Full MCRI Show: Multiple myeloma patients pick up more of the CD28 protein as they relapse. A new solution for this relapsed/refractory target and for 14;16 patients specifically with Dr. Carmen Baldino, PhD and Dr. Kelvin Lee, MD
Dr. Carmen Baldino, PhD and Dr. Kelvin Lee, MD Jasco Pharmaceuticals and Roswell Park Cancer Institute Interview Date: May 13, 2015 Summary CD28 is a protein is found on multiple myeloma cells and is present in 25% of newly diagnosed patients, in 50% of patients at first relapse, in 80-90% of patients at second relapse and in 100% of plasma cell leukemia patients. Drs. Baldino and Lee are using this significant observation to develop and test a new PIM2 kinase inhibitor called JP-11646 is a PIM2 kinase inhibitor to influence this protein. The new drug also affects the MAF gene - a gene that is changed somewhat in all myeloma patients and is especially affected in patients with the 14;16 translocation. The connection between MAF, PIM2 and CD28 are not totally understood, but this new drug is now being tested for patients with this translocation and patients with late-stage disease. Dr. Carmen Baldino and Dr. Lee describe the double strategy to bring patients back to a state where they are sensitive to chemo again and also to kill myeloma cells outright. Jasco Pharmaceuticals has taken care to find and develop this new treatment that could address the big issue of very aggressive chemo-resistant myeloma. The Myeloma Crowd Radio Show with Dr. Carmen Baldino, PhD and Dr. Kelvin Lee, MD
Welcome to today's episode of Myeloma Crowd Radio, a show that connects patients with myeloma researchers. I'm your host, Jenny Ahlstrom, and I'm joined today by my myeloma friends and co-hosts including Gary Petersen, Jack Aiello, and Pat Killingsworth. So, welcome. This is the seventh and a very important series featuring the Myeloma Crowd Research Initiative. Now if you haven't already heard about what we're doing, educated patients are connecting with top researchers to help find and fund a cure for high-risk multiple myeloma. We decided to go after high-risk myeloma because there are typically dismal outcomes for these patients with standard therapies and it was a very attractive way to have potentially amazing trickle down effects that might work in high-risk patients can also work in standard or low-risk patients. Now that's not always the case because some targets, like we are going to hear about today, are very specific to a certain type of patient. But we're very excited about offering these solutions for these patients with very limited options. Now here's what we've done so far. In February, we called for letters of intent from researchers around the world. We received back 36 very high quality proposals. Our Scientific Advisory Board then vetted those proposals and selected a top 10 and the ones in the show are those top ten. And now we are preparing to select a number of proposals to then create fundraising campaigns around. If you'd like to watch a video that we've made about the research efforts or the MCRI as we're calling it, you can go to https://mcri.myelomacrowd.org and watch what we have to say as co-host and Patient Advisory members and why we're driving this research project and why we think it's important. Now we are very privileged today to have with us Dr. Carmen Baldino and Dr. Kelvin Lee and they are both from Jasco Pharmaceuticals and Roswell Park Cancer Institute. Welcome Doctors, thank you for joining us. Dr. Lee: Glad to be here. Dr. Baldino: Thanks very much for having us. Jenny: Let me introduce you both. Dr. Baldino is scientific co-founder of Jasco Pharmaceuticals and the company's president. Prior to joining Jasco, Dr. Baldino was one of the scientific founders of China-based BioDuro, an integrated R&D services company, and served as its Vice President of Research and Business Development. He also spent ten years at ArQule, Inc., most recently as Vice President of Chemistry, managing a group of scientists responsible for early discovery technologies, medicinal chemistry, and analytical chemistry. He obtained his Bachelor of Science in Chemistry from Southern Connecticut State University, his Ph.D. from Purdue University and Scripps, and completed a post-doctoral fellowship at Yale. Dr. Baldino's academic researcs focused on the total synthesis of natural products and bioorganic chemistry. Dr. Kelvin Lee is Professor of Medicine at the Roswell Park Cancer Institute as well as Vice Chair of Medicine and Chair of Immunology. His laboratory has a long-standing interest and publication record in multiple myeloma being the first to characterize CD28's pro-survival function in myeloma. In his lab he also studies the bone marrow microenvironment and other survival proteins and as I just learned from him right before the show, he has been working on myeloma for 25 or more years. Dr. Lee: Thank you. Jenny: So thank you so much. Maybe we start with a little basic biology review in terms patients can understand because some of these get a little bit tricky and complicated. What typically triggers genes to become translocated in the first place? I know this is a subset only of myeloma patients. Dr. Lee: So let me tackle that question. So myeloma, the normal equivalent of multiple myeloma, the cancer cell, the normal equivalent is a plasma cell. Plasma cells are the cells that generally make the antibodies that protect you from measles, the flu, polio, et cetera. Plasma cells are part of a lineage of normal immune cells that are known as B lymphocytes. And it turns out that the natural biology of B lymphocytes as they become activated, as they turn into plasma cells, is to enhance the effectiveness of the antibodies that they produce. And so they go from relatively low-binding antibodies to antibodies that are much higher in affinity. But in this process of making these antibodies better, they actually splice their DNA. So they rearrange their DNA, they rearrange their chromosomes through a very controlled process that actually