Synthetic Lethal Therapy for Head and Neck Squamous Cancer

Transcript

• 00:00Barbara Burkness,
• 00:01who will be speaking today about synthetic
• 00:04lethality and head and neck cancer,
• 00:07is the Anthony Brady Professor
• 00:09of Medicine and Medical Oncology,
• 00:11the chief translational research
• 00:13officer in the Cancer Center,
• 00:15and the associate director
• 00:17for translational research
• 00:19in the Cancer Center as well,
• 00:22and leads the Head and Neck Cancer program.
• 00:26So Barbara has many accolades.
• 00:32She when I was coming to Yale,
• 00:35I was told by my,
• 00:37I think very capable colleague at
• 00:40the Inner Barber who read the Head
• 00:42and neck cancer program that I was
• 00:44moving to the institution with the
• 00:46best head and neck oncologist in the country.
• 00:48And I think it's fair to say that
• 00:51Barbara has has contributed widely to
• 00:54the field of head and neck cancer,
• 00:57both in terms of laboratory work and
• 01:00clinical trials and plain old education.
• 01:05Barbara went to Bryn Mawr College,
• 01:08went to medical school at Stony Brook,
• 01:11and then actually had the unfortunate
• 01:14experience of of coming across me because
• 01:18she was an intern when I was chief
• 01:21resident here at this fine institution.
• 01:24And I can tell you that if you're looking
• 01:27for an example of someone who fundamentally
• 01:30hasn't changed over the course of many years,
• 01:34you can look at Barbara because at
• 01:37that time she was incredibly bright,
• 01:41incredibly insightful, capable of
• 01:44doing almost anything and very direct.
• 01:48And I am,
• 01:50I am that wasn't that was pretty gentle.
• 01:54I said, I, I said there was no roast,
• 01:56just toast.
• 01:59And, and it's really a pleasure to
• 02:02have the opportunity to come back
• 02:04to yell and work with Barbara.
• 02:06I should mention that after yell,
• 02:08Barbara went on to a fellowship at at
• 02:11Memorial Sloan Kettering and then before
• 02:13finding her home in head and neck cancer,
• 02:16actually was briefly interested in breast
• 02:19cancer and GI cancer and spend time here
• 02:23at Yale and at Fox Chase and then back at,
• 02:25at Yale again.
• 02:26So we're thrilled to have you and
• 02:29we look forward to your talk.
• 02:38So it was not my misfortune to
• 02:39have run across Eric as an intern.
• 02:41He was the most beloved and the most
• 02:45inspiring chief resident and actually
• 02:48leader I think I've ever worked with.
• 02:50And so it's, it's wonderful that he's back.
• 02:53So I'm going to talk about synthetic
• 02:55lethal therapy for head and neck cancer,
• 02:57but I'm going to start out by
• 02:59just laying a little groundwork.
• 03:01So why am I interested in HPV negative
• 03:03head and neck cancer specifically?
• 03:05And why in the age of immunotherapy
• 03:07am I still studying targeted therapy?
• 03:10So just as as sort of some background,
• 03:13head and neck cancers,
• 03:14the 7th most common cancer globally,
• 03:17nearly half a million people die of
• 03:20this cancer worldwide every year.
• 03:22For HPV negative cancer,
• 03:23which globally is the most common form,
• 03:26the risk factors are age,
• 03:27nutritional status, alcohol exposure,
• 03:30tobacco, other oral carcinogen exposure.
• 03:34And then we have particularly in North
• 03:38America and in Europe a rising burden
• 03:41of HPV associated head and neck cancer.
• 03:43For both kinds,
• 03:44the definitive therapy whether it's
• 03:46surgical or radiation or multi modality
• 03:49can lead to lifelong morbidity And
• 03:51both geographically across the Gulf
• 03:54globe and within the United States,
• 03:56this is a disease where we
• 03:58see enormous disparities.
• 04:02So treatment resistance is a big
• 04:03problem in head and neck cancer.
• 04:05We know for multi modality therapy of HPV
• 04:08associated cancer that we cure about 80%
• 04:11and in HPV negative we cure about 50%.
• 04:14And for some years,
• 04:16we thought that we were curing
• 04:17more people by intensifying our
• 04:19chemo radiation approaches.
• 04:21But it turned out what was happening was
• 04:22we were seeing a rising incidence of
• 04:24HPV associated cancer and we hadn't yet
• 04:26figured out that that had a better prognosis.
• 04:28So for HPV negative cancers,
• 04:32the cure rate for definitive
• 04:34therapy has not really budged.
• 04:36Historically,
• 04:36we knew that combination chemotherapy
• 04:38was active but not curative.
• 04:40And actually the standard regimen
• 04:42was something that had Yale roots.
• 04:44We now know and I'll show you
• 04:45a little bit about this,
• 04:46that immunotherapy can provide
• 04:47long term survival benefit for
• 04:49a proportion of patients with
• 04:51recurrent metastatic disease.
• 04:53And very frustratingly,
• 04:544 large phase three studies later,
• 04:56we still do not know how to integrate
• 05:00immunotherapy with curative therapy.
• 05:02And so we we have a substantial
• 05:04number of patients who don't benefit
• 05:07from our existing therapies.
• 05:09And This is why we've been sort
• 05:11of interested in targeted therapy.
• 05:13But advances in targeted therapy
• 05:15and head neck cancer have been slow.
• 05:17And I think that part of this is due to
• 05:20the fact that the predominant genomic
• 05:22drivers in HPV negative cancer are
• 05:25really loss of tumor suppressor function,
• 05:27not not necessarily that easily targetable.
• 05:30So what's the evidence that HPV associated
• 05:33cancer's really a different disease?
• 05:35The the first observation I think
• 05:36came from a small ECOG trial,
• 05:38but this is from a large RTOG study
• 05:41showing that with the same treatment,
• 05:43HPV associated cancer has a
• 05:45much higher cure rate than
• 05:47HPV negative cancer.
• 05:49And we looked at that our committee
• 05:51at ECOG looked at this graph and said
• 05:53these are two different diseases and
• 05:55we're treating everybody in the top
• 05:57curve with a treatment that was designed
• 05:59for the people on the bottom curve.
• 06:00Maybe we could de intensify and we did
• 06:03the first actually trial of treatment
• 06:05the intensification in head neck cancer.
• 06:07We reasoned that responsiveness to
• 06:09chemotherapy would be a hallmark
• 06:11of the the favourable prognosis
• 06:14HPV associated cancers,
• 06:15that it would be a hallmark
• 06:17of radiosensitivity.
• 06:17And so we gave everybody induction
• 06:20chemotherapy and those who responded got
• 06:22a reduced dose of radiation and those
• 06:24are the patients in the dark curve.
• 06:26So you can see that despite
• 06:28getting less radiation,
• 06:29they had a higher cure rate.
• 06:30And we also from this dissected out some
• 06:33clinical risk factors for poor behavior.
