TERAPIA DIRIGIDA CON INHIBIDORES DE BRAF Y MEK. Beatriz Nieto Mangudo Unidad de Melanoma CAULE

Transcripción

1 TERAPIA DIRIGIDA CON INHIBIDORES DE BRAF Y MEK Beatriz Nieto Mangudo Unidad de Melanoma CAULE

2 El melanoma es una neoplasia conducida por la vía MAPK KIT NRAS BRAF MEK Erk Survival Proliferation

3 La inhibición de RAF depende del estatus de BRAF Mutated BRAF V6 (tumor cells) Without RAF Inhibitor Wild-type BRAF (all other cells) Mut BRAF RAF RAF RAF Active RAS MEK MEK RAF Monomers = Low MEK activity RAF Dimers = Elevated MEK activity MEK Constitutively active High MEK activity Mut BRAF DRUG With RAF Inhibitor MEK RAF inhibitor suppresses MEK activity RAF RAF RAF DRUG Active RAS DRUG ATP MEK MEK RAF Dimers = inhibitor induced MEK activity Adapted from Poulikakos PI, et al. Cancer Cell. 11;19: RAF RAF DRUG DRUG MEK All sites inhibitor-bound MEK activity inhibited

4 Inhibidores vía MAPK disponibles en Melanoma Inhibidores RAF : vemurafenib[1] y dabrafenib[] Altas tasas de respuesta Mediana de duración de la respuesta: 6-8 meses Respuesta en el cerebro[3] Inhibidor MEK : trametinib[4] y Cobimetinib Moderada tasa de respuesta (~ %) y aumento de supervivencia en melanoma BRAF-mutado No efectivo tras progresión a inhibidor RAF Papel más importante en combinación con inhibición RAF[5] 1. Martin-Liberal J, et al. Future Oncol. 15;11: Khoja L, et al. Expert Rev Anticancer Ther. 15;15: Harding JJ, et al. Oncologist. 15;: Chopra N, et al. Expert Rev Anticancer Ther. 15;15: Long GV, et al. Lancet. 15;[Epub ahead of print].

5 Terapias dirigidas en Estadio IV: principales estudios NRAS BREAK-3:BRAF Dabrafenib vs DTIC BRIM-3:BRAF Vemurafenib vs DTIC BRAF CRAF MEK Melanoma IIIC ó IV BRAF V6E/V6K PFS Primera línea PS -1 Mtx cerebrales controladas 1 semanas tras tto Crossover permitido OS ERK

6 BRIM-3 Fase III Vemurafenib vs Dacarbazine en Melanoma: OS

7 BRAFi en Primera línea: PFS Vemurafenib vs Dacarbacina Lancet Oncol 14; 15: 33 3 Dabrafenib vs DTIC Lancet. 1 Jul 8;38(9839):

8 BRAF i en Primera línea: OS Vemurafenib vs Dacarbacina Lancet Oncol 14; 15: 33 3 Dabrafenib vs DTIC Lancet. 1 Jul 8;38(9839):

9 BRAF i en Primera línea : TR Vemurafenib vs Dacarbacina Lancet Oncol 14; 15: 33 3 Dabrafenib vs DTIC Lancet. 1 Jul 8;38(9839):

10 Terapias dirigidas en Estadio IV: principales estudios NRAS BREAK-3:BRAF Dabrafenib vs DTIC RR 59%,mPFS 6.9m HR OS/PFS:.77/.37 BRIM-3:BRAF Vemurafenib vs DTIC RR 57%,mPFS 6.9m HR OS/PFS:.7/.38 BRAF CRAF MEK Metric: BRAF Trametinib vs QT ERK 3 pacientes Melanoma avanzado BRAF V6E/V6K 1ª ó ª línea no BRAFi Obj. Primario: SLP Crossover permitido

11 METRIC: Fase III Trametinib (MEKi) vs Dacarbazine o Paclitaxel 4.8 vs 1.5meses HR:.47 (95% Cl: ; P <.1) 1. Probability of OS Probability of PFS Trametinib (n = 14).4 Chemotherapy (n = 18). Trametinib (n = 14).8.6 Chemotherapy (n = 18).4 OS a 6 meses 81 vs 67% HR:.54 (95% Cl:.3-.9; P =.1) Mos Since Randomization Flaherty KT, et al. N Engl J Med. 1;367: Mos Since Randomization 1

