Targeted therapies and immunotherapy Federico Cappuzzo Istituto Toscano

Targeted therapies and immunotherapy Federico Cappuzzo Istituto Toscano Tumori Ospedale Civile Livorno-Italy Istituto Toscano Tumori –Livorno, Italy

Studies of EGFR TKIs versus chemotherapy as firstline therapy in EGFRmut+ NSCLC Study IPASS * First SIGNAL * WJTOG 3405 NEJ 002 OPTIMAL EURTAC ENSURE LUX Lung 3 LUX Lung 6 # Treatment RR % PFS OS m. PFS HR (mos) P-value m. OS (mos) HR P-value 97 Gefitinib 71. 2 9. 5 0. 48 21. 6 1. 00 111 CBDCA + TXL 47. 3 6. 3 <0. 0001 21. 9 0. 99 159 Gefitinib 84. 6 8. 0 0. 54 27. 2 1. 04 150 CDDP+ GEM 37. 5 6. 3 0. 008 25. 6 NR 88 Gefitinib 62. 1 9. 2 0. 48 36. 0 1. 18 89 CDDP + TXT 32. 2 6. 3 <0. 001 39. 0 NR 114 Gefitinib 73. 7 10. 4 0. 36 27. 7 0. 89 114 CBDCA + TXL 30. 7 5. 5 <0. 001 26. 6 0. 48 82 Erlotinib 83. 0 13. 1 0. 16 22. 6 1. 06 72 CBDCA + GEM 36. 0 4. 6 <0. 0001 28. 8 0. 68 84 Erlotinib 54. 5 9. 4 0. 34 19. 3 1. 04 82 Platinum Doublet 10. 5 5. 2 <0. 0001 19. 5 0. 87 110 Erlotinib 68. 2 11. 1 0. 43 NR NR 107 CDDP + GEM 39. 3 5. 7 <0. 0001 NR NR 230 Afatinib 56. 0 11. 1 0. 58 16. 6 1. 12 115 CDDP + PEM 23. 0 6. 9 0. 0004 14. 8 0. 60 242 Afatinib 66. 9 11. 0 0. 28 22. 1 0. 95 122 CDDP + GEM 23. 0 5. 6 <0. 0001 22. 2 0. 76 * Shown data are restricted to EGFRmut + population Istituto Toscano Tumori – Livorno, Italy

Quesiti clinici con gli EGFR-TKIs • Posso determinare lo stato mutazionale con un test sul sangue? • Qual è il miglior inibitore? • Il tipo di mutazione di EGFR è importante? • Cosa fare alla progressione? • Posso potenziare l’efficacia? Istituto Toscano Tumori –Livorno, Italy

Detection of plasma EGFR mutations Detection of EGFR mutations by UD-NGS EGFR status Baseline Progression Mutated 31 (72%) 11 (76%) Wild type 12 (28%) 4 (24%) Total 43 (100%) 15 (100%) Sensitivity: 72% Specificity: 100% Detection of EGFR mutations by cobas® test EGFR status Baseline Progression Mutated 30 (70%) 11 (73%) Wild type 13 (30%) 4 (27%) Total 43 (100%) 15 (100%) Sensitivity: 71% Specificity: 100% Marchetti, et al. WCLC 2015 Istituto Toscano Tumori – Livorno, Italy

Gefitinib versus erlotinib as second line treatment in unselected NSCLC: Phase III trial Erlotinib 150 mg/die • Stage III-IV Adenocarcinoma • Evaluable disease • 2° line & after • Age >20 years • No interstitial lung disease R Gefitinib 250 mg/die Stratification factors: Gender, PS, Stage, Smoking history, Mutation status, Institution, Prior regimen Non-Inferiority trial Katakami N, et al. ASCO 2014 Istituto Toscano Tumori –Livorno, Italy

