Jenny T. Mao, M.D., FCCP

Associate Professor

Division of Pulmonary and Critical Care

David Geffen School of Medicine at UCLA

UCLA Lung Cancer UCLA Lung Cancer Chemoprevention TrialsChemoprevention Trials

UCLA Lung Cancer UCLA Lung Cancer Chemoprevention TrialsChemoprevention Trials

Lung Cancer StatisticsLung Cancer Statistics

Leading cause of cancer death in the world. Estimated 161, 420 lung cancer death in U.S. in

2006. (> coloretal, breast and prostate cancer combined).

Over 90% caused by smoking. @ 85% will die within 5 years because most

cases are diagnosed at a late invasive stage. The lack of effective therapy underscores the

urgency to explore new frontiers of management.

Chemoprevention

Definition Chemoprevention is the use of natural or

synthetic agents to reverse, suppress, or prevent the carcinogenic process to invasive cancer.

--Michael Sporn, M.D., 1976.

The concept is similar to the use of antihypertensive and lipid lowering medications to prevent heart disease or stroke.

3p LOH/small Telomeric deletion 3p LOH/ContiguousDeletions

~80%

Microsatellite Alterations ~ 50%9p21 LOH ~ 70%

Telomerase Dysregulation TelomeraseUpregulation

~ 80%

MYC Over-expression ~ 60% 8p21-23 LOH ~ 80%

Neoangiogenesis ~ 40%Loss of Fhit Immunostaining ~ 40%P53 LOH TP53 Mutations ~ 70%Aneuploidy ~ 80%Methylation ~ 100%

5q21 APC-MCC LOH ~ 30%K-ras Mutation ~ 20%

Lung Cancer Progression Model- Sequential Changes During Carcinogenesis

Hirsch, F et al, 2001, Clin Cancer Res, 7:5-22

Normal Hyperplasia Dysplasia CIS cancer

Goals of Chemoprevention

At the cellular level, inhibit the mechanisms that may lead to or facilitate malignant transformation.

At the tissue level, reverse and/or prevent the development or progression of premalignant lesions.

At the clinical level, reduce the incidence of cancer.

AA PGG2

PGD2

PGF2

COX-2

COX-1

(constitutive)

Carcinogens

TXA2

PGH2

• Platelets

• Stomach

• Intestine

• Kidney

Inflammatory Sites:

• M• Endothelial cells

Cancer

(inducible)

PGI2

Inflammatorystimuli

Growthfactors Cytokines

PGE2

RATIONALE FOR COX-2 INHIBITIONRATIONALE FOR COX-2 INHIBITION

Celebrex

Premalignant

lesions

Cancer

Angiogenesis Apoptosis

Anti-tumor Immunity

PGE2

IL-10 IL-12

Tumor Invasiveness

I. Celecoxib for Chemoprevention of I. Celecoxib for Chemoprevention of Primary Lung Cancer in Heavy SmokersPrimary Lung Cancer in Heavy Smokers

Screening

Lung cancer detected

Enrollment

Follow up

High risk cohort: active smoker > 20 pk-yrs, age >45

Baseline risk assessment: 1. Questionnaires 3. LIFE Bronch 2. Spirometry 4. CXR

Lung Cancer detected: ineligible

Start Treatment with Celecoxib, 400 mg BID

Repeat white light bronch at 1 month, LIFE bronch at 6 months.

I. Celecoxib for Chemoprevention of I. Celecoxib for Chemoprevention of Primary Lung CancerPrimary Lung Cancer

Baseline Subject Characteristics

Mean Range

Age, yrs 54 47 - 7Gender, M/F 9/11 -Smoking hx (pky) 42 20 -159Ethnicity A/B/C/H 1/2/15/2

Family history 5COPD 10/20

I. Celecoxib for Chemoprevention of I. Celecoxib for Chemoprevention of Primary Lung Cancer in Heavy SmokerPrimary Lung Cancer in Heavy Smoker

Outcome Measures

I. Modulation of Intra-pulmonary PGE2 production.

II. BAL cells functional analysis. Antitumor immunity: balance of IL-10 and IL-12 in the lung microenvironment.

III. SEBM: Ki-67 (cellular proliferation), Histopathology.

RESULTSRESULTS

Oral administration of Celecoxib inhibits PGE2 synthesis by A23187-stimulated BAL cells

Freshly isolated BAL cells before and after 1 month Celecoxib treatment were stimulated with A23187 for 30 minutes. Celecoxib significantly inhibited the A23187-induced PGE2 synthesis. ( p < 0.01, n = 6).

