Chieti 15 th June 2017 Breast Cancer from

Chieti, 15 th June 2017 Breast Cancer from Bench to Bedside Anthropometrics and Biomarkers of Glucose Metabolism in Breast & Ovarian Cancer: from the real world setting to the underlying pathways Maddalena Barba, MD, Ph. D Division of Medical Oncology 2 Regina Elena National Cancer Institute

Pros of this pipeline Timely topic High productivity/feasibility Low costs

Timely topic

Timely topic Sonnenblick A et al. , Association of Metformin Use for Diabetes With Outcomes in HER 2 -Positive Breast Cancer. JCO 2017, 1; 35(13): 1421 -1429. Farzana L et al. , Effect of metformin chemoprevention on metabolomics profiles in Li. Fraumeni Syndrome (LFS). J Clin Oncol 35, 2017 (suppl; abstr 1556). Selmy M et al. , Modulation of the anti-tumor activity of VEGF blockade by metformin. J Clin Oncol 35, 2017 (suppl; abstr e 23009).

Underlying pathways

High productivity/feasibility Pizzuti L et al, GLUT 1 receptor expression and circulating levels of fasting glucose in high grade serous ovarian cancer. J Cell Physiol. 2017 Pizzuti L et al. , Anthropometric, clinical and molecular determinants of treatment outcomes in postmenopausal, hormone receptor positive metastatic breast cancer patients treated with fulvestrant. Results from a real word setting. , Oncotarget. 2017 Barba M et al. , Body mass index modifies the relationship between γ-H 2 AX, a DNA damage biomarker, and pathological complete response in triple-negative breast cancer. BMC Cancer. 2017. Vici P et al. , Metabolic Determinants and Anthropometric Indicators Impact Clinical-pathological Features in Epithelial Ovarian Cancer Patients. J Cancer. 2016. D’Aiuto M et al. , Body mass index and treatment outcomes following neoadjuvant therapy in women aged 45 years or younger. Evidence from a historic cohort. Cancer Biol Ther. 2016 Barba M et al, Body Mass Index and Treatment Outcomes in Metastatic Breast Cancer Patients Treated With Eribulin. J Cell Physiol. 2016. Pizzuti L et al. , Motorman and breast cancer: basic knowledge in clinical context. Cancer Treat Rev. 2015 Vici P et al. , Anthropometric, metabolic and molecular determinants of human epidermal growth factor receptor 2 expression in luminal B breast cancer. J Cell Physiol. 2015. Vici P et al. , p 53 status as effect modifier of the association between pre-treatment fasting glucose and breast cancer outcomes in non diabetic, HER 2 positive patients treated with trastuzumab. Oncotarget. 2014 Nov 15; 5(21): 10382 -92. Barba M et al. , Fasting glucose and treatment outcome in breast and colorectal cancer patients treated with targeted agents: results from a historic cohort. Ann Oncol. 2012.

High productivity/feasibility Under review: SREP-17 -08456: Pizzuti et al. , Anthropometric and metabolic predictors of efficacy and toxicity in breast cancer patients treated with everolimus-exemestane: The Ever. Ext study. “I am pleased to inform you that, after an initial assessment, your manuscript will be peer reviewed. We are now in the process of contacting referees. ” 2 nd May 2017. In course of writing Pizzuti et al. , Assessing the role of patient and disease characteristics on treatment outcomes in HER 2 -negative metastatic breast cancer patients treated with first line paclitaxel and bevacizumab in the real word clinical practice.

Where does this feasibility come from?

ASCO 2017 Sonnenblick et al. , JCO 2017 Association of Metformin Use for Diabetes With Outcomes in HER 2+ Bca Aims: to assess whether patients with diabetes at study entry-with or without metformin treatment showed different DFS, DDFS, and overall survival OS compared with patients without diabetes Patients and Methods: The ALTTO RCT randomized early HER 2 positive Bca pts to 1 year of either trastuzumab alone, lapatinib alone, their sequence, or their combination.

ASCO 2017 Results: 186 patients (2. 2%) had diabetes with no metformin treatment, and 260 patients (3. 1%) were diabetic and had been treated with metformin. Median follow-up was 4. 5 years (0. 16 to 6. 31 years), at which 1, 205 (14. 8%), 929 (11. 08%), and 528 (6. 3%) patients experienced DFS, DDFS, and OS events, respectively. Patients with diabetes who had not been treated with metformin experienced worse DFS (HR 1. 40; 95% CI, 1. 01 to 1. 94; p =. 043), DDFS (HR, 1. 56; 95% CI, 1. 10 to 2. 22; P = . 013), and OS (HR, 1. 87; 95% CI, 1. 23 to 2. 85; P =. 004). This effect was limited to HR+HER 2+ Bca pts.

Fasting glucose and treatment outcome in Bca and colon cancer pts treated with targeted agents: results from a historic cohort. Barba M et al, Ann Oncol 2012 Aims: to investigate pretreatment fasting glucose as a predictor of pts important outcomes in Bca and colon cancers undergoing targeted therapies Methods: 202 HER 2+ Bca and 218 colon cancers treated with targeted agents. Kaplan-Meier method and the log-rank test to estimate survival through tertiles of fasting glucose and the Cox proportional hazards model for multivariate analysis stratified by primary site of cancer and including gender, age and BMI

Barba M, Ann Oncol 2012 Results The median follow-up was 20 months (1– 128). At 60 months, 65% of patients in the lowest tertile of fasting glucose did not experiment disease progression compared with 34% in the highest tertile (P = 0. 001). In multivariate analysis, fasting glucose was a significant predictor of time to disease progression only in breast cancer patients in the first tertile compared with the third (P = 0. 017).

