1. New Hormonal Therapies Roberto Iacovelli The New era of CRPC: few targets for a pletora of agents! ADT Docetaxel Abiraterone Cabazitaxel Alpharadin MDV3100 Sipuleucel-T PD TAK700 Hormonal therapy Chemotherapy Radiometabolic therapy Immunotherapy Legend:

2. New Hormonal Therapies Roberto Iacovelli Current strategies for androgen inibition in CRPC AR Abiraterone TAK700 Bicalutamide MDV3100 LH-RHa

3. New Hormonal Therapies Roberto Iacovelli Molecular basis for Androgen inibition in CRPC Dillard et al. Mol Cell Endocrinol. 2008 Negative control CRPC cells Hormon sensitive PCa Il recettore per l’androgeno (AR) è espresso (RNA) sia nei tumori sensibili che resistenti alla castrazione

4. New Hormonal Therapies Roberto Iacovelli Molecular basis for Androgen inibition in CRPC H&E AR staining PSA staining Metastasis of CRPC BP=benign prostate tissue; CP=Prostate cancer; METS=castration- resistant metastatic tumor Montgomery et al. Cancer Res 2008;68:4447-4454.

5. New Hormonal Therapies Roberto Iacovelli Molecular basis for Androgen inibition in CRPC Normal epithelium CRPC cells Control CYP17 is not expressed in normal prostatic epithelium CYP17 is expressed in CRPC cells. CRPC cells Hormon sensitive PCa CYP17 is not expressed in hormone sensitive cells.

6. New Hormonal Therapies Roberto Iacovelli Molecular basis for Androgen inibition in CRPC Montgomery et al. Cancer Res 2008;68:4447-4454. Expression of steroidogenic enzyme transcripts in primary and metastatic prostate tumors BP=benign prostate tissue; CP=Prostate cancer; METS=castration-resistant metastatic tumor

7. New Hormonal Therapies Roberto Iacovelli Molecular basis for Androgen inibition in CRPC CRPC cell acquires the ability to product itself testosterone from cholesterol by CYP17

8. New Hormonal Therapies Roberto Iacovelli Molecular basis for Androgen inibition in CRPC Hormone sensitive PCa cell CRPC cell AR CYP17 Testosterone PARACRINE Pathway AUTOCRINE Pathway Increase of malignancy ENDOCRINE Pathway

9. New Hormonal Therapies Roberto Iacovelli Molecular basis for Androgen inibition in CRPC Efstathiou E. Clin Cancer Res 2010;16:1100-1107

10. New Hormonal Therapies Roberto Iacovelli Targeting CYP17 Iacovelli et al. Anti-Cancer Drugs 2011. CYP17 CYP17 inhibitor

11. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate Baseline PSA Progression Tumor/Bone Progression Pain Death Chemotherapy ECOG PS Decline Increase OS Increase the time to chemotherapy 24-48 months Proved efficacy in post docetaxel patients A new molecule who meet oncological need in prostate cancer: Adapted from Halabi S. J Clin Oncol. 2009;27: 2766-2771 Ryan et al. ASCO 2012; Abstract LBA4518 (Oral Presentation)

12. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate: proves of efficacy Iacovelli et al. Anti-Cancer Drugs 2011. Abiraterone acetate CRPC chemo- naïve CRPC TXT pretreated 1 phase III Trial 3 phase II Trials 1 phase I Trial

13. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate CRPC TXT pretreated Patients with mCRPC progressing after 1-2 chemotherapy regimens, 1 of which contained docetaxel (N = 1195) Abiraterone acetate 1000 mg/day + Prednisone 5 mg BID (n = 797) Placebo + Prednisone 5 mg BID (n = 398) Stratified by ECOG PS, worst pain over previous 24 hrs, previous chemotherapy, type of progression de Bono JS et al. N Engl J Med. 2011;364:1995-2005. Randomized 2:1 Study stopped at planned interim analysis at 534 events because OS improvement crossed predetermined stopping boundary Abiraterone acetate: selective inhibitor of androgen biosynthesis that blocks CYP17 activity Primary endpoint: OS

14. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate PboABI Median OS, mos10.914.8 HR0.65 95% CI0.54-0.77 P value<.0001 PboABI Median PFS, mos3.65.6 HR0.58 95% CI0.46-0.73 P value<.0001 OSPFS CRPC TXT pretreated

15. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate Adverse Events Treatment-Related AEs, %Abiraterone Acetate (n = 791) Placebo (n = 394) All GradesGrade 3/4All GradesGrade 3/4 All treatment-related AEs99559958 Fluid retention312221 Hypokalemia17381 Cardiac disorders*133112 Hypertension1018< 1 LFT abnormalities10383 de Bono JS, et al. N Eng J Med. 2011;364:1995-2005. Scher HI, et al. ASCO GU 2011. Abstract 4. *Most frequent cardiac disorders were tachycardia and atrial fibrillation.

16. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate Phase 3 multicenter, randomized, double-blind, placebo-controlled study conducted at 151 sites in 12 countries; USA, Europe, Australia, Canada Stratification by ECOG performance status 0 vs. 1 AA 1000 mg daily Prednisone 5 mg BID (Actual n = 546) AA 1000 mg daily Prednisone 5 mg BID (Actual n = 546) Co-Primary: rPFS by central review OS Secondary: Time to opiate use (cancer- related pain) Time to initiation of chemotherapy Time to ECOG-PS deterioration TTPP Efficacy end points Placebo daily Prednisone 5 mg BID (Actual n = 542) Placebo daily Prednisone 5 mg BID (Actual n = 542) R A N D O M I Z E D 1:1 R A N D O M I Z E D 1:1 Progressive chemo- naïve mCRPC patients (Planned N = 1088) Asymptomatic or mildly symptomatic Patients Ryan et al. ASCO 2012; Abstract LBA4518 (Oral Presentation) CRPC chemo- naïve

17. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate AA + P (n = 546) Placebo + P (n = 542) Median age, years (range)71 (44-95)70 (44-90) Median time from initial diagnosis to first dose (years)5.55.1 Median PSA (ng/mL)42.037.7 Median testosterone (ng/dL)4.0 Median alkaline phosphatase (IU/L)93.090.0 Median hemoglobin (g/dL)13.013.1 Median lactate dehydrogenase (IU/L)187.0184.0 Gleason score (≥8) at initial diagnosis54%50% Extent of disease Bone metastases >10 bone lesions Soft tissue or node 83% 48% 49% 80% 47% 50% Pain (BPI Short Form) 0-1 2-3 66% 32% 64% 33% Ryan et al. ASCO 2012; Abstract LBA4518 (Oral Presentation) CRPC chemo- naïve Treatment Arms Evenly Matched

18. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate: PFS 100 80 60 40 20 0 0 Progression-Free (%) 369151812 546 542 489 400 340 204 164 90 12 3 0000 AA PL 46 30 Time to Progression or Death (Months) AA + P PL + P AA + P (median, mos):NR PL + P (median, mos):8.3 HR (95% CI):0.43 (0.35-0.52) P value:< 0.0001 CRPC chemo- naïve Ryan et al. ASCO 2012; Abstract LBA4518 (Oral Presentation)

19. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate: OS CRPC chemo- naïve 546 542 538 534 482 465 452 437 27 25 0000 524 509 503 493 0202 120 106 258 237 412 387 100 80 60 40 20 0 0 Survival (%) 3121527 Time to Death (Months) 33 AA + P PL + P 6930242118 AA PL AA + P (median, mos):NR PL + P (median, mos):27.2 HR (95% CI):0.75 (0.61-0.93) P value:0.0097 Ryan et al. ASCO 2012; Abstract LBA4518 (Oral Presentation)

20. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate: secondary end-points AA + PPlacebo + P Median (months) HR (95% CI)P Value Time to opiate use (cancer related pain) NR23.7 0.69 (0.57, 0.83) 0.0001 Time to chemotherapy initiation 25.216.8 0.58 (0.49, 0.69) <0.0001 Time to ECOG PS deterioration 12.310.9 0.82 (0.71, 0.94) 0.0053 Time to PSA progression 11.15.6 0.49 (0.42, 0.57) <0.0001 Patient Reported Outcomes favored AA +P vs. Placebo +P Full data to be reported Note: All secondary end points remain significant after adjusting for multiplicity testing CRPC chemo- naïve Ryan et al. ASCO 2012; Abstract LBA4518 (Oral Presentation)

21. AA + P (n = 546) n (%) Placebo + P (n = 542) n (%) No. with selected subsequent therapy for mCRPC 242 (44.3)327 (60.3) Docetaxel207 (37.9)287 (53.0) Cabazitaxel45 (8.2)52 (9.6) Ketoconazole39 (7.1)63 (11.6) Sipuleucel-T27 (4.9)24 (4.4) Abiraterone acetate*26 (4.8)54 (10.0) *Prior to unblinding (e.g. not per protocol) New Hormonal Therapies Roberto Iacovelli Abiraterone acetate: Subsequent Therapy Was Common CRPC chemo- naïve Despite 16% of patients did not receive subsequent therapy compared to placebo, AA increase OS!

22. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate Adverse Events Treatment-Related AEs, %COU-AA-301 (n = 791) COU-AA-302 (n = 542) All GradesGrade 3/4All GradesGrade 3/4 All treatment-related AEs9955NA Fluid retention312280.7 Hypokalemia173 2 Cardiac disorders*133196 Hypertension101224 LFT abnormalities103 ALT increase 104 125.4 AST increase113 de Bono JS, et al. N Eng J Med. 2011;364:1995-2005. Scher HI, et al. ASCO GU 2011. Abstract 4. *Most frequent cardiac disorders were tachycardia and atrial fibrillation.