12 Eventos adversos más comunes con las nuevas terapias dirigidas en Melanoma Avanzado AE ( Grade ), % Vemurafenib[1] Dabrafenib[] Trametinib[3] Arthralgia 1 5 NR Rash 18 NR 7 Fatigue /8 6 (combined) NR 6 13 NR NR 11 NR Headache 5 5 NR Photosensitivity (any grade) 1 3 NR Hypertension NR NR 1 Cutaneous SCC/ keratoacanthoma Hyperkeratosis Pyrexia 1. Chapman PB, et al. N Engl J Med. 11;364: Hauschild A, et al. Lancet. 1;38: Flaherty KT, et al N Engl J Med. 1;367:

13 Resistencia a Inhibidores BRAF

14 Individual Patients Treated With Vemurafenib BRIM- Fase II Vemurafenib en Melanoma Metastásico : PFS TTP Time to response Died Alive with response Sosman J, et al. N Engl J Med. 1;366: Mos

15 Resistencia a inhibidor BRAF Intrínsecos CDK 4 cyclin D1 amplificada (CCN1) 15-% melanomas RESISTENCIA a BRAFi Pérdida PTEN (corta PFS), bcla1 ampl Braf fusion, GNAQ, RAC1P98, Pérdida NF1 RESISTENCIA a BRAFi HGF, CMET RESISTENCIA a BRAFi Adquiridos No dependientes de ERK (ERK todavía inhibido) ERK dependiente (ERK reactivado) Sullivan et al. Eur J Cancer 13: Turajlic Annals 14

16 Resistencia a inhibidor BRAF Alternative splicing BR AF BR AF NR AS NF1 BR AF BR AF BR AF ME K PI3 K CR AF P ME K CO T Amplification P ER K Nazarian R, et al. Nature. 1;468: Johannessen CM, et al. Nature. 1;468: Villanueva J, et al. Cancer Cell. 1;18: Wagle N, et al. J Clin Oncol. 11;9: Shi H, et al. Nat Commun. 1;3:74. Poulikakos PI, et al. Nature. 11;48: Straussman R, et al. Nature. 1;487:5-54. Whittaker SR, et al. Cancer Discov. 13;3: Maertens O, et al. Cancer Discov. 13;3:

17 Espectro de resistencias Datos de 3 grandes estudios de resistencias 1 pacientes con 13 muestras de resistencias adquiridas Douglas Jonhson ASCO 15

18 Espectro de resistencias Número Porcentaje Mutación NRAS 3 17 Mutación KRAS 3 Splicing BRAF 1 16 (5) Amplificación BRAF Mutación MEK1/ 9 7 Otras alteraciones MAPK 3 Alteraciones no MAPK Mecanismo no identificado 55 4 Douglas Jonhson ASCO 15

19 Espectro de resistencias Las mutaciones NRAS, variantes BRAF y mutaciones MEK1/ ocurren más a menudo aisladas Las amplificaciones BRAF y las alteraciones no ligadas a la vía MAPK concurren con otras alteraciones más de manera más frecuente Varias mutaciones son mutuamente excluyentes Douglas Jonhson ASCO 15

20 Espectro de resistencias: asociaciones clínicas PFS fue similar independientemente del mecanismo de progresión Diferente patrón de progresión según mecanismo de resistencia: NRAS más frecuente en cerebro, menos en pulmón MEK 1/ más frecuente en hígado Douglas Jonhson ASCO 15

21 Cómo frenar estas resistencias?

22 MEKi (Trametinib) en Melanoma Metastásico BRAF-Mutado/BRAFi-Nativo Disease Stage IIIC M1a M1b M1c Unknown 1 % Change From Baseline in Diameters of Target Lesions 8 6 Trametinib (n = 14) Confirmed RR: % (95% CI: ) % Robert C, et al. ASCO 1. Abstract LBA859.

