GOOD MORNING, I WOULD LIKE TO CALL TO ORDER THE 139th MEETING OF THE NIH RECOMBINANT DNA ADVISORY COMMITTEE H. WELCOME EVERYONE, THANK YOU FOR ATTENDING AND THOSE ON THE PHONE. WE HAVE FOUR MEMBERS ON THE RAC, I'LL INTRODUCE EACH OF YOU ONE BY ONE AND SAY A FEW WORDS ABOUT WHAT BRINGS YOU HERE. ONE MEMBER IS SCOTT ANTONIO. CHAIRMAN OF THORACIC ONCOLOGY, CO-LEADER IMMUNOLOGY, SENIOR LEADER THORACIC ONCOLOGY AND PROFESSOR UNIVERSITY OF SOUTH FLORIDA SCOOT OF MEDICINE ON COLOGIC SCIENCE AT MOFFET SENTENCER TAMPA, FLORIDA. >> MEDICAL ONCOLOGIST AND MINE BIOLOGIST AND CONDUCTED A NUMBER OF CELLS THERAPEUTICS. >> WELCOME. NEXT IS DR. KEVIN DONAHUE. >> HELLO. PROFESSOR OF MEDICINE AND DIRECTOR OF ELECTROPHYSIOLOGY RESEARCH UNIVERSITY OF MASSACHUSETTS, MEDICAL SCHOOL WORCESTER, MASSACHUSETTS. >> YES. I'M IN WOOSER, MASSACHUSETTS, I DO CARDIAC ARRHYTHMIA RESEARCH FOCUSD ON ARRHYTHMIA MECHANISMS AN GENE THERAPY IN THAT REGARD. >> GREAT. WELCOME. NEXT IS DR. PATRICK HERRING. PROFESSOR DEPARTMENT OF MOLECULAR GENETICS AND MICROBIOLOGY SCHOOL OF MEDICINE AT STONY BROOK UNIVERSITY, STONY BROOK, NEW YORK. >> (OFF MIC) >> AND DR. HOWARD KOFFMAN. >> YES. >> LET ME INTRODUCE. PROFESSOR DEPARTMENT OF SURGERY ROBERT WOOD JOHNSON MEDICAL SCHOOL RUTGERS STATE MEDICAL UNIVERSITY OF NEW YORK. BRUNSWICK, NEW JERSEY. >> I'M INTERRED IN THANK YOU MYOLOGY AND ONCOLYTIC VIRUSES FOR MELANOMA AND SURGICAL ONCOLOGIST BY TRAINING. >> NEVER HAVE ENOUGH TRAINING. -- ENOUGH SURGEONS. DR. ROSS PROFESSOR DEPARTMENT OF PEDIATRICS AND SURGERY, CO-INSTITUTE DIRECTOR FOR THE TRANSLATION HAND MCCLEAN CERTAINTY FOR CLINICAL MEDICAL ETHICS, UNIVERSITY OF CHICAGO, CHICAGO ILLINOIS. >> HI, I'M LAYNY ROSS AND MY INTEREST FOR THIS MEETING IS ABOUT HUMAN SUBJECTS PROTECTIONS, I JUST FINISHED A TERM ON SECRETARY ADVISORY COMMITTEE ON HUMAN RESEARCH PROTECTIONS. >> WELCOME ALSO. NOW LET'S HAVE THE FORMER CURRENT RAC MEMBERS GO AROUND THE ROOM AND HAVE Y'ALL INTRODUCE YOURSELF IN A SENTENCE OR TWO ABOUT YOUR RESEARCH AND EXPERTISE. >> I'M SAWATI, CHATTERJEE I WORK WITH. >> JOE PILEWSKI, PULMONARY MEDICINE AND STUDY ION TRANSPORT AND EPITHELIAL DYSFUNCTION IN THE AIRWAY. >>TY I'M MICHAEL AD ATKINS DEPUTY DIRECTOR OF THE LOMBARDI COMPREHENSIVE CANCER CENTER HERE AT D.C. AND MEDICAL ONCOLOGIST AND I DO RESEARCH WITH CYTOKINES AND ANTIBODIES PRIMARILY RELATED TO PATIENTS WITH MELANOMA AND KIDNEY CANCER. >> MIAMI NAME IS (INDISCERNIBLE) FROM MEMORIAL SLOAN-KETTERING CANCER CENTER NEW YORK WHERE I HEAD CENTER FOR CELL ENGINEERING. MY RESEARCH FOCUSES TWO AREAS MAINLY, ENGINEER T-CELLS FOR CANCER IMMUNOTHERAPY AND ENGINEERS HEMATOPOIETIC STEM CELLS FOR GENETIC DISORDERS. >> I'M LORI SO LOATH NORTHWESTERN UNIVERSITY IN THE DEPARTMENT OF STUDIES AND CLINICAL HUMANITIES ABOUT BIOETHICS. I'M INTERESTED IN BIOETHICS. >> DON WOOLY UNIVERSITY STATE SCHOOL OF MEDICINE, ASSOCIATE PROFESSOR THERE, I STUDY HIV, A NUMBER OF OTHER VIRAL VECTORS AND CERTIFIED BIOSAFETY PROFESSIONAL. >> REBECCA DRESSER, WASHINGTON UNIVERSITY IN ST. LOUIS BIOETHICS AND LAW. >> DALE KOHN, UCLA MICROBIOLOGY AND PEDIATRICS. I'M A PEDIATRIC BONE MARROW TRANSPLANT PHYSICIAN AND I DO VERGE ON GENE THERAPIES AND HEMATOPOIETIC STEM CELLS. >> I'M MARIE HAMMARSKJOLD FROM UNIVERSITY OF VIRGINIA ASSOCIATE DIRECTOR OF THE CENTER FOR AIDS RESEARCH AND I DO RESEARCH ON THE MOLECULAR RESEARCH MAINLY VIRUSES INCLUDING HIV AMONG ALSO I HAVE AN INTEREST IN RNA BIOLOGY. >>TY PEOPLE PAULA (INAUDIBLE) FROM UNIVERSITY OF SOUTHERN CALIFORNIA, I'M INTERESTED IN GENE THERAPY USING ENGINEERED NUCLEASE AND HEMATOPOIETIC STEM CELLS AND HIV. >> (INAUDIBLE). UNIVERSITY OF WASHINGTON, MEDICAL ONCOLOGIST AND CLINICALLY (INAUDIBLE) RESEARCH WISE I'M INTERESTED IN STEM CELL GENE THERAPY APPLICATIONS. >> RICH WHITLEY UNIVERSITY OF ALABAMA BIRMINGHAM IN THE DEPARTMENT OF PEDIATRICS AND JOINT WOMEN'S AND MEDICINE MICROBIOLOGY AND NEUROSURGERY, ENGINEERING HERPES SIMPLEX FOR THE TREATMENT OF BRAIN TUMORS. >> DENISE GAVIN U.S. FDA CENTER FOR BIOLOGICS, IN THE OFFICE OF CELL FISH SHOULDN'T GENE THERAPY THAT OVERSEAS GENE THERAPY REGULATION. >> KRISTINA BOHR OFFICE OF HUMAN RESEARCH PROTECTIONS DEPARTMENT OF HUMAN SERVICES. >> THANK YOU. ANY RAC MEMBERS ON THE PHONE? >> (INAUDIBLE) (INDISCERNIBLE) AS WELL AS HIV VACCINE. >> ANYONE ELSE? OKAY. SO GO AHEAD, DR. KIEM. >> I'M (INAUDIBLE) >> BIOSTATISTICIAN I BELIEVE? >> YES. >> THANK YOU. SO I WANT TO REMIND EVERYONE THAT THE PROCEEDINGS ARE BEING RECORDED AND WEBCAST SO PLEASE MAKE SURE YOU TURN YOUR MICROPHONE ON FOR YOUR ANNOUNCEMENTS AND MAKE SURE YOU TURN OFF WHEN DONE. ANYONE FROM THE PUBLIC WHO MAKES A COMMENT ALSO SPEAK TO A MICROPHONE. >> AGAIN, WELCOME, EVERYONE. IT'S IMPRESSIVE TO HEAR THE RANGE OF EXPERTISE WE HAVE AS A GROUP. AND REQUEST THAT WE ARE READY TO START OUR FIRST PROTOCOL. >> BEFORE THAT WE'RE GOING TO TAKE A MINUTE TO REVIEW THE RULES OF CONDUCT AND CONFLICT OF INTEREST LIKE WE DO EVERY MEETING. AS A MEMBER OF THIS COMMITTEE YOUR SPECIAL GOVERNMENT EMPLOYEE AND SUBJECT TO RULES OF CONDUCT THAT APPLY TO GOVERNMENT PLYEES. YOU SHOULD HAVE RECEIVED A COPY OF A REPORT CALLED STANDARDS OF ETHICAL CONDUCT FOR PLYEES AT THE EXECUTIVE BRANCH, EVERY MEETING IN ADDITION TO REMINDING YOU THE IMPORTANCE OF FOLLOWING ETHICS RULES WE HAVE -- WE LIKE TO REVIEW THE STEPS WE TAKE AND ASK YOU TO TAKE TO ENSURE ANY CONFLICT OF INTEREST ARE ADDRESSED AS YOU KNOW BEFORE EVERY MEETING IT PROVIDES US WITH INFORMATION ABOUT YOUR PERSONAL PROFESSIONAL AND FINANCIAL INTEREST AND WE USE THIS INFORMATION AS BASIS FOR ASSESSING WHETHER YOU HAVE ANY REAL OR POTENTIAL CONFLICT OF INTEREST THAT COULD COMPROMISE YOUR ABILITY TO BE OBJECTIVE. WHILE WE WAIVE GENERAL MATTER, CONFLICTS BECAUSE WE BELIEVE YOUR ABOUT TO BE OBJECTIVE ARE NOT AFFECTED BY INTEREST WE RELY TO A GET GROW ON YOU TO BE ATTENTIVE TO MEETINGS TO THE POSSIBILITY THAT AN ISSUE COULD AFFECT OR APPEAR TO AFFECT INTEREST IN A SPECIFIC WAY, IF THAT HAPPENS WE ASK YOU RECUSE YOURSELF FROM DISCUSSION AND LEAVE THE ROOM. IF YOU HAVE ANY QUESTIONS ABOUT RILES OF CONFLICT OF INTEREST OR COMMITTEE MANAGEMENT OFFICER MARY NESS WILL BE HAPPY TO ADDRESS THEM. THANK YOU. >> JUST ALSO REMIND PEOPLE ON THE PHONE TO MUTE YOUR PHONES WHEN NOT SPEAKING SO WE DON'T HEAR YOUR DOGS BARKING. OKAY. THEN WE WILL GO TO THE FIRST PROTOCOL. I'LL INTRODUCE THE FIRST PRESENTER DR. FREYTAG WHO IS FROM -- DIVISION HEAD BIOLOGY RADIATION ONCOLOGY AND WENDALL ANDERSON CHAIR AND CANCER AT THE HENRY FORD HEALTH SYSTEM. DR. FREYTAG LED RESEARCH EFFORTS IN THE DEPARTMENT OF RADIATION ONCOLOGY FOR THE PAST 15 YEARS INCLUDING VERGE ON GENE AND RADIATION CANCER THERAPIES, MOLECULAR BASIS OF CANCER AND REGULATION OF GROWTH AND DIFFERENTIATION. ALSO ON THE PHONE WE HAVE I BELIEVE BOTH CALLED DR. (INAUDIBLE) IN THE DEPARTMENT OF RADIATION ONCOLOGY AT HENRY FORD HEALTH SYSTEM AND DR. HATHAN ALI ONCOLOGIST IN THE DEPARTMENT OF INTERNAL MEDICINE DIVISION OF HEMATOLOGY ONCOLOGY AT THE HEALTH HENRY FORD HEALTH SYSTEMS. DR. FREYTAG WILL PRESENT, THIS IS PROTOCOL NUMBER 1403-1315 PHASE 1 TRIAL OF ONCOLYTIC ADENOVIRUS MEDIA CYTOTOXIC INTERLEUKIN 12 TRANS FOREPERSON: FOR RADIO RECURRENT PROSTATE CANCER. >> GOOD MORNING, EVERYONE, THANK YOU FOR INVITING US AND FOR THIS OPPORTUNITY TO DISCUSS THE PROTOCOL. FLOSS THE WAY I STRUCTURED THE TALK IS FIRST GIVE YOU BACKGROUND INFORMATION ABOUT OUR PREVIOUS ADENOVIRUSES AND CLINICAL TRIALS, THE IL-12 ADENOVIRUS DISCUSSING TODAY WAS DERIVED FROM THE PRODUCED ANTS VIRUSES AN MUCH INFORMATION WE DERIVE IN THE LABORATORY AND CLINIC IS RELEVANT HERE. TWO,LY DISCUSS PRE-CLINICAL STUDIES WITH THIS VIRUS AND MAINLY ON THE TOXICOLOGY STUDIES AND FINALLY TALK ABOUT THE PROPOSED PHASE 1 TRIAL IN RADIO RECURRENT PROSTATE CANCER. THE APPROACH WE HAVE BEEN DEVELOPING FOR THE PAST 20 YEARS NOW WHICH WE INITIALLY COINED THREE PRONGED APPROACH INVOLVE THREE MODALITIES, VIRAL THERAPY, SUICIDE GENE THERAPY AND RADIATION THERAPY. FROM WHAT WE FOUND APPROACH WE USE REALLIMYCATION COMPETENT ADENOVIRUS TO DEVELOP APPROPRIATE GENES TO THE TUMOR. REPLICATION COMPETENT VIRUS AT GENE THERAPY VEHICLES IS THE VIRUS ISLYTIC AND GIVES ANTIGEN TUMOR EFFECT SO IN CONTRAST TO REPETITION DEFECTIVE VIRUS WE GET THERAPEUTIC EFFECT. ALL THE VIRUSES CONTAIN TWO THERAPIES TO GENES ONE IS (INDISCERNIBLE) KINASE GENE WHICH CONVERTS GANG CYCLOVEER TO MONOPHOSPHATE, POTENT DNA GENE TERMINATETORS. WHEN GENES ARE EXPRESS IN TUMOR AND YOU GIVE THE PATIENT 5 FG YOU GET THE METABOLITES WITHIN TUMOR AND THEREFORE LOCAL CHEMOTHERAPEUTIC EFFECT AND YOU DON'T GET THE SECOND TOXICITY YOU NORMALLY GET WITH CONVENTIONAL CHEMOTHERAPY. ANOTHER SUICIDE GENE SYSTEM IS THEY EXHIBIT WHAT'S CALLED A BUY SON EFFECT WHERE TOXIC METABOLITES DIFFUSE TO MEMBRANE CELLS AND NOT AFFECTED BY THE VIRUS, AND KILL THOSE CELLS AND THEREFORE IN THEORY IS NOT NECESSARY TO INFECT ALL TUMOR CELLS TO KILL THEM. 20 YEARS AGO WE SHOWED NOT ONLY SUICIDE SYSTEMS EXHIBIT CHEMOTHERAPEUTIC EFFECT BUT POTENT RADIO SENSITIZERS, INCREASE THE SKILL EFFECT OF RADIATION THERAPY. INITIALLY DEVELOPING THIS APPROACH WE WERE DEVELOPING AS A MEANS TO PROVE THE OUTCOME OF RADIATION THERAPY. SO THERE'S SYNERGY AMONG THREE MODALITY, ONE PLUS ONE PLUS ONE EQUALS THREE ON THE ORDER OF 56789 ALL FLEE MODALITIES RESULT IN SIGNIFICANT TUMOR CELL DESTRUCTION AND RELEASE OF TUMOR ANTIGENS, THEY CAN BE PICKED UP BY PROFESSIONAL ANTIGEN PRESENTING CDS, LYMPHOCYTES CAUSING ACTIVATION. THIS COUPLED WITH THE DANGER SIGNAL GENERATED BY THE REPLICATION COMPETENT AD KNEE VIRUS RESULT IN -- ADENOVIRUS RESULTED IN TUMOR IMMUNITY SO IT'S POSSIBLE THERE'S FOUR MODALITY, NOT JUST THREE. WE HAVE TAKEN OUR APPROACH TO FIVE CLINICAL TRIALS USING THREE DIFFERENT RELATED ONCOLYTIC ADENOVIRUSES AND ISLE EXPLAIN THESE ON -- I'LL EXPLAIN ON THE NEXT SLIDE. THE FIRST GENERATION VIRUS WE TOO TOOK TWO PROSTATE, RADIO RECURRENT SETTING WHERE USING THE GENE TRANSFER AS A SAVAGE TREATMENT AFTER RADIATION FAIL URINE AFTER THAT TRIAL WAS COMPLETED WE THEN TOOK INTO THE NEWLY DIAGNOSED STUDY COMBINING OUR APPROACH WITH RADIATION THERAPY, AGAIN TO TRY TO IMPROVE THE OUTCOME OF RADIATION THERAPY. BACK WHEN WE DID THESE STUDIES ABOUT 10, 15 YEARS AGO ME AT A TIMES WERE NOT DEVELOPED TO ALLOW US TO MONITOR THE VIRUS WHILE IN THE PATIENT. AND THEREFORE WE WERE FLYING BLIND. WE COULDN'T MEASURE HOW MUCH THE VIRUS SPREAD WITHIN THE PROSTATE, HOW LONG GENE EXPRESSION PERSISTED, AND WHETHER OR NOT THERE WAS ANY DISSEMINATION. Z AND THEREFORE BEFORE PROCEEDING TO PHASE 2 AND 3, WE DECIDED TO GENERATE ADENOVIRUS IN THE PATIENT USING SPECK HAIR IN THE HUMAN PROSTATE, AND USING PECK SHOWN HERE IN THE DOG PANCREAS. AND THEN TOOK THIS VIRUS INTO A PHASE 1 TRIAL AGAIN, IN THE DULY DIAGNOSED SETTING COMBINED WITH RADIATION THERAPY AND MAJOR GOAL OF THE TRIAL TRIAL WAS TO STUDY THE BEHAVIOR OF THE VIRUS WHILE IN THE PATIENT. WE MADE TWO IMPROVEMENTS IN FIRST GENERATION VIRUS, BETTER FUSION GENE AS WELL AS GENE THAT MADE THE VIRUS MORELYTIC. THIS IS THE VIRUS WE TOOK INTO RANDOMIZED PHASE 2 STUDY, AGAIN, AT NEWLY DIAGNOSED SETTING COMBINING WITH RADIATION THERAPY. A LITTLE INFORMATION ABOUT ADENOVIRAL PLATFORM T ANTIVIRUSES CONTAIN CD TK FUSION GENE WHERE EXPRESSION IS DRIVEN BY THE CMV PROMOTER. OUR FIRST GENERATION VIRUS THE E-3 REGION WAS DELETE SOD THE ADENOVIRAL GENES PLAY A ROLE IN REGULATING THE HOST CELL IMMUNE RESPONSE. AS WELL AS ADP GENE WHICH MAKES IT MORELYTIC OR ABSENT. TO MAKE THAT IMAGING VIRUS WE DEVELOP IN THE HUMAN SODIUM IDE DINE SIMILAR PORTER GENE, EXPRESSED IN MULTIPLE TISSUES INCLUDING SALIVARY GLAND THYROID AND STOMACH AND IT UPTAKES THINGS LIKE IODINE AND -- THEREFORE A VIRUS EXPRESSING THIS GENE CAN BE IMAGED NON-INVASIVELY USEKING SPECK AND SET PET AS I SHOWED ON THE LAST SLIDE. BELIEVE WE THRONE HYDE HYPERBETTER THERAPEUTIC GENE THIS IS A NATURALLY OCCURRING GENE THAT MAKES IT MORELYTIC, THERE BY IMPROVING PRONG 1 OF THREE PRONGD APPROACH. WE ALSO MADE A BETTER FUSION GENE IMPROVING PRONGS TWO AND THREE PRONGS 2 AND 3 PRONG APPROACH. AND THIS IS THE VIRUS WE TOOK INTO OUR RANDOMIZED PHASE 2 IS THE DI. WE THEN MADE THE IL-12 GENE AND THE HOPE HERE -- PUT IN THE IL-12 AND THE HOPE SNOT ONLY IL-12 IMPROVE LOCAL CONTROL BUT ALSO METASTATIC TUMOR CONTROL AS WELL. ONE THING I WANT TO POINT OUT ABOUT OUR ADENOVIRUSES IS THOUGH THEY CONTAIN WILD TYPE GENE WHICH DRIVES VIRAL REPLAYMYCATION AND GENE EXPRESSION THEY LACK THE E 1B GENE THAT PLAY AS ROLE REGULATING VIRAL AND CELLULAR RNA TRANSPORT AS WELL AS HOST CELL DNA DAMAGE RESPONSE BUT THE POINT TO MAKE IS WE DELETE THIS GENE AS WELL AS THE ADP GENE IN THE E-3 REGION, YOU SIGNIFICANTLY ATTENUATE THE VIRUSES. SO HERE IS A SIDE AFFECT ASSAY OF I-12 VIRUS COMPARING TO WILD TYPE AD 5 AND THE CYTOTOXIC ACTIVITY OF THIS VIRUS -- CYTOLITHIC IS 5% OF WILD TYPE AD 5 THOUGH THE VIRUSES ARE REPLICATION COMPETENT THEY DON'T HAVE THE ACTIVITY AS WILD TYPE VIRUS. JUST TO GIVE GENERAL INFORMATION ABOUT HOW WE TREAT PATIENTS. WE RUN A BATTERY OF TESTS BEFORE WE DO THE ADENOVIRUS INJECTION TO MAKE SURE PATIENTS MEET ELIGIBILITY CRITERIA OF THE RILE. WE DO A SINGLE INJECTION OF DAY ONE AND PRIOR TRIALS WE HAVE ESCALATED THE ADENOVIRUS DOSE FROM ONE TIMES TEN TO THE TEN TO 35 TIMES TEN TO THE 12 VIRAL PARTICLES. BEFORE INJECTION WE DO A 6 TO 12 -- TO ONE CONFIRM THE PATIENT AS LOCAL RECURRENCE OF CANCER AND TWO MAP WHERE THE CANCER RESIDES. THERE'S THREE STRATEGIES TO USE TO INJECT THE VIRUS. FORMALLY SHOWN HERE, ONLY THOSE REGION KNOWN TO HARBOR CANCER OR THREE, YOU CAN DISTRIBUTE THE VIRUS ALL THROUGHOUT THE PROSTATE AND SKEW THE DOSE DISTRIBUTION TOWARDS THOSE REGIONS KNOWN TO HARBOR CANCER. THIS IS A STRATEGY WE CURRENTLY USE. BECAUSE OF THE SAMPLING ERROR ALONG WITH THE MULTI-FOCAL DISEASE IT'S VERY IMPORTANT TO TREAT THE ENTIRE PROSTATE PARTICULARLY IN TRIALS NO OTHER THERAPIES WILL BE GIVEN WITH GENE TRANSFER. SO THE INJECTION, IS DONE UNDER TRANSREP TALL GUIDANCE. I HAVE TO LOOK FOR SOMETHING HERE. I APOLOGIZE TO THIS PATIENT FOR -- I CAN SEE THE LITTLE ARM. SO CYTOKINES, UM -- PROBE IN THE RECTUM. WHICH ALLOWS THE UROLOGIST TO SEE THE PROSTATE, WE MAKE FOUR PASSES TWO MEDIAL, TWO LATERAL, STARTING THE PHASE PROCEEDING TO THE APEX. YOU SEE THE INJECTION ALLELE COMING HERE. THIS IS NOW SAGITTAL VIEW, THE NEEDLE TIP IS PLACED AT THE BASE. DEPOSIT MADE, THE NEEDLE WILL BE WITHDRAWN, ANOTHER DEPOSIT WILL BE MADE. AND THIS IS -- CONTINUED TO ALL THE ADENOVIRUS DELIVERED. WE THEN WAIT TWO DAYS TO ALLOW VIRAL REPLICATION TO GENE EXPRESSION AND GIVE THE PRODRUGS TYPICALLY BEFORE TWO WEEKS BUT WE VARY ONE TO FOUR WEEKS. WE GIVE STANDARDS EIGHT WEEK DOSE RADIATION THERAPY WITH PROGRAM THERAPY TO GET THE RADIO SENSITIZATION AFFECT. WE DO TOXICITY DERIVED MEASURING PS INFECTIOUS VIRUS AND PREVIOUS TRIAL MEASURING ANTIBODIES TO ANTIVIRUS AND PROSTATE BIOPSY IN TWO YEARS. SO NOW WE NOW TREAT 102 SUBJECTS AND FIVE CLINICAL TRIALS INCLUDING THE RANDOMIZE AVE PHASE 2 STUDY, 79 RECEIVED GENE TRANSFER. SO RANDOMIZE PHASE 2 STUDY 23 SUBJECTS ONLY RECEIVED RADIATION THERAPY. SO WHAT DID WE LEARN? THE INVESTIGATIONAL THERAPY IS WELL TOLERATED. HALF DEVELOPED FLU LIKE SYMPTOMS. STEER BREAK DOWN OF GRADE 1, 2 3, SHOWN HERE. SHORT EVENTS FOR GRADE 1 LASTING LESS THAN TWO DAYS. ABOUT A 7% OF PATIENTS DEVELOPED TRANS(INAUDIBLE) GRADE 1 AND GRADE #. WE ATTRIBUTE THESE EVENTS TO A SMALL AMOUNT OF THE ADENOVIRUS LEAKING OUT OF THE PROSTATE GLAND AND CAUSING SYMPTOMS. IN ADDITION A FIFTH OF THE PATIENTS DEVELOPED NEUTROPENIA, A VAST MAJORITY BEING GRADE 1, 2, AND A THIRD DEVELOPED THROMBO CYTOPENIA, ALL GRADE 1. WELL KNOWN SIDE EFFECTS OF THE GANG CYCLOVEER. THREE QUARTERS OF THE PATIENTS DEVELOPED LITPENIA, MAJORITY GRADE 2. WE ADISTRIBUTE TO THE PRODRUG THERAPY, THIS IS MAINLY DUE TO RADIATION THERAPY EQUAL PROPORTION ON THAT RADIATION ONLY ARM EXHIBIT THESE EVANS. FINALLY OF COURSE ALL EXPERIENCED A CERTAIN AMOUNT OF AMOUNT AND DISCOMFORT DUE TO INJECTION PROCEDURE. THAT'S IT. THIS IS REALLY ALL THE TOXICITIES THAT WE COULD SEE ACROSS FIVE CLINICAL TRIALS WE COULD ATTRIBUTE TO THE INVESTIGATIONAL THERAPY. BECAUSE SOME TOXICITIES OVERLAP THOSE OF IL-12 WE THINK IT'S ALMOST CERTAIN TO SEE UPTICK IN THE INSTANCE AND VERITY OF TOXICITIES AS WE ESCALATE THE DOSE BUT WE PROBABLY WON'T SEE UNTIL WE GET HIGHER ADENOVIRUS DOSES. WE ALSO DID A QUALITY OF LIFE STUDY IN OUR RANDOMIZED PHASE 2 STUDY USING TWO VALIDATED INSTRUMENTS. WHERE WE LOOK AT URINARY, BOWL, SEXUAL, HORMONAL AND OVERALL SATISFACTION DOMAINS AND WE COLLECTED DATA OVER TREE YEAR PERIOD. -- THREE YEAR PERIOD. WE LEARNED NO DECREASE IN QUALITY OF LIFE ASSOCIATED WITH ONCOLYTIC ADENOVIRUS GENE TRANSFER. USING THE IMAGING VIRUS, WE COULD STUDY EFFECTS OF GENE EXPRESSION IN THE PATIENT, SO IN HERE IS A MAN WHO IS INJECTED WITH 10 O TO THE 12 VIRAL PARTICLES DAY 1 AND IMAGED DAY 2, DAY 3, THE DAY 4 AND DAY 8. PHILIPPE WHAT YOU SEE IN THIS PARTICULAR PATIENT, GENE EXPRESSION PEAK ONE DAY AFTER ADENOVIRUS INJECTION AND DECLINED THEREAFTER UNTIL BARELY DETECTABLE AT BASELINE DAY 8. WHAT WE LEARNED FROM IMAGING 18 PATIENTS WAS THAT GENE EXPRESSION PEEKS ONE TO TWO DAYS AFTER THE ADENOVIRUS INJECTION AND THE PERSISTS LESS THAN # DAYS IN MOST PATIENTS BASED ON SPECK. USING THE SAME TECHNOLOGY WE CAN QUANTIFY LOCAL SPREAD AND EXAMINE DISTAL SPREAD, SHOWN HERE -- YOU WANT TO HELP ME? SHOWN HERE IS PATIENT INJECTED WITH FIVE TIMES TEN TO THE 12th IMAGING VIRUS AND YOU CAN SEE THAT THERE WAS ROBUST GENE EXPRESSION IN THE PROSTATE. AND THIS PARTICULAR PATIENT WE COVER 85% OF THE PROSTATE VOLUME WITH GENE EXPRESSION. WHAT WE LEARNED FROM IMAGING 18 PATIENTS IS THAT THERE'S ABOUT 7 FOLD INCREASE IN THE INJECTED VOLUME IN THE PROSTATE. IF YOU WANT COMPLETE ORGAN COVERAGE OF A 30 CC PROSTATE INJECT 4 MLs, MAYBE LESS FOR COMPLETE COVERAGE. WE ALSO ABLE TO EXAMINE FOR EXTRA PRODUCT SPREAD HERE OUR WHOLE BODY SPECK SCANS INJECTED WITH 5 TIMES TEN TO THE 12 VIRAL PARTICLESND PRE-AND POST INJECTION WHEN GENE EXPRESSION PEAKED. THE ACTIVITY YOU SEE IN SALIVARY GLANDS, THYROID AND IS THAT STOMACH IS DUE TO ENDOGENOUS ACTIVITY, THOSE TISSUES EXPRESS NIS. THE URINARY BLADDER, THAT'S HOW THE RADIO TRACER IS EXCRETE AND THE PENIS LIGHTS UP BECAUSE OF BLOOD FLOW THROUGH THAT ORGAN. WHAT YOU CAN SEE IS THAT WE WERE NOT ABLE TO SEE ANY EXTRA GENE EXPRESSION IN ANY MAJOR ORGAN INCLUDING LIVER. IMAGING 18 PATIENTS WHAT WE LEARNED IS THAT THERE WAS NO DETECTABLE EXTRA PROSTHETIC GENE EXPRESSION UP TO DOSE OF 5 TIMES 10 TO 12 VIRAL PARTICLES. THE CAVEAT IS IF HE CAN SNOT SPENCE SENSITIVE AND SENSITIVITY IS 10 TO THE 11 PARTICLES AND NOT CONCLUDE NO VIRUS GETS OUTSIDE THE PROSTATE. WE'RE SURE SOME DOES BECAUSE ABOUT HALF PATIENTS DEVELOP WILL GRADE TRANSIENT TRANSEMINITIS. WE CAN CONCLUDE THE VAST MAJORITY OF THE VIRUS STAYS WITHIN THE PROSTATE. IN TERMS OF EFFICACY, WE HAVE GENERATED MULTIPLE LINES OF EVIDENCE THAT THE GENE TRANSFER IS GIVING RISE TO ANTITUMOR ACTIVITY AND THE RADIO RECURRENT SETTING IS THE SAME SET WE'RE TALKING ABOUT HERE TODAY. WE SAW A SIGNATURESANT DECLINE IN PSA, SIGNIFICANT DOUBLING TIME AND DELAY IN ADDITIONAL SALVAGE THERAPY INDICATE AND I'LL GIVE AN EXAMPLE HERE: SO THIS IS A -- ONE PATIENT FROM THE FIRST TRIAL, SO THIS WAS A PATIENT TREATING WITH RADIATION BACK HERE, THE RADIATION FAILED AND HE DEVELOP ADVISE IN PSA. WHEN PSA GOT TO TEN WE INJECTED WITH 10 TO 12 VIRAL PARTICLES OF FIRST GENERATION VIRUS AND WHAT YOU CAN SEE IS HE EXPERIENCED A MARKED 80% RAPID DECLINE IN PSA. ALTHOUGH WE DIDN'T ERADICATE THE CANCER BECAUSE HIS PSA STARTED TO RISE AGAIN, PLEASE NOTE THE SCALE HERE IS YEARS, WHAT YOU CAN SEE THE RATE OF RISE AFTER GENE TRANSFER IS SLOWER THAN RAISE OF RICE PRIOR TO GENE TRANSFER. PRIOR TO THAT HE HAD PSA DOUBLING TIME OF TEN MONTHS LINKED TO 33 MONTHS AFTER GENE TRANSFER. WITH THIS DECLINE IN PSA AS WELL AS SCORING OF DOUBLING TIME, ESSENTIALLY PUTS OFF GO ON ADDITIONAL SALVAGE HORMONE THERAPY FOR PROSTATE CANCER SO TYPICALLY IN OUR PRACTICE, WE OFFER PATIENTS SALVAGE HORMONE THERAPY WHEN PSA IS AROUND 15 NANOGRAMS PER ML. THIS DESCRIBE IN PSA AS WELL AS SLOWENING DOUBLING TIME PUT OFF REQUIRE ADDITIONAL THERAPY FOR PROSTATE CANCER BY SIX YEARS. THIS GENTLEMAN NEVER HAD TO GO HORMONAL THERAPY EXPIRED OF NATURAL CAUSES 6 1/2 YEARS LATER AND NEVER HAD HORMONE THERAPY. SO RISING RADIATION AFTER RADIATION FAILURE, GIVEN A 15 MINUTE INJECTION SENT HIM HOME AND NEVER TREAT FORD CANCER AGAIN. IN THE 16 PATIENTS THAT WE TREAT TREAT IN THIS TRIAL WE WERE ABLE TO DELAY TON SET OF HORMONE THERAPY BY TWO YEARS IN ALL PATIENTS AND 2.6 YEARS IN THE PATIENTS WHO RECEIVED HIGHEST DOSE 10 TO THE 12 VIRAL PARTICLES. WE ARE COMBINING GENE TRANSFER APPROACH WITH RADIATION THERAPY WE SAW MEANINGFUL REDUCTIONS IN PROSTATE TWO YEARS. HERE ARE RESULTS TO HAVE PHASE # STUDY, 58% OF PATIENTS ON RADIATION ONLY HAD POSITIVE BIOPSY OF TWO YEARS AND DROPPED DOWN TO 33% ON THE INVESTIGATIONAL ARM. FOR 42% RELATIVE REDUCTION TO VIRAL POSITIVITY. PRIOR TRIAL WE STRATIFIED PATIENTS BASED ON TUMOR BURDEN AT BASELINE AND LOOKED AT PATIENTS WITH LOW TUMOR BURDEN YOU MIGHT EXPECT GOT BETTER. 57% HAD POSITIVE BIOPSY TWO YEARS RADIATION ONLY ARM VERSUS 23% ON INVESTIGATIONAL ARM FOR 60% RELATIVE REDUCTION IN POSITIVITY ON THE INVESTIGATIONAL ARM. SO WE HAVE SEVERAL LINES OF EVIDENCE AND TWO STUDIES OF PROSTATE CANCER THAT ARE GENE TRANSFER APPROACH IS GIVING RISE TO ANTITUMOR ACTIVITY. WHETHER OR NOT THIS IS ROBUST TO IMPROVE STANDARD OF CARE, CAN ONLY BE DETERMINED IN RANDOMIZED PHASE 3 STUDY. NOW TO MAKE THAT IL-12 VIRUS WE TOOK OUR VIRUS AND TOOK OUT THE NIS GENE AND DROPPED IN IL-12. I THINK ALL OF YOU HERE KNOW WHY IL-12 IS USE RECORD INVESTIGATORS AS CANCER TREATMENT SNOT DWELL ON THIS OTHER THAN TO SAY IT STIMULATES BOTH THE INNATE AND DEFINITE RESPONSE, IT'S SHOWN TO HAVE POTENT ANGIOGENIC EFFECTS AND MORE RECENTLY SHOWN TO CHANGE THE TUMOR MAKING IT LESS IMMUNOSUPPRESSIVE. SO RELATIVE TO OUR PREVIOUS VIRUSES THAT WE ADDED TO CLINIC THIS IL-12 VIRUS HAS SAME BIODISTRIBUTION PROPERTIES AND THAT IS WE DIDN'T CHANGE ANYTHING ANY ONE REGION FOR THE VIRAL COAT AND THEREFORE THIS VIRUS SHOULD IN FACT REPLICATE AND BIODISTRIBUTE ITSELF IN THE PATIENT MUCH LIKE IMAGING VIRUS SO ALL THE KNOWLEDGE THAT WE GENERATE PREVIOUSLY SHOULD BE APPLICABLE HERE. TWO, MUCH LESS ONCOLYTIC THAN ABV VIRUS IN RANDOMIZED STUDIES SO THE GENE SNOW LONGER THERE SO THE VIRUS IS MUCH LESS CYTOLYTIC. LIEU LOVECAL METASTATIC TUMOR CONTROL AND POTENTIALLY MORE TOXIC BECAUSE OF THE PRESENCE OF IL-12. WE CONDUCT EFFICACY STUDIES IN ORTHO TOPIC PROSTATE AND PANCREATIC MODEL AND I WON'T DISCUSS STUDIES TODAY BECAUSE I'M GOING FOCUS ON THE TOXICOLOGY STUDIES, SUFFICE TO SAY WE HAVE SHOWN ADDITIONAL IL-12 TO THERAPEUTIC PLATFORM INIMPROVES LOCAL AND METASTATIC CONTROL IN THESE MODELS AND STUDIES WILL BE PUBLISHED SOON. WE ALSO DID ID DIRECTED TOXICOLOGY STUDY AND THIS STUDY WAS DESIGNED WITH THE FDA AND DID THAT STUDY IN A C-57 BLACK SIX MALE MOUSE. ONE QUESTION THAT CAME UP DURING THE RAC REVIEW WAS HOW WELL THE MOUSE RECAPITULATE RECURS IN HUMANS. THOUGH IT'S IN OUR ANSWER TO THE QUESTION IS MUCH BETTER THAN YOU THINK, THOUGH IT'S TRUE ADENOVIRUSES DO NOT PRODUCE A BURST IN CELLS, THEY READIMY KATE SIGNIFICANT GENE EXPRESSION AND THEY DO KILL MOUSE PROSTATE EPITHELIAL CELLS. THIS IS AN AN ISSUE WE INVESTIGATED 15 YEARS AGO. HERE IS A VIRAL DNA REPLICATION IN VARIOUS MOUSE TISSUES AS WELL AS HUMANS USING REPLICATION COMPETENT VIRUS COMPARING TO DEFECTIVE VIRUS WHICH YOU CAN SEE IS REPLICATION COMPETENT VIRUS REPLICATES DNA NORMAL AND MALIGNANT MOUSE EPITHELIAL CELLS, IT ALSO REPLICATES DNA AND TESTES AND IN LIVER, THE AMOUNT OF REPLICATION YOU SEE HERE IN MOUSE PROSTATE EPITHELIAL CELLS APPROACH WHAT IS WE SEE IN HUMANS. I'M SHOWINGIL-12 INFRASTRUCTURE IN NORMAL AND MALIGNANT HUMAN MOUSE PROSTATE EPIDEALTHELIAL CELLS. IL-12 PRODUCTION INCREASES WITH TIME. AND 72 HOURS, THE AMOUNT OFIL-12 PRODUCED IN HUMAN CELLS SHOWN IN BLUE IS TWO FIVE TIMES GREATER THAN WHAT YOU SEE IN MOUSE CELLS IN BROWN. THIS IS WITH OUR REPLICATION STUDIES. THIS SHOWS REPLICATION COMPETENT VIRUS CAN KILL PROSTATE EPITHELIAL CELLS S THIS IS A STANDARD CPE ASSAY INFECT CELLS WITH, INCREASE MOILYSIS AT THE HIGHER MOI NOT DUE TO VIRAL LOAD BECAUSE YOU DON'T SEE WITH REPLICATION DEFECTIVE VIRUS. SO I THINK THESE DATA SHOW THE MOUSE THAT DOES RECAPITULATE WHAT OCCURS IN HUMANS AL BE IT A LESSER EXTENT IS MOUSE GOOD MODEL AS HUMAN, OF COURSE NOT. BUT THAT IS PRECISELY WHY WE DO PHASE 1 STUDIES IN HUMANS. SO WE DID THE ADENOVIRUS INJECTION DAY ONE, THE ADENOVIRUS DOSE WAS DOSE ESCALATED TO MATCH DOSES WE'RE GOING TO USE IN HUMANS ON A WEIGHT BASIS UP TO A DOSE OF 10 TO THE 12th VIRAL PARTICLES. THESE INJECTION WERE DONE -- WE INJECTED SUBCUTANEOUS THAT THE THE NECK AT HIGHEST DOSE TO FUTURE HEAD AND NECK CANCER TRIALS AND ALSO GAVE THE PRICE INTRAVENOUSLY AT THE HIGHEST DOSE TO A WORST CASE SCENARIO. WE THEN WAITED TWO DAYS, DID PROGRAM THERAPY FOR A WEEK THEN SACRIFICED ANIMALS DAY 3 REPRESENTED EARLY TIME POINT, DAY 17, ONE DAY AFTER DELETION COMPLETION OF PRODRUG THERAPY AND DAY 78 REPRESENTED LONG TERM END POINT MEASURING CBC LOP HISTOPATHOLOGY TO 12 ORGANS IL-12 INTERFERON GAMMA, INJECTED TISSUE AND IN BLOOD. WHAT WE FOUND IS THERE WERE NO PREMATURE ANIMAL DEATHS IN THE GROUP THAT INJECTED ID WITH THE HIGHEST DOSE ON DAY 3 WE SAW NEUTROPENIA AT THE HIGHEST AD DOSE GROUPS INJECTED INTRAVENOUSLY, TRANSEMINITI IS IN THE HIGHEST DOSE INTRAVENOUSLY. DAY 17 THE LYMPHOPENIA IN HIGHEST DOSE RESOLVED AND NOT YET RESOLVED IN ANIMALS INJECTED INTRAVENOUSLY AND THE TRANSEMINITIS INJECTED INTRASHEEN VACCINEIOUSLY RESOLVED. BY DAY 78 EVERYTHING RESOLVED. IN TERMS OF HISTOPATHOLOGY EXCEPT INFLAMMATION OF PROSTATE AND VESICLES WHICH IS EXPECTED THE HISTOPATHOLOGY WAS LARGELY UNREMARKABLE, THERE WAS NO MAJOR ORGAN PATHOLOGY. THEREFORE NO OBSERVED ADVERSE EFFECT IS 1.3 TIMES TEN TO THE 9TH VIRAL PARTICLES PER KILOGRAM, ONE TIMES TEN TO THE 11th VIRAL PARTICLES. THE STARTING DOSE IS 1 TIMES TEN TO THE TENth VIRAL PARTICLES AND LULL AND NULL. WE ALSO MEASURED IL-12 INTERFERON GAMMA LEVELS, IN BOTH SERUM AND INJECTED TISSUE AND I'M ONLY SHOWING YOU THE SERUM LEVELS BECAUSE THAT WAS A YEAH QUESTION RAISE BADE REVIEWER AND FOR COMPARISON I SHOW YOU THE LEVELS OF IL-12 INTERFERON GAMMA MEASURED IN HUMANS THAT WERE GIVEN RECOMBINANT HUMAN IL-12 SYSTEMICALLY. AT THE MAXIMUM TOLERATED DOSE OF 500-NANOGRAMS PER KILOGRAM. AT THE HIGHEST ADENOVIRUS DOSE IN OUR TOXICOLOGY STUDY WE CAN MEASURE 93 PICO GRAMS PER ML IL-12, CORRECT THE DIFFERENCE BETWEEN MOUSE AND HUMAN TISSUES AND I USE A FIVE FOLD CORRECTION HERE, THAT CORRESPONDS TO 465 PICO GRAMS PER ML BELOW THAT IN HUMANS. IF YOU SIMPLY ASKED THE QUESTION, WHAT ADENOVIRUS DOSE WOULD IT TAKE TO MOVE THIS NUMBER UP TO THIS RANGE, ASSUMING A LINEAR DOSE RESPONSE, THE ANSWER IS 1.2 TIMES TEN TO THE 13th VIRAL PARTICLE IT IS HIGHEST DOSE IN OUR TRIAL IS 1 TIMES TEN TO THE 13th THOUGH I THINK WE THINK IT'S LIKELY IT WILL BE REACHED BELOW THAT. SO IN THE CURRENT TRIAL WE TREAT PATIENTS WITH RATE OWE RECURRENT PROSTATE CANCER, THESE ARE PREVIOUSLY TRYST TREATED WITH RADIATION THERAPY ROUGHLY 5 YEARS AGO OR MORE. IN THE PROSTATE CANCER RETURNED. THESE ARE GENERALLY HEALTHY MEN WITH A MEAN AGE 70. THERE ARE NO CURATIVE THERAPIES FOR THIS SETTING, THESE ARE TYPICALLY TREATED WITH SALVAGE HORMONE THERAPY, THOUGH HORMONAL THERAPY SLOWS DISEASE PROGRESSION, IT'S NOT CURATIVE AND ASSOCIATED WITH MORBIDITY LONG TERM SO IT DEGRADES THE PATIENT'S QUALITY OF LIFE. A STRENGTH OF THE STUDY IS WE WON'T GET GENE TRANSFER WITH ANY OTHER CONVENTIONAL THERAPY, WE CAN CLAIM THE TOXICITY OF THE VIRUS BECAUSE NO OTHER THERAPIES ARE ADMINISTERED WITH THE GENE TRANSFER. WELL ESTABLISHED ENPOINTS ALLOWS TO TAKE AIRPACK ANTI-EFFICACY. AND WE HAVE EXPERIENCE IN THE DISEASE AND COMPETENT CLINICAL TEAM WORKING TOGETHER OVER 20 YEARS THOUGHT. IN TERMS OF ELIGIBILITY CRITERIA, I WON'T DISCUSS ALL. , IN TERMS OF INCLUSION CRITERIA, THE MEN HAVE PROSTATE BIOPSY PROVEN LOCAL RECURRENT TO PROSTATE CANCER WITH RISE PSA. REALLY GOOD HEALTH AND ADEQUATE BLOOD LIVER AD DIDNY FUNCTION -- KIDNEY FUNCTION. IN THIS TRIAL WE'LL EXCLUDE MEN WITH EXTRA HEPATIC DISEASE THOUGH THERE'S A SCIENTIFIC RATIONALE TO INCLUDE MEN WITH EXTRA PROS STETTIC DISEASE BECAUSE IT'S SHOWN TO IMPROVE METASTATIC ANIMAL MODELS, WEAL EXCLUDE THE MEN BECAUSE ONE ARE THERAPY IS UNPROVEN IN THAT SET, SECONDLY MEN WITH METASTATIC PROSTATE CANCER HAD SERIOUS DISEASE AND SHOULD BE GIVEN FIRST LINE THERAPIES FIRST. BUT IF AT THEIR COMPLETION OF THE TRIAL WE SEE POSITIVE RESULTS BEING ACCEPTED TOXICITY, AND EVIDENCE OF ANTITUMOR ACTIVITY IT'S VERY POSSIBLE WE MAY EXPAND THE PHASE 1 STUDY AND CLINGED MEN WITH EXTRA PROPERTY STETTIC DISEASE. ALSO -- PROSTHETIC DISEASE. THIS IS DEFINED BETTER IN THE PROTOCOL AND ALSO MEN WHO ARE ON IMMUNOSUPPRESSIVE THERAPY. SO WE'RE DO -- TO MAKE SURE THEY MEET THE ELIGIBILITY CRITERIA OF THE TRIAL. INJOKE A SINGLE -- TO INJECT DAY ONE. STARTING ADENOVIRAL WILL BE 10 TO THE 10TH VIRAL PARTICLE, TENFOLD BELOW UNTIL T NULL, WITH THE JUMP TO THE NULL WHICH WE THINK WILL BE SAFE AND PREPARED TO DO A THREEFOLD INCREASE IN ADENOVIRUS DOSE. 10 TO THE 12 VIRAL PARTICLES IS A DOSE WE WITH ADP VIRUS THE ONCOLYTIC VIRUS IN RANDOMIZED PHASE 2 STUDY, NTD IS NOT FOUND IT WILL JUMP THREEFOLD TO THREE TIMES TEN TO THE 1th WHICH IS 60% HIGHEST DOSE PREVIOUSLY TOO NCI TRIALS WITH IL-12 AND AGAIN IF MMTT SNOT REACH THERE HAD WE GO 10 TO 13th WHICH TWICE HIGHEST DOSE WE USED PREVIOUSLY. NTD WILL BE BELOW THIS. WAIT TWO DAYS AND GIVE PROGRAM THERAPY. IS THE CURRENT PROTOCOL GIVING IT FOR A WEEK AND THE REASON WE USE A WEEK HERE IS BECAUSE OUR IMAGING STUDY SHOWS THAT GENE EDGE PRESENTATION WAS SHORT LIVED. WE'RE DEBATING THIS AND MAY EXTEND IT TO TWO WEEKS. THEN TOXICITY ASSESSMENTS THROUGHOUT SO CBC BLOOD CHEMISTRY MEASURED TWICE WEEK, THERE LISTEN ON SITE PHYSICIAN ASSESSMENT ONCE A WEEK AND THE PI WILL CONTACT THE PATIENT DAILY. AS WE ESCALATE THE ADENOVIRUS DOSE, TOXICITIES INCREASE AS WE EXPECT WE MAKE THE BLOOD DRAWS MORE FREQUENT, THREE TIME AS WEEK, OR DAILY IF NECESSARY. THREE MONTH INTERVALS THEREFORE. OF COURSE WE'RE GOING TO MEASURE PS ADENOVIRAL DNA AND INTERFERON GAMMA AT BASELINE AND EVERY BLOOD DRAW AND CYTOLYTIC ASSAYS AT BASELINE AND PROBABLY TWICE DURING THE FIRST TWO WEEKS. IS THE PRIMARY END POINT IS TOXICITY DAY 30, BECAUSE MOST OF THE TOXICITIES ASSOCIATED WITH THE ADENOVIRUS PRODRUG THERAPY ARE AKITE AND ONLY GIVING ASSIEGE INJECTION WE THINK THIS TIME POINT IS SUFFICIENT TO CAPTURE MOST TOXICITIES. THIS IS THE FINAL SLIDE. WE ARE AWARE OF THE SERIOUS ADVERSE EFFECTS GOING ON OTHER I L-12 TRIALS. BREAST CANCER TRIALS TREATED BY DR. LEE ON THE PHONE AND HE'S AN ADVISE ON OUR STUDY. IN TERMS OF FLU LIKE SYMPTOMS, TYPICALLY IN THE PAST WE MANAGED WITH TYLENOL OR MOTRIN BUT IN THIS TRIAL IT MAYBE NECESSARY TO GIVE PROF PROPHYLAXIS AS WE CONTINUE THE GROWTH. VOMITING DIARRHEA AND SECONDARY HYPERTENSION THEREFORE IT'S VERY IMPORTANT TO MONITOR THE PATIENT FLUID BALANCE AND CORN RAJ ALTERATION OF AT LEAST 2-LITERS A DAY. PATIENT WHOSE EXHIBIT TACHYCARDIA OR HYPERTENSION WERE GIVEN INTRAVENOUS VIE HYDRATION H. SEVERE NINNY TRAYPENIA MANAGED WITH GSF AND CURRENT SPACING SUCH AS EDEMA WHICH IS A SECONDARY EVENT IS MEASURED WITH DIURETICS AS THEY BECOME SERIOUS PERISEN CENTESIS. >> THANK YOU FOR THAT CLEAR PRESENTATION. TWO THING BEFORE THE