Abstract IA21: Targeting WEE1 kinase to potentiate chemoradiation in the treatment of pancreatic cancer
Authors: Lawrence Theodore S. , Morgan Meredith A. 
Published: April 2017

Abstract
Pancreas cancer is projected to cause approximately 42,000 deaths in 2016, making it the third greatest cause of cancer mortality (behind lung and colorectal, but greater even than breast). Systemic failure remains the dominant cause of death, although local failure is responsible for up to 1/3 of the pancreatic cancer related mortality. We have focused on improving the treatment of locally advanced pancreatic cancer, defined as disease which cannot be resected but has not overtly metastasized, where the issue of local control becomes even more important, and have hypothesized that the treatment of locally advanced pancreatic cancer will require control of both the gross primary tumor as well as the microscopic disease that exists in virtually every patient. Gemcitabine has been a mainstay of treatment for pancreatic cancer, and we have standardized combining it with radiation for locally advanced disease. Because our initial studies revealed that activation of the DNA damage response, particularly activation of CHK1 and WEE1, were crucial in the defense pancreatic cancers mount against chemotherapy and radiation, we have studied the effect of CHK1 and WEE1 inhibitors on gemcitabine and gemcitabine-radiation mediated cytotoxicity. These inhibitors abrogate the G2 checkpoint after DNA damage. The initial hypothesis for using CHK1 and WEE1 inhibitors was that cancer cells lacking a p53 checkpoint would be selectively sensitized, compared to normal cells, because normal cells would be protected by an intact G1 checkpoint. After initial studies with several agents, we have focused on the WEE1 inhibitor AZD1775, chiefly because it was available for a clinical trial.
We have carried out both mechanistic and clinical studies using AZD1775. Mechanistically, we have evaluated both the contributions of homologous recombination repair (HRR) inhibition and G2 checkpoint abrogation by γH2AX, BRCA2 manipulation, and RAD51 focus formation and pHistoneH3 flow cytometry, respectively in pancreatic cancer model systems. AZD1775 causes inhibition of CDK1 phosphorylation and G2 checkpoint abrogation. Sensitization by AZD1775 is associated with persistent γH2AX and inhibition of RAD51 focus formation. Using BRCA2 isogenic cells, we have found that AZD1775 sensitizes to gemcitabine-radiation in BRCA2 wild type cells, while in BRCA2 null cells AZD1775 did not sensitize despite significant G2 checkpoint abrogation. In vivo, in patient-derived pancreatic tumor xenografts, AZD1775 significantly inhibits tumor growth and impairs RAD51 focus formation in response to gemcitabine-radiation. We've concluded that, whereas sensitization is accompanied by inhibition of CDK1 phosphorylation and abrogation of the G2 checkpoint, this mechanism is not sufficient for sensitization. Our findings suggest that sensitization to chemoradiation by WEE1 inhibition also requires inhibition of HRR. The importance of HRR has also supported studies combining CHK1 or WEE1 inhibition with a PARP inhibitor, which would be anticipated to potentiate the effects of HRR inhibition.
Based on these studies, we have launched a clinical trial combining gemcitabine and gemcitabine-radiation, at standard doses, with dose escalating AZD1775 for patients with locally advanced pancreatic cancer. Patients receive one cycle of gemcitabine with AZD1775, then 2 cycles of gemcitabine-radiation with AZD1775, then another cycle of AZD1775-gemcitabine, followed by assessment for response and toxicity. Optional cycles of AZD1775 and gemcitabine are then given to patients who have not progressed. AZD1775 has been escalated according to a Time-to-Event Continual Reassessment Model, in which the dose for each patient is based on the toxicity profile of all prior patients, and the goal is to establish a tolerable dose of the combination therapy and to estimate the response and survival. With 21 patients entered onto the study, the median survival has not been reached, and the 64% survival at the 18-month landmark point exceeds the 18-month median survival that was the agreed on endpoint for triggering a larger trial. The trial also includes a pharmacodynamic endpoint of a hair follicle biopsy to assess target engagement.
In summary, these findings suggest that WEE1 inhibition may act through both G2 checkpoint abrogation but, more importantly, inhibition of HRR, and is a promising potentiator of gemcitabine-radiation in the treatment of locally advanced pancreatic cancer.
Supported by P50 CA130810, R01 CA163895, P30 CA46592, and the Taubman Institute
Citation Format: Theodore S. Lawrence, Meredith A. Morgan. Targeting WEE1 kinase to potentiate chemoradiation in the treatment of pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference on DNA Repair: Tumor Development and Therapeutic Response; 2016 Nov 2-5; Montreal, QC, Canada. Philadelphia (PA): AACR; Mol Cancer Res 2017;15(4_Suppl):Abstract nr IA21.