A Phase I Trial of Scutellaria Barbata (BZL101) for Metastatic Breast Cancer Perez A 1, Shaw HS 2, Fleming G 3, Hershman D 4, Franco S 1, Shapiro C 5, Neal K 6, Caygill K 6, Cohen I 6, Tagliaferri M 6, Tripathy D 7. Memorial Cancer Institute, Hollywood, Florida 1 ; Duke University Medical Center, Durham, NC 2 ; University of Chicago, Chicago, IL 3 Columbia University, New York, NY; Ohio State University, Columbus, OH 5 ; Bionovo, Inc, Emeryville, California 6 ; University of Texas Southwestern, Dallas, Texas 7. Abstract # 1099 Background: BZL101 is an aqueous extract from herba Scutellaria Barbata. BZL101 demonstrates in vitro growth inhibitory effects on human breast cancer cell lines and does not inhibit the growth of normal human mammary epithelium. In a murine xenograph model, oral and intraperitoneal administration of BZL101 inhibited tumor formation without any observed toxicity. Treatment of breast cancer cells with BZL101 leads to sustained inhibition of glycolysis, as evident from the decreased enzymatic activities within the glycolytic pathway and inhibition of lactate production. Because tumor cells primarily rely on glycolysis for energy production (Warburg effect), targeting this pathway may lead to novel cytotoxic agents with less toxicity than the currently available treatments. We are conducting an open-label, dose escalation, phase 1 trial of BZL101 for the treatment of metastatic breast cancer to determine the maximum tolerated dose. Methods: Eligible patients had histologically confirmed metastatic breast cancer and measurable disease. Patients cannot receive any other anticancer treatment on trial. Three patients are enrolled at each dose level and treated for 28 days. If toxicity is acceptable, 3 additional patients are enrolled to a higher dose until the MTD is reached. The primary objectives are safety and toxicity and to determine the maximum tolerated dose. The secondary objectives are tumor response defined by RECIST, duration of response, survival time and change in patient reported quality of life. Results: Twenty patients have been enrolled to the study. The mean number of prior cytotoxic treatments for metastatic disease was 3.1. There have been no SAEs attributable to BZL101. There have been 3 DLTs in 2 patients; grade 4 AST elevation, grade 3 diarrhea and grade 3 fatigue. All other BZL101 related AEs were primarily grade 1 and 2, of which the most frequent were: diarrhea (40%), nausea (30%), headache (20%) and increased ALT (20%). Of the 20 patients enrolled, 12 patients (60%) were on the trial for 28 days or more and evaluable according to the RECIST criteria. Of those 12 patients evaluable according to RECIST, 5 patients (42%) had stable disease for >90 days. One patient (ID# 03002) with bone only disease was stable for 12 months and had radiologic evidence of tumor shrinkage. One patient (ID# 05005) had evidence of tumor shrinkage by physical exam and another patient (ID# 03006) reported complete resolution of bone pain. Conclusions: Oral administration of BZL101 has a favorable safety and tolerability profile and encouraging clinical activity for the treatment of metastatic breast cancer.  The MTD has not yet been reached; the study is continuing at 40g/day.  Extracts of Scutellaria Barbata inhibit the growth of breast cancer cells in vitro.  BZL101 treatment leads to the inhibition of glycolysis selectively in tumor cells, evident from the decrease in the enzymatic activities within the glycolytic pathway and the inhibition of lactate production.  Oral administration of BZL101 is well tolerated. The most common adverse events are: diarrhea (40%), nausea (30%), headache (20%) and increased ALT (20%).  There have been 3 DLTs: grade 4 AST elevation, grade 3 diarrhea and grade 3 fatigue (grade 3 diarrhea and fatigue occurred in the same patient). There have been no serious adverse events attributed to BZL101.  On average, compliance with study medication was 93% of prescribed doses taken.  In this heavily pre-treated population, of the patients evaluable according to RECIST, 5 of 12 patients (42%) had stable disease for >90 days. One patient with bone only disease has been stable for approximately 12 months. Of the 20 women enrolled, 10 patients discontinued therapy due to progression, 3 patients discontinued due to patient choice, 1 discontinued due to a non-drug related SAE, 1 discontinued due to an AE, and 1 discontinued due to non-compliance with study procedures.  