QUESTION. REMIND PEOPLE ON THE PHONE TO MUTE WHEN NOT KNOT SPEAKING. THAT SAID I WANT TO PRODUCE DR. WILLIAM CRUSH WHO ARRIVED -- WILLIAM CURRY WHO ARRIVED. A COUPLE OF SENTENCES ABOUT YOURSELF. >> BILL YAM CURRY: A NEUROSURGEON AT MASS GENERAL. SUBSPECIALIZING IN ONCOLOGY AN IMMUNOTHERAPIES. >> DR. ORNELLES, HAVE YOU JOINED ON PHONE? >> (INAUDIBLE) WAKE FOREST UNIVERSITY. >> THANK YOU. AGAIN, WE'RE GETTING A NOISE THROUGH THE SPEAKERS NOTS SURE IF IT'S SOMEONE'S PHONE OR ACTUALLY IF BUT IF YOU'RE NOT SPEAKING PLEASE MUTE YOUR KNOWNS. SO THE FIRST RAC REVIEWER IS DR. MICHAEL ATKINS. >> >> HELLO DOCTOR, THANK YOU FOR THAT CLEAR PRESENTATION. I DON'T HAVE MAJOR PROBLEMS WITH SHARE PROTOCOL, I THINK IT'S A WELL DESIGNED PROTOCOL BUT IT'S BEING REVIEWED BECAUSE OF ALL THE CONCERNS WITH THE IL-12 TOXICITY THAT HAVE COME ACROSS OUR PLATE OVER THE PAST YEAR OR TWO AND WE JUST WANTED TO ADDRESS SOME OF THOSE ISSUES. SO THE FIRST, I WILL GO THROUGH QUESTIONS I HAVE FOR THE RECORD THOUGH YOU ADDRESSED SEVERAL IN YOUR PRESENTATION. SO THE FIRST QUESTION I HAD WAS WHY WAS THE INJECTION PLANNED THROUGHOUT THE PROSTATE GLAND AS OPPOSED TO DIRECTLY WITHIN THE TUMOR, YOU ADDRESSED THAT VERY WELL IN YOUR RESPONSE. AND IN YOUR PRESENTATION. SO I DON'T NEED TO GO THROUGH THAT. FURTHER, I THINK YOU'RE REASONING MAKE SENSE. P SECOND QUESTION I ASKED MR. L ACTIVATOR LIGAND BE ADDED TO THE IL-12 FOR VECTOR, IN LOOK AT THAT TIME TOXICOLOGY OF OTHER IL-12 STUDIES SAMED ASSOCIATED WITH THE USE OF ACTIVATOR LIGAND WHICH PROBABLY INCREASED LEVELS OF IL-12 WITH THAT WERE EXPRESSED AND MY UNDERSTANDING SNOT GOING TO BE USED IN THIS SETTING. I THEN ASK WHAT ARE THE ANTICIPATED BLOOD LEVELS OF IL-12 IN THIS SETTING AND YOU RESPONDED VERY CLEARLY. AS BEST YOU COULD. IN YOUR RESPONSE, YOU PRESENTED THAT DATA. I THINK SOME OF THE ISSUES CONCERNING THIS AND DR. ORNELLES WILL GET INTO THIS, IT'S HARD TO PREDICT FROM A MOUSE STUDY WHERE THE REPLICATION AND THE INFECTIVITY OF THE HUMAN ADENOVIRUS IS NOT THE SAME. AS IN THE HUMAN. WHAT YOU'RE ACTUALLY GOING TO SEE. IT'S CONCEIVABLE YOU WILL GET INTO THE LEVELS IF YOU GET TO THE ONE TIMES TEN TO THE 13th DOSAGE YOU PROPOSED ASSOCIATED WITH BLOOD LEVELS OF IL-12 SIGNIFICANT AND ALSO INTERFERON GAMMA. AND WHAT YOU MAY ALSO IF THERE'S DISSEMINATION OF OTHER REPLICATION VIRUSIOUS MAY HAVE LOCAL LEVELS THAT ARE HIGHER THAN YOU SEE IN THE BLOOD. TO ME, I THINK YOU ADDRESSED THAT BY PHASE 1 DESIGN OF THE PROTOCOL AND YOU HAVE A CAUTIOUS DOSE ESCALATION PLAN. TO TRY THE ADDRESS WHAT THE APPROPRIATE DOSE IS. AND IF YOU FOLLOW THAT PLAN I THINK IT'S SAFE TO TRY TO ANSWER WHAT IS NOT AN ANSWERABLE QUESTION. THE FINAL QUESTION THAT I HAD HAD TO DEAL WITH HOW YOU MANAGE THE TOXICITY OF IL-12 GIVEN BY CONCERNS THAT YOU MIGHT SEE IT AT SOME OF YOUR HIGHER DOSES. YOU RESPONDED IN YOUR SLIDE ABOUT TOXICITY MANAGEMENT PROCEDURES. I THINK THAT IN SOME WAYS THOSE ARE ANTICIPATING LESS SEVERE TOXICITIES THAN HAVE BEEN REPORTED IN THE PATIENTS WHO GOT INTO TROUBLE WITH IL-12 STUDIES. I WOULD ONLY ADD TO THIS THAT YOU MIGHT CONSIDER HAVING AVAILABLE THINGS LIKE A SLOW -- LOW THRESHOLD FOR GIVING STEROIDS OR FOR SUPPORTING WITH PRESSERS OR DO THAT IF PATIENTS GET INTO SERIOUS TROUBLE. >> OKAY. >> I KNOW DR.ER THESE HAD OTHER SIGNIFICANT CONCERNS RELATED TO POTENTIAL FOR DISSEMINATION OF VIRUS AND I'LL LET HIM ADDRESS THOSE. >> THANK YOU. DR. ORNELLES WOULD YOU LIKE TO GO THROUGH YOUR QUESTIONS AND REVIEW COMMENTS? >> I WANT TO APOLOGIZE FOR RUNNING LATE, THANK YOU FOR THE CLEAR PRESENTATION. I ALSO WANT TO EMPHASIZE THAT ALL THE COMMENTARY THAT I HAVE -- (OFF MIC) >> DAVID COULD YOU SPEAK UP? YOUR VOCAL JUST WENT DOWN. >> (OFF MIC) >> NOT GREAT. >> ARE YOU ON A SPEAKER PHONE? >> NO I'M SPEAKING DIRECTLY -- >> WE CAN HEAR YOU. >> BY EEL KEEP MY VOICE UP AND SPEAK LOUD. MY FIRST CONCERN NATURE OF IL-12 COUPLED TO REPLICATION COMPETENT VIRUS AND I THINK MY BIGGEST CONCERN WAS THAT THE MOUSE DOESN'T REPLICATE THE STUDY TO THE HUMANS, THIS IS ACTUALLY ADEQUATELY INFECTED IN THE MODEL THAT PROVIDES USEFUL INFORMATION. AND IN ADDITION TO THAT, THE MOUSE IS THE BEST MODEL WE HAVE FOR (INAUDIBLE) BUT PERHAPS BIMY CONCERN WASN'T SO MUCH THE MOUSE FAILED TO REPLICATE OR REVEAL TOXICOLOGY, BUT THE BENEFITS OF BIOLOGY (INAUDIBLE) AND MY INTERPRETATION OF UNUSUAL EFFECTS WITH IL-12 AND THAT IS MY PRINCIPLE CONCERN FOR DATA ISSUES THAT ARE -- SHOULD BE UNDERSTOOD AND BEARING RELEVANCE REPRIACATION COMPETENT VIRUSES IN HUMANS. THIS IS WHERE IT'S A LITTLE BIT OUT OF MY REALM OF EXPERTISE. THE SPECTRUM OF ADVERSE EFFECTS IN TREATED IL-12 MIGHT BE CONSISTENT WITH DISSEMINATION OF THE VIRUS AND EXPRESSION OF IL-12 LOW LEVEL BIOLOGICAL EFFECTS. THIS CAN CAUSE PROBLEMS CONCERN FOR ADVERSE EFFECT. BUT ON THE OTHER HAND POSITIVE EFFECT METASTATIC (INAUDIBLE) THAT'S MY PRINCIPLE CONCERN ABOUT MISINTERPRETING CELLS DERIVED (INAUDIBLE). (OFF MIC) >> DAVID, EXCUSE ME. YOU'RE CUTTING IN AND OUT AGAIN. CAN YOU TRY SPEAKING ABOUT THE HEADSET -- WITHOUT THE HEADSET, JUST INTO A REGULAR TELEPHONE? >> I'M (INAUDIBLE). >> SHOULD WE HAVE HIM CALL BACK AGAIN? >> HOW IS THAT? >> NOT A H LOT BETTER. WE HEARD MOST OF WHAT YOU SAID. JUST FADED TOWARDS THE END. >> FOR US NEW MEMBERS YOU ALLUDED SEVERAL TIMES TO THE SPECIFIC CONCERNS OVER THE PAST COUPLE OF YEARS OF IL-12 VECTORS BUT YOU HAVEN'T SPECIFICALLY TOTAL US WHAT YOUR CONCERNS HAVE BEEN, YOU SAY UNUSUAL TOXICITY, CAN YOU BRIEFLY DESCRIBE WHAT THOSE ARE? SO WE CAN FOLLOW ALONG BETTER BERTH? >> DAVID, HOLE ON, WE HAVE A QUESTION HERE. WOULD YOU LIKE TO ADDRESS THAT? >> AM I ABLE TO SPEAK? ARE YOU ABLE TA TO HEAR ME? >> WE CAN HEAR YOU FINE NOW. HANG ON THERE IS A DISCUSSION HERE. HOLD ON ONE SECOND. (OFF MIC) >> CYTOKINE RELATED TOXICITIES INTERFERON GAMMA RELATED TOXICITY. TRANSEMINITIS HYPERTENSION, THOSE TYPE OF THINGS. JACQUELINE, DO YOU WANT TO GO THROUGH -- >> PULL UP SOME EVENTS, THE DEATH WAS IN THE SETTING OF INJECTION AND PROBABLY SEPSIS. BUT WHAT HAS BEEN UNUSUAL IS SEE MORGUE HYPOTENSION THAN WE NORMALLY SEE WITH THESE KIND OF VACCINES, TRANSOM NIGHTIS IS A NEUTROPENIA. AND MORE PEOPLE DEHYDRATION AND OTHER COMPLICATIONS FOLKS HAVE BEEN HOSPITALIZED IN THE IMMEDIATE SETTING AFTER GETTING IT. AND SO WITH NOT CLEAR, OBVIOUSLY THIS WAS IN IL-12 WHERE THEY DID HAVE ACTIVATOR LIGAND SO THEY CAN TURN ON THE IL-12 THEY GIVE SOME LEVELS AND THEY WERE BELOW WHAT YOU WOULD SEE WHEN GIVING IV IL-12. BUT IT STILL -- GETTING UNUSUAL TOXICITIES, WHAT DAVID WAS ALLUDING TO IS SOMETIMES THIS IS A TRIAL WHICH IS ME KNOW MA, THEY INJECT TO MELANOMA LESIONS, IN PARTICULAR ONE PATIENT INJECTD THROUGH A CHEST WALL AND YOU HAVE A PLURAL EFFUSION SO TALKING MAYBE SPREADING AND LOCAL TOXICITIES. WHEN WE LOOK ACROSS THE BOARD IN TERMS OF WHAT WE SEE, WE GENERALLY IT WAS UNUSUAL CONSTELLATION OF SAs WE WERE SEEING IN ONE TRIAL, IT DOES USE IL 12 WITH ACTIVATOR LIGAND. >> THANK YOU. DAVID I CAN UP WHERE YOU LEFT OFF. >> OTHER THAN THAT, THAT DID REFLECT MY COMMENTS AND (INAUDIBLE) CONSTELLATION OF THE PREVIOUS TRIAL. (INAUDIBLE) MODEL IN A ANIMALLER THAT -- (OFF MIC) Q. YOU STARTED STRONG AND STARTED FADING AGAIN. >> I'LL JUST KEEP (INAUDIBLE) >> FORTUNATELY WE HAVE A PROTOCOL LAST TIME IN THE MEETING ABOUT GENE THERAPY FOR HEARING. (OFF MIC) (OFF MIC) >> OKAY. SO IT SOUNDS LIKE THAT YOU'RE SATISFIED WITH THE RESPONSE, DID YOU HAVE ANY REMAINING QUESTIONS? >> NO, ACTUALLY I DON'T, (INAUDIBLE). >> OKAY. AND NOW THAT YOU HAVE FINISHED YOUR REMARKS IF DO YOU WANT TRY CALLING BACK IN AGAIN, MAYBE IT'S JUST THE CONNECTION. IF DOUG THAT FOR THE RECAP. >> WILL DO THAT RIGHT AWAY. >> DR. DRESSER WHO IS FULLY HERE. >> WE'LL SEE. THANK YOU, I HAD MOSTLY COMMENT ABOUT THE CONSENT FORM BUT I DID ASK NONTORRING TO MAKE SURE THAT WAS SUFFICIENT GIVEN CONCERNS ABOUT ADVERSE EVENTS SO YOU TALKED ABOUT THE DETAILS OF IT AND I THINK WE'LL BE CLOSE MONITORING AND HOPE IT'S ENOUGH. ON THE CONSENT FORM, THERE WAS A STATEMENT ABOUT ALTERNATIVE THERAPIES AND I DON'T KNOW -- ANYWAY, I THOUGHT IT SHOULD BE A LITTLE BIT MORE QUALIFIED IN THAT THERE ARE SOME ALTERNATIVE THERAPIES THAT HAVE PROMISING FIVE YEAR SURVIVAL RATES BUT WE DON'T KNOW YET, THEY HAVEN'T DONE ALL THE RESEARCH. SO YOU CHANGE THE LANGUAGE AND I THOUGHT THAT WAS FINE. IT TALKED 12 DEPOSIT AND I THOUGHT TO AN ORDINARY PERSON THAT MIGHT SOUND LIKE 12 INSTEAD OF ONE SHOT. SO YOU CLARIFIED THAT. I ASKED YOU TO CHANG THE TERM TREATMENT TO STUDY DRUG OR SNAG SHOWS THAT IT'S UNPROVEN AND YOU DID THAT, THANK YOU. ROUTINE TESTS WERE USED, I THOUGHT IT NEEDED TO BE CLARIFIED, DID YOU MEAN ORDINARY CARE OR DID YOU MEAN STUDY ROUTINE AND YOUR YOU CLARIFIED THAT. AND THE RISKS I ASKED ABOUT PAIN WITH THE INJECTION AND YOU ADDRESSED THAT, ABOUT SEPARATING THE RISK TO THIRD PARTIES FROM THE RISK TO SUBJECTS AND YOU DID THAT. THEN I MADE A COMMENT ABOUT SECONDARY CANCER, I'M JUST A COUNTRY LAWYER, I MISINTERPRETED WHY THERE'S SECONDARY CANCER SO I'M SATISFIED WITH THAT. RESPONSE. AGAIN WITH PRECAUTIONS ASKED TO SAY, THIS WAS A FAMILY MEMBER, AND YOU DID THAT. SO ALL MY COMMENTS WERE ADDRESSED. >> THANK YOU. DO ANY OTHER RAC MEMBERS HERE HAVE ANY OTHER COMMENTS OR QUESTIONS? >> DR. Q. DR. SADELAIN. >> THANK YOU FOR THE PROTOCOL. IT'S ESSENTIALLY TO BOOST IMMUNE RESPONSES. DO YOU THINK THE VERSION WE FOUND IL-12 FAILS TO INDUCE IMMUNE RESPONSES OR -- AND THERE'S SOMETHING TO ACTUALLY BE BOOSTED? # EVERYONEALL, WHAT DO YOU THINK -- OVERALL WHAT IS THE CONTRIBUTION IN RESPONSE TO THE CURRENT VECTORS VERSUS THE DIRECT TOXICITY IN IMRTS? THAT'S THE FIRST QUESTION. >> I THINK ABSENT IL-12 THERE MAYBE DEVELOPMENT OF ANTI-GERM IMMUNITY. IF YOU THINK ABOUT THAT SLIDES I SHOWED YOU ONE PATIENT HAD THE RAPID DECLINE IN PSA THEN SLOWING PSA DOUBLING TIME, THAT RAISES A VERY INTERESTING QUESTION. HOW CAN YOU GET SLOWING OF PSA DOUBLING TIME WHEN THE VIRUS IS NO LONGER THERE? TYPICALLY THE VIRUS LASTS IN THE PATIENT LESS THAN SEVEN DAYS, BASED ON GENE EXPRESSION 60 DAYS ON ADENOVIRAL DNA. HOW CAN YOU EXPLAIN THE LONG TERM EFFECT WHEN THERAPY IS NO LONGER THERE. AND WHAT WE RAISED IN PREVIOUS PAPER IS WE THINK IT MAYBE DUE TO DEVELOPMENT OF ANTITUMOR IMMUNITY. WE HAVE NO DATA, DIRECT DATA TO SUPPORT THAT. IT'S JUST A HOPE. THE ADDITION OF IL-12 MAY ENHANCE THAT. SO YOUR FIRST QUESTION. COULD YOU REPEAT THE SECOND ONE? >> SECOND, QUESTION IS ON THE -- I WAS JUST CURIOUS TO KNOW WHAT EXTENT YOU HAVE DOCUMENTS IN THE IMMUNE RESPONSE THAT WOULD BE BOOSTED BY IL-12. >> INTERFERENCE FROM SOME SORT -- >> HARD DATA, NONE. >> YOU DON'T THINK THAT'S SLOWER -- TUMOR PROGRESSION CAN BE ACCOUNTED FOR SOLELY BY DESTROYING A CERTAIN NUMBER OF CELLS? >> IT -- THERE'S ANOTHER HYPOTHESIS, THE VIRUS COULD KILL MORE BIOLOGICALLY ACTIVE TUMOR CELLS, LEADING LESS BIOLOGICAL ITEM, IT'S AN ABSOLUTE POSSIBILITY iFAVOR THE ANTITUMOR IMMUNITY HYPOTHESIS FOR THE HOPE THAT THAT'S WHAT HAPPENS. >> SECOND QUESTION IS ABOUT THE FARM TOX STUDY. I GUESS IT TESTED JUST THE AGENT, VECTOR WITH IL-12, WONDERING IF YOU HAVE DATA THAT COMPARE SAME DOSE IN THAT CHARACTER WITH AND WITHOUT IL-12 SUCH THAT WHEN YOU SEE THE NEUTROPENIA AND TRANSEMINITIS HIGHER DOSE, YOU CAN ATTRIBUTE HOW MUCH OF THAT IS ADENOVIRAL INTERACTION DUE TO ADDITIONIL-5. >> THAT PARTICULAR STUDY WE DIDN'T INCLUDE A VIRUS LACKING IL-12. BUT PRIOR TO THIS WE HAVE DONE SIX TOXICOLOGY STUDIES WITH ADENOVIRUS LACKING IL-12 SO WE GO BACK TO THOSE DATA COMPARE SIDE BY SIDE. THEY'RE NOT DONE EXACTLY STATEMENT. EXPERIMENT SAME CITY BUT YES WE CAN DO THAT. -- STUDY, BUT YES, WE DO THAT. I CAN'T GIVE YOU THE ANSWER BECAUSE I DON'T REMEMBER THE ROLLS BUT WE CAN DO THAT. >> SO YOU DON'T KNOW FROM THE ASSAY VIRAL VECTOR TOXICITY AND IL-12. >> THAT'S CORRECT. WE CAN TAKE A PEAK AT THAT. >> THANK YOU, DR. HAMMARSKJOLD. >> SO DR. ATKINS AN ORNELLES ALREADY -- YOU HAD A DISCUSSION ABOUT THE FACT THAT THE ADENOADENOVIRUS DOES NOT ACT THE SAME IN HUMANS WHEREAS YOU GET REPLICATION YOU GET LOWER LEVEL REPLICATION SO THAT'S ONE DIFFERENT. ANOTHER DIFFERENCE BETWEEN THE MOUSE AND HUMANS IS THAT MOUSE -- MICE DON'T HAVE PRE-EXISTING IMMUNE RESPONSES TO ADENOVIRUS. SO VIRUS YOUR PATIENTS WOULD HAVE EXPENSE OTHERWISE MIGHT HAVE HIGH TITER. SO I WAS WONDERING WHETHER YOU HAVE CONSIDERED WHETHER YOU HAVE DONE IN THE PREVIOUS STUDIES LOOKED AT PRE-EXISTING ADENOVIRUS RESPONSES AND ALSO WHETHER DOSE WOULD BE INCREASING WHICH COULD BE ONE WAY OF MEASURING A MORE SYSTEMATIC REPLICATION. >> RIGHT. OUR APPROACH TRIALS WE MEASURE NEUTRALIZING ADENOVIRUS OF THE TWO TRIALS IN THE RADIO SETTING AND WITH RADIATION. AND MEASURED BEFORE AND AFTER, 30 DAYS AFTER THE ADENOVIRAL INJECTION. AND ALL THE PATIENTS HAD LOW LEVELS OF PRE-EXISTING ANTIBODY, IT JUMPED MARKEDLY IN ALL PATIENTS IN BOTH OF THOSE TRIALS. AND THEN WE ASKED DOES IT CORRELATE WITH ANY TOXICITY OR EFFICACY AND THE ANSWER SNOW, THERE WAS NO RELATIONSHIP BETWEEN DEVELOPMENT OF NEUTRALIZING ANTIBODIES AN EITHER ANY TOXICITY OR EFFICACY AND THEREFORE WE HAD A DISCUSSION WITH THE FDA ABOUT THIS, AND WE'RE NOT REALLY LEARNING ANYTHING. SO IS IT REALLY NECESSARY FORS TO DO THESE STUDIES IN FUTURE TRIALS AND THEY SAID NO SO WE DROPPED FROM FUTURE PROTOCOLS. >> ANOTHER WAY OF MEASURING ADENOVIRUS GENE EXPRESSION SYSTEMATICALLY WOULD BE TO DO MORE SOPHISTICATED THINGS LIKE NEXT GENERATION SEQUENCING OF RNA FOR EXAMPLE, BLOOD CELLS, SO HAVE YOU CONSIDERED DOING SUCH THINGS TO LOOK MORE WHAT GETS INTO MORE THE SYSTEM OR HOW IT GETS THERE, WHATEVER? >> NO, WE HAVE NOT CONSIDERED IT. BUT I WILL NOW. I THINK THE BEST PLACE TO ASSESS TOXICITY OF THIS VIRUS IS IN HUMANS. I THINK THE WAY TO DO THAT STOW START SAFE DOSE AND CAREFULLY DOSE ESCALATE AND MONITOR PATIENTS CAREFULLY. SO I AGREE WITH ALL OF YOU THAT THE MOUSE DOES NOT PERFECTLY RECAPITULATE WHAT HAPPENS IN HUMANS. BUT THAT'S WHY WE DO PHASE 1 STUDIES IN HUMANS. >> THANK YOU. >> DR. WHITLEY WAS NEXT. >> I HAVE A DIFFERENT SERIES OF QUESTIONS, I CERTAINLY THINK IN CERTAIN IL-12 IN YOUR ADENOVIRUS VECTOR IS IMPORTANT. WE'RE DOING THE SAME WITH HERPES SIMPLEX. ONE IS A QUESTION, THE OTHER A CAUTION. THE Q HAVE YOU COMPARED REPLICATION COMPETENCE OF IL-12 EXPRESSING VIRUS VERSUS YOUR NON-IL-12 EXPRESSING VIRUS, IF BASIS IS IN OUR STUDIES WE FOUND REPLICATION COMPETENCE IS GREATER WITH IL-12 THAN WITHOUT. AND THAT WILL LEAD TO THE CAUTION IN THE MINUTE. >> STOLE HAVE WE COMPARED REPLICATION COMPETENT VIROS ONE WITH AND WITHOUT IL-12 LOOKING AT -- >> PEAK VIRAL LOAD. >> PEAK VIRAL LOADS. >> QUANTITY OF VIRAL REPLICATION CELL CULTURE, QUANTITY OF REPLICATION IN MOUSE MODELS. >> NO. WE HAVE NOT. >> THAT LEADS TO THE CAUTION AND THE CAUTION IS AS I MENTION, WE FOUND WITH SIR PIECE SIMPLEX WE CAN GENERATE TWO GRATER LOGS AS WELL AS IN OUR MAN MALL MODEL. AS CONSEQUENCE GOING INTO A GLIOOWE BLASTOMA MULTI-FORM STUDYS WE USED ONE TIMES 10 TO THE 9TH HSV IN NAKED VECTOR HERPES PLEX GENETICALLY DELETED WITH A NEURAL VIRULENCE GENE, ONE TIMES TEN TOP THE FIVE RA THEY WERE ONE TIME TENSE TO THE 7TH WHICH WOULD BE A MORE REASONABLE DOSE. SO MY CAUTION IS, IF YOU'RE CONCERNED ABOUT TOXICITY BUILD IN A DE deescalate dosage schedule to address issues of toxicity. >> JUST SO I'M CLEAR WHEN YOU PUT IN IL-12 YOUR VIRUS IS A GREATER BURST? >> ABSOLUTELY. AND MORE TOXIC IN THE ANIMAL SYSTEMS. >> YOU IS THAT IN VITRO AS SELL WE WOULD? >> YES. TWO LOGS GREATER REPLICATION. >> IN VITRO? >> IN VITRO. >> HOW DO YOU EXPLAIN THAT? >> WE CAN'T. BUT IT'S CAUTION. >>LY LOOK INTO THAT. -- I WILL LOOK INTO THAT. >> DR. DUNE HUE. >> -- DONAHUE? >> TWO QUESTIONS, ONE FOR THE COMMITTEE MEMBER WHOSE HAVE THE INFORMATION ON THE TOXICITY OF IL-12. WHAT IS THE TIME COURSE OF THIS? AND IS IT COMPATIBLE WITH THE MONITORING STRATEGY? IN OTHER WORDS, ARE YOU SEEING SOMETHING WHERE THERE IS ACUTE ABRUPT VASODILATION AN COLLAPSE OVER A SPAN OF MINUTES TO HOURS IN WHICH CASE DAILY MONITORING MIGHT BE INADEQUATE OR ARE YOU SEEING SOMETHING, THERE'S A MORE GRADUAL CHANGE WHERE YOU COULD PICK UP A SIGNAL AND TRY TO INTERVENE IN TIME? >> IT HAS VARIED, NOT USUALLY WITHIN MINUTES. SOME EVENTS HAVE OCCURRED WITHIN THE DAY WHERE THE PATIENT GOES HOME OR OVER SEVERAL DAYS. SO THERE HAS BEEN THE ONE EVENT WHERE THERE WAS SEPSIS GOING ON, AND THERE WAS AN ISSUE WHETHER THE LESION ITSELF WAS INFECTED, WITHIN A DAY. THEY'RE NOT HAPPENING AS IN SOME OTHER THINGS A WEEK OR SO OUT. THE ONLY ISSUE WITH THE PROTOCOL IS YOU GET VECTOR YOU GET A DOSE OF THE ACTIVATED LIGAND AND YOU CONTINUE TO GET LIGAND IS THERE MAYBE INCREASE IN IL-12 EXPRESSION GOING THROUGH THAT. BUT IT IS USUALLY WITHIN THE FIRST WEEK OR SO THAT WE SEE MOST OF THOSE EVANS. -- EVENTS. >> TWO SETTINGS WE HAVE SEEN IL-12 PROBLEM, THE ONE JACQUELINE WAS REFERRING TO WITH THE ACTIVATOR LIGAND AND THERE IT IS -- SORT OF DAYS AFTER THE VIRUS IS GIVEN THE DRUG IS STARTED AND THEN WE SEE SORT OF HYPOTENSION OR I THINK ALSO NEUROLOGIC TOXICITYIES THAT HAVE BEEN POSSIBLY ATTRIBUTED. BEFORE I CAME ON THE RAC THE TRIAL IT IS NCI USING A RETRO VIRUS WITH IL-12 THERE IT WAS A LITTLE MORE ACUTE, IT WAS MORE LIKE IN THE FIRST WEEK AS T-CELLS EXPANDED THERE WAS HYPOTENSION PROBLEMS. >> THERE WAS MORE SEVERE PROBLEMMINGS, MORE VEER LIVER TOXICITY BUT AGAIN THAT'S A T-CELL PROTOCOL, VERY DIFFERENT. SETTING THAN IV WITH POTENTIAL EXPANSION OF T-CELLS. >> I GUESS WHILE WE'RE TALKING ABOUT IL-12, I GUESS ONE OF THE THINGS I'M NOT CLEAR ABOUT IS WHAT'S THE RELATIVE SENSITIVITY OF HUMANS AND MICE TO IL-12 TOXICITY. WE TALKED ABOUT THIS BEFORE. DO MICE PREDICT THE POTENTIAL TOXICITY, I CAN'T REMEMBER IF IT'S 12 OR 12 '02 THAT'S DIFFERENCE. -- LARGE AMOUNTS WHERE HUMAN GOES TO ICU: I CAN'T REMEMBER IF IL-12 IS THE SAME OR NOT. P >> THE QUESTION I HAD, WAS THERE A NEUROLOGICAL EFFECT, ASSOCIATED WITH THIS AS WELL? AND THAT'S THE CONTEXT, EXACTLY -- WOULDN'T BE ABLE INTO AN AMOUNT? POTENTIALLY QUITE IMPORTANT FOR HUMAN SUBJECTSs SPECIALLY HUMAN SUBJECTS WHO ARE ALREADY FACING ENORMOUS LEVELS OF STRESS AND ANXIETY AROUND THIS. THAT SHOULD SURELY BE MENTIONED AS A CRITICAL PROBLEM TO WATCH OUT FOR? >> SOME OF THE PATIENTS INDUCIBLE VECTOR TRIAL DEVELOPED CONFUSION, >> DEPRESSION I THINK WAS -- SO THAT'S ONE -- THERE SHOULDN'T BE -- IT MIGHT BE EASY TO DISMISS A SIGNIFICANT DEPRESSION OR SIGNIFICANT CHANGE RELATED TO THE DISEASE AND IT SHOULD BE CAREFULLY MONITORED. SINCE THAN COULD BE ONE OF THE FIRST SYMPTOMS. >> NORMALLY THESE GUYS AREN'T DEPRESSED BECAUSE OF DISEASE, THE DISEASE IS RELATIVELY BENIGN, IT'S NOT A PANCREATIC CANCER PATIENT OR PATIENT WITH GLIOBLASTOMA, THESE ARE GENERALLY HEALTHY MEN, HERE PROSTATE CANCER, CERTAINLY RECURRENT, THEY GET ANXIETY. >> I WOULD SAY THAT DEPRESSING MOMENT. >> YEAH. YEAH. >> I THINK ACTUALLY THE DISCUSSION WE HAD ABOUT DEPRESSION FROM -- WAS A DIFFERENT CYTOKINE, I THINK IT WAS TNF, INTERFERON SOMETHING. AND OVARIAN CANCER STUDY. >> WOULD ALSO BE -- SAME STAKE WOULD BE HAPPEN (INAUDIBLE). >> WE DID HAVE AT LEAST ONE WITH A STATUS, AGAIN THE PATIENT HAPPENED TO BE QUITE ELDERLY, OVER 85 YEARS OLE THAT OCCURRED. -- OLD THAT COULD RECOLLECT. >> I HAVE ONE MORE QUESTION. -- THAT OCCURRED. >> MY SECOND QUESTION IS WITH RESPECT TO YOURSELF EXCLUSION CRITERIA, TOXICITY TO ME SEEM AD BIT LOOSE. FOR INSTANCE, YOUR CARDIAC ABSENCE OF UNSTABLE CONGESTIVE HEART FAILURE REQUIRING HOSPITALIZATION WITHIN SIX MONTHS. I THINK IF YOU HAVE A POTENTIAL TOXICITY WHICH SOME EXTENT EMULATES SYSTEMIC INFLAMMATORY RESPONSE WHERE YOU CAN HAVE A LOT OF FLUID ACCUMULATION AND HAVE MASSIVE VASODILATION, I PERSONALLY HAVE SEEN IT'S COMMONLY DESCRIBED SITUATION WHERE IS SOMEBODY CAN HAVE HEART FAILURE AND SYSTOLIC DYSFUNCTION IS COMPENSATED UNDER NORMAL CIRCUMSTANCES NOT IN THE HOSPITAL WITHIN SIX MONTHS BUT YOU STRESS THEM WITH SOMETHING LIKE THIS, AND IT CAN BE CATASTROPHIC AND THEY DON'T HAVE THE RESERVE TO COME BACK. I CAN IMAGINE SIMILAR SCENARIOS FOR MODERATE RENAL DYSFUNCTION WHERE YOU'RE TRYING TO DIE REECE THEM AND YOU CAN ANY MORE, LIVER DYSFUNCTION OBVIOUSLY AS WELL. I WONDERED, JUST TO NOT SHOOT YOURSELF IN THE FOOT WITH YOUR FIRST FOR RAY IF YOU MIGHT BE A BIT MORE CONSERVATIVE AND SAY NO OTHER COMORBIDITIES TO SUBSTANTIAL DEGREE RATHER THAN NO OTHER MAJOR COMORBIDITIES THAT GO DESCRIBE THEM NEED TO BE SEVERE. >> OKAY P. I THINK THAT'S AN EXCELLENT POINT AND CERTAINLY CONSIDER THAT. I DISCUSS THAT WITH MY COLLEAGUES AND GET THEIR INPUT BUT I'M CERTAINLY AMENABLE TO THAT. >> THANK YOU. DR. KIEM. >> I HAD A QUESTION GIVEN PROBLEMS WITH THE IL-12 AND REPLICATION IN MOUSE, WHY -- YOU MENTION THE MODEL, WHY DON'T YOU DO STUDIES IN THE SERINE HAMSTER MODEL >> WE LOOKED AT THAT, IT'S TRUE THAT THAT'S WORK DONE AND WILD TYPE ADENOVIRUS REPLICATE PRESSTY WELL IN A CERTAIN HAMSTER, THESE ATTENUATED VIRUSES DON'T SO WE HAVE LOOKED AT THAT. SO IN MY OPINION, AND I DISCUSS WITH THE FDA, I DON'T THINK THE SERENE HAMSTERS ARE ANY BETTER THAN A MOUSE. >> ANY OTHER QUESTIONS FROM PEOPLE -- YES. DR. ATKINS. >> SO TWO COMMENTS. FIRST, I THINK THAT DR. DONAHUE'S COMMENTS ARE WORTHWHILE AND PROBABLY THE ONE TEST THAT YOU MIGHT WANT TO ADD FOR SURE IS CARDIAC ECHO WITH A REASONABLE EJECTION FRACTION CONSIDERING THESE ARE LIKELY GOING TO BE SOMEWHAT ELDERLY MALES AND MAY HAVE SUBTLE CARDIAC PROBLEMS. SO THAT'S SOMETHING TO CONSIDER. SECOND THING THAT YOU MAY HAVE ADDRESS AND MISSED BUT CURIOUS AS WE'RE TALKING ABOUT THIS TOXICITY ABOUT WHAT THE EFFECT OF THE PRODRUG ADMINISTRATION WOULD HAVE ON IL-12 LEVELS, DOES IT SHUT IT OFF? OR -- DOES IT INCREASE IT OR WHAT DO YOU -- >> WE LOOKED AT THAT IN VITRO. PRO DRUGS DO INHIBIT VIRAL REPLICATION SO THAT'S A REASON WHY AFTER WE GET THE ADENOVIRAL INJECTION WE WAIT TWO DAYS TO ALLOW REPLICATION TO OCCUR AND THEN START PRODRUG THERAPY. 5 FC AND GCB BLOCK VIRAL REPLICATIONS SO THAT BRINGS REPLICATION COULDN'T AS WELL AS ENGINE EXPRESSION DOWN. >> SO ESSENTIALLY IS THAT -- DO YOU THINK THAT'S SHUTTING OFF THE IL-12 RELEASE AT THIS POINT? TWO DAY? >> I WOULD SAY SHUTTING OFF, I WOULD SAY SHUTTING OFF IS NOT LIKE AN ON OFF H SWITCH. THERE'S A DECAY TO IT. REALLY, IF YOU LOOK AT OUR IMAGING STUDIES WHERE THE VIRUS EXPRESSION PEAKED DAY 1 AND DAY 2 AND GRADUALLY DECLINED, LARGELY DUE TO THE IMMUNE RESPONSE, ADENOVIRUS INFECTED CELLS AND MAYBE THE PRODRUG THERAPY ALSO PLAY AS ROLE SO IMMUNE SYSTEMS PLAYS A VERY -- DOES A GOOD JOB CONTAINING THE VIRUS. >> DR. ANTONIO. >> SO THERE WERE A NUMBER OF GREAT TRANSEMINITIS AT YOUR LAST JEAN RIG. >> WITH THE IMAGING -- GENERATION. FROM WITH THE IMAGING VIRUS TOO. >> THAT'S GUY DEW TO VIRAL LEAK OUT PROSTATE AND INFECTION OF THE HEPATOCYTE? >> WE THINK. SO, IMPORTANT POINT. TO BE CLEAR IN THE IMAGING TRIAL WE TREATED 18 PATIENTS THE LAST SIX WERE GIVEN DOSE OF 5 TIMES TEN TO THE 12th VIRAL PARTICLES. LAST TWO PATIENTS DEVELOPED GRADE 3 TRANS-EMINITIS, BROKE THE LEVEL AND CAME BACK DOWN WITHIN NORMAL LIMITS IN TWO WEEKS. THE REASON WHY THEY DEVELOP TRANSEMINITIS IN THAT PARTICULAR TRIAL, IN ORDER TO GET 5 TIMES TEN TO THE 12 VIRAL PARTICLES PROSTATE WE HAD INTO APOLOGETIC FIVE MLs. >> YOU HAD GRADE 2 SO THERE'S INFECTION OF HEPATOCYTES. >> YES. >> POINT I'M GETTING AT YOU'RE INTRODUCING A SECOND MECHANISM OF LIVER TOXICITY WHICH IS AUTOIMMUNE IL-12 MEDIATED AND THAT VIRAL LEAK SECTION DELIVERING IL-1 LOCALLY TO THE LIVER. SO I'M NOT SO WORRIED ABOUT SYSTEMIC TOXICITY BUT I WOULD BE CONCERNED ABOUT THAT. AND THE QUESTION IS, HAVE YOU THOUGHT ABOUT HOW YOU'RE GOING TO MANAGE THAT? SO AS MIKE SAID YOU MIGHT MANAGE IL-12 TOXICITY WITH STEROIDS BUT IF YOU'RE -- IF THIS IS HEPATOCYTE DAMAGE WITH INFECTION FROM ADENOVIRUS YOU MAY NOT KNOT WANT TO USE STEROIDS. YOU MIGHT WANT TO CONSIDER THAT THERE'S MULTIPLE MECHANISMS HERE, YOU DON'T KNOW WHAT YOU'LL GET INTO AND HAVE A LOW THRESHOLD FOR INTEGRATING LIVER BIOPSIES TO GUIDE THAT MANAGEMENT. >> DR. (INAUDIBLE). >> THANKS VERY MUCH FOR YOUR PRESENTATION. I THINK I'M GOING -- THAT YOU SAID YOU DO NOT EXPRESSION TO REACH ONE TIMES TEN TOP THE 13th. >> GUT FEELING. >> SO I WAS WONDERING WHAT YOU EXPECT TO BE DOSE LIMITING TOOK AT THIS? >> WHAT DO I THINK THE DOSE LIMITING TOXICITY IS? >> YES. >> GOOD QUESTION. I GUESS I'M WORRIED ABOUT HYPERTENSION -- EXCUSE ME, HYPOTENSION. EDEMA, THINGS LIKE THAT. LYMPHOPENIA, THE TOOK AT THISES I'M NOT WORRIED ABOUT. TRANSEMINITIS IS ACUTE. THE FLU LIKE SYMPTOMS ARE MANAGEABLE. SO IT'S THE HYPOTENSION, DEHYDRATION, THINGS LIKE THAT. >> YES. >> I HAD A COUPLE OF COMMENTS ABOUT INFORMED CONSENT DOCUMENT, I HOPE I'M LOOKING AT THE MOST RECENT VERSION, IT WAS DATED AUGUST 4TH. >> PROBABLY. >> SO I THINK THERE'S STILL CONCERNS AND REFERRING TO IT AS THERAPY AND TREATMENT, FOR INSTANCE, IT SAYS SCIENTISTS WILL TREAT PROSTATE CANCER AND THESE AGENTS WILL HELP DESTROY YOUR CANCER CELLS, NOT REALLY KNOWN, I MEAN THAT'S CERTAINLY THE HOPE. ONE OTHER CONCERN WAS THERE'S SOMETHING ABOUT YOU WILL BE REQUIRED TO MAKE SCHEDULED VISITED TO THE CLINIC THE REST OF YOUR LIFE. I THINK MAYBE TO SOFTEN THAT, WE WILL BE ASKED OR EXPECTED, BECAUSE SUBJECTS HAVE BEEN KNOWN THEY CAN ACTUALLY WITHDRAW IF THEY WANT TO. >> THAT'S RIGHT. >> THE OTHER I'M STILL NOT -- STILL THINK THE WAY THE ROUTINE TESTS IS DESCRIBED IS CONFUSING. IT SAYS ROUTINE TESTS AN PROCEDURES TO BE PERFORMED WHETHER OR NOT YOU DECIDE TO PARTICIPATE IN THE RESEARCH STUDY. THE ROUTINE TESTS AN PROCEDURE IT IS SCREENING DONE IS PART OF THE RESEARCH STUDY SO THAT'S FUSING TO SUBJECTS. MAYBE ROUTINE TESTS PROCEDURES CAN BE PERFORMED TO DETERMINE WHETHER OR NOT YOU CAN RECEIVE THE EJECTIONS OR SOMETHING LIKE THAT, CAN BE CLEAR THAT THESE ARE PART OF THE RESEARCH. SIMILARLY IT TALKS ABOUT OTHER TESTS TO BE PERFORMED ONLY IF YOU DECIDE TO PARTICIPATE IN THE RESEARCH STUDY T. SCREENING AND PART OF THE RESEARCH STUDY SO MAYBE THESE TEST WILL BE ALSO PERFORM ONLY IF YOU'RE ELIGIBLE AND DECIDE TO CONTINUE IN THE RESEARCH. >> >> THANK YOU. ANY OTHER COMMENTS HERE? ANY RAC MEMBERS ON THE PHONE HAVE COMMENTS OR QUESTIONS? AND EDDIE ANYONE IN THE PUBLIC HAVE COMMENTS OR QUESTIONS? SEEING NONE WE'LL TAKE ABOUT A FIVE MINUTE BREAK TO GO THROUGH THE RECOMMENDATIONS AN READ THEM BACK. >> A DRAFT OF OUR RECOMMENDATION LETTER AND PLEASE MAKE SURE THAT WE CAPTURE THE SENSE OF YOUR INPUT ON TO THIS AND THEN WE'LL LET DR. FREYTAG RESPOND TO IT. >> OKAY SO OUR FIRST SETS OF COMMENTS RELATE TO PRE-CLINICAL RECOMMENDATIONS. THE FIRST ONE IS IT MAYBE HELPFUL TO COMPARE PREVIOUS TOXICOLOGY STUDIES DONE WITH THE SAME ADENOVIRAL VECTOR WITHOUT IL-12 WHICH CURRENT TOXICOLOGY STUDIES TO SEE WHETHER TOXICITIES SEEN IN CURRENT STUDY ARE DUE TO IL-12 RA THEY WERE VECTOR. THE SHE COULD ONE IS CONSIDER A COMPARISON OF REPLICATION COMPETENT ADENOVIRAL CONTAINING IL-12 VERSUS ONE WITHOUT IL-12 TO LOOK AT PEAK VIRAL LOAD AND VIRAL REPLICATION. AS IL-12 MAY INCREASE REPLICATION OF THE VIRUS. SIGNIFICANT INCREASE IN VIRAL PLEA REPLICATION INFORM PLAN DOSE ESCALATION LEVELS. THEN IN THE CLINICAL AREA, GIVEN POTENTIAL FOR TOXICITY AS MOUSE MODEL MAY NOT BE PREDICT OF OF IL-12 TOXICITY CONSIDER ADDING IL DOSE DEESCALATION AMPLE GIVEN TOXICITY INCLUDING HYPERTENSION AND VASODILATION, CONSERVATIVE IN YOUR INCLUSION CRITERIA TO LIMIT TO PATIENTS WITH MULTIPLE COMORBIDITIES RATHER THAN SEVERE ACTIVE DISEASE AS EXCLUSIONS. IN THIS ELDERLY POPULATION SCREENING ECHOCARDIOGRAM TO PRESERVE CARDIAC FUNCTION SHOULD BE CONSIDERED. THE NEXT COMMENT IS IN THE PREVIOUS TRIAL USING THE SAME VECTOR, THERE WAS EVIDENCE OF TRANSEMINITIS INDICATING THE VECTOR REACHED LIVER. IN ADDITION IL-12 LEAD TO LIVER COKE AT THISSISTY AS. WE USE OF STEROIDS MAYBE NOT BE IDEAL RESPONDS, WE RECOMMEND A DETAILED RESPONSE PLAN TO ADDRESS TOXICITIES INCLUDING LIVER TOXICITY AND HYPOTENSION. THEN THE ETHICAL LEGAL AND SOCIAL AREAS, THE COMMENTS ARE THERE ARE A NUMBER OF REFERENCES TO TREATMENT AND ITSELF MAY DESTROY YOUR CANCER, THESE MAYBE MISINTERPRETED PROVEN EFFICACY AND SHOULD BE CHANGED. NEXT ONE IS THERE IS A STATEMENT THAT ROUTINE TEST WILL BE ALSO PERFORMED WHETHER YOU ARE PART OF THE STUDY. THIS SHOULD BE CLARIFIED TO MAKE CLEAR THAT SCREEN TESTS ARE PART OF THE RESEARCH STUDY BUT ONLY THOSE WHO ARE ELIGIBLE FOR THE STUDY WILL BE SUBJECT TO REMAINING TESTS. THEN FINAL COMMENT IS IN THE PREVIOUS PROTOCOL USING IL-12 ADVERSE EVENTS INCLUDING NEUROLOGIC TOXICITIES THAT SHOULD BE IN THE INFORMED CONSENT DOCUMENT. DOES THAT COPTURE EVERYONE'S COMMENTS AND CONCERN? >> WHAT'S THE PUMP ASKING HIM TO THE -- PURPOSE OF ASKING TO NUMBER ONE PRE-CLINICAL STUDIES AT THIS POINT IF PROCEEDING WITH THE HUMAN STUDY, IS THAT -- >> SO THE FIRST COMMENT I BELIEVE IS JUST RECOMMENDING THEY COMPARE EXISTING STUDY DATABASES NOT ADDITIONAL TOXICOLOGY STUDY. I BELIEVE IS THAT -- THAT'S WHAT IT IS. THE SECOND ONE IS LOOKING AT REPLICATION I THINK THAT WOULD INFORM THE DOSING OF -- IF YOU SAW TEN TIME MICER VIRAL BURST. >> ANYONE ELSE WITH COMMENTS? DR. FREYTAG. >> I AGREE. WE'LL DO IT ALL. THE ONLY THING I'M A LITTLE UNCLEAR IS THE DEESCALATION STRATEGY. NOT QUITE FAMILIAR WITH THAT. >> MY ONLY COMMENT WAS AS DON SAID, THAT THE IN VITRO REPLICATION COMPETENCE MAY TEACH YOU THAT THE DOSE THAT YOU'RE PROPOSING TO START WITH MAYBE A LITTLE BIT HIGH AND YOU MIGHT WANT TO START WITH A LOWER DOSE BUT THAT HAS TO BE A JUDGMENT CALL ON YOUR PART. >> I THINK YOU'RE -- SOME DOSE ESCALATION SCHEME MAY HAVE MINUS ONE DOSE YOU CAN DROP DOWN HALF A LOG IF YOU SEE TOXICITY THAT YOU'RE STARTING DOSE, THAT WAS THE RECOMMENDATIONS, TO CONSIDER SOME DESIGN CHANGE LIKE THAT. SO I GUESS I WANTED TO BEFORE, MAKE A COMMENT THAT I THINK IT'S IMPRESSIVE SEE THIS 20 YEAR PROGRAM ADVANCES YOU HAVE MADE AND RESULTING ARE PROMISING. I THINK WE'RE ALL ENTHUSIASTIC ABILITY THIS NEW APPROACH, JUST WITH 100 PATIENTS YOU'RE CONFIDENT YOU KNOW TOXICITY, WITH IL-12 COULD BE A NEW BALL GAME FOR THERAPY AS WELL AS ADVERSE EVENTS SO I THINK THE COMMENTS ARE VERY HELPFUL. THANK YOU. I'M SORRY, YOU'RE NOT DONE. THREE MONTHS AND I HAVE TO BE RETRAINED. WE WILL NOW GO AROUND THE ROOM AND VOTE WHETHER WE ACCEPT OUR RECOMMENDATIONS OR NOT. DR. DONAHUE, YOU CAN BE THE FIRST VOTE. >> YES. >> CHATTERJEE, YES. >> PILEWSKI, QUESTION. >> -- LUCY YES. >> KAUFFMAN, YES. >> ATKINS YES. >> CURRY, YE. SADELAIN, YES. >> WOOLEY, YES. >> DRESSER, YES. >> KOHN, YES. >> HAMMARSKJOLD, YES. >> CANON. YES. >> HERRING, YES. >> WHITLEY, YES. >> ANTONIO, YES. >> ROSS, YES. >> ON THE PHONE? >> ORNELLES. YES. >> YES. >> HARDISON, QUESTION. >> DR. KIEM ARE YOU STILL THERE? WELCOME, DR. HARDISON. THAT DOES IT I BELIEVE. THANK YOU. GOODBYE, DAVID, THANK YOU. >> DR. SEGAL, HAVE YOU JOINED US ON THE PHONE? >> I'M HERE. >> THANK YOU. WE JUST ASK THAT WHILE WE'RE -- WHILE YOU'RE NOT SPEAKING TO KEEP YOUR PHONE ON MUTE TO KEEP THE BACKGROUND NOISE DOWN. SO FOR THE NEXT PROTOCOL I'M RECUSED AS ARE SEVERAL OTHER PEOPLE SO WE WILL BE LEAVING THE ROOM. I'M DR. HAMMARSKJOLD. DR. CANON, DR. CHAT GEE AND DR. KIEM RECUSED BUT NOT DR. SADELAIN. SO THIS IS A DISCUSSION OF HUMAN INTERACTIVE PROTOCOL NUMBER 1404-1304. TITLE IS PHASE 1 MULTI-CENTER OPEN LABEL SINGLE DOSE STUDY TO TO ASSESS SAFETY AND TOLERABILITY OF AUTOLOGOUS HEMATOPOIETIC STEM PROGENITOR CELLS MODIFIED AT THE BCL 11 A GENE BY ZINC FINGER NUCLEASES TO INCREASE FETAL HEMOGLOBIN PRODUCTION IN SUBJECTS WITH TRANSFUSION DEPENDENT BETA THAT THAT WILL SEEM MA. -- THAT WILL SEEMIA. >> WE HAVE TWO REVIEWERS, DR. TISDALE WHO IS PRESENT, SENIOR INVESTIGATOR IN THE CLINICAL AND MOLECULAR HEMATOLOGY BRANCH NATIONAL HEART LUNG AND BLOOD INSTITUTE AT THE NATIONAL INSTITUTES OF