WO2016094341A1

WO2016094341A1 - Triple combination therapy, comprising ganetespib, a taxane and an antibody, for use in the treatment of her2 positive breast cancer

Info

Publication number: WO2016094341A1
Application number: PCT/US2015/064379
Authority: WO
Inventors: David Proia
Original assignee: Synta Phamaceuticals Corp
Current assignee: Synta Phamaceuticals Corp
Priority date: 2014-12-08
Filing date: 2015-12-08
Publication date: 2016-06-16
Anticipated expiration: 2017-06-08
Also published as: WO2016094341A8

Abstract

Disclosed herein is a combination therapy comprising ganetespib, a taxane, and a monoclonal antibody that interferes with the HER2/neu receptor, pharmaceutical compositions thereof, and methods for use, such as to treat humans with HER2-positive breast cancer (BC).

Description

TRIPLE COMBINATION THERAPY, COMPRISING GANETESPIB, A TAXANE AND AN ANTIBODY, FOR USE IN THE TREATMENT OF HER2 POSITIVE BREAST CANCER

RELATED APPLICATIONS This application claims the benefit of U.S. Provisional Application Serial No. 62/088853, filed December 8, 2014, the entire teachings of which are incorporated herein by reference.

FIELD OF THE INVENTION

This invention relates to a combination therapy comprising ganetespib, a taxane, and a monoclonal antibody that interferes with the HER2/neu receptor, pharmaceutical

compositions thereof, and methods for use, such as to treat humans with HER2-positive breast cancer (BC).

BACKGROUND OF THE INVENTION

There remains a need in the art for novel therapies capable of effectively and reliably treating HER2-positive breast cancer. The present invention addresses this and other such needs.

SUMMARY

It has now been found that certain combinations of an Hsp90 inhibitor of Formula (I) (ganetespib), a taxane, and a monoclonal antibody that interferes with the HER2/neu receptor are surprisingly effective at treating subjects with HER2-positive breast cancer (BC).

Specifically, it has been found that in a group of human patients, out of five test subjects, one test subject achieved a partial response (i.e., at least a 30% decrease in the sum of diameters of the target lesions) to the disclosed combination therapy, and four patients achieved a stable disease state (i.e., neither growth nor shrinkage of the target lesions) after treatment with the disclosed combination therapy (see Example 1). In addition, these combination therapies did not further increase the side effect profile of the individual agents (see Figure 2 and Table 2). The particular combination therapies disclosed herein demonstrate surprising biological activity by demonstrating significant anticancer effects. Accordingly, provided herein are methods of treating HER2-positive breast cancer (BC) in a subject, comprising administering to the subject:

(a) an effective amount of ganetespib, which is represented by Formula (I):

_(I)

or a pharmaceutically acceptable salt thereof;

(b) an effective amount of a taxane, or a pharmaceutically acceptable salt thereof; and

(c) an effective amount of a monoclonal antibody that interferes with

the HER2/neu receptor.

Also disclosed herein are methods of identifying and treating a subject with HER2- positive breast cancer (BC). In one embodiment, the method comprises the steps of:

(1) testing a subject with breast cancer to determine if the breast cancer is HER2- positive cancer (BC); and

(2) if the subject is determined to have HER2-positive breast cancer (BC), treating the subject by administering to the subject:

(a) an effective amount of ganetespib, or a pharmaceutically acceptable salt thereof;

(b) an effective amount of an a taxane, or a pharmaceutically acceptable salt thereof; and

(c) an effective amount of a monoclonal antibody thai interferes with the HER2/neu receptor.

In another embodiment of the method, if the subject is determined not to have HER2- positive breast cancer (BC), said subject is treated with a drug or therapy other than ganetespib/paclitaxel/trastuzumab.

Also disclosed herein are pharmaceutical compositions comprising:

(a) an effective amount of ganetespib, or a pharmaceutically acceptable salt thereof; (b) an effective amount of an taxane, or a pharmaceutically acceptable salt thereof;

(c) an effective amount of a monoclonal antibody that interferes with

the HER2/neu receptor; and

(d) a pharmaceutically acceptable carrier or excipient.

The pharmaceutical composition can be used for treating patients with HER2-positive breast cancer.

In yet another embodiment, provided herein is a use of a composition in the preparation of a medicament for the treatment of HER2-positive breast cancer in a subject, wherein said composition comprises:

(b) an effective amount of an taxane, or a pharmaceutically acceptable salt thereof; and

(c) an effective amount of a monoclonal antibody that interferes with

the HER2/neu receptor.

In yet another embodiment, provided herein is a use of ganetespib or a

pharmaceutically acceptable salt thereof in the preparation of a medicament to be used in combination with i) an effective amount of an taxane, or a pharmaceutically acceptable salt thereof; and ii) an effective amount of a monoclonal antibody that interferes with the HER2/neu receptor for the treatment of HER2-positive breast cancer in a subject.

In yet another embodiment, provided herein is ganetespib or a pharmaceutically acceptable salt thereof for use in combination with i) an effective amount of an taxane, or a pharmaceutically acceptable salt thereof; and ii) an effective amount of a monoclonal antibody that interferes with the HER2/neu receptor for the treatment of HER2-positive breast cancer in a subject. BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing and other objects, features, and advantages of the invention will be apparent from the following more particular description of some embodiments of the invention, as illustrated in the accompanying drawings. The drawings are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the invention.