Gefitinib versus Erlotinib: PFS according to EGFR status Treatment m. PFS (mos) Erlotinib 10. 09 Gefitinib 8. 90 Treatment m. PFS (mos) Erlotinib 2. 10 Gefitinib 2. 07 p value 0. 532 p value 0. 221 Treatment m. PFS (mos) Erlotinib 2. 53 Gefitinib 2. 27 p value 0. 878 Katakami N, et al. ASCO 2014 Istituto Toscano Tumori –Livorno, Italy

Erlotinib versus gefitinib in patients with EGFR mutations: CTONG 0901 study • Advanced NSCLC • EGFR Mut+ (exon 19 or 21) • ECOG PS 0– 2 (n=256) Erlotinib 150 mg/day Until PD or unacceptable toxicity Gefitinib 250 mg/day Until PD or unacceptable toxicity R Primary end-point: m. PFS Yang, et al. WCLC 2015 Istituto Toscano Tumori –Livorno, Italy

CTONG 0901: efficacy and toxicity PFS and OS (any line) Gefitinib 10. 4 12. 4 13. 0 HR=0. 81; p=0. 108 m. PFS Erlotinib 20. 1 m. OS 0 HR=0. 84; p=0. 250 5 10 15 20 Time (months) PFS 22. 9 25 OS Treatment-emergent AEs >10% in either arm AE, % Rash Cough Diarrhoea Hand foot syndrome Nail changes Anorexia Gefitinib n=128 All grade Grade ≥ 3 63 0 30 0 19 0 13 0 12 0 Erlotinib n=128 All grade Grade ≥ 3 70 2 23 0 17 0 6 0 19 0 5 0 Yang, et al. WCLC 2015 Istituto Toscano Tumori –Livorno, Italy

CTONG 0901: PFS and OS by mutation type Subgroup HR (95% Cl) P PFS EGFR exon 19 EGFR exon 21 0. 79 (0. 56– 1. 13) 0. 84 (0. 55– 1. 26) 1. 092 0. 388 OS EGFR exon 19 EGFR exon 21 0. 83 (0. 56– 1. 22) 0. 86 (0. 55– 1. 34) 0. 345 0. 497 0. 1 0. 2 0. 5 Erlotinib 1 2 5 10 Gefitinib Yang, et al. WCLC 2015 Istituto Toscano Tumori –Livorno, Italy

Dacomitinib versus erlotinib in EGFRex 19 mut+: PFS and OS (N=78) PFS OS Suresh S. Ramalingam et al, WCLC 2015 Istituto Toscano Tumori – Livorno, Italy

Afatinib versus chemotherapy: OS by EGFR mutation type Exon 19 Exon 21 Yang J C-H, et al. Lancet Oncol 2015 Istituto Toscano Tumori – Livorno, Italy

Indirect comparison of toxicities reported with gefitinib or erlotinib or afatinib *Shown data include all patients treated with gefitinib Data are reported as percentage of AEs of any grade and, in parenthesis, of grade 3 Landi L , Expert Opin Pharmacother 2014 Istituto Toscano Tumori – Livorno, Italy

Erlotinib versus erlotinib+bevacizumab as first-line therapy in EGFRmut+ NSCLC: phase IIR study Chemotherapy-naive stage IIIB-IV or postoperative recurrence Non-squamous NSCLC Activating EGFR mutations • Exon 19 deletion • Exon 21 L 858 R Age ≥ 20 years PS 0 -1 No brain metastasis Erlotinib 150 mg/day + Bevacizumab 15 mg/kg q 3 w (N=77) 1: 1 R PD 2 -yr treatment period Erlotinib 150 mg/day (N=75) PD Primary end-point: PFS Secondary End points: OS, ORR, Qo. L, symptoms improvement FACT-L scale and safety Seto T, et al. Lancet Oncol 2014 Istituto Toscano Tumori – Livorno, Italy

Erlotinib versus erlotinib+bevacizumab as first-line therapy in EGFRmut+ NSCLC: PFS Seto T, et al. Lancet Oncol 2014 Istituto Toscano Tumori – Livorno, Italy