breaks the DNA and splices it back together again. So this works billions of times a day perfectly but every once in a while, for some reason we don't quite understand, this DNA splicing mechanism makes a mistake and puts a gene instead of splicing it in the right place, splices it into the wrong place. And that splicing event is known as the translocation. And the mistakes don't happen very often but they are part of really what is a normal biological process for B lymphocytes. Jenny: Tis a great explanation. Thank you so much. I didn't know. I just learned that that's a pretty natural process to have the DNA break apart and join back together and it makes sense that on occasion it would go wrong. Dr. Lee: Well, it's actually surprising that it doesn't go wrong more often given the fact that it really is happening millions to billions of times a day. And it's surprising that the mechanisms within the body keep this under pretty tight control. Jenny: And specifically, you were studying the 14;16 translocation. I know it's probably challenging to get a ton of samples or even patient-reported outcomes with that translocation but I'm wondering if you've seen any patterns and causes for that particular translocation like a virus or environmental or anything. Have you seen anything like that? Dr. Lee: No, we have not. I think most of these translocations that happen in multiple myeloma are pretty random and so there doesn't appear to be anything that really skews them in one direction or the other. Now the interesting aspect of the 14;16 translocation, it is that it's fairly uncommon. 8% to 10% of myelomas actually have this translocation that causes over expression of this molecule called MAF which we'll talk about in a little bit. So 8% to 10% of myeloma patients have this translocation. However, it turns out that about 50% of myeloma patients overexpress MAF in general, even patients that don't have the translocation. So it appears that this MAF gene is an important part of myeloma biology even if you don't have the translocation. Jenny: And as I understood, they talked about this in the last show where we were talking about both the 14;16 and the 14;20 translocations and they said MAF can be expressed in other patients but it's like a hundredfold or significantly higher with the 14;16. Dr. Lee: Right. So what happens in these translocations and why they're bad or why they cause problems is they take genes that are normally in one place in the DNA and under control of the normal controlling elements for that gene. They take that gene, they stick it into another place in the DNA where that gene in the new place is way more active and so it being activated at a much higher level. So now all of a sudden, this gene which was in its normal place isn't highly activated and not expressed very much, it's not being made a lot, gets put into this other gene which in the case of multiple myeloma is the antibody gene and that gene is firing like crazy and then all of a sudden MAF which normally isn't made a lot, once it gets dropped into abnormally spliced into the antibody gene locus gets made way more than it should and that's what really causes the problem. Jenny: It just goes hyper and has viral overexpression. Dr. Lee: Exactly. Jenny: Okay, perfect. When the 14;16 translocation occurs, do you want to talk about the c-Maf and what happens there with that gene? Dr. Lee: So MAF is a gene that falls into the category of what we call transcription factors. And transcription factors are those molecules that regulate a large panel of genes. So for example, there are transcription factors that are specifically designed or specifically dedicated to controlling, for example, antibody production or lymphocyte activation or a large number of genes that are required for a particular biological process. So MAF normally is involved in a lot of different biological processes in different kinds of cells. It depends on the cell what MAF is controlling. And what appears to happen in multiple myeloma is that when MAF is forced to be overexpressed by these translocations or other factors, it's thought to do three things that help the myeloma cell. One is it makes the myeloma cell divide much faster so now you're getting more myeloma cells being generated compared to the normal plasma cell. The second thing it seems to do is that it allows the myeloma cells to stick better to the bone marrow microenvironment. So myelomas are very dependent on interactions with the normal bone marrow and normal elements within the bone marrow for their survival. So normally if you take the myeloma cell out of the bone marrow and you purify it away from all its neighborhood, they die. They don't live very well outside the bone marrow so they have to interact with the bone marrow microenvironment. And MAF seems to up-regulate or increase the particular molecules that are involved in allowing the myeloma to stick better to its microenvironment and get more of those good prosurvival signals from the microenvironment. And the third thing it does is it seems to amass, it seems to control the gene program, for lack of a better word, that is involved in invasion. So now these cells can move through the bone marrow more readily and so they can spread farther and faster than if MAF wasn't overexpressed. So MAF seems to broadly control those three areas. Exactly how it does that is an area of great interest, a lot of people are working on that. But that seems to be what MAF is bringing to the table for the multiple myeloma cells and that seems to be why the myeloma cells that have overexpression of MAF are more aggressive and MAF translocation is a bad prognostic factor for patients with multiple myeloma. Jenny: Okay. So two questions about that -- do you see more bone disease in these patients? Dr. Lee: The MAF population is relatively a small population but yes the feeling is that they have more and worse bony disease. Jenny: Because it's invading at a higher level. Dr. Lee: Right. Jenny: And have you