Figure 1 shows the clinical trial study scheme. Patients received ganetespib, paclitaxel, and trastuzumab on days 1, 8 and 15, and paclitaxel and trastuzumab on day 22 (1 cycle= 28 days).

Figure 2 is a bar graph showing the most common ganetespib-related grades 1/2 adverse events in > 20% of patients. The combination of ganetespib with paclitaxel and trastuzumab in pre-treated HER2-positive metastatic breast cancer (MBC) patients was well- tolerated with expected and manageable main toxicities of grades 1/2 diarrhea and fatigue.

Figure 3 is a line graph showing mean paclitaxel concentration versus time profile (log-linear axis) for the disclosed combination therapy. Preliminary paclitaxel PK data for the first four patients was not appreciably different from those reported in the literature (see Maier-Lenz H, et al. Semin Oncol, 1997; 24 (suppl 19): S 19- 16-19- 19; Mross K, et al.

Cancer Chemother Pharmacol, 2000; 45: 463-470) upon accounting for differences in dose and sampling scheme. Mean Paclitaxel PK Parameters included: AUC: 5922 h*ng/mL, tl/2: 11.9 h, Cmax: 3308 ng/niL, CI: 13.1 L/h/ m2, MRT: 4.3 h.

DETAILED DESCRIPTION OF THE INVENTION

It is demonstrated herein that ganetespib in combination with other chemotherapeutic agents (i.e., a taxane and a monoclonal antibody that interferes with the HER2/neu receptor) is particularly effective in treating certain specific types of breast cancer, such as HER2- positive breast cancer. In some embodiments, the HER2-positive breast cancer is metastatic HER2-positive breast cancer (MBC). The particular dosing regimens disclosed herein demonstrate potency against HER2-positive breast cancer, while showing minimal side effects (see Figure 2). In another embodiment, the method comprises administering the combination of the invention to a subject that has been previously treated with an anti-HER2 agent. In certain embodiments, the anti-HER2 agent is trastuzumab. In another embodiment, the HER2- positive breast cancer is trastuzumab refractory.

Definitions

Unless otherwise specified, the below terms used herein are defined as follows:

The terms "treat", "treatment", and "treating" include the reduction of the

progression, severity and/or duration of cancer, resulting from the administration of the compound of Formula (I). The terms "treat", "treatment", and "treating" also include the reduction of the risk of recurrence of cancer or the delay or inhibition of the recurrence of cancer. In one embodiment, the terms "treat", "treatment", and "treating" includes the inhibition of the progression of cancer either physically by the stabilization of a discernible symptom, physiologically by the stabilization of a physical parameter, or both. In another embodiment, the terms "treat", "treatment", and "treating" of cancer include the reduction or stabilization of tumor size or cancerous cell count.

As used herein, and in the art, a "HER2-positive" breast tumor or breast cancer refers to a breast cancer or breast tumor comprising cells that have HER2 protein present at their cell surface. HER2 protein may be overexpressed, e.g., by gene amplification.

The term "an antibody that interferes with HER2/neu receptor" is an antibody that interacts with the HER2/neu receptor and, in doing so, inhibits its function. These agents are sometimes referred to as "anti-HER2 agents". Accordingly, the terms "an antibody that interferes with HER2/neu receptor" and "anti-HER2 agent" are interchangeably used herein.

Mutations or protein expression levels are preferably detected in a subject sample from the cancer tissue or tumor tissue, e.g., cells, extracellular matrix, and other naturally occurring components associated with the tumor. The mutation or expression level can be detected in a biopsy sample or in a surgical sample after resection of the tumor. The term "sample" as used herein refers to a collection of similar fluids, cells, or tissues isolated from a subject. The term "sample" includes any bodily fluid (e.g., urine, serum, blood fluids, lymph, gynecological fluids, cystic fluid, ascetic fluid, ocular fluids, and fluids collected by bronchial lavage and/or peritoneal rinsing), ascites, tissue samples (e.g., tumor samples) or a cell from a subject. Other subject samples include tear drops, serum, cerebrospinal fluid, feces, sputum, and cell extracts. In an embodiment, the sample is removed from the subject. In a particular embodiment, the sample is urine or serum. In an embodiment, the sample comprises cells. In another embodiment, the sample does not comprise cells. In certain embodiments, the sample can be the portion of the subject that is imaged. Samples are typically removed from the subject prior to analysis; however, tumor samples can be analyzed in the subject, for example, using imaging or other detection methods.

As used herein, "relapse" is understood as the return of a cancer or the signs and symptoms of a cancer after a period of improvement.

As used herein, the term "subject" refers to human and non-human animals, including veterinary subjects. The term "non-human animal" includes all vertebrates, e.g., mammals and non-mammals, such as non-human primates, mice, rabbits, sheep, dog, cat, horse, cow, chickens, amphibians, and reptiles. In a preferred embodiment, the subject is a human and may be referred to as a patient. Chemotherapeutic Agents

The invention, in an embodiment, provides the use of a combination therapy for the treatment of cancer, wherein said combination therapy comprises:

(a) an Hsp90 inhibitor of Formula (I) (ganetespib), or a pharmaceutically acceptable salt thereof;

(b) a taxane, or a pharmaceutically acceptable salt thereof; and

(c) a monoclonal antibody that interferes with the HER2/neu receptor.

