Bispecific T-cell Engager Antibody Research Articles

Predictors of Efficacy for Blinatumomab in BCP-ALL Patients: Non-Responders Show Impaired CD19-BiTE®-Mediated Cytotoxicity in Vitro

Bispecific T-cell engaging (BiTE®) antibody constructs recruit T cells to target antigens independent of their T-cell receptor specificity. Blinatumomab, a CD19xCD3 BiTE® antibody construct, is approved for the treatment of relapsed/refractory (r/r) B-cell precursor acute lymphoblastic leukemia (BCP-ALL), including patients with persistence or reoccurrence of measurable residual disease (MRD). Despite superior anti-leukemic efficacy compared to cytostatic agents, a majority of patients do not respond to treatment. Biomarkers for the identification of non-responders prior to or early during treatment are unknown. However, the definition of robust biomarkers for efficacy is of high importance for clinical decision-making and might also indicate ways to improve response rates. We therefore established a comprehensive immune-monitoring program for blinatumomab patients. We sequentially analysed peripheral blood of patients with r/r or MRD-positive disease receiving blinatumomab prior to the start of infusion and once weekly over the course of the first 28-day cycle. We determined CD3+ T cell counts and their subset distribution (CD4, CD8, naïve [TN], central memory [TCM], effector memory [TEM], and effector memory CD45RA-positive [TEMRA] T cells) by multiparameter flow cytometry (MPFC). Additionally, patient-derived T cells were cocultered with BCP-ALL cell lines (SEM and REH) at an effector: target ratio of 1:3 in presence of blinatumomab or a control BiTE® (0.5 ng/ml, respectively) for 3 days to assess their cytotoxic capacity. Blinatumomab-mediated cytotoxicity was determined by MPFC. T-cell proliferation was evaluated by MPFC (Far Red Cell tracer) after incubation with CD3/CD28 beads for 6 days. A total of 16 patients were enrolled. Four of these patients suffered from MRD disease, whereas the remaining 12 had overt relapse of BCP-ALL. Response rates for patients with morphological relapse were 50% (4 CRMRD- and 2 CRMRD+ after the first cycle) and 75% for patients with MRD disease (3 MRD conversions, 1 MRD persistence). Absolute lymphocyte counts were not significantly different between responders and non-responders before treatment initiation (0.9 G/l and 0.7 G/l, respectively). Whereas the percentage of CD3+ T cells (of all lymphocytes) did not significantly differ between responders and non-responders on day 0, non-responders had a significantly reduced CD3+ percentage on day 7 (81.2% vs 92.9%, p=0.03). Until day 28 of the first cycle, CD3+ percentages of responders and non-responders re-converged (80.2% and 81.4%, respectively). There were no significant differences for CD4+ and CD8+ T-cell percentages prior to and over the course of the first cycle. This was also true for TN, TCM, TEM and TEMRA subset distributions. Additionally, CD19-BiTE®-mediated cytotoxicity of patient-derived T cells was assessed against CD19 expressing target B cell lines in vitro. Interestingly, specific lysis did not differ between responders and non-responders on day 0 (89.6% vs 79.8%, p=0.89), but decreased for non-responders over the course of the first cycle (normalized AUC for cytotoxicity 149 vs 403 in responders, p=0.03). However, this observation was only true for the patients with refractory morphologic relapse, as the non-responding MRD patient maintained T cell cytotoxicity over the first cycle of therapy. Impaired T cell proliferation (leading to reduced E:T ratios) might contribute to the observed dysfunctional cytotoxicity in non-responders, as the percentage of proliferating T cells after CD3/CD28 bead-based stimulation tended to be reduced for non-responders (17.9% vs 36.1%, p=0.07). In summary, lymphocyte counts, T cell percentage and T cell subset distributions do not allow for a response prediction prior to treatment start for patients receiving blinatumomab. BCP-ALL patients with morphological relapse/persistence who do not achieve a remission with blinatumomab therapy show reduced cytotoxicity in vitro in comparison to patients responding to treatment. As this observation could not be confirmed with one MRD non-responder in our cohort, the burden of disease might contribute to the observed T cell dysfunction, possibly by interfering with T cell proliferation. Evaluation of immune checkpoint expression on effector and target cells over the course of the therapy is currently ongoing, as are analyses of the T cell transcriptome of responders and non-responders. Disclosures Kischel: AMGEN Research (Munich) GmbH: Employment, Equity Ownership. Subklewe:Celgene: Consultancy, Honoraria; Oxford Biotherapeutics: Research Funding; Miltenyi: Research Funding; Roche: Consultancy, Research Funding; Janssen: Consultancy; Gilead: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria; Morphosys: Research Funding; AMGEN: Consultancy, Honoraria, Research Funding.

Impact of p53 Knock-Down on T-Cell Proliferation and T-Cell Mediated Cytotoxicity Against AML Cell Lines Mediated By a CD33 Specific BiTE® Antibody Construct

Impact of p53 Knock-Down on T-Cell Proliferation and T-Cell Mediated Cytotoxicity Against AML Cell Lines Mediated By a CD33 Specific BiTE® Antibody Construct

CRISPR/Cas9-Mediated Protection of Normal Hematopoiesis Combined with the CD33/CD3 Bispecific T-Cell Engager (BiTE) Antibody AMG330 for Improved AML Therapy

