Methods and uses for treating cancer

Abstract

To provide methods for treating cancer using hedgehog inhibitors.SOLUTION: A method for treating a subject having cancerous tumor comprising temporary administration of a hedgehog inhibitor (HHI) to the subject in combination with one or more additional cancer therapies.SELECTED DRAWING: Figure 1

Description

[Technical Field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of priority to U.S. Provisional Patent Application No. 62 / 853,842, filed May 29, 2019, the entire contents of each of which are incorporated herein by reference.

[0002] FIELD OF THE INVENTION The present disclosure includes a method or use for treating or ameliorating cancer or the effects of cancer in a subject in need thereof, the method or use comprising administering to the subject an effective amount of a hedgehog inhibitor (HHI) or a pharmaceutically acceptable salt thereof, and a chemotherapeutic agent (CTA). [Background technology]

[0003] One distinctive feature of pancreatic cancer is its typically highly dense and fibrous stroma. Focusing on the stroma is an emerging new strategy for pancreatic cancer treatment, with different approaches currently being tested. For example, preclinical and clinical studies with Nab-P have shown that one of the mechanisms by which drugs exert their effects is by ablating pancreatic cancer tumor stroma. This ablating is accompanied by improved tumor angiogenesis and increased drug penetration into cancer cells, which can enhance antitumor efficacy. Subsequent clinical studies of patients treated with Nab-P have observed similar findings, while also demonstrating that tumors treated with a combination of Gem and Nab-P exhibited increased elasticity, as measured by elastography. Other drugs targeting the pancreatic cancer stroma are in development, including the pegylated hyaluronidase PEGPH20, which has shown interesting results in patients with hyaluronic acid-rich tumors.

[0004] One therapeutic target being investigated in pancreatic cancer is the Hedgehog (Hh) pathway. In preclinical studies, inhibition of Smo with a cyclopamine analog (IPI-926) resulted in selective stroma removal, favorable tumor angiogenesis, and greater efficacy of Gem chemotherapy in these models. Based on these studies, a series of clinical trials was initiated with Smo inhibitors in combination with Gem, with the hypothesis that stroma removal and favorable angiogenesis may be associated with better drug distribution and higher activity. However, despite promising preclinical data, these studies did not show favorable results.

[0005] Subsequent preclinical studies of genetically ablating Smo (by gene deletion) or long-term treatment with Smo inhibitors have shown results that may explain the negative data from clinical trials. In these studies, long-term ablation of stroma significantly increased tumor vascularization and malignant cell proliferation, resulting in persistently higher numbers of metastases and lower survival rates in treated animals.

[0006] The Hedgehog (Hh) pathway is a master regulator of many fundamental processes in vertebrate embryonic development, including stem cell maintenance, cell differentiation, tissue polarity, and cell proliferation. The Hh signaling pathway exerts its biological effects through a signaling cascade that alters the balance between the activator and repressor forms of the glioma-associated oncogene (Gli) transcription factor. Components of the Hh signaling pathway involved in signal transduction to Gli transcription factors include Hedgehog ligands (Sonic Hh [SHh], Indian Hh [IHh], and Desert Hh [DHh]), Patched receptors (Ptch1 and Ptch2), Smoothened receptor (Smo), suppressor of fusion homolog (Sufu), kinesin protein Kif7, protein kinase A (PKA), and cyclic adenosine monophosphate (cAMP). The activator form of Gli translocates to the nucleus and stimulates the transcription of target genes by binding to their promoters. The main target genes of the Hh signaling pathway are PTCH1, PTCH2, and GLI1.

[0007] Constitutive activation of the Hh pathway, which leads to tumorigenesis, is observed in basal cell carcinoma and medulloblastoma. Various other human cancers also demonstrate inappropriate activation of this pathway. Deregulation of the Hh signaling pathway is associated with developmental abnormalities and cancers, including Gorlin syndrome, as well as sporadic cancers such as pancreatic, breast, colon, ovarian, and small cell lung cancer. Abnormal activation of the Hh signaling pathway occurs through mutations in related genes (ligand-independent signaling) or overexpression of Hh signaling molecules (ligand-dependent signaling—autocrine or paracrine). Paracrine Hh signaling from tumors to the surrounding stroma has recently been shown to promote tumorigenesis. This pathway has also been shown to regulate the proliferation of cancer stem cells and increase tumor invasiveness. Targeted inhibition of Hh signaling may be effective in the treatment and prevention of many types of human cancer.

[0008] Several Hh signaling pathway inhibitors, such as vismodegib and sonidegib, have been developed for cancer treatment. These drugs are considered promising cancer therapeutics, especially for patients with refractory / advanced cancer. Other Hedgehog inhibitors include TAK 441, taladegib, sonidegib, salidegib (patidegib), BMS833923, and LEQ506.

[0009] As described by Ohashi et al., the pyrrolo[3,2-c]pyridine derivative TAK-441 suppressed expression of the transcription factor Gli1 mRNA in tumor-associated stromal tissue and inhibited tumor growth (treatment / control ratio, 3%) in a mouse medulloblastoma allograft model, due to an improved PK profile due to increased solubility. See Ohashi et al., "Discovery of the investigational drug TAK-441, a pyrrolo[3,2-c]pyridine derivative, as a highly potent and orally active hedgehog signaling inhibitor: Modification of the core skeleton for improved solubility," Bioorganic & Medicinal Chemistry, Vol. 20, No. 18, September 15, 2012, which is incorporated herein by reference for such background teaching.

