This document summarizes key points about precision medicine in stage IV lung adenocarcinoma as an example: - Biomarker testing like EGFR, ALK, ROS1 is essential to select appropriate targeted therapies and has become standard practice, with 92% of non-squamous cases tested for EGFR and 79% for ALK. - Ongoing clinical trials are exploring new targets like RET fusions, NTRK fusions, and KRAS G12C mutations and corresponding therapies. - Next-generation sequencing allows comprehensive genomic profiling but challenges include methodology, turnaround time, and reporting of clinically relevant alterations. - Liquid biopsies show promise for resistance mechanisms but have

1. Els Nous Reptes
de la Medicina de Precisió (Up-Date)
Barcelona, 12 de novembre de 2019
Amb el patrocini de
Nuevos retos mundiales de la medicina de precisión
Enriqueta Felip
Hospital Universitari Vall d’Hebron, Barcelona

2. Medicina de precisión, definición
• Emerging approach for disease treatment and prevention that takes into
account individual variability in genes, the environment, and lifestyle for each
person
üThe Cancer Genome Atlas, which helped define genomic changes that are
unique to different cancers
üPrecision medicine is providing “the right drug for the right patient at the
right time”

3. Yap et al, Nature Rev Cancer 2010
The shift
Determine molecular
profile of the patient´s
tumor
Determine which drugs
are most appropriate
Past
Present &
Future
Drugs Which patients respond
best?

4. Medicina de precisión ADC de pulmón estadio IV (como ejemplo)
ESMO clinical practice guidelines 2018
A personalized medicine synopsis table for metastatic NSCLC
Biomarker Method Use LoE, GoR
EGFR mutation
Any appropriate, validated method, subject to external quality
assurance
To select those patients with EGFR-sensitizing mutations
most likely to respond to EGFR TKI therapy
I, A
ALK rearrangement
Any appropriate, validated method, subject to external quality
assurance. FISH is the historical standard but IHC is now
becoming the primary therapy-determining test, provided the
method is validated against FISH or some other orthogonal
test approach. NGS is an emerging technology
To select those patients with ALK gene rearrangements
most likely to respond to ALK TKI therapy
I, A
ROS1 rearrangement
FISH is the trial-validated standard. IHC may be used to select
patients for confirmatory FISH testing but currently lacks
specificity. NGS is an emerging technology. External quality
assurance is essential
To select those patients with ROS1 gene rearrangements
most likely to respond to ROS1 TKI therapy
II, A
BRAF mutation
Any appropriate, validated method, subject to external quality
assurance
To select those patients with BRAF-V600-sensitizing
mutations most likely to respond to BRAF inhibitor, with or
without MEK inhibitor therapy
II, A
PD-L1 expression
IHC to identify PD-L1 expression at the appropriate level and
on the appropriate cell population(s) as determined by the
intended drug and line therapy. Only specific trial assays are
validated, internal and external quality assurance are
essential
To enrich for those patients more likely to benefit from
anti-PD-1 or anti-PD-L1 therapy. For pembrolizumab,
testing is a companion diagnostic for nivolumab and
atezolizumab, testing is complementary
I, A
Planchard D, et al. Ann Oncol. 2018;29(suppl 4):iv192-iv237.

5. No. at risk
Pembrolizumab 154 136 121 112 106 96 89 85 78 73 73 69 66 64 50 24 5
Chemotherapy 151 124 108 88 80 69 61 56 48 46 44 37 35 33 24 14 6
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
0
10
20
30
40
50
60
70
80
90
100
Time, months
OverallSurvival,%
51.7%
34.2% 43.7%
24.9%
41.0%
23.5%
Median (95% CI)
26.3 mo (18.3–40.4 mo)
14.2 mo (9.8–18.3 mo)
KN024 OS: updated analysis
CT vs pembrolizumab N
Events, n
(%)
HR
(95% CI)
Pembrolizumaba 154 97 (63)
0.65
(0.50–0.86)
P = 0.001b
Chemotherapy 151 113 (75)
aEffective crossover rate from chemotherapy to anti–PD-L1 therapy, 64.9% (98 patients in total crossed over to anti-PD-[L]1 therapy: 83 patients crossed over to pembrolizumab during the study, and 21
patients received subsequent anti–PD-L1 therapy outside of crossover; patients may have received >1 subsequent anti–PD-L1 therapy). bNominal P value.
Data cutoff: February 15, 2019. Reck WCLC 19