• 06:35So bulky disease and more lifetime
• 06:38tobacco exposure of more than
• 06:4110 pack years were unfavorable.
• 06:44And this work has subsequently been been
• 06:46confirmed in a number of other studies.
• 06:48We also wanted to know if you could
• 06:50de intensify post operative therapy.
• 06:51And so this is a large study that
• 06:53we did in ECOG for patients who
• 06:56were undergoing robotic surgery
• 06:57for their head and neck cancers.
• 06:59The all the surgeons were credentialed,
• 07:02everybody had good quality surgery.
• 07:04And then based on the pathology we
• 07:06assigned them to a risk category.
• 07:08And if they were in the intermediate
• 07:10risk category,
• 07:10we tried to reduce their radiation.
• 07:12And I just presented at ASCO last two
• 07:14weeks ago whenever that was the 54
• 07:17month PFS for the strategy as a whole,
• 07:19it was 90% and for reducing
• 07:23radiation from 60 to 50 Gray,
• 07:26there was no significant difference
• 07:28in progression free survival.
• 07:30Interestingly, in this study,
• 07:32having a history of tobacco
• 07:35exposure was not deleterious.
• 07:36And so this kind of highlights
• 07:38the fact that relying on clinical
• 07:42criteria like what's your T stage,
• 07:45how many pack years of smoking do you
• 07:47tell your treatment team that you've
• 07:49you've had is a little bit rough.
• 07:53And so a major focus of one of the
• 07:56projects in our SPORE or Head Neck
• 07:59Sport grant that we have is to try
• 08:02to figure out whether or not we
• 08:04could get a molecular signature
• 08:05for more favourable prognosis.
• 08:07So this is work of Del Yarbrough
• 08:10and Natalia Isayeva at UNC working
• 08:12together with a young surgeon,
• 08:14scientist Travis Schrank,
• 08:15who's had a lot of support from the spore.
• 08:18And So what they began with the
• 08:21observation that the T3 CYLD mutated
• 08:23subset of head and neck cancer
• 08:25had a more favorable prognosis.
• 08:27These patients were less likely
• 08:28to be smokers.
• 08:29The HPV was more likely to be
• 08:31episomal rather than integrated.
• 08:33The cancers were less methylated,
• 08:36had a lower APOBEC mutational signature and
• 08:40expressed a lower level of HPV oncogenes.
• 08:43And so this LED Dell's lab to
• 08:46explore demethylation therapy
• 08:47and a lot of preclinical models.
• 08:49I won't show you that,
• 08:50but this has LED us to two clinical trials.
• 08:53First, a small pilot trial of five
• 08:56asicitidine monotherapy before
• 08:57patients went to the OR for HPV
• 08:59associated head neck cancer.
• 09:01These the photo photo micrographs on the
• 09:06on the left showing immunofluorescence
• 09:08for CD4 and CD8 cells or the from
• 09:11David Rim's group and on the left
• 09:13you see two biopsies pre therapy.
• 09:16On the right you see two biopsies
• 09:18post therapy.
• 09:18I think you can see the extensive
• 09:21infiltration of CD4 and CD8 cells
• 09:23as well as the formation of some
• 09:26tertiary lymphoid structures.
• 09:27So we then took this forward with
• 09:30a a new randomized trial which is
• 09:33currently accruing 5 azacitidine
• 09:35alone immune checkpoint inhibitor with
• 09:37nivolumab alone or the combination.
• 09:39And we're seeing very dramatic
• 09:42deep pathologic responses in
• 09:44the combination patients.
• 09:46I I'm showing you here some pictures from
• 09:48a patient who had a 3.5 centimeter tumor,
• 09:5017 days later went to the OR had a 2
• 09:541/2 millimeter tumor with extensive,
• 09:56as you can see their cholesterol clefts,
• 09:58evidence of immune mediated cell death
• 10:00and very extensive T cell infiltration.
• 10:03The brown stain for P-16 shows
• 10:06the residual cancer.
• 10:08So really very few viable cancer
• 10:11cells left and we are intensively
• 10:14interrogating the tissue from from this
• 10:17trial as part of our SPORE project.
• 10:19So I just also wanted to say a word
• 10:23about immunotherapy because I think it's,
• 10:25although it's a genuine breakthrough
• 10:27for patients with head and neck cancer,
• 10:29it's because of how disappointing
• 10:30it's been that we still need to
• 10:32think about other ways forward.
• 10:33So this is from Keynote 01/2.
• 10:35This was the first head and neck cancer
• 10:38specific study of immune checkpoint
• 10:39inhibition. Yale was part of it.
• 10:41I led the head neck cohort when
• 10:43I was at Fox Chase.
• 10:45We accrued both HPV positive
• 10:47and HPV negative patients.
• 10:49You can see that there were responses
• 10:52for for both groups and some
• 10:54responses were deep and durable,
• 10:57but not all.
• 10:58And the overall response rate was about 17%.
• 11:01This actually led to the FDA approval of
• 11:03pembrolizumab for head and neck cancer.
• 11:05But the real,
• 11:06and this was performed in people
• 11:07who were all platinum refractory,
• 11:09but the real question was whether
• 11:11we could get this into first line.
• 11:13And this was problematic 'cause we
• 11:16were taking a 17% drug and we were
• 11:18putting it up against a combination
• 11:20of chemotherapy and cetuximab.
• 11:22As I said,
• 11:23that was a regimen we had developed
• 11:25years ago when I was here at Yale
• 11:27then had a 35% response rate.
• 11:29But there were data from both from
• 11:33Keynote 01/2 and from another
• 11:35platinum refractory study led by
• 11:37Ezra Cohen that had shown that
• 11:39responsiveness to pembrolizumab in
• 11:41head neck cancer correlated very
• 11:43well with expression of PDL 1,
• 11:45the ligand for PD1 on tumor and immune cells.
• 11:48So this we sort of had two plans for
• 11:52how we could dissect out who was
• 11:54going to benefit from pembrolizumab.
• 11:56One was to do hierarchical testing
• 11:58for pembrolizumab monotherapy against
• 12:00the chemotherapy setuximab combination.
• 12:02So we started looking at
• 12:04those patients with CPS 20.
• 12:05If that was positive,
• 12:06we could look at CPS one and then we
• 12:08could look at the total population.
• 12:10And indeed pembrolizumab with its
• 12:12puny 17% response rate led to better
• 12:15overall survival than chemotherapy
• 12:17and setuximab in anybody who had PDL
• 12:20one expression and pembrolizumab plus.
• 12:22And the other strategy we had was
• 12:24this pembrolizumab plus chemotherapy
• 12:26regimen that had a very similar response
• 12:29rate to chemotherapy plus setuximab,
• 12:31but LED to better overall survival
• 12:34for the entire population.
• 12:35The, the way that hierarchical testing works,
• 12:38you, you look at all the people with
• 12:40ACPS 20 and then the next analysis you
• 12:42look at everybody with the CPS one.
• 12:44So you're including the people
• 12:45you already analyzed.
