By Liseth Parra, Ph.D., and Stephanie Hawthorne, Ph.D.
A very exciting therapeutic area that has been constantly highlighted throughout ASCO this year is the enormous potential for targeting genomic instability. While genomic stability is a major force of tumor growth, it provides a vulnerable point of tumorigenesis that can be used as an actionable target in clinical oncology. BRCA1 and BRCA2 are responsible for activating DNA damage response pathways as a result of DNA double-strand breaks (DSB) and thus play an important role in maintaining the genetic stability of cells.
Hereditary (germline) mutations in one copy of either the BRCA1 or BRCA2 gene (gBRCA1/2) are associated with a high risk of developing primarily breast and ovarian cancer and represent one of the greatest unmet needs in gynecologic cancers. These mutations account for about 5% to 10% of all breast cancers and about 15% of all ovarian cancers1 and are particularly vulnerable to poly(ADP-ribose) polymerase (PARP) inhibition. PARP proteins normally function in the repair of DSB, and it’s presumed that their inhibition leads to the breakdown of the DNA machinery involved in DSB repair that cannot take place in BRCA1/2 deficient cells, a concept referred to as synthetic lethality.
Within the past two years, three PARP inhibitors gained regulatory approval for the treatment of advanced ovarian cancer – Lynparza® (olaparib, AstraZeneca), Rubraca® (rucaparib, Clovis Oncology), and Zejula™ (niraparib, Tesaro). Additionally, four PARP inhibitors – Lynparza, talazoparib (Pfizer / Medivation), veliparib (ABT-888, AbbVie), and Zejula – are in Phase III development for locally advanced or metastatic BRCA1/2 mutated breast cancer, starting a race to see which agent will be first to market in this indication.
AstraZeneca, as an output of its 2005 acquisition of the British biotechnology company KuDOS, became the first pharmaceutical company to launch a PARP inhibitor, with Lynparza obtaining accelerated approved as a monotherapy for the treatment of gBRCA ovarian cancer patients previously treated with three or more lines of chemotherapy. Following this initial launch, AstraZeneca has an extensive life-cycle management development plan in-place for Lynparza, with its eyes on breast cancer as the next indication for approval.
In the Plenary session at the 2017 ASCO conference, the first randomized results to support its development in breast cancer were presented1,2. The Phase III OLYMPIAD trial (NCT02000622) evaluated Lynparza in comparison to “physician’s choice” chemotherapy (capecitabine, vinorelbine, eribulin) in 302 metastatic HER2- breast cancer patients with deleterious or suspected gBRCA mutations.
Patients could have had up to two prior lines of chemotherapy and must have received prior anthracycline and taxane, and hormone receptor-positive patients must have received at least one prior line of hormone therapy unless considered unsuitable; ultimately, one-third of enrolled patients were treated on-study as first-line therapy for metastatic disease, one-quarter as third-line, and the remainder as second-line.
Late breaking results for this trial presented at ASCO demonstrated for the first time positive data for a PARP inhibitor in metastatic breast cancer with a statistically-significant improvement in progression-free survival (PFS) compared to standard chemotherapy and a meaningful improvement in health-related quality of life (HRQoL) in these patients.
The data showed a statistically significant PFS gain of nearly 3 months in patients treated with Lynparza (300 mg BID; n=205) versus chemotherapy (n=97) (7.0 vs 4.2 months, respectively; HR 0.58; p=0.0009). Although immature, overall survival (OS) was not statistically different between the two arms (19.3 versus 19.6 months, HR 0.90; p=0.5665). The ORR in the two arms was 60% versus 29%, respectively, with more complete responses in patients treated with Lynparza (9%) versus chemotherapy (2%). Although exploratory, data suggest similar level of benefit regardless of patient’s prior exposure to platinum or other chemotherapy, but suggest greater benefit in patients with triple-negative breast cancer (PFS HR 0.43) than in patients with hormone receptor-positive disease (PFS HR 0.82).
Fewer patients in the Lynparza arm than in the chemotherapy arm experienced Grade 3/4 adverse events (AE; 36.6% vs. 50.5%) and slightly fewer AE-related treatment discontinuations (4.9% vs. 7.7%). The most common Grade 3/4 adverse events in the Lynparza and chemotherapy arms were anemia (16% vs. 4%) and neutropenia (9% vs. 26%). As a secondary endpoint, the results showed that Lynparza led to a modest but clinically meaningful improvement in HRQOL compared to chemotherapy (estimated difference in EORTC QLQ-C30 global HRQOL score of 7.5 points, p=0.0035) and significantly longer time to deterioration of HRQOL (median not reached vs. 15.3 months; HR 0.44, p=0.0043).
These results represent the first positive Phase III trial for a PARP inhibitor in breast cancer and the discussant, Dr. Allison Kurian, had an overall positive outlook stating that these results” are practice-changing.” However, the magnitude of the benefit (3 months difference) and lack of OS benefit could raise questions by others in the field about the clinical meaningfulness of these results.
It is encouraging that the incidence of adverse events was lower, fewer treatment discontinuations were needed, and HRQOL was improved with Lynparza, but the magnitude of each of these improvements seems to run on the edge of meaningful from the a clinical perspective. When the clinical benefits run along that edge, commercial considerations have a greater likelihood of taking hold, and some physicians (and payers) may question whether the benefit with Lynparza compared to generic chemotherapy justifies the costs. Despite these concerns, Lynparza stands a good chance of gaining regulatory approval, so these debates may ultimately play out in the clinic and everyday practice.
While it may launch as a monotherapy, ultimately the greater movement forward with PARP inhibitors lies in alternative development strategies. Correlative biomarkers for PARP inhibition (beyond gBRCA1/2) may help to further identify patients that will benefit the most from Lynparza. Additionally, the double-hit approach of single-agent PARP inhibitors in gBRCA mutated disease may not be robust enough, and we could ultimately find more effective strategies with a targeted combination approach – this includes combinations with chemotherapy or radiotherapy (which can induce DSBs)or with other mechanisms of action.
The closest drug taking this approach is veliparib, which is being studied in the Phase III BROCADE 3 trial (NCT02163694), which is enrolling HER2- breast cancer patients harboring deleterious BRCA1/2 or gBRCA1/2 mutations with less than two lines of prior therapy, who will be randomized to treatment with carboplatin and paclitaxel in combination with veliparib or placebo. Other PARP inhibitors in development in breast cancer are being developed as monotherapies - talazoparib in the Phase III EMBRACA trial (NCT01945775 and Zejula in the Phase III BRAVO trial (NCT01905592). The OlympiAD results, Lynparza is now officially ahead of the competition and could emerge as a potential agent of change in gBRCA breast cancer management, creating a new standard of care for the gBRCA1/2-mutated patient population. With so many competitors hot on its heels, it will be critical for Lynparza to get a solid push off of the starting block in order to put as much distance between itself and the others in this Olympic race in the breast cancer market.