noticed any kind of resistance to maybe Bortezomib or other drugs? When we were talking to -- Dr. Lee: Yes. So this is actually what brought us in to work with Jasco. Really my laboratory's interest is understanding why myeloma cells become resistant to chemotherapy because for the vast majority of myeloma patients, when they're newly diagnosed, almost all of them are sensitive to chemotherapy and most of them with modern chemotherapy, the proteasome inhibitors and the IMiDs, most of them in fact have a very good response if not a complete response to their initial chemotherapy. And many of them will go on to high dose melphalan and stem cell rescue, transplant. But the problem is that almost all patients or many patients will relapse. Their myeloma will come back and when it comes back it is more resistant to chemotherapy. Although now we have other drugs to treat and we treat that and the myeloma will regress but then will come back again. So oftentimes many of our patients have been treated with 5 or 6 different lines of chemotherapy. Every time they relapse their myeloma is tougher, it doesn't respond to chemotherapy nearly as well or nearly as long as it did beforehand. We have patients who have undergone 8 to 10 lines of chemotherapy and usually by that point their myeloma is completely chemotherapy-resistant. And so really the major clinical obstacle that we are facing or one of the major ones is the development of chemotherapy resistance. And the question that our lab has been asking is how does that happen, what are the molecules that are involved that make these myeloma cells more resistant. And just a little bit of background of how we ended up interacting with Jasco is that one of the molecules that we study is a receptor on the surface of myeloma cells called CD28. CD28 when I first started in science really it has been mostly described as a prosurvival for T lymphocytes. It's very important for T lymphocyte activation. But what we've described since 2007 is that CD28 is a critical prosurvival receptor for multiple myeloma. And as myelomas get treated with chemotherapy, more and more of them become CD28-positive. And so when you're newly diagnosed, about 25% of cases have high expression of CD28. By the time you've had your first relapse, about 50% are CD28-positive. Your second relapse or as you relapse outside of the bone marrow, it's about 80% to 90%. All of the very late stage myelomas, the secondary plasma cell leukemia is there, all CD-28 positive. And other groups in Spain, in France have shown that CD28 expression is a poor prognostic factor in multiple myeloma. And what we've discovered in the lab is that when CD28 gets activated by interacting with the normal bone marrow microenvironment, it transduces a pro-survival signal that makes the myeloma cells completely resistant to everything we've actually tested them against including Bortezomib, dexamethasone steroid, Arsenic trioxide, melphalan which is commonly used, characteristically used in the transplant setting. So all the chemotherapies that we've tested it on where that CD28 confers significant resistance to those chemotherapies except for the PIM2 Inhibitor that Jasco generated. So the JP-11646 we were initially interested in it because Carmen and Jasco identified it being over expressed or effective against MAF-translocated myeloma cell lines. Now we also know that CD28 is significantly overexpressed in the MAF translocated subset or the MAF gene signature subset of myeloma cell so there was a connection between CD28 and MAF. And so we tested Jasco's PIM2 Inhibitor to see if it could overcome CD28-mediated protection against chemotherapy and it was the only drug that could do it, which was striking to us. And really from a scientific and research standpoint, really compelled us to go forward and take a much closer look at what this PIM2 Inhibitor was doing. Jenny: Can you give us a little background about what the PIM kinase inhibitors do and how they work? Dr. Baldino: As you can see, we found the great collaborator in Kelvin to work with on this program. Jenny: Yes, you did! Dr. Baldino: Let me start with a brief description of the PIM family of serine/threonine kinases. There are three isoforms, Pim-1, Pim-2, and Pim-3. There's a high degree of homology amongst the isoforms and a redundancy in the roles. Interestingly, the PIMs are also constitutively active which means that if they're present in a cell, they're active and operating within that cell. The PIM kinases are involved in regulating several signaling pathways that are fundamental to cancer cell development and progression. The PIMs have also been shown to be overexpressed in multiple cancer types including liver, pancreatic and hematologic malignancies especially multiple myeloma. In fact, it's been reported in the literature that Pim-2 activity is required for survival of multiple myeloma cells. So the PIM kinase inhibitors to date have all been small molecules. JP-11646 is a small molecule and these inhibitors bind to the PIM kinases and inhibit the normal function of the protein. Our drug, 646, has proven to be unique when compared to other PIM inhibitors described in the literature. Our drug is the only inhibitor that is able to inhibit the PIMs action in an ATP non-competitive fashion. What that means is that in a cellular environment, JP-11646 will not be in competition with ATP for binding to the PIMs and this gives it a distinct advantage when compared to other inhibitors. Secondly, our drug has not only demonstrated an enhanced ability to inhibit the PIMs signaling pathways but also the ability to nearly eliminate PIM expression levels in multiple myeloma cells. This is in contrast to other PIM inhibitors that have been shown to actually significantly increase PIM expression levels in multiple myeloma cells. We've confirmed this in a number of multiple myeloma cell lines in collaboration with Kelvin's group and consistently our drug has shown to dramatically decrease the PIM expression levels while the