HEALTH. HE'S ALSO DONE MORE THAN 115 PAPERS AND ON THE BOARD OF STEM CELLS AND EXPERIMENTAL HEMATOLOGY AND ALSO SENIOR EDITOR OF DRUG DISCOVERY TODAY. DISEASE MECHANISMS SO OPINIONS AND MODEL THERAPEUTIC. ON THE PHONE WE HEARD DR. SEGAL. DR. SEGAL IS ASSOCIATE DIRECTOR AT UC DAVIS IN GENOME CENTER ASSOCIATE PROFESSOR IN THE DEPARTMENT OF BIOCHEMISTRY, MOLECULAR MEDICINE, AND FORM COOL. DR. SEGAL SITS ON THE SCIENTIFIC ADVISORY BOARD OF FOUNDATION FOR AUGUSTMEN SYNDROME THERAPEUTICS AND FOR PITTS HOPKINS SYNDROME. HIS FOCUS IS ENGINEERING CUSTOM DNA BINDING PROTEINS AN APPLICATION TOWARD IMPROVING PUBLIC HEALTH. AND THE PROTOCOL TEAM WHO WILL BE -- WHO WILL BE PRESENTING THE PROTOCOL, IS DR. WALTERS, PROFESSOR -- DR. WALTERS IS FAMILY OF BLOOD AND MARROW TRANSPLANTATION PROGRAM AT CHILDREN'S HOSPITAL RESEARCH CENTER, OAKLAND AND DEPARTMENT OF PEDIATRICIAN AT THE UNIVERSITY OF CALIFORNIA SAN FRANCISCO SCHOOL OF MEDICINE. HE HAS BEEN ACTIVE IN CLINICAL TRANSPLANTATION TRIALS AND LED SEVERAL NIH SUPPORTED INVESTIGATIONS IN HEMATOPOIETIC CELL TRANSPLANTATION FOR SICKLE CELL ANEMIA AND THALASSEMIA. THE TEAM ALSO INCLUDES SEVERAL MEMBERS OF THE SANGAMA BIOSCIENCES TEAM, DR. -- HEMOGLUE BIN, CLINICAL DEVELOPMENT PROGRAM, HE'S ALSO NCI SINCE 2000 ASSOCIATED ADJUNCT PROFESSOR MOLECULAR CELL BIOLOGY DEPARTMENT OF UNIVERSITY OF CALIFORNIA BERKELEY. THEN WE ALSO HAVE DR. GREGORY, CHIEF SCIENTIFIC OFFICER AND VICE PRESIDENT OF SANGAMO. PRIOR TO JOINING THE COMPANY HE WAS AT UNIVERSITY OF MUNICH WHERE HE STUDIED CHROMATIN CONSTRUCTION AND GENE DEGREE DAY. FINALLY DR. ANDO WHO IS VICE PRESIDENT, THERAPEUTIC DEVELOPMENT AND CHIEF MEDICAL OFFICER AT SANGAMO. HELD SENIOR POSITIONS IN THERAPEUTIC PRODUCT DEVELOPMENT IN SEVERAL GENE THERAPY BIOTECHNOLOGY COMPANY SINCE 1997. FROM 1997 TO 2001 HE SERVED A MEMBER OF THIS COMMITTEE AND HE BEGAN HE IS CAREER AS FACULTY MEMBER AT UC MEDICAL SCHOOL SO WELCOME. YOU'RE GOING HAVE A PRESENTATION I ASSUME. SO YOU CAN START YOUR PRESENTATION. >> THANKS VERY MUCH. BEFORE I BEGIN, A QUICK SOUND CHECK. CAN THE FOLK TONS THE PHONE HEAR ME? DR. SEGAL, CAN YOU HEAR? >> I CAN HEAR YOU WELL. >> GREAT. G. GOOD MORNING. GOOD MORNING TO Y'ALL. WE ARE HERE TO PRESENT THE PRE-CLINICAL DATA IN SUPPORT OF OUR PLAN CLINICAL TRIAL IN BETA THAT THALASSEMIA AND ANSWER ANY QUESTIONS THE RAC MAY HAVE. BUT I WOULD LIKE TO BEGIN BY THANKING THE RAC REVIEWERS DR. SEGAL, DR. TISDALE, DR. HAMMARSKJOLD P AND ZOLOTH FOR CAREFUL READING OF PROPOSAL AND HELPFUL COMMENTS. WE HAVE A REPRESENTATIVE RESEARCH DEVELOPMENT AND CLINICAL TEAM TO SPEAK THE YOU TODAY. AS DR. HAMMARSKJOLD MENTIONED I'M THE PROLEADER FOR AT SANGAMO. WE HAVE THE PRINCIPAL INVESTIGATOR ON THE CLINICAL TRIAL WITH US TODAY DR. MARK WALTERS AND TWO WONDERFUL COLLEAGUES FROM SANGAMO WHO HAVE CONSIDER BLUETOOTHABLE EXPERIENCE WITH GENE THERAPY AND ALSO MORE SPECIFICALLY WITH GENOME EDITING. H DRL PHILLIP GREGORY, CHIEF SCIENTIFIC OFFICER. THE DISEASE INDICATION FOR THE TRIAL IS BETA THALASSEMIA WHICH CHAI HIELY PREVALENT, IT IS MONOENGINE NICK NATURE AN CAUSED BY DISTINCT MUTATIONS IN THE BETAGLOBIN LEE GENE LEADING TO EXPRESSION OR ELIMINATION OF BEST TAGLOBIN GENE. THERE'S A NEED THE DEVELOP NEW THERAPY WHICH IS IS ORDEAL GOAL. SO THE PRODUCT WE NEED TO DEVELOP ARE GENETICALLY EDITED AUTOLOGOUS HEMATOPOIETIC STEM PROGENITOR CELLS. AS I'LL DESCRIBE SHORTLY, OUR EFFORTS BASED ON RECENT EXCITING FINDINGS THAT LEVELS OF FETALGLOBIN WHICH STUDIES HAVE SHOWN ELEVATE CAN REDUCE OR ELIMINATE SYMPTOMS OF DISEASE. THESE ARE UNDER CONTROL BY THE BC-11A. SOUR APPROACH IS TO DISRUPT THE BC 11A GENE IN HEMATOPOIETIC STEM AND PROGENITOR CELLS OF THE PATIENT USING TARGETED GENOME EDITING WITH ZINC FINGER NUCLEIEASE. AND RETURN THE CELLS TO THE PATIENT IN AUTOLOGOUS TRANSPLANT. OUR PLAN TO ELEVATE TOTAL HEMOGLOBIN IN THE PATIENT CIRCULATION, VIA REACTIVATION OF THE PREVIOUSLY SILENT FETAL HEMOGLOBIN GENE AN THUS ATTAIN A LIFETIME OF RELIEF FROM NEED FOR (INAUDIBLE) EACH SUBJECT ON TRIAL SERVE HER OR HIS OWN DONOR, YES HOPEFUL TO AVOID AVOID RISK OF GRAFT VERSUS HOST DISEASE WHICH AS YOU KNOW ARE ASSOCIATED WITH TRADITIONAL BONE MARROW TRANSPLANT. I WOULD LIKE TO ALSO POINT OUT THAT THE OVERALL IDEA OF A TARGETED KNOCK OUT WITH ZINC FINGER NUCLEASE IS SOMETHING SANGAMO DEPLOYED IN CLINIC FOR T-CELLS FOR THE CCR-5 GENE. AND THE INTENT TO DO A TRIAL LIKE THIS FOR TARGETED DISRUPTION OF THE GENE IN STEM CELLS HAS RECENTLY BEEN REVIEWED BY THE RAC. THERE IS VERY STRONG EVIDENCE THAT ELEVATION OF FETALGLOBIN LEVELS AMELIORATES DISEASE IN BETA THALASSEMIA. TWO PUBLICATIONS DESCRIBE INDIVIDUAL WHOSE UNDERWENT ALLOGENEIC BONE MARROW TRANSPLANT FOR THE DISEASE BUT IT FAILED. REMARKABLY THE HEMATOPOIETIC STRESS OF THE THE TRANSPLANT REACTIVATED PERMANENTLY THEIR FETAL GENE AN AS A CONSEQUENCE THEIR ANEMIA AND MOST DISEASE SYMPTOMS HAVE BEEN ELIMINATED. HAVING SAID THAT I WOULD LIKE TO EMPHASIZE THAT THIS IS TO ACTUALLY QUITE RARE AND DR. WALTERS WILL DESCRIBE SHORTLY UNDER NORMAL CIRCUMSTANCES FOLDING TRANSPLANT, LEVELS OF FETALGLOBIN RAPIDLY BACK TO BASELINE. THERE IS ONE OTHER IMPORTANT LESSON THAT WE CAN GAIN FROM BONE MARROW TRANSPLANSATION FEEL, THIS IS THE -- CERTAIN INDIVIDUALS FOLDING ALLOGENEIC BONE MARROW TRANSPLANT BECOME CHIME CHIMERIC. THAT MEAN AS TRACTION OF MARROW CONTAINS HEALTHY DONOR CELLS. STUDIES HAVE SHOWN THAT AS LITTLE AS 25% OF NORMAL BONE MARROW IS SUFFICIENT TO PERHAPS LESS IS SUFFICIENT TO AMELIORATE OR ELIMINATE SYMPTOMS OF DISEASE. THIS IS BECAUSE OF, THIS IS A KEY POINT CORRECTED PROGENITOR CELLS HAVE DRAMATIC SIGNIFICANT SURVIVAL ADVANTAGE RELATIVE TO MUTANT CELLS. MANY THERE'S STRONG CLINICAL SCIENCE THAT SAYS FIRST THAT BASELINE LEVELS OF FETAL HEMOGLOBIN VARY FROM PATIENT TO PATIENT AND FURTHERMORE IN PARTICULAR THE CASE OF THALASSEMIA INTERMEDIATEIA AS WELL AS THAT WILL MAJOR THERE'S EVIDENCE DRUGS THAT ELEVATE FETALGLOBIN LEVELS OR NATURAL VARIATION OF FETALGLOBIN LEVELS CAN BE STRONGLY DISEASE PROTECT ABOUT THE. A WEALTH OF EVIDENCE FROM ACADEMIC LABS IN PARTICULAR THAT OF DR. STEWART ORKIN HAS IDENTIFIED THE BROADLY EXPRESSED MULTI-FUNCTIONAL TRANSCRIPTIONAL REGULATOR BCL-11A AS THE KEY REGULATOR OF FETALGLOBIN LEVELS IN ADULTHOOD. AND FURTHERMORE VARIATION IN BC 11A IS OUTSIDE THE GLOBIN LOCUST ITSELF, FETAL VARIATION IN HUMANS. WHAT DO WE KNOW ABOUT THIS PROTEIN? IT'S MOUSE KNOCK OUT IS LETHAL DUE TO FUNCTION OUT OUTSIDE OF HEMATOPOIESIS. IT'S HEMATOPOIETIC SPECIFIC KNOCK OUT LEADS TO LOSS OF B CELLS. WE ARE HOPEFUL THAT ON OUR TRIAL, NORMAL B CELL FUNCTION WILL BE PROVIDED TO OUR SUBJECTS VIA FIRST UNMODIFIED AND HETEROZYGOUS CELLS IN THE PRODUCT, AND SECOND RECOVERY OF THE SUBJECT OF BONE MARROW POST CONDITION, THAT SAID AS DR. WALTERS WILL DESCRIBE IN A SECOND WE ARE PLANNING TO MONITOR CAREFULLY B CELL FUNCTION IN OUR SUBJECT ON THE TRIAL. FURTHERMORE, SHOULD ANY ASPECT OF HEMATOLOGICAL RECOVERY FAIL TO RECOVER NORMALLY WE HAVE MODIFIED BACK UP CELL PRODUCT. I JUST RETURNED FROM HEMOGLOBIN SWITCHING MEETING AT WHICH THERE WAS A FOLLOW-UP PRESENTATION BY DR. (INDISCERNIBLE) WHO GAVE PERMISSION TO SHARE THESE CHEAT EXCITE ANYTHING DATA WITH YOU. -- TO SHARE THESE EXCITING NEW DATA. THERE'S CHILDREN WHO LACK ONE ALLELE SOW U THAT EAR HETEROZYGOUS FOR A FULL KNOCK O. THEY HAVE HAD NEUROLOGICAL ABNORMALITIES SINCE BIRTH DUE TO REQUIREMENT OF BCL 11A IN THE CENTRAL NERVOUS SYSTEM. BUT REMARKABLY AND STRIKINGLY, THESE TWO INDIVIDUALS HAVE DUTY SLEUTHLY NO DETECTABLE HEMATOLOGICAL OR IMMUNOLOGICAL ABNORMALITY WHATSOEVER. THE ONLY BLOOD RELATED SYMPTOM THAT THESE TWO GIRLS HAVE AS ANYBODY CAN TELL IS DRAMATIC SUSTAINED ELEVATION OF FETALGLOBIN SO THE TWO GIRLS HAVE 16 AND 24% FETALGLOBIN WITH SPECK WHICH IS ACTUALLY QUITE SIGNIFICANT. FURTHERMORE, THERE IS A NATURAL ALLELE THAT KNOCK DOWNS BC 11A BY 40% WHICH IS QUITE PREVALENT, MORE PREVALENT THAN THE KNOCK OUT. IT'S WIDELY DISTRIBUTED, AND TO THE BEST OF ANYONE'S KNOWLEDGE HAS NO EFFECT ON PEOPLE OTHER THAN SUSTAINED ELEVATION OF FETALGLOBIN LEVELS WE KNOW TO BE DISEASE PROTECTANT. I WILL GO THROUGH THIS QUICKLY IN THE INTEREST OF TIME BECAUSE IT'S PUBLISH AND MUCH IS WORK FROM THE LAB OF STEWART OR KIN. WE KNOW QUITE A BIT HOW BC-11A EXITS FUNCTION ON BETA BLOW BIN, IT BINDS TO THE LOCUST AND REPRESSES IT. THE KEY POINT FROM THE DATA IS IS THAT WHEN YOU DOWN REGULATE OR KNOCK OUT BC WILL HAVE 11A IN THE ERYTHROID LINEAGE YOU GET A SUSTAINED ELEVATION OF FETALGLOBIN BUT OTHER THAN THAT, NO DETECTABLE EFFECTS ON THE HEMATOPOIESIS WHATSOEVER. TO RECAP A WEALTH OF HE IS THESE AND OTHER PUBLISHED DATA ON BCL AND HEMOGLOBIN ON THINKS I TOLD YOU BETA THALASSEMIA IS CURED BY SUSTAINED ELEVATION OF FETALGLOBIN, THAT VARIATION AT LEVELS ARE UNDER TENSIVE GENETIC CONTROL, DUE TO VARIOUS BC 11A LOCUST T MAJOR REGULATOR OF FETALGLOBIN IN ADULTHOOD, IT BINDS TO LOCI AND REPRESSES GAMMA GLOW MINUTE PRESENTATION PRESENTATION. THERE'S NATURALLY OCCURRING ALLELES OF BC-11A LOWER EXPRESSION OF TRANSCRIPTION FACTOR AND THIS MUTATION ELEVATES FETALGLOBIN LEVEL BUSINESS LOWERING EXPRESSION. AND IN THE INTEREST OF TIME I DIDN'T HAVE OPPORTUNITY TO REVIEW WITH YOU SOME VERY IMPRESSIVE DATA FROM THE ORKIN LAB HAS SHOWN THE SPECIFIC KNOCK OUT OF BC-11A ELIMINATES THE DETECTABLE SICKLE CELL DISEASE LIKE SYMPTOMS IN TWO MOUSE MODELS OF DISEASE. SO THE GENERAL MESSAGE ON SUMMARY OF THIS PORTION OF THE TALK IS THERE CEASE OOH WEALTH OF THESE DATA THAT SONGLY SUPPORT THE NOTION THAT BC-11A IS A HIGHLY ATTRACTIVE TARGET FOR THE TARGETED MANIPULATION IN THE CONTEXT OF GENETIC ENGINEERING OF STEM CELLS TO INHIBIT HEMOGLOBIN IN PARTICULAR BETA THALASSEMIA. NOW DO WE PROPOSE TO OBTAIN TARGET MANIPULATION IN THE SUBJECTS OWN STEM CELLS? WE PROPOSE TO DO SO BY A TARGETED GENOME EDITING ZINC FINGER NUCLEUSEASES YOU CAN SEE HERE. ZINC FINGER NUCLEASES INFORM CFN ARE A DESIGN RESTRICTION OF ENGINEERING IN THIS CASE TO BIND TOP AN EXTENDED RECOGNITION SITE, SPECIFICALLY THEY ACT BY THE HETERODIMERRIZATION OF TWO SEPARATE MONOMER WHICH IS YOU CAN SEE HERE AND HERE. EACH BY ITSELF IS INACTIVE. ACTIVITY IS ATTAINED, WHEN AND ONLY WHEN TWO SUCH MONOMERS BEHIND TO A SPECIFIC LOCUST AN IN THIS CASE THE EXTENDED RECOGNITION CONSENSUS OF 36 BASE PAIRS WHICH IS UNIQUE BIOI HAVE BEEN FORMATIC HUMAN GENOME. THEY BIND TO THAT LOCUST IN A SPECIFIC ORIENTATION. THE SPECIFICITY OF ACTION IS OBTAINED FROM J TO POSITION OF TWO THINGS. FIRST THE NEED FOR TWO MONOMERS TO HETERODIMER SIZE IN A PRECISE WAY AND SECOND USE OF GENERAL TICKLY ENGINEERED IN NO FOLK 1 RESTRICTION AND ZINC FINGER NUCLEASE WHICH FORCES HETERODIMERRIZATION. ONCE THE HEAT ROW DIMERIZATION OF TARGET LOCUST OCCUR IT IS NUCLEASE INDUCES A DOUBLE STRAND BREAK, PREPARED BAY PROCESS CALLED NON-HOMOLOGOUS ENJOINING THAT CREATES SLOW INSERTIONS AN DELETIONS IN THE TARGET. WHEN SUCH BREAK RINSE DEUCED AT THE CODING REGION, YOU GET A KNOCK OUT. WITH THE GOAL OF LIMBNATING ALL -- ELIMINATING ALL FUNCTION THE SUBJECTS CELLS WE DESIGNED A STRATEGY WHICH WE KNOCK OUT ALL ISOFORM BUSINESS ENGENDERING SYNC FINGER NUCLEASES THAT CUTS INTO,ON THAT CUTS IN TO ALL ISOFORMS. WE USE DEEP SEQUENCING TO CHARACTERIZE INSERTIONS AN DELETIONS THAT RESULT IN STEM CELLS FROM THE TARGETED DISRUPTION PROCESS. THEIR P IN SILICO ANALYSIS SHOWS IF TRANSLATED THEY PRODUCE APPROXIMATELY 50 AMINO ACID PEPTIDES, THIS IS IMPORTANT BECAUSE FULL LENGTH BC 11A IS 835 AMINO ACIDSES. WE HAVE DEVELOP AD GMP COMPLIANT CELL MANUFACTURING PROCESS WHICH ALLOWS US TO ATTAIN HIGH EFFICIENCY TARGETED DISRUPTION OF BC-11A CLINICAL SCALE T PROCESS IS COMPATIBLE WITH USING UP TO 300 MILLION CELLS. BY USING CELLS FROM GC -- HEALTHY VOLUNTEERS IN MULTIPLE EXPERIMENT WE WAS SHOWN THAT WE CAN ATTAIN ON AVERAGE 68% TARGETED BC 11A KNOCK OUT WITH RANGE 61 TO 76%. JUST TO BE CLEAR WHAT THIS NUMBER MEAN WHENCE WE USE DEEP SEQUENCING TO ANALYZE IN UNBIASED FASHION COPIES OF THE TARGET LOCUST, THAT FRACTION HAS SMALL INSERTIONS AND DELETIONS P INDUCED BY THE ZINC FINGER NUCLEASE AT AXON 2 OR BC-11A. WE HAVE SUBSEQUENTLY PERFORMED EXTENDED SERIES OF EXPERIMENTS TO CHARGIZE THE EFFECTS EFFECTS OF THE GENOME ON THE STONES HSPCs AS WELL AS WHETHER OR NOT FETALGLOBIN SELLVATED. I WOULD LIKE TO BRIEFLY VIE THESE DATA WITH YOU. THE ANALYTICAL PIPELINE BUILT TO DO THE EMPERIMENTS IS TAKE CD34 CELLS FROM VOLUNTEERS PURIFY THEM, ELECTROFOR RATE THEM AT THE CLINICAL SCALE WITH ZIN FINK THEIR CUT BC-11A AND PERFORM ERYTHROPOIESIS WHICH IS AN 18 DAY PROCESS AND ASK WHETHER OR NOT FETALGLOBIN IS ELEVATED. WE USE A RANGE OF ANALYTICAL TECHNIQUES. WE CAN ASK AT MESSENGER RNA LEVEL WHAT HAPPEN WHENCE YOU KNOCK OUT BC-11A AND HERE IS IS A REPRESENTATIVE EXPERIMENT IN THIS INSTANCE AFTER DAYS OF ERYTHROPRO POI SIX IT WAS ELEVATED P 8.1 FOLD. TWO POINTS ABOUT THE DATA FIRST THIS EFFECT IS REALLY SPECIFIC TO THE KNOCK OUT OF BC-11A BECAUSE GENETICALLY ENGINEERING HSCs TO COMPARABLE LEVELS AT CONTROL LOCUST DID NOT AFFECT FETALGLOBIN LEVELS AT ALL. THE OTHER POINT WHICH IS IMPORTANT. CONTROL CELLS AND BC 11A DISRUPTION BEARING CELLS IN THIS AND OTHER EXPERIMENTS GREW IN DISTINGUISHABLY TO EXPANDED A DURING THE 18 DAY ERYTHROPOIESIS CULTURE. THE NEXT WE ASKED WHAT AFFECT THIS DISRUPTION AT AT THE PROTEIN LEVEL. I WOULD LIKE TO SHOW YOU DATA WITH IMPART IN RESPONSE TO THE QUESTIONS BY ONE RAC eRE VIEWER DR. TISDALE, AN IMPORTANT QUESTION TO HAVE ASKED. TO LOOK AT THE PROTEIN LEVEL WE HAVE TO LOOK AT HIGH PERFORMANCE LIQUID CHROMATOGRAPHY, REVERSE HVLC WHICH SEPARATE IT IS INDIVIDUALGLOBIN CHAIN CHAIN WHENCE YOU TAKE eATE THROW SITES AND GENERATE IN NCI THIS PROCESS YOU SEE A PICTURE OF THE TWO PROMINENT PEAKS ADULT ALPHA AND BEAND THE THE TWOGLOBIN PEAKS ARE BARELY DETECTABLE IN STRIKING CONTRAST WHEN YOU DISRUPT BC-11A ERYTHROCYTES THESE DATA IS QUANTITATE AND WE HAVE DONE THIS EXPERIMENTS MANY TIMES AND WHICHEVER WE USE REVERSE PHASE YOU SEE HERE OR CATION EXCHANGE WHICH ALLOWS US TO KEEP THE HEMOGLOBIN TETRAMER INTACT WE ARE RE PRODUCEBLY OKAY SERVE A STRIKING HEMOGLOBIN UPON DISRUPTION OF BC-11A WITH ANYWHERE BETWEEN 35 AND 43% OF HEMOGLOBIN BEING FETAL. GIVEN THAT THE UP REGULATION IS SO HIGH, FOR REASONS WE COULD ACTUALLY DETECT ACTIVATION BY IMMUNOHISTOCHEMISTRY. USING HIGHLY SPECIFIC MONOCLONAL ANTIBODIES RECOGNIZED ADULT OR FETALGLOBIN. AND IF YOU GENERATE CONTROL OF ERYTHROCYTES YOU SEE THAT THEY HAVE GHEIT QUIET A BIT OF FORMER ADULTGLOBIN AND RELATIVELY LITTLE IF ANY OF THE LATTER. IN VERY STRIKING CONTRAST KNOCK OUT BC-11A THEY STILL MAKE NORMALGLOBIN AND THEN THEY HAVE THIS LUXURIOUS LEVELS FETAL HEMOGLOBIN THROUGHOUT THE FIELD OF VISION. I MENTIONED TO YOU THE BC-11A HAS FUNCTIONS ATTRIT THROWPOIESIS AS WELL. SO TO UNDERSTAND WHAT AFFECTS ITS KNOCK OUT WILL HAVE WE TURNED TO IMMUNODEFICIENT MOUSE MODEL NG MOUSE, THIS IS ONLY ANIMAL MODEL AVAILABLE TO US TO DO THESE EXPERIMENTS AND ONE RAC REVIEWER RAISED THIS POINT AND WE AGREE THAT LARGER ANIMAL MODEL WOULD BE USEFUL, EXAMPLE NON-HUMAN PRIMATE. WE ARE ENGAGED IN ACTIVE CRAB RATION WITH AND PETER CHIME TO ESTABLISH CONDITIONS WHICH WE COULD DO AUTOLOGOUS TRANSPLANT OF NON-HUMAN PRIMATE GENOME EDITED HEMATOPOIETIC STEM AND PROGENITOR CELLS. THAT EFFORT HOWEVER VERY MUCH AT THE RESEARCH STAGE. I WANT TO POINT OUT MAJOR ADVANTAGE FROM OUR PERSPECTIVE AND PRE-CLINICAL SAFETY AND EFFICACY PERSPECTIVE DEVELOPMENT PERSPECTIVE IS THAT IMMUNODEFICIENT HOUSE ALLOWSES TO ASSESS THE ACTUAL HUMAN PRODUCT. NAMELY WE CAN LOOK AT HUMAN HSPCs WE MODIFIED WITH ZINC FINGER GENERATED IN VITRO AND ASSESS IN VIVO ENGRAFTING THEM MICE. THE NSG MOUSE WILL SUPPORT ENGRAFTMENT OF THE HSPCs AND DEVELOPMENT OF LINEAGE B CELLS CD4 T-CELLS CD8 T-CELLS AND ANOTHER CRITICAL POINT, THEY WILL UNDERGO SIGNIFICANT REPLICATION AND EXPANSION IN PERIPHERAL BLOOD AND TISSUES. NOW, HAVING SAID THIS, ONE THING THE MOUSE WILL NOT DO IS DEVELOP HUMAN ERYTHROCYTES. YOU CANNOT DETECT HUMAN CELLS OF ERYTHROID ORIGIN IN THE PERIPHERY OF THE MOUSE BECAUSE THEY ARE ARE ELIMINATED BY MOUSE MACROPHAGES. SO ADDRESS THIS LIMITATION, WE DEVELOPED THE FOLLOWING ANALYTICAL PIPELINE. WE OBTAIN CD34 CELLS, DISRUPT BC 11A AND ENGRAFT THE CELLS INTO AN MSG MICE AND STARTING IN FOUR WEEKS DEFINE TIME POINTS AT FOUR WEEK INTERVALS TO 28 WEEKS WHICH IS THE LONGEST TIME WE LOOKED AT. WE SAMPLE PERIPHERAL BLOOD IN CHIMERISM AND LINEAGE. FURTHERMORE SPECIFIC TIME POINTS, 18 TO 28 WEEKS, WE HARVEST THE BONE MARROW FROM THESE ANIMALS AND WE SEQUENTIAL WAIT RED BLOOD CELLS IN VITRO TO LOOK AT FETALGLOBIN ELEVATION. WHEN WE DO THE EXPERIMENTS WE REPRODUCIBLY FIND ANIMALS ENGRAFTED WITH CELL BARING DISRUPTION OF BC 11A AT LONGEST TIME POINTS WE LOOKED AT REPRODUCIBLY SHOW ELEVATION OF FETALGLOBIN LEVELS OVER MARROW FROM RBC GENERATED FROM MARROW OBTAINED FROM ANIMALS AND ENGRAFTED CONTROL CELLS. SO I SHOWED YOU EARLIER THAT TAKING FRESH CD34 E NEW YORK OUT BC-11A GENERATE ERYTHROCYTES IN VIVO AND GROW 18 DAYS YOU SEE ELEVATION OF FETALGLOBIN. SO THIS SHOWS THE EFFECT ON FETALGLOBIN IS PRESERVED AFTER THE HSCs HAVE BEEN INGRAFTED TO MSG MICE, 28 WEEKS, THE LONGEST TIME POINT WE HAVE LOOKED AT. WE APPRECIATE VERY MUCH BCL HAS FUNCTIONS OUTSIDE ERYTHROPOIESIS AND ASK WHAT EFFECT BCL HAS ON LINEAGES WE INVESTIGATED MULTI-LINEAGE ENGRAFTMENT AND HERE IS A REPRESENTATIVE EXPERIMENT WHICH WE TOOK CONTROL CELLS WHICH YOU SEE HERE IN BLUE. AND CELLS CELL BEARING DISRUPTION ON BC WILL HAVE 11A SHOWN IN RESUMED WE ENGRAFTED INTO MSG MICE AND AFTER 18 WEEKS WE HARVESTED BONE MARROW AND USED FACTS TO ANALYZE THE INDIVIDUAL LINEAGES. YOU CAN SEE FOR YOURSELF IN THESE DATA, HIGHLY COMPARABLE IF NOT DISTINGUISHABLE MULTI-LINEAGE ENGRAFTMENT OBSERVED. I WOULD LIKE TO DRAW YOUR ATTENTION TO FACT WE SEE ESSENTIALLY INDISTINGUISHABLE AMOUNTS OF B CELLS. AND MARROW OF CELLS ENGRAFTED WITH CONTROL OR BC,L-11A DISRUPTED CELLS CONSISTENT WITH THE NOTION I RAISED EARLIER, NAMELY THAT WILD TYPE MODIFY AND HETEROZYGOUS CELLS IN OUR PRODUCT FULLY RECONSTITUTE THE B CELL LINEAGE IN LIMITING HEMATOTOY POI TICK HOMEOSTASIS. -- HI MAT POIETIC HOMEOSTASIS. WE HAVE DONE NINE STUDIES WITH COLLABORATORS AT THAT TIME UNIVERSITY OF WASHINGTON, MORE EXCELLENT THREE AT JACKSON LAB, USING CELL MANUFACTURED AT THE CLINICAL SCALE PROCESS AND BRIEFLY THROUGHOUT THE RATHER LARGE BODY OF WORK COMPARING MICE ENGRAFTED WITH CONTROL CELLS OR ANIMALS ENGRAFTED WITH CELL BARING DISRUPTION OF BCL, WE SEE COMPARABLE CHIMERISM, COMPARABLE TO LINEAGE ENGRAFTMENT AND NO DIFFERENCE AND I WOULD LIKE TO POINT OUT THE A BASELINE DEATH RATE IS QUITE LOW. ENCOURAGED BY THIS WE HAVE INITIATED IND ENABLING TUMOR JENNY IN THISTY STUDY. THE STRUCTURE DISCUSSED WITH THE AGENCY WITH THE PRE-IND. I WOULD LIKE TO DESCRIBE OUR STUDIES OF ASSESSING THE FIDELITY OF GENOME EDITING TECHNOLOGIES AND IN THE INTEREST OF TIME I WILL GO THROUGH IT QUICKLY. WE PERFORM INDEPENDENT TESTS OF MOLECULAR SPECIFICITY THAT ARE BIOINFORMATICS GUIDED AND UNBIASED AND COMPLIMENT WITH MORE TRADITIONAL TOXICOLOGY TUMORIGENITICITY APPROACHES WITH THE GOAL OF MAXIMIZING OUR ABILITY TO DETECT ANYTHING UNTOWARD IN Z NEXTC FINGER NUCLEASES TO DO TO THE CELLS. IN THE INTEREST OF TIME I'LL SPEND A FEW MINUTES DISCUSSING AN IMPORTANT STUDY, DIRECT HIGH THROUGH PUT SEQUENCING OF POTENTIAL TARGET SITES. THE WAY THIS IS DONE IS WE BEGIN BY DETERMINING THE ACTUAL IN VITRO RECOGNITION SPECIFICITY OF THIS ZINC FINGER. I DON'T HAVE TIME TO WALK YOU THROUGH THE -- BIOCHEMISTRY OF THIS, DONE A PROCEDURE CALLED (INAUDIBLE). YOU TAKE THE ZINC FINGER AND INCUBATE WITH EVERY POSSIBLE DNA MOLECULE, THAN YOU DO MULTIPLE ROUNDS OF IN VITRO SELECTION TO IDENTIFY WHAT ARE THE ACTUAL RECOGNITION SITES OF THE TWO MONOMERS THAT FORM THE NUCLEASE HETERODIMER. ARMED WITH THIS INFORMATION YOU THEN SCAN THE HUMAN GENOME FOR PARTIAL MATCHES TO THIS CONSENSUS AND YOU HAVE TO DO -- YOU HAVE TO ALLOW MISMATCH BECAUSE LIKE I SAID, FULL LENGTH RECK ANYTHING SEQUENCE 36 BASE PAIRS SO IT'S UNIQUE BIOINFORMATICALLY IN THE HUMAN GENOME. IN OUR STUDIES FOR BCLMR WE GENERATES AD LIST OF CANDIDATE OF TARGET SITES. IDENTIFYING IN VITRO BIOCHEMISTRY BIOINFORMATICS PIPELINE, SO 172 SITES WITH MANUFACTURE CLINICAL SCALE CD34 CELLS, HARVEST GENOMIC DNA AND USE DEEP SEQUENCING TO EXPERIMENTALLY ASSESS WHETHER OR NOT Z NEXTC FINGER NUCLEUSEASES HAVE CUT TARGET SITES. WHEN WE DID THIS STUDY WITH THE CLINICAL REAGENTS FOR OUR PROGRAM, WE ACTUALLY LOOKED AT 172 POSITION IN THE HUMAN GENOME, AND THREE SHOWED ACTIVITY ABOVE BACKGROUND. AND THESE DATA ARE SUMMARIZED IN THIS TABLE, IN THE INTEREST OF TIME I'M NOT GOING TO GO THROUGH THE DETAIL THOSE ALL OF YOU HAVE THIS INFORMATION. THE ON TARGET MARKING BCL WAS IN THE 60 TO 76% RANGE AND OFF TARGET MARKETING FOR SITES WAS BETWEEN .15 AND 2% AND OTHER OFF TARGET IT WAS 8%. THE SUMMARY OF ALL THIS ANALYSIS IS WE DID NOT IDENTIFY ANY HIGH RISK ROW SIGH TO THE BEST OF OUR KNOWLEDGE. WE DIDN'T GENERATE CODING REGION KNOCK OUT AS BY THIS ASSAY. NONE OF THESE SITES AGAIN TO BEST OF OUR KNOWLEDGE ARE ASSOCIATED WITH ONCO GENIC TRANSFORMATION. SO WE THUS REASONED THAT WE DEMONSTRATED SUFFICIENT SPECIFICITY TO PROCEED ADDITION AL PANEL OF INDEPENDENT NON-CLINICAL SAFETY STUDIES SPECIFICALLY TO CARO TYPE THE CELLS TONE SURE THE GENOME EDIT PROCESS MAINTAINS THE CHROMOSOME COMPLIMENT, UNBIASED ASSESSMENT OF THE NUMBER OF DOUBLE STRANDS BREAKS IN INDUCED NUCLEASE BY IMMUNOSTAINING, CLASSICAL SOFT TRANSFORMATION ASSAY AND PERHAPS MOST CRITICALLY, TO DO AND IN VIVO TUMORIGENITICITY NOSTOC IN THE MOUSE AN MOST CRITICALLY BECAUSE THAT STUDY WILL ALLOW US TO ASSESS THE CELL PRODUCT AND ANY CONSEQUENCES ON THOSE CELLS OF BOTH ON AND OFF TARGET CLEAVAGE BY ZINC FINGER NUCLEASE AT THE SITE YOU SEE HERE, AS IMPORTANTLY ANY OF THE OTHER TARGET SITES THAT APPROACH HERE FAILED TO IDENTIFY. THIS APPROACH WE USE ONCE AGAIN IS THE NSG MOUSE AND THE ONE IMPORTANT NUMBER TO SHARE WITH YOU IS WE MANUFACTURE CLINICAL DOSE OF CELL PRODUCT AND WE ENGRAFT INTO ANIMALS ONE MILLION PER MOUSE. THIS IS SIGNIFICANT. IT MEANS WE WILL BE ASSESSING NOT JUST THIS -- AT THE TARGET BUT WILL BE ASSESSING NUMBERS 1 OR 2 MILLION CELLS THAT BEAR OFF TARGET MARK AND THIS ANIMAL WILL ALLOW US TO DETERMINE WHETHER OR NOT THIS MARKING HAS ANY ADVERSE EFFECT ON THE CELL. WE HAVE INITIATED THE STUDY AS PER PROTOCOL WE AS I MENTIONED DISCUSSED WITH THE AGENCY AT THE PRE-IND. STUDY OBJECTIVES TO EVALUATE TUMORIGENITICITY OF CELL PRODUCT IN THE MSG MOUSE, THE AGREED UPON STUDY DURATION IS FIVE MONTHS, WE ENGRAFT A CLINICAL DOSE OF CELLS FROM FIVE INDEPENDENT DONORS. MANY THERE'S A LARGE NUMBER OF END POINTS THAT IN THE INTEREST OF TIME I WON'T DESCRIBE. EXCEPT TO SAY THAT THE CONCLUSION OF THE STUDY THE AN MALLS WILL BE SUBJECTED TO COMPREHENSIVE HISTOPATHOLOGICAL ASSESSMENT TO COMPREHENSIVELY ASSESS ANY EVIDENCE OF SOLID OR NON-SOLID TUMORS. WITH THAT I WOULD LIKE TO TURN THE MICROPHONE OVER TO CLINICAL PI DR. WAHL TEARS WHO WILL TELL YOU ABOUT OUR STANDARDS OF CARE FOR THE DISEASE INDICATION AS WELL AS CLINICAL PROTOCOL. >> I REALIZE I FORGOT THE MENTION THAT I DO NEED TO ACKNOWLEDGE CALIFORNIA SUPER GENRETIVE MEDICINE WHO FUNDED THIS WORK IN PART AND THAT WE'RE DEVELOPING THIS PROGRAM AS ADVANCE DOING TO CLINIC WITH PARTNERSHIP WITH BIOJENIATIC. WITH THAT. >> Q. IN THE FEW MINUTES LEFT I THOUGHT I WOULD PRESENT THE RATIONALE AND THE DESIGN OF THE CLINICAL TRIAL PROPOSED. THE FIRST SLIDE I WANT TO SHOPE WHERE WERE NATURAL HISTORY DATA ABOUT THALASSEMIA MAJOR AND THESE FOUR PANELS SHOWS SURVIVAL DATABASED ON THE BIRTH YEAR IN COHORT FROM ITALY, GREECE AND THE UNITED KINGDOM. YOU CAN SEE 50 YEARS AGO THE MEDIAN SURVIVAL WAS 20 YEARS OF AGE BUT AFTER THE INSTITUTION OF IRON CHELATION THERAPY AND REGULAR RED BLOOD CELL TRANSFUSION THERAPY TO CURRENTER RAS HIGHLIGHTED NICELY BY THIS COHORT IN THE UK BORN AFTER 1975, THERE'S ESSENTIALLY UNIVERSAL SURVIVAL AND INTO ADULTHOOD. SO THIS ILLUSTRATES REALLY SIGNIFICANT AND STUNNING ADVANCES IN SUPPORT OF CARE BUT ALSO HIGHLIGHTS THE FACT THAT TO GET THIS BENEFIT ONE HAS TO ADHERE TO A CUMBERSOME OFTEN EXPENSIVE MODE OF THERAPY THAT IS NOT AVAILABLE WORLDWIDE. WHICH IS OPENED UP THE POSSIBILITY OF STEM CELL TRANSPLANTATION AS A CURATIVE ALTERNATIVE. THIS HAS BEEN UTILIZED ALMOST EXCLUSIVELY OR FOR THE MOST PART IN THE SETTING OF CHILDREN WHO HAVE IDENTICAL SIBLING DONORS WHICH LEADS TO GAPS IN AVAILABILITY OF THAT CURATIVE THERAPY FOR THIS DISORDER. SO I THOUGHT I WOULD FOCUS ON THREE PATIENT COHORTS WHO MIGHT BENEFIT FROM ALTERNATIVE CURATIVE APPROACH. FIRST IN PATIENTS WITH ADVANCE STAGE FEATURES THESE INDIVIDUALS HAVE TRADITIONALLY EXPERIENCED POORER OUTCOME COMPARED TO YOUNGER CALL IT PATIENTS IN BETTER SHAPE. SO THESE WERE DATA PUBLISHED NEARLY 25 YEARS AGO BUT THE STORY IS STILL IMPORTANT WHICH IS IF YOU TAKE THE BEST RISK CHILDREN WHO HAVE NO LIVER ENLARGEMENT AND NO POOR FIBROSIS BY LIVER HISTOLOGY, EVENT FREE SURVIVAL IS GOOD. BUT IN THISSER RA PATIENT WHOSE ARE OLDER HAD LARGE LIVERS AND FIBROSIS AS AN EXPRESSION OF IRON OVERLOADS AND ORGAN DAMAGE. THE OUTCOMES WERE LESS GOOD, 50% EVENT FREE SURVIVAL WAS NOT ACCEPTABLE AT ALL AND FOR THE MOST PART THESE PATIENTS DID NOT PROCEED TO TRANSPLANTATION IN THAT ERA. WE UPDATED THIS IN A DIFFERENT COHORT TREATED IN SOUTHEAST ASIA, NORTH AND SOUTH AMERICA, THESE ARE REGISTRY DATA FROM THE CENTER FOR INTERNATIONAL BLOOD BONE MARROW RESEARCH F YOU LOOK AT CHILDREN WHO RECEIVED AGE IDENTICAL SIBLING BONE MARROW TRANSPLANTATION OVER 7 YEARS OF AGE AND HAD LARGE LEVER IT IS PROBABILITY OF DISEASE FREE SURVIVAL IS ONLY 50%. WHEREAS BETTER RISK PATIENTS HAVE SUPERIOR EXPERIENCE. SO HIGHLIGHT IT IS FACT THAT THERE ARE INDIVIDUALS YOUNG AND OLD WHO MIGHT BENEFIT FROM ALTERNATIVE REDUCED TOXICITY APPROACH. NOW STORY ADOLESCENTS AND YOUNG ADULTS TREATED BY BONE MARROW TRANSPLANTATION. THESE ARE DATA REPORTED ABOUT A DECADE AGO, AGAIN, FROM THE PIONEERING WORK BY (INAUDIBLE) AND COLLEAGUES YOU CAN SEE OLDER PATIENTS DEFINED OLDER THAN 18 YEARS OF AGE WITH CLASS ADVANCE CLASS FEATURES EXPERIENCED HIGH MORTAL I DESPITE MODULATED DOSING OF CHEMOTHERAPY DRUGS BEFORE TRANSPLANTATION. AND THIS SUBPOENA A DIFFICULT HURDLE TO OVERCOME. THOUGH WITH MODULATION DEVELOPMENT OF REDUCED TOXICITY REGIMENS THIS HAS BEEN IMPROVED. BUT NOT SOLVED. THAT'S ILLUSTRATED IN THE NEXT SLIDE WHERE I ALSO LOOK AT WILL REVIEW WITH YOU SITUATION OF PATIENT WHOSE LACK A SIBLING DONOR, AGE IDENTICAL. THESE ARE DATA REPORTED BY FRANK LOGATELI AND COLLEAGUES TREATING 60 INDIVIDUALS WITH THALASSEMIA MAJOR WITH 20 RECEIVED AGE IDENTICAL SIBLING DONOR AND 40 BE MATCHED UNRELATED DONOR, VERY WELL MATCHED UNRELATED DO NO. CXFC THESE PATIENTS ARE TREATED THE LAST 15 YEARS. WHAT IS SHOWN IS THALASSEMIA-FREE SURVIVAL OF 84% IS QUITE GOOD, USING REDUCED TOXICITY REGIMEN OF (INAUDIBLE) IN FACT VERY SIMILAR RESULTS WERE OBSERVED USING SIBLING OR MATCHED UNRELATED DONOR TRANSPLANTATION APPROXIMATELY 85% THALASSEMIA-FREE SURVIVAL AND PATIENTS WITH HIGHER RISK CATEGORY FEATURE EXPERIENCED A SIMILAR OUTCOME. BUT THERE WAS STILL A PROBLEM GRAPH REJECTION AND TRANSPLANT RELATED MORTALITY SHOWN IN THIS CUMULATIVE INCIDENTING ON CUR IN 15% OF PATIENTS SO EVEN WITH THESE IMPROVEMENTS THERE APPEARS TO BE PATIENTS WHO LACK SIBLING DONOR WHO MIGHT HAVE ADVANCE FEATURES THAT WARRANT DEVELOPMENT OF ALTERNATIVE CURATIVE APPROACH. SFROM AND THAT'S IF RATIONALE FOR OUR CONSIDERING-APPROACH IN YOUNG ADULTS WITH THALASSEMIA MAJOR. AN IMPORTANT FEATURE FOR US IN THE UNITED STATES WHERE ETHNIC DIVERSITY OF OUR PATIENTS MAKES IT CHALLENGING TO FIND ALWAYS, SIBLING DONOR OR WELL MATCHED UNRELATED MARROW DONORS IS THE EXPLORATION INTO UMBILICAL CORD BLOOD TRANSPLANTATION. THESE ARE REGISTERED DATA FROM THE CENTERS FOR INTERNATIONAL BLOOD MARROW TRANSPLANT RESEARCH USING UMBILICAL CORD UNIT UNITS MISMATCHED AT VARIOUS ANTIGENS THAT WILL SEEM WHERE FREE SURVIVAL OF 18% IS NOT ACCEPTABLE AND THIS APPROACH IS LARGELY ABANDONED WHILE WE DEVELOP BETTER APPROACHES BETTER CONDITIONING REGIMENS TO ATTACK THIS PROBLEM. SO WITH THAT BACKGROUND I WOULD LIKE TO BRIEFLY INTRODUCE THE STUDY ITSELF WHICH IS A PHASE 1 MULTI-CENTER OPEN LABEL SINGLE DOSE STUDY, TO STUDY THE EFFECT OF BCL 11A MODIFICATION IN SUBJECTS WITH TRANSFUSION DEPENDENT BETA THALASSEMIA MAJOR. THESE ARE INDIVIDUALS WHO HAVE BETA THALASSEMIA MAJOR BETWEEN 18 AND 40 YEARS OF AGE, THIS POPULATION SELECTED BECAUSE THEY'RE MOST LIKELY TO BENEFIT FROM ANY INCREMENT IN THE BASELINE HEMOGLOBIN AND THE FACT WE DESIGNED THIS SO IS THEY EAR HEALTHY TO TOLERATE A MYELOABLATIVE TRANSPLANT PREP. THIS IS BASED TON PHENOTYPE OF THALASSEMIA MAJOR SO THE INTERMEDIATEIA AND MINOR PHENOTYPES ARE EXCLUDED BUT ANYONE WITH ANY GENOTYPE THAT PROGRESSES THROUGH ADULTHOOD TO MAJOR PHENOTYPE ARE ELIGIBLE TO PARTICIPATE. THE PRIMARY OBJECTIVE IS STUDY THE SAFETY OF AUTOLOGOUS BCL-11A MODIFIED STEM CELLS HEMATOPOIETIC STEM CELLS AFTER MYELOABLATIVE REGIMEN. SECONDARY OBJECTIVES ARE TO ASSESS THE QUALITY AND THE HEMOTO LOGICAL AND IMMUNOLOGICAL RECOVERY AT REGULAR INTERVALS IN THE FIRST YEAR AFTER TREATMENT. TO MEASURE THE LABORATORY MANIFESTATIONS OF THALASSEMIA MAJOR AT REGULAR INTERVALS. TO MEASURE, ASSESS IMPACT OF TRANSFUSION FREAK SANED ALSO FINALLY TO ASSESS IMPACT THERAPY ON IRON BURDEN ONE YEAR AFTER INFUSION. SO THE PRIMARY END POINTS ARE ASSESS BIDS SAFETY THAT IS MEASURING ADVERSE EVENTS AND SERIAL LABORATORY EXAMINATIONS. AFTER INFUSION AND THE SECONDARY END POINTS DETAILED HERE, FOCUS FIRST ON HEMOTO LOGICAL RECONSTITUTION AT THE TIME OF NEUTRAFILL AND PLATELET RECOVERY AND ERYTHROID RECOVERY. IMMUNE RECONSTITUTION MEASURED BY NUMERICALLY BY PERIPHERAL BLOOD B AND T LYMPHOCYTE SUBSET STUDIES AND QUANTITATIVE IMMUNOGLOBAL GLOBULIN AND RESPONSE TO MITE GENERALS FOR QUALITITATIVE ASSESSMENTS, WE'LL LOOK AT HEMOGLOBIN F EXPRESSION, ENGRAFTMENT OF BCL-11A MODIFY STEMED CELLS AND ENRICHMENT IN THE NON-NUCLEAR CELLS IN THE BLOOD. IF IT EXIST, IF IT HAPPEN, RED CELL TRANSFUSION INDEPENDENCE T TIME TO THAT OCCURRING, THE FREAK SANED THE VOLUME. -- STRIKE SAY AND VOLUME. AND THE -- FREQUENCY AND VOLUME, THAT IS WHETHER OR NOT WE'RE ABLE TO REPLACE IRON CHELATION THERAPY WITH PHLEBOTOMY TO TREAT IRON OVERLOADS AND EVENT FREE SURVIVAL AND THALASSEMIA FREE SURVIVAL WILL BE STUDIED IN THE SMALL COHORT, MEASURED IN SMALL COHORT OF TEN PATIENTS. THIS SHOW IT IS CONDITIONING REGIMEN AND THE TREATMENTS SCHEMA, IT BEGINNING WITH AFTER INFORMED CONSENT, MOBILIZATION OF PERIPHERAL BLOOD HEMATOPOIETIC STEM CELLS WHICH INCLUDE MOBILIZATION OF BOTH CELLS MODIFIED AND ALSO BACKUP CELL UNMODIFIED AND CRYOPRESERVED IN THE EVENT ENGRAFTMENT IS NOT PROMPTED AFTER INFUSION OF MODIFIED CELLS. PATIENTS WILL BE CONDITIONED WITH A STANDARD BUY MYOLOW ABLATIVE COURSE -- MYELOABLATIVE COURSE, FEW DAYS AFTER WHICH THE MODIFIED STEM CELLS WILL BE INFUSED AND PATIENTS WILL BE MONITORED THROUGH THE FIRST YEAR AFTER INFUSION. AND THEN A TWO YEAR FOLLOW-UP LONG TERM FOLLOW-UP STUDY WILL BE CONDUCTED. THAT CONCLUDES MY INTRODUCTORY COMMENTS ABOUT THE PROPOSED CLINICAL TRIAL. THE LAST THING THAT WE WANTED TO HIGHLIGHT WERE THAT THERE WERE A NUMBER OF COMMENTS FROM REVIEWERS ABOUT INFORMED CONSENT RELATED TO THE LANGUAGE BEING TECHNICAL, WHICH WILL BE CORRECTED IN SOME TYPOGRAPHICAL AND FACTUALER RAS THAT ARE ALSO BEING CORRECTED. >> THIS CONCLUDES YOUR PRESENTATION? >> YES, THAT'S THE LAST SLIDE, THANK YOU VERY MUCH. >> THANK YOU VERY MUCH FOR A VERY CLEAR PRESENTATION. AND A VERY INTERESTING PROTOCOL. SO AS YOU POINTED OUT, THE