Immunotherapy in Cancer: From Principles to Practice This program is supported by educational grants from Bristol-Myers Squibb and Merck.

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Core Faculty Program Director Michael B. Atkins, MD Deputy Director Lombardi Comprehensive Cancer Center Georgetown University Washington, DC Julie Brahmer, MD Associate Professor of Oncology Oncology/Upper Aerodigestive Cancer Program Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Baltimore, Maryland This slide lists the faculty who were involved in the production of these slides.

Faculty Disclosures Michael B. Atkins, MD, has disclosed that he has received consulting fees from Bristol-Myers Squibb, Genentech, and Merck. Julie Brahmer, MD, has disclosed that she has received consulting fees from Eli Lilly and Merck.

Tumor Immunology: Overview perforin granzyme cytokines Resting T cell Activated T cell TUMOR LYMPH NODE T cell clonal expansion Tumor antigen TCR CD28 MHC, major histocompatibility complex; TCR, T cell receptor. MHC B7 Dendritic cell

Tumor-Derived Immune Suppression Tumors go to great lengths to evade the immune response Systematic studies have identified multiple mechanisms cancers employ to defeat the immune response Immunosuppressive cytokines: TGF-β, IL-4, -6, -10 Immunosuppressive immune cells: T-regs, macrophage Disruption of immune activation signaling: loss of MHC receptor, IDO production Goal: therapy strategies that “liberate” underlying anticancer immune responses Immune checkpoints not even in the picture in 2008! IDO, indoleamine 2,3-dioxygenase; IL, interleukin; MHC, major histocompatibility complex; TGF-β – transforming growth factor beta; T-regs, regulatory T cells. Weiner LM. N Engl J Med. 2008;358:2664-2665.

HD IL-2 Therapy: Durable Responses HD IL-2 produces durable responses in 6% to 10% of patients with advanced melanoma or RCC Few relapses in patients responding for over 2.5 years (likely cured) FDA approval in 1992 (RCC) and 1997 (melanoma) Metastatic Melanoma (N = 270) Metastatic RCC (N = 255) 1.0 1.0 CR (n = 17) PR (n = 26) CR + PR (n = 43) CR PR All 0.8 0.8 0.6 CR, complete response; HD, high-dose; IL-2, interleukin-2; PR, partial response; RCC, renal cell carcinoma. 0.6 Probability of Continuing Response Probability of Continuing Response 0.4 0.4 0.2 0.2 0.0 0.0 10 20 30 40 50 60 70 80 90 100 110 120 130 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 Duration of Response (Mos) Duration of Response (Mos) Atkins MB, et al. J Clin Oncol. 1999;17:2105-2116. McDermott DF, et al. Expert Opin Biol Ther. 2004;4:455-468.

HD IL-2 Therapy in Melanoma and RCC High-dose IL-2 appears to benefit patients, but: Toxic Impractical: must be delivered as an inpatient procedure Use remains limited to selected patients treated at experienced centers Efforts to develop more tolerable regimens unsuccessful Efforts to better select patients who might benefit from HD IL-2 therapy have produced modest advances Proof of principle that immunotherapy can produce durable benefit in patients with cancer, but newer immunotherapies are needed HD, high-dose; IL-2, interleukin-2; RCC, renal cell carcinoma.

Noninflamed Tumor Phenotype Poor effector cell trafficking due to: High expression of vascular markers, macrophages, fibroblasts Low inflammation and chemokine expression, few lymphocytes Endothelial cells Macrophage Poor migration X Chemokines Tumor Cytotoxic T cell Fibroblasts Gajewski TF, et al. Curr Opin Immunol. 2011;23:286-292.

Inflamed Tumor Phenotype T cell recruitment High levels of innate immune signals Chemokine expression Nevertheless, negative immune regulators dominate Inhibitory receptors Suppressive cells Suppressive enzymes (IDO, arginase) Tumor PD-L1 Migration Cytotoxic T cell Chemokines IDO, indoleamine 2, 3-dioxygenase; MDSC, myeloid-derived suppressor cells; PD-L1, programmed death-ligand 1; T-reg, regulatory T cell. Anergy T T T reg MDSC Gajewski TF, et al. Curr Opin Immunol. 2011;23:286-292. Spranger S, Gajewski T. J Immunother Cancer. 2013;1:16.

Cancer Vaccines: Current Status Many promising phase II studies compared to historical controls Whole-cell vaccines: allogeneic melanoma cells/cell lysates Tumor antigen directed: MAGEA3, MUC1 Manipulated oncolytic virus: T-VEC Failure to show survival benefit in Phase III trials Only approved cancer vaccine: Sipuleucel-T in prostate cancer[1] Encouraging results with T-Vec in melanoma[2] MAGEA3, melanoma-associated antigen-3; MUC1, mucin-1; T-Vec, talimogene laherparepavec. 1. Di Lorenzo G, et al. BJU Int. 2012;110:E99-104. 2. Kaufman HL, et al. ASCO 2014. Abstract 9008a.

Phase III Trial of Sipuleucel-T Immunotherapy in mCRPC (IMPACT): OS 100 Median OS benefit: 4.1 months HR : 0.78 (95% CI: 0.61-0.98; P = .03) 80 60 Probability of Survival (%) Sipuleucel-T (n = 341) Median Survival: 25.8 Mos. 40 CI, confidence interval; HR, hazard ratio; mCRPC, metastatic castration-resistant prostate cancer; OS, overall survival. 20 Placebo (n = 171) Median Survival: 21.7 Mos. 12 24 36 48 60 72 Mos Since Randomization Kantoff PW, et al. N Engl J Med. 2010;363:411-422.

