The management of advanced prostate cancer has been revolutionized by the translation of the rapid progress made in understanding the biology of the disease into new therapies. While these developments are unprecedented, many challenges remain, including our need to understand how best to utilize these new treatments, how to integrate them into current treatment paradigms and how to demonstrate the most cost effective ways to use these new drugs. Dr. Dreicer briefly reviews the most important of the new developments, progress to date in integrating these new therapies, and speculates how these developments will translate into improvements in patient outcomes.

1. Management of Advanced Prostate
Cancer: Moving Towards A Chronic
Disease
Robert Dreicer, M.D., M.S., FACP, FASCO
Chair Dept of Solid Tumor Oncology
Taussig Cancer Institute
Cleveland Clinic
Professor of Medicine
Cleveland Clinic Lerner College of Medicine

2. A Brief History of the Management of
Advanced Prostate Cancer
 Pre-PSA era (Pre 1989)
 Patient presents with de novo metastatic disease
 ADT, response, followed by symptomatic
progression
 PSA directed therapy era (1989-)
 Rare de novo presentation of metastatic disease
 ADT, response assessed by PSA, biochemical
progression, followed by secondary hormonal
maneuvers (casodex shuffle), chemotherapy

3. Death from Other Causes
Clinically Clinical Clinical
Initial Prostate Rising PSA
Evaluation: No Localized Metastases Metastases
Cancer Diagnosis Salvage Rx Noncastrate
Disease Castrate
Death From Disease
Scher H, et al. Urology 2000

4. Clinical States In Prostate Cancer
Sipuleucel-T
Rad 223
Metastatic
Disease Cabazitaxel
Organ (De novo)
Confined
Metastases Metastases
Metastases Metastases Castrate Castrate
Rising PSA Castrate Castrate Resistant Resistant
Hormone Resistant Resistant Post Docetaxel Post
Asymptomatic Post Abiraterone Cabazitaxel
Naive Symptomatic
Locally Rising PSA
Advanced Castrate
Disease MDV-3100
Abiraterone
Denosumab
Zolendronic Acid
Modified from Scher H, et al. Urology 2000

5. Why Terminology Matters: Hormone-
refractory/Androgen-independent: NOT
 Limits in understanding at the molecular level
and in available therapeutics have heavily
influenced our view of the disease
 Clinical utility of “second-line” hormonal
therapy
 Mixed (essentially no) clinical data
 French-American rule

6. Testosterone Suppression with Current
Therapies
 Bilateral orchiectomy: testosterone, on
average, falls to 15 ng/dL (0.5 nmol/L)
 LHRH agonists average range of
suppression in the 30-40 ng/dl range
 Escape occurs in a subset of pts

7. Lymph node Met
(i) H&E
(ii) Nuclear AR
expression PSA and
FKBP5 are
(iii) PSA stain with androgen
cytoplasmic PSA regulated
expression genes
Montgomery BR, et al. Cancer Res 2008;68:4447-4454

8. Steroid Synthesis
Cholesterol
Low-dose steroid replacement decreases ACTH
and minimizes mineralocorticoid-related toxicity
Desmolase
Pregnenolone Progesterone Deoxy- Corticosteron Aldosterone
corticosterone e
CYP17
X
17α-hydroxylase
17α-OH- 17α –OH- 11-Deoxy- Cortisol ACTH ↓
pregnenolone progesterone cortisol
CYP17
X
C17,20-lyase
5α-reductase
DHEA Androstenedione Testosterone DHT
CYP19: aromatase
Estradiol
Attard G, et al. J. Clin. Oncol. 26: 4563–4571, 2008

9. Attard G, et al. J. Clin. Oncol. 26: 4563–4571, 2008

10. PSA Response / Progression in Phase II Trials of
Abiraterone in Docetaxel-Treated CRPC
Reid (N = 47) Danila (N = 58)
50% PSA decline – 54.8%
50% PSA decline – 45.2%
Danila DC, et al. J Clin Oncol. 2010;28:1496-1501; Reid AH, et al. J Clin Oncol. 2010;28:1489-1495.