Erlotinib+bevacizumab as first-line therapy in EGFRmut+ NSCLC: the BELIEF phase II study Chemotherapy-naive stage IIIB-IV or postoperative recurrence Non-squamous NSCLC Activating EGFR mutations • Exon 19 deletion • Exon 21 L 858 R • Brain metastases allowed Erlotinib 150 mg/day + Bevacizumab 15 mg/kg q 3 w PD Primary end-point: PFS Stahel, et al. ECC 2015 Istituto Toscano Tumori – Livorno, Italy

ETOP 2 -11 BELIEF: Best % change from baseline in the sum of tumor diameters for targeted lesions N=97 CR PR SD PD NE All 7 (6. 4) 76 (69. 7) 18 (16. 5) 3 (2. 8) 5 (4. 6) T 790 M + 3 (8. 1) 23 (62. 2) 9 (24. 3) 0 (0. 0) 2 (5. 4) T 790 M 4 (5. 6) 53 (73. 6) 9 (12. 5) 3 (4. 2) Response duration (Median, 95%CI): All : 14. 8 m (12. 0 -NE); T 790 M+ : NE (14. 7 -NE); T 790 M- : 12. 0 m (8. 2 -23. 3) Stahel, et al. ECC 2015 Istituto Toscano Tumori – Livorno, Italy

BELIEF: PFS by T 790 M mutation Events/N Median PFS (95%CI) 12 m PFS (95%CI) All 57/109 13. 8 m (10. 3 -21. 3) 56. 7% (46. 0 -66. 0) T 790 M+ 15/37 16. 0 m (13. 1 -NE) 72. 4% (53. 4 -84. 7) T 790 M- 42/72 10. 5 m (9. 2 -16. 2) 49. 4% (36. 6 -61. 0) Stahel, et al. ECC 2015 Istituto Toscano Tumori – Livorno, Italy

BELIEF: data on context with other studies Stahel, et al. ECC 2015 Istituto Toscano Tumori – Livorno, Italy

Rociletinib and AZD 9291 in patients EGFRT 790 M+ AZD 9291 Janne PA, NEJM 2015 RR: 61% Rociletinib Sequist L, ASCO 2015 RR: 53% Istituto Toscano Tumori – Livorno, Italy

PFS with rociletinib or AZD 9291 in patients EGFRT 790 M+ Rociletinib AZD 9291 Sequist L, et al. ASCO 2015 Goss G. et al, ECC 2015 Istituto Toscano Tumori – Livorno, Italy

Rociletinib and AZD 9291 in patients EGFRT 790 M- Rociletinib AZD 9291 RR: 21% Istituto Toscano Tumori – Livorno, Italy

PFS with AZD 9291 according to EGFR T 790 M status 9. 6 mos 2. 8 mos PFS with rociletinib: 5. 6 months in EGFRT 790 M- Janne PA, et al. NEJM 2015 Istituto Toscano Tumori – Livorno, Italy

AZD 9291 is distributed to mouse brain to a greater extent than gefitinib, afatinib or Rociletinib Ballard P, et al. WCLC 2015 Istituto Toscano Tumori – Livorno, Italy

(11 C) AZD 9291 is distributed to cynomolgus monkey brain Ballard P, et al. WCLC 2015 Istituto Toscano Tumori – Livorno, Italy

Treatment-related AEs occurring in patients receiving Rociletinib or AZD 9291 Rociletinib Sequist L, et al. NEJM 2015 Janne PA, et al. NEJM 2015 Istituto Toscano Tumori – Livorno, Italy

