Combination therapy for treating disease   

This application is a continuation of U.S. application Ser. No. 10/831,886, filed on Apr. 26, 2004, which is a continuation-in-part of U.S. application Ser. No. 09/871,339, filed on May 31, 2001, which is a continuation of U.S. application Ser. No. 08/913,290, filed on Mar. 20, 1998, now U.S. Pat. No. 6,241,985, which is a National Stage application of PCT application number PCT/IB96/00461, filed on May 15, 1996; each of which is hereby incorporated in its entirety by reference. International Application No. PCT/IB96/00461 was published under PCT Article 21(2) in English.

1. Field of the Invention

The invention relates to immunology. More particularly the invention relates to the use of immunotherapy in combination with chemotherapy.

2. Summary of the Related Art

Despite the progress that modern medicine has made in treating cancer, cancer recurrence remains a concern. For a majority of cancers, typical treatment includes surgery followed by high doses of chemotherapy. A majority of these patients relapse and do not respond to other chemotherapeutic treatments. These patients then avail themselves to experimental or salvage treatments.

Current experimental regimens focus on mixing chemotherapies in an attempt to overcome resistance issues. Most of these treatments result in serious blood toxicities such as neutropenia, and thrombocytopenia. Other serious and frustrating symptoms to the patient include hair loss and nausea. Researchers are now looking at ways to enhance the immune system through less toxic means while still eliminating the cancer.

Many have turned to the use of chemotherapy in conjunction with antibody treatments. Many of these have also presented similar toxicities to the chemotherapy.

Thus, there remains a need to identify new treatments that not only treat the initial symptoms of a disease, but also alleviate and/or prevent recurrence of those symptoms.

In a first aspect the invention provides a method for treating cancer, comprising concurrently administering xenotypic monoclonal antibody and a chemotherapeutic drug to a patient suffering from cancer. Preferably the patient is human.

In a second aspect the invention provides a method for treating cancer, comprising surgical removal of the cancer, concurrent administration of a chemotherapeutic drug and a xenotypic monoclonal antibody in a dose equal to or less than 2 mg.

In a third aspect, the invention provides a method for treating cancer, comprising surgical removal of the cancer, administration of a xenotypic monoclonal antibody on weeks 1, 3, 5, 9, followed by concurrent administration of a chemotherapeutic drug and a xenotypic monoclonal antibody on week 12 in a dose equal to or less than 2 mg.

In a fourth aspect, the invention provides a method for inducing a host immune response in a patient against a multi-epitopic in vivo tumor antigen, which antigen does not elicit an effective host immune response, comprising concurrently administering to the patient a chemotherapeutic drug and a composition comprising a binding agent that specifically binds to a first epitope on the antigen and allowing the binding agent to form a binding agent/antigen pair, wherein a host immune response is elicited against a second epitope on the antigen.

In a fifth aspect, the invention provides a method for treating cancer, comprising concurrent administration of a chemotherapeutic drug, a binding agent, and an antigen.

In a sixth aspect, the invention provides a method for inducing a host immune response in a patient against a multi-epitopic in vivo tumor antigen, which antigen does not elicit an effective host immune response, comprising concurrently administering to the patient a chemotherapeutic drug and a composition comprising a binding agent present in an amount of from 0.1 μg to 2 mg per kg of body weight of the host, and wherein the binding agent specifically binds to an epitope on the antigen and an effective host immune response is elicited against a second epitope on the antigen.

In a seventh aspect, the invention provides a method for treating cancer, comprising administering a xenotypic antibody and a chemotherapeutic drug to a patient suffering from cancer.

FIG. 1 provides a table illustrating the results of three clinical studies where Alt-2 is administered concurrently with a chemotherapeutic drug.

FIG. 2 is a diagram showing a non-limiting embodiment of the invention.

FIG. 3 is a graph showing the difference in the numbers between Ab2 responders (white squares) (effective immune response) and Ab2 non-responders (black squares) (ineffective immune response) over time.

FIG. 4 is a table illustrating the different disease characteristics of Ab2 responders and Ab2 non-responders.