0

50

100

150

200

250

300

350

Baseline 1 month

PG

E2

(pg

/ml)

Control

A23187

Mao J, et al, Clin Cancer Res. 2003

RESULTSRESULTS

Post-treatment BAL fluid and plasma abrogated PGE2 production by stimulated NSCLC cells

(A549)

0

50

100

150

200

250

300

350

Control BAL-B BAL-2

PG

E2

(ng

/ml)

control

A23187

0

0.1

0.2

0.3

0.4

0.5

Control plasma-B plasma-2PG

E2(n

g/m

l)

Control

IL-1B

Mao J, et al, Clin Cancer Res. 2003

0

0.2

0.4

0.6

0.8

1

1.2

1 2 3 4 5 6 7 8 9 10

c

SC58236

LPS

LPS +SC58236

IL-10 (ng/ml)

Inhibition of COX-2 decreased the LPS-induced, up-regulation of IL-10 by BAL cells collected from smokers.

Mao J, et al, Clin Cancer Res. 2003

RESULTSRESULTS

Effects of Celecoxib on Histopathology of

Bronchial Biopsies in Smokers*

Mao J, et al, Clin Cancer Res. 2006

Grade

1 - Normal

2 - Hyperplasia

3 - Squamous metaplasia

4 - Mild

Dysplasia

n = 100

Ki-67Ki-67

Ki-67 is a proliferation marker expressed in all phases of the cell cycle except in resting cells.

Abnormal epithelial proliferation is a hallmark of tumorigenesis.

Elevated Ki-67 expression is associated with poor prognosis.

Elevated Ki-67 levels can be detected in areas where squamous metaplasia is lacking.

Ki-67 may be a useful marker for lung cancer risk.

Level of Ki-67 correlated with smoking history

Mao J, et al, Clin Cancer Res. 2006

A

*

0 25 50 75 1000

10

20

pky

Ki-

67 L

I

B P = 0.032

6 months of Celecoxib reduced Ki-67 LI by 35%.

Mao J, et al, Clin Cancer Res. 2006

0

2

4

6

8

10

12

Baseline Final

Ki-

67

Labelin

g I

ndex

Baseline

*

Final

Summary Summary from the Phase IIa Smokers Studyfrom the Phase IIa Smokers Study

Oral Celecoxib blocked the capacity of PGE2 production by smokers’ AM.

Plasma and BAL fluid obtained from treated subjects blocked PGE2 production by stimulated NSCLC cells A549 in vitro.

Inhibition of COX-2 blocked the release of IL-10 by LPS stimulated AM from smokers, may restore anti-tumor immunity.

Oral Celecoxib decreased Ki-67 LI in bronchial biopsies, indicating that celecoxib may be capable of favorably modulating the proliferation indices in bronchial tissue of active smokers.

These findings support the continued investigation of COX-2 inhibitor in lung cancer chemoprevention.

II. Lung Cancer Chemoprevention II. Lung Cancer Chemoprevention with Celecoxib in Ex-Smokerswith Celecoxib in Ex-Smokers

Overall Objectives To determine the feasibility of Celecoxib for

chemoprevention of lung cancer in high risk ex-smokers. Celecoxib is being evaluated for its impact on cellular and molecular events associated with lung carcinogenesis: 1) modulation of a panel of biomarkers of field cancerization,

2) regulation of arachidonic acid metabolism, 3) antitumor immunity 4) angiogenesis in the lung microenvironment.