Different mechanisms and different options Molecular event Therapy option AZD 9291 EGFR Del 19+ and EGFR T 790 M+ and EGFR C 797 S+ Resistant to ALL EGFR-TKIs EGFR L 858 R+ and EGFR T 790 M+ and EGFR C 797 S+ Partially sensitive to cetuximab EGFR del 19+ or L 858 R+ and EGFR T 790 M- and EGFR C 797 S+ Sensitive to gefitinib/afatinib Rociletinib EGFR Del 19+ or L 858 R+ and EGFR T 790 M+ and EGFR L 718 Q+ or L 844 V+ Potentially sensitive to AZD 9291 EGFR del 19+ or L 858 R+ and EGFR T 790 M- and EGFR L 718 Q+ or L 844 V+ Sensitive to gefitinib/afatinib Ercan D et al. Clin Cancer Res 2015 Thress KS et al. Nature Med 2015 Piotrowska Z et al. Cancer Discov 2015 Eberlein CA et al. Cancer res 2015 Istituto Toscano Tumori –Livorno, Italy

Take home messages sugli EGFR-TKIs • La biopsia liquida è un’alternativa che può essere utilizzata nella pratica clinica quando il tessuto tumorale non è disponibile o al momento della progressione • Gefitinib, erlotinib e afatinib hanno simile efficacia e lievi differenze in termini di effetti collaterali • Non vi sono dati che dimostrano un diverso effetto o superiorità di un inibitore rispetto ad un altro in relazione al tipo di mutazione di EGFR • L’associazione erlotinib-bevacizumab promettente ma ad oggi NON raccomandata nella pratica clinica • Rociletinib e AZD 9291 differiscono: – – Profilo di efficacia Tossicità Capacità di penetrazione a livello del SNC Meccanismi di resistenza acquisita Istituto Toscano Tumori – Livorno, Italy

Quesiti clinici con gli inibitori di ALK • Cosa fare in presenza di metastasi cerebrali? • Bisogna ripetere la biopsia del tumore alla progressione a crizotinib? • Qual’ è oggi la migliore sequenza di trattamento? • Vi sono differenze in tossicità? • Quali nuove prospettive? Istituto Toscano Tumori –Livorno, Italy

ALK inhibitors: CNS activity Agents Brain RR Reference N % Crizotinib 22 * 18 % Costa, J Clin Oncol 2015 Alectinib 9 55 % Gadgeel, Lancet Oncol 2015 Alectinib 34 58. 8 % Barlesi, ECC 2015 Alectinib 16 75 % Shaw, WCLC 2015 Ceritinib 33 39. 4 % Mok, #8059 ASCO 2015 Ceritinib 17 * 58. 8 % Felip, #8060 ASCO 2015 PF 06463922 14 ** 36 % Shaw, #8018 ASCO 2015 AP 26113 15 ** 53 % Camidge, #8062 ASCO 2015 *ALKi naïve pts, **including ALKi naïve pts (10 -16%) Istituto Toscano Tumori –Livorno, Italy

Alectinib: activity by prior radiation Waterfall plot of patients with measurable CNS disease 70 60 Prior CNS Radiation Yes (n=34) No (n=16) Sum of longest diameter, max. decrease from baseline (%) 50 40 30 20 10 0 – 10 – 20 – 30 – 40 – 50 – 60 – 70 – 80 – 90 – 100 Patients • • In the overall population, only 17% of patients had CNS PD Progression in the CNS occurred in 8% of patients without CNS disease at baseline Gadgeel, et al. WCLC 2015 Istituto Toscano Tumori – Livorno, Italy

ALK tyrosine kinase mutations and sensitivity to new anti-ALK agents Pall Curr Opin 2015 Istituto Toscano Tumori – Livorno, Italy

ALK inhibitors at crizotinib failure Selection of second-line next generation ALK inhibitors based on ALK mutation status 1 L 2 L None Crizotinib PD Bx F 1174 Alectinib or ceritinib or brigatinib or lorlatinib Alectinib, brigatinib or lorlatinib I 1171 Ceritinib or lorlatinib G 1202 R Lorlatinib Istituto Toscano Tumori –Livorno, Italy