6. Medicina de precisión en ADC de pulmón estadio IV (como ejemplo)
ALEX trial Mok ESMO 19FLAURA trial Ramalingan ESMO 19

7. Popat ESMO 18, Camidge NEJM 18, Peters NEJM 17
Medicina de precisión en ADC de pulmón estadio IV (como ejemplo)
Intracranial efficacy

8. Medicina de precisión en ADC de pulmón estadio IV (como ejemplo)
RET

9. Medicina de precisión en ADC de pulmón estadio IV (como ejemplo)
NTRK

10. Medicina de precisión en ADC de pulmón estadio IV (como ejemplo)
KRAS G12C

11. ALK: 65% RR to crizotinib;
~70% RR to 2nd-gen TKI;
Ceritinib in resistant cancers
Alectinib 1st line
MET ex14:
30-40% RR Crizotinib
Cabozantinib
HER2 mutation:
~15% RR -Afatinib;
~20% -Dacomitinib
44% -Ado Trastuzumab
BRAF (V600E):
>60% RR to
BRAF + MEK
inhibitor combo
ROS1:
70% RR to
Crizotinib
-Ceritinib
HER2 mutation
EGFR: RR>70%
to 1st-2nd–Gen TKIs;
~60% RR to 3rd-Gen TKIs
in resistant cancers
Growing number of oncogene-driven NSCLCs with active targeted therapies
RET:
Cabozantinib:
RR=4%
Alectinib
NTRK:
Larotrectinib
71% RR
MET ex14
Capmatinib 60% RR
Tepotinib 59% RR
KRAS G12C
AMG510
48% (11/23)
responders
LOXO-292:
RR=77%
BLU-667:
RR = 50%

13. Single gene testing vs NGS

15. NGS en la práctica clínica
• Diferentes metodologías
üSensibilidad y especificidad del método escogido
(sobre todo para fusiones)
• Se deben incluir los marcadores relevantes
para la práctica clínica
• Material necesario para determinación
• Turnaround times
üDepende del número de test que se hagan
üImportante para no duplicar determinaciones
• Evaluación de resultados y control de calidad

16. Determinaciones moleculares en biopsia liquida
• Standard en algunas situaciones clínicas
üNecesidad de re-biopsia por material
escaso
üDeterminación de mecanismos de
resistencia
• Varias tecnologías, distintas
sensibilidades y especificidades
• Incluso mayores retos que con los
marcadores en tumor, dificultades claras
en el acceso
• Gold standard en el futuro próximo

17. Determinaciones moleculares en biopsia liquida

18. The NGS era
• A highly competitive field!
Available at companies’ websites

19. Medicina de precisión, implementación
• Three goals that need to be achieved for precision medicine to be made widely available
üEducation
üInformation
üAccess
• Physicians need to learn how to interpret and treat different genomic changes
• Electronic health records must support the rapid and meaningful dissemination of
information to providers at the point of care
• Genetic testing and counseling need to be covered by payers, so people with cancer have
access to the necessary treatments

20. Precision oncology and its potential to widen disparities
• Molecular information leads to clinical trials
üThe RET example, 2 randomized trials in 1L, local testing
• Payers and funding agencies have important and multifaceted roles in precision medicine

21. • Registro tumores torácicos, estudio observacional,
multicéntrico en España
• 7.872 pacientes, 58 centros (agosto 16-diciembre 18)
• 3.446 pacientes (52.2%) tenían un E-IV en el diagnóstico
• En pacientes con histología no escamosa y E-IV, EGFR y
ALK se realizó en 92% y 79% respectivamente
• Hace tan solo 2 años la determinación de ALK se realizaba
solamente en el 40% de los pacientes
• La determinación de ROS1 se realizó en el 20% de los
casos
Rodriguez-Abreu ESMO, SEOM 19

23. Biomarker testing in Spain
• La estrategias de determinación de marcadores se definen en cada hospital
• Financiación parcialmente dependiente de la industria farmacéutica
üSostenible en el tiempo
üAfecta el precio de medicamentos?
üComo incorporar nuevos marcadores?
• No información
üTiempo de respuesta
üPacientes con determinación válida
üParticipación en controles de calidad
üCoste
üDatos de vida real

