Januari 12, 2017
>> okay, we're going to start the translational research and clinical oncology course, i'm terry moody. and we've been doing this course for ten years now. they moved me to shady grove.
i have an unusual phone number for nih but i do research down here in building 10. the best way to get me is send me an e-mail. in terms of organizing, i want to thank jonathan wiest, director of the office of training and education in ctr
and pays the bills for this class. and so in terms of the schedule, we always lecture on monday except for october 13. that day is columbus day holiday sorry we check touring on wednesday that particular day. today i'm lecturing, as well as
joel smith clinical trials and we go into different types of cancer, lymphoma, ovarian cancer the following week and immune checkpoint inhibitors, a new area in clinical research, having great success, and basically it's been known for a long time that many cancers
don't really respond to the immune system such as my specialty, lung cancer it makes serb ligans neutralize the immune system and the conner is is more responsive to immune therapy. and small kinase inhibitors are used in
different types of cancer. in october we continued the class and focused on tumor imaging, a goal in cancer is always detect it early in stage one, amenable to surgical remove. cancer stem cells are resistant
to therapy such as chemotherapy. end of november we go into special topics such as rna interference, microrna, and we end talking about nanotechnology. so -- >> terry? >> yes?
>> sorry. this is frederick. we're not seeing the presentation right now. >> okay. we'll work on it. >> do you have any -- >> here it comes. so in terms of registration, we
have 150 registrants, if any of you want to take the class and haven't registered see me after class and fill out a form and we'll get you registered. and then when you need components of this class relative to academic class we have a hands-on section, where
you can sign up to visit tumor boards where they review patient cases, and then you can visit various core facilities such as places where they do next generation sequencing. so i'll be working on this later this week, and i'll be sending all of you an e-mail to see if
you want to sign up for various components, these usually occur in october as well as november. and finally you can get a certificate of passing the course. we have a computer-based examination at the end of the course, not that difficult.
there's one multiple guess answer from each lecture, and to pass you need to get 70% correct. so this course, all the lectures, we have people in nci frederick that we video conference to, two days affidavit, after,
it is archived. two days later you can call it up on your computer and see it there. are there any questions on the organization? okay. we'll get into the meat of the lecture now, and that being we
first get an overview of different types of cancers important in the u.s., and of course lung cancer kills about a third of all the patients that die from cancer in the u.s. annually we have an incidence of 170,000, and almost 160,000 are dying.
so this means that our treatment of lung cancer needs to be dramatically improved, and later on we'll be discussing kinase inhibitors coming into play in the past decade. in contrast, colon, prostate and breast cancer is more amenable to treatment.
200,000 being diagnosed in breast we're getting quite good. we've developed lots of antibodies and kinase inhibitors and various chemotherapeutic drugs. lung cancer is difficult to treat.
total 1.3 million cases of cancer diagnosed in the u.s. annually, and about 550,000 people die, annually from the disease. the treatment gets better, we have more and more survivors, now we have over 12 million cancer survivors in the u.s.
so we mentioned the big four, lung cancer, colon cancer, breast cancer, prostate cancer, other cancers that kill 10,000 to 30,000 annually are pancreatic, which joe will talk about shortly, very difficult to treat as is ovarian can kerr, and brain cancer, glioblast home
a, lung, pancreatic ovarian and glio llast are difficult to treat. drinking excessive alcohol is a risk, this can contribute to liver cancer. asbestos in the insulation of walls causes mesotheliona, and in japan they eat pickeled food,
and they get a higher incidence of stomach cancer. that's quite rare really in the u.s. there are genetics factors such as in breast cancer, we have the brca 1 and brca 2 genes which when they get mutated the women then get the breast cancer.
various hormones come into play, such as estrogen for women, and that can induce breast cancer. and for men, we have the testosterone, which can contribute to prostate cancer. in terms of obesity, a high body mass index is associated with increased risk of colon cancer.
in terms of radiation, ionic radiation leads to leukemia, when we dropped the atomic bomb in japan many people died from leukemia. tobacco is a risk for lung uv radiation can cause melanoma. arizona, texas, florida, we have a high incidence of melanoma.
and then viruses can contribute to various cancers such as the hepatitis virus causes liver cancer, this is quite high, in china, and then the cervical cancer, the hpv can lead to cervical cancer. we have many risk factors associated with cancer.
my specialty is lung cancer. we'll sort of briefly give an introduction. it kills 150,000 annually, socialed with cigarette smoking, 45 million current smokers, 45 million ex-smokers, in this country. but of these smokers, only
really 16% will die from lung many of them will die from other things such as heart disease. so in terms of the carcinogens present in cigarette smoke there's many that have been identified, such as heavy metals, chromium, but then we'll focus on the poly aeromatic
hydrocarbons, hah's, and nnk is associated. the hydrocarbons are in the cigarette smoke and have to be activated to be a carcinogen, oxidized in particular, and then they form adducts with the dna causing mutations, two genes frequently mutated in lung
canter are p-53 and k-ras. benz-a-pyrene, and the active carcinogen, bpde, and this binds to the dna, especially guanine nucleotides. and so the dna gets mutated, phase 2 enzymes will try to
convert them into water soluble products that can be excreted, but dna gets mutated. so with lung cancer, the problem is people smoke cigarettes, and after about 20 years then they start getting cancer cells in their body, and more and more genes get mutated, really dozens
of genes get altered and lung p-53 is mutated in about half of the lung cancer patients, and what we see is p-53 mediates g1 to s-face checkpoint, if the dna gets mutated, it tries to induce programmed cell death, so that's a cancer cells that will die. but when p53 gets mutated it
becomes inactive and can't cause the cancer cells to die. g to t advance versions occur at cpg rich codons, and certain codons are especially mutated such as 157, 158, 245, 248, 249 and 274. so the mutation is not a random process, it occurs at specific
areas. in the cell cycle p-53, g-1 is resting phase, s 1 is where it is replicated, additional enzymes are made in. g-2 and in m-phase chromosomes are segregate and parent becomes two daughter cells and we go back to the g-1 phase.
