NorthWest Biotherapeutics Inc (NWBO)

[ae kusterer]

https://www.youtube.com/watch?v=BWwdnedw_PA
well good afternoon everybody I think you're going to need your headsets or maybe you don't
0:09
so thank you for coming um ladies gentlemen friends colleagues ex-coliques it's really exciting to
0:17
again be here at Esco and being able to present some of her work to you
0:22
um today we really have three topics that all tied together I think in a very nice fashion and I'll walk you through
0:29
those um and and there really are sort of three separate topics one is the mechanism of action of DC facts we've
0:36
talked about that a little bit in the past but we haven't really filled you in on all the work that we've been doing to
0:42
demonstrate a DC facts indeed has all the characteristics that it needs to induce the immunological and clinical
0:49
effects that we're all seeing and we're expecting then I'll highlight the immunological
0:54
effects that we're actually seeing in patients and I'll talk a little bit in depth about the clinical trial external
1:00
controls methodology and I truly believe that we're at the beginning of a revolution here where hopefully five or
1:07
ten years from now there will be no more need for placebo-controlled clinical trials because really in the end once
1:15
you know sort of what the outcome is of a disease especially if the patients are given standard of Care at some point
1:21
there will be no more need for for Placebo controls and all patients will be able to participate in the new
1:27
inventive treatments that roar coming up with and we think that's an important development and we're happy to be one of
1:34
the leaders in that particular field um this is a the obligatory disclaimer
1:41
um don't read this whole thing um this is the overview of the presentation
1:46
um I'll first give an introduction about dcfax l a lot of you are familiar with the product
1:52
um but I still think it's useful to give you a bit of an introduction because that leads into the rest of the
1:57
presentation the mechanism of action I'll go into some detail and therefore first I will
2:04
again give a bit of an introduction on what the mechanism action should be and then I'll show you that it actually
2:10
works in the way that we expect um again for some of you that will be a bit repetitious because you may be
2:16
familiar with it but because of some of the detailed um explanations I'm giving later I think is still useful to go
2:21
through that the immune monitoring section is entirely new to everybody here in the audience and then I'll talk
2:28
um rather extensively about the use of external controls and clinical trials and some of the things that we did that
2:34
we believe are important also for other people to follow so that the design can
2:39
be and the execution can be sufficiently rigorous and well controlled I'll talk about two of our compassionate
2:45
use cases and make some observations about that and then of course I'll end with some general conclusions and a
2:51
broader perspective so what is dcfax l dcfx l is composed of
2:57
vector of autologous dendritic cells that are loaded with autologous tumor cell lysate so both components are
3:03
autolicus the tumor cell lysate is the source of the antigens they come from the patient's own tumor we use the tumor
3:10
tissue that's resected at the time of surgery to make the lysate so it comes from the patient it goes back to the
3:15
patient the dendritic cells come from the white cells that are in the blood we obtained that through a leukopheresis
3:21
and we need that because the immune system of the dendritic cells needs to match with the immune system of the
3:27
patients once we get it back so if you give dendritic cells from somebody else to a patient the likelihood is that that
3:34
match will not be there and therefore you don't get the stimulation of the immune response that you need
3:39
the tumor lysates we prefer that very much over using a limited number of antigens because tumor lysate is a broad
3:46
spectrum source of antigens every single antigen that's present in the tumor will be present in that lysate and I'll show
3:53
to you the evidence um why that is actually important um for one the reason is that at least we
4:00
presume that it makes it more difficult for the tumor to escape from the immune attack that we're targeting that we're
4:07
targeting but um of course therefore we need to show that we actually have a broad array of
4:14
antigens but also the patients are responding to a broad array of antigens and I'll show both of those factors to
4:19
you later in this presentation and of course the tumor lysate provides the correct antigens and not the wrong
4:25
antigens it's intended as active in treatment following surgery we need to tumor cell lysates from the from the resected tumor
4:32
to make the treatment and we have used it today to treat almost 600 patients with GBM both in
4:38
clinical trials and in compassionate use programs and also tensor patients with other cancers including Merkel cell
4:43
carcinoma breast cancer thyroid cancer and several others the trial results from the phase 3 trial
4:51
have now been published in John oncology with Dr Linda Liao from UCLA's the first author showing both clinically
4:58
meaningful and statistically significant extension of survival in both newly diagnosed and recurrent TBM and just to
5:05
tell you a little bit about the manufacturing of which I gave long presentation last year and Manufacturing
5:10
takes about eight days provides several years of doses that are frozen down and can then be shipped as an off-the-shelf
5:16
treatment to patients over time and that's exactly how we did it in the clinical trial
5:22
so how does how is dcfax else supposed to work how do the dendritic cells
5:28
actually interact with the T cells and induce the immune response that were after leading in the end to the
5:33
induction of cytotoxic T cells that can travel to the tumor and kill tumor cells one of the Hallmarks of this mechanism
5:41
of action is the so-called multiplier effect one dendritic cell leads to hundreds and hundreds of T cells that
5:47
are responsive to the tumors and how does that actually work so the dendritic cell
5:52