The present invention stems from the discovery that a combination of immunotherapy with traditional chemotherapy and/or radiotherapy alleviates and/or prevents the recurrence of cancer. The presence of a host anti-xenotypic antibody response in a patient will stimulate an immune response. The inventors have exploited this discovery to develop therapeutics containing binding agents useful in immunotherapy and chemotherapeutic or radiotherapeutic drugs, as well as methods for using these therapeutics. The patents and publications cited herein reflect the level of skill in this field and are hereby incorporated by reference in their entirety to the same extent as if each was specifically and individually indicated to be incorporated by reference.

Accordingly in one embodiment, the invention provides a method for treating cancer, comprising concurrently administering xenotypic monoclonal antibody and a chemotherapeutic drug to a patient suffering from cancer. In some embodiments of the invention, the binding by the xenotypic monoclonal antibody of a first epitope exposes a second distinct epitope on the antigen. In some embodiments of the invention, the xenotypic monoclonal antibody, when bound to the antigen, forms an immunogenic complex. Exemplary xenotypic monoclonal antibodies (“MAb”), preferably include IgG1 antibodies; chimeric monoclonal antibodies (“C-MAb”); humanized antibodies; genetically engineered monoclonal antibodies (“G-MAb”); fragments of monoclonal antibodies (including but not limited to “F(Ab)2”, “F(Ab)” and “Dab”); and single chains representing the reactive portion of monoclonal antibodies (“SC-MAb”). The binding agent may be labeled or unlabeled.

Where the patient is human, preferred xenotypic monoclonal antibodies include, without limitation, murine monoclonal antibodies. Particularly preferred murine monoclonal antibodies include Alt-1 (murine IgG1, specifically binds to MUC-1; ATCC No. PTA-975; American Type Culture Collection, Manassas, Va.), Alt-2 (OvaRex® MAb B43.13, murine IgG1, specifically binds to CA125; ATCC No. PTA-1883), Alt3 (murine IgG3, specifically binds to CA19.9; ATCC No. PTA-2691), Alt-4 (murine IgM, specifically binds to CA19.9; ATCC No. PTA-2692), Alt-5 (murine IgG1, specifically binds to CA19.9; ATCC No. PTA-2690); and Alt-6 (murine IgG1, specifically binds to prostate specific antigen (PSA); ATCC No. HB12526).

In certain embodiments of the invention, the chemotherapeutic drug used is commercially available. Some non limiting examples include carboplatin, cisplatin, docetaxel, paclitaxel, doxorubicin, HCl liposome injection, topotecan, hydrochloride, gemcitabine, cyclophosphamide, and etoposide or any combination thereof.

In preferred embodiments the chemotherapeutic drug is administered within a week before or after the murine monoclonal antibody.

Chemotherapeutic agents of the invention include chemotherapeutic drugs commercially available. Merely to illustrate, the chemotherapeutic can be an inhibitor of chromatin function, a topoisomerase inhibitor, a microtubule inhibiting drug, a DNA damaging agent, an antimetabolite (such as folate antagonists, pyrimidine analogs, purine analogs, and sugar-modified analogs), a DNA synthesis inhibitor, a DNA interactive agent (such as an intercalating agent), and/or a DNA repair inhibitor.