in epithelial cells, they can become quiescent. cancer cells just grow as fast as they possibly can. we mentioned p-53 mediates, the dna gets damaged then p-53 53 triesed to be increased, as well as p-21 and normally p-53 drives
programmed cell death where apoptosis after dna damage, that if the genes are mutated, this does not occur. we have a series of enzymes regulating, at the g-1 phase, cyclin is important. in g-1 phase, cycle independent kinases 4 and 6 are important,
and the s-phase kinase 2 is important and g-2 and m-phase kinase 1 is important. and cyrlind is inhabited by p-21, p-27, p-57, 15, 16, 18 and 19. so there's a whole bunch of cyclin dependened kinase and inhibitors.
we measure tobacco smoke in pack years, one pack for one year is one pack year. most chronic smokers smoke two packs each day for a year, and then after 20 years that would be 40 pack years of cigarette smoke, but we see after 10 years the lung starts to undergo
hyperplasia, after 25 years a malignant cancer can form. so the cancer cells are constantly mutating, and the cancer becomes increasingly aggressive. we see a cartoon of normal think with hyperplasia, and we see malignant cancer cells forming,
confined to the primary organs such as lung at this point, but then when a full blown cancer develops, it can undergo metastatsis to other organs, the lung cancer undergoes metastasis to the liver, lymph nodes, bone, and brain. so this is just an h and e stain
of the lung tissue, pink is cytoplasm, purpose the is nucleus. the lung is highly ordered, on the surface we see little villi. we breath in o-2, exhale co-2. when we get to hypoplasia, we see more and more cells, it's not an orderly layer, layers
have five or six cells in them. and then we get to dysplasia, cells become disordered, and we see the villi now starting to disappear and nuclei are becoming very big. cancer cells have big dark nuclei. pink cytoplasm.
this is an adenoma of the lung. in this case, these are sort of -- this is like a carcinoma in situ, and then with further progression, we can get a full blown adenoma, and this secretes mucus, and these cells can undergo metastasis to distant organs.
so the process of carcinogenesis we see less pink. here is another cartoon showing we have the carcinogen, benzate pyrene, and altered cells grow, you get a carcinoma in situ, that can undergo metastatsis. we have a carcinoma initially, a cluster of tumor cells.
but then as the tumor gets big, what happens is it needs angio genesis, whereby blood vessels from the host will grow into the tumor providing oxygen and nutrients for the tumor for further growth. if this does not occur tumor cells in the interior will die,
they will starve, they won't have oxygen, won't have nutrients. the host actually sends its blood vessels into the tumor and the tumor further grows and can undergo migration, invasion, and metastasis. and we will talk later on in the
course about angio genesis. and genetic abnormalities, we can get mutation of tumor suppressor genes such as p53, we don't always need the genes to be mutated though. we can silence the genes through epigenetic phenomenon and dr. burma will talk about this.
and you can get cyclin d1, egf receptor and erbb-2. these are big proteins with an exterior, outside the plasma membrane where they bind the various growth factors. then on the inside we have a large tyrosine kinase domain. this will find tyrosine
substrates in the tyrosine kinase receptor or in other proteins, and it will cause tyrosine phosphorylation of the proteins. then the proteins will become active, and alter second messenger production. so we not only have the agf
receptor, another one is the igf-1, insulin growth one, fibroblast growth factor receptor is important. and the veg-f is important in endothelial cell. cancer cells make veg-f and stimulates endothelial cells to grow into the tumor and cause
angio genesis. and so we'll be focusing here on the egf receptor, which has many ligands that can bind. i would have several names for it. the egf receptor is important in lung cancer, breast cancer the
erb-2 is important. and then other members of the family include the. rb3 and 4, which binds nrg-2 and nrg-3. once they bind the ligands, they can dimerize, with itself or form a heterodimer, and you'll get tyrosine phosphorated well.
621 amino acids in the extracellular domain that binds egf or alpha. there's 541 amino acids in the intracellular domain, and lysine 721 binds atp and will transfer the phospate to a tyrosine amino acid and various proteins can be tyrosine phosphorylated.
and here we see the egf receptor binds with high acidity, tgf alpha, the growth actor, toxin 38 conjugate, cytotoxic for cancer cell. getting tyrosine phosphorylated, a dark band. these participate in second for the egf receptor, what's
unique about lung cancer, it gets mutated. two areas commonly mutated are l858r and g719s. they bind tyrosine kinase inhibitors with high affinity and tyrosine kinase inhibitors used in europe and the united states, these are approved by
the fda in the u.s. for treatment of lung cancer patients who fail chemotherapy. in here we get another look at the domain of the egf receptor and mutations, g719c and l858r. there's also some deletion mutation. these make the egf receptors
sensitive to tyrosine kinase we're at the age of molecular medicine, what to do now in nci protocol is the lung patient comes in, they will do a molecular analysis, to see if the egf receptors mutated, if it is they know they can use tyrosine kinase inhibitors on
the patient. in terms of second messenger production then, when the egf receptor gets activated, it can induce proliferation of the cancer cells through this pathway called the ras, raf, mek and erk pathway. k-ras, one of the initial steps,
it's mutated in about 20% of the lung cancer patients. and when it gets mutated then, normally ras will bind gtp but get hydrolized to gps which is biologyically inactive. but when it's mutated, gtp remains bound, g to t codon 12, the frederick national lab is
doing a big project with ras to come up with new modes of therapy for patients who have mutated ras. raf is downstream from ras, once ras gets activated, raf can get phosphorylated, and then it becomes biologically active. and with raf, it's actually
mutated in melanoma, so we have the mutations of v600e and when this occurs you can use this tyrosine kinase inhibitor, the plx4032, and this is very effective on the patients initially. so both ras and b-raf when mutated are driver mutations in
the cancer. so we stated that in lung cancer you have dozens of mutations, but not all of them are what's driving the cancer. if you have ras getting mutated, however, or b-raf, that's a very serious event and then you can target that in your therapy.
