AstraZeneca and Daiichi Sankyo Company, Limited (Daiichi Sankyo)'s Enhertu (trastuzumab deruxtecan) has received acceptance for its supplemental Biologics License Application (sBLA) and has also been granted Priority Review in the US for the treatment of patients with HER2-positive metastatic gastric or gastroesophageal junction (GEJ) adenocarcinoma.

The Food and Drug Administration (FDA) grants Priority Review to applications for medicines that offer significant advances over available options by demonstrating safety or efficacy improvements, preventing serious conditions, or enhancing patient compliance. The Prescription Drug User Fee Act date, the FDA action date for their regulatory decision, will be during the first quarter of 2021.

There are more than 27,000 new cases of gastric cancer in the US each year, of which approximately one in five are HER2 positive.[1,2] For patients with metastatic gastric cancer who progress on initial treatment with an anti-HER2 medicine, there are no other approved HER2-directed medicines.

José Baselga, Executive Vice President, Oncology R&D, said: "Once patients with HER2-positive metastatic gastric cancer progress following initial treatment with an anti-HER2 regimen, there are no approved HER2-directed medicines. The prognosis for these patients is poor, as available treatment options offer only limited clinical benefit. This milestone brings us one step closer to delivering a potentially practice-changing medicine to patients with gastric cancer in the US."

Antoine Yver, Executive Vice President and Global Head, Oncology Research and Development, Daiichi Sankyo, said: "The results of the DESTINY-Gastric01 trial are unprecedented as they represent the first time a HER2-directed medicine has demonstrated an improvement in survival following chemotherapy and HER2 treatment in the metastatic setting. Building on the recent Breakthrough Therapy Designation, the filing of the application and Priority Review by the FDA for this potential new indication for Enhertu reflects the importance of the data and the significant unmet need for patients with previously treated HER2-positive metastatic gastric cancer."

The sBLA was based on results from the DESTINY-Gastric01 randomised Phase II trial, which demonstrated a statistically significant and clinically meaningful improvement in objective response rate (ORR), the primary endpoint, and overall survival (OS), a key secondary endpoint, for patients treated with Enhertu versus chemotherapy (paclitaxel or irinotecan monotherapy).

The safety and tolerability profiles of Enhertu in DESTINY-Gastric01 were consistent with that observed in the gastric cancer cohort of the Phase I trial and previously reported Enhertu trials in other tumours.[3 ]The most common Grade 3 or higher treatment-emergent adverse events were decreased neutrophil count, anaemia, decreased white blood cell count and decreased appetite. There were 12 (9.6%) cases of confirmed treatment-related interstitial lung disease (ILD) or pneumonitis in 125 patients treated with Enhertu as determined by an independent review committee. The majority of cases were Grade 1 or 2 with two Grade 3, one Grade 4 and no Grade 5 (ILD-related deaths).

The results from the trial[ ]were presented during the American Society of Clinical Oncology ASCO20 Virtual Scientific Program and simultaneously published online in The New England Journal of Medicine (https://www.nejm.org/doi/10.1056/NEJMoa2004413) in May 2020.[4]

Enhertu received Breakthrough Therapy Designation (https://www.astrazeneca.com/media-centre/press-releases/2020/enhertu-granted-breakthrough-therapy-designation-in-the-us-for-her2-positive-metastatic-gastric-cancer.html) from the FDA in May 2020 for patients with unresectable or metastatic HER2-positive gastric or GEJ adenocarcinoma who have received two or more prior regimens including trastuzumab and Orphan Drug Designation (https://www.astrazeneca.com/media-centre/press-releases/2020/enhertu-granted-orphan-drug-designation-in-the-us-for-gastric-cancer.html) for patients with gastric cancer, including GEJ adenocarcinoma. Enhertu has not been approved in the US for gastric or GEJ adenocarcinoma.