Barba M et al. , Ann Oncol 2012

Barba et al. , Ann Oncol 2012 Table 3. Cox proportional hazards model of factors associated with time to disease progression in breast and colorectal cancer patients treated with targeted agents. HR 95%CI p-value Age at Cancer Diagnosis 1. 02 0. 99 -1. 03 0. 083 BMI at Baseline 0. 98 0. 33 -1. 3 0. 406 Gender 0. 19 0. 12 -0. 31 0. 000 Fasting Glucose (2 nd vs. 1 st tertile) 1. 86 1. 10 -3. 16 0. 021 Fasting Glucose (3 rd vs. 1 st tertile) 1. 76 1. 01 -3. 08 0. 046

Barba et al, Ann Oncol 2012 Table 4. Cox proportional hazards model of factors associated with time to disease progression in breast and colorectal cancer patients treated with targeted agents. Analysis stratified by site of primitive cancer (breast vs. colorectal ). HR 95%CI P Value Breast Age at cancer diagnosis 0. 99 0. 95 -1. 03 0. 786 BMI 0. 92 0. 80 -1. 06 0. 276 _ _ _ 1. 63 0. 45 -6. 00 0. 457 Gender Fasting Glucose (2 nd vs. 1 st tertile) Fasting Glucose (3 rd vs. 1 st tertile) 4. 07 1. 29 -12. 85 0. 017

ASCO 2017 Farzana L et al. , J Clin Oncol 35, 2017 Effect of metformin chemoprevention on metabolomics profiles in Li-Fraumeni Syndrome (LFS). Aims: To explore the effect of Metformin on TCA cycle and glycolytic intermediates during cellular transformation Methods: Metabolomics profiling of stored serum of 21 adult LFS patients, each providing one sample at baseline, week 14 (on 2000 mg metformin) and week 20 (off metformin). Metformin was initiated at 500 mg per day and increased in 500 mg dose increments every 2 weeks to a maintenance dose of 2000 mg.

ASCO 2017 Results: Global metabolomics profiling suggests an increase in TCA cycle intermediates and a strong signature of fatty acid oxidation with metformin treatment in LFS. Clearance of metformin results in normalization of levels to comparable baseline values, indicating a causal role of metformin in these changes.

Vici P. et al. , Oncotarget 2014 p 53 status as effect modifier of the association between pretreatment fasting glucose and breast cancer outcomes in non diabetic, HER 2 positive patients treated with trastuzumab. Vici P et al, Oncotarget 2014 Aims: to investigate whether p 53 status affects the association of pre-treatment fasting glucose with treatment outcomes in 106 non diabetic, HER 2 + Bca pts treated with trastuzumab. p 53 status was validated against gene sequencing of selected codons in a subset if 49 randomly selected patients.

Vici et al. , Oncotarget 2014 Methods The Kaplan–Meier method and log rank test were used to compare survival by categories of fasting glucose in the overall population and separate settings. Cox models included age and body mass index Direct sequencing satisfactorily confirmed P 53 mutational status

Time to disease progression by categories of fasting glucose defined upon the median value (89. 0 mg/dl) in non diabetic, HER 2+ Bca pts treated with trastuzumab.

Selmy M et al. , Modulation of the anti-tumor activity of VEGF blockade by metformin. J Clin Oncol, 2017 Aims: to assess the effects of metformin on the anti-tumor activity of VEGF blockade Methods: In vitro: Cells were divided into normoxic and hypoxic groups. For both, four subgroups were developed: control, metformin, glucose deprivation and both glucose deprivation and metformin. Cells were assessed for Apoptosis, Cell cycle progression and western blot. In vivo: IGROV-1 subcutaneous xenografts. Animal were divided into four groups: control, metformin, bevacizumab and both drugs. After sacrifice, tumors were further analyzed for necrosis, apoptosis, proliferative capacity, activation of AMPK and its downstream effectors.

Selmy M et al. , Modulation of the anti-tumor activity of VEGF blockade by metformin. J Clin Oncol, 2017 Results: In-vitro results suggested an anti-proliferative effect of metformin in terms of apoptosis, cell cycle arrest, AMPK activation and m. TOR inhibition at various time points. In-vivo experiments revealed a significant decrease of tumor weight and proliferative capacity in tumors treated with both drugs and a trend toward a decrease in tumor growth along the treatment.

Pizzuti et al. , JCP 2017 GLUT 1 receptor expression and circulating levels of fasting glucose in high grade serous ovarian cancer Aims: to assess the association between the expression of GLUT 1, as expressed at the tumor tissue level, and circulating pre‐surgical levels of FG Our analysis included data from 40 patients with high FIGO stage serous ovarian cancer. Patients who provided data to the current analysis were randomly selected from a larger cohort.

Serous ovarian cystoadenocarcinoma with intense positive staining for glucose transporter protein 1 (GLUT 1). A. GLUT 1 x 20; B. GLUT 1 x 10.

Association between GLUT 1 staining intensity and Fasting Glucose in high Stage FIGO Ov Ca Glut 1 SI P=0. 044 ≤ 86 86 -94 >94 0 -1 1 (9. 1) 3 (27. 3) 7 (63. 6) 2 -3 12 (41. 4) 10 (34. 5) 7 (24. 1)