• 12:46I think when I was in medical school,
• 12:48the New England Journal didn't
• 12:49take papers that did that,
• 12:50but now it's pretty common.
• 12:51But anyway,
• 12:52we wanted to go back and look and you
• 12:54can see that if we break down the
• 12:56PDL 1 low expressors into those with
• 12:58no expression or those with one to
• 13:0119 expression, there's no benefit.
• 13:03In fact,
• 13:03there's probably a disadvantage to
• 13:05using pembrolizumab monotherapy in
• 13:07the patients who are not PDL 1 expressing,
• 13:10whereas for the one to nineteens
• 13:13there's a benefit particularly
• 13:15for pembrolizumab chemotherapy.
• 13:17So,
• 13:18but I think what I'm showing you across
• 13:20these is that at the end of five years,
• 13:23only 20% of people are still alive
• 13:25who've had immune checkpoint inhibitor
• 13:26based therapy with head and neck cancer.
• 13:29So what are we going to do for the others?
• 13:30So this is what has taken me back to,
• 13:34to targeted therapy.
• 13:35I I think one very interesting
• 13:37observation about head and neck
• 13:38cancer is that we have three sort
• 13:40of main buckets of how people
• 13:41*** **** and neck cancer.
• 13:43I mentioned environmental exposures,
• 13:45I mentioned HPV.
• 13:46We're also recognizing that in adult
• 13:49survivors of Franconia anemia,
• 13:51whether or not they've had
• 13:52bone marrow transplantation,
• 13:53there's a astronomical rate of
• 13:56head neck cancer about 1000 fold.
• 13:59What, what you would expect.
• 14:01And if you look at the genome
• 14:03profiles of these,
• 14:04these three separate buckets, the same,
• 14:07the same pathways are targeted.
• 14:08So you've lost AP 53 function,
• 14:10whether it's a viral oncoprotein degrading
• 14:13P53 or it's a loss of function mutation,
• 14:15you have CDKN 2A mutation or loss PIC
• 14:18three CA mutation and amplification.
• 14:20And we're starting to recognize
• 14:21that FANK genes can be mutated
• 14:23in sporadic head and neck cancer.
• 14:25And so the,
• 14:26I think the question for me was
• 14:28do these insights point to shared
• 14:31vulnerabilities and that that would
• 14:34point us towards synthetic lethal
• 14:36strategy centered on P53 loss of function.
• 14:39So this is from over 500 patients
• 14:41profiled by the broad.
• 14:43We could also look at TCGA.
• 14:45We could also look at Karas or Foundation.
• 14:48This has been published a number
• 14:50of Times Now,
• 14:51but about 85% of HPV negative
• 14:54head neck cancers have
• 14:56pathogenic mutations in P53.
• 14:59Direct restoration of this function is,
• 15:02as you probably all know has not
• 15:04translated to the clinic yet.
• 15:06Loss of P53 is associated with loss
• 15:10of the G1 SDNA damage checkpoint
• 15:14making these cells much more reliant
• 15:18on G2 M and and also leading
• 15:20to accumulation of DNA damage,
• 15:22which might indicate the role
• 15:25for immunotherapy that I was
• 15:27just telling you about.
• 15:28So a long time ago in 1993,
• 15:30ECOG started a study of assessing P53
• 15:34status in optimally resected patients.
• 15:37So this was over 500 patients,
• 15:40all of them had margin negative surgery,
• 15:42all of them got contemporary best
• 15:46post operative management and then
• 15:48their P53 status was catalogue P53.
• 15:52Disruptive mutation in this study was
• 15:54defined as either a mutation in the DNA
• 15:57binding domain or a truncation mutation.
• 15:59And you can see that if you
• 16:01had a disruptive mutation,
• 16:02your hazard ratio for death was 1.7.
• 16:04And this actually held even
• 16:06for stage 1 patients.
• 16:08So we wanted to look at whether or not we
• 16:12could intensify therapy for these patients.
• 16:15But the first question was this
• 16:17rule that had been designed for
• 16:20the study in 1993 for what was
• 16:22a significant P53 mutation,
• 16:24was that really the best?
• 16:25And in the meantime,
• 16:26a number of computational and experimental
• 16:29algorithms had come out for calling
• 16:31the significance of P53 mutation.
• 16:33So we looked at all of these and compared
• 16:36them to the rules in our in our prior paper,
• 16:38which were called the POETA rules.
• 16:40And although the POETA rules outperformed
• 16:43all the other algorithms that we looked at,
• 16:46we could make them better by adding
• 16:48information about splice variants.
• 16:50And so this has gone forward as an
• 16:52integral biomarker actually for one
• 16:54of our current adjuvant trials.
• 16:56I'm working together with Erica Golemis,
• 16:59my long term collaborator at Fox
• 17:01Chase as well as Karis Biosciences.
• 17:05We've looked at over a 1000 HPV
• 17:09negative head neck cancers profiled
• 17:11in their system to see to,
• 17:13to reassure ourselves that these
• 17:15P53 mutations are actually having
• 17:17an impact on DNA repair.
• 17:19And so we looked at the proportion
• 17:21of patients that had a tumor mutation
• 17:24burden of greater than 15 per mega base.
• 17:27And we looked at P53 mutation,
• 17:29any CDK into a abnormality,
• 17:31some mutation or loss and then Co
• 17:33occurrence of those two mutations,
• 17:35which is actually a pretty common
• 17:37thing in head and neck cancer.
• 17:38And depending on how we called
• 17:40the P53 mutation,
• 17:43there was a different level of significance.
• 17:45But with the exception of the
• 17:47gain of function mutations,
• 17:48all the P53 mutation calls showed
• 17:51a significant increase in TMB,
• 17:52all the CDKN 2A mutation calls did.
• 17:55And if you saw the two together,
• 17:57which is as I mentioned quite common,
• 18:00that was the most dramatically significant.
• 18:02So we so we do think that this is
• 18:04evidence that P53 mutation leads
• 18:08to genomic instability.
• 18:10So we then wanted to explore what
• 18:12are the target,
• 18:13what are the the regulators of
• 18:17G2M that for which
• 18:21molecular therapies might be
• 18:23available or becoming available.
• 18:24And we focused in on mitotic
• 18:28entry kinase Aurora A and
• 18:30mitotic checkpoint kinase rewind.
• 18:33So Aurora A is a serine,
• 18:35the serine threonine kinase.
• 18:37Its canonical roles are in maturation
• 18:40of the spindle assembly complex and
• 18:43it's known to be regulated by P53.
• 18:46Its content is also controlled by a couple
• 18:48of binding partners that stabilize it,
• 18:51TPX 2 and Ned 9.
• 18:54And then we one is a mitotic
• 18:56checkpoint kinase and it exerts its
• 18:59activity by putting an inhibitory
• 19:01phosphorylation on CDK one.
• 19:03And for Aurora A,
• 19:04when we started this work,
• 19:06there was a, a drug called alisertib
• 19:08that had been in development.