takes up and oh this pointer doesn't oh there it is takes up and presents the
5:59
tumor Target proteins from the lysate in the context of its own MHC molecules and
6:04
I'm not going to talk about MHC but that MHC word is important because that's how the antigens are being presented
6:11
then the antigens are presented to the anti-cancer T cells that become
6:17
activated because the resting anti-cancer T cells attached to the dendritic cells through a number of
6:24
molecules called coal stimulatory molecules those activated anti-cancer T cells then divide rapidly that's the multiplier
6:31
effect and acquire a capability to kill tumor cells something we call cytotoxic
6:37
activity um and then those multiplied T cells
6:42
then can travel anywhere including to the brain um activated T cells are one of the few
6:48
agents that can actually travel across the blood-brain barrier if you've heard about drug development for glioblastoma
6:53
you know that the blood-brain barrier is a huge hindrance towards the development of drugs because most drugs well
7:00
actually you can inject them you can ingest them but they won't get to the brain whereas activated T cells travel
7:06
everywhere including to the brain and including to the tumor and we have evidence I'll show you a picture that's
7:11
actually end up there and start killing the tumor cells so let's first talk about antigen uptake
7:18
and presentation because yes we incubate the neurotic cells with the lysate that contains the peptides and the antigens
7:24
but how do we actually know that those peptides and antigens are taken up by the dendritic cells and then presented
7:31
on their surface and this is a series of experiments that show you how we actually have garretted information how
7:37
we know that the information I just told you is actually correct so we did proteomics analyzes
7:44
on the following materials to determine protein content and diversity a very important key word here
7:50
um we did proteomics I.E proteomics means that you characterize every single Protein that's in that particular
7:56
preparation so proteomics on the tumor lysate will tell you every single Protein that's in the tumor lysate we
8:03
used unpost dendritic cells so tumor cell dendritic cells never incubate a tumor lysate but also dendritic cells
8:09
that were Pulse was tumor lysate and then we did another trick we took the peptides off of those dendritic cells
8:16
and asked what's in those peptides um because then we know what's actually being presented
8:22
so from a single sample this is one experiment that we did we found that there were 25
8:28
000 MHC class 1 Associated peptides those are short peptides that are important for cell killing we also found
8:35
almost 13 000 Class 2 Associated peptides those are more important in inducing T Cell help helper T cells are
8:43
cytotoxic T cells interact to induce the tumor killing effect of those 25 000
8:50
a lot of those were upregulated on the dendritic cells after pulsing suggesting that they actually came from the tumor
8:56
lysate and the same is true for seven thousand or more that were more abundant on dendritic cells after pulsing
9:03
that's not everything because then we found that we had 400 399 two Mercedes
9:11
tumor Associated peptides 400 different tumor-associated peptides so these are
9:16
all presented on the dendritic cells they're all presented to the immune system the immune system now has the
9:22
capability to react to every single one of those antigens so we truly do get a broad spectrum immune response just by
9:28
the function of using the tumor lysate to post the dendritic cells rather than what has been tried many other times
9:35
using a single antigen or a small repertoire of antigens and some of those peptides that you can see that are
9:41
either two full three-fold five-fold enriched on those dendritic cells are listed here and these are just amino
9:47
acid sequences so don't expect you to read those and these are just examples
9:54
for Mac Class 2 like I said important for the interaction with the helper T cells there were 220 and these are the
10:01
ones that are detected there is a certain limit of detection level of detection as well here and anything
10:06
below that limit we won't be able to detect but they can still be there so this is a low estimate of the number of
10:12
tumors Associated peptides that are presented by these dendritic cells remember these are the ones that were
10:18
taken off the dendritic cells and these are the ones that are actually presented and we've got a few examples here again
10:23
as well with the degree of upregulation on it on a two log scale
10:29
so where does that take us these are some antigens that we found because once
10:35
you have those amino acid sequences you can go to a database and you ask where does that amino acid sequence come from
10:40
which protein was that derived from and we found not to our surprise that there
10:46
were peptides that came from proteins that were previously identified in glioblastoma okay so you take a tumor
10:52
lysate from glioblastoma you put it on those dendritic cells you find antigens that were already known to be associated
10:58
with dbm interesting exciting not that novel perhaps
11:04
um some of those is an inhibitory protein known for GBM one I really love
11:09
this name the disheveled associate activator of morphogenesis number two there must be a number one out there
11:14
somewhere as well um which promotes gliomogenesis so these are known MHC associate TBM Associated
11:22
peptides so what else have we found we also found examples of peptides that
11:28
were known to be associated with other tumors so if we had taken a repertoire of known
11:35
GBM proteins we would have missed these because we would have never anticipated that these
11:40
would be presented by dendritic cells and that these might be as relevant for the activation of the immune system
11:46
against dbm as the ones that were known to be associated with GBM my motto is
11:52
always don't pretend to know more than you do and this was something that we truly did not know before
11:58
um there's this this dislike Ace that's expressed in multiple cancers um
12:04
a protein associated with propagnosis ovarian cancer so
12:10