[0010] TAK-441 is 6-ethyl-N-[1-(hydroxyacetyl)piperidin-4-yl]-1-methyl-4-oxo-5-(2-oxo-2-phenylethyl)-3-(2,2,2-trifluoroethoxy)-4,5-dihydro-1H-pyrrolo[3,2-c]pyridine-2-carboxamide, formula (I):

[0011] [ka] is.

[0012] Methods for synthesizing TAK-441 are disclosed in U.S. Patent Nos. 8,217,176 and 8,399,449, each of which is incorporated herein by reference in its entirety. Furthermore, International Application Nos. PCT / JP2017 / 003453 and WO 2017 / 135259, also incorporated herein by reference in their entireties, disclose certain co-crystal forms of TAK-441 with L-malic acid or L-tartaric acid. Such co-crystal forms can be used in the methods of the present disclosure. Summary of the Invention [Problem to be solved by the invention]

[0013] There is a need for improved cancer treatments utilizing hedgehog inhibitors. [Means for solving the problem]

[0014] One embodiment of the present disclosure includes a method of treating a subject having a cancerous tumor, the method comprising temporarily administering to the subject a hedgehog inhibitor (HHI) in combination with one or more additional cancer therapies. One embodiment of the present disclosure includes a method of temporarily administering to a cancer patient a hedgehog inhibitor (HHI) in combination with one or more additional cancer therapies, wherein administration of the HHI is discontinued before initiating clinically significant, harmful fibroblast depletion.

[0015] In one embodiment, the HHI is administered before the administration of at least one additional cancer treatment. In one embodiment, administration of the HHI is discontinued before discontinuing at least one of the additional cancer treatments. In one embodiment, at least one of the additional cancer treatments is a systemically delivered treatment. In one embodiment, the systemically delivered treatment is chemotherapy, targeted therapy, or immunotherapy. In one embodiment, the additional cancer treatment is administration of a chemotherapeutic agent (CTA), and the HHI is administered before administering the CTA. In one embodiment, administration of the HHI is discontinued before discontinuing the CTA. In one embodiment, the tumor is a fibrous tumor. In one embodiment, the tumor is a solid tumor. In one embodiment, the tumor has a high stroma mass. In one embodiment, the HHI reduces stroma mass. In one embodiment, the HHI induces angiogenesis within or around the tumor. In one embodiment, the HHI improves tumor uptake of a subsequently administered CTA. In one embodiment, administration of the HHI is discontinued so that further reduction in stroma is stopped or is not clinically significant. In one embodiment, administration of the HHI is discontinued such that further depletion of tumor fibroblasts is halted or is not clinically significant. In one embodiment, administration of the HHI improves the efficacy of additional cancer treatments but is discontinued before promoting clinically significant tumor growth. In one embodiment, administration of the HHI is discontinued such that administration of the HHI does not subsequently initiate clinically significant HHI-induced metastasis. In one embodiment, administration of the HHI is discontinued such that administration of the HHI does not significantly increase the likelihood of subsequent tumor metastasis. In one embodiment, administration of the HHI improves the efficacy of a subsequently administered cancer treatment. In one embodiment, the improvement is evidenced by one or more of metabolic response, positron emission tomography, objective response according to criteria, progression-free survival, overall survival, response based on tumor marker levels, toxicity, and tumor elasticity. In one embodiment, the improvement is evidenced by prolonged survival or prolonged time to progression. In one embodiment, the improvement is evidenced by progression-free survival. In one embodiment, the cancer is pancreatic cancer, esophageal cancer, squamous cell carcinoma, prostate cancer, colon cancer, breast cancer, hepatocellular carcinoma, renal cancer, or cholangiocarcinoma. In one embodiment, the cancer is pancreatic ductal adenocarcinoma (PDAC). In one embodiment, the cancer is hepatocellular carcinoma.In one embodiment, the HHI is an Smo antagonist. In one embodiment, the Smo antagonist is selected from the group consisting of TAK-441, glasdegib, taladegib, sonidegib, slidegib, pachidegib, BMS833923, LEQ506, and combinations thereof. In one embodiment, the HHI is TAK-441. In one embodiment, the CTA is selected from the group consisting of gemcitabine, nab-paclitaxel, taxol, irinotecan, temozolomide, capecitabine, topotecan, cisplatin, oxaliplatin, carboplatin, camptothecin, cytarabine, fluorouracil, cyclophosphamide, etoposide phosphate, teniposide, doxorubicin, daunorubicin, and pemetrexed. In one embodiment, the CTA is one or more of nab-paclitaxel, gemcitabine, and cisplatin. In one embodiment, the CTA is one or more of nab-paclitaxel and gemcitabine. In one embodiment, the route of administration of the HHI is selected from the group consisting of intravenous, oral, and topical. In one embodiment, the route of administration of the additional cancer therapy is selected from the group consisting of intravenous, oral, and topical. In one embodiment, the doses of the HHI and the additional cancer therapy are administered between a biologically effective dose and a maximum tolerated dose. In one embodiment, the patient undergoes treatment cycles, and the additional cancer therapy is a CTA, and is administered during the entire or substantially entire treatment cycle. In one embodiment, the patient undergoes treatment cycles of the additional cancer therapy, and the HHI is administered during a cycle that is shorter than the entire treatment cycle. In one embodiment, the patient is treated with the additional cancer therapy during a cycle, and one or more doses of the HHI are administered only before and during the initial treatment cycle. In one embodiment, one or more doses of the HHI are administered only 1 to 10 days before 1 to 5 cycles of chemotherapy. In one embodiment, one or more doses of the HHI are administered by the third cycle. In one embodiment, each cycle is 28 days, the HHI is administered on days -4 to -1 and days 10 to 13 of each cycle 1 to 3, and the CTA is administered on days 1, 8, and 15 every 28 days. In one embodiment, the HHI is an 800 mg dose of TAK441. In one embodiment, the CTA is 1000 mg / m. 2 of gemcitabine and 125 mg / m2 In one embodiment, the one or more doses of additional cancer therapy are followed by one or more doses of a checkpoint inhibitor (CI). In one embodiment, the CTA is a checkpoint inhibitor (CI) administered in one or more doses. In one embodiment, the route of administration of the CI is selected from the group consisting of intravenous, oral, or topical. In one embodiment, the one or more doses of the CI are administered between a biologically effective dose and the maximum tolerated dose. In one embodiment, the CI is a CTLA4 inhibitor, a PD1 inhibitor, or a PDL1 inhibitor. In one embodiment, the CI is tremelimumab, ipilimumab, durvalumab, nivolumab, pembrolizumab, atezolizumab, cemiplimab, AGEN1884, AGEN2034, or AGEN1181. In one embodiment, the CI is ipilimumab. In one embodiment, the patient is treated in cycles, and the one or more doses of the CI are administered only near the end or beginning of the treatment cycle. In one embodiment, the one or more doses of CI are administered only within 7 days of the end of a treatment cycle. In one embodiment, the one or more doses of CI are administered only after at least 1, 2, or 3 treatment cycles. In one embodiment, the cycle is 28 days and the CI is administered on days 1 and 21 of each cycle starting with cycle 4. In one embodiment, the CI dose is a 3 mg / kg IV dose of ipilimumab.

