The Story of Gleevec

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					The Story of Gleevec
Elisabeth Buchdunger, Ph.D.
Juerg Zimmerman, Ph.D.

In 2001, the FDA approved Gleevec®, a groundbreaking drug for chronic myeloid leukemia (CML). What
makes this drug both powerful and gentle is that it focuses on disrupting one specific protein that causes the
cancer. This specificity allows the medicine to be strong, while sparing other enzymes. Molecular targeting,
as this technique is known is a highly promising treatment that has been called the "wave of the future" by
Secretary of Health and Human Services Secretary, Tommy Thompson. On a human level molecular
targeting means vastly reduced side effects and better chances of survival.

The story of Gleevec began over four decades ago, in 1960 when scientists at the University of Pennsylvania
noticed chromosomal abnormalities in the blood of CML patients. It wasn't until the 1980s with the advent of
genetic mapping that University of Chicago scientists determined that the chromosomal abnormality
produces a cancer-causing kinase enzyme. With this enzyme as a target, Novartis researchers, led by Drs.
Zimmerman and Buchdunger, created and tested 400 molecules to find one that would target this enzyme
without disrupting any of the hundreds of other similar enzymes in a healthy cell. After two years of testing,
they developed the molecule that would become Gleevec.

Following another eight years of safety testing and development, scientists were ready to try the drug in
patients and found dramatic results. Nearly every CML patient who took the drug was responding and they
reported only minimal side effects. After taking the medicine, one patient said, "One minute I was looking at
death. The next I was looking at my whole life in front of me." Novartis expanded the clinical trials to make
the drug available to more patients, while the FDA put the drug on fast track to approval in 2001. The drug
and the molecular targeting approach have given back life to CML patients and brought hope to patients
with other cancers.

In early 1990, Dr. Elisabeth Buchdunger and Dr. Juerg Zimmerman, both of Novartis, accepted a challenge
from the leaders of the tyrosine kinase inhibition team - Nick Lydon and Alex Matter: Refine the lead
compound that blocks the enzyme that triggers chronic myeloid leukemia (CML) without harming other
members of the same family, called kinases, that are needed for the body to function. Two years and some
400 molecules later, the researchers and their colleagues came up with the molecule that became
Gleevec®, a medicine that is helping many patients with this debilitating and usually fatal disease and
giving hope to patients with other cancers.

The story of Gleevec actually began three decades earlier, in 1960, when scientists at the University of
Pennsylvania noticed that one chromosome in the blood cells of many CML patients was shorter than normal
- it was missing a big chunk of its DNA. The stubby chromosome was nicknamed "the Philadelphia
chromosome" and marked the first time that a chromosomal defect was linked to cancer.

Scientists now had a tantalizing clue, but they didn't yet have the tools needed to use the clue to solve the
mystery of CML. Another clue was revealed thirteen years later, when a researcher at the University of
Chicago discovered that the missing end of the short chromosome had moved and fused with another
chromosome. By the 1980s, scientists were able to use genetic mapping to show that the two ends of the
broken chromosomes produced a cancer-causing protein, known as Bcr-Abl. In 1986 and 1987, researchers
writing in Science identified the protein as a tyrosine kinase, a kind of enzyme that, among other things,
helps regulate cell growth and division. Bcr-Abl, the scientists wrote, changes the cell's normal genetic
instructions, jamming the signal that tells the body to stop producing white blood cells. As a result, while a
cubic millimeter of blood from a healthy person contains 4,000 to 10,000 white blood cells, the same volume
of a CML patient's blood contains 10 to 25 this number. The proliferating white blood cells cause pain,
debilitating illness, and, all too often, death. Only three out of ten CML patients survive for even five years.
Until Gleevec, which is a daily pill, patients faced two daunting treatment options: high-risk bone marrow
transplant or daily infusions of interferon, with side effects that have been described as "like having a bad
case of the flu every day of your life."

With the groundbreaking discovery that a single enzyme could cause CML, medical researchers had a clear
target. The search for a drug that could block the tyrosine kinase known as Bcr-Abl was on.