so once raf gets phosphorylated, it will phosphorylate mek 1 and 2, and they have inhibitors, and this is being investigated in therapy with the docetaxel. and downstream from mek is erk. when that gets tyrosine phosphorylated, it alters. so the first pathway is very
important in terms of proliferation, and here we see the egf receptor dimerizing, and then when it dimerizes, it causes gtp to be bound to the k-ras which will activate the raf which will positive for late the mek, which phosphorylates erk and goes into the nucleus
and alters the expression of transcription factors. so what we do is we get signal amplification, activating one egf receptor, you'll get thousands of phosphorylated erk. and this process occurs very rapidly. in the lab, i can add egf, and
within one minute i can see phospho-erk. it's a very rapid process. and here is a cartoon showing egf receptor, here we see on monomer. once it binds it starts to dimerize and undergoes confirmation change, and turns
on the tyrosine kinase activity. a second big pathway for the tyrosine kinase receptors, this causes survival of the cancer cell. so the erk pathway causes proliferation, here we minimize the apoptosis of cancer cells. and so what happens is when the
egf receptor dimerizes, then we get pi-3 kinase, and it produces the phospate metabolites, which then in turn stimulate the phosphorylation of akt causing phosphorylation of mtor. so the pi-3 kinase, the 100 units is involved, the metabolism, and then the pi3
kinase can be mutated in breast cancer, about 25% of the patients, glioblastoma 25 mrs., colon 30 per cent, stomach cancer 25%. when mutated it's turned on. you get more metabolites. p-10 is an enzyme which tries to metabolize, but it's mutated in
about 13% of the breast cancer patients. so when pten is mutated, the metabolite is filled up. akt spots phosphorylates, presenting apoptosis, akt is mutated in 5% of breast cancer, 6% of the colon cancer patients. and finally we get to mtor, and
mtor, one of the key things it does is it causes autophage and if not active, then there's decrease autophage, a clinical protocol that's being done at the nci, and so this is for lung cancer patients. they initially do a biopsy of the tumor to see what genes get
mutated. if the agf receptor is mutated, the patient is treated. if these get mutated, the patient is treat the with the mek inhibitor, acd-44. if that's not mutated they look for pten, and they treat with the pi3 kinase inhibitors,
mk2206 and look at erb2 and treat the patient. they look for pegf mutation, receptor a, and treat. and if that doesn't work, they try to figure out something else. but then the key thing is with these tyrosine kinase
inhibitors, they find if they give them to patients, the patients can become resistant to the drug. so at the end of the study then, if they see resistance they do another biopsy specimen and see if the tyrosine kinase enzyme has been further mutated.
so this is the age of molecular medicine, and so we do all of these analyses and what we see then, based on the mutations, dictates the therapy. we mentioned that in about 50% of the patients, they develop resistance after a year, and primarily this is a secondary
mutation of the egf resenter, t790m. so another drug that's been used in chronic myelogenous, in the early 2000's, it started the craze. they have an alteration of chromosome 22, the philadelphia chromosome, segments of
chromosome 9 and 22 get fused, resulting in an enzyme that's constituitively active. here we see on chromosome 22, and chromosome 9 there's a translocation, leading to the fused bcr-abl gene. here you can see on the chromosome for chromosome 9, it
becomes larger, the mutated chromosome 22 the mutation becomes smaller, illustrated here. the bch-abl is active and these patients respond to gleevek. there's always some toxicity, especially rash, using the tyrosine kinase inhibitors.
after a year on gleevec 53 out of 54 responded, 51 were doing well after a year, after five years 89% still responded but some developed resistance to the drug. gleevec is a tyrosine kinase inhibitor in purple, binds to the enzyme, atp can't get in and
phosphorylate substrate. so we mentioned then with the gleevec resistance, it's because of a t315i mutation, now developing new drugs for this mutation such as ponatinib. cancer is not static. it's a moving target. you can find a drug that works,
and then a year later that same drug doesn't work, because the cancer migrated, or mutated into something else. so we see here then for cml, d.c.r-abl, and the antibody herceptin is used for melanoma. and for the lung cancer, mutations in the egf
reseptemberror, gefitinib and erlotinib are biological active. we're going to conclude this lecture. check your house for radon. when i moved to maryland i lived in a house in the country, and when i went to sell this house, i was told it had radon in the
basement. so to sell the house, what i had to do was install an air pump that pumped air out of the basement, into the outside atmosphere. and so in maryland, a lot of the houses on hills especially have rock, and the rock has the radon
gas in it. so the basements can get contaminated, and i was hold if anyone had lived down there, it was the equivalent of smoking two packs of cigarettes a day. so you can get lung cancer from radon. a second thing, check your house
for asbestos such as the walls have a lot of insulation in them, and the old insulation had asbestos in it. as long as it stays in the wall, it's fine. but if you start going into that wall, the fibers will get into the air, you can breathe them
into your lungs and you can get mesothelomia of the lungs. take precautions in your workplace. my old office was in building 31, and on the walls they had a little sign, beware of asbestos. because this building was built 30 years ago, and that's when
they used all insulation with asbestos. it still hasn't been replaced in all of nih. check your community water system. you want to be drinking good water, not water that has carcinogens in it.
avoid breathing polluted air. when i was a graduate student, i lived in los angeles. and every day around 2:00 the ozone would roll in from western l.a., and pasadena, you would just start choking. your lungs would start burning, and then 5:00 it would blow east
to riverside, and they would get so more and more places now are having polluted air. protect your skin. we mentioned about the melanoma, and it's ever-increasing in arizona, as well as texas and florida. one of the primary reasons for
this is we normally have ozone in the upper atmosphere. that protects us from the uv rays of the sun but the automobile exhaust depletes ozone so we're at greater risk than we used to be. don't breathe smoke. initially they found lung cancer
in chimney sweeps in it england. people who would go up and clean off the soot. exercise daily. obesity leads to colon cancer. i myself am a am bicyclist, in a couple weeks i'll do a 100-mile bicycle ride. avoid pesticides.
pesticides can lead to prostate eat fruits and vegetables, these have lots of antioxidants and reducing agents in them, and this prevents oxidation of potential carcinogens. reduce red meat consumption. that's got quite a bit of fat in eat fish with omega fatty acids.
minimize fried foods, you don't want to eat too much of that barbecue and eat a lot of that soot. drink alcohol in moderation, too much alcohol can lead to liver avoid unnecessary x-rays. and reduce infections. infections can lead to
inflammation, it's thought that the 18% of cancers result from inflammation. what happens is the antibodies come in and they release all of these cytokines used by cancer cells to grow. and finally, we have a few references for you.
so that concludes the i'd be happy to answer any questions. (inaudible question) >> well, with cancers you have to recognize, first, a tumor, it's a mixture of cells. lung cancer in the '80s, we developed all of these cultures
from biopsy specimens, basically you get the specimen from the patient. you dissolve it in, put it in a serum-free medium so cancer cells die. in 1% of the cancer cells, they are thought to be stem cells. so what happens in lung cancer,
especially, we have what's called this field effect. one clone grows out and then you may stop this clone, but then a different clone grows out. the first clone may be resistant, sensitive to chemotherapy, the second clone isn't.