Chemotherapeutic agents may be categorized by their mechanism of action into, for example, the following groups: anti-metabolites/anti-cancer agents, such as pyrimidine analogs (5-fluorouracil, floxuridine, capecitabine, gemcitabine and cytarabine) and purine analogs, folate antagonists and related inhibitors (mercaptopurine, thioguanine, pentostatin and 2-chlorodeoxyadenosine (cladribine)); antiproliferative/antimitotic agents including natural products such as vinca alkaloids (vinblastine, vincristine, and vinorelbine), microtubule disruptors such as taxane (paclitaxel, docetaxel), vincristin, vinblastin, nocodazole, epothilones and navelbine, epidipodophyllotoxins (etoposide, teniposide), DNA damaging agents (actinomycin, amsacrine, anthracyclines, bleomycin, busulfan, camptothecin, carboplatin, chlorambucil, cisplatin, cyclophosphamide, cytoxan, dactinomycin, daunorubicin, doxorubicin, epirubicin, hexamethylmelamineoxaliplatin, iphosphamide, melphalan, merchlorehtamine, mitomycin, mitoxantrone, nitrosourea, plicamycin, procarbazine, taxol, taxotere, teniposide, triethylenethiophosphoramide and etoposide (VP16)); antibiotics such as dactinomycin (actinomycin D), daunorubicin, doxorubicin (adriamycin), idarubicin, anthracyclines, mitoxantrone, bleomycins, plicamycin (mithramycin) and mitomycin; enzymes (L-asparaginase which systemically metabolizes L-asparagine and deprives cells which do not have the capacity to synthesize their own asparagine); antiplatelet agents; antiproliferative/antimitotic alkylating agents such as nitrogen mustards (mechlorethamine, cyclophosphamide and analogs, melphalan, chlorambucil), ethylenimines and methylmelamines (hexamethylmelamine and thiotepa), alkyl sulfonates-busulfan, nitrosoureas (carmustine (BCNU) and analogs, streptozocin), trazenes—dacarbazinine (DTIC); antiproliferative/antimitotic antimetabolites such as folic acid analogs (methotrexate); platinum coordination complexes (cisplatin, carboplatin), procarbazine, hydroxyurea, mitotane, aminoglutethimide; hormones, hormone analogs (estrogen, tamoxifen, goserelin, bicalutamide, nilutamide) and aromatase inhibitors (letrozole, anastrozole); anticoagulants (heparin, synthetic heparin salts and other inhibitors of thrombin); fibrinolytic agents (such as tissue plasminogen activator, streptokinase and urokinase), aspirin, dipyridamole, ticlopidine, clopidogrel, abciximab; antimigratory agents; antisecretory agents (breveldin); immunosuppressives (cyclosporine, tacrolimus (FK-506), sirolimus (rapamycin), azathioprine, mycophenolate mofetil); anti-angiogenic compounds (TNP-470, genistein) and growth factor inhibitors (vascular endothelial growth factor (VEGF) inhibitors, fibroblast growth factor (FGF) inhibitors); angiotensin receptor blocker; nitric oxide donors; anti-sense oligonucleotides; antibodies (trastuzumab, rituximab); cell cycle inhibitors and differentiation inducers (tretinoin); mTOR inhibitors, topoisomerase inhibitors (doxorubicin (adriamycin), amsacrine, camptothecin, daunorubicin, dactinomycin, eniposide, epirubicin, etoposide, idarubicin, irinotecan (CPT-11) and mitoxantrone, topotecan, irinotecan), corticosteroids (cortisone, dexamethasone, hydrocortisone, methylpednisolone, prednisone, and prenisolone); growth factor signal transduction kinase inhibitors; mitochondrial dysfunction inducers, toxins such as Cholera toxin, ricin, Pseudomonas exotoxin, Bordetella pertussis adenylate cyclase toxin, or diphtheria toxin, and caspase activators; and chromatin disruptors. Preferred dosages of the chemotherapeutic agents are consistent with currently prescribed dosages.

The methods according to the invention are useful for providing a therapeutic benefit to patients suffering from cancer. As used herein, the term “cancer” is used to mean a condition in which a cell in a patient's body undergoes abnormal, uncontrolled proliferation. The abnormal cell may proliferate to form a solid tumor, or may proliferate to form a multitude of cells (e.g., leukemia). Note that because cancer is the abnormal, uncontrolled proliferation of a patient's cell, the term does not encompass the normal proliferation of a cell, such as a stem cell or a spermatocyte.

By “treating a patient suffering from cancer” is meant that the patient's symptoms are alleviated following treatment according to the invention. In one non-limiting example, a patient suffering from a highly metastatic cancer (e.g., breast cancer) is treated where additional metastasis either do not occur, or are reduced in number as compared to a patient who does not receive treatment. In another non-limiting example, a patient is treated where the patient's solid cancer either becomes reduced in size or does not increase in size as compared to a patient who does not receive treatment. In yet another non-limiting example, the number of cancer cells (e.g., leukemia cells) in a treated patient either does not increase or is reduced as compared to the number of cancer cells in a patient who does not receive treatment. In preferred embodiments the patient is human.