As used herein, the term "pharmaceutically-acceptable salt" refers to pharmaceutical salts that are, within the scope of sound medical judgment, suitable for use in contact with the tissues of humans and lower animals without undue toxicity, irritation, and allergic response, and are commensurate with a reasonable benefit/risk ratio. Pharmaceutically-acceptable salts are well known in the art. For example, S. M. Berge, et al. describes pharmacologically acceptable salts in J. Pharm. Sci., 1977, 66: 1-19. Pharmaceutically acceptable salts of a compound of Formula (I) (ganetespib), and the preparation thereof, can be found in U.S. Patent No. 7,825,148, incorporated herein by reference.

In an embodiment, the compound of Formula (I) is in a tautomeric form of the compound of Formula (I). The language "tautomer of a compound of Formula (I)" includes all tautomeric forms of the compound of Formula (I). In a certain embodiment, the tautomer of the compound of Formula (I) is the compound of Formula (la):

or a pharmaceutically acceptable salt thereof.

The taxanes are anti-cancer agents that include paclitaxel (Taxol ) and docetaxel

docetaxel

Both drugs have proven effective in the treatment of a variety of solid tumors including breast, ovarian, lung, and bladder cancers. The term "taxane" is defined herein to mean a compound with a taxane core:

taxane core

and that stabilize or destabilize microtubules.

Exemplary taxanes include, but are not limited to, carbazitaxel, tesetaxel, opaxio, larotaxel, taxoprexin, BMS-184476, hongdoushan A, hongdoushan B, and hongdoushan C, and others. In some embodiments, the combination therapy comprises a taxane selected from paclitaxel, docetaxel, carbazitaxel, tesetaxel, opaxio, larotaxel, taxoprexin, BMS- 184476, hongdoushan A, hongdoushan B, and hongdoushan C. In certain embodiments, the taxane is paclitaxel or docetaxel. In addition, taxanes bound to or pendent from a pharmaceutically acceptable polymer, such as a polyacrylamide, are well known in the art. Thus, the term "taxane" as used herein includes such polymer linked taxanes.

In various embodiments, the monoclonal antibody that interferes with the HER2/neu receptor of the disclosed combination therapy is trastuzumab. In other embodiments, the monoclonal antibody that interferes with the HER2/neu receptor of the disclosed combination therapy is pertuzumab.

In one embodiment, the combination therapy comprises administering:

(a) an effective amount of ganetespib;

(c) an effective amount of a monoclonal antibody that interferes with

the HER2/neu receptor.

In another embodiment, the combination therapy comprises administering:

(a) an effective amount of ganetespib;

(b) an effective amount of paclitaxel; and

(c) an effective amount of a monoclonal antibody that interferes with

the HER2/neu receptor.

In yet another embodiment, the combination therapy comprises administering:

(a) an effective amount of ganetespib;

(c) an effective amount of trastuzumab.

In preferred embodiments, the combination therapy comprises administering:

(a) an effective amount of ganetespib;

(b) an effective amount of paclitaxel; and

(c) an effective amount of trastuzumab.

In another embodiment, docetaxel replaces paclitaxel in any one of the four embodiments described immediately above. In certain embodiments, in any one of the five embodiments described immediately above, the combination therapy also includes pertuzumab. Alternatively, pertuzumab replaces trastuzumab in the combination therapy. Methods of Administration

The term "effective amount" includes an amount of any drug that is sufficient to treat the cancer, to reduce or ameliorate the severity, duration, or progression of cancer, to retard or halt the advancement of cancer, to cause the regression of cancer, to delay the recurrence, or progression of a symptom associated with cancer, or to enhance or improve the therapeutic effect(s) of another therapy. For example, an effective amount can induce, for example, a complete response, a partial response, or a stable disease state; as determined, for example, using RESIST criteria.

The precise amount of compound administered to provide an "effective amount" to the subject will depend on the mode of administration, the type, and severity of the cancer, and on the characteristics of the subject, such as general health, age, sex, body weight, and tolerance to drugs. The skilled artisan will be able to determine appropriate dosages depending on these and other factors. When administered in combination with other therapeutic agents, e.g., when administered in combination with an anti-cancer agent, an "effective amount" of any additional therapeutic agent(s) will depend on the type of drug used. Suitable dosages are known for approved therapeutic agents and can be adjusted by the skilled artisan according to the condition of the subject, the type of condition(s) being treated and the amount of a compound of the invention being used by following, for example, dosages reported in the literature and recommended in the Physician 's Desk Reference (57th ed., 2003).

The dosage of an individual agent used in combination therapy may be equal to or lower than the dose of an individual therapeutic agent when given independently to treat, manage, or ameliorate a disease or disorder, or one or more symptoms thereof.

In an embodiment, the amount of the compound of Formula (I) administered is from about 2 mg/m 2 to about 500 mg/m 2 , for example, from about 50 mg/m 2 to about 500 mg/m 2 , from about 100 mg/m 2 to about 500 mg/m 2 , from about 125 mg/m 2 to about 500 mg/m 2 , from about 150 mg/m 2 to about 500 mg/m 2 or from about 175 mg/m 2 to about 500 mg/m 2. In an embodiment, the amount of the compound of Formula (I) administered is about 50 mg/m to 2 2 2 2 about 200 mg/m , about 100 mg/m to about 200 mg/m , from about 125 mg/m to about 200

2 2 2 2

mg/m , from about 150 mg/m to about 200 mg/m or from about 175 mg/m to about 200 mg/m . In a certain embodiment, the amount of the compound of Formula (I) administered is

2 2

about 100 mg/m to about 150 mg/m .