Gastric cancer

Gastric (stomach) cancer is the fifth most common cancer worldwide and the third leading cause of cancer mortality with a five-year survival rate of 5% for metastatic disease; there were approximately one million new cases reported in 2018 and 783,000 deaths.[5,6] In the US, it is estimated that 27,600 new cases of gastric cancer will be diagnosed in 2020 and more than 11,000 people will die from the disease.[1]

Approximately one in five gastric cancers are HER2 positive.[2] HER2 is a tyrosine kinase receptor growth-promoting protein expressed on the surface of many types of tumours including breast, gastric, lung and colorectal cancers. Gastric cancer is usually diagnosed in the advanced stage, but even when diagnosed in earlier stages of the disease, the survival rate remains modest.[7] Recommended 1st-line treatment for HER2-positive advanced or metastatic gastric cancer is combination chemotherapy plus trastuzumab, an anti-HER2 medicine, which has been shown to improve survival outcomes when added to chemotherapy. For metastatic gastric cancer that progresses on 1st-line treatment, there are no other approved HER2-targeted medicines.[8]

DESTINY-Gastric01

DESTINY-Gastric01 is a Phase II, open-label, multi-centre, randomised controlled trial testing the safety and efficacy of Enhertu versus investigator's choice of chemotherapy in a primary cohort of 188 patients from Japan and South Korea with HER2-positive (defined as IHC3+ or IHC2+/ISH+), advanced gastric or GEJ adenocarcinoma who have progressed on two or more prior treatment regimens including fluoropyrimidine and platinum chemotherapy and trastuzumab. Patients were randomised 2:1 to receive Enhertu or investigator's choice of chemotherapy (paclitaxel or irinotecan monotherapy). Patients were treated with Enhertu 6.4mg/kg once every three weeks or chemotherapy.

The primary endpoint of the trial is ORR, as assessed by independent central review. OS, a key secondary endpoint, was to be evaluated hierarchically at a prespecified interim analysis if the primary endpoint was statistically significant. Additional efficacy endpoints include progression-free survival, duration of response, disease control rate and confirmed ORR assessed in those responses confirmed by a follow-up scan of at least four weeks after initial independent central review.[9]

Enhertu

Enhertu (trastuzumab deruxtecan; fam-trastuzumab deruxtecan-nxki in the US) is a HER2-directed antibody drug conjugate (ADC) and is the lead ADC in the oncology portfolio of Daiichi Sankyo and the most advanced programme in AstraZeneca's ADC scientific platform. ADCs are targeted cancer medicines that deliver cytotoxic chemotherapy (`payload') to cancer cells via a linker attached to a monoclonal antibody that binds to a specific target expressed on cancer cells. Enhertu is comprised of a HER2 monoclonal antibody attached to a topoisomerase I inhibitor payload by a tetrapeptide-based linker.

Enhertu (5.4mg/kg) is approved in the US and Japan for the treatment of adult patients with unresectable or metastatic HER2-positive breast cancer who have received two or more prior anti-HER2-based regimens in the metastatic setting based on the DESTINY-Breast01 trial, and is under accelerated assessment in the EU for HER2-positive metastatic breast cancer. In September 2020, Enhertu (6.4mg/kg) was approved in Japan for patients with HER2-positive unresectable advanced or recurrent gastric cancer that progressed after chemotherapy.