[0016] One embodiment of the present disclosure includes a method of treating or ameliorating cancer or the effects of cancer in a subject in need thereof, comprising administering to the subject an effective amount of a hedgehog inhibitor (HHI) or a pharmaceutically acceptable salt thereof, and a chemotherapeutic agent (CTA).

[0017] In one embodiment, the HHI is TAK441. In one embodiment, the CTA is nab-paclitaxel. In one embodiment, the CTA is a checkpoint inhibitor (CI). In one embodiment, the method further comprises administering a checkpoint inhibitor (CI). In one embodiment, the cancer has a fibrous stroma. In one embodiment, the cancer is pancreatic cancer, esophageal cancer, squamous cell carcinoma, prostate cancer, colon cancer, breast cancer, hepatocellular carcinoma, renal cancer, or cholangiocarcinoma. In one embodiment, the cancer is pancreatic adenocarcinoma (PDAC). In one embodiment, the cancer is hepatocellular carcinoma. In one embodiment, the efficacy of treatment is measured by tumor regression. In one embodiment, the efficacy of treatment is measured by tumor growth inhibition in a tumor growth inhibition model selected from one or more of the group consisting of metabolic response as measured by fluorodeoxyglucose (FDG), PET according to EORTC criteria, objective response according to RECIST (Response Evaluation Criteria in Solid Tumors) criteria, progression-free survival, overall survival, response based on tumor marker (e.g., CA 19.9) levels, toxicity (e.g., according to Common Toxicity Criteria for Adverse Events Terminology, National Cancer Institute, NCI CTCAE v4.03), and tumor elasticity.

[0018] One embodiment of the present disclosure includes the methods described herein as the use of the listed agents for the treatment of the listed diseases or disorders.

[0019] One embodiment of the present disclosure includes a method described herein as the use of a recited agent in the manufacture of a medicament for the treatment of a recited disease or disorder.

[0020] One embodiment of the present disclosure includes the use of the listed agents for the treatment of the listed diseases or disorders.

[0021] One embodiment of the present disclosure includes the use of the listed agents as pharmaceuticals for the treatment of the listed diseases or disorders.

[0022] One embodiment of the present disclosure includes a pharmaceutical composition comprising the listed agents for the treatment of the listed diseases or disorders.

[0023] One embodiment of the present disclosure includes the listed agents suitable for use in treating the listed diseases or disorders.

[0024] One or more aspects and embodiments may be incorporated into different embodiments even though not specifically mentioned, i.e., all aspects and embodiments may be combined in any way or combination. [Brief explanation of the drawings]

[0025] [Figure 1] 1 is a graph showing tumor growth (% refers to initial tumor volume) in the Panc163 model treated with the indicated regimens. Tumors were implanted subcutaneously. [Figure 2]

[0023] Figure 1 is a graph showing tumor growth (% refers to initial tumor volume) in the JH051 model treated with the indicated regimens. Tumors were implanted subcutaneously. [Figure 3]

[0023] Figure 1 is a graph showing tumor growth (% refers to initial tumor volume) in the Panc025 model treated with the indicated regimens. Tumors were implanted subcutaneously. [Figure 4] Representative images of Masson staining from Panc 163 tumor samples from all experimental groups. [Figure 5] Representative images of Masson staining from Panc 025 tumor samples from all experimental groups. Column 1 shows the staining pattern on the day treatment began. DETAILED DESCRIPTION OF THE INVENTION

[0026] definition As used herein, "treatment" (also "treat" or "treating") refers to any medical intervention or administration of a substance that partially or completely alleviates, improves, relieves, inhibits, delays the onset of, reduces the severity of, or reduces the incidence of one or more symptoms, characteristics, or causes of a particular disease, disorder, or condition.