While survival for patients with acute myeloid leukemia (AML) has increased in recent years, relapse and treatment-related mortality remain a significant problem, especially in older patients. Although the use of gemtuzumab ozogamicin (GO) has validated the concept of antibody directed therapy for AML targeting CD33, complications from myelosuppression and opportunistic infections due to on-target toxicity to normal CD33+ hematopoietic cells have limited this approach. In addition, only a subset of patients derives long-term benefit from GO. Thus, to improve the outcomes of CD33-targeted immunotherapy, more potent drugs are needed such as CD33/CD3 bispecific T-cell Engagers (BiTEs), as are strategies to protect normal blood cells from the cytotoxic effects of these agents. In this study, we assessed the in vivo activity of the clinically exploited CD33/CD3 BiTE AMG330 using our previously described MATCH mouse model (Haworth et al., MTM 2017), in which human CD34+ stem/progenitor cells (HSPCs) are transplanted into neonate mice. This model enables the in vivo maturation of human HSPCs to establish a fully reconstituted blood and immune system, and in particular functional T cells that permit the testing of BiTEs without risks of graft-versus-host disease. Since CD33 is expressed on normal myeloid cells, causing significant on-target/off-leukemia effects, we also investigated whether our previously validated CRISPR/Cas9-based strategy (Humbert et al., Leukemia 2019) protects hematopoiesis from AMG330 activity. Mice were engrafted with mock-(Cas9 only) or CRISPR/Cas9-edited human CD34+ HSPCs to ablate CD33 expression. Normal multilineage engraftment was observed in both experimental groups, resulting in hematopoiesis that either expressed or almost entirely lacked CD33. Mice were also infused with AML tumor cells to validate AMG330 activity, which was administered intravenously to the animals for 5 consecutive days at 0.2mg/kg. AMG330 rapidly eliminated CD33+ Molm14 tumor cells within 5 days (Figure 1A) and reduced the number of circulating CD14+ monocytes in the mock group (Figure 1B), thus confirming the functionality of in vivo-matured autologous T-lymphocytes generated. In contrast, CRISPR/Cas9-edited cells were fully protected from AMG330 cytotoxicity, as evidenced by steady CD14+ counts pre- and post-treatment (Figure 1B). Together, these results validate the MATCH model for testing the efficacy and toxicity of CD33-directed immunotherapies, in particular novel BiTEs. In addition, the combination of HSPC protection and improved CD33 targeting to more effectively kill AML should be of great value for the development of novel BiTEs and other bispecific antibodies for the treatment of AML. Figure 1: A) Leukemia burden measured by luciferase expression in mice from the two experimental groups treated or not with AMG330. B) Quantification of CD14+/CD33+ and CD14+/CD33− cells from peripheral blood of AMG330-treated animals in Cas9 only (n=3) and CRISPR/Cas9 (n = 3) groups. In A) and B), 'pre' is before AMG330 treatment and 'post' is 5 days after administration. Figure 1 Disclosures Walter: New Link Genetics: Consultancy; Argenx BVBA: Consultancy; Astellas: Consultancy; BioLineRx: Consultancy; BiVictriX: Consultancy; Amphivena Therapeutics: Consultancy, Equity Ownership; Boehringer Ingelheim: Consultancy; Aptevo Therapeutics: Consultancy, Research Funding; Boston Biomedical: Consultancy; Covagen: Consultancy; Daiichi Sankyo: Consultancy; Jazz Pharmaceuticals: Consultancy; Kite Pharma: Consultancy; Pfizer: Consultancy, Research Funding; Race Oncology: Consultancy; Seattle Genetics: Research Funding; Agios: Consultancy; Amgen: Consultancy. Kiem:Magenta Therapeutics: Consultancy; Rocket Pharma: Consultancy, Equity Ownership; Homology Medicines: Consultancy, Equity Ownership; CSL Behring: Consultancy.

Role of B-Cell Maturation Antigen (BCMA) Targeted Immunotherapies in Relapsed and Refractory Multiple Myeloma- a Systematic Review

Introduction Multiple Myeloma (MM) is a plasma cell dyscrasia characterized by neoplastic proliferation of plasma cells. Despite the recent advances in disease management, it still contributes to significant morbidity and mortality, thus highlighting the unmet need for new treatment options. B-cell maturation antigen (BCMA) is a transmembrane glycoprotein in the tumor necrosis factor receptor superfamily 17 and has been shown to have high expression on plasma cells. Preclinical studies in MM have shown significant efficacy for BCMA targeted immunotherapies, thus providing a potential therapeutic option to overcome the obstacle of myeloma relapse and recurrence. In this comprehensive review, we have reported the role of anti-BCMA therapies in the treatment of relapse and refractory Multiple Myeloma (RRMM). Methods Systematic review was performed according to PRISMA statement. PubMed, Ovid Embase, Web of Science, Cochrane Library & Clinicaltrails.gov were searched, without any filters, using the medical search terms (MeSH) "Multiple Myeloma" AND "B Cell Maturation Antigen". Most recent reports of original phase I/II/III studies reporting safety and efficacy measures of anti-BCMA immunotherapies in RRMM were considered for inclusion. After a detailed screening of 854 studies, 10 phase-1 studies (Ali, SA. 2016, Fan, F. 2017, Brudno, JN. 2018, Zhao, WH. 2018, Trudel, S. 2018, Topp, MS. 2018, Liu, Y. 2018, Cohen AD. 2019, Raje, N. 2019 & Xu, J. 2019) were considered for inclusion. Results (Table-1) A total of 294 patients with RRMM who had received a median range of 3-7 previous lines of therapies were included. Out of these, 36.7% (n= 108) patients received bispecific T-cell engager (BiTE) antibodies against BCMA antigen while rest of patients received anti-BCMA chimeric antigen receptor T-cell (CART) therapy. Patients with CART therapy received autologous derived in-vitro modified stem cells. These patients subsequently developed higher incidence of grade 3-4 cytopenias owing to myeloablation with fludarabine and cyclophosphamide. The dosage ranges for both therapies were heterogenous owing to phase I dose escalation designs. All responses were evaluated according to IMWG response criteria. The cumulative overall response rate (ORR) for studied population was 59.86% (n= 176), while individual ORR was 26.85% (n= 29) for BiTE therapy and 79% (n=147) for CART therapy. Majority of responders (82%, n= 145) received ≥VGPR (very good partial response) status. But relapse/progression of disease after achieving response was a significant issue as 42.5% (n= 125) patients relapsed or progressed and developed BCMA negative myeloma cells in their bone marrow. The progression free survival and survival data is premature at this stage and requires further elaboration in phase II/III clinical trials. Toxicity profile was consistent with use of myeloablation and with the standard toxicity profile seen in other B-cell malignancies except for the incidence of grade ≥ neuropathy which was not much common (1.7%, n= 5). Regarding the grade ≥ 3 cytopenias, incidence of neutropenia was 20% (n=59), anemia 21.4% (n=63), thrombocytopenia 19.4% (n= 57). Grade ≥ 3 cytokine release syndrome (CRS) seen in 11.2% (n= 33) patients which responded well to Tocilizumab and corticosteroids except for death in two cases. All studies showed a significant correlation of CART cell dose and myeloma tumor burden with intensity of cytokine release syndrome (CRS). In each dose escalation trial, sustained and better responses were achieved at higher doses with a parallel enhanced incidence of grade 3-4 toxicities. The responses were not found to be influenced by previous lines of therapy, and patients with higher risk cytogenetics showed a reduced response compared to patients with standard risk cytogenetics in all studies. Conclusion BCMA targeted immunotherapies provide a promising option for highly refractory multiple myeloma patients. But small patient population and phase-I design limit the projection of results to real world setting. Furthermore, relapse/progression risk needs to be weighed against the significant toxicity profile. So, more controlled clinical trials with longer follow up periods are needed to delineate the efficacy and survival outcomes of this therapeutic option. Disclosures Anwer: In-Cyte: Speakers Bureau; Seattle Genetics: Membership on an entity's Board of Directors or advisory committees.

