The findings, published in the online edition of Clinical Cancer Research on November 4,(https://clincancerres.aacrjournals.org/content/early/2020/11/04/1078-0432.CCR-20-1830) suggest that BMS-986178, an investigational OX40 agonist, has an acceptable safety profile in patients with advanced solid tumors, whether used as monotherapy or in combination with the checkpoint inhibitors nivolumab (Opdivo®) and/or ipilimumab (Yervoy®). The rationale for using an OX40 agonist in this setting is based on its binding to the OX40 protein receptor found on memory T-cells, which can trigger a signal associated with production of additional T-cells. The newly published results appear to clear the way for the continued development of BMS-986178, starting with a Phase 2 breast cancer study.
“We were pleasantly surprised to find that T-cell stimulation with an OX40 agonist did not exacerbate the inflammatory response and other off-target effects of checkpoint inhibitors,” said Dr. Gutierrez, the study’s lead investigator and first author of theClinical Cancer Researchpaper. “Indeed, the adverse events we observed in the monotherapy and combination cohorts were manageable, suggesting that BMS-986178 is safe to use in combination with checkpoint inhibitor therapy, and possibly also with a cancer vaccine.”
Bristol-Myers Squibb is developing BMS-986178 as a potential treatment for patients with solid tumors. BMS-986178 binds with a high affinity to the OX40 receptor, a member of the tumor necrosis factor receptor super family (TNFRSF), which includes several proteins with key roles in T-cell development and survival, immune activation, and anti-tumor immune responses.
“While nivolumab and ipilimumab have established a niche as viable treatments for several solid tumor types, many patients develop resistance to these checkpoint inhibitors, underscoring the need for novel immuno-oncology strategies,” explained Dr. Gutierrez. “In theory, adding an OX40 agonist to checkpoint inhibitor therapy would modulate the immunosuppression that occurs in the tumor microenvironment while enhancing the T-cell response. We tested whether we could safely combine these two immunomodulatory approaches.”
Dr. Gutierrez and colleagues conducted an open-label Phase 1/2a study of BMS-986178 (at doses ranging from 20-320 mg), both as monotherapy and in combination with nivolumab (240-480 mg) and/or ipilimumab (1-3 mg/kg of body weight), in patients with non-small cell lung cancer, renal cell carcinoma, bladder cancer, and other advanced solid tumors. Twenty patients were treated with BMS-986178 monotherapy, and 145 received various combination regimens.
After follow-up for as long as 103 weeks, the most common treatment-related adverse events (TRAEs) included fatigue, itching, rash, rise in body temperature, diarrhea, and infusion-related reactions. Overall, serious (Grade 3-4) TRAEs occurred in 1 of 20 patients (5%) receiving BMS-986178 monotherapy, 6 of 79 (8%) receiving BMS-986178 plus nivolumab, 0 of 2 receiving nivolumab monotherapy, 6 of 41 (15%) receiving BMS-986178 plus ipilimumab, and 3 of 23 (13%) receiving BMS-986178 in combination with both checkpoint inhibitors.
No deaths occurred in the study. There were no dose-limiting toxicities (side effects serious enough to prevent an increase in dose or level of treatment) observed with monotherapy. The maximum tolerated dose – the highest dose of a drug that does not cause unacceptable side effects – was not reached with escalating doses of either BMS-986178 monotherapy or any of the combination regimens.
The investigators did not observe objective tumor responses with BMS-986178 monotherapy. Objective response rates ranged from 0% to 13% among patients receiving combination therapy.
“We were somewhat surprised that the efficacy signals observed in preclinical trials did not translate to more robust efficacy in this first-in-human trial,” commented Dr. Gutierrez. “But our findings underscore the complexity of the immune system, and the importance of maintaining a delicate balance between the T-cell compartment and antigen-presenting cells in the tumor microenvironment.
“Our findings suggest we may be able to use OX40 activation as part of a priming intervention early in the course of certain cancers,” Dr. Gutierrez continued. “For example, we could use a cancer vaccine to prime T-cell stimulation, and then use an OX40 agonist to enhance T-cell activity.” As a next step, Dr. Gutierrez and colleagues plan to pursue such an approach in a Phase 2 study involving patients with triple-negative breast cancer, a type of breast cancer in which the tumor cells lack estrogen receptors, progesterone receptors, or large amounts of HER2/neu protein on their surface and have a more aggressive course than other breast cancers.
“Dr. Gutierrez, leading our Experimental Drugs program through phase I, has been at the forefront of immunotherapy, particularly in the use of checkpoint inhibitors that unleash the immune system and are now approved across many cancer subtypes,” said Andre Goy, M.D., M.S., chairman and director of JTCC and physician in chief for Oncology at Hackensack Meridian Health. “Our goal at JTCC is to explore additional combinations to re-engage the immune system to fight against cancer, and to increase the number of patients who can benefit from such potentially game-changing therapies, which are typically very durable, even after patients fail to respond to multiple lines of therapies,” added Dr. Goy, who is a Principal Investigator on a Bristol Myers Squibb research study that is unrelated to this study.
The work of this study was supported by Bristol Myers Squibb. Dr.Gutierrez reports nonfinancial support and other from Bristol Myers Squibb during the conduct of the study; personal fees from Bristol Myers Squibb, Merck, Eli Lilly, Esanex, Foundation Medicine, AstraZeneca; and from Guardant 360 for participation in speakers bureaus and an advisory board, outside the submitted work.
About John Theurer Cancer Center at Hackensack University Medical Center
John Theurer Cancer Center at Hackensack University Medical Center is New Jersey’s largest and most comprehensive center dedicated to the diagnosis, treatment, management, research, screenings, and preventive care as well as survivorship of patients with all types of cancers. The 15 specialized divisions covering the complete spectrum of cancer care have developed a close-knit team of medical, research, nursing, and support staff with specialized expertise that translates into more advanced, focused care for all patients. Each year, more people in the New Jersey/New York metropolitan area turn to John Theurer Cancer Center for cancer care than to any other facility in New Jersey. John Theurer Cancer Center is a member of the Georgetown Lombardi Comprehensive Cancer Center Consortium, one of just 16 NCI-approved cancer research consortia based at the nation’s most prestigious institutions. Housed within a 775-bed not-for-profit teaching, tertiary care, and research hospital, John Theurer Cancer Center provides state-of-the-art technological advances, compassionate care, research innovations, medical expertise, and a full range of aftercare services that distinguish John Theurer Cancer Center from other facilities. For additional information, please visit www.jtcancercenter.
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