attack against these tumors might attack TBM as well and probably will attack TBM
12:15
as well so a few of the summary observations are that the let's say preparations releases
12:22
multiple cancer-related proteins from which these peptides can be processed
12:28
I'm sorry like many of you I'm still recovering from a cold
12:36
cells pickup process and present hundreds of tumor-specific peptides to T cells literally hundreds imagine now
12:43
that you have that you're a tumor and you're attacked from a hundred different sites it's almost impossible to down
12:48
regulate those targets and escape from that immune pressure which is why we think um the product works as well as it does
12:56
it presents peptides from both known GBM Associated tumor antigens and tumor antigens which have not been reported in
13:02
GBM before and the presentation of these peptides not only through class one
13:07
remember important for cytotoxic T cells but also through Class 2 to CD4 T cells
13:13
suggests that we also get T-cell memory responses in Vivo something of course
13:19
that we believe is incredibly important and a chronic disease like TBM where you
13:24
can't just eradicate it at once you needed ongoing response that continues to hammer away
13:31
at the tumor you need to set up that battle in the brain where the immune system can continue to eradicate tumor
13:37
cells because they will continue to replicate otherwise so this immune memory is actually critical for the um
13:42
for the potential success so now we have these in the context of
13:48
MHC Class 2 and MHC class one we have these peptides that interact with the T Cell receptor but that's not sufficient
13:55
for a dendritic cell to activate a T Cell we need at least two signals in fact we need three
14:00
we'll only talk about two today we need the TC receptor with the
14:06
multiple peptide antigens we need to demonstrated that happens but we also need co-stimulatory signals we have cd40
14:12
here we have cd80 here cd82 here and they're they're given different names
14:17
here but they're the same proteins and we need those because the T Cell like I said needs at
14:24
least two signals to become activated so what do we know about those
14:30
what you see here on these little plots um this is an indicator for the size of
14:36
the cells it's called forward scatter on the x-axis and this is the degree to which the cell's label positive with the
14:43
different markers that we have here expressed on the y-axis in this case it's cd40 here at cd141 so if they're
14:51
sitting in the top right corner you can see that they're large cells they're moving in this direction and they're
14:56
positive for this particular marker so for cd40 cd141 cd82
15:03
cd86 MHC class 2. we have these pictures we have it for many more of these particular kind of
15:10
markers that are so critical for those interactions to have a positive outcome so here you see the function of those
15:16
molecules cd40 add tracks with cd40 ligand cd41 141 is directly involved in antigen
15:24
presentation cd82 stabilize the dendritic cells interactions the longer dose interactions take place
15:31
in the What's called the immunological synapse the more the stronger the T cells will be activated so all of these
15:38
molecules are critical for this for the effect that we're seeing and then their cd83 which is a marker
15:44
for Activation or maturation of dendritic cells immature and dendritic cells don't activate the immune response
15:50
very well mature or activate dendritic cells do and we showed it ourselves do
15:56
Express cd83 as expected so then the question is okay now we've
16:01
got all this right we've got the peptides on the class 1 and Class 2 molecules we got to go stimulatory molecules
16:10
what has actually happened when you put those cells together and you stimulate and re-stimulate them a few times in
16:15
vitro can we now actually generate cytotoxic T cells like we're hoping that we're going to be doing in the patient
16:22
the short answer to that is yes these are complicated experiments this
16:27
was done by Daphne friends and Mark Odell and you can I'll just make this
16:33
relatively short but you can see that if you have all the right components here which is the lysate from the mcf7 cells
16:39
the matured and ridic cells and you have the T cells present that you get a degree of cell killing that kills 60 of
16:46
the cells it doesn't work if you leave out the lysate it doesn't work if you leave out
16:52
to T cells it also works if you use only the cd8 positive T cells so you don't need CD4 cells at the end of the cell
16:59
killing process you do need them to get to that stage and you can do it at essay for either 16
17:05
hours or 24 hours at 24 hours your background becomes a little bit more disturbing so we tend to do these in
17:11
relatively short period of time like 16 hours so we find that killing of target cells
17:17
is observed if the T cells were stimulated by dendritic cells loaded because two were cell lysate
17:23
so yes we have all the components now we show that to actually work the way that they're supposed to work
17:29
but that doesn't mean they're forgetting a lot of T cells yet um this is work done by Lakeland Andrew
17:35
at flashworks the company that was helping us present last year and they're both here in the audience
17:42
this is what we call the multiplier effect or at least it's evidence of the multiplier effect whether it is demultiplier effect we really don't know
17:49
at this point in time but is strongly suggestive what this is is a T-cell stimulation
17:55
assay where T cells are dividing and every time they divide they move a little bit to the left in the Spectrum
18:01
this is a die that gets diluted so every generation of T cells has its
18:06
dye diluted by two folds and therefore you get all these multiple Peaks and you see that there's like first generation second generation third generation
18:13
fourth et cetera et cetera et cetera for this particular question we're mostly interested in the late generation T
18:19
cells because those are the ones that have undergrown the most efficient so they have to most daughter cells at this point
18:24
so what do we see when we do this Essay with T cells loaded with lysate a dender