Monoclonal Antibody Therapies in Multiple Myeloma: A Challenge to Develop Novel Targets.

The treatment options in multiple myeloma (MM) has changed dramatically over the past decade with the development of novel agents such as proteasome inhibitors (PIs); bortezomib and immunomodulatory drugs (IMiDs); thalidomide, and lenalidomide which revealed high efficacy and improvement of overall survival (OS) in MM patients. However, despite these progresses, most patients relapse and become eventually refractory to these therapies. Thus, the development of novel, targeted immunotherapies has been pursued aggressively. Recently, next-generation PIs; carfilzomib and ixazomib, IMiD; pomalidomide, histone deacetylase inhibitor (HDADi); panobinostat and monoclonal antibodies (MoAbs); and elotuzumab and daratumumab have emerged, and especially, combination of mAbs plus novel agents has led to dramatic improvements in the outcome of MM patients. The field of immune therapies has been accelerating in the treatment of hematological malignancies and has also taken center stage in MM. This review focuses on an overview of current status of novel MoAb therapy including bispecific T-cell engager (BiTE) antibody (BsAb), antibody-drug conjugate (ADC), and chimeric antigen receptor (CAR) T cells, in relapsed or refractory MM (RRMM). Lastly, investigational novel MoAb-based therapy to overcome immunotherapy resistance in MM is shown.

Multidisciplinary team Management System for Adverse Events Occurring in New Cancer Immunotherapies

Abstract Introduction Recently, promising efficacy has been reported for cell therapies using chimeric antigen receptor (CAR)-T cells, and bispecific T-cell engager antibody (BiTE) - a complex formed with antibodies against CD3 and antibodies against tumor cell surface antigens. However, severe adverse events such as cytokine release syndrome and neurotoxicity result in the incidence of high mortality, which is difficult to predict before initiating these therapies. These symptoms rapidly advance to the severe stage; therefore, a multidisciplinary team management system across the organization is necessary. Method Our multidisciplinary team developed standard operating procedure for adverse events. 1)Preparation of a symptoms checklist and action manual: A symptoms observation checklist and action manual (preparation of the tratment drugs and the treatment flow) were prepared for early detection and to decide on the early treatment approach. 2)Cooperation system with the intensive care unit: Admission and discharge criteria based on symptom severity were laid down. 3)Advance education: Training sessions were held for the expected responders, including holiday/night medical examinations (physicians, nurses, pharmacists, and research coordinators). 4)Communication system and information sharing: The communication system at the time of an event’s onset was clarified, and patient information was shared. Results The actions decided could be implemented, and adverse events could be managed properly. Discussion The careful construction of the management system prior to treatment implementation enables rapid action for the management of adverse events. As many more drugs will introduce into clinical practice in the future, it should be important to continue the verification and improvement of our system.

Long-term outcome of patients with relapsed/refractory B-cell non-Hodgkin lymphoma treated with blinatumomab.

Blinatumomab, the first-in-class CD3/CD19 bispecific T-cell engager antibody construct, has recently been approved for treating patients with relapsed or refractory (R/R) B-cell acute lymphoblastic leukemia. However, the clinical proof of concept of blinatumomab efficacy was initially demonstrated in patients with R/R B-cell non-Hodgkin lymphoma (B-NHL) in the MT103-104 phase 1 dose-escalation and expansion trial (NCT00274742), which defined 60 µg/m2 per day as the maximum tolerated dose (MTD). The clinically most relevant adverse effects were neurologic symptoms and cytokine release syndrome. Currently, there are no data on long-term outcomes and toxicity for B-NHL patients receiving blinatumomab treatment, so we performed a single-center, long-term follow-up analysis of 38 patients who participated in the MT103-104 phase 1 trial. We found no evidence for long-term toxicities, especially no blinatumomab-induced neurocognitive impairments. For the entire study population, the median overall survival (OS) was 4.6 years. Remarkably, patients who had received ≥60 µg/m2 per day and responded to blinatumomab achieved a median OS of 7.7 years. Of note, 6 of the surviving patients treated at the MTD have been treatment-free for more than 7 years. In contrast, patients who were treated at dose levels below the MTD had a median OS of only 1.1 years. These results indicate that 60 µg/m2 per day seems to represent the targeted dose level of blinatumomab required for durable remission in R/R B-NHL. Here, we provide the first clinical evidence that blinatumomab lacks long-term toxicity and has the potential to induce sustained remissions in patients with R/R B-NHL.

T-Cell Engagers Based Bioassay for Evaluation of PD-1/PD-L1 Inhibitors Activity.

PD-1/PD-L1-based therapy has been named a revolution in cancer treatment. By the end of 2018, more than 100 anti-PD-1 and anti-PD-L1 antibodies were in various stages of development, and more than 2000 clinical trials with their use have been registered. Characterization of such antibodies requires a bioassay to determine their biological activity. In this study, we developed a cell-based bioassay for analyzing the activity of anti-PD-1 and anti-PD-L1 antibodies. We chose reporter system consisting of two cell lines and compared several approaches for activation of effector cell line based on superantigens, soluble anti-CD3 antibodies, transmembrane anti-CD3 antibodies, chimeric antigenic receptors (CARs) and bispecific T-cell engager antibodies. The bispecific T-cell engager antibodies offer several advantages over the other approaches. We characterized the bioassay and demonstrated its applicability for analyzing the activity of anti-PD-1 and anti-PD-L1 antibodies. The proposed bioassay can be useful in the development of new therapeutic agents and methods for their characterization.