23 Inhibidor MEK en monoterapia tiene mínima actividad en pacientes refractarios a BRAFi Unconfirmed RR: 5% (95% CI: ) 1 CR, 1 PR, 11 SD Maximum Reduction in Target Lesions From Baseline (%) 1 8 * M Stage at Screening M1a M1b M1c 6 4 K K K K - -4 * *Discontinued prior BRAFi due to toxicity K = V6K Kim KB, et al. J Clin Oncol. 13;31: *

24 Inhibición combinada BRAF y MEK en Melanoma BRAFV6-Positivo Resistencia retardada con la combinación BRAF/MEK vs monoterapia con BRAFi Full-Dose BRAF/MEK Median PFS, mos 9.4 HR.39 (P <.1) 1. Full-Dose BRAF 5.8 Probability of PFS Full-dose BRAF/MEK Full-dose BRAF/half-dose MEK Full-dose BRAF Mos Since Randomization Flaherty KT, et al. N Engl J Med. 1;367:

25 Regresión tumoral con la combinación BRAF/MEK en pacientes refractarios a BRAFi Maximum Percent Reduction From Baseline 4 M M RR: 19% --6 M = Prior MEKi --8 Mos Since Prior BRAFi M M Best Response on Prior BRAFi PR SD PD M Flaherty KT, et al. SMR 11. Abstract LBA1-4.

26 Supervivencia con inhibición BRAF/MEK en función de inhibidor BRAF previo Part C 15/ (n = 54) Part B 15/ BRAFi naive (n = 4) Part B 15/ BRAFi failure (n = 6) 1. Proportion Alive Mos From Randomization/First Dose Flaherty KT, et al. ASCO 14. Abstract

27 Retratamiento con BRAFi Los tumores resistentes a BRAFi muestran dependencia contínua de la señalización BRAF(V6E) MEK ERK debido a sobreexpresión BRAF(V6E) Thakur MD and Stuart D D Cancer Res 13

28 Retratamiento con BRAFi La discontinuación del tratamiento conduce a la regresión de tumores resistentes Thakur MD Nature 13

29 Tratamiento discontínuo con IK/inmunoterapia Los inhibidores kinasa pueden rescatar S1 durante el curso del tratamiento Reinhard Dummer at 15 ASCO Annual Meeting

30 Tratamiento combinado BRAFi + MEKi

31 Bases para la combinación RAS BRAFi (dabrafenib/vemurafenib) PFS HR.37/.38 v DTIC Hyperproliferative skin AEs MEKi (trametinib) PFS HR.45 v chemotherapy mutbr BRAF AF BRAFi + MEKi ph3 studies 1 dabrafenib + trametinib ME K perk 1.Hauschild A., et al. Lancet 1;38:358. Updated in J Clin Oncol 13 (suppl); ab 913..Flaherty KT., et al. N Engl J Med 1;367: Long GV., et al. N Engl J Med 14;371(): Robert C., et al. N Engl J Med 15;37(4): Larkin J., et al. N Engl J Med 14;371(): % Proliferation Survival Invasion Metastasis vemurafenib + cobimetinib Decreased hyperproliferative skin AE3,4,5

32 Terapias dirigidas en Estadio IV: principales estudios COMBI-v:BRAF D+T vs Vemurafenib NRAS BREAK-3:BRAF Dabrafenib vs DTIC RR 59%,mPFS 6.9m HR OS/PFS:.77/.37 BRIM-3:BRAF Vemurafenib vs DTIC RR 57%,mPFS 6.9m HR OS/PFS:.7/.38 Metric: BRAF Trametinib vs DTIC RR %, mpfs 4.8m HR OS/PFS:.54/.45 BRAF CRAF MEK ERK

33 COMBI-v: Dabrafenib+Trametinib vs Vemurafenib en primera línea en melanoma BRAFV6E/K N = 1,644 screened BRAF V6E/K mutation Stages IIIC or IV cutaneous melanoma Treatment-naive in advanced or metastatic ECOG PS or 1 No brain metastases, unless Treated Stable > 1 weeks Stratification BRAF V6E vs V6K mutation LDH (> ULN vs ULN) Interim OS Analysis (n = ) n= 74 Final OS Analysis (n = 88) Dabrafenib (15 mg BID) + trametinib ( mg daily) (n = 35) Vemurafenib (96 mg BID) (n = 35) Primary endpoint: OS Secondary endpoints: progression-free survival (PFS), overall response rate (ORR), duration of response (DoR), safety BID, twice daily; ECOG PS, Eastern Cooperative Oncology Group performance status; LDH, lactate dehydrogenase; ULN, upper limit of normal