VIEWERS HAD SEVERAL QUESTIONS CONCERNING NOT ONLY INFORMED CONSENT PROTOCOL BUT MORE SCIENTIFIC AND CLINICAL AND PRE-CLINICAL QUESTIONS. I WILL START MY REVIEW BY ASKING MY QUESTIONS HEARING YOUR COMMENTS YOU WROTE EXTENSIVELY IN RESPONSE TO MY VIDEO AND DR. TISDALE AND DR. SEGAL AND DR. ZOLOTH WILL CONCLUDE WITH HER QUESTIONS. THE ROLE BC 11A REGULATION OF FETAL HEMOGLOBIN EXPRESSION AND PROVIDES VERY GOOD RATIONALE. YOU ADDED NOT ONLY EXTENSIVE MOUSE DATA, YOU QUITE EXTENSIVE MOUSE DATA INCLUDING THE KNOCK OUT MODEL YOU MENTIONED IN YOUR PROTOCOL BUT ALSO THE NEW DATA ON THE HUMAN -- ON THE INDIVIDUALS THAT HAS BEEN BC-11A DIVISION YOU MENTION. THAT PROVIDES GOOD RATIONALE FOR THIS APPROACH. THAT SAID, ALSO AS YOU POINTED OUT, THERE'S NO CURATIVE PROTOCOL EXCEPT BONE MARROW TRANSPLANT AND POTENTIAL CAVEATS AND YOU PRESENTED THAT AS WELL. SO THAT'S I THINK PROVIDES A GENERAL VERY GOOD RATIONAL BUT ONE POTENTIAL CAVEAT BC 11A DELETION APPROACH IS THAT IT HAS BEEN CLEARLY DEMONSTRATED EXPRESSION POINT OUT EXPRESSION OF THIS GENE IS ESSENTIAL FOR NORMAL B CELL DEVELOPMENT WHICH IS ALSO DISCUSSED IN PROTOCOL. IT'S THE MICE NULL MODIFIED HSPC AND HETEROZYGOUS DELETIONS WERE PERSISTENT TO ADOPT NORMAL LYNN FAR FUNCTION RECONSTITUTION AND PROVIDED THE BACK UP PLAN YOU WILL HAVE, BECAUSE I LOOK FOR THAT SPECIFICALLY THE PROTOCOL, YOU CAN HAVE UNMODIFIED CELLS THAT DO PROVIDE A BACK UP RESCUE FUNCTION. IT STILL REMAINS THAT GENES MODIFIED IMPLICATED IN KNEW LEUKEMIA IN MICE AND IN HUMANS. BC 11A TRANSCRIPTION FACTOR CAPABLE OF EXPRESSING MULTIPLE PROTEIN ISOFORM IT ALSO HAS FUNCTIONS YET ELUCIDATED AND YOU'RE AWARE OF THAT. SINCE THIS IS THE FIRST PROPOSED HUMAN TRIAL INVOLVED IN PATIENT OF BC-11A IN HUMANS USING IN APPROACH YOU HAVE TO BE PREPARED FOR UNEXPECTED COMPLICATIONS, YOU'RE WELL AWARE OF. WHAT'S GOOD ABOUT PROTOCOL, THE FIRST VECTOR REDUCES mRNA TO TRANSIENTLY EXPRESS ZINC FINGER NUCLEASES, THAT IS WHAT PERSONALLY HAVE NO VECTOR CONCERN. SINCE YOU'RE GOING TO HAVE A SHORT DURATION OF EXPRESSION OF TUMOR ZINC FINGER NUCLEIEASE THAT ALSO REDUCES SOME OF MY CONCERNS ABOUT OFF TARGET CONSEQUENCES BECAUSE YOU'RE NOT CONTINUOUS INSULT TO OFF TARGET SITES THAT COULD INCREASE THE RISK FOR TARGET (INAUDIBLE) BUT STILL PERMANENT DELETION OF BC-11A IN MODIFIED CELLS CAN BE ASSOCIATED ONE KNOWN ON TARGET POTENTIAL OF TARGETED EFFECTS YOU'RE WELL AWARE OF AND I THINK ALL REVIEWS POINTED TO THOSE POTENTIAL PROBLEMS THAT THOUGH YOU HAVE VARIOUS EXPERIMENTAL APPROACHES TO ADDRESS ALL THESE THINGS EACH OF THEM COULD HAVE NONE ARE PERFECT, WE DON'T LIVE IN A PERFECT WORLD SO THEY'RE NOT PERFECT AND STILL COULD BE A PROBLEM. SO I HAVE SAY THIS IS POTENTIAL COMPLICATED BY SIGNIFICANT POLYMORPHISMS AND FUNCTIONAL DIFFERENCES IN BC-11A BC-11A LEVELS AND FUNCTION YOU ALSO DISCUSS. OF COURSE YOU'RE PROVIDING EVIDENCE THAT SUGGESTS NO PARTICULAR RISK MAYBE TO HAVING AT LEAST IN THERE SOME VARIOUS CASES BUT NO RISK OF HAVING BC 11A DELETE RECORD REDUCED BUT I'M SURE YOU'RE AWARE OF MODIFIED YOU HAVE IF THIS IN BACKGROUND YOU DON'T KNOW WHETHER THAT DELETION HAS BEEN MOD -- THE SEX OF LTS EFFECT OF DELETION IS MODIFIED BY OTHER GENES THAT HAVE TAKEN ON THE ROLES. SO THAT'S ALL THAT REMAINS ON THOSE. SO I HAVE SEVERAL QUESTIONS CONCERNING THAT. SO FIRST OF ALL, BC-11A PERTURBATION IS ASSOCIATED WITH DEVELOPING LEUKEMIA, IT CAUSES POTENT IT SHALL ONCO GENIC POTENTIAL OF THESE CELLS. AND YOU HAVE ADDRESSED THAT IN YOUR PROTOCOL. IN THE PROTOCOL IT WASN'T CLEAR WHERE YOU STOOD WITH THOSE STUDIES WHEN THEY WERE GOING TO BE DONE SOY THINK SEVERAL OF MY QUESTIONS RELATED TO WHETHER THEY WOULD BE PERFORMED BEFORE YOU STARTED HUMAN TRIALS AND AND I ASSUME THIS IS ALL PRE-IND STUFF AND YOU'LL HAVE MORE DATA BY THE TIME YOU GO TO FINAL IND. SO I HAVE THE QUESTIONS HAVE ANY EXPERIMENTS PERFORMED YET. AND SHOW THEY ARE IN PROGRESS. AND YOU GET -- DON'T YET HAVE DEFINITE RESULTS ON THEM. THE OTHER THING I MUST ASK BUT NOT CLEAR FROM PROTOCOL MODIFIED CELLS FROM THE ACTUAL PATIENTS ASSESSED IN ANY WAY FOR BEFORE TRANSFUSION. WHICH ASSAYS WILL BE USED, YOU COMMENTED ON THAT, THAT THAT IS NOT POSSIBLE BECAUSE IF YOU WOULD HAVE TO DO THAT YOU USE UP YOUR -- THIS REQUIRES HEALTHY VOLUNTEERS, THE WAY YOU SET UP THE PROTOCOLS. I APPRECIATE THAT. ALSO YOU STATE YOU WILL BE -- YOU STATE THAT YOU HAVE SAFETY AND BIODISTRIBUTION DATA EXVIVO MODIFIED AUTOLOGOUS CELLS BEFORE USING THE INTEGRATING LENTIVIRUS THAT YOU USE IN THE AIDS RELATED FORMER STUDIES. HOWEVER, IN THIS CASE YOU WILL NOT BE -- YOU CANNOT REFER TO THIS AS EVIDENCE FOR THINGS YOU USE IN THE STUDY, THIS IS A VERY DIFFERENT PROTOCOL, YOU APPRECIATE THAT. SO THERE WAS A QUESTION ABOUT THE PHRASING AND SO ON T. THEN THE ON TARGET EFFECTS. SO YOU ADDRESSED ALMOST YOU LOOK AT THE CANCER AND I HAVE SPECIFIC QUESTIONS THAT CONCERN DELETION OF BC 11A RECENTLY SHOWN TO INCREASE P-53 LEVELS AND APOPTOSIS IN LYMPHOID CELLS AND I APPRECIATE THAT WOULD REQUIRE OVEREXPRESSION OF BC-11A AND WITH THE APPROACH YOU ASSUME THAT YOU'RE GOING TO DELETE ALL OF THEM. SINCE WORKING ON GENE SPLICING I CAUTION YOU YOU NEVER KNOW WHEN YOU TARGET EXOME THAT COULD BE SLICING DIFFERENCES AND THERE COULD BE SKIPPING OF THAT EXOME THAT MIGHT GENERATE PRODUCTS WITH BC-11A, MAKING A SMALL DELETION THAT YOU DON'T NECESSARILY KNOW WHAT EXACTLY WHAT'S GOING TO HAPPEN. SO I GUESS ONE QUESTION, OUTSTANDING QUESTIONS I HAVE IS IF YOU THOUGHT ABOUT LOOKING AT ACTUALLY WHAT HAPPENS TO mRNA EXPRESSION FROM BC-11A IN EITHER IN THE HEALTHY VOLUNTEERS OR IN SOME OF THE PATIENTS. >> WE HAVE. VERY REPRODUCIBLY, WE FAILED TO SEE ANY DOWN REGULATION OF BCL-11A FOLLOWING TREATMENT WITH ZINC FINGER NUCLEASES. WE SPOKE TO PEOPLE WHO WORK ON MEDIA AND THE CONSENSUS FROM THEM IS ANYWHERE BETWEEN HALF AND THREE QUARTERS OF THE mRNA IS PRODUCED BY THE HUMOR GENOME RESISTS BEING DEGRADE BY THAT PATHWAY SO SIMPLEST INTERPRETATION OF FINDINGS IS THAT BC-11A LOCUST ENCODES MESSENGER RNA WHICH IS RESISTANT TO NON-SENSE MEDIATED >> SO THAT IS INTERESTING, ALSO WORK ON NMD AND I KNOW THAT, I THINK IT'S DOG MA HAS BEEN ANY PREMATURE REGENERATIVE DNA I DON'T THINK THAT'S NO LONGER THE CONSENSUS, MANY MY VIEW SO THAT'S INTERESTING. BUT YOU HAVEN'T LOOKED -- SO YOU HAVE THE RNA STILL THERE SO THAT MEANS THEORETICALLY GENERATE PROTEIN. SO HAVE YOU LOOKED TO SEE ANY SPLICE PATTERN THAT POTENTIALLY GENERATE PROTEIN OR HAVE YOU LOOK FORD THE PROTEIN? >> WE HAVE NOT. >> THAT MAYBE SOMETHING TO CONSIDER DOING SINCE YOU KNOW YOU STILL HAVE THE RNA, THERE'S POTENTIAL FOR PROTEIN EXPRESSION ONCE YOU HAVE THE RNA. Q. UNDERSTAND. >> CAN YOU QUICKLY COMMENT ON THE -- WHETHER YOU HAVE ANY EFFECTS OF P-53, INCREASED APOPTOSIS IN THE MODIFIED CELLS SINCE THERE'S EVIDENCE IN THE LITERATURE YOU WERE TO GET -- THAT WOULD PROBABLY REQUIRE EXPRESSION OF BC-11A, NOT DELETION BUT NOTHING IS EXPRESSED YOU WOULDN'T CONSIDER THAT. >> YOU'RE RIGHT. THERE IS A PAPER DEMONSTRATING (INAUDIBLE) QUITE REPRODUCIBLY IN ERYTHROID CULTURES WHICH THE CELLS AS MANY OF YOU KNOW EXTEND BY SEVERAL LOGS, WE FAIL TO SEE ANY STATISTICALLY SIGNIFICANT DIFFERENCE AT THE GROWTH RATE BETWEEN CONTROL CELLS AND CELLS VERY SIGNIFICANT PERCENTAGE OF BC-11A KNOCK OUT SUGGESTING THAT AT LEAST IN THIS SETTLING THERE'S NOT A PRONOUNCED ACTIVATION OF P-53. AND AS I ALSO MENTIONED WE OBSERVED MARKED CELLS IN THE PERIPHERY OF IMMUNODEFICIENT MICE TO THE LONG eTIME POINT STUDY WHICH IS 28 WEEKS. THE SHORT ANSWER TO YOUR QUESTION IS WE HAVE NO DIRECT. >> IS THAT SOMETHING YOU COULD LOOK AT? >> WE CAN TAKE THAT UNDER ADVISEMENT. >> OKAY. >> SAY SINCE THIS IS FIRST IN MAN PROTOCOL, WITH TOTALLY NEW STRATEGY, YOU ARE SAYING THAT YOU WILL NOT DOSE A SUBJECT IN THE Q-1 UNTIL THE PREVIOUS GRAFTED DETERMINED BY RECONSTITUTION AND IF THE FIRST THREE SUBJECTS ENGRAFT THEN THE SUBJECT -- SUBSEQUENT SEVEN SUBJECTS IN THE STUDY WILL BE TREATED WITHOUT WAITING SO HOW WOULD YOU -- I HAD A QUESTION ABOUT HOW YOU WILL DESIGN HEMATOPOIETIC RECONSTITUTION. TESTIMONY EVIDENCE REDUCING WILL BE REQUIRED BEFORE THE NEXT SUBJECT INTEREST CAN BE TRANSDUCED. YOU ANSWERED THAT. >> WE'RE USING A STANDARD DEFINITION WHICH IS NOT HAVING AN ANC GREATER THAN 500, BY 42 DAY AFTER INFUSION. AT WHICH TIME WE SOLVE UNMODIFIED CELLS AND REINFUSE THEM. THAT SUBJECT WOULD BE SCORED AS SOMEONE WITH DELAYED OR INADEQUATE ENGRAFTMENT. THE FIRST -- >> FIRST THREE PATIENTS -- >> UNTIL WE -- ENGRAFTMENT BEFORE WE PROCEED. >> OKAY. THEN I HAD JUST SOME MINOR, YOU HAD APPENDIX M WHERE YOU SAID KNOCK OUT OF BC 11A ELIMINATES SYSTEMSES WITH ELEVATING FETALGLOBIN LEVELS, OBSERVABLE EFFECT HEMATOPOIESIS. I WANT TO POINT OUT IN THE PROTOCOL THAT THAT'S ONLY THROUGH IN THE MOUSE STUDIES ONLY THROUGH FOR THAT WAS EPO SPECIFIC RETRO SPECIFIC DELETION. I THINK AT THIS TIME'S IMPORTANT THAT YOU CLARIFY THAT. YOU DID THAT, I THINK. AND ALSO ANOTHER THING WHERE YOU WANT TO CLARIFICATION OF BC-11A, YOU HAVE DONE THAT. THEN I HAVE SEVERAL -- AS SOME OTHERS HAVE, SEVERAL COMMENTS ON INFORMED CONSENT DOCUMENT THAT THE -- IT APPEARS OVER LONG REDUNDANT AND VERY COMPLICATED. CAN YOU COMMENT ON THAT, ARE YOU GOING CHANGE THAT? AND THAT WAS QUESTION ABOUT THE GAIN THAT YOU TALKED ABOUT POSSIBLE SIDE EFFECTS, THE MOST COMMON SIDE EFFECTS SO FAR, WITHIN USE THE SAME AGENT. IT WAS A DIFFERENT ZINC FINGER AND I WANT TO POINT OUT THIS WAS FIRST MAN SO I ASSUME YOU CHANGE THAT. AND THEN THERE WAS JUST SOME THING IN INFORMED DON'T BECAUSE OF UNKNOWN AFFECTS OF THIS AGENT THERE COULD BE SERIOUS HARM TO BREAST FEEDING AND I THOUGHT THAT WAS BIT CONFUSING SINCE I WAS ASSUMING YOU REFER TO THE MYELOABLATIVE PROTOCOL WHICH IS THERE ARE KNOWN RISKS INVOLVED WITH THAT. AND YOU SHOULD SEPARATE UNKNOWN RISKS DUE TO THE SPECIFICITY OF THE PROTOCOL WITH TESTIFY (INAUDIBLE) PATIENTS KNOWN RISKS WITH MYELOABLATION, ET CETERA, I THINK YOU DID THAT. WITH THAT WE CAN GO TO DR. TISDALE. >> THANK YOU FOR YOUR COMMENTS. VERY MUCH APPRECIATED. >> AMAZING WE HAD SIMILAR COMMENTS YOU ARE AWARE OF BY NOW, YOU HAVE SEEN THE COMMENTS. I WONDER TO WHAT EXTENT I NEED TO REPEAT THOSE COMMENTS THAT I HAVE MADE IN WRITHING. >> I THINK YOU CAN SUMMARIZE >> FOR ME THERE WERE TWO MAJOR THINGS, THIS IS VERY WELL PUT TOGETHER, AND VERY WELL ARTICULATED HERE TODAY. BUT A CONCERN I HAD WAS THE UNKNOWN OFF TARGET EFFECTS, THAT'S EVERYONE'S CONCERN. I THINK EVERYONE'S FIRST COMMENT REGARDING THE PROTOCOL. YOU ADDRESSED THAT MORE SUBSTANTIALLY SINCE THEN AND WE'LL CONTINUE BEFORE IND SUBMISSION I SUSPECT. ONE THING NOT ADDRESSED IS WHETHER YOU HAVE A POSITIVE CONTROL, SO FOR EXAMPLE, COULD YOU IN YOUR MOUSE STUDIES DEMONSTRATE THAT TUMORIGENICITY WOULD BE READ OUT IN THIS MOUSE MODEL BY DISRUPTING FOR EXAMPLE, TUMOR SUPPRESS OR GENE LIKE P-106789 SO IF YOU DISRUPT A TUMOR SUPPRESSOR GENE AND YOU GET TUMOR YOU KNOW YOUR RACY IS WORKING TO FIGURE OUT WHETHER YOU GET A TUMOR AND THEN KNOW WHETHER THE OFF TAG AFFECTS COULD BE READ NOT THIS MODEL. >> SO WE HAVEN'T PUT FORWARD A POSITIVE CONTROL FOR THE TUMORIGENITICITY STUDY. HOWEVER T DURATION OF STUDY IS BASED ON TRANSPLANTS INTO THAT MOUSE MODEL, GIVING EVIDENCE OF TUMORS IN OTHER STUDIES. A REASON WE LEFT THE SYSTEM THAT LONG, WAS TO ALLOW THESE CELLS TO PRESENT THEMSELVES AND THAT WAS ONE OF SEVERAL PAPERS WE FIND IN WHICH OTHER VERSUS STUDIED CELLS THAT GAVE RISE TO VERY SOLID TUMORS IN THAT TIME FRAME. SO STUDY DURATION PARTLY ADDRESSES THAT CONCERN. >> THOSE WERE TESTING THAT MECHANISM OF DISRUPTION OF GENES, CORRECT IN >> THAT'S CORRECT. >> THERE ARE A NUMBER OF MINOR COMMENTS ALONG THESE LINES. THAT HAVE ALREADY BEEN ADDRESSED IN THE PRESENTATION. MOST CONCERN, THANK YOU FOR SHOWING THE PROTEIN LEVELS, IT'S REALLY -- THEY ARE REALLY GOOD DATA. I DON'T KNOW WHY THEY WEREN'T HERE TO BEGIN W. IT'S MUCH MORE COMPELLING TO SEE FULL CHANGE OF THIS OR THAT. WHICH WE SEE SO OFTEN IN FETAL HEMOGLOBIN INDUNK BECAUSE THERE ARE NO PROTEIN DATA. THANKS FOR SHARING THAT. THE OTHER MAJOR COMMENT I HAD THAT I HOPE YOU CONSIDER THE CONSENT WAS VERY ACCURATE BUT I THOUGHT TOO MUCH FOR AN INDIVIDUAL TO UNDERSTAND WHAT IS ACTUALLY EXPERIMENTAL HERE. WE GET BOGGED DOWN ON DETAILS OF MOBILIZATION AND CONDITIONING WITH BUSULFAN AND SIDE EFFECTS FOR POTENTIAL FOR INFECTION, BUT NOSE ARE ALL THE ROUTINE THINGS THAT ONE WOULD GET WHEN THEY UNDERGO ANY AUTOLOGOUS TRANSPLANTATION. SO IF THOSE COULD BE PRESENTED AS A WAY THAT AUTOLOGOUS TRANSPLANTS ARE DONE MANY DECADES WE KNOW THESE SIDE EFFECT, THEY ARE THE FOLLOWING. WHAT'S EXPERIMENTAL HERE IS THAT WE'RE DISRUPTING BCL-11A AMONG THOSE HEMATOPOIETIC STEM CELLS AND WHAT ARE THE RISKS INHERENT TO THAT, WHAT MIGHT BE DIFFERENT IN THE SETTING OF THIS TYPE OF INTERVENTION SO THAT THE SUBJECT KNOWS MORE OR LESS WHAT'S THE EMPERIMENTAL PART. AND WHAT'S THE MORE ROUTINE PART. >> THAT'S A GREAT SUGGESTION, WE WILL REORGANIZE THE CONSENT SO THAT IT READS THAT WAY. >> SEE IF THERE WAS ANYTHING ELSE. I THINK THOSE ARE MY MAJOR COMMENTS. THANK YOU VERY MUCH. >> THANK YOU. THANK YOU, DR. TISDALE. DR. SEGAL. CAN YOU -- HEAR YOUR COMMENTS AND QUESTIONS? (OFF MIC) (OFF MIC) (OFF MIC) >> WE INTERNALLY EVALUATE THAT BUT WE HAVE TO FILE THE IND WITH THE FDA AND THAT'S THOROUGHLY REVIEWED OVER A 30 DAY PERIOD, IF THERE ARE ANY QUESTIONS THE FDA WILL CONTACT US. SO WE WILL HAVE A STANDARD 38 DAY REVIEW, WE HAVE FDA TEAM ASSEMBLED FOR THIS. WITH DEFINITELY INCLUDES THE TOXICOLOGY PRE-CLINICAL SAFETY GROUP AND WE HAVE HAD SEVERAL DISCUSSION, TWO DISCUSSIONS WITH PRE-IND SO FAR. SO IT'S A JOINT EFFORT BETWEEN THE SPONSOR, THE CLINICAL SITE AND THE FDA HAS FINAL SAY ON REVIEW OF THE PACKAGE. >> OKAY. THANKS. >> DO YOU HAVE ANY OTHER QUESTIONS? >> I THINK I HAD A LOT THAT I HAD COVERED (INAUDIBLE) AND I THINK FOR THE SAKE (INAUDIBLE) >> OKAY. THANK YOU. >> THANK YOU VERY MUCH. >> THANK YOU FOR AN INTERESTING PRESENTATION AND YOUR RESPONSES. I AM INTRIGUED BY THE SCIENCE, I THOUGHT IT WAS FASCINATING INTERESTING IDEA. BUT I HAVE A COUPLE OF QUESTIONS, MOST OF MINE HAVE TO DO WITH CONSENT PROCESS AND WHAT IT FEELS LIKE FOR THE PATIENT SINCE (INAUDIBLE) IS NOT SCIENCE. ONE THING THAT STRUCK ME WHEN YOU GAVE YOUR PRESENTATION IS YOU MENTIONED UMBILICAL CORD TRANSPLANTATION. YOU DIDN'T MENTION WHY THAT WORKED OR WHAT'S WRONG WITH THAT STRATEGY. IN THE PRESENTATION YOU GAVE US THERE WAS ONLY TWO PATHS, ONE WOULD BE INFINITELY GETTING BLOOD TRANSFUSION AND CHELATION. OR FINDING -- HAVING BONE MARROW TRANSPLANT WITH ATTENDANT RISK. WHAT HAPPENED WITH THE UMBILICAL CORD BLOOD? THAT WASN'T PRESENT AS AN IDEA BUT YOU MENTIONED IN YOUR PRESENTATION. >> >> I DID LEAVE OUT DETAILS SORRY ABOUT THAT. UMBILICAL CORD COLLECTION CONTAINS ORDER OF MAGNITUDE FEWER CELLS THAN TYPICAL MARROW HARVEST. MOST OF THESE UMBILICAL CORD BLOOD UNITS WERE MISMATCHED TO THE RECIPIENT. BECAUSE OF THE DISPARITY AND SMALL NUMBER OF STEM CELLS N THERE BECOMES HIGH PROBABILITY OF REJECTING THE GRASS IN THAT PARTICULAR SERIES OF PATIENTS. THAT WAS THE PRINCIPLE FAILURE. >> OKAY. THE WAY I DO THIS IS LOOK AT PATIENT ADVOCACY SITES FOR DISEASE IN QUESTION AND ONE WAY TO ALSO THINGS ABOUT WHAT PATIENTS ARE THINKING ABOUT THIS DISEASE. INCLUDING THE FACT THIS IDEA WHILE INNOVATIVE, FOR PATIENTS SEE THIS ONE AND THE VIRAL VECTOR ONE, IS IDENTICAL, SEEMS THAT NEEDS TO BE THOUGHT THROUGH FOR THEM. SO THERE'S CLAIMS ABOUT ENORMOUSLY DIFFERENT INNOVATIVE IDEAS USING CORE AND NOT VIRUS BUFF TO THINK ABOUT FOR THEM THEY DON'T UNDERSTAND THAT. SO THEY'RE NOT UNDERSTANDING THE DIFFERENCES, IMPORTANT TO CLARIFY THAT IN YOUR FIRST PARAGRAPH. >> EXPLAINING THE SCIENCE IS CHALLENGING. >> RIGHT BUT NECESSARY. WHEN YOU SAY CORRECTED, I WANT A 6TH GRADE TORE READ IT NOT JUST FAN IS A TASSIE BUT A -- FANTASY 6TH GRADER BE AN ACTUAL 6TH GRADER. SO ONE THING I WERE DID LIKE MUCH OF THE CONSENT FORM I THOUGHT IT BEGAN WELL, I WAS SO EXCITED TO BE READING THE FIRST PARAGRAPH BECAUSE TESTIFY A PHASE 1 TRIAL THAT WOULDN'T AFFECT THEIR DISEASE BUT SLIP FROM THAT AND GO TRUE EACH AND EVERY TIME YOU SLIP AWAY FROM CLINICAL EQUIPOISE AND TELL THEM THAT THE CHANCES ARE COMPLETELY UNAS ARE SIDE EFFECTS. I AGREE WITH THE OTHER REVIEWERS THAT SAID WE KNOW THAT THERE'S SIDE EFFECTS GIVEN SOME OF THESE INTERVENTION BUS FOR THIS THING, WE HAVE NO IDEA. AND THAT HAS TO BE MADE COMPLETELY CLEAR, ESPECIALLY BECAUSE THIS PATIENT COHORT ARE NOT SICK OR DYING, THERE'S OTHER ALTERNATIVE, HA THEY MUST THINK OF THEMSELVES AS HEALTHY, NOT THAT -- ADULTHOOD CHELATION IS WORKING SO THEY'RE NOT UP FOR ENORMOUS RISK AND THEY NEED TO KNOW HOW UNKNOWN AND IT HAS TO BE EXTREMELY CLEAR. PRIVACY IS GOOD. MOST DON'T UNDERSTAND THE LIMITS OF THE PRIVACY BUT YOU DID AND THAT WAS GOOD. JUST ONE SENSITIVITY, PEOPLE 6TH GRADERS THOEF THEMSELVES AS HUMAN EMBRYONIC STEM CELLS, THEY DON'T UNDERSTAND THESE ARE THE OTHER STEM CELL S THAT NEEDS TO BE CLARIFIED AND MADE IMPORTANT FOR PEOPLE WHO MIGHT HAVE REASONS TO NOT USE ESLs AS WORKING BUT SO THAT HAS TO BE CLARIFIED. IN COMMON THAT'S EXACTLY THE SAME. PET RECEIVE EVERY CONSENT FORM SOW YOU CAN'T LEAVE THE STUDY ONCE YOU HAVE HAD THE INTERVENTION YOU CAN LEAVE BEING MONITORED BUT NOT REALLY -- YOU CAN'T UNDUE DO HAVING HAD THE INJECTION. AND THAT HAS TO BE REALLY CLEAR THAT'S A DIFFICULT THING TO EXPLAIN, THE FORMS ARE WRITTEN FOR ONE TIME DRUG TRIAL, NOT WRITTEN FOR GENETICS, GENE THERAPY. JUST ATTENTION ABOUT THAT. AND TENNESSEE FINALLY THE SECTION ON WHEN -- WHAT HAPPENS WHEN YOU ARE INJURED OR SICK IS VAGUE, PROBABLY DELIBERATELY SO BUT HAS TO BE CLARIFIED. WHAT ARE THE MEANS TO SAY THIS MEDICAL CARE WILL BE AVAILABLE? IN AMERICAN ENGLISH THAT MEANS WE'LL PAY FOR IT. IT WILL BE AVAILABLE TO YOU. AND IF IT'S NOT -- IF YOU'RE NOT GOING TO PAY FOR IT, UP FRONT AND CLEARLY, SECONDLY, THE INTEREST OF THE CARE IS DETERMINED BY STUDY DOCTOR WHICH IS OBVIOUS CONFLICT OF INTEREST. NOT SURE HOW YOU HAVE INDEPENDENT PATIENT ADVOCATE, THAT'S NOT ON THE PAYROLL OF THE COMPANY LIKE A STUDY WOULD BE. SO YOU HAVE TO CLARIFY THAT. WHO WILL VALUATE, WILL IT BE YOUR OWN PHYSICIAN? HOW -- BECAUSE IT'S -- WE HAVE NO IDEA WHAT WILL HAPPEN TO YOU THE COMPETITIONS ARE REALLY UNKNOWN, SIDE EFFECTS ARE COMPLETELY UNKNOWN, PERHAPS SAYING THE PATIENT DOCTOR SHOULD MAKE THAT ASSESSMENT RATHER THAN A COMPANY DOCTOR WOULD BE IMPORTANT. >> I THINK THOSE ARE ALL VALUABLE COMMENTS AND WE APPRECIATE THEM, IN ADDITION, IF YOU HAVE -- IF YOU HAVE LANGUAGE OR EXPERIENCE THOUSAND TACKLE THESE CURRENT ISSUE LIKES GENETIC MODIFICATION AND CAN'T LEAVE THE STUDY, THAT WOULD BE -- IF ANYONE CAN PROVIDE THAT LANGUAGE OR ADVICE THAT'S GREAT. >> WE CAN DO THAT. JUST WHAT YOU SAY TO THE 6TH GRADER IS ONCE WE PUT THESE GENES IN YOU, THEY WILL BE IN YOUR BODY FOREVER YOU, DON'T KNOW WHERE THEY'RE GOING TO GO, HOPE TO DO THIS BUT YOU CAN'T UNDO THAT INJECTION. YOU CAN'T LEAVE THE TRIAL, CAN'T STOP TAKING IT. WHATEVER HAPPENS YOU COMMITTED TO THIS. >> ARE THERE ANY OTHER QUESTIONS FROM ANY OTHER RAC REVIEWS? >> DR. SADELAIN. >> I HAVE A FEW QUESTIONS. THANK YOU FOR A VERY CLEAR PRESENTATION. AND I'M VERY EXCITED TO SEE THIS TECHNOLOGY COMING TO THE FLOOR. THE COMMITTEE IS PRIMARILY CONCERNED WITH SAFETY BUT ALSO RISK BENEFIT ISSUES. IN THIS STUDY YOU'RE GOING TO SELECT PATIENTS WHICH AS WE HAVE HEARD THEY HAVE A SEVERE CONDITION, PERHAPS NOT A NORMAL LIFE EXPECTANCY. ARE NONETHELESS DOING RELATIVELY WELL. YOU'RE GOING TO PERFORM BONE MARROW TRANSPLANT, AUTOLOGOUS TRANSPLANT WITH MYELOABLATIVE CONDITIONING. PART OF THAT RISK BENEFIT ANALYSIS ADDRESSES THE EFFICACY. SO WE HAVE HEARD ABOUT THE QUESTIONS RAISED BY DISRUPTING THE GENE AND TRANSCRIPT FOR BCL 11A, WE HEARD ALSO ABOUT THE CONCERNS ABOUT OFF TARGET AFFECTS. BUT I WOULD LIKE TO GET SOME CLARIFICATION ON EFFICACY OF THE PROCESS. THE LAST THING YOU WANT TO DO. IS TO GIVE AMOUNT OF CELLS IN WHICH TOO FEW STEM CELLS ARE DISRUPTED AT BOTH ALLELES WHICH CASE THERE WOULD BE NO CHANCE FOR SUCCESS. NUMBERS ARE KEEN ON THIS, IT'S REALLY A NUMBER HUNCHING OPERATION. THERE ARE THREE NUMBERS TO YOU TO CLARIFY IF YOU CAN. THE FIRST IS THE EXPECTED RISE IN THE EXPRESSION OF FETALGLOBIN. I DIDN'T SEE THE PROTEIN DATA BUT I WOULD SAY LIKE TO CLARIFY WHAT'S THE AMOUNT THAT YOU THINK YOU CAN INDUCE IN A POPULATION THAT'S PROPERLY DISRUPTED AT BOTH ALLELES. AND THAT AMOUNT I THINK WOULD BEAR ON THE TYPE OF PATIENTS YOU SELECT. CAN YOU -- YOUR CRITERIA WAS EIGHT TRANSFUSIONS PER YEAR. BUT DO YOU THINK THIS COULD BE SUFFICIENT, COULD WORK IN SOMEONE WITH BETA ZERO THALASSEMIA OR SHOULD YOU TACKLE SUBSET OF PATIENTS WITH MUTATIONS WHERE THEY ARE BETA PLUS THALASSEMIA IN WHICH ANTICIPATED GAIN -- AN AT ANTICIPATED GAIN ONE THERAPEUTIC. THAT'S ONE QUESTION. THE SECOND QUESTION, NUMBERS CRUNCHING OPERATION, YOU SHOWED HIGH LEVEL DISRUPTION OF GENE, 51 TO 76%, NOT CLEAR KNOW MOW HAO THAT TRANSLATES IN KNOCK OUT AND FURTHERMORE HOW MANY KNOCK-OUTS ARE DISRUPTIONS TRULY FUNCTIONAL KNOCK OUTS BECAUSE SOME OF THEM, IF I UNDERSTOOD CAN HAVE IN FRAME OPEN READING FRAME AND NOT DISRUPT SO FUNCTION A.M. LATE THE END OF THE DAY HOW MANY ARE TRULY DISRUPTED AT BOTH COPIES. THE THIRD PART OF THE THE NUMBERS GAME IS WHAT IS THE FRACTION OF HEMATOPOIETIC STEM CELLS OR AT LEAST PHASE 4 POSITIVE CELLS WITH LONG TERM RECONSTITUTION POTENTIAL IN WHICH YOU THINK YOU CAN ACHIEVE DOUBLE COPY DISRUPTION BECAUSE ULTIMATELY THAT'S WHAT MATTERS AND I DON'T KNOW IF THAT NUMBER IS REFLECTED IN THE NUMBERS YOU GET WHICH IS ALL CD34 POSITIVE CELLS, SOME ARE CYCLING, SOME NOT, THE PROBABILITY OF TARGETING SOME MORE SO THAN OTHERS EXIST. SO THESE ARE MY THREE NUMBERS QUESTIONS. >> FIRST, THANK YOU, THESE ARE -- WE APPRECIATE THIS LINE OF QUESTIONING BECAUSE THESE ISSUES ARE ALSO GREAT INTEREST ADVANCING THIS APPROACH TO CLINIC. WITH YOUR PERMISSIONLY BRIEFLY WALK THROUGH THE DATA I SHOWED BRIEFLY. ADDRESS YOUR QUESTIONS ABOUT BIALLELIC MARKING, FUNCTIONAL EFFECTS AND MODIFICATIONS TO THE EXTENT WE HAVE THOSE DATA. I MENTIONED THE TWO CHILDREN DESCRIBED BY DR. CXFC (INAUDIBLE) CHILDREN'S BOSTON HARVARD MEDICAL SCHOOL HAVE LOST ONE ALLELE GBC-11A AND HAVE BETWEEN 16 AND 24% FETAL HEMOGLOBIN. SO TO BE CLEAR, MY UNDERSTANDING, I'M NOT A PHYSICIAN, MY UNDERSTANDING IS A YOUNG WOMAN HAS 14 TO 15 TESSIE LIVE TEAR OF HEMOGLOBIN SO 25% FETAL FROM THAT IS A SUBSTANTIAL NUMBER. THREE AND 5-GRAMS IS QUITE A BIT. IN OUR HANDS, WE CONSISTENTLY SEE BETWEEN A THIRD TO 43% OF ALL HEMOGLOBIN, THIS IS IN VITRO. DERIVED FROM FETALGLOBIN USING TWO HVLC APPROACHES. AS DR. SADELAIN SPEAKING WITH GREATER AUTHORITY THAN I BECAUSE HE'S WORKING ON THIS IS DISEASES LONGER THAN I, THESE THE RAC SHOULD KNOW BASELINE LEVEL IN THESE IN VITRO SYSTEMS IS HIGH THAN FORMAL. -- NORMAL. MOST HAVE .5 OR 1%, IN THESERRATELY POI TICK SYSTEMS YOU GET -- THESE, ERYTHROPOIETIC, YOU GET SLIGHTLY HIGHER BUT THE REPRODUCIBILITY WHICH WE GET WELL OVER A THIRD OF ALL HEMOGLOBIN IS ACTUALLY QUITE STRIKING. THIS IS ALL WE CAN OFFER. THIS IS -- THE ONLY THINGS WE HAVE TO DIRECTLY ADDRESS YOUR QUESTION IS WHAT WE SEE BEFORE YOU. AND FINDINGS, HETEROZYGOUS PCL HAVE 25% FETAL. >> MAY I ADD (INAUDIBLE) I MISSED THAT BEFORE. WERE THESE ERYTHROID CELLS GROWN WITHOUT DISRUPTION BCL -- >> ELECTROPORATED WITH GFP ENCODED mRNA. Q. THE BACKGROUND OF FETAL YOU SEE IN YOUR ASSAY. >> RIGHT. TO AMPLIFY, REALLY WHAT YOU NEED IS PROBABLY A SMALL POPULATION OF ERYTHROID PROGENERALS FOR PROPEBBLY GLOBALIZED, MADE OF BETA LIKEGLOBIN. AND AS YOU KNOW, THOSE ARE ENRICHED AND CONFER BENEFIT BEYOND WHAT YOU WOULD SEE AS NORMAL HEMOGLOBIN GENES SO THAT WOULD BE THIS ENRICHMENT FOR THE CORRECTED CELLS. ARE THERE CERTAIN MUTATIONS? THE ENROLLMENT CRITERIA WAS BASED ON TRANSFUSION. >> WE TALKED A LOT ABOUT THAT, AND I AGREE WITH YOU, I THINK THE POINT YOU MAKE IS THAT THE THALASSEMIA INTERMEDIATEIA OR THOSE WHO HAVE HIGHER HEMOGLOBIN MAKE BETTER ENROLLEEY IS THAT YOU DON'T NEED AS GREAT INCREMENT IN THE HEMOGLOBIN BENEFIT TO HAVE CLINICAL EFFECT BUT BIOLOGICAL COUNTRY WE COULDN'T THINK OF A DIFFERENCE BETWEEN THOSE PATIENTS AND THOSE WITH BETA THALASSEMIA, IN ANY INCREMENT IN HEMOGLOBIN IS BENEFICIAL BOTH. THAT'S HOW WE LOOKED AT IT UNDERSTANDING THAT THE CLINICAL FACT MAY LOOK DIFFERENT IN THE (INAUDIBLE). >> SO THAT SECOND SET OF QUESTIONS CONCERNS THE PERCENTAGE OF FUNCTIONAL KNOCK OUT AND THE FRACTION OF CELLS, ONE VERSUS TWO ALLELES EDITED. WE LOOKED CAREFULLY AND I -- THOSE DATA WERE IN THE FIRST VERSION OF PRESENTATION. WHICH GAVE INTERNALLY THAT PRESENTATION TOOK ABOUT 50 MINUTES AND I WAS ASKED TO TRIM THE NUMBER OF SLIDES OF DATA. IN BRIEF OF ALL ALLELES ZINC FINGERS GENERATE IN CD4 CELLS, 80% ARE SMALL INSERTIONS AN DELETIONS THAT DISRUPT THE READING FRAME. 20% ARE IN FRAME. IN FACT WE BELIEVE, IN THE INTEREST OF TIME ISLE SPARE THE RATIONALE WE BELIEVE LOSS OR GAIN OF FEW AMINO ACIDS IN THAT SPECIFIC POSITION IS COMPATIBLE WITH FUNCTION. SO 80% ALLELES IN THE PRODUCT ARE ACTUAL FUNCTIONAL KNOCK OUTS. THE ONE WAY WE SAW HOW ALLELES DISTRIBUTE BETWEEN INDIVIDUAL CELLS SO DO TO DO TRADITIONAL CELL ASSAYS FOLLOWED BY DIRECT GENOTYPING. AND IN THESE EXPERIMENTS THREE QUARTERS OF THE COLONIES BEAR MARKING ON BOTH ALLELES OF BCL. ABOUT 20% COLONIES ARE HETEROZYGOUS AN REMAINING ARE WILD TYPE. BUT I WANT TO EMPHASIZE THIS EXPERIMENT -- THESE EXPERIMENTS WERE DONE I MENTIONED TO YOU THAT WE HAVE A RANGE OF MODIFICATION IN OUR PRODUCT BETWEEN 60 AND 75%. THE EXPERIMENTS WERE DONE WITH CELL SAM LES WERE HIGHER END OF THAT MARKED SPECTRUM. WITH RESPECT TO EDITING -- GO AHEAD. >> THE FINAL QUESTION WAS ASSOCIATED WITH THE LONG TERM HEMATOPOIETIC STEM CELL, WE HAVE PERFORMED EXPERIMENTS LOOKING AT mRNA BASED DELIVERY OF ZINC FINGER KNEW CLAYEASE TO PRE-SORTED POPULATIONS OF STEM CELLS T AND DON'T SEE SIGNIFICANT DIFFERENCE IN THE LEVEL OF CLEAVAGE, LOOK AT THAT POPULATION OF CELLS VERSUS THE FULL POPULATION. AS YOU I'M SURE SAW, WE RECENTLY PUBLISHED ON HUMAN HEMATOPOIETIC STEM CELLS, WE SEE DIFFERENCES IN MORE ELABORATE MODIFICATIONS WHICH WE INTRODUCE INFORMATION TO THE GENOME BUT IN FACT CLEAVAGE ACTIVITY THIS TYPE OF APPROACH GENE KNOCK OUT IN LONG TERM STEM CELLS WAS ROBUST, IN THE GENERAL POPULATION AND MORE SELECTIVE LONG TERM HEMATOPOIETIC STEM CELL SO WE DON'T BELIEVE THAT THAT SUBSET IS MARKEDLY LESS MODIFIED THAN THE GENERAL POPULATION USING FLEW COLLIEEASE ALONE, JUST ASKING FOR NON-HOMOLOGOUS ENJOIN TO HAPPEN. >> THANK YOU VERY MUCH FOR CLARIFICATION ON NUMBERS. JUST TWO SHORT QUESTIONS ON THE STRATEGY. YOU DEEMED YOU NEED A MYELOABLATIVE CONDITIONING NOT REDUCE AGAIN INTENSITY CONDITION, CAN YOU COMMENT WHY YOU THINK THAT'S NECESSARY? AND THE SECOND ONE IS MORE JUST A QUESTION FOR SCIENTIFIC INTEREST THAT YOU CAN KNOCK OUT BCL-11A AND YOU DISCUSS RISK FOR B CELLS, CONSEQUENCES EXON SKIPPING OR CREATING OTHER MOLECULES AS WE HAVE HEARD BEFORE AND UNKNOWN ABOUT THE RNA PROCESSING OF WHAT'S LEFT BEHIND. ALTERNATIVELY ONE DISRUPT IT IS BINDING SITE BCL-11A. WII AT THEGLOBIN GENE. WHICH PRESUMABLY WOULD DO AWAY WITH THOSE TWO CONCERNS, IF YOU COULD COMMENT WHY YOU CHOSE THIS APPROACH VERSUS THE LATTER. SO TWO QUESTIONS ON THE OVERALL -- >> I AGREE WITH DR. SADELAIN. THE ELIMINATION OF THE TARGET SITES OF BCL-11A FROM THE FETALGLOBIN LOCI IS A VERY ELEGANT ATTRACTIVE COMPOSITION. BECAUSE THAT WOULD LITERALLY EXQUISITELY DISRUPT THE SPECIFIC MOLECULAR CIRCUIT YES WE'RE INTERESTED IN, THE FACT THAT BCL-11A REPRESSESGLOBIN GENES. WE HAVE SPOKEN TO AS MANY PEOPLE IN THE GLOBIN FIELD WHO WORK ON THIS ISSUE AS WE COULD FIND. THAT'S CERTAINLY A GENOME WIDE OCCUPANCY DATA, ERYTHROID CELLS WHERE BCL-11A IS. TO THE BEST OF YOUR (INAUDIBLE) TO PRESENT MOMENT, THE SPECIFIC POSITION WITHIN THAT BETAGLOBIN REGION THAT'S NECESSARY AND SUFFICIENT FOR THE SILENCING EFFECT OF BCL-11A EXERTS ON ITS TARGETS IS NOT MAPPED. AND GIVEN THAT THAT INFORMATION DOESN'T EXIST, THE TARGET REGION IS TOO BIG TO BE USING PRESENT APPROACHES, ELIMINATED. AND I'LL LET DR. WALTERS ADDRESS THAT. >> SO THIS IS AN ISSUE WE SPENT TIME THINKING ABOUT AND THERE IS A DIFFERENCE OF OPINION ABOUT HOW BEST TO APPROACH THESE STUDIES IN TERMS OF CONDITIONING REGIMEN. SO WHAT -- THE REASON WE SETTLED ON THE MYELOABLATION IS WE HAVE STRUCTURED THE STUDY WE THINK IN A WAY THAT WILL SELECT PATIENTS WHO ARE WHILE YOUNG ADULTS STILL HEALTHY AND EXCLUDED THOSE IN HIGH RISK FOR UNTOWARD TOXICITY FROM MYELOABLATIVE DOSE OF THE INCREMENTAL TOXICITY ONE DWAYNES HALF GOES DOSE COMPARED TO FULL DOSE IS NOT SUBSTANTIAL. AND THE OTHER THING WE WANT TO AVOID IS TO EXPOSING THE AUTOLOGOUS -- THE ENDOGENOUS HEMATOPOIETIC STEM CELL. SO WE IF WE ABLATE WE ELIMINATE THE POSSIBILITY OF THOSE CONTRIBUTING IN A SUBSTANTIAL WAY TO ANYTHING RELATED TO -- ANY LONG TERM TUMORIGENITICITY RELATED TO BY SULFATE EXPOSURE. AND CREATING SPACE AND PUSHING THE BALANCE IN FAVOR OF ENGRAFTING MODIFIED CELLS ARE ALL CONSIDERATIONS. I WOULD BE FIRST TO AGREE MORE THAN ONE VIEW ABOUT THIS APPROACH HERE. >> SPEAKING INCREMENTAL TOXICITY FROM HALF DOSE, TO FULL DOSE, WOULD THAT EXTEND TO THE REPRODUCTIVE CAPABILITY OF THE SUBJECT? >> NO. IT WOULDN'T. BUT WE HAVE IN PLACE THE SPONSOR PROVIDING AT NO EXPENSE TO PATIENTS. GAMETE STORAGE BEFORE COMMENCING THERAPY. SO WE HOPE WE CAN ACCOMMODATE THAT CONCERN. >> SO WHAT IS THE RISK OFFER DEATH FROM TRANSPLANT PROCEDURE SNITS >> WE THINK IT IS LESS THAN 5%. PROBABLY MUCH LESS THAN 5% BUT IT'S CERTAINLY NOT ZERO. IT'S PROBABLY SOMEWHERE BETWEEN 1 AND 3%. BASED ON AUTOLOGOUS TRANSPLANTATION IN SIMILAR AGE PATIENTS. >> JUST A GENERAL COMMENT, IF YOU WANT TO COMMENT PLEASE STATE YOUR NAME SO IT CAN BE RECORDED. I HAD A COMMENT ON THE IDEA OF DELETE OR MODIFYING THE BINDING SITE, THAT'S AN ATTRACTIVE IDEA, ALSO EVEN IF YOU WERE TO KNOW THE BINDING SITE YOU MIGHT BE COMPLICATED BY THE FACT THAT YOU -- RIGHT NOW YOU CAN'T PREDICT WHAT HAPPENS TO THE TARGET REGION SO PRESUMABLY THERE IS A VERY COMPLICATED COMBINATION OF POSITIVE AND NEGATIVE FACTORS SO KNOCK OUT THE BINDING SITE YOU MIGHT ALSO KNOCK OUT THE EXPRESSION OF THE (INAUDIBLE). SOFT ADDITIONAL COMPLICATIONS WITH THAT BUT IT CERTAINLY WOULD BE INTERESTING. I HAD A QUESTION ALSO RELATING TO WHAT DR. SADELAIN WAS ASKING, THAT IS THE DURABILITY OF THE EXPRESSION FROM THESE CELLS, DO YOU EXPECT THIS TO BE A LONG TERM EFFECT AND HOW LONG CAN YOU PREDICT BASED ON THE OTHER PROTOCOLS THAT YOU HAVE DONE IN HIV ARENA? >> THE THING I CAN OFFER IS WE DETECT MARKED CELLS AND AN ELEVATION OF FETALGLOBIN POST ENGRAFTMENT IN MICE AND FUTURE DIFFERENTIATION AT THE LONGEST TIME POINT WHICH IS 28 WEEKS. NOT BEYOND THAT. I CANNOT REALLY COMMENT WE HAVE NOT GONE TO THE CLINIC WITH HEMATOPOIETIC STEM AND PROGENITOR CELLS MODIFIED ZINC FINGER DUE NUCLEASES, CAN YOU COMMENT ON MARKING THE T-CELL STUDY? Q. THE SAME MECHANISMS, EVENT MODIFICATION, AT 35 VIRUS IN CD4T CELLS, WE HAVE PATIENTS TREATED IN 2009, THAT STILL HAVE THE SAME LEVEL OF MARKING AFTER ALMOST FIVE YEARS NOW. THAT'S (INAUDIBLE) MEDIAN FOLLOW-UP IS THREE AND A HALF YEARS. WE HAVE MANY PATIENTS PROBABLY 2030 IN FOUR TO FIVE YEAR WITHOUT ANY CHANGE. SO IT'S A PERMANENT MODIFICATION. AND FOR T-CELLS THAT'S PREDICATED ON THE FACT THAT WE GET INTO THE CD4 STEM CELL MEMORY COMPARTMENT, THAT'S THE REASON WHY IT'S LONG TERM. >> THANK YOU. ANY OTHER QUESTIONS FROM ANY OF THE RAC MEMBERS? >> HOWARD KAUFFMAN. I WANT TO ASK YOU IS THERE ANY EVIDENCE THAT YOU GENERATED A T-CELL RESPONSE TO ANY OF THESE OTHER PRODUCTS OR HEMOGLOBIN ITSELF OR DO YOU PLAN TO LOOK AT THAT? >> WE HAVE NOT LOOKEDNATE MOUSE MODELS. -- LOOKED