• 19:10And for WE one,
• 19:11the lead compound for a long
• 19:13time had been adavasertib and,
• 19:15and we were able to to work
• 19:17with both of those.
• 19:18So I mentioned that P50
• 19:21threes regulates Aurora.
• 19:22So when you have loss of P53 you
• 19:25have increased Aurora levels.
• 19:27And we,
• 19:29we were able to develop an Aqua assay
• 19:33using insight to fluorescence to
• 19:38localize Aurora within the tumor compartment,
• 19:42which was labeled green for cytokeratin.
• 19:45And we did this on ATMA that
• 19:47we assembled at at Fox Chase.
• 19:49I don't know if you can see
• 19:50it with the lights on here,
• 19:51but the, the red,
• 19:53which is the Aurora kinase in,
• 19:55in these in the high expressors
• 19:57on top is localized to the nucleus.
• 19:59And that was something that we
• 20:01initially found very confusing.
• 20:02But hold that thought because I'm
• 20:04going to talk more about it.
• 20:06This is work from my lab here now
• 20:08looking at a number of either P53
• 20:11mutated or P53 null workhorse HPV
• 20:14negative cell lines that people
• 20:16use to study head neck cancer and
• 20:19all of them overexpress Aurora
• 20:21normal tracheobronchial epithelial
• 20:23cells and fibroblasts do not.
• 20:26And then we obtained as a kind gift
• 20:29from Jeff Myers at MD Anderson
• 20:31some isagenic cells for P53 either
• 20:33null gain of function or loss
• 20:36of function and looked at all
• 20:38of those regulators of G2M that
• 20:40that were potentially targetable.
• 20:42And as you can see Aurora A expression
• 20:45was far more abnormal than any
• 20:48of the other potential targets.
• 20:50This shows you the the survival
• 20:53curves from our Fox chase TMA.
• 20:55So for the cases that were HPV negative
• 20:59and overexpressed nuclear Aurora,
• 21:01a far worse survival,
• 21:05very statistically significant and
• 21:07that was independent of what kind of
• 21:10therapy the patients had received.
• 21:12At the same time,
• 21:12we were doing that work to explore
• 21:14whether or not Aurora would be a good target.
• 21:16The late Eddie Mendez's group at the
• 21:18Hutch had done a functional kinome
• 21:20analysis looking for potential
• 21:21hits in head neck cancer.
• 21:23Actually, if you read the paper,
• 21:24Aurora was a very strong hit in that paper.
• 21:26But the,
• 21:27the one that they pursued was we won
• 21:29and they were able to demonstrate
• 21:31that it enabled G2M arrest in P53
• 21:34null cells after DNA damage in the
• 21:36model they used with cisplatin.
• 21:38So that was around the time that
• 21:43my lamp here at, at Yale got going.
• 21:45And so we explored the combination
• 21:48of Aurora and we won inhibition.
• 21:50And this is very predominantly the work
• 21:53of John Woo Lee, who's here in the room.
• 21:56And I'll, I'll be mentioning
• 21:58his name over and over again,
• 22:00I think as well as some of the
• 22:02other great people in the lab.
• 22:03So anyway, the first thing that we
• 22:05did was we compared a davasortib,
• 22:08which is the wee one inhibitor,
• 22:09alasortib, which is the Aurora
• 22:11inhibitor of the combination.
• 22:12You can see that with the davasortib,
• 22:14as you might expect,
• 22:15if you're losing the mitotic checkpoint,
• 22:18there's a little bit more
• 22:20chromatin disaggregation,
• 22:21so a little bit more early mitosis alacertib,
• 22:25which effects spindle assembly.
• 22:27We saw these multipolar spindle
• 22:30cells and when we put them together,
• 22:32we saw micronuclei cell desegregation
• 22:36consistent with mitotic catastrophe.
• 22:38And Janaki Parameshwaran,
• 22:40who was one of the fellows in the lab,
• 22:42counted thousands of,
• 22:44of mitotic figures and demonstrated
• 22:46that with combination therapy,
• 22:48we essentially did not see normal mitosis.
• 22:52They we also used a,
• 22:54a flow for a Nexon 5 showing
• 22:56increase in the proportion of
• 22:58cells that were apoptotic as well
• 23:00as an increase in cleave part.
• 23:03So we started to try to dissect
• 23:05out how this was happening.
• 23:07And I,
• 23:08I'm going to try to walk you
• 23:10through this western which
• 23:11maybe is a little bit busy,
• 23:12but you can see either a Daviser to Balone,
• 23:15Aliser to Balone or combination.
• 23:17And if you focus on CDK one,
• 23:20which is that inhibitory,
• 23:21the cell cycle inhibitory phosphorylation
• 23:24that's mediated by WE one,
• 23:25you can see that after treatment with
• 23:28alacertib either at 8 hours or 24 hours,
• 23:30that is markedly up regulated.
• 23:32And if you add the WE one inhibitor
• 23:35that CDK one phosphorylation goes away.
• 23:40We validated this in animal models
• 23:43whether used high or low dose adavacertib.
• 23:46This was highly synergistic with
• 23:49significant improvement in animal survival.
• 23:51There weren't really any
• 23:53significant laboratory abnormalities
• 23:55except for mild cytopenia with
• 23:58adavasir TIB at the higher dose.
• 24:00We harvested tumor from those animals
• 24:03and looked at this under the microscope
• 24:06both for proliferation with Ki 67 which
• 24:09was markedly decreased with combination
• 24:11as well as cleaved castpase which was up.
• 24:14And then we used Aqua again to look for
• 24:18phospho CDK one in the tumor leading edge.
• 24:21So you can see here that the amount of of
• 24:25phospho CDK one goes down dramatically
• 24:28with combination therapy relative
• 24:31to either Aurora or untreated cells.
• 24:33And I don't know if again with the light,
• 24:37if you can appreciate,
• 24:38but you can also start to see some,
• 24:40some multi nucleated giant cells
• 24:42there in the combination arm.
• 24:44So around that time,
• 24:46Al Assertive disappeared from
• 24:47clinical development.
• 24:48Intriguingly, it's back now.
• 24:50So Puma Pharmaceuticals has picked it up,
• 24:53but we went looking for a second
• 24:56generation Aurora inhibitor and
• 24:58landed on what's now called Vic 1911.
• 25:01This is more strongly selective
• 25:03for Aurora A over Aurora B than
• 25:06the parent compound hip,
• 25:08good preclinical effectiveness and
• 25:09has been in phase one testing both
• 25:12his monotherapy and together with
• 25:14paclitaxel where it was found to
• 25:17be both tolerable and effective.
• 25:19So a lot of the,
• 25:20the next work that I'm going to do
• 25:22that I'm going to show you is was done
• 25:24with the second generation inhibitor.
• 25:26So we looked across head,
• 25:28neck cancer, lung cancer,
• 25:30pancreatic cancer cell lines and 12 of
• 25:33the 13 cell lines that we looked at,
• 25:35we saw a significant synergy and
• 25:38good effects on clonagenic survival.