OPTiM Study of T-Vec in Stage IIIB-IV Melanoma: Overall Survival 100 Median (95% CI) Events/N (%) in Mos 80 T-Vec 189/295 (64) 23.3 (19.5-29.6) GM-CSF 101/141 (72) 18.9 (16.0-23.7) 60 HR: 0.79 (95% CI: 0.62-1.00; unadjusted log-rank P = .051) OS, % 40 Survival, % T-Vec GM-CSF Difference, % (95% CI) 12 mos 73.7 69.1 4.6 (-4.7 to 13.8) 24 mos 49.8 40.3 9.5 (-0.5 to 19.6) 36 mos 38.6 30.1 8.5 (-1.2 to 18.1) 48 mos 32.6 21.3 11.3 (1.0 to 21.5) 20 CI, confidence interval; GM-CSF, granulocyte macrophage colony-stimulating factor; HR, hazard ratio; OS, overall survival; T-Vec, talimogene laherparepvec. 5 10 15 20 25 30 35 40 45 50 55 60 Months Kaufman HL, et al. ASCO 2014. Abstract 9008a.

Cancer Vaccines: Issues Induce immune reaction against vaccine, but not the tumor Immune system mainly recognizes “neo-antigens” from “passenger” mutations rather than shared antigens Antigens different for each tumor Vaccine must involve autologous tumor cells Most immune-responsive tumors “autovaccinate”, but immune regulation prevents an effective response Even if vaccine enhances antitumor immunity, cells likely to be suppressed in the tumor microenvironment Conclusion: Vaccines are unlikely to have a major effect in the absence of immune checkpoint control

Inflamed Tumor Phenotype T cell recruitment High levels of innate immune signals Chemokine expression Nevertheless, negative immune regulators dominate TIL therapy: remove anti-tumor T cells from immunosuppressive environment, select/expand ex vivo then re-administer Tumor PD-L1 Migration Cytotoxic T cell Chemokines MDSC, myeloid-derived suppressor cells; programmed death-ligand 1; TIL, tumor infiltrating lymphocyte; T-reg, regulatory T cell. Anergy T T T reg MDSC Gajewski TF, et al. Curr Opin Immunol. 2011;23:286-292. Spranger S, Gajewski T. J Immunother cancer. 2013;1:16.

Tumor-Infiltrating Lymphocytes + IL-2 in Metastatic Melanoma: OS 1.0 Strong data suggest that mutation- reactive T cells contribute to these responses 0.9 CR (n=20) 0.8 0.7 0.6 Proportion Surviving 0.5 0.4 0.3 CR, complete response; IL-2 interleukin-2; NR, no response; OS, overall survival; PR, partial response. PR (n=32) 0.2 0.1 NR (n=41) 0.0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96 102 Survival Time (Mos) Robbins PF, et al. Nat Med. 2013;19:747-752.

Tumor-Infiltrating Lymphocytes: Commentary Critical components appear to be Lymphodepletion to eliminate immuno-inhibitory factors within the tumor microenvironment Removal, reactivation, and ex vivo expansion of tumor-infiltrating (tumor-specific) CD8+ T cells IL-2 or other immunostimulatory cytokine to sustain transfused TIL function Corollary: tumors without TIL will not respond TIL recognize neo-antigens; therefore those with more mutations may be more likely to have TIL IL-2, interleukin-2; TIL, tumor-infiltrating lymphocytes. Can immunoinhibitory forces be blocked in vivo, restoring TIL activity without need for lymphodepletion and ex vivo expansion?

Regulation of T Cell Responses Via Multiple Co-Stimulatory and Inhibitory Interactions T cell response to antigen is mediated by peptide-MHC recognized by TCR (first signal – specificity) B7 family of membrane-bound ligands binds both co- stimulatory and inhibitory receptors (second co- stimulatory signal) Targeting CTLA-4 and PD-1 inhibitory receptors has been a major clinical focus MHC, major histocompatibility complex; TCR, T cell receptor. Pardoll DM. Nat Rev Cancer. 2012;12:252-264.

Ipilimumab a Member of Novel Class of Immunotherapeutic Abs: Anti–CTLA-4 1. Costimulation via CD28 binding transduces T-cell activating signals 2. CTLA-4 binding on activated T cells down- regulates T-cell responses 3. Blocking CTLA-4 binding enhances T-cell responses T-cell activation T-cell inactivation T-cell activation T cell CTLA-4 T cell T cell APC, antigen-presenting cell; CTLA, cytotoxic T-lymphocyte antigen; MHC, major histocompatibility complex; TCR, T-cell receptor. CTLA-4 TCR TCR TCR CTLA-4 MHC CD28 B7 CD28 B7 MHC CD28 MHC B7 Ipilimumab APC APC APC