11. COU-AA-301 Study Design
Efficacy endpoints (ITT)
R
Patients A Abiraterone1000 mg daily
• 1195 patients with Primary end point:
N Prednisone 5 mg BID
progressive, mCRPC D N=797 • OS (25% improvement; HR
• Failed 1 or O 0.8)
2 chemotherapy M
I Secondary end points (ITT):
regimens, one of
Z Placebo daily • TTPP
which contained
E
docetaxel Prednisone 5 mg BID • rPFS
D
2:1 n=398
• PSA response
 Phase 3, multinational, multicenter, randomized, double-
blind, placebo-controlled study (147 sites in 13 countries;
USA, Europe, Australia, Canada)
 Stratification according to:
 ECOG performance status (0-1 vs. 2)
 Worst pain over previous 24 hours (BPI short form; 0-3 [absent] vs. 4-10 [present])
 Prior chemotherapy (1 vs. 2)
 Type of progression (PSA only vs. radiographic progression with or without PSA
progression)
Clinicaltrials.gov identifier: NCT00638690.

12. COU-AA-301: Abiraterone Acetate Improves Overall
Survival in mCRPC
100 HR = 0.646 (0.54-0.77) P< 0.0001
Abiraterone acetate:
80 14.8 months (95%CI: 14.1, 15.4)
Survival (%)
60
40
Placebo:
10.9 months (95%CI: 10.2, 12.0)
20
2 Prior Chemo OS: 1 Prior Chemo OS
14.0 mos AA vs 10.3 mos placebo 15.4 mos AA vs 11.5 mos placebo
0
0 100 200 300 400 500 600 700
Days from Randomization
de Bono J et al: N Engl J Med 364:1995-
2005, 2011

13. Adverse Events of Special Interest
Placebo
Abiraterone Acetate
Plus Prednisone
Plus Prednisone (n=791)
(n=394)
Adverse Event, no. All Grade Grade All Grade Grade
patients (%) Grades 3 4 Grades 3 4
Fluid retention and
241 (31) 16 (2) 2 (<1) 88 (22) 4 (1) 0
edema
Hypokalemia 135 (17) 27 (3) 3 (<1) 33 (8) 3 (1) 0
Cardiac disorders 106 (13) 26 (3) 7 (1) 42 (11) 7 (2) 2 (<1)
LFT abnormalities 82 (10) 25 (3) 2 (<1) 32 (8) 10 (3) 2 (<1)
Hypertension 77 (10) 10 (1) 0 31 (8) 1 (<1) 0
• Adverse events associated with elevated mineralocorticoid levels, cardiac events, and
LFT abnormalities were deemed of special interest
• These events were more common in the abiraterone acetate group (55% vs 43%;
P<0.001) but were largely mitigated by the use of low-dose prednisone
deBonoJS et al. N Engl J Med. 2011;364(21):1995-2005.

14. Overall Study Design of COU-AA-302
R
R Efficacy end points
Patients A
A
N
N AA 1000 mg daily
AA 1000 mg daily Co-Primary:
• Progressive chemo- D
D Prednisone 5 mg BID
Prednisone 5 mg BID • rPFS by central review
naïve mCRPC O
O (Actual n = 546)
(Actual n = 546)
M
M • OS
patients II
(Planned N = 1088) Z Secondary:
Z
• Asymptomatic or E
E Placebo daily
Placebo daily • Time to opiate use
mildly symptomatic D
D Prednisone 5 mg BID
Prednisone 5 mg BID (cancer-related pain)
(Actual n = 542)
(Actual n = 542) • Time to initiation of
1:1
1:1 chemotherapy
• Time to ECOG-PS
deterioration
• TTPP
• Phase 3 multicenter, randomized, double-blind, placebo-controlled study conducted at 151 sites in 12 countries;
USA, Europe, Australia, Canada
• Stratification by ECOG performance status 0 vs 1