18:31
cells loaded with lysate or dynamitic cells not load of his lysate we see
18:36
that the ninetic cells loaded with lysate these ones here generate significantly more of these late
18:42
generation T cells so there is an additional T Cell similar stimulatory
18:49
capacity that we still need to identify and still need to understand but it's something that we observed and we think
18:54
that is very interesting and could be at least in part responsible or co-responsible for the multiplier effect
19:00
that I told you is so important for the mechanism of action so the conclusion is that these lights are low dendritic
19:06
cells have acquired this additional T Cell stimulator capacity which result in more late generation T cells that we
19:13
need to fight the tumor more is better in this particular case in summary
19:19
the dendritic cells in dcfax L expressed or regular requisites co-stimulatory molecules to perform this productive
19:25
interaction they also Express cd141 a molecule involved in effective antigen presentation to T cells
19:32
if we mix those dendritic cells the load of once with the tumor lysate then we have this additional T Cell stimulatory
19:39
capacity and we can then induce killer T cells the CTL cytotoxic T lymphocytes
19:46
and the combined these effects enhance the multiplier effect or are responsible
19:51
for the multiplier effect in conclusion mechanism action studies
19:58
demonstrate uptake presentation for broad range of antigens which is important to prevent tumor escape and I
20:05
will net I will next talk about immune monitoring data that demonstrate activation of a white repertoire
20:10
repertoire of T cells which can travel to the brain this is data that we have not shown to you before
20:16
so what is in people immune monitoring what we wanted to know is when we inject
20:23
eastendritic cells into the patient what happens to the T Cell response are we inducing a T Cell response D hypothesis
20:30
is yes that we are Linda Liao has shown that in the past that indeed in her early stage trials
20:36
this was actually this this actually happened but that's really proof of concept that is okay if I do this and I
20:42
do some complicated experiments then I can demonstrate it actually happens what we did here
20:47
was take all of the T cells from a patient out of the blood are not all the
20:53
T cells but in let's say several million T cells and ask
20:58
um are they expanded are they not expanded has these are expansion occurred like we expect what is
21:03
happening in these patients here's the experiment that we did
21:13
broad spectrum immunological stimulatory approach with all the tumor antigens
21:18
that I just explained we also use an analysis that allows monitoring of the entirety cell response
21:24
as opposed to monitoring response to a single antigen single antigen is easy to do this is
21:29
hard to do okay now what you need to realize is each T
21:35
cell that emerges from the thymus during autology on totally during development has a unique T Cell receptor DNA
21:41
sequence so um before you get hit with any pathogen or any infection as a young kid you have
21:49
all these T cells circulating and whenever you get an infection or another stimulation the T cells that respond to that
21:55
pathogen are the ones that start to expand and that's how you can fight an infection that's how you fight the
22:01
Coronavirus for instance so that's a normal process that happens
22:07
during a trumpet infection we are asking the question does it also happen in response to dcfx the hypothesis was that
22:14
it did but of course when a T Cell divides in response to team stimulus that specific
22:20
T-cell DNA sequence becomes more numerous it's a D cell has specific DNA sequence
22:25
T Cell receptor and multiplies a thousand times you now have a thousand so sequencing all the T cell receptors
22:31
allows you to identify newly expanded T cell clones that weren't there to begin with OR identify T cell clones that have
22:38
further expanded like from Baseline here's some of the data from three
22:44
patients what you see here is the number of expanded T-cell clones between Baseline
22:51
and month 4 or Baseline and month eight now remember we give several immunizations we give day 0 day 10 day
23:00
20 month to month four month eight and so and then we measure at discrete type points what happened to the T Cell
23:06
repertoire and here we measure the number of expanded T cell clones and you can see that between Baseline and month
23:13
8 800 T cell clones have expanded in this particular patient more
23:18
interestingly about 250 of those expanded ones had never been seen before in that patient so they weren't there at
23:25
Baseline at least not at a detectable level they're now very detectable at month eight this is a newly induced
23:31
T-cell response this is enhancement of a T-cell response that was already existing we think that both are
23:37
important glioblastoma is not known to be a very immunotinic tumor but it
23:42
doesn't mean that it does not induce a bit of a T-cell response already it's sitting in the brain it's well protected
23:49
from the immune system but that protection is not completely 100 black and white so it's not surprising that
23:55
there are already T cell clones present in the patient that we are expanding once we immunize it with the lysate from
24:02
the same tumor that the patient already carried in his brain patient too and also about 800 and this patient is
24:09
really taking the cape it's more than 1200 expanded T cell clones of which 500
24:15
or more are new that weren't seen at Baseline so these bars represent a total number
24:21
of expanded T cell clones um as well as the uh the pre-existing
24:26
and yeah thank you I'm getting my medication here
24:32
I need to take your drugs that's what they tell me
24:39
now the background in patients where we would not be doing this is roughly 2 to 20 clones I'll show you
24:46
a picture to illustrate that so this is the background simulation this is what's happening when you give
24:53
dcfax here's a more sort of better illustration of the T-cell Dynamics
25:00
um you're all probably old enough to remember the old 1980s commercial this
25:05