34 Dabrafenib+Trametinib vs Vemurafenib en primera línea en melanoma BRAFV6E/K :OS Median Follow-up: D + T = 11 months and Vem = 1 months

35 Análisis OS por subgrupos (ITT).75 V6K (n = 68) V6E (n = 69) Male (n = 388) Female (n = 316).71 < 65 years (n = 538) years (n = 166) Baseline LDH ULN (n = 471) Baseline LDH > ULN (n = 3) Favours D + T H R 1. 5 Favours Vem

36 Dabrafenib+Trametinib vs Vemurafenib en primera línea en melanoma BRAFV6E/K :PFS

37 Dabrafenib+Trametinib vs Vemurafenib en primera línea en melanoma BRAFV6E/K : Respuesta Best confirmed response Dabrafenib + trametinib (n = 351) Vemurafenib (n = 35) Complete response, n (%) 47 (13) 7 (8) Partial response, n (%) 179 (51) 153 (44) Stable disease, n (%) 9 (6) 16 (3) Progressive disease, n (%) (6) 38 (11) Not evaluable, n (%) 11 (3) 6 (7) Response rate, n (%) (95% CI) 6 (64) ( ) 18 (51) ( ) Difference in ORR, % (95% CI) 13 (5.7.) <.1 P-value DoR, months (95% CI) 13.8 (11. NR) 7.5 ( )

38 Terapias dirigidas en Estadio IV: principales estudios COMBI-v:BRAF D+T vs Vemurafenib RR 64%, mpfs 11,4m HR OS/PFS:.69/.56 COMBI-d:BRAF D+T vs Dabrafenib NRAS BREAK-3:BRAF Dabrafenib vs DTIC RR 59%,mPFS 6.9m HR OS/PFS:.77/.37 BRIM-3:BRAF Vemurafenib vs DTIC RR 57%,mPFS 6.9m HR OS/PFS:.7/.38 Metric: BRAF Trametinib vs DTIC RR %, mpfs 4.8m HR OS/PFS:.54/.45 BRAF CRAF MEK ERK

39 COMBI-d: Diseño N = 947 screened BRAF V6E/K Unresectable stage IIIC/IV Treatment naïve ECOG PS /1 No brain mets, unless: Treated Stable 1 weeks Stratification BRAF mut V6E v K LDH (>ULN v ULN) No crossover to combination allowed Site staff and patients remained blinded Primary Analysis (PFS) [13 events] Aug 13 dabrafenib + placebo 15 mg BID + placebo QD n = 1 N = 43 dabrafenib + trametinib 15 mg BID + mg QD n = 11 Pre-planned interim OS [95 events] Primary Endpoint: Investigator-assessed PFS Secondary Endpoints: OS, overall response rate (ORR), duration of response, safety Long GV, et al. Lancet epub 31 May 15. Final Analysis (OS) [ deaths] Jan 15

40 COMBI-d: Supervivencia Libre de Progresión 1. Proportion Progression-free Dabrafenib + Trametinib Events: 139 (66%).8 Median PFS 11. mo (95% CI: ).6 Dabrafenib + Placebo Events: 16 (76%) Median PFS 8.8 mo (95% CI: ).4. HR.67 (95% CI:.53,.84) P < Time (months) Number at risk Dabrafenib + trametinib Dabrafenib + placebo Long GV, et al. Lancet epub 31 May 15.

41 PFS y OS en pacientes con LDH aumentada

42 COMBI-d: Supervivencia Dabrafenib + Trametinib Died: 99 (47%) 1. Med OS = 5 1 mo (95% CI:19.-NR) 1-yr OS = 74% Proportion Alive.8 -yr OS 51%.6 Dabrafenib 1-yr OS = 68% Died: 13 (58%).4 Median OS = 18.7 mo -yr OS 4% (95% CI: ). HR.71 (95% CI:.55,.9) P = Time (months) Number at risk Dabrafenib + trametinib Dabrafenib + placebo Dabrafenib+Trametinib med follow up mo (range -3 mo); Dabrafenib med follow up 16 mo (range -3 mo). Long GV, et al. Lancet epub 31 May 15.