so then you look for your mutation, such as the egf receptor, if you see this second clone has the egf receptor mutations, you can use the tyrosine kinase inhibitor, erlotinib. but it's a peculiar thing. they found using these tyrosine
kinase inhibitors, cancer cells were smart because after a limited period of time they could figure out ways around it by causing further mutations. so now the scientists are trying to become smarter. they are developing a second generation, a third generation
of tyrosine kinase inhibitors. cancer, you know, it's very clever. it's always mutating, and so it's very difficult to fight. one of the things that we really have nothing for right now is if it undergoes a k-ras mutation and they have a new project in
frederick where they are trying to figure out something to treat patients with k-ras mutations. so it's a multitude of things. you not only have the mutations, there can be silencing of tumor suppressor genes, and this sort of can be switched on and off, whereas the mutations, it's an
event that can't be changed, once you get mutations. you have the epigenetic phenomenon also contributing, and so it's a very complex problem and that's why we're so much into the genetic analysis of the tumors here at nci. (inaudible question).
>> yes, in lung cancer when they find the resistance to the tyrosine kinase inhibitors, 50% of the time it's because the agf receptor has become mutated. 20% of the time the k-rsa became and 15% of the time, it's because of met mutations, and then there's about 15% where
they have absolutely no idea. so those are hard numbers for lung cancer, and 15% we just don't know. but the good news is now we have the immune checkpoint inhibitors, they are starting to work on some of the lung cancer so we have a lot of hope for
that now. so ten years ago, all we had for lung cancer was chemotherapy, and a little bit of radiation now we've got tyrosine kinase inhibitors and immune checkpoint inhibitors and we're quite excited. lung cancer deaths have leveled
off. they are no longer going up in the u.s. we would like to get it to the point of the breast cancer, where the deaths start going down. yes? >> right.
well, the egf receptor is mutated in about 13% of the lung they figured out it was mutated, they started using the erlotinib in the u.s. and it did it work very good in u.s. patients and they tried it in japan and it worked quite good. and then they found out that in
the japanese women, about 30% of them had egf receptor mutations, and most of these were nonsmokers. so then they found out in the u.s., well, this is only going to work if, you know, the patient has egf receptor mutations, and so in the u.s. we
have about 10%, but in some of the asian countries 30% have mutated egf receptors. those things are in vogue there. we worry about cancer stem cells. we don't really know what they are doing. they are in all of our cultures,
and in lung cancer it's about 1% of the cells on the average are stem cells and we don't know what they are doing because, you know, all the other cells have the egf receptors, we're not certain of the properties of the stem cells, but the notch pathway seems to be involved
we'll move on then to our next speaker, jill smith from georgetown university, and she's going to talk about translational research, bench to bedside, clinical trials. >> good afternoon. how many of you in the audience are either ph.d.'s or ph.d.
candidates? oh, okay. how many of you are m.d. or m.d. candidates? okay, good. anybody both? good! all right! well, thank you, dr. moody, for
inviting me. this is my new home at georgetown. last year i was here at nih. so this is my new place. and i haven't quite figured out in this picture, my lab is next to the medical-dental building, it's called building d because i
understand they haven't gotten a donor yet for it. i do have a few disclosures. i'm a co-inventor on a few patents and some of them i may mention some of the science from the patents here that have to do with pancreatic cancer, and i'm also the director of consulting
company that helps with some biotech developments. as far as what we're going to talk about in the next less than hour, i hope, is how to understand how an idea is actually taken from the research lab to patient care. and learn about the stems of
conducting clinical research, and to understand some of the obstacles that you have to overcome for drug development. and some examples i'll give you from my experience with translational projects, we'll talk a little bit about the pitfalls and also the prizes.
so, first of all, you guys are all here because you have dreams and ambitions and we all do, and you want to, you know, discover that cure for cancer. well, i have dreams too. my dream is that i'm going to get the nobel prize someday, i haven't given up, i lope you all
have dreams and ambitions also. there's a few people i admire. one of them is nelson mandela. and he said there is no easy walk to freedom anywhere, and many of us will have to pass through the valley of the shadow of death again and again before we reach the mountaintop of our
desires. and then there's edmond hilary, also another person i admire, he's the first person who summited mt. everest. but, you know, he didn't make it the first time. the first time he tried to summit mt. everest, actually the
majority of his crew, including his best friend, died. and when he was talking to the parliament in england, there was a big picture of mt. everest behind him. he turned around and he looked at this poster and he said, you know, mt. everest, you have
defeated me, but i will return, and i will defeat you. because you can't get any bigger, but i can. i'm building up to encourage you guys not to get discouraged when your research doesn't work out so and then of course there's martin luther king jr. who did
have a big dream, and he dreamed that one day this nation would rise up and live out the true meaning of life's creed, and hold all these truth to be self evident, that all men are created equal. we all have dreams and desires and we are here because we want
to see what you're working on in the lab, your discovery to have meaning in life and to help people. there's a problem though. i mean, many of us are involved with research and there's a lot of drugs being tested, a lot of ideas that are being tested, but
unfortunately, there's this bottleneck, and of all of the ideas and great things that we're working on in the lab, only a certain percentage of them actually get through to clinical trials, and only a certain percentage of those make it and get approved by the fda
for treatment. so what's the bottleneck? this is 495 about now, close to the 5:00 rush hour traffic. and is the bottleneck because these ideas are crazy or there's a lot of politics involved with this, and you got to get fda approval and you've got to
please everybody and the congressmen have to agree, and whatever. so there are some bottlenecks that are political too. so several years ago, nih actually set up the n-cast with ideas about improving translational science, and some
are shown up here on this slide, and they wanted to focus on six areas to take the ideas from the lab to patient care. where do you start? you're the brilliant grad student or postdoc in the lab. you get a wonderful, brilliant idea.