Ipilimumab, gp100, or Both in Advanced Melanoma (MDX010-20): Survival 1.0 Ipilimumab + gp100 (A) Ipilimumab alone (B) gp100 alone (C) Comparison HR P Value  Arms A vs C 0.68 .0004 Arms B vs C 0.66 .0026 0.9 0.8 0.7 OS, % Ipi + gp100 (n = 403) Ipi + Placebo (n = 137) gp100 + Placebo (n = 136) Year 1 44 46 25 Year 2 22 24 14 0.6 Proportion Alive 0.5 0.4 0.3 HR, hazad ratio; Ipi, ipilimumab; OS, overall survival. 0.2 0.1 1 2 3 4 Yrs Hodi FS, et al. N Engl J Med. 2010;363:711-723. 20

Anti-CTLA4 Antibodies: Disease Can Get Worse Before It Gets Better 4 distinct response patterns associated with favorable OS Response in baseline lesions (typical RECIST response) Stable disease with slow decline in tumor volume Response following an initial increase in tumor volume Response following the appearance of new lesions Infiltration of patient immune cells can cause an initial increase in tumor volume or appearance of new lesions on imaging scans (pseudoprogression) CTLA-4, cytotoxic T-lymphocyte antigen 4; OS, overall survival; RECIST, Response Evaluation Criteria in Solid Tumors. Wolchok JD, et al. Clin Cancer Res. 2009;15:7412-7420.

Ipilimumab: irRC Identifies Survivors in Patients with Progressive Melanoma 1.0 0.9 0.8 0.7 0.6 Proportion Alive 0.5 0.4 0.3 CR complete response; irRC, immune-related response criteria; irSD, immune-related stable disease; irPR, immune-related partial response; PD, progressive disease; PR, partial response, SD, stable disease; WHO, World Health Organization. 0.2 CR/PR/SD (by WHO criteria) irPR/irSD (by the irRC) PD and unknown response 0.1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Mos Wolchok JD, et al. Clin Cancer Res. 2009;15:7412-7420.

Ipilimumab: Pooled Survival Analysis from Phase II/III Trials in Advanced Melanoma 1.0 0.9 0.8 N = 1861 Median OS (95% CI): 11.4 mo (10.7-12.1) 3-year OS Rate (95% CI): 22% (20% to 24%) 0.7 0.6 Proportion Alive 0.5 0.4 0.3 CI, confidence interval; OS, overall survival. 0.2 0.1 Ipilimumab CENSORED 0.0 12 24 36 48 60 72 84 96 108 120 Months Patients at Risk Ipilimumab 1861 839 370 254 192 170 120 26 15 5 Hodi S, et al. 2013 European Cancer Congress. Abstract LBA 24.

Ipilimumab, gp100, or Both in Advanced Melanoma (MDX010-20): irAEs All grades (Gr 3/4) Ipi + gp100 N=380 Ipi +pbo N=131 gp100 + pbo N=132 Any 57 (9.7/0.5) 60 (12.2/2.3) 32 (3.0/0) Dermatologic 39 (2.1/0.3) 42 (1.5/0) 17 (0/0) GI 31 (5.3/0.5) 28 (7.6/0) 14 (0.8/0) Endocrine 3 (1.1/0) 8 (2.3/1.5) 2 (0/0) Hepatic 2 (1.1/0) 3 (0/0) 4 (2.3/0) GI, gastrointestinal; Gr, grade; Ipi, ipilimumab; irAE, immune-related adverse event; pbo, placebo. Hodi et al. N Engl J Med. 2010 Aug 19;363(8):711-23 24

Kinetics of Appearance of irAEs with Ipilumumab Rash, pruritis Liver toxicity Diarrhea, colitis Hypophysitis Toxicity Grade irAE, immune-related adverse events. 2 4 6 8 10 12 14 Weeks Weber JS, et al. J Clin Oncol. 2012;30:2691-2697.

Ipilimumab: Managing Immune-Related Adverse Events System Symptoms Management GI tract Diarrhea Abdominal pain Dark, bloody stools Moderate enterocolitis: hold ipilimumab, administer antidiarrheal. Persistent diarrhea (> 1 wk): systemic corticosteroids. 7+ stools/day: start methylprednisone, permanently discontinue ipilimumab. Consider infliximab for corticosteroid-refractory patients Skin Rash (± itching) Blistering/peeling Oral sores Moderate/nonlocalized rash: hold ipilimumab, start topical or systemic corticosteroids. Severe dermatitis: permanently discontinue ipilimumab, start corticosteroids Liver Jaundice Nausea/vomiting Assess ALT/AST, bilirubin, and thyroid function before each dose and as necessary. Hold ipilimumab if ALT/AST > 2.5 x but ≤ 5 x ULN; permanently discontinue if AST/ALT > 5 x ULN or bilirubin > 3 x ULN. The immunosuppressant mycophenolate can be used for hepatotoxicity in corticosteroid-refractory patients CNS Weakness in extremities Numbness/tingling Sensory changes Moderate neuropathy: hold ipilimumab. New or worsening neuropathy: permanently discontinue ipilimumab. Consider corticosteroids Endocrine Headaches Fatigue Behavior/mood changes Menstruation changes Dizziness/light-headedness Moderate endocrinopathy: hold ipilimumab, start corticosteroids. Endocrine abnormalities can be difficult to detect, due to nonspecific symptoms. Consider having an endocrinologist follow the patient Eyes Vision problems Irritation Monitor for redness suggesting uveitis, treat with topical steroidal eye drops ALT, alanine aminotransferase; AST, aspartate aminotransferase; CNS, central nervous system; GI, gastrointestinal; ULN, upper limit of normal. Ipilimumab adverse reaction management guide.