II. Lung Cancer Chemoprevention II. Lung Cancer Chemoprevention with Celecoxib in Ex-Smokerswith Celecoxib in Ex-Smokers

Screening

Enrollment

Follow up

Former smokers, > 30 pk-yrs, age >45;

Stage I NSCLC post curative resection

Baseline risk assessment: 1. Questionnaires 2. Spirometry3. Sputum induction 4. LIFE Bronch5. Spiral CT 6. Buccal smear7. Blood 8. Urine collection.

Lung Cancer detected: ineligible

1:1 RandomizationStratification: 1. Prior stage I NSCLC.

2. preneoplasia

II. Lung Cancer Chemoprevention II. Lung Cancer Chemoprevention with Celecoxib in Ex-Smokerswith Celecoxib in Ex-Smokers

6 months placebo

6 months Celebrex

1:1 Randomization

Repeat LIFE bronch, buccal smear, blood,

urine and questionnaires at 6

mo.6 months placebo

6 months Celebrex

CROSSOVER

CROSSOVER

Repeat LIFE bronch, CT, buccal smear, blood,

urine and questionnaires at 12

mo.

RECRUITMENT FLOWCHARTRECRUITMENT FLOWCHART

 

In e lig ib le*2 ,099

In e lig ib le ****1 64

E n ro lled1 20

In P ro ce ss13

W a lk -In S c re en2 97

P e n d in g **52

D e c lin e d ***1 ,558

T o ta l N u m b e r o f In qu iries4 ,006

1. Bronchial biospsiesImmunostaining: Ki-67, COX-2, EGFR, p16, p27, cyclin D1 & E, bcl-2, p53, CD44,HistopathologyFrozen biopsy: CXC chemokines. RNA from homogenates.DNA analysis : GSTP1, p16 methylation. GSTP1, GSTM1, CYP1A1, P53 polymorphisims.

2. . BALFluid: PGE2, IL10, IL-12, VGEF, CXC chemokines, MMP, TIMP-1, LTB4CytologyAlveolar Macrophages: 1.Functional analysis. 2. RNA

3. Sputum: CytologyImmunostaining

4. BloodPlasma: PGE2Buffy coat

5. Buccal SmearDNA analysis

6. Urine

7. Primary Tumor:

Cox-2

Laboratory Studies and SEBM

Buccal Cell Genotyping Buccal Cell Genotyping

 

w ith o u tb ron ch

61

n o rm a l p a th onb ro n ch ia l b io p sy

41

S q ua m o usm e tap la s ia

33

T o ta l # sub je c ts w ithb a se lin e bu cca l ce ll a ssa yed

1 35

~ 137 SNP genotyping assays were performed using the Applied Biosystems SNPlex assay.

Buccal Cell genotypingBuccal Cell genotyping

After adjusting for age, sex, race, education levels, income and pack-years of smoking, an association between abnormal bronchial biopsy with the following polymorphisms was found :

NBS1 (DNA repair gene: HRR pathway)

NBS1 rs1063053 (p = 0.0162)

NBS1 rs1063054 (p = 0.0231)

NBS1 rs2735383 (p = 0.0231)

NBS1 rs9995 (p = 0.0514)

ADPRT (DNA repair gene: BER pathway)

ADPRT rs1805414 (p=0.0319)

Acknowledgement

Division of Pulmonary & Critical Care

S. Dubinett B. Adams

M. Roth J. BailowR. Strieter F. BaratelliD. Tashkin M. Burdick

J . Dermand T. Ho M. Hoang V. Nguyen D. Ritter

A. Tsu L. Ying

L. Zhu

Thoracic Surgery E.C. Holmes R. Cameron S. Perez

Thoracic Imaging

D. Aberle

PathologyM. Fishbein

J.Y. Rao

Oncology

R. Figlin

BiostatisticsR. ElashoffH-J. Wang

EpidemiologyZ-F. Zhang

C ChunW. CaoUCSD

K. Serio

SUPPORTSUPPORT

TRDRP CRFA NCI/K23 NCI/UO1 UCLA Lung Cancer SPORE Stop Cancer Miller Family Grant Study drugs from Pfizer, Inc.