15. Statistically Significant Improvement in rPFS Primary End
Point
100 AA + P (median, mos): NR
PL + P (median, mos): 8.3
HR (95% CI): 0.43 (0.35-0.52)
80
P value: < 0.0001
Progression-Free (%)
60
40
20
AA + P
PL + P
0
0 3 6 9 12 15 18
Time to Progression or Death (Months)
AA 546 489 340 164 46 12 0
PL 542 400 204 90 30 3 0
Data cutoff 12/20/2010.
NR, not reached; PL, placebo.
Ryan CJ . J Clin Oncol 30, 2012 (suppl; LBA 4518)

16. Strong Trend in OS Primary End Point
100
80
Survival (%)
60
40
AA + P (median, mos): NR
PL + P (median, mos): 27.2
20 HR (95% CI): 0.75 (0.61-0.93)
AA + P P value: 0.0097
PL + P
0
0 3 6 9 12 15 18 21 24 27 30 33
Time to Death (Months)
AA 546 538 524 503 482 452 412 258 120 27 0 0
PL 542 534 509 493 465 437 387 237 106 25 2 0
Data cutoff 12/20/2011.
Pre-specified significance level by O’Brien-Fleming Boundary = 0.0008.
Ryan CJ . J Clin Oncol 30, 2012 (suppl; LBA 4518)

17. MDV3100/Enzalutamide
1. MDV3100 is an oral investigational drug T
rationally designed as a new hormonal
agent to target androgen receptor (AR)
signaling, a key driver of prostate
cancer growth. T
2. MDV3100 is the first in a Inhibits Binding of MDV3100
new class of Androgen Receptor 1 Androgens to AR
Signaling
AR
Inhibitors that affects
multiple steps in the Cell cytoplasm
androgen receptor
signaling pathway.
2 Inhibits Nuclear
Translocation of AR
Cell nucleus
AR
Inhibits Association
3 Of AR with DNA
Scher H, et al. J Clin Oncol 30, 2012 (suppl 5; abstr LBA1)

18. Antitumor activity of MDV3100 in castration-
resistant prostate cancer: a phase 1–2 study
Scher HI, et al. Lancet 375: 437 - 1446,2010

19. MDV3100 Prolonged Survival by a Median of
4.8 Months in the Phase 3 AFFIRM Trial
100 HR = 0.631 (0.529, 0.752) P < 0.0001
37% Reduction in Risk of Death
90
80 MDV3100: 18.4 months
(95% CI: 17.3, NYR)
Survival (%)
70
60
50
40
30
20 Placebo: 13.6 months
(95% CI: 11.3, 15.8)
10
0
MDV3100 800 775 701 627 400 211 72 7 0
Placebo 399 376 317 263 167 81 33 3 0
Scher H, et al. 2012 Genitourinary Cancers Symposium

20. Adverse Events of Interest
All Grades Grade ≥ 3 Events
MDV3100 Placebo MDV3100 Placebo
(n = 800) (n = 399) (n = 800) (n = 399)
Fatigue 33.6% 29.1% 6.3% 7.3%
Cardiac Disorders 6.1% 7.5% 0.9% 2.0%
Myocardial Infarction 0.3% 0.5% 0.3% 0.5%
LFT Abnormalities* 1.0% 1.5% 0.4% 0.8%
Seizure 0.6% 0.0% 0.6% 0.0%
*Includes terms hyperbilirubinaemia, AST increased, ALT increased, LFT abnormal,
transaminases increased, and blood bilirubin increased.
Scher H, et al. 2012 Genitourinary Cancers
Symposium