Lorlatinib is a potent and selective, CNS penetrant ALK/ROS 1 TKI ALK WT NIH 3 T 3 IC 50 (n. M) ALK L 1196 M NIH 3 T 3 IC 50 (n. M) ROS 1 -CD 74 IC 50 (n. M) MDR BA/AB CSF or free brain: free plasma (rodent) Log D Crizotinib PF-06463922 80 1. 5 843 21 11 0. 24 45 1. 5 – 0. 23– 0. 33 2. 0 2. 3 PF-06463922 Is Active Against All Known ALK and ROS 1 Resistance Mutations PF 06463922 activity PF-06463922 Crizotinib Zou HY, et al. Proc Natl Acad Sci U S A 2015; 112: 3493 Zou HY, et al. AACR-NCI 2013, poster A 277 Istituto Toscano Tumori – Livorno, Italy

Lorlatinib phase I: response by prior TKI R: ROS 1 translocated Bauer, et al. WCLC 2015 Istituto Toscano Tumori – Livorno, Italy

ALK inhibitors in the crizotinib-failure setting: most common AEs Alectinib (NP 28673) (n=138) 100 Brigatinib (n=137)* 90 80 Ceritinib ATU (n=208) 81 80 Ceritinib (ASCEND-2) (n=140) Percentage 70 60 52 50 40 36 36 30 29 30 20 42 40 20 17 15 10 1 1 20 15 5 6 0 1 0 Diarrhoea (all grades) Diarrhoea (grade ≥ 3/ severe) Nausea (all grades) 5 6 Nausea (grade ≥ 3/ severe) NR 0 0 NR 2 Constipation (all grades) (grade ≥ 3/ severe) NR Fatigue (all grades) 0 4 6 NR Fatigue (grade ≥ 3/ severe) Brigatinib: pulmonary events • Observed in 13/137 (9%) of patients* who received treatment with brigatinib • Incidence was numerically lower with lower starting doses Barlesi, et al. ECC 2015; Gettinger, et al. WCLC *All ALK+ NSCLC patients Cortot, et al. ECC 2015; Mok, et al. ASCO 2015 Istituto Toscano Tumori – Livorno, Italy

Take home messages sugli inibitori di ALK • Al momento crizotinib è l’agente anti-ALK da utilizzare in prima battuta • Alectinib, brigatinib e ceritinib hanno mostrato efficacia nei pazienti in progressione a crizotinib. • Alectinib, ceritinib e brigatinib hanno mostrato efficacia nei pazienti con metastasi cerebrali • La migliore sequenza di trattamento non è definita: identificare il meccanismo di resistenza può aiutare nel decidere la sequenza da utilizzare • Il profilo di tossicità di alectinib, ceritinib e brigatinib è differente • Lorlatinib sembra essere efficace in presenza di tutte le mutazioni secondarie a crizotinib inclusa la G 1202 R • Lorlatinib sembra essere efficace nei pazienti ROS 1 traslocati resistenti a crizotinib Istituto Toscano Tumori – Livorno, Italy

Quesiti clinici sui checkpoint inhibitors • Nivolumab è standard terapeutico in seconda linea? – In tutti i pazienti? – Solo negli squamosi? • Qual è il ruolo predittivo dell’espressione di PDL 1? – Vi sono pazienti che possiamo escludere? Istituto Toscano Tumori –Livorno, Italy

Check. Mate 017 (NCT 01642004) - Study Design • Stage IIIb/IV SQ NSCLC • ECOG PS 0– 1 • Pre-treatment (archival or fresh) tumor samples required for PD-L 1 analysis N = 272 Randomize 1: 1 • 1 prior platinum doublet-based chemotherapy Nivolumab 3 mg/kg IV Q 2 W until PD or unacceptable toxicity n = 135 Docetaxel 75 mg/m 2 IV Q 3 W until PD or unacceptable toxicity n = 137 • Primary Endpoint: – OS • Additional Endpoints: Investigator-assessed ORR Investigator-assessed PFS Correlation between PD-L 1 expression and efficacy Safety Quality of life (LCSS) Patients stratified by region and prior paclitaxel use • One pre-planned interim analysis for OS • At time of DBL (December 15, 2014), 199 deaths were reported (86% of deaths required for final analysis) • The boundary for declaring superiority for OS at the pre-planned interim analysis was P <0. 03 LCSS = Lung cancer symptom scale Brahmer J, et al. NEJM 2015 Istituto Toscano Tumori – Livorno, Italy