Abstract 1068: How humanized mouse models could be useful for immuno-oncology research

Abstract Immunotherapy is one of the most exiting recent breakthroughs in the field of cancer treatment. Different approaches are developed such as cancer vaccines, adoptive cellular immunotherapy or immune checkpoint blockade, and a number have been regulatory approved or are currently investigated in clinic. Effective immunity against cancer involves complex interaction between the tumor, the host and the environment. The assessment of cancer immunotherapy approaches in preclinical settings requires the use of appropriate animal models that sufficiently reflect the physiological situation in humans and that must be chosen carefully to address specific mechanisms of action. In light of evaluating the therapeutic potential of different immunomodulatory agents in mice xenografted with cancer cell lines or patient-derived xenografts, we developed multiple humanization strategies on different immuno-deficient mouse strains. Either human PBMCs, Hematopoietic Stem Cells (HSCs), or specific human immune cells such as Dendritic Cells (DCs), T cells, subset of T cells (e.g. gamma9 delta2 T cells) and NK cells were used, but also the combinations of immune subpopulations such as the co-transfer of autologous T cells and DCs. We will highlight some results of our therapeutic efficacy investigation and evaluation of novel immuno-oncology therapies eg. adoptive cell therapy, bispecific T-cell engager antibody, and vaccine immunomodulatory agents in such humanized mouse models, assessing survival, tumor growth and effects on tumors and immune cells by flow cytometry and immunohistochemistry analyses. All these different humanized models can permit to evidence significant antitumor efficacy of immunomodulatory agents in vivo and might help improve the success rate in clinical trials. Citation Format: Jean-Francois Mirjolet, Josselin Caradec, Oliver Duchamp, Francis Bichat, Damien France, Caroline Mignard, Fabrice Viviani. How humanized mouse models could be useful for immuno-oncology research [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1068.

Therapeutic Bispecific T-Cell Engager Antibody Targeting the Transferrin Receptor.

Bispecific T-cell engager antibodies (BiTE) have been explored as a means to recruit cytolytic T cells to kill tumor cells. The transferrin receptor (TfR) is highly expressed on the surface of rapidly proliferating tumor cells. Therefore, it holds great potential in T cell redirecting therapies. In this research, we developed a BiTE targeting TfR and CD3 (TfR-BiTE) and studied its therapeutic impact on TfR-positive cancer. TfR-BiTE had the ability to induce the selective lysis of various TfR-positive cancer cells through the activation of T cells, the release of cytokines, and then the coming proliferation of T cells, whereas TfR-negative cells were not affected. In a subcutaneous HepG2 xenograft model, low concentrations of TfR-BiTE inhibited tumor growth. Overall, these results reveal that TfR-BiTE can selectively deplete TfR-positive HepG2 cells; hence, it represents a novel immunotherapeutic approach for the treatment of hepatocellular carcinoma.

Nonclinical safety assessment of AMG 553, an investigational anti-FLT3 CAR-T therapy.

7032 Background: FMS-like tyrosine kinase 3 (FLT3) is a tyrosine-protein kinase involved in hematopoiesis. In acute myeloid leukemia (AML), higher FLT3 transcript levels, independent of the presence of FLT3 mutations, correlate with higher leukocyte counts and higher degrees of bone marrow infiltration by leukemic cells. FLT3 protein is detectable on the cell surface of more than 80% of leukemia isolates from adult AML patients whereas FLT3 mutations are present only in approximately one third of patients. AMG 553 is a novel, investigational, adoptive cellular immunotherapy for the treatment of relapsed refractory AML, consisting of autologous T cells genetically modified ex vivo to express a transmembrane chimeric antigen receptor (CAR) to target FLT3 protein on the surface of AML cells irrespective of FLT3 mutational status. Methods: The nonclinical safety evaluation of AMG 553 includes assessment of FLT3 expression in normal tissues; in vitro assessment of cytotoxicity against human cells with or without FLT3 expression; toxicology studies in cynomolgus monkeys administered autologous T-cells transduced with an anti-FLT3 CAR or administered anti-FLT3 bi-specific T-cell engager (BiTE) antibodies. Results: Assessment of FLT3 expression in normal tissues indicates that FLT3 protein is detected on the cell surface of a subpopulation of human bone marrow hematopoietic stem and progenitor cells; expression in other tissues is cytoplasmic and not anticipated to be accessible to AMG 553. AMG 553-induced cytotoxicity was only observed in a percentage of primary bone marrow CD34+ cells. There was no evidence of CAR-T cell-mediated toxicity, expansion, or persistence in cynomolgus monkeys likely due to restricted cell surface FLT3 protein expression in healthy animals which demonstrates the limited value of such studies for this target. All findings in toxicology studies with anti-FLT3 BiTEs were consistent with the targeted killing of cells expressing FLT3 on the plasma membrane. Conclusions: The nonclinical safety data support AMG 553 as a novel therapeutic to target FLT3 protein on AML cells irrespective of FLT3 mutational status, while only affecting a percentage of normal hematopoietic stem and progenitor cells.

Phase 1 study of AMG 757, a half-life extended bispecific T cell engager (BiTE) antibody construct targeting DLL3, in patients with small cell lung cancer (SCLC).

TPS8577 Background: SCLC is an aggressive neuroendocrine tumor; response to initial chemotherapy and radiotherapy is often followed by recurrence, rapid progression, and resistance to current therapies. Delta-like ligand 3 (DLL3) is an inhibitory ligand of Notch receptors that is expressed in most SCLC tumors but minimally expressed in normal tissues. DLL3 may therefore be a promising target for T cell–redirecting immunotherapy. AMG 757 is a half-life extended BiTE antibody construct that is designed to transiently connect DLL3-positive cells to CD3-positive T cells and induce T cell–mediated cell lysis and concomitant T cell proliferation. AMG 757 induces potent killing of SCLC cell lines in vitro and inhibits tumor growth in the SHP-77 human SCLC xenograft model in vivo. AMG 757 was well tolerated in a preclinical multi-dose toxicology study in cynomolgus monkeys, with no evidence of tissue damage at weekly doses up to 4.5 mg/kg. Methods: NCT03319940 is an open-label, ascending, multiple dose, phase 1 study evaluating AMG 757. The study will initially enroll adult patients with relapsed/refractory SCLC who have progressed after at least 1 platinum-based chemotherapy regimen. Additional inclusion criteria include ECOG performance status 0–2, at least 2 measurable lesions per modified RECIST 1.1, no untreated or symptomatic brain metastases, and adequate organ function. Primary objectives are to evaluate safety and tolerability and to determine the maximum tolerated dose (MTD) or recommended phase 2 dose (RP2D). Secondary objectives are to characterize pharmacokinetics (PK) and evaluate preliminary antitumor activity. In the dose exploration phase, patients will be monitored for dose-limiting toxicities during the first 28 days. A Bayesian logistic regression model will be used to inform dose escalation/de-escalation decisions. The dose expansion phase will confirm the MTD or RP2D and collect further safety and efficacy data. AMG 757 will be administered as a short-term intravenous infusion once every 2 weeks. Alternative dosing schedules may be explored based on emerging PK and safety data. Clinical trial information: NCT03319940.