In another embodiment, the amount of the taxane (e.g. , paclitaxel) administered is

2 2 2 from about 2 mg/m to about 500 mg/m , for example, from about 50 mg/m to about 500

2 2 2 2

mg/m , from about 60 mg/m to about 500 mg/m or from about 70 mg/m to about 500 mg/m . In an embodiment, the amount of the taxane administered is about from about 50

2 2 2 2

mg/m to about 200 mg/m , from about 60 mg/m to about 200 mg/m or from about 70

2 2

mg/m to about 200 mg/m . In a certain embodiment, the amount of the taxane administered

2 2 2 2 is about 70 mg/m to about 90 mg/m or about 50 mg/m to about 100 mg/m .

In yet another embodiment, the amount of the monoclonal antibody that interferes with the HER2/neu receptor (e.g. , trastuzumab) administered is from about 0.1 mg/m to

2 2 2 2 about 10 mg/m , for example, from about 0.5 mg/m to about 10 mg/m , from about 1 mg/m

2 2 2

to about 10 mg/m , or from about 2 mg/m to about 10 mg/m . In an embodiment, the

2 2 amount of the compound of Formula (I) administered is about 0.5 mg/m to about 5 mg/m ,

2 2 2 2

from about 1 mg/m to about 5 mg/m , or from about 2 mg/m to about 5 mg/m . In a certain embodiment, the amount of the monoclonal antibody that interferes with

2 2

the HER2/neu receptor administered is about 1.5 mg/m to about 2.5 mg/m .

₂

In one embodiment, ganetespib is administered at a dose of 2 - 500 mg/m ; the taxane

₂

is administered at a dose of 2 - 500 mg/m ; and the monoclonal antibody that interferes with

₂

the HER2/neu receptor is administered at a dose of 0.1 - 10 mg/m .

₂

In another embodiment, ganetespib is administered at a dose of 50 - 200 mg/m ; the

₂

taxane is administered at a dose of 50 - 100 mg/m ; and the monoclonal antibody that

₂

interferes with the HER2/neu receptor is administered at a dose of 0.5 - 5 mg/m .

₂

In certain embodiments, ganetespib is administered at a dose of 100 - 150 mg/m ; the

₂

taxane is administered at a dose of 70 - 90 mg/m ; and the monoclonal antibody thai interferes with the HER2/neu receptor is administered at a dose of 1.5 - 2.5 mg/m .

₂

In one embodiment, ganetespib is administered at a dose of 100- 150 mg/m ;

paclitaxel is administered at a dose of 80 mg/m ; and trastuzumab is administered at a dose of 2 mg/m². In some embodiments, the disclosed combination therapy is cyclically administered for 28 days. For example, the disclosed combination therapy is administered for a first period of time, followed by a "dose-free" period, then administered for a second period of time. Optionally, the second administration can be followed by a second "dose-free" period, then administered for a third period of time, followed by a "dose-free" period, then administered for a fourth period of time, followed by a "dose-free" period, then administered for a fifth period of time. The language "dose-free" includes the period of time in between, for example, the first dosing period and the second dosing period in which the disclosed combination therapy is not administered to the subject. A preferred cycle is administering the disclosed combination therapy for 28-days at a dose described above, wherein ganetespib, paclitaxel, and trastuzumab are administered on days 1, 8, and 15, and administering paclitaxel and trastuzumab are administered on day 22.

In one embodiment, administration on days 1, 8, and 15 of the cycle comprises the steps of:

(1) administering ganetespib at a dose of 50 - 200 mg/m ;

(2) administering paclitaxel at a dose of 50 - 100 mg/m ; and

(3) administering trastuzumab at a dose of 0.5 - 5 mg/m .

In another embodiment, administration on day 22 of the cycle comprises the steps of:

(1) administering paclitaxel at a dose of 50 - 100 mg/m ; and

(2) administering trastuzumab at a dose of 0.5 - 5 mg/m .

This cycle can then repeated, as described below.

The language "one cycle" includes the first period of time during which the disclosed combination therapy is administered, followed by a dose-free period of time. The dosing cycle can be repeated and one of skill in the art will be able to determine the appropriate length of time for such a cyclical dosing regimen. In an embodiment, the cycle is repeated at least once. In an embodiment, the cycle is repeated two or more times. In an embodiment, the cycle is repeated 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 or more times, or as many times as medically necessary as determined by one of skill in the art, e.g. , as long as the subject exhibits a response with no dose limiting toxicities. In an embodiment, the cycle is repeated until the patient has been determined to be in partial remission (e.g., 50% or greater reduction in the measurable parameters of tumor growth) or complete remission (e.g., absence of cancer). One of skill in the art can determine a patient' s remission status using routine methods well known in the art.

As used herein, the term "in combination" refers to the use of more than one therapeutic agent (e.g., 2, 3, 4, 5, 6, 7, 8, 9, 10, or more). The therapeutic agents can be administered simultaneously or sequentially When there are three therapeutic agents in the combination, any two can be administered simultaneously, all three can be administered simultaneously or all three can be administered sequentially. The use of the term "in combination" does not restrict the order in which the therapeutic agents are administered to a subject afflicted with breast cancer. A first therapeutic agent, such as a compound described herein, can be administered prior to (e.g., 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week or 2 week before), concomitantly with, or subsequent to (e.g., 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week or 2 weeks after) the administration of a second therapeutic agent or treatment, such as an anti-cancer agent, to a subject with cancer. In certain embodiments, one agent may be administered more frequently than the other agent such that multiple doses of one agent are administered for each dose of the other agent(s).