Patient has been stable for 12 months and had radiologic (bone scan) evidence of tumor shrinkage.  Patient reported complete resolution of bone pain and improved quality of life.  Patient had evidence of tumor shrinkage by physical exam.  BZL101, an aqueous extract from the herb Scutellaria barbata D. Don, has a selective cytotoxic activity towards breast cancer cell lines and does not target non-transformed cells.  The selective cytotoxicity is based on the strong induction by BZL101 of reactive oxygen species (ROS) in tumor cells leading to extensive oxidative DNA damage.  Oxidative DNA damage induced by BZL101 in breast cancer cells leads to the hyperactivation of poly ADP-ribose polymerase (PARP), followed by a sustained decrease in levels of NAD and depletion of ATP, neither of which are observed in non-transformed cells.  BZL101 treatment leads to the inhibition of glycolysis selectively in tumor cells, evident from the decrease in the enzymatic activities within the glycolytic pathway and the inhibition of lactate production.  The promising selectivity of BZL101 towards cancer cells is based on metabolic differences between highly glycolytic tumor cells and normal cells.  BZL101 via IP administration prevented tumor formation in a mouse xenograft model. Oral administration of BZL ml or 1.0 ml three times per week showed significant inhibition of tumor formation at day 28 (t-test), BZL ml vs. control, p=0.011; BZL ml vs. control, p=  Previously completed Phase I trial in 21 patients showed antitumor effects of BZL101 for patients with advanced breast cancer. Four of the sixteen evaluable patients (25%) had stable disease for >90 days and 3/16 (19%) had stable disease for >180 days. Five patients had evidence of tumor shrinkage, one of which was 1mm short of a partial response (PR). Average expected survival time was 379 days. 1 Breast Cancer Res Treat Sep;105(1): Epub 2006 Nov 17. PMID: Cancer Biol Ther Jan 7;7(4) [Epub ahead of print] PMID: pancreasprostatebreast Key Inclusion/Exclusion Criteria  Women 18 years or older with histologically confirmed diagnosis of breast cancer and clinical evidence of metastatic involvement  At least one measurable disease site defined by RECIST criteria  No more than 3 prior cytotoxic regimens administered for metastatic breast cancer  Completed prior therapies and had adequate time to recover sufficiently from the toxicities associated with prior anticancer treatments  A life expectancy of ≥12 weeks  Eastern Cooperative Oncology Group (ECOG) performance stats ≤2  Patients were excluded from the study for clinically significant gastrointestinal abnormalities, extensive liver involvement (>50% of liver parenchyma), lymphangitic pulmonary involvement, central nervous system involvement or spinal cord compression not stabilized by therapy for >3 months and organ or marrow dysfunction Definition of Dose Limiting Toxicity (DLT)  Grade 3, 4 or 5 toxicity that is possibly, probably or definitely related to study medication  Grade 2 gastrointestinal toxicity lasting for >3 weeks that is possibly, probably or definitely related to study medication or less than 70% compliance with study medication due to oral intolerability  If there were no DLTs at a dose level in which 3 patient reached 28 days with >70% compliance, the dose was escalated to the next level Study Patients EnrolledN=20 (%) Included in safety analysis20 (100) Evaluable by RECIST criteria12 (60) Number of patients with DLTs2 (10) Total number discontinued16 (80) Disease progression10 (63) Patient choice3 (19) Adverse event1 (6) Serious adverse event1 (6) Non-compliance with study procedures1 (6) Baseline Patient Characteristics Age (years)N=20 Mean (SD)59.9 (13.3) Median (Range)58 (32-78) Prior Number of Cytotoxic Regimens for Metastatic Disease Mean (SD)3.1 (2.7) Median (Range)2 (0-10) Race/Ethnicity White/Caucasian11 (55%) Black/African American5 (25%) Latina/Hispanic4 (20%) Summary of Adverse Events Possibly, Probably or Definitely Related to BZL101 Number of Patients (% in