24. Development of an Amplicon-seq panel for VHIO prescreening
We amplify 350 regions (800 amplicons) in 61 genes frequently mutated in cancer with a matched
approved/ in clinical trials targeted therapy (oncogenes and tumor supressors):
The panel is especially suited for FFPE
derived DNA and cfDNA.
There is flexibility, new genes or
regions may be included in the panel.
Mutation detection is 5-fold
compared to Sequenom panels.
Sequenom v3: 288 loci in 24 oncogenes
VHIO-Card v3: 30000 loci in 61 genes
Genes in VHIO-Card v3
ABL1 ERBB3 IDH1 MYC RNF43
AKT1 ESR1 IDH2 NF2 RUNX1
AKT2 FBXW7 JAK1 NOTCH1 SMAD4
AKT3 FGFR1 JAK3 NOTCH4 SMARCB1
ALK FGFR2 KIT NRAS SRC
APC FGFR3 KRAS PDGFRA STK11
BRAF FGFR4 MAG PIK3CA TP53
CDH1 FLT3 MAP2K1 PIK3R1 TSC1
CDKN2A GATA1
MET + E14
splice site
PIK3R5
TSC2
CSF1R GNA11 MLH1 PTCH1
VHL
CTNNB1 GNAQ MPL PTEN
ZNRF3
EGFR GNAS MSH6 RB1 BRCA1
ERBB2 HRAS MTOR RET BRCA2
Courtesy of A Vivancos

25. Fusion detection in the Prescreening program: nCounter technology
Nanostring
VHIO Fusion Panel
qPCR / FISH
1-SCREEN
2-VALIDATE
ALK, RET, ROS1, NTRKs, MET
Gene fusion VHIO nCounter (Nanostring) Mar'16
VHIO Fusion panel v4
EML4 E13-ALK E20 CD44 E1-FGFR2 E3 EIF3E E5-RSPO2_E1 Gene expression:
EML4 E20-ALK E20 SLC45A3 E1-FGFR2 E2 EIF3E E5-RSPO2 E2 EGFR
EML4 E6-ALK E20 FGFR3 E17-AES E2 PTPRK E13-RSPO3 E2 ERBB2
AKAP9 E8-BRAF E9 FGFR3 E17-ELAVL3 E2 PTPRK E1-RSPO3 E2 ERBB3
KIAA1549 E15-BRAF E9 FGFR3 E17-LETM1 intron10 PTPRK E2-RSPO3 E2 ERBB4
KIAA1549 E14-BRAF E9 FGFR3 E17 intron-TACC3 E4 PTPRK E6-RSPO3 E2 ESR1
KIAA1549 E15-BRAF E11 FGFR3 E17-BAIAP2L1 E2 PTPRK E7-RSPO3 E2 FGF19
BAG4 E2-FGFR1 E6 FGFR3 E17-TACC3 E4 NAV2 E1-TCF7L1 E4 FGF3
ERLIN2 E10-FGFR1 E4 FGFR3 E17-TACC3 E8 NAV2 E3-TCF7L1 E4 FGF4
FGFR1 E17-TACC1 E7 FGFR3 E17-TACC3 E10 VTI1A E2-TCF7L2 E4 FGFR1
FGFR2 E17-AFF3 E8 FGFR3 E17-TACC3 E11 VTI1A E2-TCF7L2 E5 FGFR2
FGFR2 E17-AHCYL1 E2 RANBP17 E28-FGFR3 E14 VTI1A E2-TCF7L2 E6 FGFR3
FGFR2 E17-ATE1 E12 EGFR vIII (E1-E8) VTI1A E3-TCF7L2 E4 FGFR4
FGFR2 E17-BICC1 E3 MET E13-E15 VTI1A E3-TCF7L2 E5 IRS2
FGFR2 E17-CASP7 E4 LMNA E2- NTRK1 E10 VTI1A E3-TCF7L2 E6 MET
FGFR2 E17-CCDC147 E2 LMNA E2- NTRK1 E11 VTI1A E4-TCF7L2 E4 NOTCH1
FGFR2 E17-CIT E23 LMNA E10- NTRK1 E12 VTI1A E4-TCF7L2 E5 NOTCH2
FGFR2 E17-FAM76A E2 LMNA E10- NTRK1 E13 VTI1A E4-TCF7L2 E6 NOTCH3
FGFR2 E17-GAB2 E2 TPM3 E7-NTRK1 E10 CCDC6 E1-RET E12 NOTCH4
FGFR2 E17-KIAA1967 E5 TPR E21-NTRK1 E10 KIF5B E15-RET E12 NTRK1
FGFR2 E17-MCU E2 ETV6 E5-NTRK3 E15 KIF5B E16-RET E12 NTRK2
FGFR2 E17-OFD1 E3 ETV6 E4-NTRK3 E14 KIF5B E22-RET E12 NTRK3
FGFR2 E17-VCL E15 PAX8 E8-PPARG E2 NCOA4 E8-RET E12 PDGFRA
FGFR2 E2-WDR11 E20 PAX8 E9-PPARG E2 PRKAR1A E7-RET E12 RSPO1
FGFR2 E16-KIAA1598 E7 PAX8 E10-PPARG E2 CD74 E6-ROS1 E34 RSPO2
FGFR2 E16-TACC3 E11 EIF3E E1-RSPO2_E1 EZR E10-ROS1 E34 RSPO3
FGFR2 E17-NOL4 E7 EIF3E E1-RSPO2_E2 SLC34A2 E4-ROS1 E32 RSPO4
Courtesy of A Vivancos