other PIM inhibitors increase and in certain cases, more than double the expression level of the PIM kinases. And Kelvin, I know that you continue to work in better understanding the mechanism and maybe you can provide a little additional information on some of those findings. Dr. Lee: Sure. The mechanism of action, as Carmen alluded to, the mechanism of action of JP-11646 seems to be very different than the other PIM2 inhibitors that are currently under development by other companies. So one of the things that we expect it to do which it does both in cell lines and also when we've tested it in animal models is that it blocks the activity of the kinase activity of the enzyme so it is a traditional or characteristic enzyme inhibitor. The one thing that it does that is very different is that through mechanisms that we're still trying to work out, it shuts off the expressing of Pim-2 at the gene level and at the protein levels. So not only does it block the enzymatic activity of the protein molecule but it turns it off. And that whole area of how -- as Carmen mentioned, Pim-2 is normally if you make it, it's on, so what controls the activity of Pim-2 is how much is there. So if you could turn it off and block its activity whatever else is there, then you have a sort of a doubly effective mechanism. What is controlling Pim-2 expression is not very well known in the entire Pim-2 field but it's something that we're trying to work out. But it seems to be a very different way of reducing Pim-2 activity compared to the other PIM inhibitors. Jenny: And just a basic question on kinases, kinases are related to the signaling pathway, they are the signaling pathway? What exactly are they? Dr. Lee: They are the signaling pathway so a lot of how cells signal internally We tend to think of it as wiring but it's not really wiring. Very typically it's an enzyme that can add a phosphate group on to another molecule. And by sticking that phosphate atom on to another molecule it changes the quality of that molecule and that molecule then usually is an enzyme itself which now gets activated by the fact that the kinase stuck a phosphate on it and then now goes and activates its target and that's how the signal sort of moves from the surface of the cell all the way into the nucleus where the DNA and gene regulation is taking place. Jenny: And that sounds like from what you were saying earlier, it's shutting it down as an earlier stage in the process so it's checking the gene on the protein. So you're kind of like trying to stop it at the source, is that correct? Dr. Lee: Right. It's a double whammy against Pim-2. Jenny: That makes sense. So how did the two of you get connected? Dr. Baldino: Jasco, we founded the company with really an expertise in medicinal chemistry and early drug discovery but our mission was really to address unmet patient needs. And as a small company, we weren't going to be able to build all the expertise internally and so we identified the approach of going after a strategic alliance to bring in that clinical expertise and a knowledge of the unmet patient needs. And as Kelvin sort of alluded to, we identified Kelvin's research as interesting and well connected with what we were doing. And I think from our very first meeting up in Buffalo, we found that there was just the perfect match of not only scientific interest but also a desire to bring new approaches, new treatment options for high-risk multiple myeloma patients. Jenny: And Dr. Baldino, how did you develop this compound in the first place? Dr. Baldino: So the compound was developed at Jasco. As I said, the company was founded with an expertise in medicinal chemistry and also in the design and optimization of enzyme inhibitors. So the first thing we did at Jasco is to build the proprietary library of small molecules that were fashioned with binding elements in order to bind to kinases. We then took a small subset of those compounds and screened them against a panel of oncology-relevant kinases and identified a number of areas where we were inhibiting the kinases. Again, as a small company, we had to be very careful about the kinase we chose to work in. So we were inhibiting some kinases such as EGFR, c-Met, PI3K that were in very crowded areas. A lot of larger companies' are involved in that. The initial PIM hits were micromolar inhibitor of the PIMs but the PIM kinases were fairly novel and there was some clinical validation in the literature. But I think more importantly we had identified that Pim-2 was implicated in multiple myeloma and so we felt that this was a good match of the science and our mission as a company. So we took those initial hits and went through a lead optimization phase and were able to optimize the potency of the compound against Pim-2 from a single digit micromolar inhibitor down to a 500 picomolar inhibitor and actually drove the activity in multiple myeloma cells down to 12 nanomolar. So we had a very strong optimization program. And again, this is sort of the point where we met with Roswell and talked things over with Kelvin's group and began to work together to now move these effects into more sophisticated animal models and really focus on how to develop the program for high-risk multiple myeloma patients. Kelvin, maybe if you want to say a few words. I know you've already mentioned the CD28 assay but a few words about our initial interactions? Dr. Lee: Sure. Working with Carmen and Justin at Jasco has been a real treat. So as I mentioned, we initially were very interested in what can overcome what we think is a dominant mechanism of chemotherapy resistance in multiple myeloma. So we looked at the JP-11646 ability to overcome CD28-mediated resistance and that was very exciting. Then we subsequently have done a number of studies also with the Center for Drug Development here at Roswell Park looking at both the mechanism of action, how does it work and how is it inhibiting the survival signals that are getting into the multiple myeloma which I talked about a little bit, and