AT ANY MOUSE MODELS. DO WE HAVE ANY PLANS TO LOOK AT IMMUNOLOGIC RESPONSE TO REACTIVATING FETALGLOBIN? >> IN THESE PATIENTS THEY GENERALLY HAVE A HIGHER LEVEL OF FETAL ANYWAY. SO THE REACTIVATION OF FETAL SHOULD NOT PRESENT A NEW FOREIGN PEPTIDE -- WITH THESE PATIENTS. MOST NATURAL HEMATOPOIESIS IS A FUNCTION OF ELEVATED APP. >> DR. WALTERS POINTS OUT, YOU ARE EXPOSED POSTNATALLY I THINK. WE ARE ESSENTIALLY -- >> MOST PATIENTS START TRANSFUSION THERAPY IN THE FIRST YEAR OF LIFE WHICH MEANS THEY MAY SEVERAL MONTHS THEY LIVE ON FETAL HEMOGLOBIN IN CIRCULATION AND THAT'S NOT IMMUNOGENIC. >> ANY OTHER QUESTIONS FROM RAC MEMBERS? ANY PUBLIC COMMENTS OR QUESTIONS? OKAY. SO WE WILL TAKE A SHORT BREAK WHILE WE CONSIDER RECOMMENDATIONS AND THEN READ THEM BACK TO YOU BOTH PROTOCOL. >> SINCE WE'RE RIGHT BEFORE LUNCH IF YOU WILL STAY IN THE ROOM WE WILL DO IT AS QUICKLY AS POSSIBLE, THAT WILL LET THE TEAM GET ON THEIR WAY SHORTLY. THANKS. >> SO IF THAT'S GOING TO BE AN OFFER THAT NEEDS TO BE EXPLAINED THAT THE TERM ONCO FERTILITY IS NOT NOVEL TO THERAPY, IT'S DONE FOR A LOT OF INTERVENTIONS WITH THAT PARTICULAR CANCER DRUG. BUT PIT'S TRICKY. I MEANS THE WOMAN HAS TO GO THROUGH STIMULATION OF FOLLICLINGS IF THEY DO THAT OR TAKE OVARIAN TISSUE, WHICH IS ALSO VERY EXPERIMENTAL SO BOTH ARE EXPERIMENTAL AND THE CHANCES OF GOING THROUGH IBF AND HAVING A CHILD ARE NOT AS HIGH AS IF THEY WOULD HAVE BEEN HAD NAY THEY HAVE NOT DOWN DUNN IT. WHO IS GOING TO PAY FOR IT? IT'S EXPENSIVE. IS THERE THERE A TREATMENT SIDE EFFECT THAT WOULD BE COVERED -- IN YOUR RESPONSE TO BELIEVE CARE FOR, WHO CARES FOR THIS? WHO RESPONSIBILITY TO PAY FOR THIS? THAT NEEDS TO BE FULLY EXPLAINED. REPRODUCTIVE IMPLICATIONS NEED TO BE FULLY EXPLAINED. THAT IS 6TH GRADER READING IT WHY FETAL HEMOGLOBIN INVOLVEMENT, MESSING AROUND WITH THAT GENE HAS IMPLICATIONS FOR PREGNANCIES AND -- AND NURSING. >> YOU'RE RIGHT. I DON'T BELIEVE WE INCORPORATED ALL THAT INFORMATION INTO THIS CONSENT, THIS DRAFT CONSENT. BUT WE DO HAVE LANGUAGE THAT ADDRESSES THIS ISSUE FROM OTHER TREATMENTS THAT WE CAN INSERT FOR SURE. THE COLLECTION OF THE GAMETES IS COVERED IN THE CURRENT CONTRACT. I DON'T KNOW ABOUT ANY FUTURE IN VITRO FERTILIZATION LEADING TO PREGNANCY COVERAGE. SO THAT WOULD HAVE TO BE DISCUSSED FIRST. >> HOW LONG ARE YOU GOING TO STORE THOSE GAMETE? THESE ARE YOUNG ADULT, THEY CANNOT USE IT 20 YEARS, ARE YOU MAKING A COMMITMENT TO STORE THEM 20 YEARS? >> THAT'S RIGHT. >> WOW. OKAY. >> (INAUDIBLE) DR. SADELAIN? ARE YOU SATISFIED WITH THAT, DR. SADELAIN? >> YES. >> WE'RE GOING TO INCORPORATE IT IN THE RECOMMENDATIONS. >> SO WE'RE GOING TO READ BACK THE RECOMMENDATIONS. FIRST THE PRE-CLINICAL RECOMMENDATIONS YOU HAVE EXAMINED mRNA EXPRESSION OF BCL 11A TO UNDERSTAND IMPACT OF DISRUPTION OF BCL 11 OF THE DISEASE ON mRNA LEVELS AND HAVE FOUND THE mRNA LEVELS TO BE UNCHANGED. GIVEN THIS FINDING WOULD BE IMPORTANT TO LOOK AT BOTH SPECIFIC mRNA EXPRESSED OR THE SPLICING AYUSO FORMS AND POTENTIALLY EXPRESSED WHICH YOU CAN DO BY NEXT GENERATION SEQUENCING, AS WELL AS POTENTIAL PROTEIN EXPRESSION FROM THOSE mRNAs. DELETION OF BCL-11A SHOWN TO INCREASE P-53 LEVELS APOPTOSIS AND EXAMINING WHETHER THERE'S CHANGE IN P-53 LEVELS THAT RECEIVE THE ZINC FINGER NUCLEASE. CONSIDER WHETHER DEVELOPING A POSITIVE CONTROL IN MOUSE MODEL FOR EXAMPLE BY DELETING A TUMOR REPRESSSOR GENE MIGHT FORM THE POTENTIAL OF THE ZINC FINGER APPROACH. NO CLINICAL ETHICAL LEGAL AND SOCIAL. THE INFORMED CONSENT BY THE RAC WAS NOTED VERY LONG INDUCED COMPLICATED TERMINOLOGY, WE UNDERSTAND THIS CONSENT WOULD BE MORE CONSISTENT WITH THE GREAT 6TH AND 8TH GRADE LEVEL OR TESTED REAL 6TH GRADER. IN ADDITION TO SIMPLIFYING THE LANGUAGE FOLLOWING CHANGES SHOULD BE CONSIDERED. ORGANIZING OF THE CONTENT TO MAKE IT CLEAR WHAT RISKS ARE DUE TO EXPERIMENTAL APPROACH VERSUS THE RISK DUE TO THE GENERAL TRANSPLANT PROTOCOL. WHICH ARE MORE WELL ESTABLISHED IN KNOWN RISKS THAT COULD BE EXPLAINED. IMPROVE THE SUBJECTS UNDERSTANDING OF THE EXPERIMENTAL RISK AND MAYBE ALSO STEM CELL ISSUES. SEVERAL APPROACHES FOR THIS DISEASE USE VIRAL VECTOR, MANY USE INTEGRATING VECTORS, YOUR APPROACH IS USING mRNA APPROACH WITHOUT THE -- ANY INTEGRATING BECK VECTOR, IT WILL BE IMPORTANT TO DESCRIBE THE SCIENCE BEHIND THIS, PERHAPS THE DISTINCTION BETWEEN THIS APPROACH AND OTHER VIRAL VECTOR APPROACHES FOR EXAMPLE THE (INAUDIBLE) MAY MEAN MORE FAMILIAR WITH. IT'S ALSO IMPORTANT THE MAKE CLEAR THIS PROTOCOL USING HEMATOPOIETIC STEM CELLS, DIFFERENT FROM EMBRYONIC STEM CELLS REGARDING USE OF EMBRYONIC STEM CELLS, RELIGIOUS CONCERNS ET CETERA. THE INFORMED CONSENT DOCUMENT SPEAKS ABOUT LEAVING THE TRIAL BUT THIS IS GENE THERAPY APPROACH AND THE CELLS SHOULD PERSIST. THE CONCEPT OF LEAVING THE TRIAL NEEDS TO BE CLARIFIED. CONSIDER THE FOLLOWING LANGUAGE. IF YOU DECIDE TO WITHDRAW THE GENE MODIFIED GENE MODIFIED CELLS THE K NOT BE REMOVED FROM YOUR BODY AND CAN POTENTIALLY PERSIST INDEFINITELY. THE SECTION ON WHAT HAPPENS IF YOU'RE INJURED OR SICK IS (INAUDIBLE) THERE WAS A PHRASE MEDICAL CARE WILL BE AVAILABLE. THIS COULD BE INTERPRETED MEANING THAT CARE WILL BE PAID FOR AND THIS SHOULD BE CLARIFIED. IN ADDITION, THE INTEREST TO THE CARE SEEMS TO BE DETERMINED BY STUDY DOCTOR IN WHICH APPEARS TO BE POTENTIAL CONFLICT OF INTEREST FOR PRIVATE COMPANY SPONSOR TRIALS. CONSIDER CLARIFYING THE STATEMENT EVENT. THE (INDISCERNIBLE) WILL EFFECT FERTILITY AND CAN POTENTIALLY AFFECT FERTILITY AND THERE'S A PLAN OF COLLECTION OF GAMETES. THIS NEEDS TO BE EXPLAINED IN INFORMED CONSENT ANDS CAN BE QUEENSES ARE WITHIN SOME INFORMATION ON THE RISK AND POTENTIAL COST ARE OFFICIAL REPRESENTING SERVICES IN THE FUTURE NEEDS TO BE EXPLAINED. SO THAT'S ALL. CAN WE VOTE ON THIS PROTOCOL? MOTION. >> WE HAVE A MOTION. >> WE HAVE A MOTION TO VOTE IN? >> SO MOVED. >> SECOND. OKAY. LET'S VOTE. >> DONAHUE YES. >> PILEWSKI, YES. >> KAUFFMAN YES. >> KIRBY, YES. >> SADELAIN, YES. >> WOOLEY, YES. >> DRESSER, YES. >> HAMMARSKJOLD, YES. >> TISDALE, YES. >> HERRING, YES. >> WHITLEY, YES. >> ROSS, YES. >> ANTONIO, YES. Q. ON THE PHONE? >> KIEM, YES. >> ANYBODY IN THE RAC MEMBERS ON THE PHONE? OKAY. THANK YOU. NOW WE ARE -- THANK YOU VERY MUCH, AGAIN AND FOR A VERY INTERESTING PROTOCOL. >> THANK YOU FOR SUBSTANTIVE (INAUDIBLE) PLEASURE. >> THANK YOU. >> THANK YOU DR. SEGAL. THANK YOU, DR. TISDALE FOR JOINING US. >> WE'RE GOING TO BREAK FOR LUNCH, WE WERE SUPPOSED TO MEET AT 1 TO START THE SECOND HALF OF ORIENTATION. I'M GOING TO SAY WHY DON'T WE BREAK UNTIL 1:10. I WILL TELL THE FOLK WHOSE ARE PRESENTING. THE FIRST PRESENTATION IS THE FACA PRESENTATION THAT TAKES ABOUT TEN MINUTES. THAT'S FOR NEW MEMBERS. MOST OF YOU HAVE HEARD IT, THE SECOND PRESENTATION IS THE ETHICS PRESENTATION AND WE ARE GOING TO ASK FOR EVERYONE TO COME BACK AND GET REFRESHER ON THAT. NEW MEMBERS BACK HERE AT 1:10. AND OLD MEMBERS AT 1:20. I GUESS I'LL START OUT SUMMARIZING THE QUESTIONS THAT I HAD ASKED IN MY WRITTEN REVIEW. AND SUMMARIZE YOUR RESPONSES TO THIS -- TO THEM. SO THE FIRST QUESTION HAD TO DO WITH THE MAJOR CONCERN I THINK MOST OF US HAD IN THAT THE TARGETS YOU WERE TARGETING THE PROTEINS YOU WERE TARGET WERE UNIVERSALLY EXPRESSED, MOST TRANSCRIPTION FACTORS. AND THE POTENTIAL OF THAT TO INDUCE SYSTEMIC T-CELL RESPONSES AND POTENTIAL CYTOKINE STORMS. YOUR -- YOU ANSWERED THAT QUESTION VERY THOROUGHLY, CITED THE STUDIES YOU ALSO CITED NOW IN YOUR PRESENTATION. AND I THINK YOU WERE QUITE CONVINCING THAT IN A NUMBER OF STUDIES WITH VACCINES AGAINST SELF-ANTIGEN SYSTEMIC T-CELL RESPONSES ATTACKING NORMAL CELLS, NORMAL TISSUES DOES NOT SEEM TO BE A PROBLEM ALTHOUGH THERE WERE IN SOME OF THE STUDIES THERE WERE SOME ELEVATED ANTI-NUCLEAR ANTIBODIES, I THINK YOU SAID YOU WILL BE VIGILANT FOR THE -- FOR INEXPECTED IMMUNE RESPONSES AND YOU HAVE. PLAN TO ADDRESS THOSE SHOULD THEY OCCUR. SO THAT WAS MY MOST SIGNIFICANT CONCERN HERE. AND I THINK YOU HAVE ADDRESSED THAT VERY WELL. MY NEXT QUESTION HAD TO DO WITH THE MOUSE MODEL AND HOW SIMILAR THE EPITOPES WOULD BE BETWEEN THE MOUSE MODEL YOU WERE USING TO VALIDATE YOUR IMMUNOGENIC APPROACH, THE STEMVAC, HOW SIMILAR THE PROTEIN HEARSAY BETWEEN MOUSE AND HUMAN MODELS AND AGAIN YOU ADDRESS THAT VERY WELL, YOU PROVIDE A TABLE AND SHOWED CLEARLY THAT THE EPITOPES WERE HIGHLY HO MOLL GUS. YOU ALSO SHOWED SOME DATA THAT SHOWED EFFICACY WITH STEMVAC AGAINST MICE EXPRESSING THESE EPITOPES AND THAT ALSO ADDRESSES THE QUESTION OF WHETHER THE REPERTOIRE, THE MOUSE REPERTOIRE WOULD BE COMPARABLE TO THE T-CELL REPERTOIRE. SO THAT IS ADDRESSED TWO OF MY QUESTIONS. MY OTHER TWO QUESTIONS DEALT WITH -- THE THIRD QUESTION WAS ACTUALLY ADDRESSED BY THE ANSWERS TO THE SECOND QUESTION T MOUSE IMMUNE SYSTEM VERSUS THE HUMAN IMMUNE SYSTEM AND THE REPERTOIRE OF THE T-CELL IN THE TWO SPECIES. MY LAST QUESTION WHETHER YOU HAD HUMAN T-CELL CLONE CELL LINES AGAINST A PANEL OF HUMAN TISSUES TO ENSURE THAT YOU WOULD NOT SEE OFF TARGET EFFECTS. BASICALLY SINCE YOU DO NEED MHC MATCHED TISSUES FROM DIFFERENT -- OF DIFFERENT ORIGINS FROM THE SAME DONOR, YOU STATED THAT THIS WOULD BE VERY DIFFICULT TO DO WHICH I ACCEPT. SO I THINK OVERALL AS LONG AS YOU ARE VIGILANT FOR LOOKING OUT FOR UNTOWARD IMMUNE RESPONSES AND YOU HAVE PLAN OF ATTACK, SHOULD YOU HAPPEN TO SEE THAT -- SEE ANY OF THAT OTHERWISE I'M PRETTY SATISFIED WITH YOUR ANSWERS. >> THANK YOU. Q. DR. PILEWSKI. DR. DISIS. THANK YOU FOR THAT WONDERFUL PRESENTATION. IT WAS REALLY INFORMATIVE FOR THOSE WHO DON'T SPEND A LIVING STUDY TUMOR IMMUNOLOGY, THE ANIMAL ETCH CHASSI DATA YOU SHOWED WAS VERY HELPFUL BECAUSE ONE OF THE CHALLENGES I HAD AS I READ THE PROTOCOL WAS ASSESSING THE LIKELIHOOD OF BENEFIT VERSUS THE MAJOR RISK WHICH SEEMED TO BE AUTO-IMMUNITY. MY MAJOR CONCERN WAS THE SAME EXPRESSED BY DR. CHATTERJEE, THESE ANTIGENS ARE EXPRESSED IN NORMAL CELLS, NORMAL TISSUE, SOME UP-REGULATED ACTIVATED ENDOTHELIAL CELLS AND WON ONE WONDER ALSO IN THE PROCESS OF BERE PAIR, FOR EXAMPLE, EPITOPES MIGHT BE EXPOSED AND ALLOW AUTOIMMUNE RESPONSE, YOUR DATA FROM THE TOXICITY STUDIES ANIMAL STUDIES HELP REASSURE THAT'S NOT A PROBLEM AND I THINK THAT ELEGANT DESCRIPTION OF HOW YOU FORMULATED AND CHOSE THE EPITOPES BASED ON IN SILICO WORK WAS VERY INTERESTING. IN GENERAL I THINK YOU ADDRESSED THOSE AS WELL AS YOU CAN. I THINK IT'S VERY DIFFICULT TO KNOW FOR CERTAIN WHAT THE LONG TERM LIKELIHOOD OF AUTOIMMUNE DISEASE IN EXAMPLES LIKE THIS, BECAUSE YOU HAVE PROTEINS THAT ARE WIDELY EXPRESSED AND A LOT OF THE AUTOIMMUNE DISEASES THAT I SEE DEVELOP OVER YEARS AN DECADES NOT OVER ACUTE WEEK AND MONTH TIME PERIOD. ONE WILL ONLY KNOW WITH TIME AND LONG TERM MONITORING WHETHER THESE THING ALSO DEVELOP. THE POPULATION YOU'RE CHOOSING IS SUCH THEY HAVE LIMITED SURVIVAL N. THEY REGARD IF YOU WAY RISK AND BENEFIT THIS IS AN APPROPRIATE POPULATION TO TAKE A RISK IN RATHER THAN TAKING A POPULATION OF PATIENTS WITH EXPECTED LONG TERM LIFE STAN SPAN THEY HAVE THE OPPORTUNITY TO DEVELOP AUTO-IMMUNITY THROUGH YEARS OF TISSUE EXPOSURE TO T-CELLS THAT YOU GENERATED WITH THE VACCINE. THE NEXT ISSUE YOU ADDRESSED VERY WELL, ISLE RUN THROUGH THEM FOR THE SAKE OF DISCUSSION. WHY EXCLUDE HER2 NE BREAST CANCER, VERY CLEARLY TALKED PRE-LIST EXISTING IMMUNITY MIGHT PROHIBIT ASSESSMENT OF DOSE AND THAT MAKES PERFECT SENSE. MY THIRD COMMENT WAS SAFETY MONITORING. I RAISED THE QUESTION WHETHER MORE FREQUENT CONTACT IN THE PROTOCOL MIGHT BE BENEFICIAL, INTERESTING AND SOMEWHAT AMUSED BY YOUR PREVIOUS EXPERIENCE CONTACTING PATIENTS 48 HOURS AND SEVEN DAYS AFTER VACCINATION LED TO LOTS OF FRUSTRATION ON BOTH ENDS. YOUR IRB SUGGESTED MAYBE THAT'S NOT A GREAT IDEA. DEFER TO JUDGMENT AND LEAVE TO IT YOU TO DO AGGRESSIVE COUNSELING THAT PATIENTS WILL CONTACT YOU SHOULD THEY DEVELOP ANY PROBLEMS. I THINK THE SHORT TERM (INAUDIBLE) IS QUITE SMALL BUT THE LONG TERM RISKS ARE VERY MUCH UNKNOWN. THE FOURTH COMMENT WAS INFORMED CONSENT DOCUMENT, I MADE SUGGESTIONS ABOUT THE LANGUAGE, IT STRUCK ME IT WAS FAR TOO SOPHISTICATE FORD THE AVERAGE 8TH GRADER AND YOU COMMENTED ABOUT HOW YOU'VE UPDATED THE LANGUAGE IN THE INFORMED CONSENT AND THAT REALLY SHOULD HELP SIGNIFICANTLY THE OTHER INFORMED DON'T WAS AUTO-IMMUNITY AND HOW YOU DESCRIBE THAT TO PATIENTS AND ROOKS LIKE -- LOOKS LIKE YOU WILL TRY TO DO A BETTER JOB DESCRIBEING WHAT THAT MEANS AND WHAT IT MIGHT LOOK LIKE. LAST COMMENT WAS INDEMNIFICATION AND THE RISK OF THE FINANCIAL RISK TO SUBJECTS YOU CLARIFIED THAT BY BASICALLY MAKING IT CLEAR THAT INSURANCE COMPANIES MAY NOT PAY FOR UNTOWARD EFFECTS AND PATIENTS MAYBE LIABLE FOR THE COST. FEW COMMENTS ABOUT APPENDIX M, MAYBELY CHRONICITY OF THE TOX STUDIES LOOKS LIKE THE STUDIES IN THE APPLICATION WERE THREE MONTH TOXICITY STUDIES AND I ASK THE QUESTION HOW LONG YOU LOOKED AT THAT TIME MICE FOR LONGER TERM TOXICITY GIVEN POTENTIAL CONCERN. OUR GOAL SO BRING VACCINES INTO PREVENTION SETTING TO PREVENT BREAST CANCER THAT'S OUR GOAL. SO WE HAVE SET UP PREVENTION STUDIES IN THE ANIMALS JUST LIKE THE ONE I SHOWED YOU HERE. THESE PREVENTION STUDIES WE HAVE HAD ANIMALS ALIVE NOW ALMOST A YEAR AFTER VACCINATION. AND VERY SIMILAR TO WHAT I DESCRIBED WE HAVEN'T SEEN UNTOWARD EFFECTS. THE STUDY I SHOWED YOU OUT 180 DAYS AFTER VACCINATION, I DON'T HAVE THE DATA YET IN FRONT OF ME THE DATA WAS A MONTH OLD BUT NO PROBLEMMINGS WHATSOEVER IN IMMUNIZING COHORTS OF THE NEW TRANSGENIC MICE OR IMMUNIZING COHORTS OF THE C-3 TAG MICE FROM SIX WEEKS OF AGE ON. ABOUT A YEAR IS WHERE WE ARE RIGHT NOW. >> THAT'S HELPFUL TO KNOW YOU'RE LOOK AT LONGER TERM TOXICITY GIVEN LIMITATIONS OF A MOUSE MODEL, BETTER TO LOOK THAN TO JUST STOP AT SIX MONTHS. SO THANK YOU FOR SHARING THIS PROTOCOL WITH US. I CONGRATULATE YOU ON A REALLY INTERESTING APPROACH TO DEVELOP A NEW VACCINE FOR PATIENT POPULATION WHERE NEW THERAPIES ARE BADLY NEEDED. YOU HAVE ANSWERED MY QUESTIONS VERY THOROUGHLY, THANK YOU FOR THAT. >> THANK YOU. >> THANK YOU AFFECT HARDISON IS ON THE LINE I HOPE. >> I AM. I CAN HEAR THE FOLKS ON THE PHONE REALLY WELL BUT I CAN'T HEAR YOU PEOPLE IN THE ROOM REALLY GOOD. CAN YOU HEAR? >> YES, WE CAN. >> I JUST HAD A FEW COMMENTS IN REGARD TO ICD. PAGE 1 I SUGGESTED VERBIAGE TO IMPROVE PARAGRAPH 2, IT WAS VERY WELL ADDRESSED IN THE RESPONSE FROM THE -- FROM THE TEAM. SO I'M SATISFIED WITH THAT. ON PAGE 7 IN THE PARAGRAPH IN REGARD TO BENEFIT, I THINK THAT BENEFITS WERE CAREFULLY STATE BUD I STILL HAD A LITTLE BIT OF CONCERN. SO I ASKED FOR THAT CHANGE WAS MADE I'M OKAY WITH THAT. ON PAGE 8, I WASN'T -- STATEMENT WITH REGARD TO HOW PHI WAS STATED SO I ASKED FOR A LITTLE BIT BETTER LANGUAGE TO DESCRIBE SAFEGUARDS IN REGARD TO PHI. I HAD A QUESTION ABOUT THAT. THE TEAM ADDRESSED THAT AND I'M SATISFIED THE APPROPRIATE CONSIDERATION WAS GIVEN THERE. SO I'M OKAY. THAT'S ALL. >> OKAY. THANK YOU. DOES ANYONE -- I KNOW RAC HAS QUESTIONS. >> THE STUDY SAYS BURIED IN THE CONSENT FORM THAT IF YOU START THE STUDY YOU CAN -- YOU HAVE TO TAKE CONTRACEPTION FOR THE REST OF YOUR CHILD BEARING YEARS SO IF THAT INFORMATION THE CRITICAL TO ANYONE TAKING THIS STUDY SEEMS TO ME THAT SHOULD BE THE NUMBER ONE FIRST RISK FIRST REALITY SAID IN THE VERY BEING, NOT ON PAGE 8 OF A SEVERAL PAGE FORM. THAT'S THE SINGLE MOST IMPORTANT THING FOR A YOUNG WOMAN FACING WHO HAS GONE THROUGH BREAST CANCER. IT'S ASKED TO PARTICIPATE AND TEST THIS OUT. NO BENEFIT TO HER IMPLIED THE STUDY DOESN'T MAKE A SIDE EFFECT. IN ADDITION THE STUDY PROMISED TO STOP THE STUDY AT ANY TIME THAT'S NOT TRUE BECAUSE YOU WERE JUST TOLD YOU HAVE TO TAKE CONTRACEPTION THE REST OF YOUR CHILD BEARING YEARS BECAUSE THEY HAVE NO -- THEY DON'T KNOW WHAT IMPLICATIONS ARE. FOR NURSING OR PREGNANT SCHISM INFORMED CONSENT SHOWED THE CONFUSION BECAUSE ONE REASON FOR DROPPING OUT OF THE STUDY IF ONE COULD DROP OUT, IS IF YOU'RE PREGNANT. BUT THAT WOULD SEEM TO BE AL CATASTROPHIC EVENT AND THAT'S NOT REPORTED OR DESCRIBED IN THE STUDY. I'M CONCERNED ABOUT REPRODUCTIVE IMPLICATIONS OF THIS STUDY AND MAYBE I'M MISSING IT BUT WHEN WE WANT TO USE THIS AS A PREVENTIVE VACCINE NOT SURE HOW THAT WILL WORK GIVEN NATURE OF THIS STUDY AND THE EFFECT ON REPRODUCTIVE CAPACITY. UNLESS I'M MISSING IT ENTIRELY BUT SOMEONE RANDOMLY READING THAT CONSENT FORM THAT LEFT OUT SIGNIFICANT ETHICAL CONCERNS. >> DR. DISIS, WOULD YOU LIKE TO RESPOND? >> WE -- THIS PATIENT POPULATION OF COURSE STAGE 3 AND 4 BREAST CANCER, THE VAST MAJORITY OF THE PATIENTS ARE POST MENOPAUSAL AFTER CHEMOTHERAPY OR THEY'RE OF AN AGE WHERE THEY ARE NO LONGER CHILD BEARING. WE PUT THAT JUSTIFICATION IN FOR THE PURPOSE OF ALLOWING WOMEN WHERE THEY CAN'T DOCUMENT OR THEIR PHYSICIAN HAS NO DOCUMENTATION OF THEIR POST MENOPAUSAL STATUS. IN THE PAST WE HAVE HAD SEVERAL WOMEN WHO HAVE ACTUALLY GONE AND GOTTEN TUBAL LIGATIONS TO BE ON THE STUDY. WE DIDN'T WANT PEOPLE GOING AND HAVING SURGICAL PROCEDURES JUST TO MEET THAT TYPE OF ELIGIBILITY CRITERIA. WE HAVE NOT YET HAD ANYONE USUALLY WHEN WE ASK THEM AND WE COUNCIL THEM ABOUT FUTURE CHILD REARING, WE ASK THEM DURING THE TIME H WHERE WE EVALUATE THEM, WE SEND THEM BY EMAIL, THIS IS ELIGIBILITY CRITERIA, WE HAVE TO TAKE CONTRACEPTION FOR THE REST OF YOUR LIFE AND THEY HAVE TO RESPOND BACK YES THEY UNDERSTAND AND AGREE BEFORE WE START TALKING CONSENT. BUTTON HOB NEST WITH YOU, THE TIMES THAT WE GET WOMEN IN WHO ACTUALLY ARE CHILD BEARING, HAVE CHILD BEARING POTENTIAL ARE VERY, VERY RARE. >> LET US BE HONEST, SO ARE YOU SAYING IF THEY CAN'T HAVE CHILDREN IN PATIENT -- BECAUSE THEY'RE SO SICK? AND THEY'RE TERMINAL? THEY HAVE A TERMINAL DISEASE AND THEREFORE UNREALISTIC TO EXPECT THEY WOULD HAVE HAVE B CHILDREN IN THE FUTURE; IS THAT WHAT I'M HEARING BECAUSE THEY'RE STAGE 3 AND 4? >> I CAN'T UNDERSTAND WHAT YOU'RE SAYING. YOU'RE BREAKING UP. >> TRY AGAIN? >> SO THERE SEEMS TO BE TWO WAYS THINKING ABOUT THIS. THE FIRST IS TO RESTRICT PATIENT POPULATION POST MENOPAUSAL WOMEN FLAT OUT. SECOND I HEAR YOU SAYING SOMETHING LIKE WE DON'T WORRY WOMEN STAGE 3 AND 4 AND IT'S UNLIKELY THEY'RE GOING TO LIVE A LONG TIME OR BE IN A POSITION TO GET PREGNANT. IS THAT WHAT I'M HEARING? >> IT'S BOTH. THE FIRST THING IS MANY OF THESE WOMEN HAVE HAD MENOPAUSE BY CHEMOTHERAPY. SECOND IS ADVANCE STAGE BREAST CANCER PATIENTS. THREE PATIENTS COME ON TO STUDY IN THE PAST HAVE NOT HAD DOCUMENTATION OF MENOPAUSE BY HORMONES AND THEY UNDERWENT SURGICAL PROCEDURE TO ALLOW THEM TO QUALIFY FOR THE STUDY ALL BE IT ADVANCE STAGE CANCER PATIENTS. I GUESS AS PHYSICIANS WE WANT TO MAKE THE PROTOCOL SO THAT THOSE THREE PERCENT OF PATIENTS WOULDN'T HAVE TO DO THAT. >> I WOULD STRONGLY ADVISE YOU DROP THAT LANGUAGE BECAUSE IF YOU HAVE WOMEN FACING THIS REGALE THEY NEED TO BE HELPED TO THINK THROUGH WHAT THEY'RE FACE. NEAR FACING A FATAL DIAGNOSIS ALL THIS TALK ABOUT BABIES AN BREAST FEEDING AND PREGNANT I IS INAPPROPRIATE IN THIS INFORMED CONSENT. IT GIVES THE WRONG IMPRESSION. AND I DON'T SEE WHY THAT'S USEFUL. I THINK YOU SHOULD -- I THINK IT'S MORE STRAIGHT FORWARD TO SAY THIS IS SNOT A PROTO-- IS NOT A PROTOCOL FOR A WOMAN CAPABLE OF BEING PREGNANT AND YOU CAN DO A SCREENING TEST FOR HORMONE LEVELS TO SEE IF IT'S NOT DOCUMENTED. RELATIVELY SMALL END THAT WOULD BE POSSIBLE TO DO IT. OTHERWISE SEEMS LIKE YOU'RE HOLDING UP A FALSE REALITY THEY CAN'T PARTICIPATE IN AS IF THEY COULD. I FOUND THAT I ALWAYS FIND THAT IN THESE INFORMED CONSENT PROCEDURES. PREGNANCY END OF LIFE CONSENT FORM, IT SEEMS COUNTER INTUITIVE TO ME AND DIFFICULT. >> I DISAGREE WHY WOULD YOU DENY ACCESS TO THIS PROTOCOL TO WOMEN WHO AREN'T POST MENOPAUSAL? I DON'T SEE THAT AS FAIR. AND TAKING CARE OF PATIENTS WITH ADVANCED DISEASE, NOT ALLOWING THEM THIS OPTION OF PARTICIPATING IN CLINICAL RESEARCH IS PROBLEMATIC TO THEM. THAT -- I SEE YOUR POINTS AND THOSE ARE GOOD POINTS, BUT IT WOULD BE FAR LESS ETHICAL TO RESTRICT THE PROTOCOL SIMPLY BECAUSE THEY HAVE CAPABILITY OF BEARING CHILDREN. NOT TOO WORRIED ABOUT THIS ANYWAY, WHAT IS THE PURPOSE OF PUTTING IN FROM, VERTICAL TRANSTRANSMISSION AND PROPAGATION THROUGH THE GERM LINE. WITH PLASMIDS. >> I THINK CONCERN ISN'T GERM LINE TRANSMISSION IT'S TEAR TOE GENICITY AND IMMUNE RESPONSE CROSS REACTIVE TO THE FETUS, IS THAT CORRECT, DR. DISIS? >> I CAN'T SEE HOW THAT WOULD BE TERATOGENIC. I CAN SEE HOW IT MIGHT CAUSE REJECTION OF THE FETUS. >> AT THIS TIME'S LESS OF A PROBLEM -- IT'S LESS OF A PROBLEM IN TERMS OF THE SELECTIVE T-CELL (INAUDIBLE) GENERATE ANTIBODIES. >> IT SEEMS LIKE THAT JUST WITH A LITTLE REWORDING, SOMETHING LIKE MANY OF YOU MAY ALREADY HAVE MENOPAUSE BECAUSE OF YOUR AGE OR BECAUSE OF YOUR TREATMENT, YOU WILL BE SCREENED IF YOU ARE NOT YOU WOULD BE REQUIRED TO OR COUNCIL TO TAKE BIRTH CONTROL FOR THE REST OF YOUR LIFE OR SOMETHING LIKE THIS SO I THINK IT COULD BE COVERED -- COVER THE CASE ALLOW NOT CLINGED PATIENT BUS YET GIVE THE CAUTION FOR THOSE WHAT IT'S NEEDED FOR. >> THIS IS NOT A PROVEN TREATMENT SO YOU'RE NOT DENYING THEM TREATMENT. THIS IS A PHASE -- >> DENYING THEM THE OPTION OF PARTICIPATING IN CLINICAL RESEARCH IS IMPORTANT TO END STAGE CANCER PATIENTS. >> TRUE BUT THERE'S A LOT OF EXCLUSION CRITERIA IN MANY PROTOCOLS, IT'S A PHASE 1 AND WE DISCUSSED THIS AT LENGTH ABOUT HOW THERE TYPICALLY IS NO BENEFIT TO THE PATIENT IN THIS TYPE OF TRIAL. >> ALL THE EXCLUSION CRITERIA WE PUT IN THERE'S MEDICAL OR SCIENTIFIC BASIS FOR IT. NOT JUST BECAUSE -- >> I THINK IN SOME PROTOCOLS -- >> K WOMEN THAT CAN BARE CHILDREN. >> THERE IS CRITERIA FOR POST MENOPAUSAL AND SOME OTHER STUDIES SO I DON'T THINK THAT'S OUT OF THE ORDINARY, IT'S JUST VERY SMALL FRACTION WE'RE TALK ABOUT ANYWAY, SO I DO AGREE WITH LORI ON THIS ONE. >> THEY CANNING CARE OF LOTS OF END STAGE CANCER PATIENTS IT'S VERY IMPORTANT TO THEM WHEN THERAPEUTIC OPTIONS ARE NO LONGER AVAILABLE TO THEM FOR THEM TO BE ABLE TO PARTICIPATE IN CLINICAL RESEARCH IN THEIR DISTRAUGHT WHEN EXCLUDED. >> I HAVE TO JUMP IN AND SAY WHAT ABOUT BENEFITS OF PARTICIPATION IN THIS PARTICULAR PROTOCOL IS LACK OF TOXICITY. MANY PATIENTS ESPECIALLY VACCINE STUDIES, YOU GET LOTS OF PATIENTS, I'M CONSTANTLY REFERRING THIS PATIENT POPULATION TO COLLEAGUES BECAUSE YOU FEEL LIKE DO YOU WANT DO SOMETHING YET DON'T WANT ANY MORE CHEMOTHERAPY. THERE ARE STUDIES WE PRESENTED TO YOU TWO YEARS AGO THAT ENROLL IN 15 MONTHS. >> I GENERALLY COMPLETELY AGREE WITH YOU, BUT HAVE TO SAY IT. WRITE A CONSENT FORM THAT SAYS YOU ARE BRAVE NOBLE HUMAN BEING BECAUSE YOU WERE VOLUNTEERING AT END OF YOUR LIFE FOR THIS. BE STRAIGHT UP AND FLAT OUT. GIVE SOMEONE FULL CREDIT. DON'T SAY DON'T MAKE IT SEEM AS IF THERE'S A FUTURE BEHIND THIS AND THEY CAN GET PREGNANT BEHIND, THERE'S SOMETHING ABOUT THE WAY THIS IS WRITTEN THAT DOESN'T GIVE CLARITY TO THAT -- TO THEIR SITUATION AND LOSE NO BUILT TO COME ALONG WITH THAT. I AGREE, JUSTICE DEMANDS THAT. I COMPLETELY AGREE WITH YOU. >> SOUND LIKE WE'RE ALL IN AGREEMENT. >> IT SOUNDS AS IF YOU -- FOR A PERSON READING IT SOUNDS AS IF THIS MIGHT WORK FOR ME. THE ONLY DRAW BACK IS I WON'T BE ABLE TO HAVE KIDS. THAT'S WHAT IT LOOKS LIKE WHEN YOU READ THIS PROCEDURE. ITS DOESN'T -- IT CAN'T GIVING THAT IMPRESSION IS WRONG. I THINK YEAH, EVEN WITH GREAT RESPECT, I HOPE THIS ALL WORKS, I REALLY DO. AS NORM POST REMINDS US THE CHANCE OF THIS WORKING FOR ANY ONE PATIENT IS SCANT. SO WHEN THEY SAY THEY ARE -- THEY DON'T -- THEY WANT TO DO SOMETHING, THIS IS ALLOW BOG DIS TO BE USED AS A HUMAN SUBJECT IN A TRIAL WITH UNKNOWN RISK. AS LONG AS THEY THANS AND ARE GIVEN THE SUPPORT FOR THAT CHOICE, I THINK IT'S A DIGNIFIED WONDERFUL CHOICE TO MAKE. COURAGEOUS CHOICE TO MAKE BUT IT'S VERY DIFFERENT FROM THINK THEY'RE DOING SOMETHING FOR CANCER. >> I AGREE WITH ALL THE POINTS BUT WOULD NOT DISCOUNT THE TRUE MEDICAL BENEFIT THE PEOPLE GIVE FROM PARTICIPATING CLINICAL TRIALS EVEN IF THAT THERAPY DOES NOTHING FOR THEIR DISEASE. >> TRUE MEDICAL BENEFIT BEING PSYCHOLOGICAL BENEFIT? >> I WOULDN'T CHARACTERIZE IT AS JUST A PSYCHOLOGICAL BENEFIT, I THINK IT'S QUITE SIGNIFICANT >> WHAT IS IT EXACTLY? >> HOWARD KAUFFMAN, I WOULD CHIME IN THERE'S BEEN A PAPER PUBLISHED SUGGESTING OVER 50% CANCER PATIENTS IN PHASE 1 TRIALS DO GOAL SORT OF MEANINGFUL CLINICAL BENEFIT IN TERMS OF RESPONSE RATE, PROGRESSION FREE SURVIVAL OR OVERALL SURVIVAL. SO I DON'T THINK THERE IS THE EXPECTATION OF NO BENEFIT FOR PHASE 1 STUDY. >> I THINK WE'RE SEEING THE SAME THINGS, IT'S JUST KEEPING DISCUSSION AND INFORMED CONSENT FORM BALANCED BUT NOT SWINGING IT QUITE SO FAR AS I HAVE HEARD. BUT CERTAINLY NOT SWINGING SO FAR TO SAY TO IMPLY IN ANY WAY THAT YOU COULD -- YOU CAN DERIVE SOME CLINICAL BENEFIT FROM THE THERAPEUTIC ITSELF. Q. DR. DONAHUE. >> SO THIS IS NOT MY AREA AND I'M AN OUTSIDER LOOKING IN. WITH THAT CAVEAT, IT WAS NOT CLEAR TO ME FROM THE INITIAL PRESENTATION, IT'S NOT MY LANGUAGE THESE ARE TERMINAL PATIENTS. AND IF THEY ARE, THEN I WOULD SAY WE SHOULD AT SOME LEVEL CONTAIN OUR DISCUSSION TO THE STUDY AND I THINK THAT IF THESE ARE TERMINAL PATIENTS, THERE IS A DISCUSSION THAT THEY SHOULD HAVE HAD BEFORE THIS STUDY I WOULD ARGUE, BUT CERTAINLY INDEPENDENT OF THIS STUDY WITH THEIR MEDICAL CARE PROFESSIONAL ABOUT THE PROGNOSIS OF THEIR DISEASE AND I THINK IT'S AN UNFAIR EXPECTATION TO HAVE THESE STUDY COORDINATORS BE RESPONSIBLE FOR THAT. OR THE CONSENT FORM BE RESPONSIBLE FOR THAT. IT'S NOT A DISCUSSION THAT WOULD EVER EVEN HAPPEN WITH THESE PATIENTS. >> DR. DISIS WHEN YOU WERE PRESENTING WE WERE HAVING AUDIO PROBLEMS YOU WERE SHOWING SURVIVAL DATA AND I THINK EITHER YOU MISSPOKE OR I MISHEARD I THINK YOU SAID PATIENT VERSUS GREATER THAN 50% CHANCE OF SURVIVAL BUT LESS THAN 50% CHANCE BUT IT WASN'T ZERO. IT WAS 30, 40 DEPENDING ON STRATA. >> LESS THAN 50% CHANCE OF FIVE YEAR SURVIVAL IN THIS PATIENT POPULATION FOR STAGE 4 PATIENTS, IT'S MORE IN THE RANGE OF A 20% CHANCE OF A FIVE YEAR SURVIVAL. >> RIGHT. SO WE CAN ALL HAVE DIFFERENT VIEWS HOW BAD THAT IS. Q. THE WAY BREAST CANCER WORKS IS PATIENTS RELAPSE AND THEN RELAPSE AGAIN AND RELAPSE AGAIN, THEY'RE OVERALL ALL SURVIVAL MIGHT BE LONG LIVING WITH CANCER BUT THEIR CHANCE OF A CURE AT THAT POINT IS NIL. >> THIS IS DR. SALASAR. WHAT DR. DISIS IS SAYING CORRECT T. OVERALL SURVIVAL MAYBE -- BUT THE PROGRESSION FREE SURVIVAL IS THE SHORTER ONE DEPENDENT ON WHETHER OR NOT YOUR HORMONE RESTORE POSITIVE OR NOT, AND I ALSO JUST WANT TO GET BACK TO THAT, THERE WAS A QUESTION ABOUT WHY NOT JUST DO FS ESTRA DIAL AND DETERMINE IF THEY'RE -- THAT'S FOR PATIENTS ALREADY ON HORMONE THERAPY. SOME OF THESE WILL BE ON LONG TERM ENDOCRINE THERAPY AND YOU CANNOT DETERMINE A MENOPAUSAL STATE WITH HORMONES LEVELS WHEN YOU'RE TAKING ENDOCRINE THERAPY: WE WOULD NEVER ASK PATIENTS TO GO OFF ENDOCRINE THERAPY JUST TO DETERMINE MENOPAUSAL STATE HORMONE LEVELS. SO THOSE ARE THE PATIENTS DR. DUCES WAS REFERRING TO, NEVER DOCUMENTED OFF, CHEMOTHERAPY OR ENDOCRINE THERAPIES (INAUDIBLE) ONCE WE START LONG TERM THERAPY YOU CAN'T TAKE THEM OFF. >> OKAY. THANK YOU FOR THAT, I THINK WE HAVE EXHAUSTED THIS TOPIC AND WE'LL RECOMMEND WE'LL COME UP WITH A RECOMMENDATION DR. CORRIGAN CURAI WILL COME UP WITH A RECOMMENDATION OF THIS. ARE THERE OTHER ISSUES TO DISCUSS? >> HOWARD KAUFFMAN, MORE A COMMENT TO MAKE. IN MELANOMA WE HAVE HAD A LOT OF EXPERIENCE WITH TRYING TO GENERATE IMMUNE RESPONSE BOTH THROUGH VACCINES AND MORE EVENTUALLY WITH THE T-CELL CHECK POINT INHIBITORS. IT SEEMS THAT WHEN YOU DO GENERATE AUTO-IMMUNITY THAT CAN BE A FAVORABLE RESPONSE FOR GETTING THE TUMOR REJECTION THOUGH IF DIRECT RELATIONSHIP THE JURY IS OUT. HOWEVER, I THINK AN IMPORTANT POINT IN MELANOMA, WE CAN CONTROL THE AUTO-IMMUNITY WELL SO IT DOES SEEM LEUKOSES DOSES CORTICAL STEROIDS CAN CONTAIN THAT AUTO-IMMUNITY SO I THINK WE WOULD PROBABLY AS TUMOR IMMUNOLOGISTS GET EXCITED IF WE STARTED SEEING SIGNS OF AUTO-IMMUNITY IN THESE STUDIES AND I THINK WE'RE INCREASINGLY COMFORTABLE THAT WE CAN CONTROL IT. AS WELL. SO THE AUTO-IMMUNITY POTENTIAL SIDE EFFECTS DIDN'T BOTHER ME SO MUCH IN LOOKING AT THIS. >> THOUGH MELANOMA, THE OFF TARGET TISSUES ARE NOT SO BAD AS NOT THE HEART, GUT, GI TRACT, MORE SKIN EYE AND EAR. >> NOT WITH THE CHECK POINT INHIBITORS, WE SEE AUTOIMMUNE REACTIONS AGAINST THE BALL, AGAINST ENDOCRINE ORGANS, AGAINST PERIPHERAL NERVE OPTIC NERVE. >> RIGHT NOW I WAS THINKING T-CELL THERAPIES AGAINST MEL MONA. HOW MANY MICE DUD THAT YOU TREATED WITH CONSTRUCTS HAD THAT NEUROLOGIC CONDITION? AND HOW CERTAIN ARE YOU THAT IT'S NOT RELATED TO THE VACCINE? >> WELL, WE HAD SIX OUT OF 30 WHICH WAS 20% RANGE CONSIST WENTS THE LITERATURE. (INAUDIBLE) ONLY REST ON CERTAINTY OF VETERINARY HISTOPATHOLOGIST WHOSE SAID THESE WERE CLASSICALLY EPILEPTIC SYNDROME DEED IN (INAUDIBLE). >> SO YOU HAD A CONTROL GROUP WITH SAME FREQUENCY? >> PARDON? >> WAS THERE A CONTROL GROUP WITH WHERE YOU SAW THE SAME FREQUENCY OF THE -- THOSE NEUROLOGIC EVENTS? IN THE SAME MICE? >> THE EVENTS WERE DISTRIBUTED ACROSS CONTROL AND VACCINE. >> I SEE. >> NOT SPECIFIC TO THE VACCINE. >> THEY WERE EQUALLY DISTRIBUTED. >> OTHER QUESTIONS? COMMENTS? YES. >> I WANT TO MAKE A COUPLE OF COMMENTS ABOUT INFORMED CONSENT DOCUMENT. THE -- I READ THE NON-TECHNICAL ABSTRACT AND THOUGHT IT WAS A VERY GOOD LADY SUBSCRIPTION OF WHAT THE RESEARCH WAS DOING AND I THOUGHT IT WAS MUCH BETTER THAN DESCRIPTION IN THE INFORMED CONSENT DOCUMENT SO YOU MIGHT THINK ABOUT USE LANGUAGE FROM THE NON-TECH TALLCAL ABSTRACT IN THAT INFORMED CONSENT DOCUMENT AND NOTED THAT THE INFORM CONSENT DOCUMENT REFERS A LOT TO INTERVENTION OF THE VACCINE AND PEOPLE HAVE A CERTAIN IDEA ABOUT WHAT VACCINES ARE, AND ALSO LIT ACTUALLY WORK. AND SUGGEST THAT MAYBE EVERY TIME YOU REFER TO AS VACCINE PUT IN FRONT OF IT EXPERIMENTAL VACCINE OR STUDY VACCINE OR SOMETHING SIMILAR. >> THANK YOU. ANY OTHER COMMENTS FROM RAC MEMBERS HERE OR RAC MEMBERS ON THE PHONE? NO? OKAY. WE WILL TAKE A BREAK FIVE OR TEN MINUTES TO COME UP WITH OUR RECOMMENDATIONS. >> SO WE'LL RECONVENE T. FIRST THING WE FORGOT TO ASK IF THERE ARE ANY COMMENTS FROM THE PUBLIC. ANYONE PRESENT OR ON THE PHONE WANT TO MAKE A COMMENT ON THIS PROTOCOL? OKAY. THENLY READ BACK OUR RECOMMENDATION LETTER FOR PEOPLE WHO COMMENTED BEFORE WE VOTE ON RECOMMENDATION. SO WE DIDN'T HAVE ANY PRE-CLINICAL OR CLINICAL COMMENTS TO MAKE, WE HAS DISCUSSION ABOUT ETHICAL LEGAL. SO TO CAPTURE THE WHOLE DISCUSSION ABOUT CONTRACEPTION THAT WE HAD AND PREGNANCY, IF THE REALITY IS MOST WOMEN ENTERING THE STUDY WILL BE INFER UNTIL DUE TO PREVIOUS CONTRACEPTION OR STATE OF THE DISEASE PREVIOUS CHEMOTHERAPY, NOT CONTRACEPTION WOULD PREVENT PREGNANCY, CONTRACEPTION SHOULD RECOGNIZE REALITY IS WITHOUT THAT CAVEAT STATEMENT ABOUT FUTURE PREGNANCIES AND NURSING AND COULD BE MISINTERPRETED ASSESSMENT OF POTENTIAL FOR SUCCESS OF THIS APPROACH FUTURE PREGNANCIES AND LONG TERM SURVIVAL ARE EXPECTED. THE OTHER TWO POINTS WE HAVE, IN THE SECTION REGARDING LEADING THE STUDY CLARIFY ONCE VACCINE IS GIVEN IT CAN'T BE WITHDRAWN AND WITHDRAWAL FROM THE STUDY WITHDRAWING FROM FUTURE MONITOR ING. E DESCRIPTION OF PROTOCOL NON-SCIENTIFIC ABSTRACT WAS WRITTEN AND UNDERSTANDABLE AND THE LANGUAGE COULD BE INCORPORATED INTO THE INFORMED CONSENT DOCMENT. IN ADDITION THE TERM VACCINE COULD BE MISINTERPRETED AS ESTABLISHED TREATMENT AND SHOULD BE MODIFIED USING THE ADJECTIVE THAT MAKES ITS CLEAR EXPERIMENTAL APPROACH EG EXPERIMENTAL VACCINE OR STUDY VACCINE. SO THOSE ARE OUR RECOMMENDATIONS. ANY COMMENTS FROM THE COMMITTEE? DR. DISIS, ANY RECOMMENDATION? >> I THINK THOSE ARE MY POINT RECOMMENDATIONS AND WE BEAL ABLE TO MODIFY OUR DOCUMENTS ACCORDINGLY. >> ANY OTHER COMMENTS BEFORE WE