26. 26
March
2012 –
Kick off
July 2012 –
Application
March 2013 –
ENAC Audit
July 2013 –
Accreditation
April 2016
NGS
Amplicon-
seq
CANCER GENOMICS LAB
MOLECULAR PATHOLOGY LAB

27. 259 298 313 305
379 382
452 484
572
673 675
795
843
771
979
1129 1096
1502
0
200
400
600
800
1000
1200
1400
1600
2000 2001 2002 2003 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Medical Oncology Hematology Radiotherapy
1374
111
15
Patients included in therapeutic clinical trials per year

28. Vall d’Hebron: Tumores torácicos, pacientes incluidos en ensayos clínicos
2015 2016 2017 2018
Total 161 244 202 250
Fase I-Basket 53 51 66 78
Fase II-III 108 193 136 172

29. EC thoracic malignancies 2018
• Estadio IV inmunoterapia 1 línea: 59 pacientes
• Estado IV inmunoterapia 2 línea y sucesivas: 72 pacientes
• Estadio I-III: 25 pacientes
• EGFR-mut: 12 pacientes
• ALK: 5 pacientes
• MET-exon 14: 4 pacientes
• ROS/RET: 1 paciente
ü 101 NSCLC pacientes determinación Guardant en plasma
ü 75 NSCLC pacientes determinación F1 en plasma

30. Lung cancer biomarkers in Europe and US
• Italy, EGFR/ALK/PDL1 reimbursed by Health system
• National System in France, Netherlands, Germany
ASCO 18

31. France organisation of molecular centres for personalised medicine
u Perform molecular
testing for all patients;
u Whatever the
healthcare institution
status (public hospitals,
private hospitals…);
u Perform high quality
tests;
u leukemia, solid tumours
Objectives
u Partnerships between
several laboratories
located in University
hospitals and cancer
centers
u Regional organization
u Cooperation between
pathologists and
biologists
28 regional centres
2006: The French Genetic Centers Network
Provides nationwide molecular diagnostic tests
Leaded by:
DGOS (Health Ministery)
INCa (French NCI)
Courtesy of Prof. Besse

32. France organisation of molecular centres for personalised medicine
A pan-cancer network
Analyses per year: >125,000 (2016)
Available at www.e-cancer.fr
Biomarker Cancer type Targeted therapies #Patients
KIT mutations GIST Imatinib 1 218
HER2 amplification Breast and gastric cancers
Trastuzumab, lapatinib, pertuzumab, trastuzumab
emtansine
10 832 (B)
770 (G)
RAS mutations Colorectal cancer Panitumumab, cetuximab 21 923
EGFR mutations Lung cancer Gefitinib, erlotinib, afatinib, osimertinib 28 563
ALK translocations Lung cancer Crizotinib, ceritinib, alectinib 23 434
ROS1 translocations Lung cancer Crizotinib 17 680
BRAFV600 mutation Melanoma Vemurafenib, dabrafenib, trametinib, cobimetinib 5 583
BCR-ABL translocation
Chronic Myeloid Leukaemia/
Acute Lymphoblastic Leukaemia
Imatinib, nilotinib, dasatinib, ponatinib, bosutinib 9 570
17p deletion / TP53 mutation Chronic Lymphocytic Leukaemia Ibrutinib, idelalisib
2 857
1 808
BRCA mutation Ovarian cancer Olaparib 1 608
Courtesy of Prof. Barlesi and Prof Besse