Ipilimumab Treatment: Commentary Immune responses and anti-tumor responses noted in some individuals Activity powerful enough to work in the CNS and overcome concurrent immunosuppression Response appears to be associated with autoimmunity Ipilimumab represents an option for the majority of patients with advanced melanoma Management of immune-related toxicities requires attention Role in other cancers not established Activity in RCC not pursued Prostate and lung cancer studies (negative) May not address the immunosuppressive microenvironment CNS, central nervous system; RCC, renal cell carcinoma.

Ipilimumab in Melanoma: Current Issues Dose: 3 mg/kg or 10 mg/kg? Phase III ongoing in pts with metastatic melanoma (NCT01515189) Schedule: Maintenance therapy or not? Role in the adjuvant setting? EORTC 18071[1] E1609 (NCT01274338) In combinations? Bevacizumab, other immunotherapies (GM-CSF, IFN, IL-2, PD-1 abs, and T-Vec), and radiation therapy High toxicity when combined with BRAF inhibitors[2] EORTC, European Organisation for Research and Treatment of Cancer; GM-CSF, granulocyte macrophase colony-stimulating factor; IFN, interferon alfa, IL-2, interleukin-2; irAEs, immune-related adverse events; OS, overall survival; PD1, programmed death 1. 1. Eggermont A, et al. ASCO 2014. LBA9008. 2. Ribas A, et al. N Engl J Med. 2013;368:2861365-1366.

Inflamed Tumor Phenotype T cell recruitment High levels of innate immune signals Chemokine expression Nevertheless, negative immune regulators dominate Blocking PD1:PD-L1 binding might activate immunity within the tumor microenvironment Tumor PD-L1 Migration Cytotoxic T cell Chemokines PD1 MDSC, myeloid-derived suppressor cells; PD-1, programmed death 1; PD-L1, programmed death-ligand 1; T-reg, regulatory T cell; Anergy T T T reg MDSC Gajewski TF, et al. Curr Opin Immunol. 2011;23:286-292. Spranger S, Gajewski T. J Immunother cancer. 2013;1:16.

PD-1 Adaptive Resistance to Immunotherapy Anti–PD-1 Anti–PD-L1 Tumor cell PD-L1 PD-1 TCR MHC Interferons PD-1, programmed death-1; PD-L1, programmed death-ligand 1. PD-L1 can be expressed on tumor cells either endogenously or induced by association with T cells (adaptive immune resistance)[1,2] PD-1:PD-L1 interaction results in T cell suppression (anergy, exhaustion, death) In RCC, melanoma, and other tumors, PD-L1 expression has been shown to be associated with adverse clinical/pathologic features, eg, more aggressive disease and shorter survival[3] 1. Topalian SL, et al. Curr Opin Immunol. 2012;24:207-212. 2. Taube JM, et al. Sci Transl Med. 2012;4:127ra37. 3. Thompson RH, et al. Proc Natl Acad Sci USA. 2004;101:17174-17179.

Clinical Development of Inhibitors of PD-1 Immune Checkpoint Target Antibody Molecule Development stage PD-1 Nivolumab (BMS-936558) Fully human IgG4 Phase III multiple tumors (melanoma, RCC, NSCLCa, HNSCC) Pembrolizumab (MK-3475) Humanized IgG4 Phase I-II multiple tumors Phase III NSCLC/melanoma Pidilizumab (CT-011) Humanized IgG1 Phase II multiple tumors PD-L1 MEDI-4736 Engineered human IgG1 MPDL-3280A Phase III NSCLC MSB0010718C Fully human IgG1 Phase I solid tumors HNSCC, head and neck squamous cell carcinoma; NSCLC; non-small cell lung cancer; PD-1, programmed death-1; PD-L1, programmed death-ligand 1; RCC, renal cell carcinoma. Highly Cofidential

Nivolumab: Clinical Activity Tumor Type Dose, mg/kg ORR (CR/PR), n (%) SD ≥ 24 Wks, n (%) Median PFS, Mos Median OS, 1 yr, % 2 yr, % MEL (n = 107) 0.1-10 32 (34) 7 (7) 3.7 17.3 68 48 NSCLC (n = 129) 1-10 22 (17) 13 (10) 2.3 9.9 42 24 RCC (n = 34) 1 or 10 10 (29) 9 (27) 7.3 > 22 70 50 CR, complete response; MEL, melanoma; NSCLC, non-small cell lung cancer; ORR, objective response rate; OS, overall survival; PFS, progression-free survival; PR, partial response; RCC, renal cell carcinoma; SD, stable disease. 28 responses (16 MEL, 6 RCC, and 6 NSCLC) lasted ≥ 1 yr among 54 patients with treatment initiation ≥ 1 yr before data analysis 13 patients (4 MEL, 6 NSCLC, 3 RCC) demonstrated nonconventional patterns of response but were not included as responders Topalian SL, et al. N Engl J Med. 2012;366:2443-2454. Hodi FS, et al. ASCO 2014. Abstract 9002. Brahmer JR, et al. ASCO 2014. Abstract 8112.