The disclosed combination therapy can be administered to a subject by routes known to one of skill in the art. Examples of routes of administration include, but are not limited to, parenteral, e.g., intravenous, intradermal, subcutaneous, oral, intranasal (e.g., inhalation), transdermal, topical, transmucosal, and rectal administration. Each of the agents can be administered by the same or by different routes of administration. In preferred embodiments, each of the agents is administered by intravenous infusion.

Pharmaceutical compositions are disclosed that include the disclosed combination therapy, and typically at least one additional substance, such as an excipient, a known therapeutic other than those of the present disclosure, and combinations thereof.

The pharmaceutical composition of the invention is formulated to be compatible with its intended route of administration. In an embodiment, the composition is formulated in accordance with routine procedures as a pharmaceutical composition adapted for intravenous, subcutaneous, intramuscular, oral, intranasal, or topical administration to human beings. In preferred embodiments, the pharmaceutical composition is formulated for intravenous administration. In some embodiments, the compound of Formula (I) is formulated at a concentration of 8 mg/niL in 90%v/v PEG 300 and 10% v/v Polysorbate 80 for intravenous administration. Pharmaceutically acceptable formulations of the compound of Formula (I), and the preparations thereof, can be found in U.S. Patent Publication No. US 2013/0172333, incorporated herein by reference.

Methods of Detection of Mutations

Methods and procedures for the detections and/or identifications of HER2 over- expressions and/or mutations are known in the literature and can be easily carried out by a skilled person. Thresholds of expression to that constitute HER2 status are also well known in the art.

In some embodiments, the HER2-positive metastatic breast cancer is defined by having an Immunohistochemistry (IHC) score of 3+, or by having a Fluorescence in situ Hybridization (FISH) ratio of >2.0.

In certain embodiments, the subject is identified as having HER2-positive metastatic breast cancer that is trastuzumab refractory. As used herein, the term "refractory" cancer or tumor is understood as a malignancy that is either initially unresponsive to chemo- or radiation therapy, or which becomes unresponsive over time. For example, "trastuzumab refractory", as used herein, refers to a cancer or tumor that is initially unresponsive to trastuzumab, or which becomes unresponsive trastuzumab over any given period of time. A cancer refractory to a given intervention may not be refractory to all interventions. A refractory cancer is typically not amenable to treatment with surgical interventions.

As used herein, "detecting", "detection" and the like are understood that an assay performed for identification of a specific analyte in a sample, e.g., a gene or gene product with a mutation, or the expression level of a gene or gene product in a sample, typically as compared to an appropriate control cell or tissue. The specific method of detection used is not a limitation of the invention. The detection method will typically include comparison to an appropriate control sample.

As used herein, the terms "identify" or "select" refer to a choice in preference to another. In other words, to identify a subject or select a subject is to perform the active step of picking out that particular subject from a group and confirming the identity of the subject by name or other distinguishing feature. With respect to the instant invention, it is understood that identifying a subject or selecting a subject as having one or more mutations in one or more genes of interest, having a wild-type gene, or having a change in the expression level of a protein, and can include any of a number of acts including, but not limited to, performing a test and observing a result that is indicative of a subject having a specific mutation; reviewing a test result of a subject and identifying the subject as having a specific mutation; reviewing documentation on a subject stating that the subject has a specific mutation and identifying the subject as the one discussed in the documentation by confirming the identity of the subject e.g., by an identification card, hospital bracelet, asking the subject for his/her name and/or other personal information to confirm the subjects identity.

The term "control sample," as used herein, refers to any clinically relevant comparative sample, including, for example, a sample from a healthy subject not afflicted with cancer, a sample from a subject having a less severe or slower progressing cancer than the subject to be assessed, a sample from a subject having some other type of cancer or disease, a sample from a subject prior to treatment, a sample of non-diseased tissue (e.g., non- tumor tissue), a sample from the same origin and close to the tumor site, and the like. A control sample can be a purified sample, protein, and/or nucleic acid provided with a kit.

Such control samples can be diluted, for example, in a dilution series to allow for quantitative measurement of analytes in test samples. A control sample may include a sample derived from one or more subjects. A control sample may also be a sample made at an earlier time point from the subject to be assessed. For example, the control sample could be a sample taken from the subject to be assessed before the onset of the cancer, at an earlier stage of disease, or before the administration of treatment or of a portion of treatment. The control sample may also be a sample from an animal model, or from a tissue or cell lines derived from the animal model, of the cancer. The level of signal detected or protein expression in a control sample that consists of a group of measurements may be determined, e.g., based on any appropriate statistical measure, such as, for example, measures of central tendency including average, median, or modal values. EXEMPLIFICATION

Example 1: Phase 1 Clinical Trial

Study Design

A Phase I trial was conducted to determine the safety, tolerability and maximum tolerated dose (MTD) of the combination of ganetespib, paclitaxel, and trastuzumab for HER2+ MBC in a standard 3+3 dose escalation schema (Table 1). Patents received ganetespib, paclitaxel and trastuzumab on days 1, 8 and 15 and paclitaxel (Figure 3).