It will be appreciated that a “patient suffering from cancer” of the invention may express the mutant protein and not yet be symptomatic for the disease. For example, where the cancer is colon cancer (which is associated with the mutant K-ras protein), a patient with a mutant K-ras protein in some cells of the colon is a patient according to the invention even though that patient may not yet be symptomatic for colon cancer. “Associated with a mutant protein” means signs or symptoms of illness in a majority of patients are present when the mutant protein is present in the patient's body, but in which signs or symptoms of illness are absent when the mutant protein is absent from the patient's body. “Signs or symptoms of illness” are clinically recognized manifestations or indications of disease.

In one embodiment of the present invention, the patient in need of treatment is suffering from cancer of the prostate, ovaries, breast, stomach, lung, colon, and skin. In a preferred embodiment, the patient in need of treatment is a human.

Preferably, the therapeutic compositions of the invention further comprise a pharmaceutically acceptable carrier. By “pharmaceutically acceptable carrier” is meant carrier that is physiologically acceptable to the administered patient. One exemplary pharmaceutically acceptable carrier is physiological saline. Other pharmaceutically-acceptable carriers and their formulations are well-known and generally described in, for example, Remington's Pharmaceutical Sciences (18th Edition, ed. A. Gennaro, Mack Publishing Co., Easton, Pa., 1990).

“Administering” as used herein means providing the composition to the patient in a manner that results in the composition being inside the patient's body. Such an administration can be by any route including, without limitation, parenteral, sub-cutaneous, intradermal, intravenous, intra-arterial, intraperitoneal, and intramuscular.

Regardless of the route of administration selected, the compounds of the present invention, which may be used in a suitable hydrated form, and/or the pharmaceutical compositions of the present invention, are formulated into pharmaceutically acceptable dosage forms such as described below or by other conventional methods known to those of skill in the art.

Actual dosage levels of the active ingredients in the pharmaceutical compositions of this invention may be varied so as to obtain an amount of the active ingredient that is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient.

The selected dosage level will depend upon a variety of factors including the activity of the particular compound of the present invention employed, the route of administration, the time of administration, the rate of excretion of the particular compound being employed, the duration of the treatment, other drugs, compounds and/or materials used in combination with the particular composition employed, the age, sex, weight, condition, general health and prior medical history of the patient being treated, and like factors well known in the medical arts.

In a second aspect the invention provides a method for treating cancer, comprising surgery, administration of a chemotherapeutic drug, administration of a xenotypic monoclonal antibody in a dose equal to or less than 2 mg given by intravenous infusion over 20 minutes during weeks 1, 3, 5, 9, then every 8 weeks, followed by administration of a chemotherapeutic drug within 5 days of the administration of the binding agent.

In certain, non-limiting embodiments of the invention, the xenotypic antibody, e.g., Alt-2, is administered as a 2 mg dose dissolved in 50 mL saline and infused slowly preferably over approximately 20 minutes. If an allergic or other reaction occurs that may limit the completion of the dose, then a lower dose may be employed at that time or with subsequent treatments, so that the expected dose range would be 1-2 mg per treatment. Premedication with oral or intravenous dyphenhydramine (25 to 50 mg) is usually administered to lessen the risk of allergic reaction to the protein. The schedule used for combined Alt-2 and chemotherapy comprises administering Alt-2 at the dose above at weeks 1, 3, 5, 7, 9 with chemotherapy administered with Alt-2 on weeks 12 through 26. Administration of Alt-2 may be started after recovery from any required surgery that is done prior to the chemotherapy and then continued up to, and during, the chemotherapy treatment period. The chemotherapy can be given in 3-4 week cycles or other schedules according to the treating physician and common clinical practice. Chemotherapy may continue for up to six cycles followed by the xenotypic antibody administration every twelve weeks for up to two years.

In another aspect, the method provides for treating cancer comprising surgery, followed within seven days by administration of a xenotypic monoclonal antibody in a dose equal to or less than 2 mg given by intravenous infusion over 20 minutes during weeks 1, 3, 5, 9, then every 8 weeks with concurrent administration of a chemotherapeutic drug at week 3 and thereafter.