43 COMBI-d: Tratamiento tras la progresión Study treatment continued post progressionc Subsequent anti-cancer therapyd Ipilimumab BRAF inhibitor (vemurafenib and/or dabrafenib) Pembrolizumab or nivolumab Chemotherapy regimens Other Dabrafenib + Placeboa n = 1 n (%) Dabrafenib + Trametinibb n = 11 n (%) 65 (31) 6 (9) 18 (51) 7 (33) 59 (8) 37 (18) 9 (14) 18 (9) 14 (7) 6 (3) 66 (31) 45 (1) 14 (7) 4 () a 35 (17%) remained on study treatment at data cut. 64 (3%) remained on study treatment at data cut. c Received study treatment for at least 15 days after disease progression. d Study treatment is not included. b Long GV, et al. Lancet epub 31 May 15.

44 COMBI-d: OS por subgrupos Favors Dabrafenib + placebo Favors Dabrafenib + trametinib Number of patients Factor Age: BRAF mutation: Stage: LDH: No disease sites All patients < 65 years years 118 V6E 36 V6K 61 IIIc/M1a/M1b 14 M1c 8 ULN 73 > ULN Hazard ratio and 95% confidence Long GV, et al. Lancet epub 31 May 15. interval.

45 COMBI-d: Respuesta Dabrafenib + Placebo (n = 1a) n (%) Dabrafenib + Trametinib (n = 1a) n (%) CR 8 (13) 33 (16) PR 84 (4) 111 (53) SD 66 (31) 5 (4) PD 19 (9) 13 (6) NE 13 (6) 3 (1) 11 (53) 144 (69) (46.3, 6.) (61.8, 74.8) 79 (7) 86 (6) 1.6 ( ) 1.9 ( ) P-valueb Best response Response rate CR+PR 95% CI Duration of response Progressed or died, n (%) Median, months (95% CI) a Number of patients with measurable disease at baseline. Chi-square test was used to calculate the P-value for difference between response rates. b Long GV, et al. Lancet epub 31 May 15..1

46 Terapias dirigidas en Estadio IV: principales estudios COMBI-v:BRAF D+T vs Vemurafenib RR 64%, mpfs 11,4m HR OS/PFS:.69/.56 COMBI-d:BRAF D+T vs Dabrafenib RR 69%, mpfs 11 m HR OS/PFS:.71/.67 cobrim: BRAF V+Cobimetinib vs Vemura NRAS BREAK-3:BRAF Dabrafenib vs DTIC RR 59%,mPFS 6.9m HR OS/PFS:.77/.37 BRIM-3:BRAF Vemurafenib vs DTIC RR 57%,mPFS 6.9m HR OS/PFS:.7/.38 Metric: BRAF Trametinib vs DTIC RR %, mpfs 4.8m HR OS/PFS:.54/.45 BRAF CRAF MEK ERK

47 cobrim Vemurafenib 96 mg BID 8 days (Days 1-8) + Cobimetinib 6 mg QD 1 days (Days 1-1) Melanoma, unresectable locally advanced or metastatic (n = 495) BRAFV6 mutation (cobas 48) No prior systemic therapy for advanced disease ECOG PS /1 Stratification Geographic region Extent of disease (M1c vs other) 1:1 Disease progression, unacceptable toxicity, or withdrawal of consent Vemurafenib 96 mg BID 8 days (Days 1-8) + Placebo Primary end point PFS, investigator assessed1 Secondary end points OS, objective response rate, duration of response, PFS, IRC assessed, safety, pharmacokinetics, quality of life: QLQ-C3 and EQ-5D BID, two times daily; ECOG, Eastern Cooperative Oncology Group; EQ, EuroQol; HR, hazard ratio; IRC, independent review committee; OS, overall survival; PS, performance status; QD, once daily; QLQ, quality-of-life questionnaire. 1. Larkin J et al. N Engl J Med. 14;371: Primary analysis for PFS: Performed in 14 with the data cutoff as May 9, 14. Protocol-specified first OS interim analysis was also performed1 Updated analysis for PFS: Presented here with the data cutoff as January 16, 15.