Table 1. Standard 3+3 dose escalation schema

Inclusion Criteria

Subjects were required to meet all of the following inclusion criteria to be eligible for enrollment into the study:

1. Pathologically confirmed diagnosis of breast cancer (central confirmation is not required)

2. At least 18 years of age

3. Metastatic or advanced breast cancer that is evaluable OR metastatic or advanced breast cancer that is measurable for response as per RECIST 1.1

4. Eastern Cooperative Oncology Group (ECOG) Performance Status 0-2

5. Life expectancy of at least 3 months as assessed by the investigator

6. Patients with ER+ breast cancer must have received prior treatment with at least one hormone therapy

7. Adequate hematologic function as defined by:

o Absolute neutrophil count > 1,500 cells^L;

o Platelets >100,000/μί; and

o Hemoglobin > 9.0g/dL. Adequate hepatic function as defined by:

o Total bilirubin < 1.5 x the upper limit of normal (ULN);

o AST and alanine aminotransferase (ALT) < 2.5 x ULN; and

o Albumin > 3.0 g/dL.

Adequate renal function as defined by a serum creatinine < 1.5 x ULN.

Willingness and ability to comply with scheduled visits, treatment plans, laboratory tests, and other study procedures.

Female subjects of childbearing potential and males must agree to use adequate contraception (e.g. , hormonal or barrier method of birth control; abstinence) for the duration of study treatment.

Female subjects of childbearing age must have a negative serum pregnancy test at study entry.

Patients with HrV/AIDS are allowed on study if they have an undetectable viral load, CD4 > 300 and are on a stable Highly Active Antiretroviral Therapy (HAART) regimen for 1 month prior to study enrollment.

Patients are required to have HER2+ breast cancer defined as a FISH- ratio of > 2.0 or IHC 3+.

Any number of prior chemotherapies or biological therapies are allowed, patients are required to have prior treatment with pertuzumab and ado-trastuzumab emtansine with the exceptions listed below:

o Metastatic patients who have not received prior pertuzumab are eligible if:

heavily pretreated prior to FDA approval of pertuzumab (08-Jun-2012) for first line treatment ofHER2+ MBC.

o Metastatic patients who have not received ado-trastuzumabemtansine are eligible if: Heavily pretreated prior to FDA approval of ado-trastuzumab emtansine (22-Feb-2013) for the treatment of patients with HER2+ MBC who previously received trastuzumab and a taxane, separately or in combination. No prior history of intolerance or hypersensitivity to trastuzumab and/or adverse events related to trastuzumab, murine proteins, or any of the excipients that resulted in trastuzumab being permanently discontinued. Exclusion Criteria

Subjects were ineligible for enrollment into the study if they met any of the following criteria:

1. Fewer than 21 days since last anti-tumor therapy, including chemotherapy, biologic except trastuzumab, experimental, immune, radiotherapy for the treatment of breast cancer, with the following exceptions:

o Hormone therapy; or

o Palliative radiation therapy involving <25% of marrow-bearing bone is

allowed if completed within > 14 days prior to first study treatment.

2. Surgery, radiotherapy, or lesion ablative procedure to the only area of measurable/ evaluable disease.

3. Major surgery within 4 weeks prior to first dose of ganetespib.

4. Poor venous access for study drug administration.

5. Study drug administration via indwelling catheters is allowed only if the catheter is made of silicone material.

6. History of severe (grade 3 or 4) allergic or hypersensitivity reactions to excipients (e.g., Polyethylene glycol [PEG] 300 and Polysorbate 80).

7. History of intolerance or hypersensitivity to paclitaxel and/or adverse events related to paclitaxel that resulted in paclitaxel being permanently discontinued.

8. Peripheral neuropathy of grade ~ 2 per NCI CTCAE, Version 4.0, at the time of or within 3 weeks prior to the first study therapy.

9. Baseline QTc > 470 msec (average of triplicate ECG recordings); a consistent method of QTc calculation must be used for each patient's QTc measurements. QTcF

(Fridericia's formula) is preferred.

10. Use of medications that have been linked to the occurrence of torsades de pointes:

o Patients will be eligible for the study if they discontinue any of the listed

medications two weeks prior to registration and study enrollment.

o Stable regimen of antidepressants of the SSRI class is allowed (common

SSRls include escitalopram oxalate, citalopram, fluvoxamine, paroxetine, sertraline and fluoxetine).

11. Left ventricular ejection fraction (EF) <50% at baseline. Serum potassium, magnesium, and calcium levels (corrected for albumin) outside the laboratory's reference range despite correction.

Treatment with chronic immunosuppressants (e.g. , cyclosporine following transplantation).

Women who are pregnant or lactating.

Current known active infection with HIV, hepatitis B or C viruses.

Uncontrolled systemic disease (e.g. , clinically significant cardiac, pulmonary or metabolic disease).

Other medications, or severe acute/chronic medical or psychiatric condition, or laboratory

abnormality that may increase the risk associated with study participation or study drug

administration, or may interfere with the interpretation of study results in the judgment of the investigator.

History of clinically significant cardiac dysfunction, including:

o Unstable angina;

o Unstable atrial fibrillation;

o Symptomatic bradycardia;

o Indwelling temporary pacemaker;

o History of MI within 6 months prior to first study treatment;

o History of symptomatic CHF (grade> 3 by NCI CTCAE or Class> II by New York Heart Association (NYHA) criteria;

o Ventricular tachycardia or a supraventricular tachycardia that requires

treatment with a Class la antiarrhythmic drug (e.g. , quinidine, procainamide, disopyramide) or Class III antiarrhythmic drug (e.g. , sotalol, amiodarone, dofetilide). Use of other antiarrhythmic drugs is permitted;

o Second or third degree atrioventricular (AV) block unless treated with a permanent pacemaker;

o Complete left bundle branch block (LBBB); and/or

o History of long QT syndrome or a family member with this condition. 19. Brain metastases that are:

o Progressive; or

o Have required any type of therapy (including radiation, surgery or steroids) to control symptoms from brain metastases within 60 days prior to the first study treatment.