In another aspect of the invention, the murine antibody is administered at week 1 after completing standard surgery but has not yet begun chemotherapy. The murine antibody is administered in a dose equal to or less than 2 mg via a 20 minute intravenous infusion followed by a second treatment and concurrent administration of a chemotherapeutic drug on weeks 6 and beyond. “Concurrent Administration” means administration within a relatively short time period from each other. Preferably such time period is less than 2 weeks, more preferably less than 7 days, most preferably less than 1 day and could even be administered simultaneously.

The expected progression-free survival times may be measured in months to years, depending on prognostic factors including the number of relapses, stage of disease, and other factors. Overall survival is also measured in months to years. In the case of ovarian cancer, the addition of the xenotypic monoclonal antibody, Alt-2 is expected to increase the time to recurrence or progression, and may also prolong the survival time. Any improvement of 2 months or longer is usually considered to be clinically meaningful.

In one aspect, the invention provides a method for inducing a host immune response in a patient against a multi-epitopic in vivo tumor antigen in present in the host's serum, which antigen does not elicit a host immune response, comprising administering to the patient a chemotherapeutic drug and a composition comprising a binding agent that specifically binds to a first epitope ton the antigen and allowing the binding agent to form a binding agent/antigen pair, wherein a host immune response is elicited against a second epitope on the antigen. Exemplary multi-epitopic antigens are described in and herein incorporated by reference in Nicodemus C. F. et al, Expert Rev. Vaccines 1(1): 34-48 (2002); Qi et al, Hybridoma and Hybridomics 20: 313-323 (2001); and Berlyn et al., Clin. Immunol. 101: 276-283, (2001).

A “binding agent”, as used herein, refers to one member of a binding pair, including an immunologic pair, e.g., a binding moiety that is capable of binding to an antigen, preferably a single epitope expressed on the antigen, such as a pre-determined tumor antigen. In some embodiments of the invention, the binding of a first single epitope exposes a second distinct epitope on the antigen. In one embodiment of the invention, the binding agent, when bound to the antigen, forms an immunogenic complex. Exemplary binding agents include, but are not limited to: antibodies, monoclonal antibodies (“MAb”), preferably IgG1 antibodies; chimeric monoclonal antibodies (“C-MAb”); humanized antibodies; genetically engineered monoclonal antibodies (“G-MAb”); fragments of monoclonal antibodies (including but not limited to “F(Ab)2”, “F(Ab)” and “Dab”); single chains representing the reactive portion of monoclonal antibodies (“SC-MAb”); antigen-binding peptides; tumor-binding peptides; a protein, including receptor proteins; peptide; polypeptide; glycoprotein; lipoprotein, or the like, e.g., growth factors; lymphokines and cytokines; enzymes, immune modulators; hormones, for example, somatostatin; any of the above joined to a molecule that mediates an effector function; and mimics or fragments of any of the above. The binding agent may be labeled or unlabeled.

Preferred binding agents of the invention are monoclonal antibodies. Where the patient is human, these xenotypic monoclonal antibodies include, without limitation, murine monoclonal antibodies. Particularly preferred murine monoclonal antibodies include Alt-1 (murine IgGl, specifically binds to MUC-1; ATCC No. PTA-975; American Type Culture Collection, Manassas, Va.), Alt-2 (OvaRex® MAb B43.13, murine IgG1, specifically binds to CA125; ATCC No. PTA-1883), Alt3 (murine IgG3, specifically binds to CA19.9; ATCC No. PTA-2691), Alt-4 (murine IgM, specifically binds to CA19.9; ATCC No. PTA-2692), Alt-5 (murine IgG1, specifically binds to CAI 9.9; ATCC No. PTA-2690); and Alt-6 (murine IgG1, specifically binds to prostate specific antigen (PSA); ATCC No. HB-12526).

A “multi-epitopic in vivo tumor antigen” is an antigen that present multiple epitopes on its surface. Some non-limiting examples of such antigens include CA 125, MUC-1, PSA, CAI 9.9, and TAG-72.