and then, you know, of course you have to think about this idea and this is the idea downloading, so you've got to come up with an idea, and then once you have the idea, you have to have a hypothesis. so what is this idea that you have, and what's the hypothesis
that you've planned to test? well, there's different phases of clinical trials, and most of the trials involve new drugs and they go through a series of steps. many of you are working at this stage where you're in the laboratory, you may be working
with cells in vitro, or cancer cells, or with animals testing a drug or treatment on tumor or knockout animal. once it's deemed safe in animals you go through different phases, phase one through four that's testing it in humans before it then will be approved by the
f.d.a. there's also several different types of clinical trials, there's the treatment trials, prevention trials, early-detection like biomarker trials, screening trials, diagnostic trials, quality of life trials, if you're into
psychology, clinical benefit. and today as dr. moody talked about there's a lot of genetic trials going on, based upon what we know about the new genome. also it can be phase one through four, it can be randomized, or it can be nonrandommized, blinded or open, it can have a
placebo control or maybe not. and it can be a pilot trial or maybe not a pilot trial. so just to review for you what some of these different phases are, we'll start with phase 1 trial, and phase 1 is when you have -- you test it in a small number of people, and the whole
purpose is to determine whether your treatment is safe. phase 1 is primarily for safety and toxicity. you want to also decide how the treatment should be given. some phase 1 is you're trying to decide if better to give it subcutaneously, can you give it
orally, what is the bioavailability, and therefore you do a lot of pharmaco kinetics to evaluate how this drug is metabolized in human subjects and what will side effects be so mainly safety and toxicity but it doesn't tell you anything about how well it's
going to work. you may be doing phase 1 in normal people, not with cancer drugs but some of the drugs we do. then phase 2 is when you get into the efficacy, and you want to know, okay, we know it's safe in humans, does it really work?
and so the number of people that are tested in a phase 2 trial are a little bit greater. usually phase 2 trials are blinded, randomized with a placebo. you want to know does it work, and is your treatment better than the placebo, but in the
phase 2 you usually don't compare it to other treatments at that point. however, i will say that in cancer treatment, sometimes we compare it to the standard of care, and when we do that, we look at either an equivalency trial, rather than -- or a
superiority trial but a lot of drugs are approved because they are shown to be equivalent to another fda-approved drug, but they may have a better safety profile. and then phase 3 trial is when it takes a lot of people to do a phase 3 trial, and there's equal
chance to be assigned to one of the two groups, and it looks as how the new treatment then compares to the standard treatment. or you can also compare it to a placebo, but it's a lot larger study. phase 4 is usually after the
drug has been released, it's out in the market. it's usually a post-marketing trial. and it involves thousands of for example, they want to know now that they have this vaccination approved, how is it going to decrease the incidence
of, say, hepatitis b throughout the world, or whatever. so they do post-marketing trials. so this kind of summarizes the different phases of the trial, how long they take, what the purpose of the trial is, and the number of drugs that actually
get to that point. you can see that once you get up to phase 3, the number of drugs actually starts to drop off. so a lot of drugs once they get into phase 1, they find out they are not safe and they can't go any farther. or you go to phase 2, and
there's no difference than a so they don't move on any further. so those are a lot of the bottleneck and weeding out of the drugs to find out which ones actually work. with the randomized trials, there's an equal chance to be
assigned to one group or the other, one gets the most widely accepted treatment, and like the standard treatment, the other gets a placebo. the other one may get a standard of care, and then the groups need to be fairly well balanced. you can't have all women in one
group, and men in the other group. so if -- you try to balance the two groups. with randomization you have a control and treatment group. as i mentioned, this group can either be placebo or the standard of care.
because we usually don't like to test our new cancer drugs in normal people and you don't also like to withhold therapy from patients by giving them a placebo if they have known so often we will -- when we randomized they will get standard of care versus the new
so what's a pilot trial and when would you want to do a pilot trial? i'm working on one of them right now. usually it's a small study, and it's your first venture into an area, and it helps you kind of iron out the difficulties
involved with doing a bigger and the other important part about doing a pilot trial is it gives you some idea of how patients might respond to the treatment, and then you can have your statistician use that information to calculate the sample size that you need to do
the larger phase 2 trial. so often a pilot trial is an open labeled study where you're treating everyone and you want to know how many of them respond. and then you use that information for the phase 2 so again these are treatment
trials and it's to determine the most effective treatment for patients who have cancer, test the safety and efficacy of new drugs and interventions for cancer drugs. and i'm not going to spend time on all the treatment trials and but the early detection trials,
there's a lot going on now, looking for different biomarkers, they call them the liquid biopsies. if you can take a blood sample from somebody and try to make a diagnosis, of cancer, so the early detection trials are really important right now, and
if you can actually intervene at an earlier phase, and maybe prevent cancer, or prevent the bad outcomes we have from some of the cancers. so then there are some other studies like quality of life studies, that we do supportive care studies, and then there's
the genetic trials, with the genetic trials and a lot of gwa studies it's important that we realize there are ethical considerations, and there's a lot of these huge tumor banks where blood samples have been banked away, now we know that the irb requires if you're doing
a new study you have to have special language in there that talks about that you're going to be testing the person's blood or tissue for genetics, so just keep that in mind if you're doing any of these mutation studies because that's now required.
and how are the patients' rights protected? well, of course, there's ethical and legal codes that govern the medical practice, and there are review boards that dr. moody talked about that you can sit in on. there's the institutional review
board, and in order to do a clinical trial you have to be approved and take the city training, an online training to get approved so that you can be involved in human subject research. there are also data safety monitoring boards that actually
monitor conduct of the study while it's going on. so how do you do it? what are the nuts and bolts and how do you actually take your idea in the lab to a phase 1, 2 trial or get a drug approved? i'm going to share a little bit of what i do and how i've done
it with some examples. the first thing you need to do, this is from the nci we're talking about cancer, you need to think about what target you're going to look at. there's plenty of targets here. you can choose your favorite target, in signalling or
receptor, or choose a different pathway like apoptosis and work on a pathway, on you pick a particular cancer itself, and you are going to focus on breast cancer or lung cancer, whatever. i mean, my research is focused primarily on growth receptors on cancer, and i also focus mostly
on pancreatic cancer. these are just some of the faces of pancreatic cancer, and we can see how old the audience is. i'm sure most of you guys know these two guys down here. does anybody know who they are? does anybody know who this guy is?