VOTE ON A RECOMMENDATION? SO WE WILL VOTE WHETHER WE APPROVE RECOMMENDATION LETTER TO INVESTIGATORS. CAN I HAVE A MOTION. THANK YOU. CAN YOU HAVE A SECOND? OKAY. DR. DON DONAHUE. >> DONAHUE. YES. >> CHAT GEE, YES. >> PILEWSKI YES. >> KAUFFMAN YES. >> CURRY, YES. >> SADELAIN. YE. >> WOOLEY, YES. >> DRESSER YES, SIR YE. >> FOST, YES. >> KOHN, YES. >> HAMMARSKJOLD, YES. >> CANON, YES. >> HERRING, YES. >> WHITLEY, YES. >> ANTONIO, YES. >> ROSS, YES. >> ANY RAC MEMBERS ON THE PHONE? (INAUDIBLE), YES. >> KIEM, YES. >> WE HEARD THOSE. THANK YOU VERY MUCH FOR THIS, IT'S HA LITTLE MORE CHALLENGING BY REMOTE CONTROL BUT IT SAVED Y'ALL A LONG TRIP. SO THANK YOU AND GOOD LUCK WITH YOUR STUDY. >> THANK YOU VERY MUCH. BYE-BYE NOW. ANYONE NEED A FIVE MINUTE BREAK? REI DO GO. OKAY. THE INVESTIGATORS ARE HERE. THE NEXT PROTOCOL IS PROTOCOL NUMBER 1406-1320 TITLED FADES 1 STUDY OF T-CELLS EXPRESSING ANTI-CD 2 CHIMERIC RECEPTOR IN CHILDREN AND YOUNG ADULTS WITH B CELL MALIGNANCIES. PRESENTER DR. TERRY FRY, NATIONAL CANCER INSTITUTE BETHESDA, MARYLAND. DR. FRY IS HEAD OF IMMUNOLOGIC MALIGNANCY SECTION IN PEDIATRIC ONCOLOGY BRANCH NATIONAL CANCER INSTITUTE AT THE NIH. DR. FRY SERVES CHAIR OF THE ONCOLOGY STRATEGY GROUP IN BLOOD AND MARROW TRANSFECTED CONSORTIUM, AS MEMBER OF THE STEM CELL TRANSPLANTATION COMMITTEE CHILDREN'S ONCOLOGY GROUP. DR. FRY. >> ALL RIGHT. ON BEHALF OF THE PROTOCOL GROUP I WOULD LIKE TO THANK YOU FOR GIVING US AN OPPORTUNITY TO PRESENT THIS PROTOCOL. AT THE RAC MEETING. JUST AS WAY OF BACKGROUND, ACUTE LYMPHOBLASTIC LEUKEMIA IS ONE OF THE MAJOR SUCCESS STORIES IN THE AREA OF PEDIATRIC ONCOLOGY WITH MARKEDLY IMPROVED OUTCOMES OVER THE LAST 30 YEARS, AS RESULT OF RISK ADAPTED THERAPY USING MULTI-AGENT OVER EXTENDED PERIOD OF TIME. WE KNOW WITH THERAPIES APPROXIMATELY 85% OR MORE OF CHILDREN WILL ULTIMATELY BE CURED OF THEIR LEUKEMIA. IN SPITE WE BELIEVE NEW THERAPIES ARE NEEDED. SO IN PATIENT WHOSE DO RELAPSE, OBTAINING A SECOND COMPLETE REMISSION IS RELATED TO NUMBER OF RELAPSES SO 85% OF PATIENTS FIRST RELAPSE ACHIEVE A SECOND CR, 44% IN SECONDARY LABS AND DOWN 27% IN THIRD RELAPSE. IF YOU LOOK AT PATIENT WHOSE ACHIEVE A CR, BY NUMBER OF RELAPSES, SURVIVAL IS HERE FROM CHILDREN'S PEDIATRIC ONCOLOGY GROUP SHOWING RESPONSE, PATIENT WHOSE DO ACHIEVE TREATMENT AT SIX YEARS ONLY ABOUT 20 TO 30% PATIENTS WILL STILL BE SURVIVING. JUST AS AN ASIDE THE TYPES OF PATIENTS ENROLLENING THIS TRIAL IS A PATIENT THAT WOULD ACHIEVE A CR AFTER A SECOND RELAPSE OR NOT SHOWN IN THIS DATA ARE PATIENT WHOSE FAIL TO ACHIEVE CR AT ALL. SO WE KNOW THOSE PATIENTS DO WORSE. A FEW OTHER ADDITIONAL POINTS, AS A RESULT OF THIS LEUKEMIA REMAINS THE LEADING CANCER RELATED MORTALITY IN CHILDREN. WORSE FOR ADULTS. TREATMENT RELATED MODALITY IN THESE PATIENTS SO ALTERNATIVE THERAPY, THERE IS RECENT SUCCESS USING GENETICALLY IDENTIFIED T CELLS, THE (INAUDIBLE) HEARD ABOUT THESE PROTOCOLS. AS WAY OF BACKGROUND CHIMERIC ANTIGEN RECEPTOR CONSISTS OF AN ANTIBODY BINDING DOMAIN AND LINKS TO T-CELL SIGNALING MACHINERY INCLUDING CD 3 ZETA CHAIN WITH SIGNAL ONE AS WELL AS CO-STIMULATORY DOMAIN SIGNAL WITH SHARE TWO, THESE ARE SECOND GENERATION AND THESE ARE THE CD 28 AND CD 137 OR (INAUDIBLE). THE ADVANTAGE OVER T-CELL RECEPTORS ARE THESE ARE SPECIFIC FOR A CIRCUMSTANCE ANTIGEN FREE OF MHC RESTRICTION AND THE SIGNALS FOR ACTIVATION ARE SELF-CONTAINED WITHIN THE WHOLE SIGNALING CONSTRUCT. THERE'S BEEN EXTENSIVE EXPERIENCE WITH CD 19 CAR T-CELLS. THIS WAS AS OF LAST FALL WHEN DR. (INAUDIBLE) AND I PUBLISHED THIS TABLE IN EDUCATIONAL SUPPLEMENT, THIS IS PROTOCOLS OPEN ACROSS A NUMBER OF INSTITUTIONS, AND I WILL POINT OUT THAT ALL OF THE PROTOCOL HIGHLIGHTS IN RED WITHER ENROLL ROLED IN PEDIATRIC PATIENTS. STILL ENROLLED IN PEDIATRIC PATIENTS. GENETICALLY MODIFIED T-CELL WAS A VERY, VERY POTENT ACTIVITY OF THESE CELLS. AND THE VERY, VERY HIGH RESPONSE RATES SO THIS IS DATA FROM OUR INSTITUTION AND PROTOCOL PUBLICATION IN LANSETT. WE SAW 12 OF 20 ACHIEVED MRD COMPLETE REMISSION AND SHOWN ON THE RIGHT, WAS SURVIVAL IN PATIENTS THAT ACHIEVE MRD REMISSION. SURVIVING PATIENTS UNDERWENT CONSOLIDATED HEMATOPOIETIC STEM CELL TRANSPLANTATION. THE RESPONSE RATE IS SIMILAR TO PUBLISH RESPONSE RATES IN NUMBER OF OTHER INSTITUTIONS. IN PEDIATRIC PATIENTS AND YOUNG ADULTS INCLUDING CHILDREN'S HOSPITAL PHILADELPHIA, PUBLICATION NEW ENGLAND JOURNAL OF MEDICINE 2013 AND ONE IN PRINT REPORTING 90% COMPLETE REMISSION RATE AND DATA FROM MSKC REPORTING 88% COMPLETE REMISSION RATE. IN ADDITION TO PATIENTS WHO DON'T RESPOND TO GENETICALLY MODIFIED GENE CELLTHER WHICH WE'RE LEARNING NOT UNSUBSTANTIAL NUMBER OF PATIENTS. WHO RELAPSE LEUKEMIA 10% THOUGH IT HASN'T BEEN LOOKED AT SKI MATICALLY, THIS IS A LOOK AT PATIENTS WITH OUR OWN INSTITUTION IDENTIFIED BY CD 45 AND CD 10, PRE-CD 19 CAR THERAPY WITH DUAL EXPRESSION OF CD 22 AND CD 19. THEN THIS IS AFTER CD 19 TARGETED THERAPY, WHERE THE PATIENT LOSES CD 19 EXPRESSION ON LEUKEMIC BLAST BUT RETAIN CD 22 EXPRESSION. WE LOOKED AT THIS ACROSS SIX PATIENTS WITH CD 19 NEGATIVE LEUKEMIA ON THE RIGHT. AND WE HAVE SEEN CD 22 EXPRESSION IN ALL THE PATIENTS, AND LEVELS ARE COMPARABLE WITH SMALL NUMBERS OBVIOUSLY TO 134 CONSECUTIVE PATIENTS SCREENED WITH CD 19 POSITIVE LEUKEMIA FOR CD 19 -- EXCUSE ME, B-22 IMMUNOTHERAPY TRIAL. CD 22 IS A GLYCOGLYCO PROTEIN, EXPRESSIONED IN NORMAL B CELL AT THE PRE-D CELL STAGE AND HE CAN EXPENDER TENDING TO MATURE, AND EXPRESSIONED ON MALIGNANCIES AS I SHOWED ON PRIOR SLIDE. SCHEMATIC OF THE CD 22 MOLECULE DOWN BELOW AND CONTRAST TO CD 19 IS LARGER IN THE EXTRA CELLULAR DOMAIN. THERE IS ALREADY CLINICAL EXPERIENCE TARGETING CD # 2 USING ANTIBODY BASED THERAPY, WANT TO BODIES THAT HAVE BEEN TESTED IN THE CLINIC, (INDISCERNIBLE) TESTED T AT OUR INSTITUTION IN ALL, THAT IS CONJUGATED TO PSEUDOMONAS EXOTOXIN, REMISSION RATE 57% FOR (INDISCERNIBLE) AND 24% INTERESTINGLY, (INDISCERNIBLE) NOT CONJUGATED TO A TOXIN, THERE'S NO RESPONSE RATE THOUGH THERE SEEMS TO BE SOME BENEFIT WHEN COMBINED WITH CHEMOTHERAPY. IN PARTICULAR AS HEMATOPOIETIC ANTIGEN, WE LOOKED AT EXPRESSION OF CD34 POSITIVE CELLS WHICH CONTAIN HSC. SCREEN MANY HEALTHY DONOR, IN THE BOTTOM SHOWING NEGATING STRATEGY, SHOWING CD POTTSTIVE CELLS, HIGH EXPRESSION CD 22 ON THE RIGHT HAND SIDE. CD34 ON THE LEFT-HAND SIDE SHOWING NO EXPRESSION OF CD 22 IN THE CD 133 DEPARTMENT AND CD 133 POSITIVE COMPARTMENT, ONE BEING ANOTHER PUNITIVE STEM CELL MARKER N. TERMS OF CD 22 EXPRESSION IN NORMAL TISSUE THERE IS PUBLISHED DATA RESTRICTED TO THE B LINEAGE. I APOLOGIZE FOR THE SIZE OF THIS SLIDE, THIS IS DATA FROM THE HUMAN PROTEIN ATLAS, PUBLICLY AVAILABLE DATABASE LOOK AT CD 22 EXPRESSION ACROSS A NUMBER OF TISSUES TON LEFT-HAND SIDE. TO FIENDISH CHEWS OR APPENDIX WHICH CONTAINS P LYMPHOID TISSUES. THIS IS IN CONTRAST TO THE CD 19 WHERE THERE IS ACTUALLY EXPRESSION FOUND IN THE NUMBER OF OTHER ORGAN SITES. WE RECOGNIZE THAT THIS IS NOT A COMPREHENSIVE (INAUDIBLE) SYSTEMATIC ASSESSMENT SO WE ARE IN THE PROCESS OF PERFORMING A CONFIRMATORY TUMOR MICROARRAY SCREEN IN COLLABORATION WITH PAUL SON SON IN VANCOUVER. SO BASED ON THIS DATA, WITHIN THE PEDIATRIC ONCOLOGY BRANCH WE DEVELOPED A CD 22 TARGETED CAR AND THE OBVIOUS PLACE TO START WAS USING THE, -- UTILIZED IN THE (INAUDIBLE) ANTIBODY. AND THE BINDING USED IN THE ANTIBODY IS AFFINITY ENHANCED MUTATED (INAUDIBLE). WHICH AGAIN HAS VERY HIGH AFFINITY FOR THE CD 22 MOLECULES. BUT WHAT WAS INTERESTING IS WHEN WE UTILIZED THIS AS A CAR CONSTRUCT AND TESTED THIS IN A LUCIFERASE EXPRESSED IN LEUKEMIA MODEL MICE INJECTED TO LEUKEMIA AND RECEIVED T-CELLSES ON DAY PLUS THREE. WE SAW NO ACTIVITY OF THAT CONSTRUCT SHOWN IN THE MIDDLE. SO THE GROUP WENT TO ADDITIONAL THAT WE CHANGED FROM (INAUDIBLE) AT NCI A FULLY HUMAN CONSTRUCT FROM A B CELL PHASE HUMAN B CELL DISPLAY T NAME IS N 97 # IN CONTRAST WE GOT (INAUDIBLE) ACTIVITY IN THIS MOUSE MODEL. THIS WAS ASSOCIATED WITH ENHANCED PERSISTENCE OF THE CAR T-CELLS, SHOWN DOWN BELOW ON THE RIGHT HAND SIDE LOOKING AT BONE MARROW AND SPLEEN RECIPIENTS OF THIS VERSUS THE CAR T-CELLS. BUT WHAT WE NOTED AS WELL, THOUGH INITIAL NICE RESPONSES IN THE XENOGRAPH SYSTEM THE MICE ULTIMATELY RECURRED SO THE RESPONSES WERE NOT DURABLE. AND SO IN AN EFFORT TO CONVERT THIS TO MORE DURABLE THERAPY WE TESTED CO-STIMULATORY DOMAIN 41BB. I FAILED TO MENTION IN THE PREVIOUS SLIDE WE USED CD 28 BECAUSE THAT WAS THE CONSTRUCT USED IN THIS CD 19 CAR TRIAL. WHEN WE TESTED THESE CONSTRUCTS SAME CONSTRUCT ONLY DIFFERENCE IS CO-STIMULATORY DOMAIN, WE SAW EQUIVALENT ACTIVITY IN IN VITRO SYSTEM LOOKING ATLYSIS OF LEUKEMIC BLAST. CHROMIUM RELIEF ASCESES SHOWN BELOW. WHEN WE PUT CELLS IN THE MICE WE SAW IN CONTRAST TO 28 CONSTRUCTS MICE RECURRED BY DAY 27 THESE RESPONSES APPEARED DURABLE. WE WENT TO COMPARE ACTIVITY OF CD 22 CAR EXPRESSING CD CELLS BEGIN UTILIZED IN CLINICAL TRIAL, WHAT WE HAVE SEEN ACROSS A NUMBER OF EXPERIMENTS COMPARABLE EFFICACY BETWEEN CD 22 CAR AND CD 19 CAR. SO BASED TON DATA WE PROPROPOSE A PHASE 1 TRIAL IN CHILDREN AND YOUNG ADULTS WITH CD 22 EXPRESSING LEUKEMIA OR LYMPHONA WITH THE PRIMARY OBJECTIVE BEING FEASIBILITY OF PRODUCING THESE CELLS. CHEMOTHERAPY REGIMEN STANDARD ACROSS ALL PATIENTS. STANDARD IS PHASE 1 DOSE ESCALATION DESIGN, WE CHOSE INCLUDE EXPANSION COHORT AT THE DOSE LEVEL WE CHOOSE ONE BELOW TOXICITY AND WE THINK IS ACTIVE. AT THAT EXPANSION COHORT WE PROPOSE STRATIFY WHETHER OR NOT PATIENTS PREVIOUSLY RECEIVED CAR THERAPY, A LOFT PATIENTS POTENTIALLY COMING OFF CD 19 CAR TRIALS WHAT'S SEEN IN THE COMMUNITY WITH CD 19 CARS IN THE PATIENTS WHO RESPOND AND SUBSEQUENTLY RELAPSE AFTER CD 19 CAR THERAPY, THEY FAIL TO RESPONDS SECOND REINFUSION OF CAR T-CELLS, THAT MAYBE DUE TO IMMUNOGENICITY OF THE MOUSE DERIVED IN THAT CONSTRUCT. GO BECAUSE WE'RE LOOKING AT EFFICACY IN THE EXPANSION COHORTS WE CHOSE TO STRATIFY BASED ON PRIOR CAR THERAPY. DOSE ESCALATION SHOWN BELOW, EXTREMELY CONSERVATIVE DOSE ESCALATION OF OF 110 TIMES TEN CELL PER KILOGRAM, TEN TOP THE 6 LOG HIGHER CELLS CURRENTLY USED IN MOST OF THE CAR CLINICAL PROTOCOLS. AS ANOTHER ADDITIONAL FEATURE OF THE DESIGN, WE REQUIRE IN THE PROPOSE TRIAL FIRST PATIENT EACH DOSE LEVEL BE OLDER THAN OR EQUAL TO AND CONSENT PRIOR TONE ROLEMENT ON THE TRIAL. THEY WOULD BE FOLLOWED FOR TOXICITY EVALUATION PERIOD BEFORE THE NEXT PATIENTS ALLOW TO ENROLL, WE'RE PROPOSING THOSE PATIENTS COULD BE CHILDREN. ELIGIBILITY IN THE TRIAL IS AGE 1 TO 30. TRYING TO CAPTURE PEDIATRIC AND YOUNG ADULT AGE RANGE BUT WE REQUIRE THAT PATIENT BE AT LEAST 15-KILOGRAMS SO PRACTICALLY SPEAKING ALMOST ALL PATIENTS WOULD BE AT LEAST FIVE YEARS OF AGE IN ESTIMATION. CD 20 -- THESE PATIENTS WOULD HAVE TO HAVE CD 22 E PRESSING LYMPHOBLASTIC LEUKEMIA, THEY HAVE TO HAVE MEASURABLE DISEASE GOING ON IN THE TRIAL, DETERMINED BY PHONE BONE MARROW EVALUATION AND ALLOW PATIENTS WITH RESIDUAL DISEASE. AS POINTED OUT INITIALLY, THESE PATIENTS NEED TO BE PATIENTS WHO RELAPSE AFTER THERAPY AND FAIL AFTER SECOND SUBMISSION OR HAVE RELAPSED DEBEST BEYOND THAT. WE DO WHAT WE WOULD ALLOW PATIENTS WITH CNF # OR 2 ON THE TRIAL, WE HAVE SEEN THE CD 19 CAR TRIAL THESE CELLS CROSS INTO THE CENTRAL NERVOUS SYSTEM AND SEEN CLEARANCE OF LEUKEMIC BLAST FROM THE CENTRAL NERVOUS SYSTEM. THESE PATIENTS NEED ADEQUATE CD 3 COUNT FOR APHERESIS TO COLLECT T-CELLS AND HAVE TO HAVE ADEQUATE ORGAN FUNCTION BY STANDARD CRITERIA. VECTORS PROPOSED IN THIS TRIAL WERE PRODUCED IN COLLABORATION AS PART OF A CREDA WITH STANDARD THIRD GENERATION PLASMID SYSTEM, THE TRANSFER VECTOR IS SHOWN ON THE LEFT INCLUDING CD 22 CONSTRUCT, DOWNSTREAM OF ES ONE ALPHA PROMOTER. THE ENVELOPE IS STANDARD DSVG ENVELOPE ON THE RIGHT. TWO ADDITIONAL PLASMIDS ONE CONTAINING RAD AND THE OTHER CONTAINING GAG PAUL ELEMENTS. SO THE CELL PRODUCTION FLOW DIAGRAM IS SHOWN HERE AND THIS IS RELEVANT TO CURRENT CD 19 TRIAL. IT WOULD BE IDENTICAL EXCEPT WHERE PATIENTS UNDERGO APHERESIS. PUT INTO CULTURE IMMEDIATELY OR SUBSTANTIALLY CRYOPRESERVED. PRIOR TO INITIATION OF CULTURE DEPENDING ON TIMING AND PATIENT STATUS. IT WILL CELLS UNDERGO CD 3 CD 28 B BASE EXPANSION PROCESS SAME IN CD 19 CAR TRIAL. THE TRANSDUCTION IS DONE IN BAGS INSTEAD OF RETRO NECTIN PROTOMEAN SULFATE A CLINICAL REAGENT GIVEN THE PATIENTS FOR REVERSAL, IS QUITE EFFECTIVE AT ENHANCING TRANSDUCTION EFFICIENCY. INSTEAD OF TWO DAY TRANSDUCTION WE PROPOSE ONE DAY TRANSDUCTION BASED ON DATA THAT I'LL SHOW YOU IN A MINI. THESE CELLS GROUNDS FURTHER EXPANSION AND PROBABLY AROUND AGE 9 TO 11 DEPENDING ON NUMBERS HARVESTED AND INFUSED IN THE PATIENT. USING CLINICAL GRADE VECTOR PRODUCED PRE-CLINICAL VALIDATION, THESE ARE HEALTHY DONOR CELLS. GIN GIVEN AS I POINTED OUT WITH ONE AND TWO TRANSDUCTION, WE GET VERY HIGH GENE TRANSFER 50, TO 60% LEVEL, WHETHER 24 TO 48 HOURS AFTER ACTIVATION WOMEN GET MARKED EXPANSION OF CELLS PARTICULARLY BEYOND DAY 4, APPROXIMATELY ABOUT (INAUDIBLE) 100 FOLD DEPENDING ON THE PATIENT OR DONOR. P AND SHOWN ON THE RIGHT ARE THREE PATIENTS TESTED USING THE VECTOR SHOWING TRANSDUCTION EFFICIENCY AND RANGING ABOUT OF L IN THE 50 TO 60 TO 70 FIRST RANGE IN AIL THE DONORS. WE CHECKED QUALITY OF CELLS PROSTACRYOPRESERVATION, AND HAVE FOUND THE TRANSDUCTION IS MAINTAINED, THIS IS SHOWING TRANSDUCTION LEVELS OF 42%, USING PROTEIN L AND 32% USING CD 22 SV DETECTION AGENT. THAT WE VALIDATED. THE PRODUCT IS 50% TRANSDUCTION EFFICIENCY GOING INTO CRYOPRESERVATION. POST DOC RECOVERY IS 72 TO 83% AND SAMPLES THAT CHECKED PRODUCED BY OUR CELL PROCESS P VIABILITY IS EXCELLENT AND I SHOULD NOTE THESE NUMBERS ARE COMPARABLE TO WHAT WE SEE WITH CD 19 CAR T-CELLS IN PREVIOUSLY PUBLISHED BY CELL PROCESSING SECTION. WE PUT THE CRYOPRESERVED CELLS BACK INTO THE MICE AND HAVE FOUND THEY RETAIN THEIR ACTIVITY, AT COMPARABLE DOSE LEVELS WHAT WE SEE FRESH INFUSION TYPE THE MICE. WE HAVE PRODUCED CLINICAL VECTOR THAT HAS BEEN TESTED AND PERFORMED THREE EXPANSIONS TO DATE, SHOWED TWO HERE. I WILL NOTE THAT THE SECOND PATIENT OR SECOND CELLS COLLECTED FROM A LEUKEMIC PATIENT ENROLLED IN CD 19 CAR TRIAL. SO EXCELLENT EXPANSION USING THE SCREEN BASED SYSTEM ON TOP, THE CONTENT IS IN THE SECOND BOX AND EXCELLENT TRANSDUCTION EFFICIENCY. 65 TO 70% LEADS IN THESE TWO EXAMPLES. WITH POTENT ACTIVITY IN THE BOTTOM EXAMPLE BEING CELLS PRODUCED WITH FROM THE ALL PATIENT THAT WAS UTILIZE FORD THIS TEST. SO THE TESTIFY TREATMENT SCHEMA, APHERESIS WITHIN 28 DAYS, THE CELLS CRYOPRESERVED AT THAT POINT OR PUT INTO CULTURE FRESH. WE PLAN FOR FRESH INFUSION IN PATIENT THOSE WE INCLUDE IN PROTOCOL OPTION TO CRYOPRESERVE THE CAR TRANSDUCE CELLS IN CLINICAL CONDITION ALL PATIENTS RECEIVE CHEMOTHERAPY TO ALLOW INTENT TO TREAT ANALYSIS IN THIS COHORT OF PATIENTS. CAR T-CELLS ON DAY ZERO AND LOOK FOR RESPONSE TOXICITY 28 DAYS AFTER INFUSION OF THE CAR T-CELL. JUST A FINAL SLIDE, AND A MENTION CYTOKINE RELEASE SYNDROME WHICH IS TOXICITY THAT HAS BEEN SEEN IN A NUMBER OF CD 19 CAR TRIALS. OUR GROUP IN COLLABORATION WITH UNIVERSITY OF PENNSYLVANIA DEVELOPED A ALGORITHM FOR MONITORING P FOR CYTOKINE RELEASE SYNDROME. IN PATIENTS AND PUBLISHED IN BLOOD. ON THE RIGHT HAND SIDE. ONE NUANCE IS DEVELOPMENT OF CYTOKINE RELEASE SYNDROME IN THE CAR TRIAL AND ABOUT IN LANSETT HAS SHOWN AND OTHERS HAVE SEEN THE SAME THING, THAT RESPONDERS TEND TO HAVE HIGHER LEVELS OF CIRCULATING CAR T-CELLS AND THOSE ARE THE ONES MOST LIKELY TO SHOW SOME DEGREE OF CYTOKINE RELEASE. SO THE IDEA IS TO MANAGE THESE PATIENTS EARLY ON BUT MAINTAIN ACTIVITY OF CAR T-CELLS SO THE RATIONALE FOR DEVELOPING TREATMENT ALGORITHM INCLUDED IN THE PROTOCOL. WITH THAT I WILL STOP MY PRESENTATION AND TAKE ANY QUESTIONS. >> THANK YOU VERY MUCH FOR THAT CLEAR PRESENTATION. OUR FIRST RAC REVEUR VIEWER IS DR. MAC -- MARCELLA SARZOTTI-KELSOE. >> CAN YOU HEAR ME? >> A LITTLEMENT TRY TO SPEAK LOUDLY. >> CAN YOU HEAR? >> THEY ARE GOING TO TRY TO ADJUST IT AGAIN, MARCELLA. HOLD ON ONE SECOND. >> OKAY, MARCELA, DO YOU WANT TO TRY ONE MORE TIME? >> YES. SO FIRST OF ALL (INAUDIBLE) (OFF MIC) MY FIRST QUESTION WAS REGARDING CONTRADICTORY STATEMENT REGARDING FUSION CRITERIA FOR (INAUDIBLE). AND (INAUDIBLE) MALIGNANT CELL GREATER THAN 30%. MY SECOND QUESTION WAS REGARDING (INAUDIBLE) (INAUDIBLE) FDA GUIDELINE, HOWEVER BY THE TIME (INAUDIBLE) ENVELOPE. MY THIRD QUESTION REGARDED I WAS INTERESTED IN FINDING HOW THE (INAUDIBLE) PERCENT RANGE OF THE (INAUDIBLE) CELLS (OFF MIC) NEXT QUESTION WAS REGARDING (INAUDIBLE) CRYOPRESERVED (INAUDIBLE) DR. FRY PRESENTED DATA ON THE VALIDITY OF USING THIS (INAUDIBLE) (INAUDIBLE) MINOR COMMENT BUT THEY WERE ALL ADDRESSED. (INAUDIBLE) SO HAPPY WITH THAT. DO YOU HAVE ANY QUESTIONS FOR ME? >> NO, NO, THANK YOU VERY MUCH FOR ALL OF YOUR COMMENTS, VERY HELPFUL AND INSTRUCTIVE AND CERTAINLY NOTE AD FEW THINGS IN THE PROTOCOL THAT NEEDED TO BE CHANGED. THANK YOU. >> THANK YOU. THE SECOND REVIEWER IN THE PROTOCOL, AND I HAD SOME SIMILAR QUESTIONS. IF FIRST WAS ABOUT THE NORMAL TISSUE DISTRIBUTION OF CD 22 AND WE JUST SAW NEW DATA THAT IF WE HAD SEEN A WHILE AGO CLINICAL TRIAL 19 MIGHT NOT BE IN CLINICAL TRIALS, C. CXFC 22 WOULD BE SO GOOD TO KNOW. THAT LOW LEVEL RESOLUTION LOOKS LIKE IT'S RELATIVELY LYMPHOID RESTRICTED THAT WAS YOUR COMMENT YOU HAVE OTHER STUDIES IN PROGRESS ALSO YOU REFER TO TODAY SO THAT WAS FINE. THE ISSUE BECAUSE THIS IS FIRST IN HUMAN T INITIAL COHORTS RESTRICTED TO EXCLUDING CHILDREN FROM INITIAL DOSING YOU GET A GOOD RESPONSE BUT I THINK I HADN'T SEEN BEFORE, EACH PATIENT AND EACH DOSE LEVEL WOULD BE ADULT. IS THE FIRST WE'RE HEARING THAT? >> TRIAL INITIALLY. (INAUDIBLE) REQUIRE FROM THE BEING THE FIRST PATIENT EACH DOSE LEVEL 18 OR OLDER. >> MISSED THAT. THAT SATISFIES THAT CONCERN. OBVIOUSLY I'M A PEDIATRICIAN SO I DON'T WANT TO EXCLUDES PEDIATRIC PATIENTS FROM THERAPEUTIC TRIALS BUT JUST DOING THE FIRST ADULT FOR DOSE ESCALATION A REASONABLE. MY THIRD QUESTION, THE ISSUE RAISED WAS THAT THE INCLUSION CRITERIA REQUIRED CD 22 AT 15% BY IMMUNOHISTOCHEMISTRY, 30% FLOW CYTOMETRY. YOU PROVIDED SOME DATA THAT SHOWED DENSITY OF DISTRIBUTION BUT I GUESS THIS WAS ONE I STILL WASN'T COMPLETELY CLEAR ON. THE DATA I INTERPRET LIKE MFI EXPRESSION, AVERAGE BIMODAL WITH BRIGHT CELLS, NEGATIVE CELLS, SO YOUR COMMENT WAS THAT ALL THE ONES THAT HAVE CD 22, MANY HAVE IT BUT STILL DIDN'T GET A CLEAR ANSWER ABOUT PERCENTAGE OF CD 22 POSITIVE CELLS THAT MAKE SENSE TO PURSUE THIS. >> I GUESS MY COMMENT WOULD BE BACK (INAUDIBLE) CD 22 IMMUNOTOXIN TRIALS, WHAT WE HAVE SEEN IS THAT ALL THE PATIENTS THAT WE HAVE LOOKED AT SHOWN IN THE DATA HAVE BEEN SCREENED FOR THE CD 22 IMMUNOTOXIN TRIAL. CD 22 POSITIVE THERE. IS VARIABILITY IN SIGHT DENSITY IN EACH OF THOSE PATIENTS AND WE ACTUALLY INTEREST IN FINDING THAT THE MLL REARRANGED PATIENTS HAVE LOWER EXPRESSION LEVELS OF CD 22 FOR REASONS THAT ARE NOT KNOWN AT THIS POINT. IN TERMS OF DISTRIBUTION OF CD 22 EXPRESSION ACROSS THE ENTIRE BLAST POPULATION IS FAIRLY CONSISTENT. SOME REARRANGED PATIENT VERSUS BIDER DISTRIBUTION THAN CD 22 EXPRESSION T. NUMBER AS INDICATE WED DON'T KNOW WHAT, HOW MANY CELLS NEED TO EXPRESS CD 22 OR WHAT THE SITE DENSITY NEEDS TO BE FOR RESPONSE. I WILL MENTION THAT THE CD 22 SITE STENS DENSITY IS LOWER THAN CD 9 SITE DENSITY, THAT WILL BE AN IMPORTANT THING WE LEARN FROM THIS TRIAL. TO WHETHER IT'S ANTIGEN CD 19 IS A UNIQUE ANTIGEN NOT REPLICATED WITH OTHER TARGETS, THAT'S POTENTIALLY SOMETHING IMPORTANT TO LEARN FROM THIS. BUT THE NUMBERS ARE NOT BASED ON DEATH DATA KNOWING EXACTLY WHAT THE EXPRESSION LEVEL NEEDS TO BE. WE CAN INCREASE THAT EXPRESSION LEVEL AND NOT LOSE MANY PATIENTS FROM OUR TRIAL BASED ON SCREENING SO FAR. BUT WE TRY TO BE CONSISTENT ACROSS ALL OF OUR TRIALS SINCE WE SCREEN NUMEROUS TRIALS. >> YOU GATHER THAT DATA ANALYZING SAMPLES FOREIGN ROLEMENT YOU'LL LOOK BACK TO SEE IF ONES AT LOWER PERCENT POSITIVE HAT POOR RESPONSE RATE. >> INTERESTING QUESTION THOUGH AS I SHOWED THE CD 22 EXPRESSION AND CD 19 NEGATIVE LEUKEMIAS APPEAR COMPARABLE WITH SMALL NUMBER, THEY THERE MIGHT A LOWER SITE DENSITY IN THOSE PATIENTS CD 19 NEGATIVE. THAT'S IMPORTANT FORS TO LOOK AT. THAT IS NOT SYSTEMATICALLY LOOKED AT SO SOMETHING ELSE WE POTENTIALLY LEARN FROM THE TRIAL. >> EXAMPLE BILL OF RELAPSE NEGATIVE 22 POSITIVE LOOKED VERY GOOD SO SUPPORT IT IS HYPOTHESIS. MY FOURTH QUESTION, TWO COHORTS PREVIOUS PATIENTS, IF SOMEONE FAILED YOU CLARIFIED WHO GOES WHERE IN TERMS OF THE PREVIOUSLY SEEN CAR ONES WITH CD 19 CAR AND HAD THE RECURRENCE AT SOME POINT THEY WOULD BE ELIGIBLE AND YOU ANALYZE SEPARATE STRATUM. >> RIGHT. WE WOULD ANALYZE BASED ON FIRST CAR T-CELLS. THE PATIENTS THAT ARE RETREATED WOULD BE BECAUSE THEY HAD INITIAL RESPONSE TO REINFUSION, WE WOULD ENROLL PATIENTS WHO BENEFITED FROM THE PRIOR CURRENT FUSION SUBSEQUENTLY RELAPSE BUT THE EVALUATION FOR RESPONSE, AS SECONDARY END POINT WOULD BE CONFINED THE THE FIRST COHORT AND THEY WOULD BE ENROLLED IN A FIRST COHORT AS P IF THEY HADN'T RECEIVED CAR THERAPY, THEY WOULDN'T BE SWITCHED TO THE SECOND, PREVIOUS CAR TREATED PATIENTS FOR SECOND INFUSION IF THAT MAKES SENSE. HOPE I STATE THAT CLEARLY. >> THAT RAISES ANOTHER -- YOU STILL HAVE CD 19 CAR TRIALS OPEN AND IF YOU HAVE A NEW PATIENT HOW THEY WOULD BE HOW THEY OFFER EACH STUDY? >> WE HAVE BOTH TRIALS OPEN. OR CLINICAL STEAM IS IN THE BACK AND WE TALK ABOUT THIS. WE HAVE PATIENTS WITH -- ALREADY THAT HAVE CD 19 NEGATIVE LEUKEMIA THAT WOULD CERTAINLY BE AMONG THE FIRST POTENTIAL TO BE ENROLLED ON CD 22 TARGETED TRIAL. I THINK IF WE'RE VERY FORTUNATE AND PATIENTS ARE FORTUNATE AND WE SEE RESPONSES TO THE CD 22 CAR IT BECOMES MORE CHALLENGES TO PICK BUT RIGHT NOW, I THINK WE SEE A LOT OF THOSE PATIENTS AND WE ALSO INCLUDE YOUNG ADULTS IN THE TRIAL AND JUST DUE TO AVAILABILITY OF SLOTS IN THE PRO-TWO PROTOCOLS POTENTIALLY ENROLL IN CD 22 CAR. RIGHT NOW EARLY PATIENTS ARE PROBABLY THOSE THAT RECEIVED CD 19 CAR AND DIDN'T RESPOND OR RELAPSE CD 19 NEGATIVE LEUKEMIA. >> MY FINAL COMMENT WAS THE CONSENT, I THOUGHT THEY WERE WELL WRITTEN FROM MY STANDPOINT, I LIKE YOU SPLIT TO ENROLLMENT CONSENT AND TREATMENT ONE, IS MORE WORK BUT SOME WAYS BETTER AND WE HAD A DISCUSSION PREVIOUSLY DOESN'T MEAN YOU'RE BEING TREATED ONE YEAR ENROLLED. THOSE ARE MY COMMENTS. THANK YOU. >> THANK YOU VERY MUCH. >> THE LAST REVIEWER IS DR. FOST. >> THANK YOU. THANKS VERY MUCH FOR YOUR PRESENTATION. MY FIRST COMMENT HAD TO DO WITH THINGS THAT I COULDN'T NINE ON THE CV AND HOPE YOU WEREN'T OFFENDED BY YOUR REPUTATION AND PEDIATRIC ONCOLOGY, AND P BONE MARROW TRANSPLANT IS NOT IN QUESTION. YOU ARE OBVIOUSLY A LEADER IN THE FIELD BUT I COULDN'T FIND ANYTHING ABOUT GENE THERAPY EXPERIENCE. YOU SUBMITTED INFORMATION SHOWING INVOLVEMENT PRIOR TO THE STUDY. >> FOR A GROUP THIS WOULD BE THE FOURTH GENETICALLY MODIFIED T-CELL TRIAL THAT WE WOULD BE OPENING IN THE PEDIATRIC ONCOLOGY BRANCH. >> THANK YOU. SECOND, P CONCERNS ABOUT CHILDREN SIMILAR ONE DR. KOHN RAISE BUD I DON'T KNOW I'M COMPLETELY SATISFIED BY YOUR RESPONSE YET. THIS IS A PHASE 1 STUDY, LIKELIHOOD ONE DOESN'T GO THROUGH THE TIME EFFORT MONEY TO GET TO A PHASE 1 STUDY UNLESS YOU'RE REALLY OPTIMISTIC THIS IS GOING TO BENEFIT, YOU ONE DO IT OTHERWISE. BUT THAT'S TRUE OF EVERY PHASE 1 STUDY SINCE THE BEGINNING OF TIME. THE CHUM CLINICAL BENEFIT IS LOW, I DON'T HAVE RECENT NUMBERS. YOU SAID IT'S IMPROVING BUT EARLIER DISCUSSION TODAY BEFORE YOU CAME THERE WAS A DISCUSSION ABOUT REFERENCE TO A 2005 NEW ENGLAND JOURNAL ARTICLE ABOUT RESPONSES TO PHASE 1 TRIALS AND THE SHORT ANSWER WAS FOR NOVEL AGENTS IN PHASE 1 TRIALS THE RESPONSE RATE THEN AT LEAST WAS STILL LESS THAN 5% AND FOR GENE THERAPY TRIALS IT WAS 3%. SO I UNDERSTAND THERE'S MORE -- LOT OF RECORD WATER OVER THE BRIDGE AND MAYBE THE NUMBERS ARE BETTER BUT THE PURPOSE OF PHASE 1 TRIAL IS SAFETY, DOSAGE, IT'S NOT CLINICAL BENEFIT, AND THE LIKELIHOOD OF BENEFIT OVERALL IS STILL LOW SO SEEMS TO ME IT WOULD BE PREFERABLE FOR A NEW AGENT TO BE TESTED AND SUBJECTS CAPABLE OF CONSENTING. THE SAFETY ISSUES T YOU REFERRED TO THE CD 19 TRIALS AND OUT OF 16 PATIENTS IN WHICH MAJORITY HAD HAD FAVORABLE BENEFICIAL EFFECT BUT THREE I NOTICE THREE OF 16 HAD SEVERE ADVERSE EVENT ONE LIFE THREATENING. SO THE TOXICITY IN THAT, I DON'T KNOW WHAT IT WILL BE WITH CD 22, IT WAS NOT TRIVIAL, BUT MAYBE EVEN MORE IMPORTANCE TO ME IS THE NUMBER OF PROCEDURES REQUIRED TO BE IN THIS STUDY. IT'S 7 LPs, AND 7 BONE MARROW BIOPSIES. >> ALL POINTED NOT RESPONSE LOOK ACROSS CHILDREN'S ONCOLOGY GROUP PROTOCOLS IN OUR CD 19 CAR TRIAL, WOULD BE FAIRLY STANDARD FOR LEUKEMIA PATIENT AND I POINTED NOT MY RESPONSE, IMPORTANT TO IDENTIFY EARLY RECURRENCE OF LEUKEMIA TO INTERVENE PARTICULARLY CENTRAL NERVOUS SYSTEM LEUKEMIA SO ALL PATIENTS IN THIS TRIAL WOULD HAVE RECEIVED COMPARABLE NUMBERS OF THOSE TYPES OF PROCEDURES IN PRIOR TREATMENT. >>LY COME BACCHANAL A MINUTE. FOR A FIVE-YEAR-OLD CHILD OR TEN OR 12-YEAR-OLD CHILD ADOLESCENTS THEY CAN UNDERSTAND THAT AND DECIDE WHETHER OR NOT TO GO AHEAD WITH IT. BUT YOUNG CHILD, 14 PROCEDURES NOT RISKY BUT VERY UNCOMFORTABLE IN CHILDREN THAT'S ALREADY HAD LOTS OF HOSPITALIZATIONS AND PROCEDURE, THIS IS NOT WELCOME. >> THE 14 CALCULATION IS NOT ENTIRELY ACCURATE, WE REQUIRE A BONE MARROW OR LP FOR ELIGIBILITY IN PROTOCOL, HAS TO BE DONE WITHIN TWO WEEKS OF INITIATION SAME FOR BONE MARROW PRE-TREATMENT, IT HAPPENS THAT WE HAVE TO REPEAT PROCEDURE CLOSER TO INFUSION TO LOOK FOR RESPONSE BUT MOST PATIENTS WE CAN USE THE SAME BONE MARROW. THERE'S ANOTHER BONE MARROW DAY 28. IF YOU STAY ON PROTOCOL, THEY CAN GET PROCEDURES BUT THE VAST MAJORITY OF PATIENTS ON THE CD 19 CAR TRIAL WENT TO GET CONSOLIDATED HEMATOPOIETIC STEM CELL TRANSPLANT DAY 28 TAKEN OFF OUR PROTOCOL FOR THAT TREATMENT. SO FOR OUR PROTOCOL BONE MARROW ELIGIBILITY AND BONE MARROW DAY 28 AND MAYBE ONE MORE. >> HOW MANY LP NECESSARY >> SAME NUMBER. CHEMOTHERAPY IS STANDARD FOR MANAGEMENT OF CENTRAL NERVOUS SYSTEM LEUKEMIA. WE HAVE STARTED TO DO LESS LPs THAN OUR PATIENTS BASED ON RESPONSE IN CENTRAL NERVOUS SYSTEM THAT WE HAVE SEEN IN THE CD 19 CAR TRIAL. Q. I WILL COME BACK TO THAT. THE NUMBER -- I ASKED YOU SAID THAT THE NUMBER OF PROCEDURES MAYBE P 7 AND I ASKED HOW THAT'S DECIDED AND YOUR ANSWER CLARIFIES THAT A LITTLE SO MAYBE AS FEW AS TWO OR THREE OF EACH, SIX PROCEDURES AND MAYBE AS MANY AS 7 OR 14 TOTAL. >> IF PATIENTS REMAIN ON TRIAL, DURABLE RESPONSES IN PATIENTS DON'T GO ON TO TRANSPLANT THEY WOULD BE FOLLOWED IN A CONSISTENT MANNER PATIENT WHOSE WOULD HAVE RECEIVED THE TRANSPLANT MUTATIONS THAT THE POINT WOULD HAVE BEEN PATIENTS WHO REMAIN IN REMISSION FROM THE CAR THERAPY. >> SO GOING THROUGH SEVEN OR HOWEVER MANY LPs BONE MARROW BIOPSIES FOR THERAPEUTIC PROTOCOL FOR ALL FIRST IMPRESSION VERY HIGH LIKELIHOOD OF CURE, IT'S WORTH IT, IT'S ARDUOUS AND UNCOMFORTABLE BUT TO HAVE A CHILD LIVE A NORMAL LIFE SWELL WORTH IT. THIS IS NOT THAT. THIS IS NOT -- THIS IS REMOTELY POSSIBLY CURATIVE THERAPY BUT THIS IS -- >> I DISAGREE WITH THAT STATEMENT AND I IN ALL DUE RESPECT I UNDERSTAND THE RESPONSE RATE PREVIOUSLY CD OF PHASE 1 STUDIES THE REASON WE HAVE OUR EXPANSION COHORT IN THERE THOUGH EXPLORATORY MANNER IF WE DON'T SEE A CR RATE OF 30% OR HIGHER IN THIS TRIAL WE WOULD NOT CHOOSE TO TAKE THIS FORWARD BASED ON GREATER THAN 80% COMPLETE REMISSION RATE IN THE CD 19 CAR TREATMENT TRIAL. OUR CONSTRUCT IS IDENTICAL TO THE CONSTRUCTS USED IN THOSE OTHER CAR TRIALS WHICH BINDS CD 22 AND AS SHOWED WITH TOXIN CONJUGATED ANTIBODIES WE HAVE RESPONSE RATES OF 25 TO 50% LARGE NUMBERS OF PATIENTS INCLUDING CHILDREN WITH ALL SO ACTUALLY ALTHOUGH I RECOGNIZE THAT IF YOU THEY CAN ALL PHASE 1 STUDIES THAT MAYBE CLOSE TO TRUE THOUGH I THINK THOSE NUMBERS ARE IMPROVING, I CHECKED WITH ORINASE 1 EXPERT IN THE BRANCH SHE'S IN THE PROCESS OF DOING A SYSTEM MA IT CAN ANALYSIS AND THOSE NUMBERS ARE CHANGING IN CHILDREN, TOXICITY IS IN FACT LOWER IN CURRENT PHASE 1 TRIALS IN THIS PARTICULAR INSTANCE I WOULD ARGUE THAT THE SITUATION IS POTENTIALLY DIFFERENT BASED ON EXPERIENCES CD 19 CAR. >> YOU SAID A REASON FOR LP IS IF THERE'S CNS RECURRENCE OTHER REMEDIES, THAT'S TRUE FOR A CHILD WITH FIRST PRESENTATION OF LEUKEMIA BUT THESE ARE CHILDREN ALL THESE ARE CHILDREN WHO FAILED TWICE AND FAILED BONE MARROW TRANSPLANT. SO IT IS NOT CLEAR THERE ARE OTHER REMEDIES. >> IF A PATIENT GOES IN TRIAL AND HAD HISTORY OF LEUKEMIA TREATED EFFECTIVELY WITH AS LOW AS 1800 CENTIGRADE RADIATION AND DEVELOP AD CNS RELAPSE IN AN EFFORT TO PRESERVE QUALITY OF LIFE, AND PREVENT MORBIDITY ASSOCIATED WITH CENTRAL NERVOUS SYSTEM LEUKEMIA KNOWING RELAPSE OFFERING THAT PATIENT PALLIATIVE RADIATION CENTRAL NERVOUS SYSTEM OVER A WEEK IS A VERY, VERY STANDARD WAY OF APPROACHING THOSE PATIENTS. >> INCLUDING PATIENTS THAT ARE WHO HAVE NO CURATIVE THERAPIES LEFT. >> THAT GETS TO THE ASSENT ISSUE. YOU SAID YOU WOULD GET ASSENT FOR CHILDREN OVER 12 MORE STANDARD AGE IS 7 AND YOU'RE COMFORTABLE WITH THAT. NO ASSENT LANGUAGE SUBMITTED AND YOUR RESPONSE HAD COMMENTS ABOUT YOUR CENTER DOES NOT TYPICALLY REQUIRE SIGN CONSENT FORMS. I AGREE. I DON'T THINK THERE'S MUCH POINT IN HAVING A 7-YEAR-OLD SIGN ANYTHING. ANY COMMENT WAS NOT ABOUT SIGNAGE, IT WAS ABOUT SIGNATURES, IT WAS ABOUT HAVING DRAFT LANGUAGE THAT GIVES THESE CHILDREN AGE 5 THROUGH ADOLESCENCE A REASONABLE CHANCE TO UNDERSTAND WHAT'S GOING ON. AND A CHANCE TO SAY NO. YOU SAY YOUR HONOR COMMENTS SAY IT'S TAKEN SERIOUSLY AT YOUR INSTITUTION. MY OBSERVATION IS THAT IT'S GENERALLY NOT TAKEN VERY SERIOUSLY. THAT IS ASSENT MEANS FOR PHASE 1 TRIAL THIS IS OPTIONAL, YOU DON'T HAVE TO DO IT IF YOU DON'T WANT IT. IT'S GOING TO INVOLVE STICKING NEEDLES INTO YOU, AND THIS IS NOT THERAPY, THIS IS NOTS ALL FIRST STAGE WE GO TO COURT OVER A PARENT WHO REFUSED TREATMENT. THIS IS NOT THAT. THIS IS OPTIONAL ACTIVITY. THIS IS WHAT ASSENT MEANS TO ME AND ALL I HAVE ASKING FOR IS A SCRIPT SO YOU AND COLLEAGUES AND NURSES AND OTHERS WHO TALKED TO PARENTS CAN BE STANDARD LANGUAGE ABOUT THAT. AND KEY POINTS INCLUDED WHICH THE SINGLE MOST IMPORTANT POINTES YOU DON'T HAVE TO DO IT IF YOU DON'T WANT TO. >> IF I UNDERSTAND, I APOLOGIZE IF I'M MISUNDERSTANDING REGARDING YOUR COMMENT. THERE ARE DISCUSSIONS WHETHER A SIGNED ASSENT FORM SHOULD BE ASKED FOR, SOUNDS LIKE YOU AGREE WITH MY FEELING. >> CORRECT. >> OUR FEELING ABOUT THAT. I HAVE HAD A NUMBER OF DISCUSSIONS WITH LEADERS IN THE PEDIATRIC ONCOLOGY FIELD INCLUDING LEADERSHIP AT THE CHILDREN'S ONCOLOGY GROUP ABOUT THIS ISSUE AS RELATES TO PHASE 1 STUDIES NUMEROUS PHASE 1 STUDIES CONDUCTED P CHILDREN'S ONCOLOGY GROUP, I DISCUSS THE LANGUAGE IN THE PROTOCOL AND THE LANGUAGE IS CONSISTENT WITH WHAT THEY USE IN ALL THE COG PHASE 1 TRIALS. I WILL AGREE THERE IS A MOVEMENT TOWARDS PROVIDING INFORMATION SHEETS THAT ARE DEVELOPMENTALLY APPROPRIATE. AND WILLING TO LOOK AT PLACES IN THE INFORMATION SHEET FOR THE PATIENTS, BUT WE AND ALL THE COG INSTITUTIONS TAKE ASSENT VERY SERIOUSLY AND IT IS NOT A SIMPLE DISCUSSION WE'RE GOING TO DO A FEW PROCEDURES AND TREAT YOU. ALL OF THIS WE'RE ALL PEDIATRIC ONCOLOGISTS IN THE BRANCH, WE ARE USED TO ASSENTING AT DIFFERENT DEVELOPMENTAL AGES THAT HAVE TO BE DONE FOR ALL THESE PATIENTS BEFORE THEY'RE ENROLLED IN THE TRIAL, THIS IS DOCUMENTED IN THE CHART, AND SO NO, I ACTUALLY THINK WE TAKE EXTREMELY SERIOUSLY IN OUR GROUP. >> I DIDN'T SEE ANY LANGUAGE IN THE PROTOCOL. >> NOT REQUIRED BY OUR INSTITUTIONAL REVIEW BOARD. THERE IS NOTHING IN THE OFFICE OF HUMAN RESEARCH SUBJECTS PROTECTION THAT REQUIRES A MANNER IN WHICH ONE OBTAINS CONSENT, IMIT SIMPLY SAYS ASSENT