• 25:40I'll talk to you a little bit
• 25:43later about SCC 61 and what may
• 25:45be different about that.
• 25:49We were able to demonstrate that in
• 25:53platinum resistance cells the effect
• 25:55of Aurora inhibition is maintained
• 25:57including in conogenic survival assays.
• 26:01And this just shows you the the
• 26:05unfocal microscopy to emphasize the
• 26:07the reliability with which we develop.
• 26:10We see these multipolar spindle
• 26:12cells forming with Aurora inhibition,
• 26:14so suggesting that the canonical
• 26:17activity on spindle assembly
• 26:19complex is is being achieved.
• 26:21And then the micronuclei that we
• 26:23see during mitotic catastrophe
• 26:24and using live cell imaging,
• 26:26you can see that with combination
• 26:28the micronuclei start to appear
• 26:30by about 27 hours.
• 26:34There's dose dependent effects and
• 26:36xenograft and you can see that at the
• 26:39highest doses which are doses that have
• 26:41been used in preclinical studies for
• 26:43monotherapy development of these agents.
• 26:45Actually the we see
• 26:48outstanding tumor control.
• 26:50There's no effect on normal,
• 26:53normal organs of these animals.
• 26:58We've developed a couple of
• 27:00HPV negative PDXS here at Yale.
• 27:02This is one that interestingly
• 27:04does not have AP 53 mutation but
• 27:07has loss of FANK A and MRE 11.
• 27:10And here you can see outstanding
• 27:13synergy of combination therapy.
• 27:15No effects on animal body weight.
• 27:17We've also taken this forward
• 27:19in P53 mutant lung cancer,
• 27:21where we see very similar effects
• 27:23both in xenografts and PDXS.
• 27:25And thanks to Katie Politi
• 27:27for sharing the PDXS.
• 27:30We've wanted to see whether or not our
• 27:33original hypothesis about P53 was holding.
• 27:35And so you can see that we do see
• 27:37synergy across a wild type and,
• 27:39and both loss of function and
• 27:41and gain of function mutations.
• 27:43But the effect is most strong with P53
• 27:47null or loss of function mutations.
• 27:49And so this led to a model that we
• 27:52that we had of how this was working
• 27:55in that we gave Aurora inhibition.
• 27:57This led to the expected effects on
• 28:00mitotic entry with the multipolar
• 28:03spindle formation.
• 28:04But that this led to cell cycle
• 28:06arrest and that we could abrogate
• 28:08that cell cycle arrest by giving a
• 28:11Wee 1 inhibitor and the cell with
• 28:12its four poles could not pull into
• 28:15two normal daughter cells when
• 28:17it was accelerated into mitosis.
• 28:20And this led to apoptosis and
• 28:22mitotic catastrophe.
• 28:23The only thing that was not 100% clear
• 28:26about this story was why we won.
• 28:29Was there to be inhibited in the 1st place?
• 28:31And I had shown you the data from
• 28:33Eddie Mendez in that functional kinome
• 28:35analysis that suggested that if you
• 28:37enhanced replication stress with platinum,
• 28:39maybe you would see we won.
• 28:41We hypothesized maybe it was hypoxia
• 28:44or the P53 mutation background was
• 28:47leading to elevated replication stress.
• 28:50I'm not gonna show you this,
• 28:51but the to the limited extent
• 28:53that we've tried replicating
• 28:54this under hypoxic conditions,
• 28:56it doesn't seem that much more dramatic.
• 29:00And so around this time we read a paper
• 29:02that indicated that there were some
• 29:05non canonical activities of Aurora A
• 29:08that perhaps we were also inhibiting
• 29:12and that these might explain the we
• 29:15one dependency that we were creating.
• 29:17So it was reported that TPX 2 bound
• 29:23to the DNA repair protein 53BP1 and
• 29:28that once Aurora was recruited,
• 29:31that complex then recruited BRCA 1 and
• 29:34that this that this complex ultimately
• 29:38protected stalled replication,
• 29:39replication forks from MRE 11 degradation.
• 29:43So we started to look at replication
• 29:46stress as a potential outcome
• 29:48of of these inhibitors.
• 29:49I don't know if people are familiar
• 29:51with this DNA fiber spreading assay,
• 29:54but you give a a red
• 29:56labeled chlorideoxyuridine.
• 29:57You then chase that with a
• 29:59green labeled IO deoxyuridine.
• 30:01If the replication force is progressing,
• 30:04you'll get a strip of red
• 30:05followed by a strip of green.
• 30:07But if it's not, you'll just see the
• 30:09red because the forks have arrested.
• 30:11And so as you can see here
• 30:15with either monotherapy,
• 30:16we see a little bit of decrease in the
• 30:19amount of green that gets incorporated.
• 30:21And then with combination, we see
• 30:23almost no replication fork progression.
• 30:25And this is, there's,
• 30:27there's a software out there
• 30:28for counting this week.
• 30:30We've heard that people are
• 30:31are not very happy with it.
• 30:32A a lot of this work was done
• 30:34by people in the lab.
• 30:36Julian Barantes, a really talented
• 30:38Yale undergrad named Jackie,
• 30:40she and Pratima Charasia.
• 30:41And so we looked at this across
• 30:44a number of different cell lines
• 30:46and we see this amplification of
• 30:49replication stress is measured
• 30:51by reduced fork progression in
• 30:53all of our sensitive models and
• 30:54we don't see it in SCC 61.
• 30:56And so we've been trying to figure
• 30:58out what's different about SCC 61.
• 31:00Just looking at the literature on
• 31:02this cell line it it is very highly
• 31:05expressing of Rand 54 L and DSCC
• 31:07one which may indicate just a a
• 31:09better background for DNA repair,
• 31:11but we have a lot more work
• 31:13to to figure that out.
• 31:15We've also looked at proximity ligand
• 31:17assays for our PCNA and RNA Pol
• 31:212 and accumulation of replication
• 31:24protein A at sites of replication
• 31:27for extolling in the we one field.
• 31:31The lead compound at DAVA Certib
• 31:33had was found to have a lot
• 31:35of toxicity when it went into
• 31:37combination with PARP inhibitors
• 31:38and ultimately has been withdrawn.
• 31:41There are a number of second generation
• 31:43inhibitors that seem to have much cleaner
• 31:45toxicity profiles moving forward.
• 31:46We've been working with a a
• 31:48company named Zentalis that's
• 31:52developing a Zen assertib and this
• 31:54has been moving forward predominantly
• 31:55I think in GYN malignancies.
• 31:57So far they've reported that
• 31:59cyclin E expression can be a
• 32:01favorable biomarker for this.
• 32:03And this is certainly something that
• 32:05was also touted for Adavasor Tib.
• 32:08But what we think we,
• 32:10we may not need to use that for this
• 32:12combination because we think that we're
• 32:14inducing it with the replication stress
• 32:16that the Aurora inhibitor is inducing.
• 32:19So here you see cells that were synchronized.