Checkmate 017: updated overall survival Reckamp, et al. WCLC 2015 Istituto Toscano Tumori – Livorno, Italy

• Stage IIIB/IV non-SQ NSCLC • Pre-treatment (archival or recent) tumor samples required for PD-L 1 • ECOG PS 0– 1 • Failed 1 prior platinum doublet • Prior maintenance therapy allowed a • Prior TKI therapy allowed for known ALK translocation or EGFR mutation N = 582 Randomize 1: 1 Check. Mate 057 (NCT 01673867) Study Design Nivolumab 3 mg/kg IV Q 2 W until PD or unacceptable toxicity n = 292 Docetaxel 75 mg/m 2 IV Q 3 W until PD or unacceptable toxicity n = 290 • Primary Endpoint – OS • Additional Endpoints – ORRb – PFSb – Safety – Efficacy by tumor PD-L 1 expression – Quality of life (LCSS) Patients stratified by prior maintenance therapy and line of therapy (second- vs third-line) • PD-L 1 expression measured using the Dako/BMS automated IHC assay 14, 15 – Fully validated with analytical performance having met all pre-determined acceptance criteria for sensitivity, specificity, precision, and robustness a Maintenance therapy included pemetrexed, bevacizumab, or erlotinib (not considered a separate line of therapy); b Per RECIST v 1. 1 criteria as determined by the investigator. Paz-Ares L, et al. ASCO 2015 Istituto Toscano Tumori – Livorno, Italy

Overall Survival 100 Nivolumab (n = 292) Docetaxel (n = 290) 12. 2 9. 4 90 80 m. OS, mo 70 HR = 0. 73 (96% CI: 0. 59, 0. 89); P = 0. 0015 OS (%) 60 1 -yr OS rate = 51% 50 40 1 -yr OS rate = 39% 30 Nivolumab 20 10 Docetaxel 0 0 3 6 9 12 15 18 21 24 27 Time (months) Number of Patients at Risk Nivolumab 292 232 194 169 146 123 62 32 9 0 Docetaxel 290 244 194 150 111 88 34 10 5 0 Symbols represent censored observations. Paz-Ares L, et al. ASCO 2015 Istituto Toscano Tumori – Livorno, Italy

OS by PD-L 1 Expression 1% PD-L 1 Expression level 5% PD-L 1 Expression level m. OS (mo) 10% PD-L 1 Expression level m. OS (mo) Nivolumab Docetaxel 100 90 80 PD-L 1 ≥ 1% 9. 3 7. 2 PD-L 1 ≥ 5% 10 6. 4 PD-L 1 ≥ 10% 11 7. 1 PD-L 1 <1% 8. 7 5. 9 PD-L 1 <5% 8. 5 6. 1 PD-L 1 <10% 8. 2 6. 1 70 OS (%) 60 50 40 30 20 10 0 0 3 6 9 12 15 Time (months) 18 21 24 0 3 6 9 12 15 18 21 24 Time (months) Nivolumab PD-L 1+ Nivolumab PD-L 1– Docetaxel PD-L 1+ Docetaxel PD-L 1– 0 3 6 9 12 15 18 21 24 Time (months) Brahmer J, et al. NEJM 2015 Istituto Toscano Tumori – Livorno, Italy