Nivolumab (10 mg/kg): Response of Metastatic NSCLC Diagnosis: 2004, EGFR mutation + Previous treatment: gemcitabine/carboplatin; erlotinib; erlotinib + LBH589 (trial for T790 mutation); and lastly pemetrexed Nivolumab treatment: initial progression in pulmonary lesions of a NSCLC patient with non-squamous histology was followed by regression EGFR, epidermal growth factor receptor; NSCLC, non-small cell lung cancer. Oxnard GR, et al. J Natl Cancer Inst. 2012;104:1534-1541. Topalian SL, et al. N Engl J Med. 2012;366:2443-2454.

Nivolumab: Durability of ORR in Pts With Advanced NSCLC, MEL and RCC 65 of 306 pts had ORR (CR/PR): 30 of 65 (46%) responses were evident at first tumor evaluation (8 wks) 42 of 65 (65%) pts had responses lasting > 1 yr 35 of 65 (54%) responses were ongoing at time of data analysis Responses persisted off drug Squamous Maximum treatment duration NSCLC Nonsquamous MEL CR, complete response; MEL, melanoma; NSCLC, non-small cell lung cancer; ORR, overall response rate; PR, partial response; RCC, renal cell carcinoma. Ongoing response Time to response RCC 24 48 72 96 120 144 168 Wks since treatment initiation Topalian SL, et al. ASCO 2013. Abstract 3002.

Nivolumab: Duration of Response 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0 3 6 9 12 15 18 21 24 27 30 33 Med., mo. (95%CI) NSCLC (n=22) 17.0 (9.7 - NE) Melanoma (n=33) 24.0 (17.0 - NE) RCC (n=10) 12.9 (11.4 - NE) Censored Proportion progression-free MEL, melanoma; NSCLC, non-small cell lung cancer; NE, not estimable; RCC, renal cell carcinoma. Months since initiation of response No. at Risk 22 21 16 14 12 8 5 2 2 1 1 0 33 33 30 27 19 15 12 9 5 0 0 0 10 10 10 9 5 3 2 2 2 1 0 0 NSCLC MEL RCC Topalian SL, et al. ASCO 2013. Abstract 3002.

Nivolumab Exposure-adjusted irAEs: Toxicity Is Not Cumulative 140 120 Observation period (no. pts; P-Y) 0-6 mo. (n = 306; P-Y = 138) 6-12 mo. (n = 189; P-Y = 59) 12-24 mo. (n = 85; P –Y = 49) 100 Events per 100 person-years 80 60 40 20 GI Skin Renal Hepatic Thyroid Inf. Rxion AE, adverse event; GI, gastrointestinal; irAE, immune-related adverse event; Inf, infusion; P-Y, person-years; Rxion, reaction. Pulmonary Multiple occurrences of all-cause select AEs in individual pts are included in this exposure-adjusted analysis. Treatment-related Gr 3-4 AEs occurred in 17% of pts, including select AEs in 6%. Topalian SL, et al. J Clin Oncol. 2014;32:1020-1030.

Pembrolizumab (MK-3475) in Melanoma: Response by Prior IPI and Dose/Schedule 34% Overall 365 2 mg/kg q3w 146 10 mg/kg q3w 168 Pts N CR, % ORR, % (95% CI) IPI-N 168 8 40 (32-48) IPI-T 197 2 28 (22-35) Total 365 5 34 (29-39) 10 mg/kg q2w 51 IPI-N 168 2 mg/kg q3w 65 10 mg/kg q3w 66 CR, complete response; IPI-N, ipilimumab naïve; IPI-T, ipilimumab treated; irRC, immune-related response criteria; ORR, overall response rate; q2w, every 2 weeks; q3w, every 3 weeks. 10 mg/kg q2w 37 IPI-T 197 2 mg/kg q3w 81 10 mg/kg q3w 102 10 mg/kg q2w 14 10 20 30 40 50 60 70 80 90 100 ORR (%) Ribas A, et al. ASCO 2014. LBA9000.

Individual Patients Treated with Pembrolizumab Pembrolizumab (MK-3475) in Advanced Melanoma: Max % Change in Tumor Size 100 80 60 40 20 Change from Baseline in Sum of Product Perpendicular Diameters of Index Lesions, % -20 -40 IPI-N, ipilimumab-naïve; IPI-T, ipilimumab treated; irRC, immune-related response criteria. -60 IPI-T -80 IPI-N -100 Individual Patients Treated with Pembrolizumab In patients with measurable disease at baseline by irRC by central review and ≥1 postbaseline assessment (n = 319). Percentage changes >100% were truncated at 100%. Ribas A, et al. ASCO 2014. LBA9000.

Pembrolizumab: Time to Response and On-Study Duration 6 months 12 months 18 months 88% of responses ongoinga Median response duration not reached (range, 6+ to 76+ weeks) Individual Patients Treated With Pembrolizumab IPI-T IPI-N IPI-N, ipilimumab-naïve; IPI-T, ipilimumab treated Complete Response Partial Response Progression On Treatment 10 30 50 70 90 Wks aOngoing response defined as alive, progression free, and without new anticancer therapy. Ribas A, et al. ASCO 2014. LBA9000.