[0027] As used herein, "temporary administration of a drug" refers to administration that is discontinued permanently or for a period of time so as not to continue administration for a full treatment cycle.

[0028] As used herein, "cancer," "malignancy," "neoplasia," "tumor," and "carcinoma" can be used interchangeably and can refer to cells that exhibit abnormal, uncontrolled, or autonomous growth.

[0029] As used herein, a "chemotherapeutic agent" refers to one or more of a pro-apoptotic agent, a cytostatic agent, or a cytotoxic agent.

[0030] As used herein, "clinically significant" refers to, but is not limited to, something that is worthy of consideration for or influences clinical decision making.

[0031] As used herein, the term "clinical" refers to information relating to or based on the actual observation and treatment of patients, as distinguished from theoretical or basic science.

[0032] As used herein, the phrase "dosing regimen" or alternatively "treatment regimen" refers to a series of, typically more than one, unit doses that may be administered individually to a subject, typically separated by periods of time.

[0033] As used herein, "time to progression" ("TTP") refers to the period, generally measured in weeks or months, from the time of first treatment to cancer progression or worsening. Such progression can be determined by test or observation and can be assessed, for example, by a skilled clinician.

[0034] As used herein, "prolonged TTP" refers to an increase in the time to disease progression in treated versus untreated patients.

[0035] As used herein, "survival" refers to the patient remaining alive, and includes overall survival and progression-free survival.

[0036] As used herein, "overall survival" refers to a patient surviving for a defined period of time, such as 1 year, 5 years, or longer, from either the time of diagnosis or treatment.

[0037] As used herein, "progression-free survival" refers to a patient surviving without their cancer progressing or worsening. Such progression can be determined by test or observation and can be assessed, for example, by a skilled clinician.

[0038] As used herein, "prolonged survival" refers to an increase in overall survival or progression-free survival in treated versus untreated patients.

[0039] As used herein, relative terms of therapeutic outcome, such as "improve," "increase," or "reduce," or grammatical equivalents thereof, refer to values ​​and conditions compared to a baseline measurement or condition, e.g., a measurement of the same individual prior to the initiation of a treatment described herein, or a measurement of a control individual (or control individuals) without a treatment described herein.

[0040] As used herein, "biologically effective dose" refers to the amount of absorbed compound that reaches its target or site of action in the body and produces a biological effect.

[0041] As used herein, "maximum tolerated dose" (or MTD) refers to the highest dose of a drug or treatment that does not cause unacceptable side effects.

[0042] As used herein, a "cycle" refers to a treatment regimen administered over a period of time.

[0043] As used herein, "fibrotic response to malignant tumors" refers to an increase or decrease in the occurrence and / or persistence of fibroma in tumors.

[0044] As used herein, "tumor regression" refers to the cessation of growth of tumor bodies or tissues or a decrease in their size, mass, or number.

[0045] As referenced herein above, TAK-441 is an investigational small molecule that is orally administered and inhibits Smo. In an in vitro model, TAK-441 inhibited the binding of the human Smo inhibitor cyclopamine with a median inhibitory concentration (IC) of 8.6 nM. 50 In a mouse model of castration-resistant prostate cancer, TAK-441 was shown to inhibit Hh ligand paracrine signaling and thus inhibit tumor progression.

[0046] TAK-441 was studied in a Phase I trial at participating centers in Spain. This recently published study investigated the safety, tolerability, pharmacokinetics, and preliminary clinical activity of single and multiple doses of TAK-441. A total of 34 patients (median age: 59 years, range: 28-82 years) with advanced solid tumors (colorectal cancer (26%), basal cell carcinoma (21%), and pancreatic cancer (9%)) were included. Patients received oral TAK-441 (PO) at daily doses ranging from 50 to 1600 mg. The daily dose was subsequently doubled in each cohort until the maximum tolerated dose (MTD) was reached. Blood samples were collected to assess plasma concentrations of TAK-441 after administration, and skin biopsies were used to determine inhibition of Gli1 gene expression.

[0047] The MTD was established at 1600 mg / day based on tablet size and its potency. Dose-limiting toxicities included muscle cramps and fatigue. Oral absorption was fairly rapid, with a mean time to maximum (T maxThe median elimination half-life was 12.9 to 18.3 hours. The pharmacokinetics of TAK-441, based on the area under the plasma concentration-time curve (AUC), was linear across the entire dose range. Inhibition of Gli1 gene expression in skin biopsies was observed at all doses analyzed.

[0048] As described above, the present disclosure includes a method of treating a subject having a cancerous tumor. The method includes temporarily administering to the subject a hedgehog inhibitor (HHI) in combination with one or more additional cancer therapies. The additional cancer therapies may be selected from the group consisting of, but not limited to, chemotherapy, immunotherapy, and targeted therapy. The present disclosure further includes a method of temporarily administering an HHI to a cancer patient in combination with one or more additional cancer therapies, wherein administration of the HHI is discontinued before initiating clinically significant, deleterious fibroblast depletion, including, but not limited to, the development of systemic side effects such as cachexia, anemia, and other paraneoplastic syndromes, as well as the induction of immunosuppression and cancer promotion.

[0049] In this regard, reducing stroma and inducing angiogenesis can be considered beneficial because they allow for better delivery of chemotherapy drugs.Fibrous tumors have low blood vessel density and are hypovascular.For these reasons, drugs cannot penetrate fibrous tumors.Therefore, inducing angiogenesis improves drug uptake.However, there is a delicate balance between when this effect is beneficial and when it subsequently becomes harmful.If fibrosis is removed or excessively restricted, tumors will become excessively vascularized, metastasis will increase, and patient survival will be shortened.