Abstract A152: Investigating metabolic basis of neurotoxicity during CAR-T therapies

Abstract Chimeric antigen receptor T (CAR-T) cell therapies are rapidly becoming first in line therapies for treatment of hematologic malignancies. This is due to the efficacy of the treatment and long-lasting tumor responses. However, CAR-T therapies are associated with unique set of acute toxicities— cytokine release syndrome (CRS) and neurologic toxicities—the cause of which is not clear. As other immune therapies are becoming more widely used, these toxicities are observed in patients undergoing bispecific T-cell engaging antibodies (BiTEs) and checkpoint blockade therapies. Here, we sought to define metabolic changes in patients undergoing chimeric antigen receptor (CAR) T-cell therapy for B-acute lymphoblastic leukemia. We performed metabolic analysis of amino acids in serum samples, and identified significant up-regulation of tryptophan-kynurenine metabolism in patients with high-grade neurotoxicity. In-depth look at tryptophan-kynurenine pathway in cerebrospinal fluid patient samples determined quinolinic acid up-regulation to correlate with low- and high-grade neurotoxicity, indicating local production of this metabolite. We show that quinolinic acid is produced by activated monocytes and microglia in response to Il1beta and TNF. Importantly, tryptophan metabolite—kynurenine— stimulates Il1beta production and further activation of monocytes, possibly exacerbating CSR and neurotoxicity. This study suggests that inhibition of tryptophan-kynurenine pathway may offer some benefit to manage neurotoxicity and CRS associated with CAR-T-cell therapy treatment. Citation Format: Darin Salloum, Bianca Santomasso, Renier J. Brentjens, Hans-Guido Wendel. Investigating metabolic basis of neurotoxicity during CAR-T therapies [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr A152.

Blinatumomab for the treatment of acute lymphoblastic leukemia: an update

ABSTRACTIntroduction: Blinatumomab is a first-in-class bispecific T-cell engager (BiTE) antibody that has demonstrated high response rates, including minimal or measurable residual disease (MRD) negativity, in the treatment of acute lymphoblastic leukemia (ALL). As a single agent, blinatumomab has demonstrated significant activity in patients with both relapsed/refractory Philadelphia chromosome-negative and Philadelphia chromosome-positive disease and in patients with persistent MRD. Its unique mechanism of action accounts for its ability to induce durable responses as well as its side effect profile.Areas covered: This manuscript will review the place in therapy for blinatumomab as well as the phase I, phase II, and phase III clinical trials which led to its development and FDA approval for the treatment of ALL.Expert opinion: Blinatumomab is a welcomed addition to the available treatment options for patients with relapsed or refractory ALL. Furthermore, it is currently the most effective treatment in eradicating MRD, and subsequently allowing patients to proceed to allogeneic stem cell transplantation. Improved efficacy is observed in patients treated earlier and in those with lower disease burden, therefore continued evaluation of blinatumomab in combination with chemotherapy in the frontline treatment setting is essential.

Health-Related Quality of Life in Adults with B-Cell Precursor Acute Lymphoblastic Leukemia and Minimal Residual Disease Treated with Blinatumomab