48 cobrim: Supervivencia libre de Progresión Kaplan-Meier Plot for PFS Intent-to-Treat Population 1 + ITT Population Survival Distribution Function (%) Cobimetinib + vemurafenib (n=47) Placebo + vemurafenib (n=48) Censored Months 9 Months 7.b ( ) Data cutoff of January 16, 15 was 1 year from enrollment of last patient Months 17 Months 1 Months 5 Months Time No. of patients at risk a Stratified b 1.5b ( ).58b ( ) Vemurafenib + cobimetinib Vemurafenib + placebo 18 (7.6) HRa (95% CI) Months 143 (57.9) Median PFS, months (95% CI) 6 + Pbo + Vem n = 48 PFS events, n (%) Cobi + Vem n = HR. The median PFS was 6. months in Pbo + Vem, and 9.9 months in Cobi + Vem (HR,.51; 95% CI, ) at the May 9, 14 data cutoff. Larkin J et al. N Engl J Med. 14;371:

49 PFS por subgrupos Placebo + vemurafeni b (n=48) Baseline Risk Factors Total n n Event s Cobimetinib + vemurafenib (n=47) Median (months) n Event s Median (Months) Hazar d Ratio 95% Wald CI All Patients Disease Stage (IIIc/M1a/M1b, or M1c) M1 C Unresectable Stage AgeIIIC/M1A/M1B Group (.47,.73) (.4,.68) (.49, 1.8) (yr)< (.47,.79) (.34,.8) (.4,.8) (.44, ) (.3, 1.3) (.45,.75) (.8, ) (.49,.85) (.35, Screening Serum LDH Elevate d Norma ) (.4,.78) (.43, l Adjuvant Prior Therapy Ye s No ) (.8, 1.7) (.47, ) (.49,.83) (.7, Se x Femal e Mal e Geographic Region Australia/New Zealand/Others Europ e N. America ECOG Performance Status 1 BRAFV6 Mutation Status V6 E V6 K 1.) 1/1 Cobimetinib + Placebo + vemurafenib vemurafenib better better 1/

50 cobrim : Tasa de Respuestas Cobimetinib + Vemurafenib n = 47 Placebo + Vemurafenib n = 48 Complete response (CR), n (%) 39 (15.8) 6 (1.5) Partial response, n (%) 133 (53.8) 98 (39.5) 17 (69.6) (95% CI, ) 14 (5.) (95% CI, ) Objective response rate (ORR), n (%) Difference in ORR, % Duration of response Patients with event, n (%) Median (95% CI) Range a 19.64a (95% CI, ) 84 (48.8) 1.98 ( ) (58.9) 9.3 ( ) At the primary analysis ORR was 68% and 45%, respectively, and CR was 1% and 4%, respectively. Larkin J et al. N Engl J Med. 14;371: Data cutoff was January 16, 15.

51 Supervivencia 1 Overall Survival, % * OS events, n Median OS NE NE 7.5 ( ) 81.1 ( ) Vemurafenib + cobimetinib (n = 47) HR (95% CI) Vemurafenib + placebo (n = 48) P value two-sided ++ Censored placebo Vemurafenib + Cobimetinib 9-month OS (95% CI), % No. at Risk Vemurafenib + cobimetinib Vemurafenib + Vemurafenib + Placebo Time, months.65 (.4-1.) P =.46* CI, confidence interval; NE, not estimable. Descriptive p-value. Did not cross the pre-specified stopping boundary for the interim analysis (boundary p <.37) 18 Data Cutoff: May 9, 14

52 Update of Progression-Free Survival and Correlative Biomarker Analysis From cobrim: Phase 3 Study of Cobimetinib Plus Vemurafenib in Advanced BRAFMutated Melanoma James Larkin, Yibing Yan, Grant McArthur, Paolo Ascierto, Gabriella Liszkay, Michele Maio, Mario Mandalà, Lev Demidov, Daniil Stoyakovskiy, Luc Thomas, Luis de la Cruz-Merino, Victoria Atkinson, Caroline Dutriaux, Claus Garbe, Matthew Wongchenko, Isabelle Rooney, Ilsung Chang, Stephen P. Hack, Brigitte Dréno, Antoni Ribas