• 32:23They after they were released
• 32:26from synchronization,
• 32:27cyclone goes up in all of them,
• 32:28then it comes down in all of them.
• 32:30But if they're treated with the Aurora
• 32:32inhibitor alone or in combination,
• 32:34cyclone E is is up by 4 hours.
• 32:38We've also looked at RNA seek and this will
• 32:40come back around at the end of the talk.
• 32:42But we do see a compensatory up
• 32:45regulation of PLK one in these
• 32:48cells after Aurora inhibition.
• 32:49And then if,
• 32:50if we look sort of in a pathway
• 32:54process pathway way at what's
• 32:56happening with the RNA seek,
• 32:57we see significant focus both
• 33:00on mitotic cell processes as
• 33:02well as on replication stress.
• 33:05So the new model that we have
• 33:07incorporates the old model.
• 33:09So the allocer Tib leads to
• 33:11the weird spindle formation.
• 33:13We one inhibitor allows this
• 33:16incompetent cell to enter mitosis
• 33:18and and lead to mitotic catastrophe.
• 33:21But we've supplemented this now
• 33:23with the with the notion that
• 33:26amplifying replication stress with
• 33:28Aurora inhibition is necessary to
• 33:31creating this we one dependency.
• 33:34This is the the new agent that
• 33:36that we're working with.
• 33:37As I mentioned a Zen assertib,
• 33:39it's been through phase one both
• 33:41in monotherapy and is tolerable in
• 33:43combination with a large number of
• 33:46conventionally cytotoxic agents.
• 33:48And we've been able to show that we
• 33:52see very similar synergy with a Zen
• 33:55assertib as we did with a DAVA certib.
• 34:01Yes, OK. So that, that that part of
• 34:05the talk sort of encompasses why
• 34:07we've gotten so interested in using
• 34:09this Aurora we won combination.
• 34:11And I'll, I'll talk to you a
• 34:13little bit later about how we've
• 34:14taken this forward to combo match.
• 34:16Another way in which Aurora has
• 34:19become very interesting is for
• 34:20its role in adaptive resistance.
• 34:22And I think many of you may
• 34:24know Katie Politi's work on this
• 34:26in ASA Mertonib resistance.
• 34:27But so we wanted to ask whether
• 34:30coordinated inhibition of these
• 34:32mitotic entry and mitotic checkpoint
• 34:34kinases would also be effective
• 34:36in resistance that's in adaptive
• 34:38resistance that's Aurora driven.
• 34:40And I'm gonna tell you both one
• 34:42story where it looks like that's
• 34:43true and then a countervailing
• 34:45example where it doesn't look like
• 34:46it's true and why I think that is
• 34:50so. And and I should say that I'm
• 34:55extremely grateful to the Yale Sporin
• 34:57lung cancer for the pilot funds
• 34:59that allowed us to do this project,
• 35:01this part of the project.
• 35:02So people probably just spent a
• 35:05couple days at West Campus learning
• 35:08a lot about lung cancer and you'll
• 35:10be familiar that we now have
• 35:12direct inhibitors of K Ras G12C,
• 35:14which is an important driver
• 35:15in non small cell lung cancer.
• 35:17And that although these agents are
• 35:20very clearly highly active with
• 35:22response rates in the 40 to 50% range,
• 35:25they have median progression free
• 35:27survivals of only six or seven
• 35:29months related to both
• 35:34adaptive resistance and mutational
• 35:36resistance that develops And the
• 35:39adaptive resistance is Aurora dependent
• 35:41and goes through map kinase signaling.
• 35:44And this was very beautifully worked
• 35:47out by Pure Alito's group in in a
• 35:50publication a few years ago in nature.
• 35:52And so we kind of perked up because we're
• 35:56interested in Aurora and understood that
• 35:58Aurora is a key effector of KRAS signaling.
• 36:02It phosphorylates Ralgef and Ral A and
• 36:06this enhances KRAS driven to moragenesis.
• 36:10And so we and and in the original
• 36:13Purelita paper,
• 36:14they had shown that knockdown of
• 36:17Aurora A abrogated that effect.
• 36:20So we looked at the combination of an an
• 36:24Aurora inhibitor and sodorasib in K Ras
• 36:27G12C driven non small cell lung cancer cells.
• 36:31And I'm just going to talk you through the
• 36:34middle part of I don't know if you're able
• 36:37to see my not really able to see this.
• 36:39Are you all right talking about
• 36:45this? So we created a a quiescent cell
• 36:49reporter by M Cherry labeling of P27
• 36:53and exposed cells either to the Aurora
• 36:56inhibitor sotorasib or the combination.
• 36:58And if you focus on that little blue
• 37:02hump in the sotorasib treated cells,
• 37:06those are cells that are non quiescent
• 37:08that are escaping from sotorasib and
• 37:10that's through and you can see the
• 37:14phospho URC that goes that
• 37:16goes up as that happens.
• 37:17And we're able to abrogate that
• 37:19by adding an Aurora inhibitor.
• 37:21And so we've looked at synergy.
• 37:24We do see synergy with Aurora
• 37:26inhibition and sotorasib in these,
• 37:28in these models. If we look at
• 37:36the combination of Aurora and we one
• 37:39inhibition, we see again the very similar
• 37:42phenotypes with multipolar spindle
• 37:43cells when we give an Aurora inhibitor
• 37:46mitotic catastrophe when we give the
• 37:49combination again very few normal
• 37:51mitotic cells after combination therapy.
• 37:53And so we see this as oh,
• 37:56and I forgot to tell you that we've
• 37:59also confirmed this in animal models,
• 38:00which is at the far right.
• 38:02You can see the,
• 38:04the blue line is the combination therapy.
• 38:06And even after three cycles of therapy,
• 38:09these cells are or these tumors
• 38:11are still sensitive.
• 38:12So we have taken this to combo match.
• 38:16So for those of you who are not
• 38:18in the clinical trial field,
• 38:20when you're doing work with novel
• 38:23targeted therapies where you may be
• 38:26working with small drug companies
• 38:27and they have one of the drugs that
• 38:29you want to use in your combination
• 38:31but not the other.
• 38:32It's historically been very difficult
• 38:35to conduct trials of combinations.
• 38:37And this has been a a major barrier
• 38:40in the field of,
• 38:41of synthetic lethal therapies.
• 38:44And so the NCI working together with
• 38:47the cooperative groups has started
• 38:49this mechanism called combo match
• 38:51where they will do single trial Cradas
• 38:53with the companies for that drug
• 38:55and provide support for doing a a
• 38:59phase two trial with the combination.
• 39:02So we took this concept to combo
• 39:05match proposing a combination of as
• 39:08an assertive with BIC 1911 with a
• 39:11primary endpoint of objective response rate,
• 39:14secondary endpoints of progression
• 39:15free survival,
• 39:16toxicity and duration of response.
• 39:19All of the combo match trials
• 39:21require biopsy and you have the
• 39:23opportunity on baseline material
• 39:24to do extensive correlatives.