also how effective is it in animal models of multiple myeloma. And we've done a lot of those studies trying to determine the right dose and schedule and toxicity that's involved. We found at least in mouse models of multiple myeloma that a 15 mg/kg dose which is reasonably well-tolerated by the mice given twice a week, Mondays and Tuesdays. Essentially about 60% of the mice were being cured of their myeloma and these were not little myeloma tumors -- these were pretty big myeloma tumors that they were being cured of. So at least in mouse models the drug appeared to be very effective with pretty well-tolerated side effects. Now we also found in those mouse models that it could be combined at a lower dose with dexamethasone which is commonly used in the treatment of multiple myeloma. So that combination also seemed to be very well, even better tolerated and have similar degree of effectiveness against the multiple myeloma. Jenny: Well, let me back up and ask a question about chemo resistance overall because we've seen this as a recurring theme, I guess. There are a lot of people who want to overcome chemo resistance, find out what cells are surviving all the chemo and then study those. So is the goal to enable the chemo to work and then get rid of all the residual myeloma cells? Or I guess, in other words, do you bring a high-risk patient back to normal or low-risk or are you looking for how do we cure this patient forever? Dr. Lee: I think it's actually both and that's a great question. I think that there are in fact two mechanisms that are at play. One is that it's very clear that myeloma is really not one cancer but is really a whole tribe of different kinds of cancer cells and that's what the genetics and gene profiling research has shown us. And it's really a tribe of different myeloma cells that have different resistance to chemotherapy. So as you beat on myeloma with chemotherapy, the ones that are resistant to the chemotherapy now can continue to grow were the ones that are sensitive get killed off. So one strategy which we are pursuing is can you identify the molecular mechanisms by which those resistant myeloma cells are being resistant, what's their basis for the resistance and can you target those molecular mechanisms to do exactly as you were saying. Can you now re-sensitize all those myeloma cells to chemotherapy that they were previously resistant to? So can you reset the clock back to when they were newly diagnosed, for example. So that's one strategy. The other strategy is actually find compounds like this PIM2 inhibitor which we think bypasses all those resistance mechanisms and will kill cells regardless. So that's a different mechanism and that's finding a drug that's not affected by these pro-survival mechanisms, chemotherapy-resistant mechanisms, in multiple myeloma. So I think those are two approaches, they are linked. They're conceptually a little bit different but both of them in fact are actually aiming to cure patients and I think that chemotherapy resistance is in fact probably one of the major signatures of high-risk myeloma. It's really those myelomas that can adapt very quickly to the chemotherapy that they're being faced with that causes the major problems. Jenny: Well, I want to go back to what you said earlier because you said CD28 expression goes up and up and up while it's present in the 14;16 translocation, you keep seeing increases as people keep relapsing. So this may not just be some solution for 14;16 -- it might be a solution for everyone. Is that correct? Dr. Lee: Exactly. And that's why the additional excitement, because we don't think that PIM2 inhibitors is limited to 14;16 translocations. We actually think that it is more broadly applicable because CD28 is expressed on lots of different kinds of myelomas. And also again, I alluded earlier that MAF overexpression seems to be detectible in 50% of myelomas even though the translocation is seen at a lot lower level. So the fact that this drug might affect MAF-related biology in addition to anything that is associated with a translocation means that there are actually a fair number of myeloma patients that this drug might be very active in. Jenny: That would be great, that will be terrific. So it sounds like you've ran mouse models, can you kind of walk us through where you're at in your process? Dr. Baldino: Right now we were in pre-clinical. We have a very comprehensive package of data from PK studies and efficacy studies, mechanistic studies continue to move forward and we're ready to move into our GLP tox studies which is really the last remaining study before we're able to file an IND. We have a very good plan how to move forward and filing from where we are today to filing the IND, we believe it to be about a nine-month process. We have very strong interest from the clinical community and a number of different clinical sites and investigators willing and interested to participate in the trials. Of course we view Kelvin as a key driver in that process and Roswell Park as a key component to that process. But we believe we're nine months away from filing an IND and moving forward. Kelvin, if you want to add anything about the interest level from your side? Dr. Lee: It's extremely high. And again, like I said, the patients that I treat that have the biggest clinical challenge and the biggest challenge are those patients that have chemotherapy-resistant multiple myeloma. And those are the patients that we really need good options for and that we really need new approaches for so we are really excited to do this trial. It's one of those I suspect we could have this trial for Phase I completely accrued within three months --probably shorter than that depending on the trial design. We have a lot of patients that this PIM2 inhibitor has a tremendous amount of potential for. Jenny: Thats amazing. So, the IND, what does that stand for and how long between the time you file for an IND can you get a clinical trial started because that's a process in itself, right? Dr. Baldino: IND stands for Investigational New Drug application. That's filed with the FDA. The way it works is if they don't contact you within 30 days of filing that document, that means you're okay and ready to move in to Phase I trials. I think a lot of the legwork, it comes in putting the IND package together which will have a description of the clinical protocol and all the information that you've compiled during your preclinical work. So it really is a kind of a 30-day waiting period. As long as everything passes through the FDA without a hitch, you're able to move forward into your clinical trials. And usually there is an intermediate step where you'll have an interaction with the FDA as you're preparing the IND so that some of the questions can be answered at the point where you filed the IND things go fairly smoothly. Jenny: And of course you're working with mice so they might not be telling you about their side effects and there has been no Phase I clinical trials yet but do you have any indication about what potential side effects could exist? Dr. Baldino: So at this point we've done a number of initial toxicity studies in both rodents and dog and what we've demonstrated is that doses that provide efficacious plasma levels of JP-11646 are well tolerated by the animals. Of course that's a good first step but we need to move into the GLP tox studies. We have protocols for those studies that have already been designed. The studies take about six months to complete and then the results from those studies will really give the answers to this question and help us to design the clinical protocol as we move forward into those trials. And then really the key question is how is it tolerated by humans as you move into the Phase I studies. Dr. Lee: Right. And one interesting observation that we made is that we've actually looked at the effect of JP-11646 in normal human blood mononuclear cells so the white cells in your blood. Those cells in fact express Pim-2 but for some reason, JP-11646 doesn't shut off Pim-2 expression in normal cells, or at least the normal blood cells. So there appears to be a differential mechanism where it turns off Pim-2 expression in myeloma cells but doesn't seem to do the same thing in normal blood cells. So that is promising to us that the side effects will be reasonably modest with this drug. Jenny: Well, that would be great because we've heard about some other drugs that could potentially, depending on what target you go after, could potentially be damaging. We don't really want that. Dr. Lee: Right, exactly! Jenny: So just a couple more questions from me and I'll I'm kind of hogging all the time. Will this work for the 14;20 MAFB translocation as well or would it mostly be present in the c-Maf which is the 14;16? Dr. Lee: As you alluded to earlier, I think it has efficacy beyond just MAF. So my guess is that it will work on all the MAF translocations because I don't think it's working on MAF specifically; I'm thinking it's working on what MAF is doing to the cell. So as long as the MAFs are going through a common pathway and if other processes like CD28 is going through that pathway, JP-11646 is going to be able to target that. So I think that it's not just c-Maf that is going to be targeted by this drug. I think other processes that are important for the survival of the myeloma are going to be targeted too. Dr. Baldino: Just to add, we've also looked at a panel of myeloma cells and showed kind of broad efficacy. We've had good efficacy with cells that have the t(4;14) and the t11;14 translocation. Unfortunately we haven't tested the cell line with the 14;20 translocation. Jenny: Jack, would you like to ask any questions that you have? We'll go through Jack, Pat and Gary and see if they have other questions. Jack: Sure, Jenny, I'm happy to. Thank you very much for letting me participate in this. Some of the questions I had have already been asked so I want to ask some questions related to better understanding the biology, I guess. Can you explain to me what's the relationship if there is one, among MAF, Pim-2 and CD28? Dr. Lee: That's a great question that we don't know because that is what we are trying to figure out. So currently, the literature does not connect, there's no scientific research that says that Pim-2 and CD28 are connected although our data suggest that those two are connected, that Pim-2 maybe somewhere in the CD28 signaling pathway. And there is very little literature between how MAF and CD28 is connected although again, our data suggests that MAF is regulating CD28 expression or activity and there's not very much data connecting the MAF and Pim-2. But all the sort of work that we've done suggests that they all are in the same bucket, that there are interactions that simply haven't been identified yet but there are all interacting with each other. One of the things that seem true is they all travel together, they travel in packs. So if one looks at say the myeloma cells from patients that seem to have overexpression of MAF, you also see that those cells overexpress CD28 and those cells have overexpression of Pim-2. So they tend to travel in packs, which says to me that they are related to each other and they are all connected to each other, we just don't know what those connections are yet. Jack: Thank you. In the letter of intent, you wrote that "The treatment of MM cells with JP-11646 at low mm levels rapidly decreases Pim-2 protein." Low mm levels, is that the micromolar, is that just basically the dosage level of JP-11646? Dr. Baldino: Yes, that's minimolar. At minimolar levels when cells are treated with the drug, it decreases the PIM expression levels. Jack: And then you followed that by saying "Interestingly, this happens in MM cells but not PMBCs." Is that the same response you were explaining to Jenny earlier about --? Dr. Lee: That stands for Peripheral Blood Mononuclear Cells so those are human white blood cells essentially. Jack: Got it. And currently, is Jasco Pharmaceuticals funding all