IS OBTAINED FROM CHILDREN WHO CANNOT CONSENT TO THE PROCEDURE. SO HISTORICALLY UP UNTIL NOW OUR IRB HAS NOT REQUIRED THAT AND THAT IS WHY WE HAVE NOT DONE THAT IN OUR PROTOCOL. >> WITH ALL RESPECT RESPECT THAT'S A SHORTCOMING OF YOUR IRB. I HAVE BEEN CHAIR FOR 31 YEARS INCLUDING HUNDREDS OF PEDIATRIC PROTOCOLS AND WE DO REQUIRE ASSENT LANGUAGE, NOT SIGNATURES BECAUSE SCRIPT THE PERSON CONNECTED, AND APART WHETHER THE IRB REQUIRES, I CANNOT THINK OF A REASON WHY YOU WOULDN'T DRAFT SUFFICIENT LANGUAGE SO THERE'SES ISENT MESSAGE SENT TO CHILDREN. >> LIKE I SAID, I CAN -- I WILL -- I AM WILLING TO LOOK INTO THAT. (INAUDIBLE) LOOK INTO THAT AND DISCUSSION THE IRB BUT I UNDERSTAND AND AGAIN AFTER DISKISSING WITH THE COG THERE'S A INFORMATION SHEET THE PATIENTS WILL BE GOING TO LOOK INTO DOING THAT ON THE TRIAL ABSOLUTELY. >> I WILL BE DELIGHTED TO SEE SUCH LANGUAGE. WHAT'S NEEDED IS A SIMPLE HALF PAGE PARAGRAPH SAYING WHAT'S GOING ON, THE SINGLE MOST IMPORTANT SENTENCE IS YOU DON'T HAVE TO DO THIS IF YOU DON'T WANT TO, I THINK IF WE SAID THAT THAT SENTENCE TRULY TO CHILDREN IN PHASE 1 TRIAL AS LOT WOULD OBVIOUSLY SAY NO. WHAT WANTS NEEDLES INTO THEM WHETHER ARM BACK OR BONE MARROW. AND THAT'S FINE. I DON'T THINK GENERALLY NATIONALLY IT'S BEEN -- I HAVE BEEN INVOLVED WITH A LOT OF NCI SPONSORED CHILDREN'S STUDIES AND I DON'T THINK THAT'S GENERALLY DONE. SO I WOULD LIKE TO SEE IT DONE, SEEMS TO ME HAVING DRAFT LANGUAGE IS COST FREE AND WOULD CLEAR THE AIR ON ALL OF IT. SECONDLY WITH REGARD TO THE CONSENT THE PARENTS WOULD SIGN OR PERMISSION THE PARENTS SIGN, THERE IS EXTENSIVE NIH GUIDANCE DOCUMENT ON THAT, I GATHER COLLUDE SOME TROUBLE ACCESSING. BUT I INCLUDED IN MY COMMENT A PARAGRAPH EXCERPT FROM THE NIH GUIDANCE YOU DID NOT REPLICATE THAT IN YOUR RESPONSE NOT SURE WHY BUT IT'S STANDARD NIH LANGUAGE FOR PHASE 1 GENE THERAPY PROTOCOLS. FOR THE REST OF THE COMMITTEE NOT PRESENT IN YOUR RESPONSE AND I DON'T KNOW IF THEY SAW MY ORIGINAL DRAFT, THIS IS FROM THE NIH GUIDANCE DONG. THE GENE TRANSFER IN THIS STUDY IS NOT LIKELY THE CHANGE THE NATURAL COURSE OF YOUR DISEASE. ROUGHLY LESS THAN 50%, THIS IS NOT MEANT TO BE A TREATMENT FOR YOUR DISEASE. THE MAIN PURPOSE OF THIS STUDY IS TO FIND IF THE EXPERIMENTAL INTERVENTION IS SAFE. THE INVESTIGATORS HOPE THE INFORMATION LEARNED FROM THIS STUDY CAN BENEFIT PATIENTS WITH THIS CONDITION IN THE FUTURE. THERE ARE ALTERNATIVE PARAGRAPHS TO THAT BUT THERE ARE ALL SIMILAR TO THAT. SO I'M NOT CLEAR FROM YOUR RESPONSE YOU SAID YOU WERE ABLE TO FIND SOME OTHER SOURCE DOCUMENT, I GATHER YOU'RE WILLING TO PUT A PARAGRAPH LIKE THAT BUT I HAVEN'T SEEN IT SO MAYBE CLARIFY YOUR PLANS. >> BE HAPPY TO INCORPORATE THAT LANGUAGE. >> I DON'T KNOW REQUIRED, SEEMS TO ME DESIRABLE. NEXT I HAD QUESTIONS ABOUT DATA MONITORING PLANNING COMMITTEE, YOU CLARIFIED THAT, IT'S IN THE A PROBLEM. IT'S NOT A PROBLEM. I SUGGESTED AVOIDING WORD TREATMENT IN THERAPY AND YOU WERE AGREEABLE TO AND THIS YOU HAVE AGREED TO CHANGE THAT. THERE WERE REFERENCE IN THE PROTOCOL TO EFFECTS ON COGNITIVE FUNCTION AND VARIOUS MEASUREMENTS YOU WERE GOING TO MAKE ABOUT THAT, IT WASN'T CLEAR WHAT THOSE TOOLS WERE GOING TO BE FOR INFANTS AND CHILDREN YOUNGER THAN FIVE. YOU HAVE SINCE CLARIFIED THAT THE ENTRY CRITERIA IS 15 DALE KILOGRAM SWISS LIKELY TO MAKE AT LEAST CHILDREN FOUR OR FIVE IN WHICH COGNITIVE EFFECTS ON COGNITIVE FUNCTION WOULD BE MORE LIKELY APPARENT BY JUST COMPETENT NEUROLOGIC EXAM. >> AND AGAIN I WOULD POINT OUT THAT ONE OF THE END POINTS IN THIS TRIAL IS (INAUDIBLE) CD 19 CAR TRIAL THERE HAS BEEN CYTOKINE RELEASE SYNDROME REVERSIBLE IN THESE PATIENTS BUT WE FELT IT WAS VERY IMPORTANT TO LOOK SYSTEMATICALLY, WE INCLUDED OR NEUROPSYCHOLOGISTS ON THE TRIAL THAT WILL AID US IN DOING THE SCREENING AND HAVE EXPERIENCE IN MONITORING CHILDREN WITH KNOWN PSYCHIATRIC FUNCTION IN ONCOLOGY TYPE TRIALS. >> INCLUDING LONG TERM FOLLOW-UP OF COGNITIVE FUNCTION? >> AS LONG AS WE CONTINUE TO SEE THE PATIENTS, CD 19 CAR TRIALS GOING BACK AND GETTING BONE MARROW TRANSPLANTATION WE RECEIVE SAMPLES ON THE PATIENTS AS REQUIRED FOR THERAPY PROTOCOL. >> WAS THAT IN THE PROTOCOL, MY QUESTION IS WHETHER THERE'S LONG TERM FOLLOW-UP OF COGNITIVE IMPAIRMENT. >> WE CHOSE TO KEEP SECONDARY END POINT EVALUATION SHORT. SO WE CAN CAPTURE THE MAJORITY TO HAVE PATIENTS WITHIN THAT 28 DAY EVALUATION PERIOD T PRIMARY QUESTION BEING BLUETOOTH CNS TOXICITY THAT DEVELOPED ACUTELY IN THE FIRST COUPLE OF WEEKS AFTER INFUSION REVERSIBLE BY DAY 28 EVALUATION PERIOD, IF THOSE PATIENTS RETURN WE WILL CERTAINLY CONTINUE TO MONITOR THEM FOR COGNITIVE FUNCTION. >> OKAY. JUST LAST, IS A RESPONSE TO INTERCHANGE WITH DR. KOHN ABOUT ENTRY CRITERION WHETHER YOUNG CHILDREN SHOULD BE INCLUDED, I AGREE CHILDREN SHOULDN'T BE EXCLUDED FROM ACCESS TO NOVEL REMEDIES FOR FATAL DISEASE BUT SEEMS TO ME PHASE 1 STUDIES ON OLDER CHILDREN AND ADULTS CAN FILTER OUT LARGE NUMBER OF NEW -- NOVEL AGENTS THAT AREN'T GO FOG GO ANYWHERE BECAUSE OF SAFETY OR OTHER CONCERNS SO THAT ONCE WE HAVE A STUDY THAT THIS PRODUCT IS REASONABLY SAFE SEEMS TO ME THERE'S A STRONGER ARGUMENT FOR INCLUDING CHILDREN IN PHASE 2 AND CERTAINLY PHASE 3 TRIALS. ONE WOULD HAVE -- WOULD WANT PHASE 1 STUDY IN YOUNG CHILDREN ALSO BUT SEEMS TO ME USE AGO ADULTS AND ADOLESCENTS AS FILTER FOR NOVEL AGENTS FOR INFORMATION I HAVE NAVAL GENTS STILL GENERALLY DON'T WORK THAT WOULD BE PREFERABLE. >> WHEN YOU SAY AD LESSENS I CAN I ASK YOU TO DEFINE THE ADOLESCENT AGE GROUP? >> 12 AND OVER. YOU MIGHT BE ABLE TO PULL THAT YOU HAVE WITH 12 AND OVER? >> I'M GOING TO LET OTHERS IN THE BACK OF THE ROOM, MY GROUP -- >> THAT WILL MAKE ME MORE COMFORTABLE. I MEAN, THE GENERAL 14 IS GENERALLY THE AGENT WHICH CHILDREN ARE CAPABLE OF OF THINKING LIKE ADULTS AND WEIGHING RISKS AN BENEFITS AND SO ON. THERE ARE TWO ISSUES UNRESOLVED, ONE IS ENTRY CRITERIA AND AGE -- ENTRY CRITERIA OF 12 OR 14 MAKES ME VERY COMFORTABLE WITH IT AND THE SECOND IS THE ASSENT PROCESS WHICH FOR ADOLESCENTS ONE STILL CALL IT ASSENT >> I THINK WE'RE IN AGREEMENT ABOUT THE ASSENT PROCESS THAT WE'RE WILLING TO MAKE CHANGES AND I THINK IT'S VERY REASONABLE TO INCLUDE INFORMATION SHEETS, ET CETERA. IT WAS A BIT OF A MISUNDERSTANDING REGARDING THE SIGNED ASSENT WHICH IS DISCUSSED AND WE FEEL STRONGLY ABOUT IT OR GUIDANCE, WE AGREE CRITERIA AGE 12 WE CERTAINLY HAVE PATIENTS YOUNGER THAN AGE 12 AND OUR GOAL TO ENROLL ANY CHILD ELIGIBLE ON BASIS OF CRITERIA, WE HAVE TO DISCUSS THAT AS A GROUP. BASED ON THE RECOMMENDATIONS. OUR BRANCH CHIEF IS IN THE BACK OF THE ROOM AND SHE'S ENTITLED TO COMMENT. >> IS IT AN APPROPRIATE TIME? >> DR. FOST, THANK YOU FOR YOUR COMMENTS AND YOUR CAREFUL REVIEW, THEY CAUSED A FAIR AMOUNT OF CONSTERNATION AND THAT'S A GOOD THING BECAUSE WE NEED TO CROSS-EXAMINE OURSELVES EVERY TIME WE ADMINISTER AN INVESTIGATIONAL THERAPY TO CHILDREN AND CERTAINLY THE BAR IS HIGHER. THAN FOR ADULT TRIALS. THAT SAID AS AN ETHICIST LOOKING AT THIS PICTURE, I UNDERSTAND YOUR OPINION BUT I CAN POINT OUT SEVERAL LOOKING AT THE SAME PICTURE TO COME ONE THE CONCLUSION THAT IT'S UNFAIR STOKES COLLUDE CHILDREN. BY NOT ENROLLING CHILDREN UNDER 12 YOU ARE EXCLUDING THEM. IF THEY HAD A DISEASE THAT COULD WAIT, IF THEY HAD INBORNE METABOLISM WHERE YOU COULD HAVE THE LUXURY OF DOING YOUR PHASE 1 TRIAL IN ADULTS, AND BRINGING IT TO PHASE 2 BEFORE YOU OFFER IT TO CHILDREN, SURE. WE WOULD LIKE TO DO THAT. THESE KIDS HAVE LEUKEMIA. IF THEY DON'T HAVE ACCESS TO AN INVESTIGATIONAL THERAPY WHEN THEY NEED IT THIS, THEY DIE. THEY MAY DIE ANYWAY BUT MOVE THESE FAMILIES AND CHILDREN, WE SPEAK TO THESE KIDS, CHOOSE TO GO DOWN TRYING. AND IN FACT, WE HAVE ALL BEEN INCREDIBLY BLOWN AWAY BY 90%, 84% BY SADELAIN GROUP AND 84% RESPONSE RATE TO CD CAR. PEOPLE ARE CLAMORING AT OUR DOOR FOR THIS CAR THERAPY. FORS TO SAY WE HAVE A NEW CAR, THAT LOOKS LIKE IT COULD RESCUE THE ONE WHO RECUR BUT NO CHILDREN UNTIL TAKEN TO PHASE 2 ADULTS, YOU'RE GOING LOSE SEVERAL CHILDREN ALONG THE WAY. AND AS FAR AS THERAPEUTIC THE BONE MARROW AND LPs THEY HAVE TO GO THROUGH, THIS IS ALL PART OF STANDARD CARE WHEN YOU HAVE LEUKEMIA. IT'S NOT LIKE IF YOU DON'T GONE A TRIAL YOU GO HOME AND FEEL GOOD. YOU WILL HAVE PEOPLE STICKING NEEDLES IN YOUR BACK. >> I WANT TO ASK A QUESTION ABOUT THE MARROWS AN LPs, WHAT PERCENTAGE ARE BUN DUNN UNDER CONSCIOUS SEDATION? >> 100%. >> FULL ANESTHESIA IF WE FEEL MORE APPROPRIATE WITH PEDIATRIC ANESTHESIOLOGIST. ATTENDING THE PROCEDURE. >> PEOPLE CLAMORING, I U ASSUME IT'S PARENTS. I DOUBT 7-YEAR-OLDS AT YOUR DOORSTEP. PARENTS OBVIOUSLY CARE DEEPLY ABOUT THEIR CHILDREN BUT ALSO A LOT OF TROUBLE LETTING GO WHEN A CHILD HAS A FATAL DISORDER SO PARENTS ARE FAMOUSLY WILLING TO TRY ANYTHING TO PARENTS ARE NOT CHILDREN ANDSYMES THEY OVER ENTHUSIASTIC OR SUSCEPTIBLE OVERENTHUSIASTIC REMEDIES. YOUR COMMENT THESE CHILDREN DIE IS CLEAR BUT THAT WOULD BE TRUE IF CHILDREN WOMAN YOU HAVE PROPOSED INTERVENTION HAS 1% CHANCE OF JUST PARTIAL RESPONSE. ISN'T THAT BETTER THAN NOTHING? FOR SOME IT IS, FOR SOME IT ISN'T. SO IF YOU TOOK ASSENT BOARD SERIOUSLY, YOU WOULD HAVE CONSIDERABLY LESS THAN 100%, YOU MIGHT HAVE 100% PARENTINGS SAYING LET'S GO BUT FEWER CHILDREN. AND I UNDERSTAND WE USE SEDATION THESE DAYS FOR THESE PROCEDURES BUT ALSO UNDERSTAND FOR SOME CHILDREN JUST GOING TO THE HOSPITAL, GOING TO THEIR DOCTOR, IS A BIG DEAL. IT'S JUST MY OPINION, I'M NOT REPRESENTING THE BIOETHICISTS OF AMERICA, OTHERS IN THE ROOM CAN SPEAK TO IT. THAT IS MY VIEW. THANK YOU. >> DR. FOST, ANYTHING ELSE? >> NO, THANK YOU. COULD YOU COMMENT ON THE AGE THRESHOLD? WHETHER YOU WOULD BE USER FRIENDLY TO UPPING THE AGE TO CHILDREN WHO COULD MEANINGFULLY PARTICIPATE IN THE DISCUSSION? >> WE HAVE NOT -- THE ANSWER IS THIS IS NOT A POLICY WE HAVE TAKEN. BECAUSE YOU CAN MAKE THE ARGUMENT THAT THE 12-YEAR-OLD IS NOT CAPABLE NOR IS IS THE 14 OR 15-YEAR-OLD AND THERE SOME 7-YEAR-OLDS WHO ARE. SO IT BECOMES AN ARBITRARY LINE. YOU END UP EXCLUDING CHILDREN BECAUSE THEY'RE YOUNG. FROM A POTENTIALLY CURATIVE THERAPY. TO WE WERE TALKING A THERAPY WITH 5% RESPONSE RATES BUT CHIMERIC RECEPTOR ANTIGEN FOR LEUKEMIA IS A BREAK THROUGH THERAPY, WHY CHOOSE TO RESTRICT THIS PHASE 1 WHEN YOU OPEN UP TO PORTFOLIO, NUMBER OF PHASE 1 TRIALS ADMINISTERED IN CHILDREN UNDER 18, THERE MUST BE 100, 150. TO SINGLE OUT THIS ONE AS UNETHICAL WHEN IT'S EXTENSION OF THERAPY WITH 90% RESPONSE RATE, IT JUST SEEMED ARBITRARY TO ME. >> WITH ALL RESPECT I JUST CAME FROM GIVING A LECTURE ON EXTENSIVE HISTORY OF INNOVATIVE THERAPY AND PEDIATRICS THEY WERE BREAK THROUGH THERAPIES WHICH KILLED TENS OF THOUSANDS OF CHILDREN, CAUSED UNBELIEVABLE HARM AFTER DECADES PEOPLE SAID WE SHOULD LOOK AT THIS, MAYBE WE SHOULD STUDY IT AND THEN FOUND OUT THINGS LIKE BICARBONATE THERAPY FOR RESPIRATORY ACIDOSIS WHICH IS GIVEN TO EVERY NEONATE IN NORTH AMERICA FOR 15 YEARS WITH ONLY ONE PERSON SAYING THIS IS CRAZY AND CAREFUL TRIALS WERE DONE, NOBODY DOES IT ANY MORE, I CAN GIVE YOU 50 EXAMPLES SO ENTHUSIASM IS GREAT. WHERE WOULD WE BE WITHOUT YOU WHO ARE TRYING THIS STUFF ANY I'M ALL FOR IT T. FDA APPROVES IT AND SAYS PROVEN SAFE EFFECTIVE IT'S WRONG TO WITHHOLD IT FROM SOMEBODY, THAT'S WHY I GO TO COURT WHEN WE HAVE A CHILD WHO HAS A DISEASE THAT HAS CURATIVE PROVEN SAFE EFFECTIVE TREATMENT LIKE STANDARD TREATMENT FOR ALL, THIS IS NOT YET STANDARD TREATMENT FOR ALL. IF YOU BELIEVE THE CENSUS SERIOUSLY YOU'RE OPEN TO THE FACT THAT SOME CHILDREN WILL DIE. SOME CHILDREN FOR WHATEVER REASON CRAZY IRRATIONAL INFANTILE FEAR THIS IS WILL SAY NO. IF YOU TAKE OFFENSE YOU'RE OPEN TO THAT. THAT'S PART OF WHAT ASSENT IS ALL ABOUT. >> DR. ZOLOTH IF I CAN GET YOUR HAND UP. >> I SPEAK FOR ALL BIOETHICISTS IN AMERICA. >> I SUPPORT -- I MEAN I SUPPORT NORM'S CONCERN THAT THE MOST YOU DEFEND YOUR TRIAL THE MORE WORRIED I GET. YOU THINK IT'S THERAPY AND NOT AN EXPERIMENT. AND IF IT'S AN EXPERIMENT IT COULD FAIL AND PARENTS NEED TO KNOW THAT. OF PARTICULAR INTEREST STATEMENT FOLLOWS CHILDREN ENROLLING HAVE A LIFE EXPECTANCY OF WEEKS TO A MONTH. WE VEAL NO OTHER CURATIVE OPTION AND MANY WILL HAVE A LIMITED TREATMENT OPTION OTHER THAN PALLIATIVE CARE IT'S CHILDREN WHO ARE IMMINENTLY DYING WITHIN WEEKS AND THEY NEED TO MAKE THE CHOICE NOT TO SPEND IT AS A RESEARCH SUBJECT IF IT'S RESEARCH, AND I BELIEVE IT IS YOU HAVE TO HAVE EQUIPOISE AND YOU HAVE TO FEEL LIKE IT MIGHT FAIL AS LIKELY AS IT MIGHT SUCCEED. WHILE I CELEBRATE YOUR OPTIMISM, LIKE NORM WE HAVE SEEN MANY OPTIMISTIC PEOPLE COME HERE AND IN OUR EXPERIENCE IRBs. AND IT'S SCIENCE. IF IT'S GOOD SCIENCE, IT WILL FAIL. THAT'S JUST MART OFFER THE DYNAMIC. WHEN YOU DESCRIBE THIS AS A CHANCE FOR A CHILD THAT'S SOMETHING DIFFERENT THAN A RESEARCH PROTOCOL. AND THAT CONFUSION HERE I THINK IS JUST FEEDS THAT ANXIETY DESPERATION OF PARENTS. I GO ON THE WEBSITE SEE WHAT'S PROMOTED AND IF IT'S A CHANCE FOR A CURE. GOD WILLING IT WILL BE. BUT YOU HAVE TO PROVE IT AND THESE ARE PATIENTS WHO ARE DYING PATIENTS IN YOUR WORDS, THEY HAVE A VERY LIMITED TIME TO SPEND WITH THEIR FAMILIES. AND YOU'RE ASKING THEM TO PLEASE BE PART OF BODIES THAT HOPEFULLY WILL SOON PROVE SUCCESSFUL SO NOT FOR THEM BUT OTHER CHILDREN IN THE FUTURE. THAT'S GOT TO BE MADE REALLY CLEAR TO THE KIDS. DOING IT, IT'S NOT EXCLUSIVE OF THE 7-YEAR-OLD, WHAT EXCLUDES THEM IS THEIR DISEASE. IF THEY HAVE DISEASE WITH NO KNOWN CURE YET THAT'S EFFICACIOUS. SOME PORTION OF KIDS THAT GIVE MEANINGFUL ASSENT THEY'LL BE GUINEA PIGS AND TESTED ON BEHALF OF THOSE 7-YEAR-OLD WHOSE ARE TRAGICALLY PERFORMING BUT NOT GOOD SUBJECTS FOR EXPERIMENTS. HA DOES THAT HELP YOU THINK IT THROUGH? OTHERWISE IT'S LIKE A WE DON'T BELIEVE IN THE THEORY. (OFF MIC) >> YOU WANT TO SEE WHAT WE'RE TALKING ABOUT WRITTEN DOWN? >> EVERY ONE -- >> WE'RE IN AGREEMENT. >> I THINK IT'S IMPORTANT especially given grade and noble positivity your family to describe it and use of word therapy which Dr. Fox said take the word therapy out, not only of the protocol but of your presentation to parents. AND TO CHILDREN. IT'S REALLY -- I'M TRYING TO HARD TO MAKE THIS DEFINITION AND OF COURSE BASIC THERAPY. OBVIOUSLY THEY DO. THEY'RE DIAGNOSE. THEY HAVE A MONTH. TWO MONTHS. YOU SAY THESE ARE SAVVY PARENTS THAT GONE ON INTERNET, OF COURSE -- THIS IS JUST AS LIKELY TO FAIL AS IT IS TUSSUCK SEED AND THAT'S WHAT IT IS TO DO THIS EXPERIMENT. OKAY. AS LONG AS I SEE THAT LANGUAGE, THAT WOULD MAKE IT EASIER TO APPROVE THE PROCESS. >> I WOULD BE HAPPY TO DRAFT THE LANGUAGE. NOT AT ALL, PURELY A MISUNDERSTANDING ABOUT THE SCIENTISTS THAT I THINK DISCUSSIONS VERY REASONABLE AND APPROPRIATE AND WE AGREE WITH THAT I HAD DISCUSSION WITH THE COG AND IT'S NOT REQUIRE FORD COG PROTOCOLS THROUGHOUT LOCAL IRBs BUT THEY'RE STARTING TO PROVIDE RELATIONSHIPS FOR CHILDREN IN OUR PROTOCOLS AS WELL. >> THAT'S HELPFUL AND WE USED THE NCI IRB AND FUNDED CANCER TRIALS AND ASSENT LANGUAGE IS ALWAYS IN THERE SO I'M PUZZLED WHY WITHIN MINI NIH IT'S NOT STANDARDS. (OFF MIC) NHLBI IRB SCIENTIFIC (INAUDIBLE) EVALUATE PROTOCOLS TO PROVIDE ASSURANCE AND WE HAVE ASSENT DOCUMENTS BEFORE NIH SCHOOL TEACH TORE PROVIDE USER APPROPRIATE LANGUAGE SO THERE'S LANGUAGE SPECIFIC MEDICATION MAKES ME YUCKY, THIS MAY HURT, (INAUDIBLE) I BELIEVE WE'LL PROVIDE YOU WITH LANGUAGE AS WELL THAT MEETS THE REQUIREMENT, WHAT'S REQUIRED BUT I THINK SIGN AID SENT DOCUMENT IS DIFFERENT FROM WHAT (INAUDIBLE) WHAT YOU WANT IS A (INAUDIBLE) OTHER PROTOCOLS. DOES YOUR STANDARD LANGUAGE THIS IS NOT PART OF YOUR TREATMENT, YOU DON'T HAVE TO DO THIS IF YOU DON'T WANT TO? >> I CAN EMAIL YOU THAT HAVE BUT ONE SAYS THIS IS SPECIFICALLY YOUR CHOICE, YOU CAN SAY NO, IF YOU DON'T WANT TO DO THIS. THAT'S IN THE AGE 5 TO 10 GROUP. SO WE WILL HAVE (INAUDIBLE) ALL BROKEN INTO DIFFERENT CATEGORIES AND WE HAVE THE SCHOOL TEACHERS PROVIDE TO MIC SURE IT IS AGE APPROPRIATE LADIES AND GENTLEMEN. -- APPROPRIATE LANGUAGE. Q. DR. FOST, IS THAT AMEN SOMEBODY JUST MAKE SURE. >> SO BIGGEST CONCERNS ARE THESE THINGS THAT ARE THEY ARE SO POTENT THEY CAN PRODUCE SEVERE TOXICITY FOR SOME UNEXPECTED OFF TARGET DEATH EVEN. SO DISTRIBUTION OF EXPRESSION IS IMPORTANT. TELL ME ABOUT THE PROTEIN ATLAS. REMIND ME WHAT IS THAT ASSAY, IHC? >> IMMUNOHISTOCHEMISTRY. >> SO LOW SENSITIVITY, A POOR TEST. >> YEAH. >> THERE IS GENE EXPRESSION DATA, WE BOOK THE GENE EXPRESSION DATA AS WELL. IT APPEARS TO BE VERY CONSISTENT WITH (INAUDIBLE) ATLAS, AS I SAID WE HAVE SORT OF AGREED WE DEFINITELY AGREE THAT THE SYSTEMATIC EVALUATION OTHER THAN IN THAT PUBLICLY AVAILABLE DATABASE IS PROBABLY LACKING TO A CERTAIN EXTENT SO WE AS PART OF A LARGE MULTI-INSTITUTIONAL PEDIATRIC IMMUNOTHERAPY GRANT COLLABORATE WITH PAUL SORNSEN WHO HAS A SYSTEMATIC (INAUDIBLE) SO HE IN THE PROCESS OF DOING THAT RIGHT NOW THEY VALIDATE THE ANTIBODY. >> A BIT OF A -- COMING FROM THE ANTI-CD 22 IMMUNE CONJUGATES WHAT DO YOU SEE FOR TOXICITY WITH THAT? >> IT'S INTERESTING, AND (INAUDIBLE) -- DR. SHAW CAN COMMENT ON TRAITBY. ONE THING THAT'S STRIKING SYSTEM THERE'S SO MANY DIFFERENT TOXICITIES DEPENDING ON THE (INAUDIBLE) WHICH MAKES UNIT'S NOT TARGET. DR. SHAW. >> (INAUDIBLE) QUITE VARIABLE (INDISCERNIBLE) HAS SOME TRANSAM MACE ALLOCATION, BUT AFTER TRANSPLANT THERE'S INCREASE RISK OF PHENO OKAY COLLUSIVE (INAUDIBLE) PARRISH RELATED TO THE IMMUNE CONJUGATE, THE (INAUDIBLE) CONJUGATE TO THE STATEMENT (INAUDIBLE) >> THAT TARGET IS ANTI-CD 33 WHICH IS MYELOID CELL MARKERS. OUR GREATEST CONCERN IS CAPILLARY (INAUDIBLE) SYNDROME AMELIORATED WITH THE USE OF DEXAMETHASONE AS STEROID PROPHYLAXIS. TIE DOWN THE INFLAMMATORY RESPONSE AND (INAUDIBLE) BUT THEN WE SEE LATER ON IS HEMOLYTIC SYNDROME WHICH IS WE DON'T HAVE A GOOD EXPLANATION WHY IT HAPPENS BUT IT'S A KIDNEY PROBLEM (INAUDIBLE) DYSFUNCTION WHICH AGAIN SEEMED TO BE RESULT OF A CUMULATIVE DOSE OF DOSE EFFECT OF THE TOXIN. WHAT WE DON'T KNOW CD 22 TARGETING, THESE ARE (INAUDIBLE) CD 22 NO (INAUDIBLE) MORE (INAUDIBLE) >> THAT'S THE FULL RANGE OF TOXICITY IN TERMS OF SERIOUS TOXICITIES, NOL NC-1 CARDIAC PROBLEM. >> IT'S A WHOLE RANGE, THESE ARE ALL (INAUDIBLE) AND WE ARE JUST STARTING PHASE 2 (INAUDIBLE). ASSOCIATED WITH IMMUNE CONJUGATE T MORE TOXIC THEY WOULD BE FOUND (INAUDIBLE) LAB ABNORMALITIES, NO CLINICAL SIGNIFICANCE. >> THEN THE NEXT IS -- ANOTHER QUESTION WOULD BE CAN YOU DEBULK PEOPLE OF THEIR DISEASE WITH THE ANTIBODY PRIOR TO THE CAR T INFUSION TO LIMIT CYTOKINE -- WELL, CYTOKINE STORM >> WE HAVE NOT, WE WEREN'T PLANNING TO DO THIS IN THIS TRIAL ANDLY TELL YOU ON CD 19 CAR TRIAL WE HAVE COMPLETED THE DOSE ESCALATION, DR. LEE COMPLETED DOSE ESCALATION ON THAT TRIAL. THERE IS CORRELATION BETWEEN DISEASE BURDEN AND TOXICITY, ONE QUESTION ON THE ONGOING EXPANSION COHORT IN THAT TRIAL IS ESTABLISH WHETHER PATIENTS WITH HIGH DISEASE BURDEN USING CHEMOTHERAPY TO DEBULK THOSE PATIENTS F IT'S A VERY GOOD POINT. IT BECOMES CHALLENGING WHEN TRYING TO EVALUATE TOXICITY IN PHASE 1 STUDY. SO WE DID NOT REQUIRE IT ON THIS, KEEP IN MIND THESE PATIENTS DO RECEIVE PSYCHOPHOSPHAMIDE WHICH ARE AGENT THAT DO ACTIVITY IN IN LIEU CHEMOIA PRIOR TO INFUSION OF CAR T-CELLS. >> DR. SADELAIN. >> I HAVE TWO QUESTIONS. THOUGH THEY HAVE BEEN PARTIALLY ASKED AND ADDRESSED. STILL WORTH ASKING. FIRST HAVE TO DO WITH CD 19 TAKEN AS A REFERENCE CD 22. BASED ON EVERYTHING YOU KNOW ABOUT THOSE TWO MOLECULES, THEIR BIOLOGY, THEIR EXPRESSION IN TUMORS MEAN FREQUENCY OF EXPRESSION, HETEROGENEITY OF THE AVERAGE LEVEL OF EXPRESSION AND THEIR PRESENCE ON PUNITIVE CANCER STEM CELLS OR PRESENT OR ABSENCE WOULD YOU EXPECT MORE CD 19 POSITIVE ALL RESULTING IN EMERGENCE OF CD 19 NEGATIVE VARIANT OR CD 22 POSITIVE TUMOR LIKELY LEADING TO EMERGENCE OF CD 2 -- CD 22 NEGATIVE VARIANT? >> THIS IS SOMETHING THAT MY LAB IS BEGINNING TO LOOK AT BECAUSE CD 22 BIOLOGICALLY IN NON-MALIGNANT B CELLS SEEMS TO BE INHIBITOR SIGNAL. AND SO DOUBLE KNOCKOUT MICE LOSE REGULATORY B CELL POPULATIONS. AGAIN, SEEMS TO BE MORE NEGATIVE REGULATOR OF SIGNALING, COULD BE RECEPTOR TUNING BECAUSE IT'S B CELL RECEPTOR POTENTIALLY BUT THE BIOLOGY IS REALLY NOT WELL UNDERSTOOD. SOMETHING PEOPLE ARE LOOKING AT. WE CAN GENERATE SOME OF OUR DATA WE'RE LOOKING AT IN THE LAB RIGHT NOW F. CO-CULTURE EXPERIMENTS USING CD 19 TARGETED THERAPY, WE CAN MORE EASILY GENERATE CD 19 NEGATIVE LEUKEMIA AND CD 22 NEGATIVE LIEU CHEMOY THE FACT IT MIGHT BE MORE IMPORTANT FUNCTIONALLY FOR THE LAST BUT IT IS DEFINITELY NOT (INAUDIBLE) EVALUATED. >> SO THANK YOU. THAT SETS MY SECOND QUESTION WHICH IS -- THIS WILL COME BACKNA DISCUSSION WHICH PATIENTS TO ENROLL. YOU PROPOSE TWO TWO TREATMENT COHORTS. >> EXPANSION ONLY NOT DOSE ESCALATION. >> BUT STILL ONE TO TREAT THOSE RELAPSED AFTER ACD CD 19 CAR THERAPY. AND CD 22 POSITIVE YOU WOULD TRY THIS BUT THEN YOU HAVE THIS OTHER GROUP IN PRINCIPLE, DON ALREADY ASKED THIS QUESTION, COULD BE TREATED WITH EITHER SINCE IT HAPPENS YOU HAVE BOTH PROTOCOLS. SO ONE HAS 70% RESPONSE RATE A AS YOU BEAUTIFULLY SHOWED US AND THE OTHER IS TOTALSLY UNKNOWN SO HOW ARE YOU GOING TO PROCEED ON THAT, AND THAT TOUCHES A LITTLE BIT ON THE LAST DISCUSSION WE HAVE HAD ABOUT ASSENT, CONSENT. >> WE HAVE HAD THOSE DISCUSSIONS, BEING THE INSTITUTION THAT HAS CD 19 CAR TRIAL OPEN, WE HAVE PATIENTS COME AND ESSENTIALLY REFRACTORY COMPLETELY CHEMOTHERAPY REFRACTORY LEUKEMIA WITH LARGE DISEASE BURDENS MRD NEGATIVE THAT ARE STILL ALIVE. WE HAD A DISCUSSION ABOUT WHETHER WE WOULD REQUIRE PATIENTS RECEIVE CD 19 CAR THERAPY BEFORE ENROLLENING THIS TRIAL AGAIN RELEVANT TO DR. FOST COMMENTING, IT CERTAINLY HASN'T BEEN FDA APPROVED SO (INAUDIBLE) THAT'S WHY WE HAVE THE ELIGIBILITY CRITERIA BUT YOUR POINT IS WELL TAKEN >> SO IT IS 70% UNKNOWN. BUT IT'S NOT THERAPY, AS DR. FOST REFER TO FDA APPROVED THERAPY. >> RIGHT. >> TO ME THAT'S AN INTERESTING DECISION. IT'S THEIR DECISION. >> YES. DR. ROSS. >> A TOPIC THAT WAS BARELY TOUCHED ON WHICH IS THE LONG TERM SINCE YOU'RE USING LANGUAGE OF CURATIVE, I GUESS I'M A LITTLE SAD WE'RE NOT DOING MORE TO UNDERSTAND THE LONG TERM NEUROLOGICAL COGNITIVE IMPACT BECAUSE THAT WOULD BE VERY IMPORTANT FACT WHEN WE HAVE MORE THAN ONE AVAILABLE THERAPY. FOR PARENT TO CHOOSE BETWEEN. >> WE WOULD LOVE TO BE ABLE TO SYSTEMATICALLY EVALUATE LONG TERM COGNITIVE ACCESS TO THESE PATIENTS BECAUSE I WOULD ASSUME THEY'RE ALIVE TO EVALUATE THAT TOXICITY FOR SURE. HARD TO BUILD THAT SYSTEMATICALLY IN THE PROTOCOL WHERE AGAIN OUR EXPERIENCE CD 19 CAR TRIAL HAS SHOWN US THESE PATIENTS COME ON TREATMENT AND LEAVE OUR INSTITUTION BECAUSE THEY HAVE CARE FOR MRD NEGATIVE REMISSION BONE MARROW TRANSPLANT AND HEMATOPOIETIC STEM CELL TRANSPLANT SO IT'S AN INTERESTING DISCUSSION WHETHER WE CAN TURN THIS INTO A CURATIVE THERAPY IN AND OF ITSELF BUT THAT IS NOT OUR DECISION THIS, IS THE PARENT'S DECISION. AND THE OTHER (INAUDIBLE) SO THE POINT IN ORDER TO WRITE THIS IN AND SYSTEMATIC SECONDARY END POINT WOULD BE VERY DIFFICULT, WITH PATIENTS ENROLLED IN TRIALSK TO HAVE AVAILABLE FOR EVALUATION. I WILL TELL YOU CONFIRMATORY WAY OUR INSTITUTION HAS BEEN VERY, VERY COMMITTED TO DOING COGNITIVE AND NEUROPSYCHIATRIC TESTING IN PATIENTS WITH (INAUDIBLE) CANCER, THE LONGER WE HAVE THOSE PATIENTS RECEIVING PATIENTS WITH FOLLOW-UP AND CONTINUE WITH THE FOLKS ON THE PROTOCOL LISTED AS (INAUDIBLE) INVESTIGATORS ON THE PROTOCOL. DR. MARTIN AND WALTERS, HAVE EXTENSIVE EXPERIENCE IN THIS AREA ALONG THE PROTOCOL, WOULD PLAN TO HE WILL VALUE WAIT PATIENTS AS LONG AS IT COULD, IF YOU WANT TO BUILD THAT IN A REQUIRED SECONDARY END POINT OR MANDATE SECONDARY END POINT BECAUSE NOT SURE ABOUT THE NUMBERS BUT WE SHARE YOURSELF CONCERN AND VERY MUCH LIKE TO HAVE INFORMATION. >> THIS IS MY FIRST MEETING SO I DON'T FULLY UNDERSTAND WHAT I'M DOING HERE BUT GIVEN THAT, I'M SHOCKED THAT WE DON'T HAVE REGISTRIES, FOR THESE TYPE OF TRIALS BECAUSE YOU'RE SO EAGER TO ENROLL KIDS. IF THEY REALLY DO BECOME CURATIVE WE HAVE 40, 50 HOPEFULLY EVEN MORE YEARS IF FACT WE'RE NOT DOING SYSTEMATIC. THAT'S NOT YOUR RESPONSIBILITY I'M JUST MENTIONING THAT BECAUSE I'M OVERWHELMED BY THE LACK OF FOR SIGHT. >> I'M ANSWERING QUESTION RELATED TO PROTOCOL. NOW ANSWERING THE QUESTION MORE BROADLY IN CHILDREN ONCOLOGY. IN CHILDREN'S ONCOLOGY GROUP IS PERFORMED EXTENSIVE BUT Q. BUT NOT GENE TRANSFER. Q. I'S A NEW FIELD IN ONCOLOGY. I CAN'T COMMENT ON GENE THERAPY PROTOCOLS FOR OTHER INDICATIONS I'M JUST SAYING IN THE ONCOLOGY WORLDH THE CHILDHOOD CANCER SURVIVORS GROUP HAS BEEN PERFORMING VERY SMALL TICK EVALUATIONS OF LONG TERM SURVIVORS OF CHILDHOOD CANCER TREATMENT AND WE'RE LEARNING IN SPITE OF THE OUTCOMES THAT I DISCUSSED IN MY FIRST SLIDE, THERE ARE LONG TERM SEQUELLA ASSOCIATED WITH THERAPIES AND WE'RE JUST NOW BEGINNING TO LEARN WHAT THOSE ARE BECAUSE NOW HAVE THE FIRST GROUP OF PATIENTS 30 YEARS OUT OF TREATMENT FOR EXAMPLE. LARGE NUMBERS OF PATIENTS SO THERE'S A LOT OF WORK BEING DONE IN THAT AREA IN GENERAL. ONCOLOGY. SO I ANSWERED THE QUESTION ONLY TO THIS RELATED TO THIS TRIAL AND WHAT WE LEARN FROM SMALL NUMBERS OF PATIENTS FOR TOXICITY ASSOCIATED SPECIFICALLY WITH THIS TRIAL. THE VAST MAJORITY OF CHILDREN ENROLLED FOR LEUKEMIA IN THE UNITED STATES ARE ENROLLED FOR COG TRIALS. MOST CHILDREN POTENTIALLY MONITORING FOR THOSE SORTS OF TOXICITIES MORE BROADLY AS PART OF THE COG TRIALS. >> UNLIKE ADULT CANCER, 80% COOPERATIVE GROUP STUDIES. >> UNFORTUNATELY THAT'S OLD DATA I.'S BEEN DECREASING IN THE PAST DECADE. SHOCKING OUR FOLLOW-UP HOW MANY KIDS DON'T KNOW THEY WERE TREATED FOR CANCER, THEY WERE TREATED CHILDREN AGE 5. I WISH WE WERE KEEPING BETTER DATA BECAUSE IT SHOULDN'T BE A CATCH UP WHICH IS REALLY WHAT HE EAR DOING IN LONG TERM SURVIVORSHIP CLINICS. >> AGREE COMPLETELY. I AGREE WITH YOU COMPLETELY ON THAT ONE. >> STUDYING THAT COHORT IN ISOLATION WOULDN'T BE INFORMATIVE, OBVIOUSLY HOW THEY COMPARE TO OTHER CHILDREN COMPONENTS TO OTHER THERAPYS THEY'RE GETTING. ANY OTHER QUESTIONS OR COMMENTS HERE? ANY OF THE RAC MEMBERS ON THE PHONE HAVE COMMENTS OR QUESTIONS? WE HAVE ONE PUBLIC COMMENT. >> POINT YOU MADE, I DON'T KNOW IF I'M THE ONLY PERSON WHO UNDERSTANDS. IN THE PROTOCOL IT SAYS THESE PATIENTS HAVE ONLY THIS CHOICE PALLIATIVE CARE, NO OTHER CURE RAYTIVE OPTIONS BUT DR. SADELAIN POINTED OUT THIS OTHER 70% THEY COULD CHOOSE SO IS THAT PRESENTED, IS IT NOT PRESENTED TO THEM? SHOULD THIS WILL BE A -- BE OFFERED OFFERED THAT F THEY FAIL THAT GIVE THEM THIS? WHAT DO WE THINK ABOUT THAT? >> CERTAINLY OUR INSTITUTION, SINCE WE HAVE CD 19 CAR TRIAL OPEN IT'S LIKELY TO STILL BE OPEN, THIS IS APPROVED FOR CHILDREN TO GO FORWARD IN CHILDREN IT WOULD BE OFFERED IF THEY MET OTHER ELIGIBILITY CRITERIA FOR THE CD 19 CAR TRIAL. WE OFTEN OFFER PATIENTS -- WE HAVE A NUMBER OF EARLY PHASE CLINICAL TRIALS, WE HAVE CD 22 ANTI-TOXIN TRIAL, PHASE 2 LEVEL AT OUR INSTITUTION. SO IT'S PART OF THE DISCUSSION WITH THE FAMILY IN THEY'RE OVER 18 THEY SHOULD BE PART OF THE CONSENT PROCESS AND DISCUSS WHAT THE OPTIONS ARE. THE QUESTION DR. SADELAIN WAS ASKING IS WHETHER THERE WAS REQUIREMENT THOSE PATIENTS CD 19 CAR T-CELL BEFORE ENROLLING ON THIS TRIAL, I JUST MADE THE COMMENT THAT RESPONSE RATE IS REMARKABLE FOR PHASE 1 STUDY, WE HAVEN'T HISTORICALLY REQUIRED PATIENTS GET A PHASE 1 TREATMENT BEFORE THEY GO IN ANOTHER PHASE 1 TREATMENT BUT IT'S AN INTERESTING DILEMMA, NICE ONE TO HAVE IN SOME WAYS. >> JUST TO CLARIFY MY COMMENT A LITTLE BIT, IT WASN'T THAT IT WOULD BE REQUIRED M FOR PROLONGED PERIOD, IT WAS MORE WHETHER YOU WOULD TRY YOUR CD 22 CAR FIRST AND CD 22 POSITIVE RELAPSE AFTER CAR THERAPY AND THEN IF YOU HAVE A GOOD INITIAL INSIGHT TO THE CD 22 THEN START PROPOSING THAT FIRST. >> I THINK PRACTICALLY SPEAKING THAT'S THE WAY IT WOULD WORK IN OUR CLINIC IS IF WE HAD PATIENTS ELIGIBLE FOR BOTH. WE WOULD CERTAINLY DISCUSS THE FAMILY, THEY WOULD CHOOSE BUT WE HAVE TO PRESENT THE DATA AVAILABLE FOR CD 19 CAR. AND MOST FAMILIES WOULD PROBABLY CHOOSE TO GO THAT ROUTE IF THAT WAS AN OPTION FOR THEIR CHILD OR THEMSELVES. SO I THINK PRACTICALLY SPEAKING THAT'S WHAT WILL HAPPEN, WE FEEL FORTUNATE AND SEE RESPONSES IN CD 22 CAR, THEY WOULD BE A DIFFERENT DISCUSSION. >> ONE QUICK Q SO IF THEY RESPOND TO CD 22 CAR WOULD THEY BE ELIGIBLE FOR SECOND TRANSPLANT? >> SO WE HAVE BEEN VERY CAREFUL ABOUT NOT NECESSARILY DICTATING WHAT IS DONE, MOST PATIENTS, ALL THESE PATIENTS WERE NOT CENTER THAT TREATS NEWLY DIAGNOSED LEUKEMIA, CENTER FOR PATIENTS FOR EXPERIMENTAL THERAPIES, EXPERIMENTAL PROTOCOLS. SO THEY ALL HAVE REFERRING INSTITUTION IN TRANSPLANT CENTER FOR LEUKEMIA PATIENTS SO THOSE DECISIONS ABOUT RECEIVING SECOND TRANSPLANT, FOR EXAMPLE THEY RECEIVE AFTER FIRST HEMATOPOIETIC STEM CELL TRANSPLANT MADE BY REFERRING INSTITUTION. >> THAT WOULD GIVE ANOTHER CHANCE FOR ANOTHER POTENTIALLY CURATIVE. >> WE FOUND ALL PATIENTS IN CD 19 CAR TRIAL IS AN OPTION. THE STORY FOR ACUTE LYMPHOBLASTIC QUEUE CHEMOIA, LOW LEVELS MC LEVELS .01% LEUKEMIA, IDENTIFY PRIOR TO BONE MARROW TRANSPLANT PREDICTIVE FOR TRANSPLANT. THOSE PATIENTS IF THEY HAVE A GOOD DONOR ARE NOT GETTING TRANSPLANTABLE CENTERS WE'RE SEE THOSE PATIENTS AND IF THEY ACHIEVE AN MRD NEGATIVE REMISSION, ALMOST ALL PATIENTS THAT HAVE THAT AS AN OPTION IN OUR TRIAL HAVE GONE BACK AND GOTTEN TRANSPLANTS INCLUDING SECOND TRANSPLANTS. >> SO THAT WOULD BE A FANTASTIC OPTION FOR THESE PATIENTS. Q. SLEUTHLY. >> THAT WOULD BE BE AVAILABLE WITH THE OTHER TREATMENT. >> THEY WOULDN'T BE TRANSPLANTED OTHERWISE, STANDARD OF CARE BECAUSE OF THE OUTCOME OF MRD POSITIVE LEUKEMIA. >> OKAY. THANK YOU. SO LET ME READ -- WE HAVE A COMMENT FROM SORRY, IS THERE SOMEONE HERE WHO WANTED TO COMMENT? (OFF MIC) MONOPOLIZE TEN MINUTES -- (OFF MIC) (OFF MIC) EAR INFECTION, OUR DAY UNFOLDED TO THE DIE DIAGNOSIS, THE SHOCK EVERY PARENT THE CHILD IS A CANCER PATIENT. (INAUDIBLE) LEUKEMIA. THE WORD WAS TERRIFYING ENOUGH ON ITS OWN BUT AS FIRST FEW DAYS THE NEWS GREW WORSE, WE LEARNED THE DIFFERENCE BETWEEN LYMPHOBLASTIC AND MYELOID AND WE WERE CRUSHED TO FIND OUT IT WAS MYELOID. WE LEARNED THE FAB CLASSIFICATION (INAUDIBLE) (INAUDIBLE) WHY (INAUDIBLE) WE READ EVERYTHING WE COULD FIND AND CONFRONTED WITH THE NAUSEATING PHRASE, DISMAL PROCESS. HER ONCOLOGIST (INAUDIBLE) AND TOLD US SHE HAS A CHANCE IT'S JUST NOT A VERY GOOD ONE. FROM THE AGE OF 16 MONTHS TO JUST OVER TWO YEARS SHE SIMPLY ENDURED, ROUND OF ROUND OF SURGERIES INFECTIONS RADIATION, AND A ILL FATED CORED BLOOD TRANSPLANT. AS A PARENT IT'S PAIN TO FEEL SUBMIT YOUR CHILD TO TO THAT LEVEL OF SUFFERING BUT CARRIED US THROUGH WITH THE RIGHT THERAPY SHE MIGHT HAVE A SHOT AT SURVIVAL. THAT WASN'T TO TO BE AND ON DECEMBER 1st 2006 SHE DIED AT HOME SURROUND BY FAMILY IN MOTHER'S ARMS. I REMEMBER THE CONVERSATION (INAUDIBLE) HAVE THE TALK THAT WE HOPED AGAINST ALL ODDS TO NEVER HAVE. I DIDN'T HAVE THE PRESENCE OF MIND TO WRITE DOWN EXACTLY WHAT WAS SAID BUT I THINK ANYBODY SPENT ENOUGH NAME PEDIATRIC ONCOLOGY KNOW IT IS VIRGIN ISLANDS THINGS ARE NOT GOING AS WELL AS HOPEDS THAT POINT, THERE ARE NO OTHER TREATMENT OPTIONS AND WE NEED TO FOCUS ON KEEPING HER COMFORTABLE NOW. HER PRIMARY THOUGHT IS ONE OF THESE DAYS LEUKEMIA IS SOMETHING TO CURE A SINGLE INJECTION BUT IT'S NOT WHERE WE ARE RIGHT NOW. I TRIED MY BEST TO GET ON WITH THE BUSINESS OF LIVE BUG COULDN'T RESIST OCCASION TO SEARCH THE WEB FOR SIGNS OF REAL PROGRESS AGAINST AML. THE NEWS WAS ABSENT OR CONSISTENTLY DEPRESSION UNTIL I READ THE FIRST PRESS RELEASES TOUTING EMMA WHITE HAS INCREDIBLE AGAINST ALL ODDS RECOVERY FROM OTHERWISE INCURABLE LEUKEMIA. THEY USED HIV TO REPROGRAM HER BODY TO FIGHT CANCEL? I WAS BLOWN AWAY BY THE NOVELTY OF THE CONCEPT. AND