53 cobrim Oncogenic Mutation Profiling Sequencing Targets Materiales Métodos Se analizaron mutaciones BRAF y 58 mutaciones conocidas activantes en 17 proteínas kinasas oncogénicas (Ion Torrent next generation sequencing) RAS/RAF DNA de tejido previo al tratamiento Los datos se correlacionaron con PFS y ORR Codon Range HRAS 9-, KRAS 4-15, 55-65, NRAS 9-, BRAF FGFR , , , , , , , 5-6 FGFR , FLT KIT , MET PDGFRa 56-57, RET ABL , AKT AKT 16-6 JAK PIK3CA , EGFR RTK 43 muestras secuenciadas La mutación fue positiva cuando la frecuencia del alelo mutado fue detectada en >3% de las lecturas Gene

54 Baseline Oncogene Mutations Coexist With BRAFV6 Mutations in cobrim Patients Distribution of Mutations in Assayed Oncogenes* En 46 de 43 muestras de pacientes (11%) se demostraron mutaciones coexistentes en RAS, RAF, y/o RTK 1 Coexisting mutation RAS/RAF/RTK RAS/RAF HRAS KRAS NRAS BRAF Non-V6 EGFR FGFR3 FLT3 KIT PDGFRa JAK PIK3CA Number of Patients 5 RAS/RAF RTK *Includes patients with 1 coexisting mutation. # Allelic frequencies of co-existing oncogene mutations in baseline tumor tissues ranged from 5 99 % with median of 8.6%

55 Coexisting Baseline RAS/RAF/RTK Mutations Were Not Associated With Worse PFS or ORR in cobrim Patients perk in Available Samples by RPPA1 Kaplan-Meier Plot of PFS for Sequenced Patients in Both Treatment Arms RAS/RAF/RTK co-mutants have higher MAPK pathway activity, as measured by perk ORR 1 RAS/RAF/RTK WT RAS/RAF/RTK Mut 6% 61% RPPA, reverse-phase protein array. 55 Coexisting mutations were not associated with worse PFS in either treatment arm

56 Greater Clinical Benefit Obtained in Advanced BRAFV6mutated Melanoma with Cobimetinib/Vemurafenib Over Vemurafenib Is Consistent Across Mutation Subtypes ESMO 15

57 Resumen eficacia BRAFi+MEKi TR SLP SG %LDH elevado DabrafenibTrametinib (Combi-d) 69% 11m 5,1m 36% DabrafenibTrametinib (Combi-v) 64% 11,4m NA 34% 69,6% 1,5m NA 46% VemurafenibCobimetinib Co-BRIM

58 Resumen Eventos Adversos Vem EA (total) EA >=G3 EA que conducen a la discontinuación del tto Vem+Cobi 98% 59% 1% 98% 65% 13% Dabra 97% 3% 7% Dabra+Trame 97% 3% 11% Larkin J et al. N Engl J Med. 14;371: Long GV, et al. Lancet epub 31 May 15.

59 COMBI-d: Eventos Adversos en % de pacientes Preferred Term All Events Pyrexia Chills Fatigue Rash Nausea Arthralgia Hyperkeratosis Hand-foot syndromec Alopecia a Dabrafenib + Placeboa n = 11 n (%) Dabrafenib + Trametinibb n = 9 n (%) All Grades 189 (9) 5 (5) 9 (14) 59 (8) 4 () 31 (15) 49 (3) 7 (33) Grade 3 63 (3) 4 () 1 (<1) (<1) 1 (<1) 1 (<1) 1 (<1) All Grades 181 (87) 18 (5) 58 (8) 56 (7) 5 (4) 41 () 34 (16) 13 (6) Grade 3 66 (3) 15 (7) 4 () 1 (<1) 57 (7) 1 (<1) 13 (6) 1 (<1) 55 (6) 1 (5) Three grade 4 events; 1 grade 5 event, treatment-related (bile duct adenocarcinoma). One grade 4 event; 5 fatal SAEs, not treatment related (3 intracranial hemorrhage,1 pneumonia,1 drowning). c Combined terms of palmar-plantar erythrodysesthesia and palmoplantar keratoderma. Long GV, et al. Lancet epub 31 May 15. b

60 Co-BRIM: Eventos Adversos en % de pacientes Vemurafenib + Placebo (n = 39) Vemurafenib + Cobimetinib (n = 54) G I Diarrhea Nausea Vomitin g Dermatologi c Rash Photosensitivity reaction Hyperkeratosis Alopecia Laborator y Increased CPK Increased ALT Increased AST Othe r Arthralgia Fatigu e Pyrexia Percentage Grade 1 Grade Grade 3 Grade 4 Larkin J et al. N Engl J Med. 14;371: Data Cutoff: May 9, 14

61 EA relacionados con BRAFi o MEKi Vemurafenib+Co bimetinib(%) EA relacionados con BRAFi cuscc + KA EA relacionados con MEKi Dabrafenib + Trametinib n (%) Pirexia 9 5 (G3-4: 7%) Disminución Fracción eyección 7 4 (G3-4 <3%) <1 Chorioretinopathyb Larkin J et al. N Engl J Med. 14;371: Long GV, et al. Lancet epub 31 May 15.