who? that's dizzy gillespie, agues musician, julia produces, her man munster, jack benny, michael landon, the faces of pancreatic cancer. the reason i became interested, you have to identify with whatever you're working on,
what's the problem? that's where you come up with the idea. there's a problem here and i'm going to fix it. well, the problem with pancreatic cancer is the survival from pancreatic cancer has not improved in over 50
years. in spite of our technology, the gwa studies, in spite of all the mri's, cat scans and all the technology there's been no improvement. why? are we going the wrong way? there's one car on this highway
that's driving the wrong direction. you know, the problem is there's not been any improvement in survival. over 70 regiments have been thrown at pancreatic cancer but the problem is chemotherapy has been nonselective and
nonspecific for pancreatic cancer, and in the end pancreatic cancer is resistant to chemotherapy, and it wins out. so because of this congress has actually named pancreatic cancers as one of the recalcitrant malignancies and
asked the nih to improve funding for pancreatic cancer because of this. there was a recent article published in cancer research two months ago that showed by the year 2020 pancreatic cancer will surpass breast and colon cancer, and after lung cancer will be
the number two killer in the united states, if we don't do something. so nothing's changed for 50 and if you keep doing the same thing and for those who are into cloning in the lab, you know if you keep doing the same thing you're going to get the same
results. so we need to change our strategy with this disease. so that's where i came in and said there's a problem here. so what are you going to do? when you're doing research, it's really important, you always wonder why do i have to take all
those basic science courses and why do i have to understand that and whatever. well, you do have to understand that. you know, the med students, why do you need gross anatomy. you have to understand physiology and biology to
understand the normal before you understand the abnormal. in the area i'm working on, with growth receptors, there's a couple of gastrointestinal peptides that involve growth of the gastrointestinal tract. one of them is called cck, just to review since i'm sure you're
up on physiology of the g.i. tract, cck is released from the high cells when there's fatty acids and certain amino acids in the duodenum. it gets in the blood system and circulates in the blood and acts on receptors in the pancreas. when it does that it releases
digestive enzymes that help you digest food. the other thing it does is it reacts to the receptors that are on your sphincter and the gallbladder and causes contraction of the gallbladder so the bile is released and helps you emulsify the fat so
you can digest your fat. this is what ckc ck does, it regulates insulin release. one area i was interested in, my mentor was working on growth and regeneration of the pancreas, and they knew than the cck worked on its receptor to help the normal pancreas grow.
if you have a bout of pancreatitis, cks works to restore the normal cells. the other related peptide that acts on the same receptors is gastrin. you may be familiar with it because it stimulates the release of gastric acid.
gas trin was present in the fetal pancreas, it shut off at week 14. however, it gets turned back on again in cancer and actually stimulates the growth of cancer. it also stimulates the growth of the stomach, and for any of you who take chronic proton pump
inhibitors, i don't want to scare anybody, but emiprozole, the other drugs, i don't want to name them all, any of the drugs that block proton pump in the stomach to block acid release over time, what happens is that gastrin levels are elevated because the body see there's not
enough acid so you block the normal feedback loop. i'm a gastroenterologist. what we see is they grow polyps in the stomach after being on it a long time. they are benign polyps, and you can grow carcenoidz, but it abilities on the cck receptors
and cause growth. if they are elevated, they stimulate growth. what does cck do besides that? the other thing is that cck can cause pancreatitis, and one of the things that dr. moody talked about is inflammation can predispose to cancer.
there's a compound on the skin of this pretty green frog. cerulein, it's a cck peptide, a dekapeptide. if you take that cck and inject it into your laboratory animal, you will get pancreatitis. and if you continue to do that over a long period of time, you
can get chronic pancreatitis, which can increase risk for so if you have a little bit of cck that helps you digest your food and considerate your gallbladder, it's good, like it's a bit of wine might be good. if you have a little bit too
much, these are my liver too much cck is not good, and it may stimulate chronic pancreatitis and pancreatic so the other thing that i wanted to tell you, not only does cck cause pancreatitis, it has another property, how does it caught growth?
in order to understand how these peptides cause growth you have to understand the difference between hypertrophyy and h yperplasia, an example of hyper trophy, it's when you increase in size but not in number, that happens to many of us at middle age.
this is an example of hyperplasia. she doubled, more than doubled, in number, you're increasing the dna content, so one of the things they knew a long time ago is that cck and gastrin because hypertrophyy and hyperplasia. if you treat animals can cck, it
increases the dna content and tritiated thymic up take, stimulating synthesis. they used to think let's give animals cck and maybe the inflammation in the pancreas is increasing the cancer, but they now know that it's not just because of the inflammation
that's induced, it's because cck has the other property that causes hyperplasia. if they give cck to animals receiving a carcinogen they find they can significantly increase the number of animals getting pancreatic cancer by doing this. so that's because cck has
properties of both hyper plasia and causing inflammation, both can predispose to cancer. when i was a postdoc, i said this was interesting. pancreatic cancer doesn't have i tested human pancreatic cancer cells and treated them with cck and with gastrin and lo and
behold cancer cells responded to peptides and we stimulated growth of cancers and could block the effect by using receptor antagonist. so this showed peptides are driving the growth of pancreatic so just a little bit about the receptors that are involved,
there's three main receptors for this cck receptor, and they are easy to remember. a, b and c. a was discovered in the alimentsary tract, b in the brain, c discovered in cancer. that's how you can remember them.
and the c receptors, our lab discovered that, i'll talk a little bit more about this c receptor, but the receptors themselves are significantly overexpressed in pancreatic cancer, just like estrogen drives breast cancer, androgen drives prostate cancer,
gastrointestinal hormones drive g.i. cancers, compared to the normal pancreas, the number of receptors increase in pancreatic so what happens in the normal situation, if this is a normal pancreas and has normal receptors on it, and when cck is released into the circulation,
or gastri, it binds to the receptor and as we learned, it releases enzyme. but in cancer, the receptors are markedly overexpressed, some of them have this variant of receptor, which i'll mention in a minute. when they respond to the ligands
they don't release digestive entimes but cancer doesn't care if you digest your food. gastric gets turned back on. it was originally in the cancer cells and it's suppressed, and the messenger rna gets turned back on in early pre-cancerous lesions and regulates its own
growth by an autocrine mechanism. one of the things we discovered is that not only are the receptors overexpressed but some pancreatic cancers make a mutant rekeptor, ccc-c receptor, the fourth intron is not sliced out. humans have an open reading
frame through the fourth intron, whereas animals, mice in particular have a stop code and do not transcribe the intron. this occurs in 35% of people with pancreatic cancer, and i won't go into the details but we did some dna sequencing and we actually identified the snp that
causes this slice variant. for the people that don't slice out the fourth intron it causes the addition of 69 amino acids to be added to the third intracellular loop. for any who work on g-protein coupled receptors you know the this third intracellular loop is
involved in gtp protein coupling, and that's what causes the growth and proliferation. so when this additional piece is added on here, it makes the receptor active. so we actually raised an antibody against this specific receptor, and we found that we
could get staining in the people who had the asnp but people with the wild genotype did not have binding to our antibody. i'm still translating as a human, we've made this into a mono clonal antibody. if we treat the mice, the red bars, those treated with
controls continued to grow. so this just gives an example of how it works in that we found that the snp becauses a misbinding to splicing protein, so if you have this c variant it does bind to the splicing protein but with the a genotype or snp there's no binding.
