1. Precision Medicine: From stratified therapies to personalized therapies Fabrice ANDRE Institut Gustave Roussy Villejuif, France

2. Frequent cancers include high number of very rare genomic segments Stephens, Nature, 2012 (whole genome sequencing breast cancers)

3. Working hypothesis Targeting mechanisms that lead to cancer progression can improve patient’s outcome These mechanisms are individual Goal: to identify the mechanism of cancer progression at the individual level, in order to target it

4. Precision Medicine Concept: Identify the targets to be treated in each patient Molecular analysis Therapy matched to genomic alteration Andre, ESMO, 2012 Target identification What is the optimal Biotechnology ? What is the optimal Algorithm ? Clinical evidence

5. Outline Stratified medicine Personalized medicine

6. Stratified medicine Drug development or implementation in a strate defined by a molecular alteration FGFR1 amplification: 10% of breast cancer

7. Translational research to feed stratified medicine FGFR1 inhibitors present higher sensitivity on FGFR1-amplified CC FGFR1: amplification in 10% BC Set-up genomic test (FISH) Run phase II trial Testing the FGFR1 Inh in patients with FGFR1 amp BC

8. Research and medical questions related to stratified medicine How to facilitate translation of discoveries ? Develop translational research units How to set-up a molecular assay for stratified medicine ? Develop genomic units for clinical use How to optimally run trials of stratified medicine ? Set-up molecular screening programs

9. Molecular screening with High Throughput Genomics IF Progressive disease IF Progressive disease Target identification Target identification Trial A Trial F Trial E Trial D Trial C Trial B Andre, Delaloge, Soria, J Clin Oncol, 2011 Molecular screening programs: to identify patients eligible for phase I/II trials

10. SAFIR02 lung Ongoing molecular screening or personalized medicine programs in France SAFIR01 MOSCATO (Hollebecque, ASCO 2013) SAFIR02 breast MOST preSAFIR (Arnedos, EJC, 2012) Overall : >2 000 planned patients (all tumor types), >800 already included Breast Cancer: > 1 000 planned, >70 already treated Goal: To generate optimal algorithm for individualized therapy SHIVA (Letourneau AACR 2013) Pilot study 1st generation trials No NGS NGS Randomized trialsSponsor Gustave Roussy Unicancer L Berard Lyon Curie Institute Unified Database: Pick-up the winner targets 2nd generation Algorithm for Personnalized medicine WINTHER Profiler

11. Molecular screening: Challenges No research in stratified medicine without molecular screening programs

12. Evolution: GENOMIC DISEASES ARE BECOMING TO RARE OR COMPLEX TO ALLOW DRUG DEVELOPMENT IN GENOMIC SEGMENTS How to move forward ? Stephens, Nature, 2012 Are we going to make a drug development for this AKT1 mut / FGFR1 amp segment ?

13. Solution to improve outcome with targeted therapies in the genomic era: test the algorithm not the drug How to move there ???

14. Her2-negative metastatic breast cancer no more than 1 line chemotherapy Biopsy metastatic site: Next generation sequencing Array CGH Chemotherapy 6-8 cycles No alteration Target defined by 1st generation Virtual cell (CCLE) Followed up but not included R 10 Targeted therapy According to 51 Molecular alterations SOC No PD metastatic NSCLC no more than 1 line chemotherapy EGFRwt / ALKwt SAFIR02: Study Design

15. SAFIR02 lung Ongoing molecular screening or personalized medicine programs in France SAFIR01 MOSCATO (Hollebecque, ASCO 2013) SAFIR02 breast MOST preSAFIR (Arnedos, EJC, 2012) Overall : >2 000 planned patients (all tumor types), >800 already included Breast Cancer: > 1 000 planned, >70 already treated Goal: To generate optimal algorithm for individualized therapy SHIVA (Letourneau AACR 2013) Pilot study 1st generation trials No NGS NGS Randomized trialsSponsor Gustave Roussy Unicancer L Berard Lyon Curie Institute Unified Database: Pick-up the winner targets 2nd generation Algorithm for Personnalized medicine WINTHER Profiler

16. Long term perspective 1st generation trials database 2 nd generation algorithm 2 nd generation trials Targeting oncogenic drivers Integration of other systems: DNA repair Immunology metabolism database 2013 2015 2018-2020

17. Challenges / Research questions Bioinformatic algorithm for treatment decision, that integrates all biological systems Technologies: –whole exome sequencing –RNA seq –Protein-based assays

18. Conclusion: genomic medicine for cancer patients bioinformatic algorithm for treatment decision Integration of DNA repair, immunology, metabolism in personalized medicine large scale screening and implementation new technologies Target identification for stratified medicine understanding mechanisms of resistance