“Inducing a host immune response” means that the patient experiences alleviation or reduction of signs or symptoms of illness, and specifically includes, without limitation, prolongation of survival. In certain preferred embodiments of the methods according to the invention, a CD8+ IFN-γ producing T cell is activated to induce a cytotoxic T lymphocyte (CTL) immune response in the patient administered the murine monoclonal antibody. In certain embodiments of the methods according to the invention, a CD4+ IFN-γ producing T cell is activated to induce a helper T cell immune response in the patient administered with the composition. These activated CD4+ IFN-γ producing T cells (i.e., helper T cells) provide necessary immunological help (e.g. by release of cytokines) to induce and maintain not only CTL, but also a humoral immune response mediated by B cells. Thus, in certain embodiments of the methods according to the invention, a humoral response to the antigen is activated in the patient administered with the composition.

Activation of a CD8+ and/or CD4+ IFN-γ producing T cells means causing T cells that have the ability to produce IFN-γ to actually produce IFN-γ, or to increase their production of IFN-γ. “Induction of CTL” means causing potentially cytotoxic T lymphocytes to exhibit antigen specific cytotoxicity. “Antigen specific cytotoxicity” means cytotoxicity against a cell presenting an antigen that is associated with the antigen associated with the cancer that is greater than an antigen that is not associated with the cancer. “Cytotoxicity” refers to the ability of the cytotoxic T lymphocyte to kill the target cell. Preferably, such antigen-specific cytotoxicity is at least 3-fold, more preferably 10-fold greater, more preferably more than 100-fold greater than cytotoxicity against a cell not presenting the antigen not associated with the cancer.

In another aspect, the invention includes a method for treating cancer, comprising concurrent administration of a chemotherapeutic drug, a binding agent, and an antigen.

In a further aspect, the invention provides a method for inducing a host immune response in a patient against a multi-epitopic in vivo tumor antigen, which antigen does not elicit an effective host immune response, comprising concurrently administering to the patient a chemotherapeutic drug and a composition comprising a binding agent present in an amount of from 0.1 μg to 2 mg per kg of body weight of the host, and wherein the binding agent specifically binds to an epitope on the antigen and an effective host immune response is elicited against a second epitope on the antigen.

Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments of the invention described herein. Such equivalents are intended to be encompassed by the following claims.

All of the above-cited references and publications are hereby incorporated by reference in their entireties.

The following example is intended to further illustrate certain particularly preferred embodiments of the invention and is not intended to limit the scope of the invention.

Patients with recurrence after platinum therapy and a first surgery and were enrolled if they were candidates for secondary surgery and continued chemotherapy. Alt-2 was administered by 20-minute infusion in weeks 1, 3, 5, and 9 prior to initiation of chemotherapy, and then an option to continue every 8 weeks×2 doses concurrent with chemotherapy on weeks 12 and 26. Humoral immune responses, including HAMA, Ab2 and anti-CA 125 antibody, were assessed at baseline and serially. Using gamma-interferon ELISPOT assay, T cell responses were evaluated for activation by Alt-2, CA125, or autologous tumor.

20 patients were enrolled; median follow-up was 6 months ranging up to 2 years. Alt-2 was well tolerated and did not produce drug-related serious adverse reactions. In 14 of 19 (710/6) evaluable patients, robust treatment-emergent humoral responses were observed to the constant (HAMA) and variable region of the antibody (Ab2). To date, 5 of 8 (62.5%) patients tested demonstrated functionally active T cells, stimulated by CAI or by autologous tumor. T cell responses to Alt-2 were demonstrated in 4 patients. T cell responses were MHC class I and 11 restricted, indicating the activation of CTL (cytotoxic T lymphocytes) and T helper cells. Immune responses were commonly induced by wk 12 after 4 doses, and were generally maintained in patients continuing combined treatment with Alt-2 and chemotherapy. 75% are still alive and median survival has not been reached at 120 weeks.

Alt-2 is well tolerated and induces multiple antigen-specific immune responses, even when combined with chemotherapy. In advanced EOC, these data are among the first to demonstrate induction of tumor-specific T cells.