Ciba-Geigy, the company that later became Novartis, already had an active program of searching for
molecules that inhibited cancer causing tyrosine kinases, targeting breast cancer and various solid tumors.

Enter Dr. Zimmermann, a medicinal chemist, and Dr. Buchdunger, a cell biologist.

"From the existing kinase program we had a molecule that showed some activity against the enzyme but
was weak, non-selective, and toxic," says Dr. Zimmermann. "The toxicity supported the hypothesis that we
shouldn't inhibit all kinases. There are hundreds of kinases in a healthy cell, and many are important for
housekeeping, such as metabolism. We had to increase the activity of the compound and fine-tune it so it
wouldn't harm the good kinases."

It was a team effort. Dr. Zimmermann and his colleagues would design and synthesize a molecule, and Dr.
Buchdunger and her colleagues would test the molecule against the cancer-causing enzyme.

"She would tell us 'the compound is not selective' or 'it does not penetrate the cell' and I'd have to come up
will another," recalls Dr. Zimmerman. " I would change the molecule. It's similar to what a locksmith does
when he has to make a key fit. You change the shape of the key and test it. Does it fit? If not, you change it
again. The molecule has to fit into a pocket of the enzyme.... We had to do it many times. That was
frustrating, but it keeps you up and running. For me personally, I would be bored if I only had to attempt it
once. You learn from your failures. You learn how you could do a better job."

"You go from one step to the next," says Dr. Buchdunger. "When you find a compound that looks interesting
in terms of specificity and potency, then you test it for toxicity, and you hope and pray. You keep your
fingers crossed that it passes the next hurdle."

In addition to finding a molecule that was both active and selective, the scientists had to find one that could
be taken orally, in pill form.

"Oral bioavailability was a big, big hurdle," says Dr. Zimmermann. "For us, it was a given. We wanted a
breakthrough treatment where the patient could stay home and doesn’t have to go through all the side
effects. We had to go back to the lab to improve the uptake of the drug without losing activity and

Novartis had been working with Dr. Brian Druker, a haematologist and oncologist with specific expertise in
tyrosine kinases relative to CML and then of the Dana-Faber Cancer Institute in Boston, to profile the lead
compounds identified by Buchdunger and Zimmerman. Dr. Druker’s work highlighted one compound in
particular and his work enabled the company to focus on this one compound.
The compound that would become Gleevec was synthesized in 1992. For the next several years, company
and academic scientists conducted the additional research and initial chemical and pharmaceutical
development needed to start clinical trials.

"So many things need to happen before you dare give the compound to a patient," explains Dr. Buchdunger.

The first Phase I study began in June 1998. The results of these preliminary studies were dramatic. Nearly
every CML patients who took the drug was responding. Most patients experienced a significant reduction in
the number of white blood cells and a reduction or disappearance in the number of cells containing the
cancer-triggering chromosome. Moreover, the patients reported only minimal side effects.

Word of the drug's effectiveness spread rapidly in the CML community - through word of mouth and Internet
patient chat groups. One of the patients who was encouraged by the trial data was Suzan McNamara.

After being diagnosed with CML in March 1998, Ms. McNamara began her battle against the disease with a
combination therapy of hydroxyurea and interferon. She began to experience debilitating side effects,
including depression, weight loss, hair loss, and fatigue so severe she had to stop working. She tried to
enroll in a Gleevec clinical trial, but, at that time, the supply was only adequate for the limited number of
patients needed for the Phase I Study. Knowing what a difference the drug could make for her and others,
Ms. McNamara circulated a petition to members of the Internet support group, collecting some 4,000
signatures. The petition asked Novartis to move more quickly to develop the drug. In October 1999 she sent
the petition, along with a letter, to Dan Vasella, M.D., Chief Executive Officer of Novartis. In the letter, Ms.
McNamara explained how encouraged CML patients were about the data generated by the trials and asked
that the studies be expanded so that more patients could participate.