OS by PD-L 1 Expression ≥ 1% PD-L 1 expression level 100 OS (%) 90 ≥ 5% PD-L 1 expression level 100 m. OS (mo) 90 80 Nivo 17. 2 80 70 Doc 9. 0 70 Nivo m. OS (mo) 18. 2 Doc 8. 1 80 70 60 50 50 50 40 40 30 30 20 20 Nivo Doc 30 20 10 10 HR (95% CI) = 0. 59 (0. 43, 0. 82) 0 0 3 6 9 12 15 18 21 24 27 60 10 HR (95% CI) = 0. 43 (0. 30, 0. 63) 0 0 3 6 9 12 15 18 21 24 27 <1% PD-L 1 expression level 70 Nivo 50 Doc <5% PD-L 1 expression level 30 10. 4 60 10. 1 50 20 10 6 9 12 15 18 Time (months) Symbols represent censored observations. 21 24 27 12 15 18 21 24 m. OS (mo) 70 9. 7 60 Nivo 9. 9 10. 1 50 Doc 10. 3 Doc 40 40 30 30 20 20 27 m. OS (mo) 10 HR (95% CI) = 1. 01 (0. 77, 1. 34) HR (95% CI) = 1. 00 (0. 76, 1. 31) 0 0 0 3 9 <10% PD-L 1 expression level 90 Nivo 10 HR (95% CI) = 0. 90 (0. 66, 1. 24) 0 6 80 70 Nivo Doc 40 3 Time (months) 80 m. OS (mo) 60 0 100 90 80 8. 0 HR (95% CI) = 0. 40 (0. 26, 0. 59) Time (months) 100 90 Doc 0 Time (months) 100 Nivo m. OS (mo) 19. 4 90 60 40 OS (%) ≥ 10% PD-L 1 expression level 100 0 3 6 9 12 15 Time (months) 18 21 24 27 0 3 6 9 12 15 18 21 24 27 Time (months) Paz-Ares L, et al. ASCO 2015 Istituto Toscano Tumori – Livorno, Italy

Checkpoint inhibitors in NSCLC: Data in 2 nd/3 rd line POPLAR Ph. II allcomer 2/3 L atezo vs. doc (n=287) HR 0. 73 p=0. 040 Time (months) 15. 0 HR 0. 94 Check. Mate 017 Ph. III 2 L Sq nivo vs. doc Check. Mate 057 Ph. III 2/3 L NSq nivo vs. doc KEYNOTE-001 Ph. Ib (inc. NSCLC) pembro (n=272) (n=582) (n=394 for previously treated) HR 0. 59 / 0. 62 HR 0. 63 p=0. 00025 / p=0. 0004 p=0. 0008 12. 6 HR 0. 92 p=0. 3932 12. 2 9. 7 10. 0 HR 0. 73 p=0. 0015 10 mg/kg* q 2 w and q 3 w 11. 3 9. 4 9. 2 6. 0 5. 0 0. 0 Atezo OS Doc OS 2. 7 3. 0 Atezo PFS Doc PFS 3. 5 Nivo OS Doc OS Nivo PFS 4. 2 2. 8 Doc PFS 3. 0 2. 3 Nivo OS Doc OS Nivo PFS Doc PFS Pembro OS Pembro PFS ORR, % Atezo 15% vs doc 15% Nivo 20% vs doc 9% Nivo 19% vs doc 12% Pembro 18% Notes G 3– 4 treatment-related AEs: 12 vs 40% G 3– 4 treatment-related AEs: 8 vs 56% Reduction from baseline in lung cancer symptoms with nivolumab G 3– 4 treatment-related AEs: 10 vs 54% Low incidence of immune-related AEs Refs. Spira, et al. ASCO 2015 Vansteenkiste, et al. ECC 2015 Spigel, et al. ASCO 2015 Reckamp, et al. WCLC 2015 Gralla, et al. WCLC 2015 Reck, et al. ECC 2015 *Phase III dose: 2 mg/kg q 3 w and 10 mg/kg q 3 w Paz-Ares, et al. ASCO 2015 Horn, et al. ECC 2015 Garon, et al. AACR 2015 Soria, et al. ECC 2015 Istituto Toscano Tumori – Livorno, Italy