• 39:26And we propose P53 mutation class comb
• 39:29mutation markers of replication stress.
• 39:32And in work that comes from Faye
• 39:33Johnson's group at MD Anderson and she's
• 39:36a partner with me on this proposal,
• 39:38IHC for retinoblastoma.
• 39:40We've met with the NCI combo
• 39:44match statistical team and the
• 39:47agreement is for three cohorts of
• 39:50P53 mutated solid tumor patients.
• 39:52Firstly,
• 39:52recurrent metastatic head neck cancer
• 39:55that's platinum and PD1 inhibitor,
• 39:57refractory or ineligible non small
• 40:00cell lung cancer that's progressed
• 40:02on two prior lines of therapy
• 40:04that's P53 mutated including
• 40:07KRAS G12C that's post inhibitor.
• 40:10And we wrote sotorasib and adagrasib,
• 40:12but I'm learning that there are
• 40:14many new drugs coming in this field
• 40:15and then other solid tumors that
• 40:17are P53 mutated and have progressed
• 40:19on two prior lines of therapy.
• 40:23The experience with the NCI statistical
• 40:26folks was interesting and we learned
• 40:29that it's very necessary to have a
• 40:31futility analysis for a trial like this.
• 40:33And so we have generated one of
• 40:35those and they are also recommending
• 40:37that we have a rapid phase one,
• 40:39which there's a mechanism for
• 40:41doing in the ETCTN.
• 40:44OK,
• 40:45so that the the K Ras story was
• 40:48my example of where I think Aurora
• 40:50and we won seems to work in the
• 40:53face of adaptive resistance.
• 40:55And now I'm going to tell you a story that
• 40:57where it doesn't seem to work.
• 40:58And this is work from Seb
• 41:00Cruz Gomez in the lab.
• 41:02And this isn't an HPV positive model.
• 41:05And I think you might remember
• 41:06from the beginning of the talk,
• 41:07I said P53 is disrupted in head neck cancer,
• 41:11but it's because the viral oncoproteins
• 41:14are degrading a wild type P53 and
• 41:17in response to replication stress,
• 41:18you can actually see that
• 41:20these cells up regulate P53.
• 41:22And so I think that that maybe is
• 41:24why we're not seeing the effect here.
• 41:27But So what Seb has has been working
• 41:30on is the Aurora mediated adaptive
• 41:33resistance to pan her inhibitors.
• 41:36And so I'll,
• 41:37I'll start by summarizing a lot of
• 41:39background and say that EGFR inhibitors
• 41:42in general have not appeared very
• 41:44active in HPV positive cancer.
• 41:46And this was initially believed to
• 41:48be because of PIC 3 CA mutation or
• 41:51because there wasn't a lot of EGFR around.
• 41:54I think that that's probably not true,
• 41:56but a recent publication from Jenny
• 41:58Grandis and Silvio Gookin showed
• 42:00that the viral onchoproteins actually
• 42:02drive expression of her three.
• 42:04And Seb is now also seeing that
• 42:06there's her two expressed here.
• 42:08So he's moved from using a conventional
• 42:11EGFR inhibitor like erlatinib
• 42:13to pan her inhibitors.
• 42:16One of the other projects in our
• 42:18spore has to do with optimizing pan
• 42:22Hearn inhibitors for head neck cancer
• 42:24based on Mark Lemons observation
• 42:26that the conformational specificity
• 42:27of these agents is very important
• 42:30and we've taken a hint from him and
• 42:32moving from a fat NIB to decamitnib.
• 42:34And as I think you can see here,
• 42:36there's strong synergy for decamitnib with
• 42:40our second generation Aurora inhibitor.
• 42:43What mediates this here we think
• 42:46is an EMT like process.
• 42:48And I think you can appreciate
• 42:51here the up regulation of Ned 9,
• 42:53whether we're using a fat nib
• 42:56or a dacomitinib.
• 42:57This has been confirmed
• 42:59in our RNAC experiments.
• 43:02He's able to show marked synergy for
• 43:05these agents in in xenograft models.
• 43:08And the the way this experiment goes
• 43:11is he treats the the mice for 19
• 43:13days and then he sacrifices them.
• 43:15But he kept three alive in each
• 43:18group and we're now out to about
• 43:20six weeks and no tumor has regrown
• 43:22in the combination animals.
• 43:24So we think that that's pretty,
• 43:25pretty interesting
• 43:29in terms of what potentially is driving
• 43:33resistance to that combination.
• 43:35We do see pretty dramatic up regulation
• 43:37of PLK one in the treated cells.
• 43:40And part of our stand up to cancer
• 43:42grant has allowed us to collaborate
• 43:45with the Mandy Paulson group at Fred
• 43:47Hutch really expert proteomics group.
• 43:49And so they've been performing
• 43:52shotgun proteomics on on cell line
• 43:57experiments that Seb has done.
• 43:59And we see this very dramatic
• 44:01up up regulation of PLK 1 as a
• 44:04potential resistance mechanism.
• 44:06So he's taking this forward in
• 44:08combination with PLK 1 inhibitors
• 44:10with very strong activity.
• 44:12And this is LED us to go back to it
• 44:15also in our HPV negative models where
• 44:18we see pretty strong synergy for PLK 1
• 44:22inhibition with with we one inhibition.
• 44:26And so we're planning to take
• 44:28that forward into animal models.
• 44:29This work represents so many
• 44:32contributions from so many people.
• 44:34I, I first want to call out the
• 44:36amazing groups in the head.
• 44:38Next, four, We have three projects.
• 44:41One, as I mentioned on
• 44:45specificity for P and her
• 44:46inhibitors led by Joe Contessa,
• 44:48Kate Ferguson and Mark Mark Lemon.
• 44:51Our project that I've just been
• 44:52telling you all about with synthetic
• 44:54lethal therapy and the demethylation
• 44:56project that I alluded to earlier on,
• 44:59Arnala Stoppe is here.
• 45:00She's been our very capable
• 45:02administrator for the team.
• 45:04We have great cores and
• 45:07developmental programs.
• 45:08And then I particularly want
• 45:09to thank the people in my lab,
• 45:12Jong Muli, Pratyama, Chaurasia,
• 45:15Sebastian, Jackie Shee,
• 45:16Mei Jin and Dixon Adah.
• 45:19And then I also just have to call out
• 45:22our collaborators at at Fox Chase,
• 45:25the Hutch, MD Anderson and Georgetown.
• 45:27So I left some time for questions.
• 45:29Thank you,
• 45:37Roy.
• 45:40September in Bangkok, that was
• 45:42when Dixon joined us. You mentioned
• 45:48that you went to targeted therapy,
• 45:49but immunotherapy only worked at
• 45:515%. So the mechanisms of resistance
• 45:54and this type of paths are any different
• 45:55than what we see elsewhere. And
• 45:57would you be, is it,
• 45:57is it T cell exclusion? Is it
• 46:00regulatory cells?
• 46:00Do you have any sense on that?