Background: Positive minimal residual disease (MRD) is an established prognostic marker for hematologic relapse, negative hematopoietic stem cell transplantation (HSCT) outcome, and mortality in adults with B-cell precursor acute lymphoblastic leukemia (ALL; Gökbuget N, et al. Blood. 2012;120:1868-1876). In the open-label, single-arm phase 2 BLAST study (N=116; ClinicalTrials.gov, NCT01207388), treatment with blinatumomab, a bispecific T-cell engager (BiTE®) antibody construct that redirects cytotoxic T cells to residual CD19+ blast cells, led to complete MRD response in 88 of 113 (78%) patients after cycle 1 (Gökbuget N, et al. Blood. 2018;131:1522-1531). Median overall survival was 36.5 months. Among patients with Philadelphia chromosome-negative B-cell ALL in complete MRD remission, relapse-free survival was 54% at 18months. In this analysis of the BLAST study, we assessed the health-related quality of life (HRQoL) of patients during and after treatment with blinatumomab.Methods: Eligible patients (≥18 years) had B-cell precursor ALL in first or later hematologic complete remission and persistent or recurrent MRD ≥10-3 after ≥3 blocks of intensive chemotherapy. Blinatumomab 15 μg/m2/day was administered by continuous intravenous (cIV) infusion for 4 weeks, followed by a 2-week infusion-free interval, for up to 4 cycles. Patients could receive HSCT any time after cycle 1. HRQoL was assessed using the EORTC QLQ-C30 Questionnaire at baseline, on day 29 of each treatment cycle, at the safety follow-up visit (30 days after end of treatment), and at the efficacy follow-up visits (3, 6, 9, 12, 18, and 24 months after treatment start). The questionnaire included 1 global health status scale, 5 functioning scales (physical, role, emotional, cognitive, and social functioning), 3 symptom scales (fatigue, nausea and vomiting, and pain), and 6 single-symptom items (dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties). For global health status and functioning scales, a higher score indicates better HRQoL; for symptom scales/items, a lower score indicates better HRQoL. A 10-point change is often viewed as the minimum clinically important difference (MID) in EORTC QLQ-C30 (Zikos E, et al. EORTC, 2016). In this analysis, the mean (SD) and the mean (SD) change from baseline to end of cycle 1 of the scores for each scale/item was summarized at each scheduled assessment during and after blinatumomab treatment.Results: In total, 89 patients had a nonmissing baseline value and a nonmissing value of any scale on day 29 of cycle 1, and thus were evaluable for HRQoL. The patient-reported global health status and functioning scale scores were stable over time during and after blinatumomab treatment (Figure 1). Symptom-scale and single-symptom scores were similarly stable during and after treatment (not shown). Mean (SD) changes from baseline to end of cycle 1 in global health status and in physical functioning, role functioning, emotional functioning, cognitive functioning, and social functioning were 2.5 (18.5), 0.3 (12.5), -4.0 (30.0), 4.2 (20.5), -1.7 (16.2), and 10.4 (31.8), respectively (Figure 2). These results show that, after 1 cycle of blinatumomab, the change in HRQoL was minimal for most scales, with potential clinically meaningful improvements in social functioning. Similar minimal changes were observed for all symptom scales/items (not shown).Conclusions: In this population of patients with B-cell precursor ALL and MRD successfully treated with blinatumomab 15 μg/m2/day cIV for up to 4 cycles, HRQoL was maintained during and after blinatumomab treatment, which is an important result considering the potential HRQoL impact of standard chemotherapy. [Display omitted] DisclosuresZugmaier:Amgen Inc.: Consultancy, Employment, Patents & Royalties: 20170327581, 9688760, 20170122947, 9486475, 20160208001, 9192665, 20150071928, 8840888, 20140227272, 20140228316, 20130323247, 20130287774, 20130287778, 20110262440, 20100112603, 7700299, 20070037228. Bonifacio:Incyte: Consultancy; Pfizer: Consultancy; Amgen: Consultancy; Novartis: Research Funding; Bristol Myers Squibb: Consultancy. Topp:Boehringer Ingelheim: Research Funding; Regeneron Pharmaceuticals, Inc.: Honoraria, Research Funding; F. Hoffmann-La Roche Ltd: Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Research Funding. Tran:Amgen Inc.: Employment. Zhang:Amgen Inc.: Employment, Equity Ownership. Goekbuget:Kite / Gilead: Consultancy; Celgene: Consultancy; Novartis: Consultancy, Other: Travel support, Research Funding; Pfizer: Consultancy, Other: Travel support, Research Funding; Amgen: Consultancy, Other: Travel support, Research Funding.

Disease Burden Subgroup Analysis of Health-Related Quality of Life of Blinatumomab Versus Standard-of-Care Chemotherapy in Patients with Relapsed or Refractory Philadelphia Chromosome-Negative B-Cell Precursor Acute Lymphoblastic Leukemia in a Randomized, Open-Label Phase 3 Study (TOWER)

Disease Burden Subgroup Analysis of Health-Related Quality of Life of Blinatumomab Versus Standard-of-Care Chemotherapy in Patients with Relapsed or Refractory Philadelphia Chromosome-Negative B-Cell Precursor Acute Lymphoblastic Leukemia in a Randomized, Open-Label Phase 3 Study (TOWER)

Treatment with AMG 420, an Anti-B-Cell Maturation Antigen (BCMA) Bispecific T-Cell Engager (BiTE®) Antibody Construct, Induces Minimal Residual Disease (MRD) Negative Complete Responses in Relapsed and/or Refractory (R/R) Multiple Myeloma (MM) Patients: Results of a First-in-Human (FIH) Phase I Dose Escalation Study

Treatment with AMG 420, an Anti-B-Cell Maturation Antigen (BCMA) Bispecific T-Cell Engager (BiTE®) Antibody Construct, Induces Minimal Residual Disease (MRD) Negative Complete Responses in Relapsed and/or Refractory (R/R) Multiple Myeloma (MM) Patients: Results of a First-in-Human (FIH) Phase I Dose Escalation Study

High Molecular Remission Rate in Pediatric Patients (pts) with Relapsed/Refractory B-Cell Precursor Acute Lymphoblastic Leukemia (r/r ALL) Treated with Blinatumomab: Rialto an Open-Label, Multicenter, Expanded Access Study