is your brain this is your brain on drugs well this is your blood and this is your blood on DCF XL
25:11
sorry I have to throw that in there um here you see so an orange here you
25:16
see expanded T cell clones and here you see the converse it's contracted to T Cell clone so T cell clones that were
25:23
detectable at Baseline without no detected in slow and smaller numbers they don't disappear they get out
25:29
competed by the ones that are expanding and so you see in a normal patient between sort of Time Zero and month four
25:36
you see basically almost nothing happening there's one newly expanded tesl clones here there's two that are
25:42
Contracting here you see literally hundreds that are expanding and the ones here on the left
25:47
are all the new ones and here you see the ones that are um that are less numerous following the
25:53
simulation so there is a shift in the T Cell response there's a dynamic going on that results mostly in the uh generation
26:01
of a new immune response against the tumor antigens presented by DC hacks
26:06
oops sorry here's example three patients and these two are very strong responders
26:13
you can see that all these new clones here all these expanded clones here that were already existing same participation
26:19
this patient like any drug is a slightly less strong responder you still see new T cell clones you still see expanded T
26:25
cell clones it's still quite different from the patient where there had been no stimulation it's not as potent and not
26:32
as powerful and of course we're very interested why some patients respond stronger than others this is true for
26:38
any drug and every drug so it's not a surprising finding but we think it's very interesting finding this by the way
26:44
is a comparison between Baseline and months eight
26:49
very exciting once you have these two receptor sequence you can go to a database and you ask oh the T Cell
26:56
receptor is that known to already be associated with a T Cell response that
27:01
has already been characterized to a known antigen those algorithms and those predictions
27:06
are I would say they're they're limited um and they're only indicative at this
27:12
point in time but within that we could still make the following observations we found Tesa
27:18
responses there for potentially responding to a very broad range of antigens not surprising we give a broad
27:23
range of antigens we get a broad T-cell reaction the predicted epitopes include several
27:30
known tumor antigens surprise surprise some known to be associated associated with GBM but some
27:35
not previously identified in TBM just like we found in the proteins present presented by the dendritic cells we also
27:43
found several viral antigens both CMV and EBV and both CMP and EBV have been found in
27:50
the past to be associated with dbm so that's not a surprise either and then we found multiple molecules that we really
27:56
don't know what they do so we'll be looking into that some further as well
28:02
then this is a picture that you may have seen before it is a picture by Linda Liao that she shows a lot and I've shown it a couple times and these are um this
28:10
is a section of the brain tumor from a patient operated post-vaccination
28:15
and you can see that post vaccination you have a lot of T cells that are getting actually to the tumor there's
28:21
very few prior there's a lot after and it includes both CD4 cells and cd8 cells
28:27
so now we have the whole chain complete we know how dendritic cells work we know what they present we know how they interact with T cells we know to induce
28:34
T cells responses expansion in the patient and we now know that to actually
28:39
make it to the brain so that completes the whole sequence of events that's important for how the dendritic cells
28:44
and the specific DC facts works so just a summary of these Data before I
28:51
go to the clinical trial diesel receptor sequencing demonstrates extensive expansion of specific t-soak loans in
28:58
response to a broad repertoire of antigens and I love this quote so I put it in this was by the technician of the
29:04
company that actually did this work he said this level of colonial expansion especially of the new detective clones
29:10
provide strong evidence for a novel stimulus of the immune system during this interval I couldn't have said it
29:16
better myself so these observations together all support to postulated mechanism of
29:21
action of these defects so let me move on to the clinical trial
29:26
methodology oh just mention the date out real quick to you your most of you are familiar
29:33
with the data so I'm not going to spend much time on that um but one thing that was overlooked by
29:39
a lot of people that had the chance to read our paper in Jama oncology was that there was a lot of methodology explained
29:45
in the online only supplement but I understand that not everybody gets to the online only supplement and it also
29:52
induced introduced some new statistical methodologies that are not typically um that are typically used in health
29:58
economics analysis but not always used in analysis of clinical trial data so therefore we thought it would be useful
30:04
to spend some time on those here today now of course you are aware sorry of all
30:10
of this and primary endpoint overall survival a newly diagnosed TBM versus external controls that I will be talking
30:17
about next and the secondary endpoint is in recurrent TBM also compared to external controls
30:23
when it's good recent use external controls I won't go into that that's all extensively explained in the paper and
30:31
these are just the two observations that the findings in both newly diagnosed and recurrent disease are both clinically
30:37
meaningful and statistically significant showing extension of survival uh in this case of about three months in
30:44
this case with more than five months and a five months increase in survival in recurrent TBM
30:50
um is not something that you see every day um Mr Landmark survival data you see that
30:56
we have more than two-fold increase of the relative rate of survival at five years five-year survival in GBM is where
31:03
we are finding um in any in any case any recurrent disease 30-month survival of 21 of 11
31:12
