This document provides an overview of immunotherapy and how it works to treat cancer. It discusses the roles of T cells, antigen presenting cells, and cytokines in the immune response. It describes how tumors evade immune surveillance and strategies used in immunotherapy to overcome tumor resistance, such as blocking inhibitory receptors like CTLA-4 and PD-1 to reactivate T cells. Several studies are summarized that show improved survival outcomes for cancers like melanoma when treated with immunotherapies like nivolumab compared to chemotherapy. Combination approaches blocking multiple pathways are also discussed.

1. Immunotherapy 101
Claire Friedman
10/8/15

2. Let’s take a step back…
• To basic immunology!
• T cells
– Two main subsets: CD4+ (helper) and CD8+ (effector)
– CD4+ cells can be broken down further into Th1, Th2
and Treg
– Th1 : proinflammatory, stimulated by IFN-ɣ, support
anti-viral and anti-tumor responses.
– Th2: anti-inflammatory, associated with secretion of
IL-10. Favor anti-parasitic responses.
– T reg: Inhibit and dampen immune response

3. T cells
• Cytotoxic T cells
– Upon activation can proliferate and directly kill
infected or cancerous cells
– Activation requires two signals: One from an APC,
one from a costimulatory molecule such as CD28
• Helper T cells
– Facilitate a coordinated immune response
– Can differentiate down a number of pathways
based on the cytokine milieu

4. Antigen Presenting Cells
• Cells that display foreign antigens complexed
with MHCs
• Examples: Dendritic cells, macrophages, some
B-cells
• Can interact with T cells via the T cell receptor
and direct the pathway of the T cell

6. Cancer and the immune system
• Our immune system is constantly looking for
abnormal cells and destroying them
– It’s called tumor necrosis factor (TNF) for a reason
• So how does cancer evade this surveillance?

9. Tumor Intrinsic Factors
• Antigen Loss or MHC loss
• Secretion of immunosuppressive cytokines
• Expression of cell-surface markers such as
programmed death ligand 1 (PD-L1) that alter
T cell function
• Like the invisibility cloak from Harry Potter

10. Tumor Extrinsic Factors
• Geographic barriers
• Suppressive or regulatory immune cells
– Tregs
– Myeloid derived suppressor cells (MDSCs)
– Tumor-associated macrophages (TAMs)

11. So, where do we go from here?
• How can we train our immune systems to
overcome both types of resistance?

12. Driving the T cell
T cells have both a gas pedal and a brake pedal (otherwise
known as activating receptors and inhibitor receptors)
(Mellman I., Coukos G., and Dranoff G. Nature.2011;480(7378):480-9)

13. Ipilimumab AugmentsT-Cell Activation and Proliferation
Adapted from O’Day et al. Plenary session presentation, abstract #4, ASCO 2010.
T-cell
APC
TCR
HLA CD80/
CD86
T-cell
inhibition
CTLA-4
CD28
T-cell
APC
TCR
HLA
T-cell
activation
CD28TCR
HLA
T-cell
APC
CD80/
CD86
T-cell
remains active
Ipilimumab
blocks
CTLA-4
T-cell
APC
CTLA-4
CD80/
CD86
TCR
HLA

14. Immune-RelatedAdverse Events
• Rash (approx 20%)
• Colitis/enteritis (approx 15%)
• Elevated AST/ALT (approx 10%)
• Endocrinopathies: Thyroiditis, Hypophysitis, Adrenal
insufficiency(2-5%)
Severity is inversely related to vigilance of surveillance.
If detected early, most are easily treated and reversible.

15. Ipilimumab Pattern of Response:
Responses After the Appearance and Subsequent Disappearance of
New Lesions
3 mg/kg
ipilimumab
Q3W X 4
Pre-treatment
Week 36: Still Regressing
Week 12: Progression
Week 20: Regression
New lesions
Source: 2008 ASCO
Abstract #3020 Wolchok.
July 2006

16. irRC Identifies Survivors in Patients with Progressive Disease
by mWHO
Pooled data from phase II studies CA184-008 and CA184-022:
ipilimumab monotherapy 10 mg/kg (N=227)
Wolchok et al, Clin Cancer Res, 2009

17. Patients at Risk
Ipilimumab 4846 1786 612 392 200 170 120 26 15 5 0
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 12 24 36 48 60 72 84 96 108 120
Ipilimumab
CENSORED
Ipilimumab LongTerm Pooled Survival Analysis:
4846 Patients
Median OS (95% CI): 9.5 (9.0–10.0)
3-year OS Rate (95% CI): 21% (20–22%)
ProportionAlive
Months
Schadendorf, Hodi Wolchok, ESMO, 2013