that's just another example of is this clinically relevant? we did go back and we did an analysis, which is another type of research you can do, and we went into our tumor data bank and we analyzed patients with pancreatic cancer and said, well, we know if you have this
slice variant it seems to stimulate growth, does that really affect the survival of patients? and indeed we found that it did. so people who had the slice variant receptor did not live as long, it was statistically significant.
this may be one of the reasons why patients with pancreatic cancer have such a poor so now we've identified it's a germline mutation for pancreatic and you have to correct for the stage of disease which we did and showed it was still statistically significant.
so the other receptor that i worked on, since my work has been with g protein coupled receptors is with an opioid receptor, also a g protein coupled receptor and we identified a protein, ogf, that when it binds to its receptor it inhibits growth of pancreatic
and we did receptor binding studies to show it was physiologically relevant, and then you can see in these nice mice that if we treated the mice with this ogf tumors shrunk, 5 milligrams per kilogram three times a day. i want to do a phase 1 trial,
how much do i give to a human being? you have to calculate, well, if this is how much i give my 22-gram mouse, how much do i have to give to my 70-kilogram man and decrease that by a thousand-fold and start low and work my way up.
so we had identified the problems that pancreatic cancer had a dismal prognosis, hypothesis was ogf could inhibit growth but could it work in humans? we went into a phase 1 trial. before you do phase 1 trial, you have to apply to the fda, you
have to get an investigational new drug number or ind number, and you have to fill out what they call a 1571, and 1572 form. you write a protocol. you get a consent form. you have to get irb approval. you find a sponsor who is going to fund your study.
that's probably the hardest part. and then, you know, you have different responsibilities of the principal investigators and you have to register your trial on the clinicaltrials.gov website. if you do not register before
you enroll your first patient you're not allowed to publish your research. this is a 1571 form, you get assigned an ind number and you have to include that number with everything single time you submit a form, to the f.d.a. this form has to accompany every
communication to the fda concerning your protocol. and then every time you submit it, you have to keep a record of -- this is number one i submitted, this is my second communication, and you're given a serial number, and the fda records all of these.
but it's very important to keep good records with your f.d.a. so then when you do the -- these are the things you have to put on the 1571 and 1572 form, and some of the details about that. and then you go into what the aims of the study are. so we wanted to look at the
safety and toxicity of ogf, we didn't know what dose to use. so we wanted to calculate what was the right dose, we did pharmaco kinetics, we test the iv and sub-cu. we tested chronically to see how well it was tolerated over time. when you're doing a phase 1
trial you have to decide who is your population, a lot of phase 1 trials are done in healthy controls. well, since we were interested in getting information on cancer patients, we tested this in pancreatic cancer patients. and you just come up with the
criteria that you think that will be good, who you're going to include and who you're going to exclude from your study. basically you want to make sure you're going to hopefully include patients that are going to live long enough so that you'll get some information from
the study. what we did in our phase 1 study where you enroll three patients, give them the first dose and started a 25 milligrams per kilogram and if three people tolerate that dose you move up to the next dose. the very first person that i
gave this drug to was a little lady with pancreatic cancer and she ended up in the hospital that weekend with abdominal pain. and i had to make a decision, wow, did i do this to her? is it her cancer? am i going to dose the next
couple patients? and i ended up going ahead and dosing the next couple patients, and if i hadn't taken a risk, or moved ahead, this study would have never gone further. so she did fine and recover, it was probably her cancer that caused her to be that way
because no one else had that problem. we did escalated and found out 250 was our maximum tolerated dose. we did pharmaco kinetic studies where we measured and sometimes you need to do this in your phase 1 trial, we proved it was
increasing in the blood. when we knew the maximum tolerated dose we went into a phase 2 trial and you want to know phase 2, as i said before, efficacy. does it really work? we ended up doing an open label study, and we used the dose that
we had found in the patients in the phase 1 study. our patients couldn't be respectable. i went round and round with the i wanted to compare it to standard of care, but they said that i couldn't do that because we didn't prove yet that it was
efficacious. the fda made us treat patients who had already failed therapy, which if you know anything about pancreatic cancer, you know they are not doing too well at that stage but we took what we could get and did this study, and actually we looked at survival
in those patients, we looked at other outcomes like time progression, quality of life, clinical benefit which is something else we look at often in cancer studies, and we looked at cat scans, there's the recist criteria to see if you're having shrinkage of tumors by measuring
them periodally on tumors. we found with primary end point of survival that compared to patients who chose not to go in this study, that we had significant improvement in survival of our patients who had this treatment. so after we did the phase 2
trial, we actually then went back to the lab. and we thought we would test it in combination with another standard chemotherapy at that time, gemcitabine. and what we found is that when we gave the gemcitabine alone or ogf alone, tumors didn't shrink
as much as in combination. you can see with the mice, if you work with nude mice, the mouse that got the chemotherapy lost weight and his skin was kind of scaly but the animal who got the combination, it had a protective effect and he did okay and the tumor was smaller.
so to make a long story short, i went back and applied for another grant and got more approval. we tested this combination in human subjects, and we actually found compared to our own monotherapy with og, if we could improve the survival of patients
who got the combination. so this drug actually -- this is when i was at penn state. penn state has the intellectual property for this but this is an important point because before you go out and disclose any research that you do, including an abstract, you want to make
sure that you have filed an invention disclosure or provisional patent to protect it, if -- i mean if you're working -- and the discovery actually belongs to your employer, not to you unless you own your own company. so anyway, that's important,
with the og, if we did intellectual property, penn state got the patent, and they actually have licensed the patent, it's going on now for development through the f.d.a. so it is moving forward. i'm an inventor, eventually i may get royalties.