um I.E doubling of overall survival it's quite um we would say meaningful
31:17
and significant so how did we actually do this
31:23
we enter these effects our trial originally designed as a placebo That Was Then depleted because those Placebo
31:28
patients mostly got treated with DC vacs so you can do that comparison anymore
31:34
but um so we used external controls and we got those external controls for a
31:40
newly diagnosed CBM from five other randomized clinical trials in newly diagnosed GBM where the patient's got a
31:47
treatment but the other half the basically got a placebo we use the data from those Placebo patients those
31:54
generate the external controls that then our newly diagnosed patients treated as
31:59
DC effects L are compared to now then we had a crossover arm by which the
32:06
placebo patients could also get DC vacs so we needed external controls for that as well
32:12
10 trials with recurrent GBM randomized controlled clinical trials there is no Placebo in most of those so those spaces
32:20
got standard of care mostly or physicist choice again the control pieces from those
32:26
trial form to external controls that then the recurrent patients from our trial are compared to
32:32
this is a concept that that is that is very important and um that that I wanted to explain one
32:38
more time because it's important background for the rest of the the small presentation that I still have left
32:45
now we showed you how we did the analysis there was the analysis against external
32:50
controls discipline analyzes but when you use external controls you
32:55
have to be conscious of bias by the way when you do a randomized trial you also have to be considerable biased that is something that tends to
33:01
be forgotten sometimes where people say oh it's a randomized trial and therefore it's perfect
33:07
it really isn't and um I I feel that the field has sometimes lost sight of that
33:12
um but okay we are very consciously a fact for the consciously aware of the
33:17
fact that we need to control for bias and we used four layers of methods to make sure that we had at least thought
33:23
about that and addressed it to the extent possible to minimize both known and unknown biases
33:29
and to closely match the internal control population and the dcfxl patients
33:34
so we match the comparator clinical trials from which external control population was drawn and I'll tell you
33:42
how we did that in the next slide then we validated whether the external control population was a useful and
33:49
meaningful control population by comparing it to the trials from which we
33:54
drew those individual control populations pulled them and then compared them again to the treatment arm
33:59
of those trials I'll show that to you as well then we did some sensitivity analysis because yes there are known and unknown
34:06
biases when you do it this way we are aware of that we address them and then we adjusted also for individual patient
34:12
characteristics we did not not have access to individual patient data it turns out that there's mechanisms if
34:19
you don't have that to address differences in prognostic factors it's called the maic matching adjusted
34:25
indirect comparison and we did that as well so here's how we selected those
34:31
comparator trials we used an independent expert firm and the company was not actually not involved in that we asked
34:38
the question what are trials that can provide controls that demonstrate what the outcome is with standard of care for
34:45
patients that participate in clinical trials so we set up the criteria at least the experts did 14 criteria seven
34:52
for newly nice diagnosis and seven for recurrent disease they needed to be contemporaneous we did not want to use
35:00
historical controls standard of care changes outcome in disease changes just because surgeons
35:06
get better oncology oncologists get better they had to be contemporaneous and they were
35:11
we needed the reported outcomes and Kaplan Meyer curves we needed the same standard of care now in TBM that's easy
35:18
because everybody gets these two protocols if you're on a trial you get to Stew protocol that's what you get
35:24
um it needed to be a randomized study design we need patients that matched an age to patients that we had in our trial
35:29
we need a Kepler mire Plus for available for survival and for subgroup analyzes and they had to be in the English
35:35
language the data that we got got from here are actually very high quality data because
35:41
there are very few patients lost to follow up it's not that this was muddied because some patients were never tracked
35:48
for a long time and these patients we have all the data for all these patients for a whole period of time for all of
35:53
these trials therefore the comparative studies weren't actually fit for this particular
35:58
purpose to compose an external control arm for our trial and those compared to
36:03
our trials not just the criteria for selected but the actual trials were identified prior to unblining the data
36:11
we did not know what the data looked like before the trials were identified
36:17
by the external experts this is this is a critical point
36:22
um you can't look at the data first and then say okay which trials are are a good fit for me you have to do it
36:29
beforehand and that's exactly what we did so what were these trials these are
36:35
trials that everybody knows about because these are the big trials in TBM and newly diagnosed TBM
36:41
those dense Tim isolomite trial deficism have trial a newly diagnosed the celldex
36:46
trial with Reno peppermotes the anti ETF arm peptide um trial tumor treating Fields
36:54
by by stupid all the opportune device and ICT 107 which is the Patrick when
36:59
trial number of patients in those trial add up to 1366. that is the power of
37:05
using external controls you're not stuck with 100 patients that you had in your trial that you could use as controls
37:11
you're adding tremendous statistical Power by doing this but you're also adding a much more realistic comparison
37:17
because your numbers are bigger look how tight the outcomes are in this
37:23
trial median is 16.5 months to 95 confidence interval is 16.0 to 17.5
37:29