18. MHC
PD-L1
PD-1 PD-1
PD-1 PD-1
Nivolumab, Pembrolizumab:
PD-1 Receptor Blocking Abs
Recognition of tumor by T cell through
MHC/antigen interaction mediates IFNγ release
and PD-L1/2 up-regulation on tumor
Priming and activation of T cells through
MHC/antigen & CD28/B7 interactions with
antigen-presenting cells
T-cell
receptor
T-cell
receptor
PD-L1
PD-L2
PD-L2
MHC
CD28 B7
T cell
NFκB
Other
PI3K
Dendritic
cellTumor cell
IFNγ
IFNγR
Shp-2
Shp-2
Role of PD-1 Pathway inTumor Immunity
18
Sznol et al., ASCO, 2013

19. Tumor Burden in Patients with Melanoma Receiving Nivolumab
19
Vertical line at 96 weeks = maximum duration of continuous nivolumab therapy
Horizontal line at −30% = threshold for defining objective response (partial tumor regression) in absence of new lesions or non-target disease
according to RECIST
Unconventional response = response patterns that did not meet RECIST criteria (e.g., persistent reduction in target lesions in the presence of new
lesions, or regression following initial progression)
All Mel patients treated with 3 mg/kg nivolumab 4 Mel patients treated with unconventional responses
from nivolumab
1st occurrence
of new lesion
3 mg/kg
Weeks since treatment initiation
Changeintargetlesionsfrombaseline(%)
1st occurrence
of new lesion
Weeks since treatment initiation
Changeintargetlesionsfrombaseline(%)
1 mg/kg
1 mg/kg1 mg/kg
10 mg/kg
Sznol et al., ASCO, 2013

20. Georgina V. Long, Victoria Atkinson, Paolo A. Ascierto, Benjamin Brady,
Caroline Dutriaux, Michele Maio, Laurent Mortier, Jessica C. Hassel, Piotr Rutkowski,
Catriona McNeil, Ewa Kalinka-Warzocha, Kerry J. Savage, Micaela Hernberg,
Celeste Lebbé, Julie Charles, Catalin Mihalcioiu, Vanna Chiarion-Sileni, Cornelia Mauch,
Henrik Schmidt, Dirk Schadendorf, Helen Gogas, Christine Horak, Brian Sharkey,
Ian Waxman, Caroline Robert
Nivolumab Improved Survival
vs Dacarbazine in Patients with
Untreated Advanced Melanoma

21. Phase 3 CA209-066: Study Design
*Patients may be treated beyond initial RECIST v1.1-defined progression if considered by the investigator to be experiencing
clinical benefit and tolerating study drug
Treat until
progression* or
unacceptable
toxicity
Primary endpoint:
• OS
Secondary endpoints:
• PFS
• ORR
• PD-L1 correlates
R
1:1
Nivolumab
3 mg/kg IV Q2W
+
Placebo
IV Q3W
N=210
(206 treated)
Placebo
IV Q2W
+
Dacarbazine
1000 mg/m2 IV Q3W
N=208
(205 treated)
Double-
blind
Eligible patients with
unresectable stage III
or IV melanoma
(N=418)
• BRAF wild-type
• Treatment-naïve
Stratified by:
• PD-L1 status
(≥ 5% cell-surface
staining cutoff)
• M-stage

22. Best Overall Response
Nivolumab
(N = 210)
Dacarbazine
(N = 208)
ORR, % (95% CI) 40% (33–47%) 14% (10–19%)
Best overall response
Complete response 8% 1%
Partial response 32% 13%
Stable disease 17% 22%
Progressive disease 33% 49%
Unable to determine 11% 15%
Based on 5 August 2014 database lock.

23. 0 3 6 9 12 15 18
Primary Endpoint: Overall Survival
Patients who died,
n/N
Median OS
mo (95% CI)
Nivolumab 50/210 NR
Dacarbazine 96/208 10.8 (9.3–12.1)
NR = not reached.
Based on 5 August 2014 database lock.
100
90
80
70
60
0
50
40
30
20
10
HR 0.42 (99.79% CI, 0.25–0.73; P < 0.0001)
(Boundary for statistical significance 0.0021)
210
208
185
177
150
123
105
82
45
22
8
3
0
0
Nivolumab (N = 210)
Dacarbazine (N = 208)
Months
PatientsSurviving(%)
1-yr OS 73%
1-yr OS 42%
Patients at Risk
Nivolumab
Dacarbazine
Follow-up since randomization: 5.2–16.7 months.

24. Improved OS irrespective of PD-L1 status
OS by PD-L1 Status*
100
90
80
70
60
0
50
40
30
20
10
0 3 6 9 12 15 18
Months
Nivolumab PD-L1+
Dacarbazine PD-L1+
Nivolumab PD-L1-
Dacarbazine PD-L1-
Patients at Risk
Dacarbazine PD-L1-
Nivolumab PD-L1-
Dacarbazine PD-L1+
Nivolumab PD-L1+
74
128
74
126
69
108
64
107
56
88
44
78
39
63
30
52
18
26
11
11
1
7
1
2
0
0
0
0
PatientsSurviving(%)
1-Yr OS
% (95% CI)
82.1 (69.6–89.8)
67.8 (58.3–75.7)
52.7 (37.7–65.7)
37.4 (26.4–48.3)
Patients
who died,
n/N
Median OS
mo (95% CI)
Nivolumab PD-L1+ 11/74 NR
Nivolumab PD-L1- 37/128 NR
Dacarbazine PD-L1+ 29/74 12.4 (9.2–NR)
Dacarbazine PD-L1- 64/126 10.2 (7.6–11.8)
*PD-L1 positive: ≥ 5% tumor cell surface staining. PD-L1 negative: < 5% tumor cell surface staining. NR=not reached.
Based on 5 August 2014 database lock.