[0050] TAK-441 is being developed for oral use in the treatment of advanced hematologic and non-hematologic malignancies. Preclinical studies have determined that TAK-441 is orally bioavailable in multiple species. TAK-441 demonstrated a 50% inhibition (IC) of 4.4 nM in a luciferase-Gli-sensitive (Gli-luc) promoter assay in NIH3T / Gli-luc cells. 50TAK-441 also inhibited Gli1 mRNA expression in MRC5 human embryonic fibroblasts with an IC50 of 1.9 nM. 50 Furthermore, TAK-441 inhibited the binding of cyclopamine to human Smo (hSmo) in 293T cells overexpressing hSmo with an IC of 8.6 nM. 50 These data suggest that TAK-441 inhibits the Hh signaling pathway through its binding to Smo.

[0051] Administration of TAK-441 in a medulloblastoma allograft model harboring Ptch1 (+ / -) (Ptch1 heterozygote) and p53 (- / -) (p53 null) mutations, or in the PAN-04 mouse xenograft model of primary human pancreatic tumors, resulted in dose-dependent inhibition of in vivo Gli1 mRNA expression in the mouse or stromal tumors, respectively. TAK-441 demonstrated significant dose-dependent antitumor activity in these models (p<0.025). Furthermore, the combination of TAK-441 with rapamycin, an inhibitor of mTOR (mammalian target of rapamycin), demonstrated superior antitumor activity compared with the activity of either agent alone in the PAN-04 mouse model of pancreatic cancer.

[0052] In vivo pharmacokinetics TAK-441 is characterized by a low CL (161.3 and 397.9 ml / h / kg), a moderate volume of distribution (Vss) in steady-state plasma (681.6 and 2181.3 ml / kg), and a moderate t1 / 2 (1.7 and 9.8 hours), along with oral bioavailability in rats and dogs of 31.7% and 90.3%, respectively. There were no differences in plasma exposure between sexes in either rats or dogs. Regarding food effects, in dogs, an approximately two-fold increase in the extent of absorption was observed when TAK-441 was administered to fed dogs (compared to fasted dogs), with a C max Both the area under the plasma concentration versus time curve (AUC0-24h) and the area under the plasma concentration versus time curve (AUC0-24h) increased.

[0053] At a concentration of 1.73 mM, TAK-441 exhibits high binding to plasma proteins in mice (99.7%) and rats (96.2%), and low binding in both dogs (79.6%) and humans (87.7%). Following oral administration to rats and dogs, TAK-441 is metabolized to unidentified metabolites by the cytochrome P450 (CYP) isoenzymes CYP3A4 / 5. No human-specific metabolites were detected in liver microsomal incubations. TAK-441 is a weak inhibitor of CYP2C8 and has no inhibitory effects on other CYP isoenzymes. TAK-441 is not a time-dependent inhibitor of CYP isoenzymes in human liver microsomes. Therefore, TAK-441 is unlikely to affect the pharmacokinetics of other co-administered CYP3A4 / 5 substrates. However, co-administration of CYP3A inhibitors and / or inducers may affect the pharmacokinetics of TAK-441. TAK-441 has high permeability to Caco-2 cells (Papp, A~B 19.6'10-6 cm / sec; Papp, B~Un 37.8'10-6 cm / sec), is a poor substrate for the P-glycoprotein (P-gp) flow pump, and is a weak inhibitor of P-gp (IC of 6.59 mM). 50 )

[0054] Safety Pharmacology The biochemical activity of TAK-441 (at a concentration of 10 mM) was investigated in a total of 126 assays. Among the enzymes, receptors, and transporters included in the assays for TAK-441, TAK-441 inhibited the enzyme human PDE4 phosphodiesterase and the transporter for the human neurotransmitter dopamine by more than 50% (67% and 75%, respectively).

[0055] toxicity research In toxicity studies conducted under good laboratory practice (GLP), TAK-441 was administered to rats and dogs at exposures exceeding those expected for efficacy, and this was associated with a variety of changes attributable to pharmacological inhibition of the Hh signaling pathway. These changes included weight loss, atrophy of the growth plates of the ribs and hair follicles, erosions or ulcers of the gastric mucosa, anemia, bone marrow necrosis and hypocellularity, and pulmonary inflammation and hemorrhage. Dose-limiting toxicities observed in dogs consisted of weight loss, decreased food intake, and gastrointestinal damage (vomiting, diarrhea, anorexia, weight loss, ulcers, and bleeding). Each of these effects is considered susceptible to both clinical and laboratory follow-up.

[0056] Results from studies conducted with TAK-441 indicate that the observed clinically relevant changes, including changes in hematological parameters, gastrointestinal disorders, decreased appetite, and weight loss, are reversible. Isolated changes that were not shown to be reversible included growth plate atrophy in hair follicles and bones, and changes in incisors. Because growth plates have already closed and incisors have already matured in adult patients, neither growth plate atrophy nor incisor changes are considered relevant toxicological findings when TAK-441 is administered clinically to adult patients with cancer. On the other hand, the gait changes and tremors observed in rats are of unknown relevance to humans and are susceptible to clinical follow-up.