Checkpoint inhibitors: efficacy by PD-L 1 expression POPLAR Ph. II all comer 2/3 L atezo vs. doc (n=287) HR 0. 77 HR 0. 98 Improved survival with p=0. 1071 p=0. 8606 Time (months) 15 HR 0. 59 atezolizumab correlated with increasing PD-L 1 expression 11. 4 Subgroup HR TC 3 or IC 3 Efficacy by PD-L 1 5 status 0. 49 9. 5 10 Check. Mate 017 Ph. III 2 L Sq nivo vs. doc (n=272) HR 0. 62 Benefit from nivolumab was p=0. 00025 p=0. 0004 independent from PD-L 1 expression in squamous NSCLC Subgroup HR ≥ 1% cut-off 0. 69 9. 2 <1% cut-off 0. 58 TC 2/3 or IC 2/3 0. 54 ≥ 5% cut-off 0. 53 TC 1/2/3 or IC 1/2/3 0. 59 <5% cut-off 6 0. 70 TC 0 and IC 0 3. 41. 04 2. 8 ≥ 10% cut-off 0. 50 3. 5 2. 8 0. 70 <10% cut-off Not quantifiable 0 Check. Mate 057 Ph. III 2/3 L NSq nivo vs. doc (n=582) Atezo OS ITT Doc OS 0. 73 Doc PFS Atezo PFS 0. 2 1 HR atezo 2 doc PD-L 1 assay SP 142 (Ventana) on ICs and TCs Refs. Spira, et al. ASCO 2015 Vansteenkiste, et al. ECC 2015 Nivo OS Doc ITT OS 0. 39 Nivo PFS Doc 0. 63 PFS 0. 1 1 2 HR nivo HR 0. 73 HR 0. 92 PD-L 1 expression is predictive of p=0. 0015 p=0. 3932 nivolumab benefit in non-squamous NSCLC 12. 2 Subgroup ≥ 1% cut-off 0. 59 9. 4 <1% cut-off ≥ 5% cut-off 0. 43 <5% cut-off ≥ 10% cut-off 1. 01 ITT Doc OS Median OS (months) 9. 3 PD-L 1 cut-off ≥ 50%: 15. 5 PD-L 1 cut-off 1 -49%: 7. 8 PD-L 1 cut-off <1%: 8. 6 4. 2 3 0. 40 2. 3 <10% cut-off Nivo OS PD-L 1 proportion score ≥ 50% showed greatest benefit from pembrolizumab HR 0. 90 1. 00 Nivo PFS 0. 1 doc Doc 0. 73 PFS 1 HR nivo Pem OS Pem PFS 2 doc 28 -8 (Dako) on TCs Spigel, et al. ASCO 2015 Reckamp, et al. WCLC 2015 Gralla, et al. WCLC 2015 KEYNOTE-001 Ph. Ib (inc. NSCLC) pembro (n=394 for previously treated) Paz-Ares, et al. ASCO 2015 Horn, et al. ECC 2015 22 C 3 (Dako) on TCs Garon, et al. AACR 2015 Soria, et al. ECC 2015 Istituto Toscano Tumori – Livorno, Italy

Take home messages sui checkpoint inhibtors • Nivolumab è lo standard terapeutico di seconda linea nei pazienti con NSCLC senza driver (EGFR, ALK e ROS 1 negativi) indipendentemente dall’istologia • Confronti indiretti suggeriscono che pembrolizumab e atezolizumab hanno un’efficacia simile a nivolumab • PDL 1 è un predittore debole di sensibilità a nivolumab • Al momento i dati sono insufficienti per escludere qualsiasi paziente pretrattato con chemioterapia da un trattamento con checkpoint inhibitors Istituto Toscano Tumori – Livorno, Italy