25. KEYNOTE-006 (NCT01866319):
International, Randomized, Phase III Study
Patients
• Unresectable, stage III or IV
melanoma
• ≤1 prior therapy, excluding anti–
CTLA-4, PD-1, or PD-L1 agents
• Known BRAF statusa
• ECOG PS 0-1
• No active brain metastases
• No serious autoimmune disease
Pembrolizumab
10 mg/kg IV Q2W
Pembrolizumab
10 mg/kg IV Q3W
R
1:1:1
Stratification factors:
• ECOG PS (0 vs 1)
• Line of therapy (first vs second)
• PD-L1 status (positiveb vs negative)
Ipilimumab
3 mg/kg IV Q3W
x 4 doses
aPrior anti-BRAF targeted therapy was not required for patients with normal LDH levels and no clinically significant tumor-related symptoms or evidence of rapidly
progressing disease.
bDefined as membranous PD-L1 expression in ≥1% of tumor cells as assessed by IHC using the 22C3 antibody.
• Primary end points: PFS and OS
• Secondary end points: ORR, duration of
response, safety

26. 0 2 4 6 8 10 12 14
0
10
20
30
40
50
60
70
80
90
100
Time, months
Progression-FreeSurvival,%
No. at risk
279 231 147 98 49 7 2 0
277 235 133 95 53 7 1 1
278 186 88 42 18 2 0 0
PFS at Interim Analysis 1 (IA1)
Analysis cut-off date: September 3, 2014.
Median
(95% CI), mo
Rate at
6 mo
HR
(95% CI) P
5.5 (3.4-6.9) 47.3% 0.58
(0.46-0.72)
<0.00001
4.1 (2.9-6.9) 46.4% 0.58
(0.47-0.72)
<0.00001
2.8 (2.8-2.9) 26.5% — —
Pembrolizumab Q2W
Pembrolizumab Q3W
Ipilimumab

27. 0 2 4 6 8 10 12 14 16 18
30
40
50
60
70
80
90
100
Time, months
OverallSurvival,%
No. at risk
279 266 248 233 219 212 177 67
277 266 251 238 215 202 158 71
278 242 212 188 169 157 117 51
19
18
17
0
0
0
OS at the Second Interim Analysis (IA2)
Analysis cut-off date: March 3, 2015.
Treatment Arm
Median
(95% CI), mo
Rate at
12 mo
HR
(95% CI) P
Pembrolizumab
Q2W
NR (NR-NR) 74.1% 0.63
(0.47-0.83)
0.00052
Pembrolizumab
Q3W
NR (NR-NR) 68.4% 0.69
(0.52-0.90)
0.00358
Ipilimumab NR (12.7-NR) 58.2% — —

28. What about other malignancies
besides melanoma?

29. Ansell SM et al. N Engl J Med 2015;372:311-319.
Response Characteristics and Changes in Tumor Burden in Patients with Hodgkin's
Lymphoma Receiving Nivolumab.

30. Brahmer J et al. N Engl J Med 2015;373:123-135.
Efficacy of Nivolumab versus Docetaxel in Patients with Advanced Squamous-Cell Non–
Small-Cell Lung Cancer.

31. Motzer RJ et al. N Engl J Med 2015. DOI: 10.1056/NEJMoa1510665
Nivolumab vs Everolimus for the treatment of metastatic RCC

32. Blocking CTLA-4 and PD-1
T cell
Tumor cell
MHC
TCR
PD-L1PD-1
- - -
T cell
Dendritic
cell
MHC
TCR
CD28
B7 CTLA-4
- - -
Activation
(cytokines, lysis, proliferation,
migration to tumor)
B7
+++
+++
CTLA-4 Blockade (ipilimumab) PD-1 Blockade (nivolumab)
anti-CTLA-4
anti-PD-1
Tumor Microenvironment
+++
PD-L2PD-1
anti-PD-1
- - -

33. Larkin J et al. N Engl J Med 2015;373:23-34.
Nivolumab vs ipilimumab vs combination therapy in patients with metastatic
melanoma: progression-free survival.

34. Larkin J et al. N Engl J Med 2015;373:23-34.
Tumor-Burden Change in Target Lesions.

35. Where do we go from here?
• Combination immunotherapy in other disease
areas (AML, CLL, head and neck)
• Other checkpoint antibodies (LAG3, GITR,
OX40) alone and in combination with PD-1
• Checkpoint inhibitors in combination with
therapeutic vaccines (Ty-Vec with anti-PD-1)

36. Questions?