[0057] Phase 1 trial of TAK-441 As outlined herein above, TAK-441 was evaluated in a Phase 1 study in patients with advanced cancer. A total of 34 patients (median age: 59 years, range: 28-82 years) with advanced solid tumors (colorectal cancer (26%), basal cell carcinoma (21%), and pancreatic cancer (9%)) were included. Patients received daily doses ranging from 50 to 1600 mg of TAK-441 PO. The daily dose was subsequently doubled in each cohort until the maximum tolerated dose (MTD) was reached. Blood samples were collected to assess plasma concentrations of TAK-441 after administration, and skin biopsies were used to determine inhibition of Gli1 gene expression. The MTD was established at 1600 mg / day (based on tablet size and potency). Observed adverse effects are detailed in Table 2. Dose-limiting toxicities included muscle cramps and fatigue. Oral absorption was fairly rapid, with a mean T max The median elimination half-life was 1.8 to 4.2 hours after administration of a single dose and 2.4 to 4.0 hours after administration of multiple doses. The median elimination half-life was 12.9 to 18.3 hours. The pharmacokinetics of TAK-441, based on the AUC of plasma concentration time, was linear across the entire dose range. Inhibition of Gli1 gene expression in skin biopsies was observed at all doses analyzed.

[0058] A partial response was observed in a patient with basal cell carcinoma, and disease stabilization was observed in seven patients with several solid tumors.TAK-441 was well tolerated, demonstrated an MTD of 1600 mg / day, and demonstrated antitumor activity.

[0059] Chemotherapy Agents (CTAs) Two exemplary CTAs include cytostatic drugs, particularly gemcitabine ("Gem") and nab-paclitaxel ("nab-P") (Abraxane®). Gem has marketing authorization for patients with locally advanced or metastatic pancreatic adenocarcinoma. Nab-P (Abraxane®) is a nanoparticle formulation of paclitaxel bound to albumin, which may have significantly different properties compared to other paclitaxel formulations. Nab-P has been approved by the European Medicines Agency (EMA) for commercialization in combination with Gem for the treatment of patients with advanced pancreatic cancer.

[0060] All cytotoxins are prepared by a compounding pharmacy and administered intravenously according to the specifications listed on their respective technical data sheets. When possible, treatment should be performed in the hospital during the day to allow the patient to remain an outpatient, and at home. Nab-P may be administered as a 30-minute IV infusion, followed by a 30-minute IV infusion of Gem.

[0061] One typical dose and administration schedule is nab-P 125 mg / m 2 IV, then Gem 1000mg / m 2 IV is administered on days 1, 8 and 15 of a 28 day cycle.

[0062] Further CTAs include, but are not limited to, taxol, irinotecan, temozolomide, capecitabine, topotecan, cisplatin, oxaliplatin, carboplatin, camptothecin, cytarabine, fluorouracil, cyclophosphamide, etoposide phosphate, teniposide, doxorubicin, daunorubicin, and pemetrexed. [Example]

[0063] [Example 1] Targeting pancreatic cancer stroma with TAK441 To determine whether combining TAK441 and nab-paclitaxel results in antitumor synergy and to assess the impact of sequential promotion and inhibition of angiogenesis, three different pancreatic ductal adenocarcinoma (PDAC) tumors from the PanXenoBank (Panc163, JH051, and Panc025) were treated with a combination of nab-paclitaxel (ABI) and TAK-441 (a hedgehog inhibitor).

[0064] After several dose-ranging studies to define the most feasible dose of nab-paclitaxel, a dose of 50 mg / kg 1 day q4 x 3 was used. TAK-441 was selected and administered daily at the recommended dose (25 mg / kg / day po). The study was conducted for 21 days.

[0065] As shown in Figures 1-3, the combination of the two agents resulted in synergistic tumor regression in all models analyzed compared to either agent alone.

[0066] Based on the tumor volume values ​​on experimental day 21, tumor growth inhibition (TGI) factors were estimated as shown in Table 1. The greatest inhibition was observed in all three pancreatic cancer models when mice were treated with a combination of nab-paclitaxel and the anti-stromal agent TAK-441.

[0067] [Table 1]

[0068] To assess the histological status of the stroma after treatment, Masson's trichrome stained slides from the Panc 163 and Panc 025 models were analyzed.

[0069] As shown in Figures 4 and 5, samples from the ABI-treated group showed further tumor shrinkage and increased presence of fibrosis (by collagen staining).

[0070] [Example 2] (Example not supported by data) The Phase I / II clinical trial, which may be one or more of open, multicenter, and non-randomized, includes patients with advanced pancreatic cancer who meet protocol-specified inclusion criteria and / or who are not excluded or subsequently removed according to relevant criteria and / or protocol, and the number of patients is selected to ensure sufficient power, such as 25.

[0071] Patients received gemcitabine (1000 mg / m 2 IV) (G) and Abraxane® nab-P (125 mg / m 2IV) (A) conventional chemotherapy is administered on days 1, 8, and 15 of each cycle (every 28 days). In cycles 1 to 3, prior to treatment on days 1 and 15, TAK-441 (also known as NLM-001) is administered at a dose of 800 mg / day PO for 4 days, followed by a rest day before chemotherapy treatment. Initially, a subset, e.g., 6 patients, is included and toxicity is observed for one treatment cycle. If more than two grade 3 or higher toxicity events related to TAK-441 occur, the drug dose is reduced to 400 mg / day.

[0072] Tumor elasticity will be measured by endoscopic ultrasound with elastography at baseline and on days -1 and 13 of cycle 1. Primary tumor biopsies will be performed simultaneously at baseline and on day 13 of cycle 1. After the first cycle, patients will continue treatment until disease progression or unacceptable toxicity.