that's what happens when you work for a company. you can also -- you have to find a company, you have to license your patent. if you really want to get it out there, because most of us are -- you get it to a stage and then you have to find a company that
can actually take it to the next level. what are some of the obstacles with doing translational research today? well, of course the biggest obstacle is always money. how i did it with $50,000 is unbelievable but i had a company
give me a little grant that helped me buy the drug and the other thing we used is the ctsa's at the university because that helps keep costs down. soy there are -- it is probably, but it is expensive. and funds are hard to come by. the other thing, i mean i'm a
clinician, i'm an m.d. clinicians often don't get protected research time, which it would be nice if they had more protected time, and the indirect costs we get on our grants don't cover our malpractice, you're required to have malpractice if you're doing
clinical research, it's required by the fda and irb. you have to somehow pay for that's another problem. there's also this chiasm between industry and nih and academia. in order for us to move forward with a lot of these drug discoveries, that chiasm has to
come to a close. it's about team science today and we all have to work together and i think that industry has a lot to offer, academia, nih has a lot to offer, but they all need to get together and work together if we're going to come up.
like i said, there's no more one-man bands. this is all about team science. so as we look back on the problem, you know, survival of pancreatic cancer, why hasn't it improved, are we all going the wrong way, well, maybe you got to take a different strategy.
maybe actually this guy is going the right way and everybody else is going the wrong way on the highway. so in order to change things, with research, i suggest we have to transform our minds, we have to think outside of the box. we've got to do things
differently or else things aren't going to change. and don't be afraid to take some risk. if i hadn't moved on and pushed forward we never would have gotten the drug moving through an approval in the f.d.a. you have to be able to take some
and the bottom line is does research have any real clinical relevance, does it help people? these are a couple of my long-term survivors from the pancreatic cancer studies, i have their permission to show pictures. bobby and vickie.
and yes, it means everything because of people like this. so that's the reason why we're doing the research is to improve survival and help save lives. so the important thing is don't give up. and i'm here to tell you that. i haven't won the nobel prize
yet but i haven't given up. if it's not me, i hope it's one of my students or somebody else. but as far as your dreams, there's some sayings, one is strivers achieve what dreamers believe. you got to work for it. there's also a saying, i stand
for freedom of expression, doing what you believe in, and going after your dreams. and a dream doesn't become reality through magic. it takes sweat, determination, and hard work. and this is what i said, you know, if you don't believe in
yourself or your dreams, no one else is going to believe in them either. so you have to believe in yourself. you have to have the faith in your work, and most of all don't be encouraged. so i want to thank dr. moody and
dr. zia and some of my colleagues for helping with all this research and thank you for your attention. [applause] questions? >> so it does -- so the ogf receptor is a nuclear receptor, and so there's three classic
opioid receptor on the plasma membrane. when the ogf binds, it shuts down ogf synthesis. five amino acids, small, it can penetrate the cell. entertaining it, yeah, that would be good. yes.
(inaudible). >> i want to do that. that's coming in the future. the paper is still in press, hopefully to come out in a couple -- it takes so long. i want to say a couple weeks, that we discover this splice variant but now that we know
about it, i mean, it would be ideal if you could screen for patients and you know who might be at risk for developing pancreatic cancer because right now we're just looking at people who have familial pancreatic cancer which only makes up 10% of pancreatic cancers.
one, if you know you have the mutation, like the brca 2, you might be able to improve surveillance and follow people more closely. also, if we know that they have it, and we have the monoclona antibody and can target the receptor, as dr. moody was
talking about, now that we know different mutations we can do target-specific therapy and i think that's where the future is going with all of this treatment. >> the maximum tolerated dose is determined based upon the side effects and toxicity that you
get with your patients. so you escalate it to a certain dose and when you get to the dose, certainly if you kill somebody you don't want to use that dose. then you have to back down to the next dose, prior to that. so there's different -- you
designed the protocol but you look at the different things that you would expect for toxicity, and if you get those toxic side effects, then you know that you have to back down. so that's what you do. you go up to a level where you find that it's well tolerated,
the majority of the people will tolerate this. you don't have the serious adverse event. if you do get a serious one you have to back down to the prior dose. >> of the ogf? the off is actually a peptide.
we gave it by infusion. and we found that we could measure it in the blood, they had it peaked within 30 minutes, is this what you're asking? no? maybe not. okay. the median overall survival of
people who are treated with this? so most of our patients were people who had prior therapy, and so in mono therapy in those patients, we had survival up to nine months and in our patients with combination, it's more than 11 months, which is the current
thing with sulferinox. are they what? [ inaudible ] yes. so in the only study that we did when they were treatment naive was the combination where we gave it along with gemcidominie that we had several patients
living several years with combination therapy and using patients who hadn't d eveloped drug resistance and failed other therapies. in the mono therapy study survival was 9.1 months but some patients already failed prior so, you know, ideally if you
could use this drug from the onset and maybe give it with current therapy, whether you are using a stain or sulfuronix it may improve survival and decrease toxicity, which is what we were seeing. they act by different mechanisms.
so that's why they potentiate each other. yes, in a way. when we went into our study, i wanted to do it like as a phase 3 study, and the fda actually made us go back and do a phase 1 study, because they said that we hadn't yet looked at the safety
and toxicity of the two drugs in combination. so, you know, there are certain rules you have to go back because nobody knew that if you gave gemcidoni with this compound was it going to make it better or worse. they do have certain
requirements and unfortunately it sometimes slows things down, but they do. >> i mean, that's a great idea. do you want to come work in my lab and we'll figure it out? yeah. i mean, as dr. moody said, the stem cells become resistant and
that's a problem with recurrence. with pancreatic cancer right now most people survive only three to six months. i mean, we're happy, you know, the latest and greatest treatment with a brack stain is 8.1 months and sulfuronox 11
months. we're not at a year. we would just like to get someone to regress. it's a very important point about the stem cells. we have to make sure we attack the stem cells so when we get to the point we have effective
therapy they don't come back or get resistance. well, thanks for your attention.
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