In fact, the company had already assigned the highest priority to the development of Gleevec and was
already expanding the larger clinicacl trials to test the drug. Ms. McNamara, and thousands of other CML
patients, gained access to Gleevec through the trials. Says Ms. McNamara, whose cancer is now in remission
and who is studying to be a molecular biologist: "One minute I was looking at death. The next, I was looking
at my whole life in front of me."

Positive clinical trial results prompted the U.S. Food and Drug Administration (FDA) to grant "fast track"
designation to the drug. On May 10, 2001, only ten weeks after the company submitted a New Drug
Application, the FDA approved Gleevec for the treatment with Philadelphia chromosome-positive CML in the
blast crisis, accelerated phase or in chronic phase after failure of
interferon therapy.
                                                                                 There's a disconnect between
                                                                                 lab work and real life. When
                                                                                 we heard from patients, we
                                                                                 could share the excitement. A
                                                                                 gentleman from Texas wrote
                                                                                 us that he had sold his house.
                                                                                 'My doctor told me I was going
                                                                                 to die,' he wrote. Now he said
                                                                                 his only problem is that the
                                                                                 new owner won't sell him back
                                                                               the house. And people told us
Gleevec was immediately hailed as a major breakthrough by officials and
                                                                               that there were no side effects.
scientists. Secretary of Health and Human Services Tommy Thompson
                                                                               Before, we would just
called it "the wave of the future." Dr. Harmon Eyre of the American
                                                                               hypothesize about selectivity,
Cancer Society called it "a huge breakthrough…a great drug, a great new
                                                                               but now we know from real
discovery." But for Dr. Buchdunger and Dr. Zimmermann, the most
                                                                               patients that selectivity means
important affirmation came from patients.
                                                                               freedom from side effects. For
                                                                               scientists, it's a dream come
"When the data started to come in, it was hard to believe," recalls Dr.
                                                                               true: to do something in the
Buchdunger. "But it was obvious looking at the white blood cell counts
                                                                               lab and have it help in real
that some patients were experiencing absolute normalization of their
blood counts."
                                                                               - Juerg Zimmerman, Ph.D.

"There's a disconnect between lab work and real life," says Dr.
Zimmerman. "When we heard from patients, we could share the excitement. A gentleman from Texas wrote
us that he had sold his house. 'My doctor told me I was going to die,' he wrote. Now he said his only
problem is that the new owner won't sell him back the house. And people told us that there were no side
effects. Before, we would just hypothesize about selectivity, but now we know from real patients that
selectivity means freedom from side effects. For scientists, it's a dream come true: to do something in the
lab and have it help in real life."

Gleevec is also helping real-life patients with another kind of cancer.        "We have learned many
Because of the proven activity of Gleevec against tyrosine kinases,            lessons from this compound.
George Demetri, M.D. of the Dana-Farber Cancer Institute, developed
and tested the hypothesis that Gleevec could be effective as a therapy         The scientific community has
for gastrointestinal stromal tumor (GIST), a rare solid tumor. After           benefited from the idea of
clinical trials, the FDA approved Gleevec for GIST on February 1, 2002.        targeting. We have learned
                                                                               useful lessons for the
Now, even after more than four decades of discovery, trials and
triumphs, the Gleevec story is not over. Novartis, in conjunction with the     development of new drugs, not
National Cancer Institute, is conducting studies on how the drug works,        only for cancers but for other
and on its long-term effect on patients. Clinical trials are underway to
study whether Gleevec works against other cancers, including brain
cancers and soft-tissue sarcomas. And scientists in the pharmaceutical         - Elisabeth Buchdunger,
industry and in academia are conducting intensive research to identify         Ph.D.
cancer-causing proteins in other tumors.

Says Dr. Richard Klausner, director of the National Cancer Institute: "Gleevec offers proof that molecular
targeting works in treating cancer, provided that the target is correctly chosen. The challenge now is to find
these targets."

"We have learned many lessons from this compound," says Dr. Buchdunger, who is overseeing preclinical
research on whether Gleevec might work against other cancers. "The scientific community has benefited
from the idea of targeting. We have learned useful lessons for the development of new drugs, not only for
cancers but for other diseases."

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