dose level) Adverse Event 10g/day N=11 20g/day N=6 30g/day N=3 Grade (NCI-CTCAE)IIIIIIIVIIIIIIIVIIIIIIIV Blood/Bone Marrow Hemoglobin1 (9) Constitutional Fatigue2 (33)1 (17) Sweating1 (9)1 (17) Gastrointestinal Anorexia2 (18) Distension1 (9)1 (17) Dehydration1 (9)1 (17) Dental: teeth1 (17)1 (33) Diarrhea2 (18) 1 (17) 2 (67) Flatulence1 (9)1 (17) Heartburn1 (33) Mucositis1 (17) Nausea1 (9) 1 (17) 1 (33) Vomiting1 (17)2 (67) Metabolic Alk Phosphate1 (9) ALT2 (18)1 (17)1 (33) AST1 (9) 1 (17) Total protein1 (9) Ocular/Visual Watery eye1 (17) Pain Pain-abdomen1 (9)1 (17) Pain-back1 (9) Pain-headache2 (18)1 (17)1 (33) Pain-joint1 (9) Pain-vagina1 (9) TOTALS Compliance with Study Medication Clinical Activity  Of the 20 patients enrolled, 12 patients were on the trial for 28 days or more and evaluable according to RECIST criteria.  Of the 12 patients evaluable by RECIST, 5 patients (42%) had stable disease for >90 days.  One patient with bone only disease has been stable for approximately 12 months. Dose-Escalation Schedule Dose of BZL101Administration of BZL101 Dose 10g/day10 grams in 100 mls of water or fluid, daily 20g/day10 grams in 100 mls of water or fluid, twice daily 30g/day15 grams in 150 mls of water or fluid, twice daily 40g/day20 grams in 200 mls of water or fluid, twice daily Primary  Safety and tolerability  Maximum tolerated dose (MTD) Estrogen Receptor StatusN=20 (%) ER Positive14 (70) ER Negative6 (30) HER2/neu Status Positive1 (5) Negative16 (80) Unknown3 (15) Baseline ECOG PS 013 (65) 15 (25) 22 (10) Compliance 10g/day N=10* 20g/day N=6 30g/day N=3 Total N=19 Mean93% 96%93% Range73-100%61-100%94-98%61-100% Summary of Study Patients Secondary  Tumor response (RECIST)  Duration of response and survival time  Change in patient reported quality of life (EORTC QLQ-C30) *One patient did not return study drug, compliance unknown. ID# (dose) Response Areas of Disease Number of Prior Therapies for Metastatic DiseaseComments (10g/day) Stable for 12 Months* Bone only disease (not evaluable by RECIST)3 At Month 2, the radiologist reported “Mild improvement in the patient’s bone scans with less intrusive activity noted in the left anteromedial rib and left acetabular region” (see bone scans below). Discontinued due to patient choice. Patient still has stable disease (10g/day) Stable for 8 Months Lung, local regional7 Discontinued due to patient choice at Month 4. Patient still has stable disease (10g/day) Stable for 4 Months* Bone, lung liver, local regional, contra-lateral4 Axillary tumor decreased from 2.5cm at baseline to 1.5cm at Month 1 on physical exam; breast tumor also decreased in size at Month 1 on exam. Discontinued due to unwillingness to schedule study procedures (20g/day) Stable for 1 Month Lung, breast, chest wall, axillary lymph nodes1 Discontinued at Month 1 due to a new skin lesion on left breast. Scans demonstrated a decrease in size of total measurable lesions by 8% (a 55mm chest wall lesion decreased to 50mm and a 21mm lymph node decreased to 18mm) (20g/day) Stable for 5 Months Lung, distant nodes2 Active patient. Month 4 scans demonstrated two lymph node tumors decreased in size compared to Baseline. The total percent change in measurable disease at Month 4 is 0% from baseline (20g/day) Stable for 4 MonthsBone, lung5 Despite progression noted in lung lesion at Month 4, bone scans demonstrated stable disease and patient reported complete resolution of bone pain and improved quality of life. Average Time on Study Medication 10g/day N=11 20g/day N=6 30g/day N=3 Total N=20 Number of Days Range Summary AbstractObjectivesResults Methods Background Results (cont.)  BZL101 is well tolerated. The most common adverse events are diarrhea (40%), nausea (30%), headache (20%) and increased ALT (20%).  No serious adverse events were classified as related to BZL101.  The MTD has not yet been determined; the maximum dose of 40g/day is currently being evaluated.  There have been 3 DLTs; grade 4 AST elevation, grade 3 diarrhea and grade 3 fatigue (grade 3 diarrhea and fatigue occurred in the same patient). Results Adverse Events Classified as Related to BZL101 *Status unconfirmed in database Patients Demonstrating Clinical Activity Baseline Bone Scan of 03002Month 2 Bone Scan of 03002