these research? Dr. Baldino: Yes. We have funded all the research to date and we continue and are dedicated to move in this program forward. We're thrilled to be working with Roswell Park. And we, like every small company, are looking for multiple mechanisms to be able to move the program forward. Jack: Thanks very much. I'll let someone else's questions. Jenny: Now, Gary, you have several questions. Gary: Yes, I do and thank you very much. My lawn guys are out there so hopefully I don't have any background noise. In some of the literature and there's not a whole heck of a lot I guess because you're relatively new. You can Google JP-11646 and there's just a handful of information. But online it has shown activity against solid tumors including breast, colon, liver, lung and pancreatic cancers as well as multiple myeloma. So what have been the results for these other cancers or has there been and have some gotten to human trials? And with JP-11646, does it have efficacy for other myeloma FISH abnormalities other than 14;16 or could it be beneficial for low-risk disease as well? Dr. Baldino: So let me start to address the question. That's a good question. So in our work with Roswell Park, there was an interest to study the compound in other cancer types. In all the ones that you've mentioned there, it's known that the PIMs are overexpressed in those cancer types. So again, we were able to confirm that in a cancer type where there's overexpression of the PIMs, the drug, JP-11646, has efficacy. So all of those studies are sort of at a preliminary stage. We as a company focus on multiple myeloma with the potential to show an enhanced effect within this high-risk MAF subgroup. So kind of our mission was to identify a critical need and focus our effort in that area. And as Kelvin -- and maybe Kelvin you can add to this -- already mentioned, we've also demonstrated broad efficacy within the different multiple myeloma subtypes. So we think there is applicability broadly for multiple myeloma and the potential in other cancers but our focus as a small company is to drive the program as quickly as possible to the clinic for these high-risk patients. Dr. Lee: Yes. And as Carmen alluded to, I think that it does have efficacy against both -- other translocations so both high-risk and low-risk. Our initial testing suggests that at least ten to a hundredfold more potent than the other PIM2 inhibitors that we've tested that are also currently out in clinical testing. Now most of the other pharmaceutical companies had focused on acute myeloid leukemia in their PIM2 inhibitor programs. So there's not very much going on in multiple myeloma although there is suggestion that other pharmaceutical companies are also interested in that. AML seems to be another target and certainly as Carmen alluded to, we see broad activity in a wide range of solid tumors -- lung, prostate cancer, bladder -- so it is a drug that in addition to its efficacy in multiple myeloma may be broadly effective in a whole range of cancers. Gary: Could wipe cancer clean, huh? Dr. Lee: Well, I don't know about that. Gary: So somebody walks in they've got breast, colon, liver, lung, pancreatic and multiple myeloma, boom! One size fits all. Dr. Lee: Give them one dose. That way I could retire and just go drink margaritas on the beach or something. That would be great from my standpoint. Gary: Of course. Sell your company to Google for $400 million. Dr. Lee: Well, I'll let Carmen worry about that part. Gary: Okay. Well, one other question and this could be a stupid question. I hear so many times that drugs are tested in vitro. And then somebody says unfortunately whenever you put the drug into a human, the bone marrow microenvironment creates an issue that you can't duplicate in vitro. And as a result, I'm thinking to myself, well, then why not throw a little bone marrow in that darn test tube. Dr. Lee: That's a great question and that's actually one of the big challenges for the multiple myeloma field is that we don't have yet although people are developing great models of how the myeloma interacts with the bone marrow microenvironment. That having been said, we believe, and we're probably biased, that CD28 is one of those major interactions that happen between multiple myeloma and the bone marrow. And so if you can target anything that CD28 is doing, you're essentially targeting how the myeloma interacts with the bone marrow microenvironment. So we think that that's one of the reasons why we think that this PIM2 inhibitor has real promise because it goes after one of the key communication pathways between the myeloma and the bone marrow microenvironment. Gary: Okay, thank you. One last question and maybe a short follow up. You want to study the role of the PIM kinase and how they play in CD28 signaling pathways and that is a survival mechanism that is a major cause of resistance to frontline multiple myeloma treatments. What percentage of myeloma patients have this CD28 signaling pathway? I think you said something on the order of depending on how many times you've been treated, it becomes more and more. So likelihood is that this becomes more and more important the later you are in your stage of myeloma development? Dr. Lee: Exactly right. So it starts off about 20% but as people relapse, it essentially by the very end, really almost 100% of multiple myeloma patients are CD28 positive. So again, we think that anything that can interfere with that pathway like JP-11646 is going to be very useful with that later stage chemotherapy-resistant multiple myeloma. Gary: Well, that's very, very interesting. I'll leave it up to Pat because I see we're running out of time. Jenny: Pat, did you have some questions? Pat: Well, my first thought -- Gary sort of kidded about this with the Google thing -- was so why isn't Novartis or Celgene backing up with a dump truck full of $100 bills. This sounds too good to be true so what are some of the possible sort of sticking points, some of the landmines? Dr. Lee: Well, I'll just