Introduction Despite a high cure rate for pediatric ALL, the prognosis for pts who suffer from r/r disease remains poor. Pediatric pts with r/r ALL face multiple lines of therapy, acute and long-term treatment toxicities, and have limited survival. New agents that are able to provide durable disease control and long-term survival with limited toxicity are needed. Blinatumomab (blin) is a bispecific T-cell engaging (BiTE®) antibody construct that redirects CD3+ cytotoxic T cells to lyse CD19+ B cells. We evaluated the safety and efficacy of blin in pediatric pts with B-cell precursor r/r ALL enrolled in an expanded access study initiated in 2014 (NCT02187354). Methods Eligible pts with r/r CD19+ ALL (≥ 2 relapses, relapse after allogeneic hematopoietic stem cell transplant [HSCT], or refractory to prior treatment) were > 28 days to 25% blasts. Subsequent therapy, including HSCT, was off protocol and per investigator preference. The primary endpoint was incidence of treatment-emergent (TE) and treatment-related (TR) adverse events (AEs). Secondary endpoints included morphologic complete response (CR; Results Of 98 treated pts (median age, 8.5 [range 0.4-17.0] years), 93% were enrolled in Europe, 54% had > 25% blasts at baseline, 41% had ≥ 50% blasts, and 48% had a cytogenetic abnormality. Prior treatments included HSCT (44%), radiotherapy (15%), and blin (4%); 56% of pts had ≥ 2 relapses, 41% had relapsed after HSCT, 14% were primary refractory and 20% were refractory to reinduction therapy. At data cutoff (March 9, 2018), 37 pts were on study. The median number of completed treatment cycles was 2 (range 1-5), with 4 pts completing 5 cycles of blin. Overall, 99% of pts experienced a TEAE, with a rate of 64% for grade ≥ 3. TRAEs were reported in 77% of pts (26% for grade ≥ 3); 21% were deemed serious. The most frequent TEAEs (any grade) included pyrexia (83%), vomiting (27%), headache (24%), and anemia (19%). Among TEAE categories of interest, rates of any grade/grade ≥ 3 were 67%/9% for infusion reactions, 44%/16% for infections, 43%/5% for neurologic events, 40%/31% for cytopenias, 18%/12% for elevated liver enzymes, 16%/2% for cytokine release syndrome, 8%/0% for decreased immunoglobulins, 4%/2% for tumor lysis syndrome, and 1%/0% for capillary leak syndrome. Dose interruption due to a TRAE was required by 19% of pts, and 4% discontinued blin due to a TRAE. There were 9 fatal AEs, all unrelated to blin. In the first 2 cycles of treatment, 60% of all 98 pts achieved CR, 40% achieved CR with full recovery of peripheral blood counts (PBC), and 48% achieved MRD response. Of 2 pts with t(17;19), both achieved CR with full PBC recovery and MRD response; of 4 pts with Down syndrome, 3 achieved CR (2 full PBC recovery) and MRD response; of 4 pts who had received prior blin treatment, 3 achieved CR (3 full PBC recovery) with blin retreatment and 2 achieved MRD response. Among 59 pts who achieved CR within 2 cycles, 27 (46%) proceeded to HSCT; 19 relapsed and 5 died after a median follow-up 5.3 (range, 0.3-13.2) months for a median RFS of 8.5 (95% CI, 2.9-NE) months from the time of CR. Among all 98 pts, median follow-up was 12.2 (range, 0.5-14.1) months; there were 38 deaths (32 disease related), and median OS was 13.0 (95% CI, 9.3-NE) months. Conclusions The safety profile of single-agent blin in this expanded access study was generally consistent with profiles reported in prior controlled trials of blin in pediatric and adult pts with r/r ALL. Blin was active in this pediatric r/r ALL population. Blin induced MRD response in almost half of the pts, including pts with t(17;19) or prior blin treatment. Pts with a lower leukemia burden ( Disclosures Locatelli:Bellicum: Consultancy, Membership on an entity9s Board of Directors or advisory committees; Miltenyi: Honoraria; bluebird bio: Consultancy; Amgen: Honoraria, Membership on an entity9s Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity9s Board of Directors or advisory committees. Zugmaier:Amgen Inc.: Consultancy, Employment, Patents & Royalties: 20170327581, 9688760, 20170122947, 9486475, 20160208001, 9192665, 20150071928, 8840888, 20140227272, 20140228316, 20130323247, 20130287774, 20130287778, 20110262440, 20100112603, 7700299, 20070037228. Bader:Riemser: Research Funding; Neovii: Research Funding; Cellgene: Consultancy; Medac: Patents & Royalties, Research Funding; Novartis: Consultancy, Speakers Bureau. Bourquin:Amgen: Other: Travel Support. Handgretinger:Miltenyi Biotec: Patents & Royalties: Co-patent holder of TcR alpha/beta depletion technologies, Research Funding. Rossig:Genetech: Consultancy; Roche: Consultancy, Honoraria; MorphoSys: Honoraria; Celgene: Consultancy; Amgen: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; BMS: Honoraria; EUSA Pharm: Consultancy.

Cytokine Gene Polymorphisms Are Associated with Disease Response to Blinatumomab in Patients with B-Cell Acute Lymphoblastic Leukemia

Blinatumomab (BT), a CD19/CD3 bispecific T-cell engager (BiTE) antibody recently approved for treatment of relapsed/refractory acute lymphoblastic leukemia (r/r ALL), has resulted in a 40-50% complete response (CR)/CR with incomplete count recovery (CRi) rate and frequent cytokine release syndrome (CRS) events. While extent of disease burden has been identified as a key predictor of disease response, there have been no studies to date evaluating the impact of single nucleotide polymorphisms (SNPs) in cytokine genes on disease response or CRS after treatment with BT. Here, we evaluated the possible association between cytokine SNPs, disease response, and/or CRS in r/r ALL patients with receiving BT.A total of 82 patients (consecutive case-series) received BT between 2012 and 2017 at City of Hope. Of these, 68 patients had archived DNA samples available for study and analysis. Genotyping was done using Illumina's Omni 5-4 bead array, which interrogates more than 4.2 million SNPs. Array processing was done following manufacturer's recommendations and arrays were scanned by Illumina's iScan instrument. Beeline software and Genome Studio (Illumina) were used for analysis of scanned images and to generate the genotyping calls and quality control reports, respectively. Our analysis focused on the following cytokine genes of interest (known to be associated with autoimmune diseases/graft-versus-host disease): IL-1B, IL-2, IL-6, IL-7R, IL-10, IL-11, IL-12, IL-17A, IL-23R, TNF-α, TGF-β, and IFN-γ. Two modes of inheritance (dominant and recessive) were considered whenever appropriate. Univariate analyses of SNPs, response and CRS were performed using Fisher's exact test. P values were not adjusted for multiple hypothesis testing due to the exploratory nature of the analyses.In our cohort, median age of patients at BT treatment was 34 years old (range: 7-85), with 32 females (39%) and 50 males (61%). Patients' race/ethnicity included 49 Hispanic (60%), 20 non-Hispanic Caucasians (24%), 9 Asians (11%), and 3 African Americans (3%). All patients had primary refractory (n=16) or relapsed disease status (1st relapse: n=38, 2nd or subsequent relapse: n=27) with median lines of prior therapy of 2 (range: 0-5). Cytogenetic abnormalities included Ph+ALL in 11 patients, while 50 patients had other cytogenetic abnormalities and 15 had normal cytogenetics. Bone marrow blasts of >50% at BT treatment was detected in 45 patients, and 22 patients had a history of or active extra-medullary involvement. After BT treatment, 37 patients (45%) achieved CR/CRi with a median duration of 9.5 months (range: 1-37), 54 patients (66%) experienced CRS (grade 1: n=35, grade 2: n=14, and grade 3: n=5), and 9 patients developed neurotoxicity. Lastly, the peak C-reactive protein level (median/range) was 17 mg/L (range: 1-392).By univariate analysis, disease response (CR/CRi) to BT was significantly associated with the following cytokine SNPs: IL2 rs2069762 [48.3% (T/T-G/T: n=60) Vs. 0% (G/G; n=7), p=0.016], IL17A rs3819024 [30.8% (A/A; n=39) Vs. 58.6% (A/G-G/G; n=29), p=0.027], and IL17A rs4711998 [54.5% (A/A: n=33) Vs. 29.4% (A/G-G/G: n=34), p=0.049]. (Table 1) These three cytokine SNPs and two additional SNPs with p-values between 0.05 and 0.1 (IL7R rs1494555, IL17A rs8193036) were evaluated by multivariable analysis, adjusted for >50% bone marrow blasts, which was associated with lower rate of CR/CRi (33% vs. 63% with <50%, p=0.02). By multivariable analysis, IL17A rs3819024 remained significant while IL17A rs4711998 was at borderline significance (p=0.06). (IL2 rs2069762 could not be tested due to no CR/CRi occurrence). None of the cytokine SNPs analyzed were associated with CRS (0 vs. any grade, or grades 0-1 vs. 2-3).In conclusion, to our knowledge this is the first study to demonstrate a possible association between treatment response to BT and cytokine genetic polymorphisms. Our hypothesis-generating data suggest a potential role of IL17 and IL2 in BT response and justify a larger confirmatory study, which may lead to personalized BT immunotherapy for B-ALL. [Display omitted] DisclosuresStein:Amgen Inc.: Speakers Bureau; Celgene: Speakers Bureau. Forman:Mustang Therapeutics: Other: Licensing Agreement, Patents & Royalties, Research Funding.