Pembrolizumab: NSCLC Clinical Activity First-line1 Previously treated2 PD-L1+ (n = 42) (n = 159) PD-L1 – (n = 35) ORR*, % 26 23 9 DCR*, % 64 42 31 Median duration of response, wks NR *RECIST v1.1 DCR, disease control rate; NR, not reached; NSCLC, non-small cell lung cancer; ORR, overall response rate; PD-L1, programmed death-ligand 1; RECIST, response evaluation criteria in solid tumors. ~ 80% of screened patients in each study were PD-L1+ Among previously treated patients with NSCLC, ORR was 26% in current/former smokers and 9% in never smokers 1. Rizvi N, et al. ASCO 2014. Abstract 8007. 2. Garon E, et al. ASCO 2014. Abstract 8020.

MPDL3280A Phase Ia: Efficacy Summary 26 of 29 responders continued to respond at last assessment Time on study in responders: 3 to 15+ months Additional delayed responses not reflected in above ORR Other tumor types (14) include CRC (PR in 1/4) and gastric cancer (PR in 1/1) Generally well tolerated Grade 3/4 related AE 13%; 2% immune related Population, % RECIST 1.1 Response Rate (ORR*) SD of 24 Weeks or Longer 24-Week PFS Overall population (N = 140) 21 19 42 NSCLC (n = 41) 22 12 46 Melanoma (n = 38) 29 5 43 RCC (n = 47) 13 32 53 AE, adverse event; CR, complete response; CRC, colorectal cancer; NSCLC, non-small cell lung cancer; ORR, overall response rate; PFS, progression-free survival; PR, partial response; RCC, renal cell carcinoma; RECIST, Response Evaluation Criteria in Solid Tumors; SD, stable disease. *ORR includes unconfirmed PR/CR and confirmed PR/CR. Herbst RS, et al. ASCO 2013. Abstract 3000.

MPDL3280A: Patients With Other Solid Tumors Tumor Type Dose, mg/kg Patients, n Best Response (Investigator Assessed) Time on Study for Responders (Mos) PR SD PD CRC 20 4 1 2 10.4+ GC -- 9.8 Sarcoma 3 NA SCCHN Breast 10, 20 Pancreato-duodenal Pancreatic 10 Ovarian CRC, colorectal cancer; GC, gastric cancer; PD, progressive disease; PR, partial response; SCCHN, squamous cell carcinoma of the head and neck; SD, stable disease. Data cutoff February 1, 2013; only includes patients first dosed at 3-20 mg/kg prior to August 1, 2012. Best response includes unconfirmed and confirmed PR/CR. Tabernero J, et al. ASCO 2013. Abstract 3622.

MPDL3280A: Tumor Burden Over Time in Urothelial Bladder Cancer Median time to first response was 42 days (range, 38 to 85 days) Median duration of response has not been reached 0.1+ to 30.3+ weeks IHC (IC) 2 or 3 and 0.1+ to 6.0+ weeks for IHC (IC) 0 or 1 Best response is not known for 7 patients. Patients dosed by Nov 20, 2013 (≥ 6 wk follow-up) with measurable disease at baseline and at least 1 post-baseline measurement. Clinical data cutoff was Jan 1, 2014. Powles T, et al. ASCO 2014. Abstract 5011.

Tumors Shown to Respond to Anti-PD1 or Anti-PD-L1 Therapy Melanoma Pembrolizumab approved by the US FDA in September 2014 for unresectable or metastatic disease with progression following ipilimumab and, if appropriate, a BRAF inhibitor RCC NSCLC Bladder Head and Neck cancer Lymphomas ??? NSCLC, non-small-cell lung cancer; RCC, renal cell carcinoma.

Summary of PD-1/PD-L1 Blockade Immune-Mediated Toxicities Occasional (5-20%) Fatigue Rash: maculopapular and pruritus Topical treatments Diarrhea/colitis Initiate steroids early, taper slowly Hepatitis/liver enzyme abnormalities Infusion reactions Endocrinopathies: thyroid, adrenal, hypophysitis Infrequent (<5%) Pneumonitis Grade 3/4 toxicities uncommon PD-1, programmed death-1; PD-L1, programmed death-ligand 1. 1. Topalian SL, et al. N Engl J Med. 2012;366:2443-2454. 2. Patnaik A, et al. ASCO 2012. Abstract 2512. 3. Brahmer JR, et al. N Engl J Med. 2012;366:2455-2465. 4. Herbst RS, et al. ASCO 2013. Abstract 3000.

Pembrolizumab: AEs in > 5% of Patients Adverse Event (N = 135) All Grades, n (%) Grades 3/4, n (%) Any 107 (79.3) 17 (12.6) Fatigue 41 (30.4) 2 (1.5) Rash 28 (20.7) 3 (2.2) Pruritus 1 (0.7) Diarrhea 27 (20.0) Myalgia 16 (11.9) Headache 14 (10.4) Increased AST 13 (9.6) Asthenia Nausea Vitiligo 12 (8.9) Hypothyroidism 11 (8.1) Increased ALT Cough Pyrexia 10 (7.4) Chills 9 (6.7) Abdominal pain 7 (5.2) ALT, alanine aminotransferase; AST, aspartate aminotransferase. Ribas A, et al. ASCO 2013. Abstract 9009.

