 0

Weight decreased 46 27 14 5

Fatigue 36 27 5 4

Nausea 29 21 7 1

Decreased appetite 23 14 6 3

Diarrhea 22 16 5 1

Discontinuation of study drug due to adverse event was reported in 1

(3.0%) mBCC patient and 11 (15.5%) laBCC patients as of the data
cutoff
MedDRA, Medical Dictionary for Regulatory Activities
67 y.o. with BCC Metastatic to
Lung, Liver and Bone
Baseline At 8 months (confirmed PR)
 Vismodegib activity in locally advanced BCC

Before Treatment After 2 Months After 6 Months

Patient 29, a 41-year-old woman with facial lesions

At time of data cutoff, this patient had stable disease
as assessed on imaging

Von Hoff D et al. N Engl J Med 2009

Vismodegib in locally advanced BCC

Baseline Week 24

No residual BCC on biopsy

Vismodegib provides a substantial clinical
benefit for patients with advanced BCC

Efficacy results of ERIVANCE phII study

mBCC laBCC
 The Hh Pathway is activated in all BCC

GLI1 PTCH2

PTCH2 expression (2-DCt)

GLI1 expression (2-DCt)

100 100

10 10

1 1

0.1 0.1
ki n a

C
C
C

kin b
laBC

laBC
mBC
mBC
rol s

rol s
Cont

Cont
• Evidence of Hh pathway activation in all metastatic and locally advanced BCC
 Medulloblastoma Molecular Subgroups

Molecular Group
Hh Wnt Non-Wnt/Hh
Proportion of
15-30% ~15% ~60%
medulloblastoma
Mainly infancy &
Age at Childhood-pre-teen yrs; Mainly childhood;
adulthood; Uncommon
presentation mean age ~10 yrs mean age ~8 yrs
in 5-15 yrs old
Metastatic Most cases of
disease at Rare Rare metastatic disease
presentation in this group
Mainly classic
Pathological D/N tumors and MBENs Nearly all classic tumors;
tumors ~50% of
variant ~50% of LC/A tumors No D/N tumors
LC/A tumors
Outcome with
first-line Good/Average Very good Poor
therapies

Hh = Hedgehog; D/N=desmoplastic/nodular; LC/A=large cell/anaplastic; MBEN=medulloblastoma with

extensive nodularity.

Derived from: Northcott et al. 2011; Kool et al. 2008; and Thompson et al. 2006
26 y.o. with widespread metastatic
medulloblastoma
• Initially diagnosed with
April (pre-tx) medulloblastoma at age 22, confined
to cerebellum, resected, tx with
radiation and chemotherapy

• Recurred 2 years later and treated

with chemotherapy, autologous bone
marrow transplant

• Recurred 18 months after that as

widespread metastatic disease,
treated with mulitple surgeries,
radiation, chemotherapy and
bevacizumab, each with disease
progression Rudin C. et al. N Engl J Med 2009
Evidence for active Hh signaling in
primary and metastatic disease tissue

Transcriptional profiling PTCH1 sequencing

CAAAAT G T G G C T G

Skin
R

Tumor
R

homozygous mutation
(results in PTCH1
aa.844 W>C)
 26 yo with widespread metastatic
medulloblastoma

April (pre-tx) June 23 July 23

• Began GDC-0449 (540 mg/day) on April 22, then daily beginning on April 29.
• Partial response seen on June 23 was to be confirmed by imaging on July 23
• Disease progression documented on July 23; biopsied 7/25/2008 (FNA)
• Patient died on September 23 with no response to subsequent experimental therapies
D473 SMO Mutation Identified in Tissue
Biopsy Taken at Relapse

Fz N

Yauch et al., Science 2009

 SMO D473H is sensitive to PTCH but
insensitive to Vismodegib inhibition

Gli-Luc Activity in 10T1/2 cells Vismodegib Binding

120%
SMO-WT+449
SMO-D473H+449 350
291
300

Bound [14C]-449 (cpm)

100%
Residual Hh pathway activity

250

200
80%
150
100 67
60% 50 50 55
44
50

0
40%

449

449

449
5nM C14-

5nM C14-

5nM C14-
w/5uM 449
competition

competition
w/5uM 449

competition
w/5uM 449
20%
empty vector wt Smo mutant Smo

0%
0 0.3 3 30 300 3000

Concentration of GDC-0449 (nM)

 Compound 5 inhibits Tumor Growth
Mediated by Vismodegib-resistant SMO

Tumor growth inhibition and Hh target gene inhibition in SmoD477G

A D E

Cpd 5

Dijkgraaf et al., Cancer Res.2011

 Conclusions

• Mutational activation of the Hedgehog pathway leads to the

development of tumors such as basal cell carcinoma and
medulloblastoma.