PLEASANTLY SHOCKED THAT FINALLY WE WERE GETTING CLOSE TO REAL BREAK THROUGH. IT WASN'T A CURE FOR AML BUT IT WAS GOING HELP SOMEBODY ELSE IN A HOPELESS SITUATION. AS IT TURNS OUT, AFTER ELSIE'S DEATH WE DECIDED TO TRY FOR ANOTHER CHILD. SOME PEOPLE MIGHT THINK AFTER LOSING A CHILD TO A RARE CANCER WE WOULD BE MORE KEPT AL ABOUT PROBABILITIES BUT WE FELT CERTAIN A DISEASE AS RARE AS HERS WASN'T ANYTHING HEREDITARY T. DATA INDICATED A MINOR INCREASE IN CHANCES THAT A STILLING MIGHT HAVE SAME ISSUES AND BESIDES A LOT OF OTHER CANCER KIDS FAMILIES WENT ON TO HAVE CHILDREN DOING JUST FINE. SO WE DID WHAT PARENTS DO AND JUNE 7TH 2008 OUR SON JOINED OUR BROKEN CLAN. HE WAS EVERYTHING WE NEEDED TO HELP GET PAST THE TRAUMA OF LOSS AND FOUR AND A HALF YEARS LIFE WAS GOOD. ALMOST NORMAL AGAIN UNTIL MARCH 2013. A MONTH OR SO AFTER FIRST READ ABOUT THE CAR T-CELL MY WIFE TOOK HIM TO THE DOCTOR H. HAD A PERSISTENT LOW GRADE FEVER AND SORE THROAT SHE WANTED TO RULE OUT SHE SETTLED FOR APINTMENT WITH A UNFAMILIAR PEDIATRICIAN. THE DOCTOR FOUND SWOLLEN LYMPH NODES AND POINTED OUT A RASH ON HIS TORSO, TRYING TO SWALLOW RISING PANIC MY WIFE ASKED DOES THAT LOOK LIKE PETECHIAE TO YOU? AFTER A WHILE HE RETURN AND SAID THERE WAS SOMETHING WRONG WITH THE FIRST SAMPLE T NUMBERS WERE WAY OFF, PROBABLY A CLOT AND THEY NEEDED TO REPEAT THE TEST. AT THAT POINT SHE KNEW BEFORE THE POOR MEDPEDIATRITION DID AND I GOT THE SECOND WORST PHONE CALL. AS WE WENT THROUGH THE INTAKE PROCESS WE WERE CONVINCED WE WERE GOING TO REPEAT THAT AWFUL YEAR. BUT TO OUR SURPRISE THE PATHOLOGY REPORTS INDICATE LYMPHOBLASTIC LEUKEMIA. HIS PRESENTING LEUKOCYTE COUNT WAS 150,000, AND HE WAS INITIALLY CLASSIFIED AS HIGH RISK ALL, BUT AT THAT POINT ALL WE FOCUSED ON WAS THANK GOD IT'S NOT MYELOID. BAFFLED BUT HOME WE WENT THROUGH THE HIGH RISK INDUCTION PROTOCOL AND CELEBRATED HIS GOOD EARLY MORPHOLOGICAL RESPONSE. ALL THAT WAS TURNED UPSIDE WOULDN'TDOWN WHEN HIS MRD CAME BACK AT 2% POSITIVE. OVER THE NEXT THREE MONTHS THROUGH SEVERAL ROUNDS OF CHEMO AND --RY LICK DOUSE LIVER ENZYME ISSUES AND OTHER SIDE EFFECT IN THE BOOK HIS MRD LEVELS DIPPED SLIGHTLY AND BEGAN CREEPING UP AGAIN, IT BECAME BLAZINGLY OBVIOUS WE WERE DEALING WITH PRIMARY REFRACTORY DISEASE. WE BEGAN SCRAMBLING TO SAVE OURBY. CHEMOTHERAPY WOULDN'T DO THE JOB AND BONE MARROW WAS A LONG SHOT AT BEST UNLESS A SOLID NRD NEGATIVE REMISSION. CAR 19 TRIALS WERE ACTIVELY RECRUITING AT THREE SILTS. CHOP SLOAN AND HEN WE BEGGED THE TEAM TO REACH OUT TO ALL THREE AND FORTUNATE FOR US THEY DID. UNBLAKE OTHERS WHO SHALL GO NAMELESS, DR. LEE AT NIH ENTHUSIASTICALLY RETURNED THE CALL AND AFTER A FEW FALSE STARTS HE WAS ABLE TO GET INTO THEIR TRIAL. HE HAS A ROBUST RESPONSE AND BY END OF SEPTEMBER DECLARED MRD NEGATIVE. THE (INAUDIBLE) MATCHED UNRECOMMEND DODD NOR OCTOBER 23RD, 2013 AND LONG STORY SHORT, THANKS TO AMAZING COMBINATION OF LUCK PERSISTENCE EXCELLENT HEALTHCARE PROVIDERS AND GOOD SCIENCE, OUR NOW GENETICALLY MODIFIED FULLY IRRADIATED HEMATOLOGICALLY TRANSGENDERED CHIMERA STARTED KINDERGARTEN LAST MONTH. HE HAD A CYTOKINE RELEASE SYNDROME AND NO, THE IN PATIENT ROOM SERVICEMEN EWE DESCRIPTIONS AT NIH ARE NOT REPRESENTATIVE FOODS DELIVER BUDS CALORIST ARE CALORIES AND TOE LOUGH TOXICITY OF CAR APPROACH GAVE HIM TIME TO HEAL AND GROW STRONGER. I'M NOT GOING TO SAY TRANSPLANT WAS EASY PROCESS FOR HIM BUT HE WENT HEALTHIER THAN MOST AND THE EXPERIENCE WAS. FAR CRY FROM THE TORTURE YOU ARE YOUR DAUGHTER ENDURED BEFORE. OUR FAMILY IS NOT GOOD PREDICTING THE FUTURE BUT FOR NOW THE SON IS OFF THE MEDS AND HES IS THRIVING. WE'RE CAUTIOUSLY OPTIMIST AND GRATE FOR THE AMAZING PEOPLE WE HAD THE PRIVILEGE OF DEPENDING UPON THROUGHOUT THIS OR DEAL. THE TEAM AT NIH WAS COMPETENT INNOVATIVE COMPASSIONATE GROUPS I HAVE EVER METS AND TRIUMPH AND TRAGEDY EXCELLED AND I'M DEEPLY HOPEFUL THAT THEY CAN CONTINUE THEIR WORK TO ADVANCE SCIENCE AND SAVE CHILDREN'S LIVES WITH THE NEW ANTI-CD 22 VARIANT CAR AS SOON AS HUMANLY POSSIBLE. I KNOW SEVERAL FAMILIES OF CHILDREN WITH B CELL MALIGNANCIES THAT HAVEED THAT HAD THE TALK WITH THE TRIER TEAMS. THEY HAVE LITTLE TIME AND NO GOOD OPTIONS LEFT. MOVING THIS TRIAL FORWARD NOW WILL NOT SAVE ALL BUT FOR MANY IT'S THEIR BEST SHOT AS REAL FUTURE TOGETHER. IT MIGHT NOT BE THE SINGLE INJECTION CURE WE'RE LOOKING FOR BUT IT'S INFEW LIT KNIT LIBERATES THAN DISMAL PROGNOSIS. THANK YOU. -- INFINITELY BETTER THAN DISMAL DIAGNOSIS. THANK YOU. >> THANK YOU VERY MUCH. >> HELLO, THANK YOU FOR THE OPPORTUNITY TO BE HERE TODAY. I WANT TO PERSONALLY THANK YOU FOR THE WORK THAT YOU DO. MY NAME IS SUSIE MATTER BUT MOST KNOW ME AD COLTON'S MOM. FIVE YEARS AGO TODAY WE HEARD THE WORDS FOR THE FIRST TIME YOUR SON HAS CANCER, THOSE THOSE WORDS ARE SCARY BUT COLTON HAS BEEN -- EXCUSE ME, COLTON HAS BEEN CALLED TO BATTLE LEUKEMIA FIVE TIMES IN FIVE YEARS, FIVE TIMES TOO MANY. WITH EACH BATTLE CRY THERE BLESSINGS OF REMISSION IN BETWEEN, DURING THOSE BLESSED REMISSION MONTHS I KNOW DOCTOR LIKES YOU ARE WORKING TIRELESSLY IN THEIR LABS RESEARCHING TESTING, EXPERIMENTING AND LOSING SLEEP AT NIGHT. WHILE TAKING BABY STEPS AND THANKFULLY GIANT STEPS, TOWARDS FINDING A CURE. WITH EACH BATTLECAL THE CONVERSATIONS WITH DOCTORS GETS INCREASINGLY MORE TERRIFYING THE LIST OF OPTIONS TO TREAT AND CURE COLT ON'S CANCER GETS SHORTER AND SHORTER. WHEN COLTON RELAPSED LAST YEAR WE WERE TOLD BY OUR DOCTOR THERE WAS NOTHING ELSE HE COULD DO. TO HEAR THOSE WORDS AT A PARENT CHANGES YOU. IT CAN SHRIVEL YOU UP ON YOUR BEDROOM FLOOR OR MAKE YOU FIGHT LIKE YOU HAVE NEVER FOUGHT BEFORE. THAT IS WHY I'M I TRAVELED FROM SEIALITY. COLT ON ISN'T DONE FIGHT ORGANIZE LIVING. HE'S MY 14-YEAR-OLD SON WHO JUST START HIDE SCHOOL WHO LOVES TO LAUGH, LOVES TO PLAY A MEAN GAME OF BASEBALL. LOVES LIFE AND JUST WANTS TO BE NORMAL. THANKFULLY OUR DOCTOR WAS WRONG LAST FALL AND AFTER ADDITIONAL RESEARCH THERE WAS SOMETHING ELSE. FOR COLTON AND AFTER MANY TRIPS TO PHILADELPHIA, HE WAS BLESSED PEDIATRIC PATIENT NUMBER 22 ON THE CLINICAL TRIAL TARGETING CART 19 CELLS, AFTER THIS TREATMENT HE WENT TO IMMEDIATE AND COMPLETE REMISSION AND STAYED THAT WAY FOR NINE BEAUTIFULLY BLESSED MONTHS UNTIL WE LEARNED HIS CANCER WAS BACK LAST MONTH. TO SAY COLTON IS A WARRIOR SAN UNDERSTATEMENT, HE'S BATTLED THROUGH THREE BONE MARROW TRANSPLANT AND ONE T-CELL IMMUNOLOGY TREATMENT AND HE'S NOT DONE YET. IF YOU SAW HIM WALK DOWNING THE STREET YOU WOULD NEVER KNOW THE BATTLES HE FACED AND WON. COLTON IS A PRIME CANDIDATE FOR THIS CLINICAL TRIAL TARGETING THE CD 22 CELLS BECAUSE THAT IS HOW HIS CANCER HAS COME BACK EXPRESSING CD 22 AND NO LONGER CD 19. IN MANY WAYS COLTON IS HELPING THE WORLD FIND A CURE TO THIS HORRIBLE DISEASE HELPING DOCTORS FIGURE OUT WHAT CANCER CAN AND CAN'T DO. AND ALSO WHAT PATIENTS ARE WILLING TO DO TO LIVE. OUR T-CELL DOCTORS HAVE TREAT IN ORDER THAN 25 KIDS WITH 90% GOING TO A COMPLETE REMISSION. I KNOW MANY MY HEART THIS CLINICAL TRIAL AND DISCUSSION HERE TODAY WILL DO THE SAME AND SAVE SO MANY LIKE COLTON WHO HAVE WHERE YOU KNOW OUT OF OPTIONS, AND THIS IS THEIR ONLY HOPE LEFT. COLTON'S BONE MARROW WAS 40% LEUKEMIC CELLS A MONTH AGO AND AFTER THE FIRST ROUND OF CHEMO IS NOW LESS THAN 1%. AMEN. HE SHOULD BE MAKING PLANS FOR THAT FRIDAY NIGHT FOOTBALL GAME COLTON IS STARTING HIS SECOND ROUND OF CHEMO TO KEEP THIS HORRIBLE DISEASE AT BAY, THE BEST WE CAN. UNTIL THERE IS AN OPTION. THIS TRIAL IS THE OPTION HE NEEDS TO SAVE HIS LIFE OR GIVE A SHOT AT IT. I DON'T SAY THESE WORDS LIGHTLY. I SAY THEM WITH EVERY FIBER OF MY BEING. THROUGH HIS ACTIONS, THROUGH HIS WORDS COLTON ISN'T DONE LIVING. HE'S GOT PLANS TO ATTEND FOOTBALL GAMES, HE'S GOT PLANS TO GO TO COLLEGE. AND HE'S MAKING NEW PLANS EVERY DAY. BECAUSE HE'S A FIGHTER AND HE HAS HOPE. PLEASE DON'T DELAY IN APPROVING THIS CLINICAL TRIAL. PLEASE DON'T LET HIM DIE WAITING. THIS IS COLTON. I FEEL LIKE THERE'S SOMETIMES NO FACE BEHIND THE NAME. THANK YOU VERY MUCH FOR YOUR TIME. >> THANK YOU. WE HAVE ONE MORE THAT CAME IN IN WRITING. I'M SORRY. >> I DON'T HAVE A SCRIPT SO I'M GOING OFF THE CUFF BUT I JUST THOUGHT IT WAS IMPORTANT TO TALK. MY NAME IS LIUKA WATKINS MY SON IS NICHOLAS. PATIENT NUMBER 15 AT CHILDREN'S HOSPITAL FILL DELL FEEIA. WHEN HE WAS FOUR HE WAS DIAGNOSED WITH ACUTE LYMPHOBLASTIC LIEU CHEMOY UNDERWENT TWO AND A HALF YEARS OF CHEMOTHERAPY AND CAME OFF TREATMENT WHEN DONE. THREE YEARS SHORT OF BEING OFF TREATMENT FOR FIVE YEARS WE FOUND OUT HE RELAPSED. HE WENT THROUGH 15 WEEKS OF INTENSIVE CHEMOTHERAPY AND WAS LUCKY TO GO THROUGH BONE MARROW TRANSPLANT WITH EXACT MATCH SIBLING FROM OLDER SISTER. THREE YEAR FOLLOW-UP AT DUKE WE FOUND HE RELAPSED AGAIN. HE'S NOW BATTLING CANCER FOR OVER 12 YEARS. WHEN WE FOUND OUT HE RELAPSED WE WENT IMMEDIATELY STARTED CHEMOTHERAPY AGAIN, A MONTH AFTER TREATMENT WE FOUND OUT HE WAS RESISTANT TO HIS LEUKEMIA RESISTANCE CHEMOTHERAPY. HIS DOCTORS FORTUNATELY REFERRED US TO CHILDREN'S HOSPITAL PHILADELPHIA, AND AT THE TIME THAT WE WENT TO GO I VISIT CHOP, THERE WERE ONLY RESULTS OF TWO PATIENTS AT THE TIME. EMILY WHITE HEAD AND SECOND PATIENT. SO AT THE TIME AS A PARENT WE DID AS MUCH RESEARCH AS WE COULD WHICH QUITE HONESTLY WAS NOT A LOT OF TIME, THERE WAS NOT A LOT OF DATA, CHOP PROVIDED NO GUARANTEES OF THIS BEING A CURE. BUT AS A PARENT THIS IS HOPE FOR US. THIS IS SOMETHING THAT WE HAD TO DO BECAUSE IT GIVES A CHANCE FOR SOMETHING. FORTUNATELY HE UNDERWENT HIS T-CELL RE-ENGINEERED AND HE HAD THEM GIVEN TO THEM MAY OF 2013. AND A MONTH LATER WE FOUND OUT HE WAS NOW MRD NEGATIVE. HE IS NOW 15 MONTHS POST RE-ENGINEERING OF RECEIVING T-CELLS AND IS BASICALLY LIKE ANY NORMAL KID WANTS TO PLAY BASEBALL, IS A JUNIOR IN HIGH SCHOOL, AND JUST LIVING THE LIFE. WE WERE LUCKY LAST FRIDAY TO BE AT STAND UP TO CANCER WHERE HIS VIDEO WAS SHOWN WITHIN TWO OTHER PATIENTS. TO REALLY SHOW EFFECTS OF IMMUNOLOGY, SO I TRULY BELIEVE THIS IS WHERE WE'RE HEADED AND FEEL STRONGLY THIS IS WHERE WE NEED TO GO. THANK YOU. >> >> WE HAVE ONE MORE I WILL READ BUT I'M NOT AS STRONG AS THESE PARENTS. SEE HOW I DO. THIS THIS IS FROM PARENTS THAN SANE GREG SANDERS. THANK YOU FOR ALLOWING US TO MAKE COMMENTS ON THIS CRITICAL ISSUE WHY PROTOCOL 14061320 SHOULD CONTINUE TONE ROLE PEDIATRIC PATIENTS AND WHY THEY SHOULDN'T BE DELAY IN CONTINUING THE PROTOCOL WITH THOSE PEDIATRIC PATIENTS. AS A PARENT YOU HAVE -- YOU DO EVERYTHING TO CURE HEAL AND COMFORT YOUR CHILD WHEN HE OR SHE IS DIAGNOSED WITH ALL. WE HAVE DIFFICULT DISCUSSIONS WITH DOCTORS ANT HEAR WORDS YOU NEVER THOLED YOU WOULD IN CONNECTION WITH YOUR CHILD. BUT THE TOUGH DISCUSSIONS ARE HELD WITH THAT CHILD. YOU ARE FIXED WITH EXPLAINING WHAT MAKING HIM SO SICK. YOU'RE FACED WITH TELLING HIM THE CANCER HE FOUGHT BRAVELY THREE AND A HALF YEARS EVERYONE THOUGHT WAS GONE HAS RETURNED. YOU WERE ALSO THE ONE WHO HAS TO TELL THEM THERE'S NO CHOICE IN THE WAY OF OPTIONS IN ORDER TO BEAT THIS CANCER AGAIN. THIS HEART FREAK HAVE TO SIT DOWN AND GO THROUGH THE LIST OF POSSIBLE COMPLICATIONS AND HAVE DEATH BE AMAJOR SIDE EFFECT MENTIONED OVER AND OVER. SINCE. 2005 WHEN (INAUDIBLE) WAS APPROVED FOR TLL THE ONLY OTHER WAS ELANASE IN 20116789 MANY DRUGS WERE APPROVED FOR LEUKEMIA, FOR CHRONIC FORMS. (INAUDIBLE) IN 2008 HE RECEIVED IT AGAIN THIS PAST DECEMBER WHEN HE RELAPSED AFTER TREATMENT FOR TWO YEARS FOUR MONTHS. IT DIDN'T WORK THE SECOND TIME AROUND. HE WAS USING (INAUDIBLE) TO GET TO REMISSION AFTER RELAPSING. SO OUR SON BENEFITED FROM THE ONLY TWO DRUG DISCOVERED AND DEVELOPED THE LAST NONPLUS + YEAR. THERE SHOULD BE MORE THAN JUST TWO NEW DRUGS EFFECTIVENESS AGAINST CHILDREN'S CANCER DISCOVERED IN THE PAST TEN YEARS. THERE SHOULD BE MORE TO CHOOSE FROM TO BEAT THIS BEAST CALLED ALL. CHILDREN SUFFICIENT FROM THE SIDE EFFECTS OF STANDARD OF CARE PROTOCOLS THAT ARE OFFERED TO CURE LEUKEMIA. THEY SUFFER IN SO, SO MANY WAYS YOU ALL KNOW THAT, YOU RESEARCHERS WANT THE SPARE KIDS AND OFFER A GENTLER APPROACH BUT P ONE THAT OFFER AS CURE. OUR SON RELAPSED WITH T C ALL IN NOVEMBER 202013. WHILE WE KNOW -- NOVEMBER 2013. WHILE WE KNOW IT MIGHT NOT HAVE BENEFIT OUR SON WE BELIEVE WE HAVE MUCH TO SAY AND COMMENTS ARE PERTINENT. WHEN OUR 17-YEAR-OLD SON REARE LAPSED WE WERE TOLD ONLY A BONE MARROW TRANSPLANT. NOTHING ELSE TO TRY. WE COULD HAVE TRIED JUST CHEMO BUT WE WERE TOLD A HIGH CHANCE LEUKEMIA WOULD RETURN AND BE STRAINTS, MIGHT NEVER GET HIM INTO REMISSION. WE THOSE CHOUGHS A BONE MARROW TRANSPLANTS, WE ALMOST DIDN'T GET INTO TO REMISSION AS LEUKEMIA WAS RESISTANT TO THE FIRST ROUNDS WE TRIED. WHICH MANY CHEMOS WE USED AT FIRST DIAGNOSE. DALE PASSED AWAY IN JULY 26, # 2014 A DAY AFTER SUFFERING NUMEROUS COMPLICATIONS DUE TO BONE MARROW TRANSPLANT. WHILE THERE'S NO EVIDENCE HAVING LIEU CHEMOI CELLS LEFT HE DIED DO TO IMNEXTS DUE TO SEVERE GRAFT VERSUS HOST DISEASE ISSUES IF HE HAD OTHER OPTIONS NOT AVAILABLE TO HIM, HE MIGHT STILL BE ALIVE. MAY NOT HAVE HAD SO MANY THINGS GO WRONG AND SUFFER SO IN THE END. WE'RE HERE TO BEG AND PLEAD ON BEHALF OF OTHER PEDIATRIC PATIENTS. WE PRAY THESE CHILDREN CURRENTLY HEARING THEY WERE CANCER RETURNED ARE GIVEN THE CHANCE TO CONQUER THE LEUKEMIA WITHOUT HAVING TO GO THROUGH WHAT OUR SON ENDURED IF OUR SON HAD ANY OTHER OPTIONS WE WOULD BE PURSUED THEM. WE DID NOT HAVE THIS OPTION. PLEASE MAKE THIS OPTION AVAILABLE TO OTHER CHILDREN BY KEEPING IF T PROTOCOL OPEN TO PEDIATRIC PATIENTS NOT BY MAKING CHILDREN WAIT UNTIL PROTOCOL IS VETTED BY ADULTS. CHILDREN CAN'T WAIT, A FEW MONTHS MIGHT BE A DEATH SENTENCE. NONE WANT TO HEAR CANCER OR RELAPSE AND HEAR THERE ARE FEW GOOD OPTIONS TO TRY. KEEP THIS MANY PRO-MISSING OPTION AVAILABLE BY KEEPING PROTOCOL 14061320 OPEN ENROLLING NEW PEDIATRIC PATIENTS. SINCERERY PLAN NANCY AND GREG SANDERS. -- SINCERELY, THAN SANE -- NANCY AND GREG SANDERS. IN HE'S NO OTHER COMMENTS WE'LL TAKE TEN MINUTES TO GO THROUGH THE RECOMMENDATIONS. THANK YOU, EVERYONE FOR SPEAKING. >> GO TO THAT MEETING IS LIKE COINCIDENCE, I'M A LAB MEMBER BROUGHT ME TO HERE SO I'M ONE OF THE MEMBERS FROM DR. FRY LAB AND (INAUDIBLE) PARENT CHILDREN SO I ACTUALLY A CANCER SURVIVOR FOR OVER 15 YEARS AND I GOT ALL BACK IN -- WHEN I WAS REALLY YOUNG SO THE THING I WANT TO SAY TO YOU GUYS, BECAUSE THE WORK YOU ARE DOING HELPING THE PATIENTS IN THE PAST, HELPING FORCE AND -- RIGHT HERE WE TRY AGAIN AND LET YOU KEEP THAT HOPEFULLY INCREASING ALL THE PEOPLE (INAUDIBLE) FOR THE FUTURE PATIENTS. SO I HOPE -- BECAUSE I SEE EVERY DAY PEOPLE IN MY LAB AND ALSO DR. FRY, ALL THE PEOPLE IN PEDIATRIC ONCOLOGY BRANCH TRY REALLY HARD TO PURSUE AND GIVE TO THE PATIENT. SO YOU CAN PURSUE PUSH IT FORWARD. THE REASON I WANT TO BECOME A DOCTOR BECAUSE YOU WANT TO SAVE A LIFE FOR THE WE HERE REALLY YOUNG, I CAN TELL YOU THAT WE ARE STRONG, REALLY STRONG AND WE KNOW THAT FIGHT THIS BATTLE, WE (INAUDIBLE) DO THAT FOR US. >> SO MY NAME IS (INDISCERNIBLE) I WAS A SCIENTIST DOING MOST OF THE PRE-CLINICAL WORK AND I HAVE TO COMMENT ON HOW DIFFICULT IT WAS TO WORK IN THE LAB AND I WAS VERY MOTIVATED TO SEE THE PATIENTS AND ALL THE TRIALS OPEN. IT TOOK ME MORE THAN FOUR YEARS WORKING ON MAKING THIS CD 22 CAR. I WAS VERY HAPPY TO SEE IT SUCCESSFUL, IT TOOK MANY SLEEPLESS NIGHTS IN THE LAB, I WORKED SO HARD AND I'M THE ONLY MOTIVATION WAS SEEING THE PATIENTS PEOPLE LIKE WORKING WITH ME IN THE LAB MADE ME MORE MOTIVATED TO FIND MORE THERAPIES, MAKING NOVEL THERAPIES PROVEN DIFFICULT AND VERY LUCKY TO HAVE THE CD 22 CAR ACTIVE JUST AS ACTIVE AS CD 19 CAR, TOOK ME TWO YEARS, I WAS 22 YEARS OLD WHEN I JOINED THE LAB DOING RESEARCH AND I'M ONLY MOTIVATED BY SEEING THE PATIENTS, ALL THE FAMILIES STRIVING TO FIND CURES. THANK YOU VERY MUCH AND REALLY SUPPORT THIS TRIAL. I HOPE IT DOESN'T GET DELAYED. THANK YOU. >> OKAY. WE'LL TAKE A BREAK NOW DRAFTED THE FIRST COMMENT IS POTENTIAL RESEARCH MAYBE ELIGIBLE FOR ANTI-CD 19 CAR TRIAL, WHICH IN PHASE 1 TRIAL SHOWED IMPRESSIVE 70% RESPONSE RATE. OTHER GROUPS SHOWN RATES WITH ANTI-19 CAR AL. THE ANTI-CD 19 DATA FROM PHASE 1 TRIALS ARE IMPORTANT RESEARCH PARTICIPANTS UNDERSTAND THAT ALTHOUGH THIS IS A CAR APPROACH, THE CD 22 THE EFFICACY AND CD 19 TRIALS MAY NOT BE SEEN WITH THERE CAR AND PARTICIPANTS MADE AWARE OF THIS ALTERNATIVE CAR TRIAL IF ELIGIBLE. THE ASSENT FOR CHILDREN OVER AGE SEVEN YEARS. ASSIGNED ASSENT FORM IS NOT NECESSARY, HAVING A WRITTEN DOCUMENT THE THAT PROVIDES CONSISTENT AGE APPROPRIATE MESSAGE THAT MAKES IT CLEAR THIS IS AN EXPERIMENTAL PROTOCOL ALLOW US TO BE DONE CONSISTENT MANNER AND ASSIST CHILDREN IN MAKING INFORMED DECISION TAKE INK TO ACCOUNT AGE AND DECISION MAKING CAPACITY. THE THIRD COMMENT IS WHILE CERTAINLY NOT IMPRESSIVE BENEFITS BY GROUP AND OTHERS USING ANTI-CD 19 CAR IT IS NOT CLEAR THE CD 22 TARGET OFFER IT IS SAME BENEFIT. THEREFORE DESPITE IMPRESSIVE PRE-CLINICAL DATA POTENTIAL RESEARCH PARTICIPANTS NEED TO UNDERSTAND THERE MAYBE NO BENEFIT CONSIDER SOME OF THE LANGUAGE PROVIDED IN THE NIH INFORMED CONSENT GUIDANCE FOR GENE THERAPY TRANSFER REGARDING POTENTIAL BENEFITS IN EARLY PHASE TRIALS. FINALLY A LONG THESE LINES CONSENT DOCUMENTS AVOID THE WORD THERAPY OR TREATMENT AND CONSIDER EXPERIMENTAL INTERSECTION OR MODIFIED T CELLS TO AVOID THERAPEUTIC MISCONCEPTION. THOSE ARE THE COMMENTS. >> THERE WAS NOTHING ABOUT THE ENTRY CRITERIA. WAS INTENTIONALLY OMITTED IN Q. WE DISCUSSED DECIDED TO OMIT IT, -- WOULD YOU LIKE TO START THAT DISCUSSION? >> EVERYTHING IS FINE AND HELPFUL AND I WANT TO THANK DR. FRY HIS ASSOCIATES FOR BEING PATIENT WITH THESE DIFFICULT KINDS OF DISCUSSIONS. I'M STILL CONCERNED ABOUT THE ENTRY CRITERIA MORE COMFORTABLE AND I HEARD DR. FRY SUGGESTING IT'S POSSIBLE THEY MIGHT BE ABLE WITHIN THEIR GROUP MAYBE NOT TODAY BUT -- MAYBE THERE ARE OTHERS TO TALK TO BUT IF ENTRY CRITERIA WERE HIGHER AND HIGHER AGE IN CHILDREN WHO WERE CAPABLE OF PARTICIPATING MORE ACTIVELY IN THIS CHOICE I WOULD FEEL MORE COMFORTABLE WITH IT. >> THE PATIENT WHOSE NEED THIS THE MOST ARE NOT THE PATIENTS YOU'RE TALKING ABOUT. THEY'RE IN A YOUNGER AGE GROUP. THOSE ARE THE CHILDREN WHO WILL DEFINE THE SAFETY OF THIS INTERVENTION AND ALLOW CONSIDERATIONS OF FUTURE. SO I DISAGREE WITH YOU AS PEDIATRICIAN. AND ANOTHER EXAMPLE, I'M ABOUT TO LAUNCH A STUDY OF RESPIRATORY VIRUS, RESPIRATORY SYNCYTIAL VIRUS CAUSES DISEASE MAINLY IN CHILDREN LESS THAN TWO YEARS OF AGE AND IN YOUR PATIENT WHOSE ARE IMMUNOCOMPROMISED. I HAVE GOTTEN THE FOOD AND DRUG ADMINISTRATION TO AGREE TO START STUDY IN CHILDREN LESS THAN TWO YEARS OF AGE. THIS WAS AN EXPERIMENTAL THERAPY NEVER ADMINISTERED TO A PATIENT BEFORE. SO WE'RE GOING TO PLOW NEW GRAND GROUND BECAUSE OF RISK BENEFIT RATIO AND THE KNOWLEDGE WE HAVE ABOUT THE SAFETY OF THE APPROACH BOTH IN ANIMAL MODELS AND IN PHASE 1 PRE-CLINICAL HUMAN TOXICITY STUDIES. SO I WOULD DISAGREE STARTING WITH OLDER PATIENTS. >> ANYONE HAVE ANOTHER COMMENT ON THAT TOPIC? I GUESS I WILL WEIGH IN. I WOULD SAY I ALSO STIVERRER FAVOR NOT RESTRICTING TO OLDER CHILDREN. -- ALSO FAVOR NOT RESTRICTING TO OLDER CHILDREN BECAUSE I'M SWAYED BY TRACK RECORD OF CARS AND THOUGH THIS IS UNKNOWN PRE-CLINICAL DATA SUGGESTS IT MAY HAVE SIMILAR ACTIVITY AND BECAUSE OF THE COMPASSION AND CONSIDERATION I THINK FOR THE PATIENT WHOSE GET TO THIS POINT TO HAVE THIS AS A POSSIBLE TREATMENT CERTAIN EXPERIMENTAL THERAPY OR INTERVENTION AS PHRASED IS REASONABLE. >> DR. WHITLY, DO YOU MEAN THAT THE RISK BENEFIT RATIO FOR KIDS IN THIS TRIAL IS BETTER FOR YOUNGER ONES? >> THE MORTALITY IN CHILDREN LESS THAN TWO YEARS OF AGE AND IN THE IMMUNOCOMPROMISED HOST IS WHERE WE SEE SIGNIFICANT DISEASE. WE DON'T HAVE GOOD ANIMAL MODELS OF RSV. >> I'M TALKING ABOUT THIS TRIAL. >> I'M SORRY IN THIS TRIAL. >> OPENING STATEMENT YOU SAID WHY YOUNGER PATIENT'S >> ALL I WAS SAYING IS AS RELATES TO THIS TRIAL, THE PATIENTS HOT THEORETICALLY TEACH US THE MOST WILL NOT BE THE 16 OR 14-YEAR-OLDS AND OLDER, IT'S GOING TO BE IN THE YANKEE UNDER PROBABLY 8 YEARS AND THOSE ARE THE CHILDREN WHO ARE MORE LIKELY TO RELAPSE THAN SOME OF THE OLDER GROUPS THAT DR. FRY DESCRIBED. SO WE WOULD EXCLUDE A LARGE NUMBER OF PATIENT WHOSE COULD BENEFIT FROM PARTICIPATING IN THE STUDY, AND AT LEAST PROVIDING SAFETY DATA. >> ALL PATIENTS IN THIS TRIAL WILL HAVE RELAPSED PROBABLY TWICE. >> SO WHATEVER THEIR AGE, IT'S NOT MATTER WHO IS MORE LIKELY, 100% WILL HAVE RELAPSED ALREADY. >> BUT STARTING IN THE OLDER PATIENTS REALLY DOESN'T ACCOMPLISH ANYTHING, THE SAFE -- YOU NEED TO EVALUATE IS IN THE YOUNGER CHILD WHERE IT'S MOST LIKELY USED IN THE FUTURE, NOT IN THE OLDER CHILD. AND THEE CREDIT ETHICALLY YOU CAN SLOW DOWN THE RECRUITMENT OF CHILDREN WHO IF THIS THERAPY IS BENEFICIAL WILL DERIVE GREATEST BENEFIT FROM IT. >> UNDERSTANDING WHY THEY GET -- LOOK AT THE SAME LEVEL BENEFIT REGARDING OF AGE, CORRECT? >> NO, YOU SLOW DOWN RECRUITMENT BECAUSE YOU HAVE -- MY INTERPRETATION OF THE DISEASE FROM WHAT WE HAVE SEEN IS MORE DIFFICULT TO RECRUIT OLDER PATIENTS THAN THE YOUNGER, AND YOU CAN EVER YOU CAN CONFIRM OR REFUTE THAT. (INAUDIBLE) MOST LIKELY TO NEED ALL MOST COMMON BETWEEN AGE 2 AND NINE. YOU HAVE TO DO IT LATER. AND THEY WILL EXCLUDE THE PATIENT. I THINK THAT'S WHAT YOU'RE SAYING. POPULATION THAT GETS THE DISEASE. >> I WOULD CONCUR. ALL IS DEFINITELY PREDOMINANTLY A PEDIATRIC DISEASE. THERE ARE ADULTS WITH ALL, WE BELIEVE THEY'RE DIFFERENT. WE ACTUALLY HAVE OPEN TRIAL NCI SARCOMA PATIENT WHO IS PREDOMINANTLY YOUNG ADULT AND ADULT DISEASE WHERE WE TALK -- WE HAVE AN OLDER AGE FOR ENTRY BUT THIS IS A DIFFERENT SITUATION WITH THE DISEASE DISEASE WE'RE TREATING, PREDOMINANTLY PEDIATRIC DISEASE TEENS WHERE MUCH BENEFIT IS SEEN THUS FAR WITH THE CAR THERAPY SO I WOULD AGREE. >> COULD YOU CLARIFY, SUGGESTION WAS MADE TO HAVE TROUBLE RECRUITING? >> NO, SLOW DOWN RECRUITMENT IN THE CHILDREN THEORETICALLY WHO BENEFIT THE MOST IF YOU CAN IMMEDIATELY JUMP IN TO THAT POPULATION RATHER THAN JUST STUDYING THE OLDER PATIENTS WHERE RECRUITMENT WILL BE MUCH SLOWER. >> THIS IS DON WOOLEY. DO YOU THINK THE SAFETY PROFILE IS DIFFERENT? IF YOU TRIED 12 TO 14-YEAR-OLDS IT APPEARS SAFE AND YOUNG YOUNGER CHILDREN MAY NOT SO IT'S IMPORTANT TO TEST THE POPULATION YOU WANT TO TARGET DOWN THE ROAD. IS THAT WHAT YOU'RE SAY SOMETHING >> I'M A FIRM BELIEVER YOU GO TO POPULATIONS YOU NEED TO ULTIMATELY TREAT. THAT'S GOING TO BE IN THE CHILDREN BETWEEN FOUR AND 8 YEAR FOUR AND 9-YEAR-OLD AGE RANGE, STARTING ADULTS AN WORKING DOWN TO CHILDREN IS ARCHAIC. >> I THINK THE FIRST PATIENT IN YOUR COHORT IS GOING TO BE AN OLDER PATIENT. MUCK MIC (OVERLAPPING SPEAKERS) ADULT ALL IS DIFFERENT FROM PEDIATRIC ALL. >> IF I CAN ADD THAT, I THINK IT'S IMPORTANT TO GET SAFETY DATA IN THE PHASE 1 STUDY AND THIS IS DONE IN THE EXPERIENCE CENTER WHERE I DON'T THINK THERE'S ANY REAL CONCERN THESE KIDS ARE NOT WELL TAKEN CARE OF. SO I WOULD FEEL BETTER WITH THIS THAN IF YOU EXCLUDE THEM HAVE THAT INFORMATION MOVING FORWARD, IT WILL DELAY THE PROCESS. >> ARE YOU SUGGESTING REDO IT, THIS IS DONE TWICE, I DON'T THINK THAT'S SUGGESTION -- THAT'S -- >> NOT UP TO US BUT IF WE HAD A RESTRICTED OLDER LIMIT FOR ENROLLMENT THERE'S CERTAINLY A LOT OF DISCUSSION ABOUT REDOING A PHASE 1, WE HAVE DONE THAT WITH OTHER SITUATIONS. REDO ESCALATION TRIAL AT YOUNGER AGE GROUP TO GENERATE TOXICITY DATA. >> THANKS. >> H NEITHER PEDIATRICIAN, I HAVE M.D. BUT NOT CLINICALLY ACTIVE BUT I THINK -- I TOTALLY AGREE THAT THERE IS NO REASON TO EXCLUDE THE YOUNGER CHILDREN. FIRST OF ALL I THINK I AGREE WITH DR. WHITLEY YOU LEARN MORE FROM THE TRIAL IF YOU DON'T EXCLUDE THEM, SECONDLY, I WANT TO REMIND EVERYBODY THE TALK CHILDREN WHO HAVE FEW OTHER OPTION, NOT THEY'RE GOING TO LIVE VERY LONG PRODUCTIVE LIVES IF THEY DON'T HAVE ANY TREATMENT AVAILABLE. SO AGAIN, PROVIDING HOPE BY MYSELF AS A CHILD WHO HAD CANCER AND PROVIDING HOPE IS AN IMPORTANT THING. SO EXCLUDING CHILDREN JUST BECAUSE THEY CAN NECESSARILY FULLY UNDERSTAND WHAT IS BEING OFFERED, I DON'T THINK IS RIGHT. >> ANY FURTHER COMMENT? SO WE COULD TAKE A STRAW POLL NOT A VOTE BUT STRAW POLL HOW MANY FAVOR NOT HAVING AGE RESTRICTION AND THEN DECIDE WHETHER TO CHANGE THE LETTER OR NOT. IF THAT'S OKAY. YOUR PREROGATIVE TO CALL FOR THAT. HOW MANY PEOPLE WOULD FAVOR ADDING AGE RESTRICTION OF 12 OR 14? HOW MANY ARE OKAY WITH LEAVING IT AS IT IS OVER 7? SO I THINK REFLECTING MAJORITY OF OPINION WE'LL LEAVE THAT OUT OF THE STATEMENT AND YOU CAN DECIDE USE YOUR CONSCIENCE AS I SAY. >> ASEPTEMBER WAS OVER 7 BUT CHILDREN OF ALL AGES -- >> NOT CHANGING THE CRITERIA, WHATEVER IT WAS. >> THAT'S A DIFFERENT VOTE. IF YOU'RE GOING TO TELL ME DOWN TO ONE I'M GOING VOTE -- (OVERLAPPING SPEAKERS) >> 15-KILO GRAMS. >> OKAY. >> I WASN'T TRYING TO REWRITE THE PROTOCOL. 15-KILOGRAM WHICH IS FIVE, SEVEN YEARS OLD IN THAT RANGE. >> I GUESS THAT WAS MY PEDIATRICIANS BADGE. (OFF MIC) >> SO CAN WE HAVE A MOTION ON THE RECOMMENDATION? >> SECOND. >> OKAY. THEN LET'S VOTE ON THESE RECOMMENDATION AS WE HAVE WRITTEN THEM. >> DONAHUE, YES. >> CHATTERJEE, YES. >> PILEWSKI, YES. >> KAUFFMAN, YES. >> (INAUDIBLE) QUESTION. >> WOOLY, YES. >> DRESSER YES. >> FOST ABSTAIN. >> KOHN, YES. >> HAMMARSKJOLD, YES. >> CANON, YES. >> KIEM, YES. >> HERRING YES. >> WHITLEY, YES. >> ANTONIO YES. >> ROSS, YES. >> ANYONE ON THE PHONE? (INAUDIBLE), YES. >> ONE MORE TIME. >> (INAUDIBLE), YES. >> SO ALL THREE ON THE PHONE SAID YES. OKAY. THANK YOU VERY MUCH FOR COMING. BEARING WITH THIS LONG DISCUSSION WE HOPE IT HELPS YOUR RESEARCH BE BETTER AND OBVIOUSLY IT'S IMPORTANT WORK YOU'RE DOING AND WE THANK EVERYONE WHO CAME TO SPEAK ABOUT THEIR PERSONAL EXPERIENCES. >> THANK YOU VERY MUCH FOR YOUR EXTREMELY HELPFUL COMMENTS AND I THINK AN IMPORTANT DISCUSSION. >> THANK YOU. OUR FINAL ITEM IS THE GTSAB REPORT WHICH I WILL DO SINCE I HAVE NOT DONE ENOUGH ORAL READING. THE GTSAB MET TO REVIEW THE ADVERSE EVENT REPORTS FROM THE CURRENT QUARTER. I WILL GO UP THERE. >> JUST THE REPORT ON THE PROTOCOLS (INAUDIBLE) >> THANK YOU. >> SO IN THIS THIRD QUARTER OF 2014 THERE WERE 31 GENE THERAPY PROTOCOLS SUBMITTED TO THE COMMITTEE AND FOUR WERE SELECT FORD THE PUBLIC REVIEWS THAT WE'RE DOING NOW WHICH IS A 13% OR COMES OUT TO 17% PROTOCOLS SUBMITTED FOR THIS YEAR SELECTED FOR PUBLIC REVIEW. THE TYPES OF PROTOCOLS NOT SELECTED 19 FOR CANCER, FOUR MONOGENIC DISEASE, TWO INFECTIOUS DISEASE, ONE HEART FAILURE, ONE RENAL DISEASE AND VECTORS OF THOSE 27 I THINK THAT WERE NOT CHOSEN ARE SHOWN THERE. SO MIXTURE OF DIFFERENT GENE TRANSFER APPROACHES. NEXT SLIDE. AND WE REVIEW THE SERIOUS AD ADVERSE EVENTS REPORTED THIS QUARTER AND THERE WERE 16 OF THESE FROM 13 PROTOCOLS, YOU CAN DO INITIAL AND FOLLOW-UP REPORTS. ABBREVIATED PUBLIC WEB SUMMARIES AVAILABLE WITH RAC MEETING MATERIALS ON THE WEBSITE AND FUTURE AVAILABLE ON (INAUDIBLE) HALF THE EVENTS OF 16 WERE PROTOCOLS USING T-CELLS THAT EXPRESS CHIMERIC ANDROGEN RECEPTORS MAINLY CD 19 CAR T-CELLS. 7 INVOLVE CYTOKINE RELEASE SYNDROMES OF VARYING SEVERITY, THE DOSING FROM THE EVENT RANGED FROM 24 HOURS TO 11 DAYS. THREE OF THESE WERE MILD MAINLY FEVERS AND MILD DROPS IN BLOOD PRESSURE, FOUR REQUIRED INTENSIVE CARE UNIT CARE DUE TO COMBINATION OF RECEIVE REAR HYPOTENSION, HYPOXEMIA AND OTHER SYMPTOMS. THERE WAS ONE CASE OF NEUROLOGIC SYMPTOMS, SEIZURES AN ENCEPHALOPATHY IN CD 19 CAR RECIPIENT PROTOCOL. TWO WERE COMPLICATED WITH DEVELOPMENT OF CONCOMITANT OR SEPSIS. IN THESE REPORTS 11 REPORTED -- I'M SORRY, ELEVATED IL-6 LEVELS REPORTED FOUR EVENTS, C REACTIVE PROTEIN CONSISTENT WITH HEMOPHAGOCYTIC COMPLICATION IN THREE EVENTS. AND IN THE REPORTS WE WERE TOLD IN SOME CASES ANTI-IL-6 DRUGS (INDISCERNIBLE) AND AS WELL AS STEROIDS USED TO REVERSE THE SITE TUNE RELEASE SYNDROME. JUST LAST ONE, WE HAVE HAD A LOT OF DISCUSSIONS AND WHAT WE DON'T HAVE HERE FULLY IS THE DENOMINATOR HOW MANY PATIENTS WERE TREATED ON PLOT PROTOCOLS DURING THESE TIMES. CERTAINLY THE BEST WAS IN THE -- >> IN THE PROTOCOLS REPORTING THESE EVENTS AT LEAST MORE IN THE 25 AND I THINK OF THOSE PROTOCOLS REPORTED THEY HAVE HAD ONE OTHER EVENT THAT WAS NOT AS QUITE AS SERIOUS. >> RIGHT. SO IT IS VERY UNCERTAIN AREA OF 25 OR A THIRD OF THE PATIENTS AND THERE HAVE BEEN A COUPLE OF PUBLISHED CASE REPORTS THAT COULD REPORT ANYWHERE FROM 25 TO 75% OF THESE COMPLICATIONS WITH THE CARS. AND JUST TO HIGHLIGHT ONE PAPER PUBLISHED ON CARS PROTOCOL REVIEWED HERE SEVERAL YEARS AGO ASSESSMENT OF SAFETY AND FEASIBILITY OF ADMINISTERING T-CELLS EXPERIENCING ANTI-CD 19 DIMERIC ANDROGEN RECEPTOR WITH B CELL LYMPHOMA, THIS COMES FROM THE SURGERY BRANCH NATIONAL CANCER INSTITUTE. CHEMOTHERAPY REFRACTORY DIFFUSE LARGE B CELL LYMPHO& MALIGNANCIES EFFECTIVELY TREATED WITH AUTOLOGOUS T-CELLS EXPRESSED ANTI-CD 19 CHIMERIC ANDROGEN RESTORE. NEXT SLIDE. THEY REPORT 15 PATIENTS WITH ADVANCE B CELL MIAULING LINK NANCYS WERE TREATED WITH ANTI-CD 19 CAR AFTER LYMPHODEPLETING CHEMOTHERAPY. NONE HAD DIFFUSE LARGE B CELL LYMPHOMA AND TWO LYMPHOMANNED FOUR HAD CLL. 18 OF 15 PATIENTS ACHIEVED COMPLETE REMISSION, FOR PARTIAL REMISSIONS AND ONE STABLE LYMPHOMA AND TWO NOT AVAILABLE FOR RESPONSE. FOUR SEVEN AVAILABLE PATIENTS WITH CHEMOREFRACTORY ACHIEVE AD COMPLETE RESPONSE, THREE COMPLETE RESPONSES ARE ONGOING WITH DURATIONS OF 9 TO 22 MONTHS. AND THIS IS THE FIRST REPORT TO HIRE KNOWLEDGE OF SUCCESSFUL TREATMENT OF THIS B CELL LYMPHOMA WITH ANTI-CD 19 CAR T-CELLS. NEXT SLIDE. WE WERE ALSO REPORTED THAT TEN NEW PROTOCOLS OPENED AS YOU KNOW WHEN YOU ENROLL A FIRST SUBJECT ON A RAC REVIEW PROTOCOL M 1C 1 REPORTING RESPONSES TO THE REVIEWS. SO WE HEARD OF TEN OF THOSE. TWO OF THESE WERE PUBLICLY REVIEWED, RESPONSES TO COMMENTS SUGGESTIONS MADE WERE SUBMITTED PREVIOUSLY. NEXT SLIDE. JUST TO GO THROUGH THEM, ONE IS A GENE TRANSFER FOR PATIENTS WITH SICKLE CELL DISEASE, USING GAY BLAH M&AGLOBIN LENTIVIRAL VECTOR OPEN 1, 2, PHASE PILOT STUDY REVIEWED IN MARCH OF 2010. THEY REPORT IN RESPONSE TO THE REVIEWS THE PRE-CLINICAL STUDIES IN MICE NON-HUMAN PRIMATES DEMONSTRATED NO EVIDENCE OF VECTOR DERIVED MALIGNANCY IN ANY ANIMAL MODEL. THOSE THIS WAS REVIEWED SHORTLY AFTER THE PATIENT IN FRANCE WITH BETA THALASSEMIA WITH CLONAL EXPANSION SO A LOT OF DISCUSSION AT THIS MEETING ABOUT INSERTIONAL ONCOGENESIS SO ADDITIONAL PRE-CLINICAL STUDIES SUGGESTED WHICH DIDN'T SHOW EVIDENCE OF MALIGNANCIES. IN ORDER TO GATHER ADDITIONAL SAFETY DATA TV BEFORE ENROLLING IMMEDIATEPEDIA TRICK SUBJECTS THE FIRST WERE ADULTS. AND THEN THERE WAS DISCUSSION HYDROXYUREA AND ESTABLISHED THERAPY FOR SICKLE CELL DISEASE, THEREFORE ONLY CHILDREN COWHO TOLERATE HYDROXYUREA ARE ELIGIBLE AND ADULTS PARTICIPATE IF THEY REFUSE THERAPY. ANY QUESTIONS? >> SO THE QUESTION IS, WE MENTIONED THE SICKLE PROTOCOLS REVIEWED IN 2010, WE'RE GETTING REPORTS OF OPENING THE 2014. FOUR YEAR LAG. I DON'T KNOW THE STATISTIC BUT MY EXPERIENCE NO, IT'S NOT BECAUSE RANK IS ONE OF THE FIRST PLACES PEOPLE GO TO GET THEIR INPUT, GAUNTLET IMB RWC FDA END VECTOR PRODUCTION, ET CETERA, SO FOUR YEARS IS PROBABLY AVERAGE, I DON'T KNOW IF WE HAVE DATA. >> >> WE HAVEN'T ANALYZED IT, THERE ARE SOME PROTOCOLS STARTING SIX MONTHS REVIEW WITHIN A YEAR AND OTHERS MAY HAVE COME EARLIER ESPECIALLY IN LOOK AT WHAT PRE-CLINICAL DATA THEY WERE GOING TO DO IN THIS CASE WITH VECTORS THAT MAY TAKE LONGER TO DO. ONE MORE CLARIFICATION. EVERYONE FILES NOTICE THAT THEY START THIRD PROTOCOL WHETHER REVIEWED OR NOT BUT WE ONLY HIGHLIGHT ONES REVIEWED BECAUSE THEY HAVE TO GIVE INFORMATION HOW THEY RESPOND. >> WITH THAT WE'LL ADJOURN FOR TODAY. WHAT TIME ARE WE STARTING TOMORROW? >> 8:306789 THE BUS IS THERE AT 7:45 TO GET EVERYONE HERE. WITH LUGGAGE.