[0073] TIFF2025143272000004.tif57167

[0074] Patients are treated for 4 cycles: 4 days on and 4 days off.

[0075] Treated patients are believed to exhibit improvements over control patients, including, but not limited to, improvements in one or more of the following:

[0076] Metabolic response by FGD, PET according to EORTC criteria Objective response according to RECIST criteria. Objective response as determined by Response Evaluation Criteria in Solid Tumors (RECIST) v 1.1. These criteria are a set of published criteria that define when a cancer patient improves, is stable, or worsens during treatment. Results are tabulated according to different response classifications.

[0077] Progression-free survival, overall survival: Progression-free survival (PFS) rates at 3 and 6 months (%PFS-3m; %PFS-6m), defined as the percentage of patients whose cancer has not progressed (grown or spread) 3 or 6 months after enrollment, as recorded from randomization. Estimated by creating survival tables using the Kaplan-Meier method. For statistical analysis, the dates corresponding to disease progression are as follows: i. Planned response review if progression is documented by CT and / or physical exam. ii. Death from any cause without previously documented progression. iii. Initiation of secondary treatment following a decision to discontinue protocol treatment for any reason, whether due to toxicity or tolerability. iv. Documentation of progress if secondary treatment was not continued after discontinuation of protocol treatment. v. Determine overall survival from the start of treatment to the patient's death from any cause, which is estimated by constructing survival tables using the Kaplan-Meier method.

[0078] Response based on tumor marker CA 19.9 levels CA 19.9 response is calculated as the maximum percent change from baseline in patients with a baseline greater than 1.25 times the upper limit of normal in each center's local laboratory. Results are further tabulated according to responder and non-responder classification, using three different response criteria: >50%, >75%, and >90% reduction, respectively.

[0079] Toxicity according to CTCAE NCI v4.03 All observed adverse effects, including clinical events and laboratory data, will be tabulated to document the safety of the treatment. These will be classified and their severity quantified according to the Common Terminology Criteria for Adverse Events, National Cancer Institute, version 4.3 (CTCAE-NCI v. 4.3). Disease progression will be considered a result of the natural history of the disease and will therefore be collected on the patient CRF and not treated as an adverse event in this study. Therefore, disease progression will not be communicated according to pharmacovigilance procedures; it should be recorded in the response classification according to the protocol-defined procedures.

[0080] Tumor elasticity The secondary variable of the study is the measurement of tumor elasticity by elastography, defined as the "strain rate ratio" between tumor and normal tissue, as previously described. A Pentax linear ultrasound endoscope and a Hitachi EUB900 device are used for the measurement. Areas representative of the tumor and surrounding normal tissue are selected. The elastography results are expressed as the "strain rate ratio" between tumor and normal tissue. In previous studies, this index has a mean value of 32. Treatment with TAK-441 is expected to reduce this by at least 50%.

[0081] Biomarkers Expression of Gli-1 mRNA, smooth muscle actin-positive cancer-associated fibroblasts (SMA+CAFs), collagen structure, and lymphocyte infiltration (CD3, CD4, and CD8).

[0082] [Example 3] (Example not supported by data) A Phase I / II clinical trial, which may be one or more of open, multicenter, and non-randomized, similar to Example 2, further includes the administration of a checkpoint inhibitor, such as a PD1 or CTLA4 inhibitor, one example of which is ipilimumab.

[0083] As an example, a 3 mg / kg IV dose of ipilimumab is administered on days 1 and 21 of each cycle starting with cycle 4, as illustrated in Scheme 2. Alternatively, the dose and improvement endpoints remain as described in Example 2.

[0084] TIFF2025143272000005.tif243141

[0085] As another example, the treatment regimen may include NLM-001: 800 mg / day orally on days -4 to -1 and days 10 to 13 of each cycle 1 to 3; gemcitabine (G): 1,000 mg / m 2 IV Abraxane (A): 125 mg / m on days 1, 8, and 15 every 28 days 2 IV every 28 days on days 1, 8, and 15, and CTLA-4 inhibitor (CTLA-4): 1 mg / kg on day 15 of cycle 1 and days 1 and 15 of subsequent cycles. Illustrated in Scheme 3.

[0086] TIFF2025143272000006.tif77167

[0087] Tumor elasticity will be measured by endoscopic ultrasound with elastography at baseline and on days -1 and 13 of cycle 1, as described above in Example 2. Primary tumor biopsies will be performed simultaneously at baseline and on day 13 of cycle 1. After the first cycle, patients will continue treatment until disease progression or unacceptable toxicity, and improvement endpoints will remain as described in Example 2.

[0088] The unsupported examples, Examples 2 and 3, together provide direction to demonstrate that transient, so-called "shock," administration of TAK441 in patients with advanced pancreatic cancer temporarily reduces pancreatic cancer stroma, thereby favoring the action of chemotherapy treatment.