62 Terapias dirigidas en Estadio IV: principales estudios COMBI-v:BRAF D+T vs Vemurafenib RR 64%, mpfs 11,4m HR OS/PFS:.69/.56 COMBI-d:BRAF D+T vs Dabrafenib RR 69%, mpfs 11 m HR OS/PFS:.71/.67 cobrim: BRAF V+Cobimetinib RR 69,6%, mpfs 1,m HR OS/PFS:,65/,58 NRAS BREAK-3:BRAF Dabrafenib vs DTIC RR 59%,mPFS 6.9m HR OS/PFS:.77/.37 Fase II NRAS Binimetinib (MEK 16) ORR 63% BRIM-3:BRAF Vemurafenib vs DTIC RR 57%,mPFS 6.9m HR OS/PFS:.7/.38 Metric: BRAF Trametinib vs DTIC RR %, mpfs 4.8m HR OS/PFS:.54/.45 BRAF CRAF MEK ERK

63 Phase I/II Study: LEE11 + Binimetinib (MEK16) in NRAS-Mutant Melanoma Phase Ib/Dose Escalation Metastatic or Locally Advanced NRAS-Mutant Melanoma (N 15) Phase II/Dose Expansion Metastatic or Locally Advanced NRAS-Mutant Melanoma (N 4) MTD and/or RPD LEE11 + Binimetinib Phase Ib Doses and Schedule* LEE11: oral selective CDK4/6 inhibitor Binimetinib: oral selective MEK1/ inhibitor Phase Ib endpoints Primary objective: determine the MTD and/or recommended phase II dose using a Bayesian logistic regression model with overdose control principle Secondary objectives: safety and tolerability, PK, and clinical efficacy Sosman JA, et al. ASCO 14. Abstract 99. Cohort Binimetinib, mg BID LEE11, mg QD Patients, n *LEE11 for 1 consecutive days followed by a 7-day planned break and binimetinib on a continuous dosing schedule.

64 LEE11 + Binimetinib (MEK16) in NRAS-Mutant Melanoma: Responses Overall Response CR PR Confirmed PR Unconfirmed PR SD 1 LEE11 + Binimetinib (N = ) 7 (33) 3 (14) 4 (19) 11 (5)* % to 3% tumor mass decrease by RECIST (33) Clinical benefit rate (CR + PR + SD) 18 (86) PD 3 (14) Unevaluable 1 (NA) *Includes 1 patient with KRAS-mutant pancreatic cancer. 8 Best Percentage Change From Baseline Response, n (%) Individual Patient Responses n = * K * * * * * * * * * Treatment Group LEE mg + MEK 45 mg LEE 5 mg + MEK 45 mg *Ongoing as of April 14, 14 K denotes patient with KRAS-mutant pancreatic cancer Sosman JA, et al. ASCO 14. Abstract 99. LEE 3 mg + MEK 3 mg LEE 3 mg + MEK 45 mg Several patients had early tumor shrinkage with major symptomatic improvement * *

65 Selumetinib (melanoma uveal) n i t n i o p d y n d E u t s S e s a s i m o M n b a i l n e i t M e l m a u e v U Sel I I I e s a h P T I M M SU R Carvajal et al JAMA. 14 Jun 18; 311(3):

66 Conclusiones Para el 5% de los pacientes con melanoma, la inhibición combinada BRAF y MEK mejora las respuestas y la SLP Aumento en la supervivencia con medianas aún no alcanzadas y supervivencias prolongadas (51% a años) Tratamiento en primera línea, pendiente de establecer su papel en combinación/secuenciación con inmunoterapia Es preciso mayor conocimiento de los mecanismos de resistencia y estrategias para revertirlos/retrasarlos