20. History of an invasive second primary malignancy diagnosed within the previous 3 years, except for appropriately treated stage I endometrial or cervical carcinoma or prostate carcinoma treated surgically, and non-melanoma skin cancer.

Results: Patient Characteristics, Pharmacokinetics, and Toxicity

Table 2. Patient Demographics

setting (median, range)

Table 3. Ganetespib Related Grade 3/4 Adverse Events

Results: Efficacy

Table 4. Efficacy results of the Phase 1 clinical trial.

ORR

• Complete response (CR) 0

• Partial response (PR) [duration, weeks] 1 (17%), 17 ; continues on study

Stable disease (SD) [duration;, weeks] 4 (67%) (11-29 weeks)

CBR 3 (50%)

(CR + PR + SD > 24 weeks)

Median PFS [weeks, range] 19.4 (11-29)

*1 patient came off study after cycle 1 due to clinical progression. This patient is only evaluable for safety but not efficacy. The PR is confirmed and the patient remains on study. Response Criteria:

(1) Complete Response (CR): Disappearance of all target and non-target lesions. Any pathological lymph nodes (whether target or not) must have reduction in short axis to <10 mm. Normalization of tumor markers, if elevated at baseline, is required for solid tumor malignancies.

(2) Partial Response (PR): At least a 30% decrease in the sum of diameters of target lesions, taking into reference the baseline sum diameters.

(3) Progressive Disease (PD): At least a 20% increase in the sum of diameters of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study). In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm.

(4) Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum diameters while on study.

(5) Not Evaluable (NE): NE is when no imaging/measurement is done at all at a particular time point. The patient is not evaluable (NE) at that time point.

(6) Discontinuation of Treatment: Early death is defined as having NO repeat tumor assessments following initiation of study therapy resulting from the death of the patient due to disease or treatment. Conclusions

The combination of ganetespib with paclitaxel and trastuzumab in pre-treated HER2+ MBC patients was well-tolerated with expected and manageable main toxicities of grades 1/2 diarrhea and fatigue (see Figure 2 and Table 2). The MTD of weekly ganetespib in this triplet combination is 150 mg/m . Preliminary paclitaxel PK data are consistent with those reported in literature (see Figure 3). Despite prior taxanes, pertuzumab, and T-DM1, the CBR in this heavily pre-treated cohort of patients was 50%.

Claims

CLAIMS We claim:

1. A method of treating HER2-positive breast cancer (BC) in a subject, comprising administering to the subject:

(a) an effective amount of ganetespib, which is represented by Formula (I):

or a pharmaceutically acceptable salt thereof;

(c) an effective amount of a monoclonal antibody that interferes with

the HER2/neu receptor.

The method of claim 1, wherein the taxane is selected from the group consisting of: paclitaxel, docetaxel, carbazitaxel, tesetaxel, opaxio, larotaxel, taxoprexin, BMS- 184476, hongdoushan A, hongdoushan B, and hongdoushan C.

The method of claim 2, wherein the taxane is paclitaxel or docetaxel.

The method of claim 3, wherein the taxane is paclitaxel.

The method of any one of claims 1 - 4, wherein the monoclonal antibody that interferes with the HER2/neu receptor is trastuzumab.

The method of claim 5, wherein the method also comprises administering to the subject pertuzumab.

7. The method of claim 1, wherein the method comprises administering to the subject:

(a) an effective amount of ganetespib;

(b) an effective amount of paclitaxel; and

(c) an effective amount of trastuzumab.

8. The method of any one of claims 1 - 7, wherein the subject has been previously

treated with an anti-HER2 agent.

9. The method of claim 8, wherein the anti-HER2 agent is trastuzumab.

10. The method of any one of claims 1 - 9, wherein the HER2-positive breast cancer is trastuzumab refractory.

The method of any one of claims 1 - 10, wherein the HER2-positive breast cancer (BC) is defined by having an Immunohistochemistry (IHC) score of 3+, or by having a Fluorescence in situ Hybridization (FISH) ratio of >2.0.

The method of any one of claims 1 - 11, wherein the HER2-positive breast cancer (BC) is metastatic.

The method of any one of claims 1 - 12, wherein administration of each drug occurs by intravenous infusion.

The method of any one of claims 1 - 13, wherein administration to the subject occurs over a 28-day cycle, wherein the 28-day cycle comprises administering ganetespib, paclitaxel, and trastuzumab on days 1, 8, and 15, and administering paclitaxel and trastuzumab on day 22.

The method of claim 14, wherein ganetespib is administered to the subject at a dose of 50 - 200 mg/m².

The method of claim 14, wherein paclitaxel is administered to the subject at a dose of 50 - 100 mg/m².

The method of claim 14, wherein trastuzumab is administered to the subject at a dose of 0.5 - 5 mg/m².

The method of claim 14, wherein administration on days 1, 8, and 15 of the cycle comprises the steps of:

(1) administering ganetespib at a dose of 50 - 200 mg/m ;

(2) administering paclitaxel at a dose of 50 - 100 mg/m ; and

(3) administering trastuzumab at a dose of 0.5 - 5 mg/m .