21. Second-line Hormonal Therapy: This
time with drugs that actually work
 Many issues remain
 Optimal timing
 Role of combination therapy
 When to stop androgen biosynthesis inhibitors
 Major issue in the pre-chemotherapy setting
 Optimal dose of steroids for ABI’s
 Issues of divergent practice urology vs. oncology

22. Randomized Phase 3 IMPACT Trial
(IMmunotherapy Prostate AdenoCarcinoma Treatment)
P P Treated at
Treated at
Asymptomatic or
Asymptomatic or Sipuleucel-T
Sipuleucel-T R R Physician
Physician S
Minimally Q2
Q2 OO discretion S
Minimally discretion
weeks x 3
weeks x 3 G U
U
Symptomatic
Symptomatic G
R R
R
Metastatic
Metastatic R
2:1 V
V
Castrate
Castrate E
E
S II
Resistant
Resistant S Treated at
Treated at
S V
V
Prostate Cancer
Prostate Cancer Placebo
Placebo
Placebo S Physician
Physician
II discretion A
A
(N=512)
(N=512) Q 2 Q 2 weeks
weeks x 3
Q 2 weeks discretion
O and/or Salvage
and/or Salvage L
L
x3
x3 O
N Protocol
Protocol
N
Primary endpoint: Overall Survival
Secondary endpoint: Time to Objective Disease Progression

23. Kantoff, P et al. N Engl J Med 363;5 2010

24. The Sipuleucel-T Conundrum
 What sipuleucel-T appears to provide patients
 improvement in survival
 What sipuleucel-T DOES NOT DO
 It is not a therapeutic replacement for therapy in patients in
need of an objective anti tumor response in real time
 Unprecedented development and integration of a
novel therapy
 No improvement in OR/PFS
 Limited access dampens learning curve
 Cost

25. TROPIC: Phase III Registration Study
mCRPC patients who progressed during and
after treatment with a docetaxel-based regimen
(N=755)
Stratification factors
ECOG PS (0, 1 vs. 2) • Measurable vs. non-measurable disease
cabazitaxel 25 mg/m² q 3 wk mitoxantrone 12 mg/m² q 3 wk
+ prednisone* for 10 cycles + prednisone* for 10 cycles
(n=378) (n=377)
*Oral prednisone/prednisolone: 10 mg daily.
Primary endpoint: OS Inclusion: Patients with measurable
Secondary endpoints: Progression-free disease must have progressed by RECIST;
survival (PFS), response rate, and safety otherwise must have had new lesions or
PSA progression

26. TROPIC: Overall Survival
100
MP CBZP
Median OS, mos 12.7 15.1
Patients remaining alive, %
80
HR 0.72
60 95% CI 0.61-0.84
P value < .0001
40 Censored
MP
CBZP
20
Combined median
follow-up: 13.7 mos
0
0 6 12 18 24 30
Mos
Patients at Risk, n
MP 377 299 195 94 31 9
CBZP 378 321 241 137 60 19
de Bono JS, et al. Lancet. 2010;376:1147-1154.

27. Skeletal Complications in Prostate
Cancer: Issues
 Prevention of osteoporosis and related
complications
 Prevention of bone metastases
 Impact of disease related complications
(SRE)
 Impact on survival

28. Approved Agents
 Zolendronic acid
 Prevention of osteoporsis
 Decrease in SRE
 Denosumab
 Prevention of osteoporsis
 Decrease in SRE
 Delay in time to metastatic bone disease

29. Fizazi, K, et al. Lancet 2011; 377: 813–22

30. Radium-223 Targets Bone Metastases
• Radium-223
acts as a
calcium mimic
• Naturally targets Ca
new bone
growth in and
around bone Ra
metastases
• Radium-223 is
excreted by the
small intestine

31. ALSYMPCA (ALpharadin in SYMptomatic
Prostate CAncer) Phase III Study Design
TREATMENT
PATIENTS 6 injections at
R 4-week intervals
STRATIFICATION
• Confirmed A
symptomatic N Radium-223 (50 kBq/kg)
CRPC D + Best standard of care
• ≥ 2 bone • Total ALP:
O
metastases < 220 U/L vs ≥ 220 U/L
• Bisphosphonate use:
M
• No known I
Yes vs No
visceral S
• Prior docetaxel: Placebo (saline)
metastases Yes vs No E
• Post-
+ Best standard of care
D
docetaxel or
unfit for 2:1
docetaxel
N = 922
Planned follow-up is 3 years
Clinicaltrials.gov identifier: NCT00699751.