Enhertu clinical development

[][][][][][][]
Clinical
development
programme for
Enhertu
Name Phase Population Design
Breast cancer
DESTINY- II HER2-positive Enhertu
Breast01 unresectable and/or
metastatic breast
cancer previously
treated with
trastuzumab
emtansine
DESTINY- III HER2-positive Enhertu vs.investigator's
Breast02 unresectable and/or choice chemotherapy
metastatic breast
cancer previously
treated with
trastuzumab
emtansine
DESTINY- III HER2-positive Enhertu vs. trastuzumab
Breast03 unresectable and/or emtansine
metastatic breast
cancer previously
treated with
trastuzumab and
taxane
DESTINY- III HER2-low Enhertu vs.investigator's
Breast04 unresectable and/or choice chemotherapy
metastatic breast
cancer previously
treated with one or
two therapies
DESTINY- III HER2-low Enhertu vs.investigator's
Breast06[a,b] unresectable and/or choice chemotherapy
metastatic breast
cancer previously
treated with
endocrine therapy
DESTINY- I/II HER2-positive Enhertu in combination with
Breast07[a,b] metastatic breast Imfinzi (durvalumab),
cancer paclitaxel or pertuzumab
DESTINY- I HER2-low metastatic Enhertu in combination with
Breast08[a,b] breast cancer capecitabine, capivasertib,
anastrozole, Faslodex
(fulvestrant) or Imfinzi and
paclitaxel
BEGONIA[b,c] I/II Metastatic triple Imfinzi in combination with
negative breast paclitaxel and Imfinzi in
cancer combination with either
Enhertu, capivasertib, or
oleclumab with or without
paclitaxel
Gastric cancer
DESTINY- II HER2-positive Enhertu vs. investigator's
Gastric01 locally advanced or choice chemotherapy
metastatic gastric
cancer and/or
gastroesophageal
junction (GEJ)
adenocarcinoma
previously treated
with two or more
lines of therapy
DESTINY- II HER2-positive Enhertu
Gastric02 unresectable and/or
metastatic gastric
cancer or GEJ
adenocarcinoma
previously treated
with a trastuzumab
-containing regime
DESTINY- II HER2-positive Enhertu monotherapyor in
Gastric03[a,b] advanced or combination with
metastatic gastric chemotherapyand/or Imfinzi
cancer or GEJ
adenocarcinoma
Lung cancer
DESTINY- II HER2 mutant or Enhertu
Lung01 overexpressing
unresectable and/or
metastaticnon
-squamous non-small
cell lung cancer
(NSCLC) previously
treated with one or
more systemic
therapies
HUDSON[b,c] II Metastatic NSCLC Umbrella trial of Imfinzi in
previously treated combination with either
with anti-PD-1/PD-L1 Enhertu, Lynparza, AZD9150,
therapy AZD6738,vistusertib, oleclumab
or cediranib
Other or non
-tumour specific
DESTINY- II HER2-expressing Enhertu
CRC01 RAS/BRAF-wild type
unresectable and/or
metastaticcolorectal
cancer previously
treated with two or
more lines of
therapy
DESTINY- II HER2-expressing Enhertu
PanTumor02[a,b] solid tumours
(bladder, biliary
tract, cervical,
endometrial, ovarian
cancer, pancreatic
and rare tumours)
NCT04042701(U106) Ib Locally Enhertu in combination with
-advanced/metastatic pembrolizumab
breast or NSCLC
NCT03523572(U105) Ib HER2-expressing Enhertu in combination with
breast and nivolumab
urothelial cancer
who had disease
progression during
or after prior
therapies, did not
respond to standard
therapies, or for
whom no standard
therapy is available
NCT03523572 I Advanced solid Enhertu
(J101) malignant tumours

Trials led by AstraZeneca [b]New trials that have been added to the clinical development programme and have achieved FPCD [c]Enhertu arm added to ongoing AstraZeneca trial.

Collaboration between AstraZeneca and Daiichi Sankyo

AstraZeneca and Daiichi Sankyo entered into a global collaboration to jointly develop and commercialise Enhertu (a HER2-directed ADC) in March 2019, and DS-1062 (a TROP2-directed ADC) in July 2020, except in Japan where Daiichi Sankyo maintains exclusive rights. Daiichi Sankyo is responsible for manufacturing and supply of Enhertu and DS-1062.