months if you're a patient with GBM your opponent clinical trial you're given Placebo we know how long you're going to
37:35
live this is the answer and recurrent disease variation
37:40
looks to be a little bit broader but actually turns out that when you match all the numbers it really isn't 7.8
37:47
months survival for first recurrence and the 95 concentration interval 7.2 to
37:54
8.2 months so we feel that this is a very very solid
37:59
database against which you can compare the outcome of your trials
38:04
so this is the validation that I that I mentioned where we compare it now the
38:09
treatment arm this is validation of the external external external control population
38:14
actually work as an external control population we can test that by comparing
38:19
the treatment arm of these trials do the external controls as a whole through the 1366 instead of to their own internal
38:27
control population and it turns out the outcome is exactly the same every single
38:33
time all of these trials basically unfortunately were negative there was no survival advantage in any
38:39
of these trials and as you can see if you can see these statistics the hazard
38:45
ratio shows that too they're all very close to one or even above one except
38:50
for one trial the uptune trial and lo and behold that was the only trial that was positive out of all of
38:56
these trials so whether you compare that trial to its own controls or to the ECP the outcome is exactly the same and
39:02
that's true for all the other trials as well so the ECP is hereby validated this is a good external control population we
39:09
did the same thing of course for the recurrent disease in the outcome there is exactly the same
39:14
let's talk about biases like I said every trial has biases and
39:19
they need to be addressed and and we are aware of that and we did that in this case I'm just giving you an
39:25
example of a known bias in our trial patients who had disease
39:31
recurrence post chemoreadiation were excluded from The Trial they were often put into compassionate use protocols but
39:38
they were excluded from The Trial itself now the five trials that we used for
39:44
external comparisons also excluded external controls but two trials also sorry also excluded pace of
39:51
his Progressive disease but two trials did not explicitly state that so we
39:57
could not be sure that they excluded those patients so we said okay let's remove those from the ECP let's not use
40:02
those let's only use the other three just that making out a difference an outcome the answer to that is absolutely
40:07
not the hazard ratio instead of 0.8 is now 0.77 so the effect is actually stronger
40:14
The p-value Remains exactly the same and the confidence interval is almost exactly the same as well
40:20
one of the known biases hereby addressed and dismissed unknown biases
40:26
remember that all of those five trials had slightly different including criteria because they're all testing
40:32
different drugs so you need to like tweak your inclusion criteria a little bit to make sure that your patient
40:37
population is the right patient population for what you're testing so they were all slightly different so
40:43
therefore we removed each of these individually one by one to make sure that not one trial because
40:50
of its inclusion criteria may be skewed to data to the extent that it would favor us or disfavor US the answer to
40:57
that is if you remove each of these one by one doesn't make one bit of a difference asset ratio remains around
41:02
0.8 a little bit higher a little bit lower the p-value Still Remains
41:08
0.001.002 there's an outlier 0.007 highly significant and the difference really is the same that it was before so
41:16
what we did in these different sensitivity analyzes like I said this is only one example of one where we address
41:21
a known bias is that we actually did address this very carefully and we come
41:27
to the conclusion that the sensitivity analysis that we did don't refuel any biases that our data could have been
41:34
subjected to and it could have skew to results in one way or the other
41:39
and then the last thing we did because no matter how carefully your comparator
41:44
trials are chosen there's always going to be differences in the patient population in terms of for instance prognostic factors we know that Ace is
41:52
prognostic Factor extended for sex is a prognostic factor we know that and you can using the matching adjusted indirect
41:58
comparison you can adjust for that and you adjust for that by it's actually a
42:04
very complicated statistical method but it works really well like I said it's being used a lot in health economics
42:09
analyzes in Europe all countries have payers the hda's health technology
42:14
associations and they determine whether a drug should be paid for or not and they use this technology a lot so it's a
42:20
well-established technology but in a slightly different field related field um and and used in reimbursement
42:27
decisions it can adjust for even small difference in patient characteristics the net effect is that the sample size
42:33
is reduced so you lose some statistical power because when you adjust your population becomes smaller and smaller
42:39
and smaller every time because the differences weren't really that big with the comparator cohort the loss in sample
42:46
size wasn't that great but there was a lot of sample size irrespective but when we did this for these known
42:53
prognostic factors which is quite a bit eight sex race MGMT methylation status KPS score extent of perception or
42:59
residual disease we did either one the difference remains statistically significant it still favorites DC
43:05
effects the outcome is still these effects is clinically meaningfully and statistically significantly better
43:11
against the pool controls but also against each of the comparator studies so again we address the fact what our
43:18
one study was maybe a strong component in making up this control population the answer to that is no
43:25
conclusions from these external control methodology um sort of enlightenments I hope
43:31
survival of TBM patients participating in clinical trials as control subject is remarkably consistent
43:38