• 46:02Yeah. So I, I, I think we've
• 46:07come back again and again to,
• 46:11and this is not for true for
• 46:12I think for the HPV positive
• 46:14where I'm extremely enthusiastic
• 46:15about the demethylation story.
• 46:17But in the HPV negative a lot
• 46:20of things have failed. So sting,
• 46:22sting agonists haven't gone anywhere,
• 46:24OX40 and it looks really like our best
• 46:30combination partner to date is Platinum.
• 46:32So we're trying to figure out,
• 46:35you know what's different about head neck
• 46:37cancer compared to even lung cancer,
• 46:38which genomically is so similar,
• 46:40right And the the tumor microenvironment,
• 46:45I think in head neck cancer it
• 46:47has a lot of hallmarks that are
• 46:49very hostile to immune cells.
• 46:51So we have very high concentration
• 46:54of cancer associated fibroblasts,
• 46:56lots of MDS,
• 46:57CS macrophages are predominantly M2
• 47:00and then the tumor is just in a very
• 47:04fibrotic background that's actually
• 47:05difficult for T cells to to migrate into.
• 47:09And so you know that the interest in
• 47:13platinum is both is it killing MDSCS and
• 47:15is it disrupting this architecture in
• 47:18a way that T cells can can migrate in better.
• 47:21So, so we are working with,
• 47:24we've had clinical trials here
• 47:27with Papinimab,
• 47:28which is a semaphore, a inhibitor.
• 47:33We have a,
• 47:34a umbrella trial coming from GSK with a
• 47:38couple of different combination partners.
• 47:40But to be honest,
• 47:42I think it's not so much that,
• 47:43you know,
• 47:44this is a very PDL 1 expressing cancer.
• 47:48I think the PDL 1 inhibitors work.
• 47:51I think it's that the the environment for the
• 47:53T cells when they get there is is different.
• 47:55And I think that that's why the
• 47:57Co stimulatory approaches have
• 47:58not been so successful.
• 47:59Kurt I signature and I was
• 48:07wondering if you saw any
• 48:11synergy between, you know,
• 48:13P1 inhibitor by visa in those.
• 48:17Yeah. So we've just actually started
• 48:19sending the samples off for methylation.
• 48:21We we don't have any data about that yet,
• 48:22but we've had the same thought Karen.
• 48:27Fantastic. You know, when
• 48:29you think of head and neck cancers
• 48:30that I'm not certainly an expert,
• 48:31but it seems like local regional
• 48:33therapies seem to work pretty well for how
• 48:37do you vision this word say translating
• 48:40to the clinical space and number one,
• 48:43the three cancerous lesions.
• 48:44So like do you think this will
• 48:46translate into that documentation?
• 48:48And 2nd, how do you think it translated
• 48:50around local regional therapy?
• 48:52Like you envisioned this being
• 48:53only for the metastatic side or do
• 48:55you think that these pathways are
• 48:57activated even if those that get
• 48:58cured or at least get local regional.
• 49:01Yeah. So I think in HPV negative disease,
• 49:06the, the possibility of doing a window
• 49:10trial to answer that question is,
• 49:12is quite reasonable.
• 49:15Just to go back to Roy's question,
• 49:17A a very interesting observation
• 49:19in head neck cancer is that
• 49:22neoadjuvant immunotherapy works
• 49:23much better than immunotherapy
• 49:25in the chemo radiation setting or
• 49:27the recurrent metastatic setting.
• 49:29And there's also a lot of interest
• 49:31and I see Mike Chiairazzi sitting
• 49:32here and and he's working on this in
• 49:36what what is it that our standard
• 49:39therapy is doing to tumor draining
• 49:40lymph nodes that might really be
• 49:42wiping out part of the immune response.
• 49:44So I actually am am expecting that we'll
• 49:47see a lot more use of immunotherapy
• 49:49in the new adjuvant setting.
• 49:52Why we haven't been able to incorporate
• 49:55immunotherapy with chemo radiation I think
• 49:57is a whole other long talk in and of itself.
• 50:00But clearly the fact that the studies
• 50:03were done with no patient selection
• 50:06and that the immunotherapy was started
• 50:08at the same time as the radiation,
• 50:10so all the T cells were migrating right
• 50:12into the radiation field probably were
• 50:14two major limitations of those studies.
• 50:16So I think we'll see a lot more
• 50:19neoadjuvant immunotherapy maybe
• 50:20in combination with chemotherapy,
• 50:22which seems to have a very high
• 50:23response rate.
• 50:24So I do think that I'm,
• 50:25I'm mostly thinking about
• 50:27this approach for recurrent
• 50:29metastatic disease and tumors like
• 50:36a small cell also activity
• 50:39of Alistair especially fit
• 50:44out. Do you have some cell lines?
• 50:45Yeah, we'd love to.
• 50:50Yeah, we have not done it,
• 50:51but that would be cool
• 50:59interest with the new agents.
• 51:00Yeah, OK, great.
• 51:04So why doesn't head neck cancer
• 51:07metastasize distant sites as much as
• 51:11it's because it it does.
• 51:14So there there's a, a really cool
• 51:17paper from the Chicago Consortium,
• 51:19University of Colorado and Northwestern,
• 51:22actually written by a former Yale
• 51:25fellow that shows that as your
• 51:27local regional therapy improves,
• 51:29the rate of distant metastases goes up.
• 51:32And so, you know,
• 51:34I think it's a matter of the fact that
• 51:37it's so prone to local regional recurrence,
• 51:40particularly when it's HPV
• 51:42negative that has LED that to.
• 51:44But if you look at the
• 51:45current immunotherapy trials,
• 51:46about 1/3 of the patients local regional,
• 51:48only a third distant Mets,
• 51:50a third both.
• 51:52We never have adequate power to
• 51:55address the distant Mets question
• 51:57in our chemo radiation studies.
• 51:59But
• 52:03right, that's totally related to your talk.
• 52:06But you did mention that that cancer,
• 52:07the disparities that exist and I
• 52:11think you have before with mentions.
• 52:15Can you say a few words about
• 52:17anything here? Actually,
• 52:25yeah. And and I'm sorry, I sort of
• 52:26let that part of Karen's question go.
• 52:28But so our surgeons go out in April,
• 52:31which is head neck cancer awareness
• 52:33month and they do a lot of free
• 52:36events where they screen people. The
• 52:41recruitment of Sarah pay to
• 52:43to the surgery department.
• 52:44She has a, a head grant from an IDCR looking
• 52:48at preclinical models of, of prevention.
• 52:52Curtis Pickering who joined us from
• 52:54MD Anderson about two years ago is,
• 52:57is funded in, in oral pre malignancy.
• 53:00So I think we, we are developing a program,
• 53:04I think Sarah's assembling a,
• 53:05a, a, a tissue bank.
• 53:08I think that that's something that
• 53:09that you can expect to see more sure
• 53:17in the graph.
• 53:28All of our models are P53 mutated.
• 53:35Ok. Thank you.