The method of claim 14, wherein administration on day 22 of the cycle comprises the steps of:

(1) administering paclitaxel at a dose of 50 - 100 mg/m ; and

(2) administering trastuzumab at a dose of 0.5 - 5 mg/m .

A method of identify and treating a subject with HER2-positive breast cancer (BC), said method comprising the steps of:

(1) testing a subject with breast cancer to determine if the breast cancer is HER2-positive breast cancer (BC); and

(a) an effective amount of ganetespib, which is represented by Formula (I):

or a pharmaceutically acceptable salt thereof; (b) an effective amount of an a taxane, or a pharmaceutically acceptable salt thereof; and

(c) an effective amount of a monoclonal antibody that interferes with the HER2/neu receptor.

21. The method of claim 20, wherein if the subject is determined not to have HER2- positive breast cancer (BC), said subject is treated with a drug or therapy other than ganetespib/paclitaxel/trastuzumab.

22. The method of claim 20, wherein the taxane is selected from the group consisting of: paclitaxel, docetaxel, carbazitaxel, tesetaxel, opaxio, larotaxel, taxoprexin, BMS- 184476, hongdoushan A, hongdoushan B, and hongdoushan C.

23. The method of claim 22, wherein the taxane is paclitaxel or docetaxel.

24. The method of claim 23, wherein the taxane is paclitaxel.

25. The method of any one of claims 20 and 22 - 24, wherein the monoclonal

antibody thai interferes with the HER2/neu receptor is trastuzumab.

26. The method of claim 25, wherein the method also comprises administering to the subject pertuzumab.

27. The method of claim 20, wherein treatment of the subject having HER2-positive breast cancer (BC) comprises administering to the subject:

(a) an effective amount of ganetespib;

(b) an effective amount of paclitaxel; and

(c) an effective amount of trastuzumab.

28. The method of any one of claims 20 and 22 - 25, wherein the subject having HER2- positive breast cancer (BC) has been previously treated with an anti-HER2 agent.

29. The method of claim 28, wherein the anti-HER2 agent is trastuzumab.

30. The method of any one of claims 20 and 22 - 29, wherein the HER2-positive breast cancer (BC) is trastuzumab refractory.

31. The method of any one of claims 20 and 22 - 30, wherein HER2-positive breast

cancer (BC) is defined by having an Immunohistochemistry (IHC) score of 3+, or by having a Fluorescence in situ Hybridization (FISH) ratio of >2.0.

32. The method of any one of claims 20 and 22 - 31, wherein the HER2-positive breast cancer is metastatic.

33. The method of any one of claims 20 and 22 - 32, wherein treatment of the subject having HER2-positive breast cancer (BC) comprises administration by intravenous infusion.

34. The method of any one of claims 20 and 22 - 33, wherein treatment of the subject having HER2-positive breast cancer (BC) comprises administration over a 28-day cycle, wherein the 28-day cycle comprises administering to the subject ganetespib, paclitaxel, and trastuzumab on days 1, 8, and 15, and administering to the subject paclitaxel and trastuzumab on day 22.

35. The method of claim 34, wherein ganetespib is administered to the subject at a dose of 50 - 200 mg/m².

36. The method of claim 34, wherein paclitaxel is administered to the subject at a dose of 50 - 100 mg/m².

37. The method of claim 34, wherein trastuzumab is administered to the subject at a dose of 0.5 - 5 mg/m².

38. The method of claim 34, wherein administration on days 1, 8, and 15 of the cycle comprises the steps of:

(1) administering ganetespib at a dose of 50 - 200 mg/m ;

(2) administering paclitaxel at a dose of 50 - 100 mg/m ; and

₂

(3) administering trastuzumab at a dose of 0.5 - 5 mg/m .

39. The method of claim 34, wherein administration on day 22 of the cycle comprises the steps of:

(1) administering paclitaxel at a dose of 50 - 100 mg/m ; and

₂

(2) administering trastuzumab at a dose of 0.5 - 5 mg/m .

40. The method of any one of claims 20 and 22 - 39, wherein administration of each drug occurs by intravenous infusion.

41. A pharmaceutical composition comprising:

(a) an effective amount of ganetespib, which is represented by Formula (I):

or a pharmaceutically acceptable salt thereof;

(b) an effective amount of an taxane, or a pharmaceutically acceptable salt thereof;

(c) an effective amount of a monoclonal antibody that interferes with

the HER2/neu receptor; and

(d) a pharmaceutically acceptable carrier or excipient.

The pharmaceutical composition of claim 41, wherein the taxane is selected from the group consisting of: paclitaxel, docetaxel, carbazitaxel, tesetaxel, opaxio, larotaxel, taxoprexin, BMS-184476, hongdoushan A, hongdoushan B, and hongdoushan C.

43. The pharmaceutical composition of claim 42, wherein the taxane is paclitaxel or docetaxel.

44. The pharmaceutical composition of claim 43, wherein the taxane is paclitaxel.

45. The pharmaceutical composition of any one of claims 41 - 44, wherein the monoclonal antibody thai interferes with the HER2/neu receptor is trastuzumab.

46. The pharmaceutical composition of claim 45, wherein the pharmaceutical

composition also comprises pertuzumab.

47. The pharmaceutical composition of claim 41 comprising:

(a) an effective amount of ganetespib;

(b) an effective amount of paclitaxel;

(c) an effective amount of trastuzumab; and

(d) a pharmaceutically acceptable carrier or excipient.

48. The pharmaceutical composition of any one of claims 41 - 47, wherein the pharmaceutical composition is formulated for intravenous administration.