make one comment and Carmen knows this field better. My impression has been that large pharmaceutical companies are risk-averse which is why what you guys do is so important. Large pharmaceutical companies want to see the Phase I, Phase II study done and then dive in and they don't want to assume the risk of very early stage development. So that's where the big gap is, this is why I think you guys are doing phenomenal work. Because this is the whole where Celgene or Amgen or Bristol-Myers Squibb is not going to come in and say, "Hey, you have a product. We don't know how it's going to work in patients but here's a zillion dollars just on promise" So that's just not the way that pharmaceutical companies who have to make money, which is what their shareholders want, that's how they operate. So they don't really like taking risks on early development, which is why I think what you guys do is phenomenal. Dr. Baldino: So let me add to that and I think that Kelvin is right that a lot of companies have talked to us and the PIM area is becoming very exciting within the pharmaceutical and biotech industries. So there are a lot of folks getting involved in the area and there is interest. And I think what a lot of companies and groups would like to see a program move a bit further, get at least to the IND stage, start some clinical trials, efforts before they jump in. That can always change but I think the challenge for a lot of small companies like Jasco is to find a way to continue to progress the program until somebody makes the decision to jump in and help out. So I think ultimately to bring a drug to market, a small company like Jasco is going to need help and we continue to pursue that help. But it's sort of a juggling act where you're trying to find ways and continue to progress the program, to answer questions and to reduce the risk so that people are able to jump in and help out. So we're very positive about the program. We're dedicated to finding those mechanisms and we continue to have people like Kelvin who give us a lot of excitement about moving the program forward and that there's the potential that can it do some good. So that's what drives us. But it's kind of the way the industry works. The small companies have to prove things in order to make that program move forward and that's what we're doing. Pat: Sure, I get it, but this sounds pretty darn good. So let's say you get some help from people like ourselves and maybe others and things start progressing. As a high-risk late stage myeloma patient myself, how long until something like this might actually I'm not sure FDA-approved but at least get to a point where there will be enough clinical trials that it could be helping patients? Dr. Baldino: So as I mentioned, we believe we can complete the preclinical and file the IND within nine months of Phase I trial for high-risk multiple myeloma patients could initiate a month after filing that IND. And that Phase I study on average in the industry would take about 12 months, could be shorter if you're optimistic. And then you can move into a Phase IIa study where you're treating a larger group of patients. So within a couple of years, you have the potential to be in a larger group of patients. Pat: Sure, so 3 or 4 years, and this thing could really be rocking and rolling. Dr. Lee: That would be great. Pat: I wish you guys the best of luck. Thanks for including me, Jenny. Jenny: Oh, thank you. And I just want to comment, I think you're in the classic what's called the valley of death. So I interviewed Craig Crews about Carfilzomib and that stage where you first start testing compounds, you have that early pharmaceutical company that's working and growing and then you start showing results, you move to different sources of funding. There's this classic gap that exists. And so it sounds like you're in that gap that needs to be filled to really move forward. Dr. Lee: Yes, exactly. And again, like I said, this is exactly what we think that your guys' efforts are phenomenal. Jenny: Well, if no one else has any other question I'll ask one last question. You talked a little bit about this. Can you walk us through your next step milestones and then just an estimated budget of how much you would need to get those steps finished or completed. Dr. Baldino: Sure, sure, happy to do that. So really the next key milestone is to complete the GLP tox studies and then to use that data to compile our IND package and file that. As I've said, we think that's about a nine-month process and we believe we can get that done with about $800,000. The next milestone would be to then initiate a Phase I study for relapsed, refractory multiple myeloma patients. We would look to enhance the patient population to have enough of the MAF subgroup patients in order to show an enhanced effect in that subgroup. And using sort of industry averages, you'd look at about a 12-month study there and you'd need about $2.1 million to complete that study. Jenny: And do you usually have pharma partners at that point or you would still just drive that yourself? Dr. Baldino: We as a small company would be happy to have a pharmaceutical partner at any point along that path. As we gained a lot of knowledge working with Roswell Park and Kelvin's group, we'd be thrilled to have another group come in with more expertise to help guide and move the program forward. Our goal is really to find the best path forward for the program and certainly would be happy to have a partner to help move that along. Jenny: I'm just curious about how that works. Well, Dr. Baldino and Dr. Lee, we are so thrilled that you're joining us today. This is very exciting stuff. Dr. Lee: Thanks! Jenny: We're very excited with what you're doing and hope your work will continue and hope we can help you. Dr. Lee: All right, great! Thank you very much. Dr. Baldino: Thank you. Enjoyed the discussion. Jenny: Thank you so much for listening to the Myeloma Crowd Radio and the new MCRI series. 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