Pneumonitis Associated With PD-1 Pathway Blockade Treatment algorithms for early detection and management implemented (dose delay/discontinuation, immunosuppression)[1] Clinical Trial Tumor Histology Any Grade % (n/N) Grade 3/4 % (n/N) Nivolumab monotherapy[2] Multiple 3 (9/296) 1 (3/296)* Nivolumab + ipilimumab[3] Concurrent treatment Sequential treatment (ipi → nivo) Melanoma 6 (3/53) 3 (1/33) 2 (1/53) 0 (0/33) Nivolumab ± peptide vaccine[4] 3 (3/90) 2 (2/90) Nivolumab ± peptide vaccine adjuvant[5] 0 (0/153) Nivolumab + chemotherapy[6] NSCLC 14 (8/56) 7 (4/56) All nivolumab trials total All Tumors 4 (27/691) 2 (11/691) Anti-PD-L1 (BMS-963559) monotherapy[7] 1 (3/284) 0 (0/284) CRC, colorectal cancer; NSCLC, non-small cell carcinoma; PD, programmed death. *3 pts with grade 3/4 pneumonitis died (1 CRC, 2 NSCLC). Data analysis in February /March 2013. Hodi FS, et al. 12th International Congress on Targeted Anticancer Therapies. Abstract O2.3. Topalian SL, et al. N Engl J Med. 2012;366:2443-2454. 3. Wolchok JD, et al. J Clin Oncol. 2013;31(18 suppl):abstr 9012. 4. Weber JS, et al. J Clin Oncol. 2013;31(18 suppl):abstr 9011. 5. Gibney GT, et al. J Clin Oncol. 2013;31(18 suppl):abstr 9056. 6. Rizvi NA, et al. J Clin Oncol. 2013;31(18 suppl):abstr 8072. 7. Topalian SL, et al. J Clin Oncol. 2013;31(18 suppl):abstr 3002.

CTLA-4 and PD-1/L1 Checkpoint Blockade for Cancer Treatment Priming phase (lymph node) Effector phase (peripheral tissue) T-cell migration Dendritic cell Cancer cell T cell T cell Dendritic cell T cell MHC TCR B7 CD28 CTLA-4 TCR MHC CTLA-4, cytotoxic T-lymphocyte antigen-4; MHC, major histocompatibility complex; PD-1, programmed death-1; TCR, T cell receptor. T cell PD-1 Cancer cell PD-L1 Ribas A. N Engl J Med. 2012;366:2517-2519.

Ipilimumab + Nivolumab: Change in Target Lesions All patients in concurrent cohorts 300 250 250 First occurrence of new lesion 200 200 150 Cohort 2: 1 mg/kg nivolumab + 3 mg/kg ipilimumab 150 100 50 100 Change in target lesions from baseline (%) Change in target lesions from baseline -20 50 -40 -60 -80 -50 ORR, overall response rate. -100 -100 10 20 30 40 50 60 70 80 90 100 110 120 Patients Weeks since treatment initiation Therapy, % ORR ≥ 80% Tumor Reduction Ipilimumab 7 < 3 Nivolumab 28 < 2 Combination (cohort 2) 53 41 Wolchok JD, et al. N Engl J Med. 2013;356:122-133. Wolchok JD, et al. ASCO 2013. Abstract 9012.

Phase I Study of Nivolumab + Ipilimumab in Melanoma: OS for Concurrent Tx 100 2-yr OS 88% 90 80 70 2-yr OS 79% 60 Survival (%) 50 2-yr OS 50% 40 Censored 30 Nivo 0.3 mg/kg + IPI 3 mg/kg Nivo 1 mg/kg + IPI 3 mg/kg Nivo 3 mg/kg + IPI 1 mg/kg Nivo 3 mg/kg + IPI 3 mg/kg Concurrent cohort IPI, ipilimumab; Nivo, nivolimumab; OS, overall survival; Tx, treatment. 20 10 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 Mos Pts at Risk Nivo 0.3/IPI 3 Nivo 1/IPI 3 Nivo 3/IPI 1 Nivo 3/IPI 3 Concurrent 14 17 16 6 53 13 17 16 6 52 11 16 15 6 48 10 15 15 6 46 8 15 15 6 44 7 14 13 6 40 7 14 4 6 31 7 13 2 6 28 7 9 0 3 19 7 4 0 0 11 5 3 0 0 8 2 3 0 0 5 2 3 0 0 5 2 2 0 0 4 1 0 0 0 1 1 0 0 0 1 0 0 0 0 0 Sznol M, et al. ASCO 2014. LBA9003.

Nivolumab + Ipilimumab Adverse Events Treatment-Related AE, Number of Patients (%) Concurrent All Cohorts (n = 53) All Grades Grades 3/4 Any adverse event 49 (93) 28 (53) Rash 29 (55) 2 (4) Pruritus 25 (47) Fatigue 20 (38) Diarrhea 18 (34) 3 (6) Nausea 11 (21) Pyrexia  AST 7 (13)  ALT 6 (11)  Lipase 10 (19)  Amylase 8 (15) Cough Vomiting 1 (2) Vitiligo Headache ALT, alanine aminotransferase; AST, aspartate aminotransferase. Wolchok J, et al. ASCO 2013. Abstract 9012.

Phase I Study of Nivolumab + Ipilimumab in mRCC 120 120 100 100 80 80 60 60 40 40 20 20 Change in baseline (%) 1st occurrence of new lesion -20 -20 -40 -40 -60 -60 -80 -80 -100 -100 6 12 18 24 30 36 42 48 54 6 12 18 24 30 36 42 Wks Since First Dose Wks Since First Dose 120.00 mRCC, metastatic renal cell carcinoma. 100.00 80.00 60.00 40.00 N3 + I1 (n=20) N1 + I3 (n=22) 20.00 Change in baseline target lesions (%) 0.00 -20.00 -40.00 -60.00 -80.00 -100.00 Hammers HJ, et al. ASCO 2014. Abstract 4504.