33. France organisation of molecular centres for personalised medicine
The NGS era
•Launched in 2015
• Tested since 2013
• Half of centers in 2016
Ø12,000 tumors
sequenced in 2016
• All centers in 2017
• Iso15189 certified
Available at www.e-cancer.fr
Minimal NGS panel as per French NCI guidelines
Courtesy of Prof. Barlesi and Prof Besse

34. Implementation of national External Quality Assessment rounds for
the main tests in the 28 centres
u Oncohematology
u Solid tumours
France organisation of molecular centres for personalised medicine
Ensure the best quality for molecular tests
Implementation of a quality assurance program
Fx
Towards ISO 15189 accreditation
Gen&tiss : a NATIONAL PROGRAM and A
yearly practice survey
Courtesy of E.Rouleau and Prof Besse

35. France organisation of molecular centres for personalised medicine
Assessment
NGS diffusion and its routine application
within 48 labs from 2013 to 2016 (projection)
Average turnaround time for each scheme
(common time for 2014) from
receiving the slides to validate the genotyping.
NGS techniques Turnaround time
Courtesy of E.Rouleau and Prof Besse

36. Germany: challenges for the implementation of personalized cancer care
into clinical routine
• Implementation of high-quality molecular multiplex diagnostics
• State-of-the-art consultation with regard to therapeutic consequences
• Rapid innovation transfer from the academic centers into broad cancer patient care
• Evaluation of post-approval and off-label personalized therapies
• Cost – reimbursement
Courtesy of Prof Wolf

37. Speakers: J.Wolf, R.Büttner
Scientific coordination: A Kron
Hospitals and
private practice-
based
oncologists
Center for Integrated Oncology
University Hospital Cologne
Inst. of Pathology &
NGM-Study Center
Allocation to
clinical trials
Evaluation of
personalized therapy:
- molecular epidemiology
- outcome
- costs
tumor tissue
Cancer Registry
genotype
+ recommendation
Comprehensive
Genotyping
+
Consultation
+
Coordination
Germany: Network Genomic Medicine: Founded in 2010 with
funding from Ministry for Innovation and Research
Translational Genomic
Research
Health Insurance
Companies
Patient advocacy
groups
Courtesy of Prof Wolf

38. Germany: Nationwide extension of NGM:
the national Network Genomic Medicine (nNGM) Lung Cancer
Oncology Centers of Excellence
Berlin
Dresden
Düsseldorf
Erlangen
Essen
Frankfurt
Freiburg
Hamburg
Heidelberg
Köln/Bonn
Mainz
München (LMU/TU)
Tübingen-Stuttgart
Ulm
Würzburg
Speakers: J.Wolf, R.Büttner, C.v.Kalle
Head of nNGM office Cologne: A.Kron Courtesy of Prof Wolf

39. partner sites
Germany
Long-term goal:
Integrate data for all patients over time
to improve therapeutic
recommendations
(evidence-generation)
nNGM
office
health insurance
companies
NGM pathologies
(multiplex diagnostics)
external pathologies
(primary diagnostics)
research partnerships lung cancer patients
Courtesy of Prof Wolf

40. Speakers: J.Wolf, M.Sebastian, M.Thomas
Germany
TF 4: Clinical Trials
• Status quo assessment of trial
activity in nNGM centers
> ongoing harmonization
• Central Clinical Trial Registry
in collaboration with DKTK
> www.nngm.de
• 1st nNGM trial launched in
Q1 2019: FGFR-inhibition in
squamous cell lung cancer
(phase II IIT FIND)
45
ROS1fus
, BRAF-V600mut
, RETfus
, KRASmut
, NRG-1fus
, NTRK 1-3fus
Fig. 6: -
Courtesy of Prof Wolf

42. Precision medicine…some final thoughts
• Genomic testing: a true therapeutic revolution
ü If you don´t look for genetic alterations…forget the concept of precision
medicine
ü Tumor tissue availability
ü Role of liquid biopsy…the immediate present/future
• Drug access, clinical trials
• Education, collaboration, organization, validation, equity, evaluation…

43. Gracias
efelip@vhebron.net
efelip@vhio.net