23. New Hormonal Therapies Roberto Iacovelli Totalmente dipendente da T circolante >20-50 ng/dl DIPENDENTE da T circolante  20-50 ng/dl IPERSENSIBILE INDIPENDENTE da T circolante - autoproduzione T AR normale No enzimi produzione T AR ipersensibile o iperespresso sintesi di alcuni enzimi produzione T AR ipersensibile o iperespresso sintesi di TUTTI gli enzimi produzione T AR stimolato anche aspecificamente sintesi enzimi produzione T Abiraterone acetate: Correct timing

24. Cytoreduction and androgen signaling modulation by abiraterone acetate (AA) plus leuprolide acetate (LHRHa) versus LHRHa in localized high-risk prostate cancer (PCa): Preliminary results of a randomized preoperative study. AA 1000 mg daily Prednisone 5 mg BID + LHRHa for 12 wks AA 1000 mg daily Prednisone 5 mg BID + LHRHa for 12 wks Co-Primary: difference in down staging (≤ ypT2) safety Secondary: difference in androgen biosynthesis, androgen signaling, proliferation apoptosis and candidate treatment resistance pathways. Efficacy end points LHRHa For 12 wks LHRHa For 12 wks R A N D O M I Z E D 2:1 R A N D O M I Z E D 2:1 high risk PCa (clinical stage ≥T1c and biopsy Gleason score ≥8, or ≥T2b, Gleason ≥ 7 and PSA > 10ng/ml). Patients AA+LHRHaLHRHa ypT2N0 60%33% Near pCR24%8% N+28%50% R18%33% Results:

25. New Hormonal Therapies Roberto Iacovelli Abiraterone acetate 35% of patients had PD as best response a 3 mos with Abiraterone. What is the mechanism of resistance?

26. New Hormonal Therapies Roberto Iacovelli Enzalutamide (MDV3100)

27. New Hormonal Therapies Roberto Iacovelli Enzalutamide (MDV3100)

28. New Hormonal Therapies Roberto Iacovelli Enzalutamide (MDV3100) Antitumor activity of Enzalutamide in Phase I/II study Scher HI, et al. Lancet 2010;375:1437 Activity seems to be independent of previous chemotherapy

29. New Hormonal Therapies Roberto Iacovelli Enzalutamide (MDV3100) The AFFIRM Trial Design Primary End-Point: OS Stratification variables: ECOG-PS, meand BPI (<4, ≥4) Statistical design: power 90% to detect a 24% reduction in mortality (target HR= 0.76).

30. New Hormonal Therapies Roberto Iacovelli Enzalutamide (MDV3100) Baseline patient demographics:

31. New Hormonal Therapies Roberto Iacovelli Enzalutamide (MDV3100) RESULTS: The AFFIRM study was halted and unblinded after the interim analysis (520 events). Target 0.76!

32. New Hormonal Therapies Roberto Iacovelli Enzalutamide (MDV3100) RESULTS: PSA response rate, PSA-PFS and Time To First Skeletal Event HR denosumab vs placebo 0.84!* *Smith MR et al. Lancet 2012

33. New Hormonal Therapies Roberto Iacovelli Enzalutamide (MDV3100) RESULTS: Survival benefit across all subgroups

34. New Hormonal Therapies Roberto Iacovelli Enzalutamide (MDV3100) RESULTS: Safety

35. Conclusions Androgen pathways is the driver of tumor progression of prostate cancer. Resistance to LHRHa don’t mean resistance to all hormonal strategies. CYP17 and AR are the main targets of new hormonal therapies The sequential use of these agents may be feasible but not proven in large prospective trial. Precocious use of new agents seems to be more active.

36. Hormonal strategies in CRPC: it’s only the beginning…

37. New Hormonal Therapies Roberto Iacovelli Q&A Durante il trattamento l’analogo deve essere proseguito? È Possibile rinunciare al trattamento con prednisone? In controllo con placebo o Prednisone è idoneo?

38. AA + P (n = 546) Placebo + P (n = 542) RR (95% CI)P Value PSA decline ≥50%62%24%NA<0.0001 N=220N=218 RECIST: Defined objective response Complete response Partial response Stable disease Progressive disease 36% 11% 25% 61% 2% 16% 4% 12% 69% 15% 2.273 (1.591, 3.247) <0.0001 The AFFIRM study reported a PSA decline >50% in 2% of patients treated with placebo alone! New Hormonal Therapies Roberto Iacovelli Is prednisone an active control for CRPC?