AstraZeneca in gastrointestinal cancers

AstraZeneca has a broad development programme for the treatment of gastrointestinal (GI) cancers across several medicines spanning a variety of tumour types and stages of disease. In 2018, GI cancers collectively represented nearly five million new cancer cases leading to more than 3.5 million deaths.[5] Within this programme, the Company is committed to improving outcomes in gastric, liver, oesophageal, pancreatic, and colorectal cancers.

The Company aims to understand the potential of Enhertu in the two most common GI cancers, colorectal and gastric cancers.[5] Lynparza (olaparib) is a first-in-class PARP inhibitor with a broad and advanced clinical trial programme across multiple GI tumour types including pancreatic and colorectal cancers. Lynparza is developed and commercialised in collaboration with MSD (Merck & Co., Inc. inside the US and Canada). Imfinzi (durvalumab) is being assessed both as monotherapy and in combinations including with tremelimumab across the two main types of liver cancer, hepatocellular carcinoma and biliary tract cancer, and in oesophageal and gastric cancers.[10 ]

AstraZeneca in oncology

AstraZeneca has a deep-rooted heritage in oncology and offers a quickly growing portfolio of new medicines that has the potential to transform patients' lives and the Company's future. With seven new medicines launched between 2014 and 2020, and a broad pipeline of small molecules and biologics in development, the Company is committed to advance oncology as a key growth driver for AstraZeneca focused on lung, ovarian, breast and blood cancers.

By harnessing the power of four scientific platforms - Immuno-Oncology, Tumour Drivers and Resistance, DNA Damage Response and Antibody Drug Conjugates - and by championing the development of personalised combinations, AstraZeneca has the vision to redefine cancer treatment and, one day, eliminate cancer as a cause of death.

 AstraZeneca

AstraZeneca (LSE/STO/Nasdaq: AZN) is a global, science-led biopharmaceutical company that focuses on the discovery, development and commercialisation of prescription medicines, primarily for the treatment of diseases in three therapy areas - Oncology, Cardiovascular, Renal & Metabolism, and Respiratory & Immunology. Based in Cambridge, UK, AstraZeneca operates in over 100 countries and its innovative medicines are used by millions of patients worldwide. Please visit astrazeneca.com (http://www.astrazeneca.com/) and follow the Company on Twitter @AstraZeneca (https://twitter.com/AstraZeneca).

Contacts

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References

1. American Cancer Society. Stomach Cancer: About Stomach Cancer. Available at: https://www.cancer.org/cancer/stomach-cancer/about/key-statistics.html.
2. American Cancer Society. Stomach Cancer: Treating Stomach Cancer. Available at: https://www.cancer.org/cancer/stomach-cancer/treating/targeted-therapies.html.
3. Shitara, K, et al. Trastuzumab deruxtecan (DS-8201a) in patients with advanced HER2-positive gastric cancer: a dose-expansion, phase 1 study. Lancet Oncol. 2019; 20:827-36.
4. Shitara, K et al. Trastuzumab Deruxtecan in Previously Treated HER2-Positive Gastric Cancer. N Engl J Med. 2020;382(25):2419-2430. DOI: 10.1056/NEJMoa2004413.
5. Bray F, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J. Clin. 2018; 68:394-424.
6. American Cancer Society. Stomach Cancer: Early Detection, Diagnosis, and Staging. Available at: https://www.cancer.org/cancer/stomach-cancer/detection-diagnosis-staging/survival-rates.html.
7. Curea F.G, et al. Current Targeted Therapies in HER2-Positive Gastric Adenocarcinoma. Cancer Biotherapy & Radiopharmaceuticals. 2017;32 (10).
8. NCCN Guidelines® Gastric Cancer. Version 4.2019. December 20, 2019: MS-22-36
9. ClinicalTrials.Gov. NCT03329690. Available at: https://www.clinicaltrials.gov/ct2/show/NCT03329690
10. Hilmi, M et al. Immune Therapy for Liver Cancers. Cancers (Basel) 2020 Jan; 12(1): 77.