PD-1/PD-L1 Therapy: Select Pivotal Trials Tumor Type Phase III (unless otherwise indicated) Melanoma Pembro (2 doses) vs ipi[NCT01866319] Nivo vs ipi vs ipi/nivo[NCT01844505] Nivo vs chemo (ipi progression)[NCT01721772,NCT01721746] Pembro vs chemo (ipi progression; Phase 2)[NCT01704287] RCC Nivo vs everolimus (TKI progression)[NCT01668784] Nivo/ipi vs sunitinib MPDL + bev vs MPDL vs sunitinib (Phase 2)[NCT01984242] NSCLC Pembro (2 doses) vs doc[NCT 01905657] Nivo vs doc (squamous or nonsquamous)[NCT01642004,NCT01673867] Nivo vs chemo choice[NCT02041533] HNSCC Nivo vs investigator’s choice[NCT02105636] bev, bevacizumab; HNSCC, head and neck squamous cell carcinma; ipi, ipilimumab; nivo, nivolumab; NSCLC, non-small cell lung cancer; PD-1; programmed death 1; PD-L1, programmed death-ligand 1; pembro, pembrolizumab; RCC, renal cell carcinoma; TKI, tyrosine kinase inhibitor. Patients with known or suspected autoimmune disease are generally excluded from these trials.

Key Translational Questions for PD-1 Pathway Blockade Predictive Biomarkers Which tumors to treat? Which patients to treat? Other combinations? Line of therapy? What to do for tumors without immune infiltrates?

Biomarkers of Activity for Checkpoint Inhibitors

ORR by PD-L1 Expression in Patients with Solid Tumors Rx Antibody Testing Method N PD-L1 + RR PD-L1 - RR Nivolumab[1] Manual staining – 5H1 5% cutoff Tumor staining 49 13/31 42% 0/18 0% Nivolumab[2] Dako automated 38 7/17 41% 3/21 14% MPDL3280A[3] Automated Roche Dx IHC 1% cutoff Tumor immune cell staining 103 13/36 36% 9/67 13% Ipi/Nivo[4] 56 8/14 57% 17/42 40% IHC, immunohistochemistry; Ipi, ipilimumab; Nivo, nivolumab; ORR, overall response rate; PD-L1, programmed death-ligand 1; RR, response rate. 1. Topalian SL, et al. N Engl J Med. 2012;366:2443-2454. 2. Grosso J, et al. ASCO 2013. Abstract 3016. 3. Herbst RS, et al. ASCO 2013. Abstract 3000. 4. Sznol M, et al. ASCO 2014. LBA9003.

Issues with PD-L1 as a Biomarker PD-L1 negativity an unreliable biomarker Assays are technically difficult, imperfect; results may differ depending on the antibody/assay (tumor vs immune cells) 5% expression, tumor heterogeneity, and inducible gene = sampling error (false negative) Archived tissue different than recent biopsy May be more useful in determining which tumors rather than which patients to treat PD-L1 expression may be less relevant for combination therapies PD-L1 expression might be constitutive (no immune infiltrate) PD-L1, programmed death-ligand 1.

Other Combinations with PD-1 Checkpoint Inhibitors Other coinhibitory pathways TIM-3, LAG-3, IDO Co- or immunostimulatory pathways OX40, 4-1BB, GITR, IL-2, IFN, IL-21 Standard of care Chemotherapy, TKI, VEGF inhibitor, XRT Cancer vaccines Epigenetic therapy GITR, glucocorticoid-induced TNFR family related gene; IDO, indoleamine,3-dioxygenase; IFN, interferon; IL-2, interleukin-2; IL-21, interleukin-21; LAG-3, lymphocyte activation gene 3; PD-1, programmed death-1; TIM-3, T cell immunoglobulin and mucin protein 3; TKI, tyrosine kinase inhibitor; VEGF, vascular endothelial growth factor; XRT, radiation therapy.

How to Approach Tumors Without Immune Infiltrates Combination immunotherapies 4-1BB, IL-2, OX40, others Adoptive Cellular Therapy (ACT) Genetically manipulated cells CAR T cells Professional killers. Don’t need to have pre-existing immunity CAR T cells are not HLA restricted Issue is finding antigens expressed only on the tumor ACT, adoptive cell therapy; CAR, chimeric antigen receptor; HLA, human leukocyte antigen.

Conclusions Immunotherapy can produce durable antitumor responses in some patients with cancer Treatment of patients with immune checkpoint inhibitors can be different than with conventional therapies, including Identifying unconventional responses to immune checkpoint inhibitors (eg, pseudo-progression) Understanding and managing immune-related adverse events Mounting data indicate that checkpoint inhibitors targeting PD- 1/PD-L1 are active in multiple tumor types Ongoing studies will help define the optimal use of checkpoint inhibitors in different tumor types as single agents or as part of combination therapy

Go Online for More CCO Coverage of Immunotherapy! Additional CME-certified slideset on immunotherapy in melanoma with expert faculty commentary on all the key studies Downloadable slidesets on immunotherapy across tumor types for self- study or use in your own presentations clinicaloptions.com/oncology