32. ALSYMPCA Overall Survival
100
90 HR 0.695; 95% CI, 0.552-0.875
80 P = 0.00185
70
60
Radium-223, n = 541
% 50 Median OS: 14.0 months
40
30
20
Placebo, n = 268
Median OS: 11.2 months
10
0
Month 0 3 6 9 12 15 18 21 24 27
Radium- 223 541 450 330 213 120 72 30 15 3 0
Placebo 268 218 147 89 49 28 15 7 3 0
Parker C . J Clin Oncol 30, 2012 (suppl; LBA 4512)

33. ALSYMPCA Time to
First Skeletal-Related Event
100
90
HR 0.610; 95% CI, 0.461-0.807
80 P = 0.00046
70
% Without SRE
Radium-223, n = 541
60
Median: 13.6 months
50
40
Placebo, n = 268
30
Median: 8.4 months
20
10
0
Month 0 3 6 9 12 15 18 21
Radium-223 541 379 214 111 51 22 6 0
Placebo 268 159 74 30 15 7 2 0
Parker C . J Clin Oncol 30, 2012 (suppl; LBA 4512)

34. Agent/Trial/Year Disease State Comparator Hazard Ratio P Value
Docetaxel/Tax 327 Chemo naïve Mitoxantone/ 0.76 0.009
(2004) mCRPC Prednisone
Sipuleucel T/ Chemo naïve Placebo 0.775 0.032
Impact ( 2010) mCRPC
Abiraterone Cougar Chemo naïve Placebo/ 0.43 (PFS) < 0.0001
301 (2012) mCRPC Prednisone
Abiraterone Cougar Post docetaxel Placebo/ 0.65 < 0.001
302 (2010) mCRPC Prednisone
Cabazitaxel Tropic Post docetaxel Mitoxantone/ 0.7 < 0.001
(2010) mCRPC prednisone
Radium 223 Bone metastases Placebo + best 0.695 0.00185
ALSYMPCA (2011) mCRPC supportive care
MVD 3100 AFFIRM Post docetaxel Placebo 0.631 < 0.001
(2012) mCRPC

35. Normalization of Bone Scan With XL-184
Docetaxel-pretreated (n=10)
Baseline Week 12 Evidence of bone scan
resolution (partial or complete) Yes
Maximum tumor change,
per mRECIST -41%
Change in bone pain Improvement
1000 tALP 5000
800 PSA 400
tALP
PSA
Change in tALP 600 300
and PSA 400 200
200 100
0 0
Scr 0 5 10 15 20
Weeks on Study
Maximum change in
-88%
plasma CTx
Bone scans at baseline and
during therapy with XL184 Best change in hemoglobin NE
Smith et al. EORTC; 2010.

36. Clinical States In Prostate Cancer
Sipuleucel-T
Rad 223
Metastatic
Disease Cabazitaxel
Organ (De novo)
Confined
Metastases Metastases
Metastases Metastases Castrate Castrate
Rising PSA Castrate Castrate Resistant Resistant
Hormone Resistant Resistant Post Docetaxel Post
Asymptomatic Post Abiraterone Cabazitaxel
Naive Symptomatic
Locally Rising PSA
Advanced Castrate
Disease MDV-3100
Abiraterone
Denosumab
Zolendronic Acid
Modified from Scher H, et al. Urology 2000

37. “Everyone has a
photographic memory
Some just don’t have film”
- Steven Wright