Abstract PO3-29-04: Patient selection for high RSK2 expression is key for achieving improved PFS in metastatic breast cancer in the PMD-026 Phase 1/1b study

Abstract Background: PMD-026 is a first in class, reversible, oral small molecule inhibitor of p90 ribosomal S6 kinase (RSK), a kinase family activated by the MAPK and PDK-1 pathways, which regulate substrates involved in cancer cell proliferation and drug resistance. Both pathways are implicated in HR+ and triple negative breast cancer (TNBC). RSK2 can modulate the growth of breast cancer (BC) by promoting cell cycle progression through G2/M, specifically through pYB-1S102 which nucleates spindle pole formation in M-phase of cancer cells. This mechanism of action (MOA) for PMD-026 can be monitored by measuring the loss of pYB-1S102 and pCDK2Y15, a marker for G2/M arrest. Therefore, PMD-026 presents a novel mechanism to inhibit resistance at G1/S which is common for CDK4/6 inhibitors as well as ADCs such as those that contain Topoisomerase 1 conjugates. Here in, we show for the first time that PMD-026 inhibits P-YB-1S102 and pCDK2y15 in a dose-dependent manner in TNBC cells and address whether this could be translated as a pharmacodynamic marker of PMD-026 activity in patients. To guide patient selection, we are co-developing a unique and simple IHC based companion diagnostic (CDx) with Roche based on the principle that activated RSK2 translocates from the cytoplasm into the nucleus. In mBC, RSK2 was found to be highly expressed in ~70% of patients using a staining algorithm. An H-score was developed and ultimately H-score 180 (75% nuclear staining with staining intensity of 2+ or 3+ by IHC) was used as the cut-off in our Phase 1/1b trial retrospective study. This IHC assay will be used to select patients in the upcoming Phase II, as PFS in the PMD-026 Phase I/1b study showed remarkable differences when comparing patients with high and low RSK2. Results: In this Phase 1/1b study, PMD-026 was evaluated in an ethnically diverse population of women across all breast cancer subtypes. Patients had a median of 5 prior lines of therapy and PMD-026 achieved stable disease in 44% (11/25) of the subjects. Consistent with the MOA, PMD-026 inhibited pCDK2Y15 in PBMCs from patients at C1D15. Corresponding plasma concentrations were ~ 1µM, which correlates with the IC90 of PMD-026 in preclinical models. To guide patient selection in the future, the RSK2 IHC with an H:Score 180 was used to evaluate patient outcomes. Using this criterion, PFS was significantly longer in RSK2 high vs low patients (3.6 months vs 1.3 month, HR = 0.27, p = 0.031, N=20 patients representing de novo TNBC and HR+/CDK4/6 refractory subtypes). Upon further analysis, patients who had 5 lines of therapy or less benefited the most. PFS in these less heavily pretreated RSK2 high patients was 4.8 months vs 1.3 months for RSK2 low patients (HR = 0.07, p = 0.001 N=14 representing the same subtypes above). It was clear that the time on study was longer for patients with high RSK2 vs low, and this was specifically noted in de novo TNBC and HR+ patients that previously failed CDK4/6 inhibitors as well as endocrine therapies. A key observation in this study was that the PFS benefit was based on the RSK2 levels and not on any pharmacokinetic differences between patients, as the AUC (p=0.53), Cmax (p=0.73) and plasma levels (p=0.76) did not differ between RSK2 high and RSK2 low groups. These data strongly support the activity of this first in class RSK inhibitor, PMD-026, in RSK2 high breast cancers. Our integrated IHC based CDx strategy plans to prospectively enroll RSK2 high patients for our Phase 2 trials will be described. Conclusions/Translational Significance: CDx guided breast cancer therapeutics are often lacking for the treatment of TNBC, as well as HR+ breast cancers that have failed CDK4/6 inhibitors. The ability to identify patients who could potentially benefit most from RSK-targeted agents such as PMD-026 is an important step forward in delivering practice changing therapies for patients. Citation Format: Sandra Dunn, Judy Wang, Hyo Han, Robert Wesolowski, Amita Patnaik, Shakeela Bahadur, Nicolaos Palaskas, My-my Huynh, Aarthi Jayanthan, Gerrit Los, Andrew Dorr. Patient selection for high RSK2 expression is key for achieving improved PFS in metastatic breast cancer in the PMD-026 Phase 1/1b study abstract. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-29-04.