• Treatment with a Hh pathway inhibitor such as vismodegib

provides significant clinical benefit for patients with tumors
where the Hh pathway is activated via mutations

• Acquired resistance to vismodegib can develop and mostly

converges on reactivation of the Hedgehog Pathway through
multiple mechanisms
 Acknowledgements
Genentech:
• Karmanos Cancer Institute, Wayne
State University
Jim Marsters Suzie Scales P.M. LoRusso, Elisabeth Heath, Lisa Malburg,
Bob Yauch Lesley Murray MaryJo Pilat, Carolyn Shearer, Andrea Smoots,
Stephen Gould Leslie Lee Denise Weiss, Jie Zhang
Peter Dijkgraaf Michelle Nannini • Translational Genomics Research
Christina Ahn Kirk Robarge Institute (TGen) and Scottsdale
Bruno Alicke Janet Gunzner Healthcare
Tracy Tang Thomas Januario Dan Von Hoff, Mitesh Borad, Raoul Tibes, Glen
Weiss, Lisa Blaydorn, Molly Downhour, Gayle
Hua Tian Ling Fu Jameson, Katy Schroeder
Chris Callahan Hilary Nelson
Richard Graham Howard Mackey • Johns Hopkins University
Charles Rudin, Barbara Coleman, Christine
Jennifer Low Sekar Seshagiri Hann, Rosalyn Juergens
Josina Reddy George Kan
Fernando Bazan • Children’s Hospital of Oakland
Lisa Nelson Research Institute
Ervin Epstein, Jean Tang, Michelle Aszterbaum,
Curis: Joselyn Lingren, Kris Chang, Ginny Gildengorin
Lee Rubin Chang Qian • Columbia University
Karen Kotkow Oivin Guicherit David Bickers, Julian Mackay-Wiggan, Carol
Coppola, Angela Campbell, Jackleen Marji

"Through the Genentech-Curis collaboration, GDC-0449 was discovered by Genentech and was jointly validated by the parties through a series
of preclinical studies.   Genentech and Roche collaborate on the clinical development and commercialization of GDC-0449."
And a special thank you to the patients!
 Thank you all!
Acknowledgements
Genentech:
• Karmanos Cancer Institute, Wayne
State University
Jim Marsters Suzie Scales P.M. LoRusso, Elisabeth Heath, Lisa Malburg,
Bob Yauch Lesley Murray MaryJo Pilat, Carolyn Shearer, Andrea Smoots,
Stephen Gould Leslie Lee Denise Weiss, Jie Zhang
Peter Dijkgraaf Michelle Nannini • Translational Genomics Research
Christina Ahn Kirk Robarge Institute (TGen) and Scottsdale
Bruno Alicke Janet Gunzner Healthcare
Tracy Tang Thomas Januario Dan Von Hoff, Mitesh Borad, Raoul Tibes, Glen
Weiss, Lisa Blaydorn, Molly Downhour, Gayle
Hua Tian Ling Fu Jameson, Katy Schroeder
Chris Callahan Hilary Nelson
Richard Graham Howard Mackey • Johns Hopkins University
Charles Rudin, Barbara Coleman, Christine
Jennifer Low Sekar Seshagiri Hann, Rosalyn Juergens
Josina Reddy George Kan
Fernando Bazan • Children’s Hospital of Oakland
Lisa Nelson Research Institute
Ervin Epstein, Jean Tang, Michelle Aszterbaum,
Curis: Joselyn Lingren, Kris Chang, Ginny Gildengorin
Lee Rubin Chang Qian • Columbia University
Karen Kotkow Oivin Guicherit David Bickers, Julian Mackay-Wiggan, Carol
Coppola, Angela Campbell, Jackleen Marji

"Through the Genentech-Curis collaboration, GDC-0449 was discovered by Genentech and was jointly validated by the parties through a series
of preclinical studies.   Genentech and Roche collaborate on the clinical development and commercialization of GDC-0449."
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