Age Subgroup Analysis of Health-Related Quality of Life of Blinatumomab Versus Standard-of-Care Chemotherapy in Patients with Relapsed or Refractory Philadelphia Chromosome-Negative B-Cell Precursor Acute Lymphoblastic Leukemia in a Randomized, Open-Label, Phase 3 Study (TOWER)

Background: Despite the availability of new therapies for acute lymphoblastic leukemia (ALL), older patients have historically poor responses to treatment and poor outcomes versus younger patients, with 5-year survival rates of approximately 20% or less. Blinatumomab is a bispecific T-cell engager (BiTE®) antibody construct that redirects cytotoxic T cells to lyse CD19-positive B cells and is approved for the treatment of relapsed or refractory (r/r) B-cell precursor (BCP) ALL and for minimal residual disease-positive ALL in the US. In the phase 3 TOWER study in patients with r/r Philadelphia chromosome-negative (Ph-) BCP ALL who received blinatumomab compared with standard-of-care (SOC) chemotherapy, overall survival was improved (median, 7.7 vs 4.0 months; P=0.01; Kantarjian H, et al. N Engl J Med. 2017;376:836-847), and posttreatment health-related quality of life (HRQoL) across all EORTC QLQ-C30 scales was better (Topp MS, et al. Blood. 2018;131:2906-2914). TOWER efficacy results did not differ by age group. In this subgroup analysis of TOWER, we assessed the HRQoL of older patients versus younger patients who received blinatumomab or SOC chemotherapy.Methods: Patients (N=405) with r/r Ph- BCP ALL were randomized 2:1 to receive 2 cycles of induction blinatumomab by continuous intravenous infusion (n=271) or SOC (n=134). Patients could receive transplant at any time following cycle 1. Those in remission could receive up to 3 consolidation cycles; 12 months of maintenance was allowed for those who received up to 3 consolidation cycles and had bone marrow response. HRQoL was assessed using the EORTC QLQ-C30 Questionnaire on days 1 (baseline), 8, and 15, on day 29 of cycle 1; day 1, 15, and 29 of each consolidation cycle; and at the safety follow-up. The questionnaire included 1 global health status scale, 5 functioning scales, 3 symptom scales, and 6 single-symptom items. For global health status and functioning scales, a higher score indicates better HRQoL; for symptom scales/items, a lower score indicates better HRQoL. A 10-point change was viewed as the minimum clinically important difference in EORTC QLQ-C30 (Zikos E, et al. EORTC. 2016). In this analysis, HRQoL in TOWER was assessed using two different age cutoffs: <35 versus ≥35 years (the randomization stratification in TOWER) and <55 versus ≥55 years (the stratification factor for INO-VATE, a phase 3 trial for another therapy in r/r ALL). Analyses included patients with baseline and ≥1 postbaseline result of any multi-item scale or single-item measure. Mean change from baseline in scores for each scale/item were summarized for cycle 1. Time to deterioration (TTD) analyses assessed the treatment effect based on timing from the initiation of treatment to a ≥10-point decrease for the functional scales and/or a ≥10-point increase for the symptom scales respectively.Conclusions: Consistent with the efficacy results, compared with SOC, blinatumomab improved HRQoL and delayed the deterioration in HRQoL regardless of the age group in patients with r/r Ph- BCP ALL. DisclosuresTopp:Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Research Funding; Boehringer Ingelheim: Research Funding; F. Hoffmann-La Roche Ltd: Membership on an entity's Board of Directors or advisory committees, Research Funding; Regeneron Pharmaceuticals, Inc.: Honoraria, Research Funding. Zimmerman:Amgen Inc.: Employment, Equity Ownership. Dombret:Cellectis: Consultancy, Honoraria, Other: Travel expenses; Servier: Consultancy, Honoraria; Immunogen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Other: Travel expenses, Speakers Bureau; Ambit (Daiichi Sankyo): Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Sunesis: Consultancy, Honoraria; Astellas: Consultancy, Honoraria; Menarini: Consultancy, Honoraria; Karyopharm: Consultancy, Honoraria; Shire-Baxalta: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria; Agios: Consultancy, Honoraria; Otsuka: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Kite Pharma: Consultancy, Honoraria, Research Funding; Jazz Pharma: Consultancy, Honoraria, Research Funding; Ariad (Incyte): Consultancy, Honoraria, Other: Travel expenses, Research Funding, Speakers Bureau; Roche/Genentech: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria, Research Funding, Speakers Bureau; Amgen: Consultancy, Honoraria, Other: Travel expenses, Research Funding, Speakers Bureau. Stein:Celgene: Speakers Bureau; Amgen Inc.: Speakers Bureau. Franklin:Amgen Inc.: Employment, Equity Ownership. Cong:Amgen, Inc.: Employment, Equity Ownership. Zhang:Amgen Inc.: Employment, Equity Ownership. Schuh:Amgen Inc.: Consultancy; Pfizer: Consultancy; Celgene: Consultancy; Novartis: Consultancy; Otsuka: Consultancy; Shire: Consultancy; Teva: Consultancy; Jazz: Consultancy.