for us I mean that's unfortunate for the patient population but for us it creates a landscape in which internal control
43:44
populations can be used as synthetic control arms against this background
43:50
is associated with statistically significant in the clinically meaningful extended survival both in newly
43:56
diagnosed and recurrent disease and these results are robust and they hold up well against multiple analyzes
44:03
to address both known and unknown sources of bias
44:08
so that's what I wanted to talk about about the clinical trial and now I just want to highlight two cases that we've
44:14
treated in a compassionate use setting there are by the way several people here in the room that are long-term survivors
44:20
who have been treated as dcfxl um I think we have a 20-year Survivor here in the room somewhere
44:27
um there he is Brett so happy to have you um and there's there's several more as
44:34
well and they will be all in our booth and if you're interested they'll be happy to talk to you
44:39
um so this lady is also here in the audience uh Sarah
44:44
so these are these are real patients these are real people
44:52
Sarah came to us in 2012 had only received schema radiation and then edge
44:58
of intimizolamide and the first box of dcfxl was made in 2013 let's get
45:03
repeated treatments here became uh once every six months or so the second batch
45:08
was made and we are now 11 years out and as you can tell she's alive and doing
45:14
well um I don't have to have many scans but I
45:20
have one scan that looks really clean for those of you who understand what is what a scan but for GBM looks like
45:26
no no evidence of progression to date um here's a 70 year old gentleman um his
45:34
daughter is here actually this patient came to us at third recurrence at 70 years old
45:40
um third recurrence typically is is not a time um that's that's the time when the doctor tells you to get your your
45:47
Affairs in order um this patient had two course of DC
45:52
facts I believe the second course of DC facts was made after the fourth recurrence with a new preparation of
45:58
tumor tissue and again this patient is also alive and doing well and here's a
46:03
series of stance that shows that the enhancing matter has reduced over time and this base here actually the dcfx was
46:10
given as a monotherapy so let me just summarize this part of the talkative here's a broader perspective and then
46:16
I'll wrap it up and then if there's questions we'll be happy to address those individually with people in the
46:22
booth and we prefer that to over doing it here because it gives us much more meaningful interaction with people that
46:28
are truly interested so these are anecdotal observations but we think they're meaningful the drug is
46:34
well tolerated and can be effective in older patients patients that you'll probably not treat with many other drugs
46:40
at that stage in life including Pace with substantial comorbidities and we've got a few examples of those as well
46:47
um my patient experience recurrence we can make a new bags of dcfax L and
46:53
those patients can respond again to a no whole new host of tumor antigens that are in the recurrent tumor which may be
46:59
different from the original tumor because tumors change over time they have plasticity um but when they were experience
47:05
recurrence before all doses are used we can also continue to treat them with the original DC facts and that can still
47:11
extend survival and we think again that is because we're presenting hundreds of antigens to the tumor or to the to the
47:18
immune system that the immune system can respond to so broader perspective
47:24
we get a broad spectrum immune response I think that that I think I've made that very clear by now
47:31
we think it's suitable for combinations of wide range of other treatments I did not have time to go into the safety of DCF XL but it's extremely well tolerated
47:39
um there were very few series Adverse Events that were associated with the treatment among thousands of doses that
47:44
we have administered both inside and outside the clinical trial so good candidate for combination
47:50
checkpoints Inhibitors don't believe the viruses cytokine therapy chemotherapy Etc
47:56
like I said when a patient has recurrence new batches can be made the treatment targets are not lost the
48:01
tumors still have treatment targets that that it's not that when you give a small molecule against a a kinase like a
48:09
kinase inhibitor if the the tumor develops a Superfluous Pathways to overcome that blockage of kinase
48:15
inhibitor that you cannot use that drug again but these effects L you can continue to use it
48:21
um we can apply it to any solid tumor you saw that even from a TBM lysate we already got antigens that are present in
48:28
other tumors so if we use lysate from another tumor we'll get new new antigens
48:33
again that are more probably more appropriate to that particular tumor that will also again contain antigens
48:38
that we would not have known existed beforehand it's very easy to administer treatment it's administered as an intradermal
48:45
injection we ship the treatment every single dose and can be and has been administered in community settings we
48:51
don't need an academic Hospital even though they can do very well as well of course
48:56
let me just acknowledge the patients and their families both patients and families that are here and pacing their families that could not be here with us
49:03
the clinical trial investigators we had we had 90 hospitals where this trial was
49:08
conducted and we're very proud of that amount of collaboration that we found in the field at UCLA of course Dr Linda
49:15
Leon Robert Prince have stood really at the beginning of this particular type of Fermi therapy Dr ashken was the
49:22
principal investigator in Europe Mike Scott Alexander and the team at Advent some of which are here as well
49:30
um we've got people from flash works here including lekna and Andrew Mark and Daphne are not here we have people from
49:36
corporate bioservices that have worked on this a lot during the trial and of course the team at Northwest
49:41
Biotherapeutics and with that I'd like to thank you for your time and attention here today and wrap it up thank you very
49:48
much [Applause]