[0089] [Example 4] (Example not supported by data) Hepatocellular carcinoma (HCC) is a fatal tumor whose incidence is increasing in the United States, primarily due to the spread of hepatitis C infection. HCC is the most common primary liver cancer and the second leading cause of cancer death worldwide. See Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al., Cancer incidence and mortality worldwide: sources, methods, and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359-E386. doi: 10.1002 / ijc.29210. Despite significant advances in the diagnosis and treatment of HCC, its prognosis remains very poor, with a 5-year overall survival (OS) rate of 12% for all stages combined (ibid.). Most HCC (80-90%) occurs in the setting of underlying chronic liver disease (with or without cirrhosis), with major causes including chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, alcohol consumption, nonalcoholic steatohepatitis, or other less common etiologies such as hemochromatosis, tobacco, and aflatoxin B1. The highest incidence of HCC is observed in Southeast Asia and Central Africa, where the endemic prevalence of chronic HBV infection accounts for 70% of cases.Each is incorporated by reference with respect to the background of HCC, e.g., Pawlotsky JM., Pathophysiology of hepatitis C virus infection and related liver disease. Trends Microbiol. 2004;12(2):96-102; Trepo C et al., Hepatitis B virus infection. Lancet. 2014;384(9959):2053-2063; Morgan TR et al., Alcohol and hepatocellular carcinoma. Gastroenterology, 2004;127 (5 Suppl 1):S87-S96; Zhang DY et al., Fibrosis-dependent mechanisms of hepatocarcinogenesis. Hepatology. 2012;56(2):769-775; Bugianesi E et al., NASH and the risk of cirrhosis and hepatocellular carcinoma in type 2 diabetes. Curr Diab Rep. 2007;7(3):175~180; Forner A et al., hepatocellular carcinoma. Lancet. 2012; 379(9822):1245~1255; and Llovet JM, Zucman-Rossi J, Pikarsky E, Sangro B, Schwartz M, Sherman M et al., hepatocellular carcinoma. Nat Rev Dis Prime. 2016.

[0090] The Barcelona Clinical Liver Cancer (BCLC) classification is currently recommended to assess the prognosis of HCC patients and select the most appropriate treatment for each patient (available online at https: / / www.esmo.org / Guidelines / Gastrointestinal-Cancers / Hepatocellular-Carcinoma). There are five BCLC classifications (0, A, B, C, and D), which consider both baseline liver function, as assessed by the Child-Pugh score, and the patient's general condition according to the Eastern Collaborative Oncology Group performance status (ECOG PS). The only curative treatments for HCC reserved for patients with early-stage HCC (BCLC stage 0, A) are surgical resection, thermal ablation, radiation therapy, and / or liver transplantation. Adjuvant treatments have not been effective against HCC.

[0091] Hedgehog signaling promotes tumor-associated macrophage polarization and suppresses intratumoral CD8+ T cell recruitment. See Petty et al., Journal of Clinical Investigation (2019), incorporated herein by reference for a description of such a testing protocol. The disclosed compound TAK-441 can be administered in combination with a PD-1 blocker to produce synergistic efficacy. See also the editorial "Scientists discover reasons why targeted immuno-oncology drugs sometimes fail" (October 23, 2019), at https: / / medicalxpress.com / news / 2019-10-scientistsimmuno-oncology-drugs.html, incorporated herein by reference for a description of such a testing protocol. This synergistic effect may be particularly suitable for the treatment of HCC.

[0092] PD-1 is a checkpoint protein on T cells, a type of immune cell, that helps the body recognize abnormal cells and diseases within the body. PD-1 normally acts as an "off switch" that prevents T cells from attacking other cells. PD-1 inhibitors are used to selectively block this protein and enhance the immune response to attack cancer cells. Previously reported data indicated that the primary reason some cancer patients do not respond to PD-1 therapy is because fighter T cells (known as CD8 T cells) are unable to infiltrate the tumor microenvironment, a condition also known as "cold tumor." In their study, Yang et al. reported data indicating a specific cellular mechanism that limits the ability of CD8 T cells to infiltrate the tumor microenvironment. They showed that hedgehog signaling blocks chemokine secretion by tumor-associated macrophages, which is essential for CD8 T cell infiltration. By blocking (inhibiting) the hedgehog pathway, the researchers were able to reverse the process and promote CD8 T cell infiltration into the tumor microenvironment. The data demonstrated that in preclinical models involving both liver and lung cancer, hedgehog inhibitors administered in combination with PD-1 blockade were more effective at killing cancer cells than either agent alone.

[0093] The Hedgehog (HH) pathway is involved in liver embryonic development, and its reactivation plays a critical role in maintaining cancer cell growth and progression in hepatocellular carcinoma (HCC). During hepatocellular carcinoma formation, HH signaling is required for the differentiation, proliferation, and polarization of hepatic germ cells. High levels of HH expression in HCC tissue correlate with mesenchymal characteristics and maintain the proliferation of cancer stem cells, a dynamic source of malignant cells in HCC progression. Current data on HH inhibition in preclinical models further confirm the role of HH, making it worthy of further investigation in clinical settings. See, for example, "Implications of the Hedgehog pathway in hepatocellular carcinoma," Della Corte et al., World J Gastroenterol. 2017 June 28;23(24):4330-4340. Published online June 28, 2017.

[0094] Examples of checkpoint inhibitors include one or more PD-1 inhibitors, such as pembrolizumab (KEYTRUDA®), nivolumab (OPDIVO®), and cemiplimab (LIBTAYO®); PD-L1 inhibitors, such as atezolizumab (TECENTRIQ®), avelumab (BAVENCIO®), and durvalumab (IMFINZI®); and CTLA-4 inhibitors, such as ipilimumab (YERVOY®). Additional checkpoint inhibitors include tremelimumab, AGEN1884, AGEN2034, or AGEN1181.

[0095] Study Description A Phase I / II clinical trial that is open, multicenter, and non-randomized, similar to that of Example 2, but further includes administration of a checkpoint inhibitor, e.g., a PD1 or CTLA4 inhibitor, as described herein.

[0096] The hedgehog inhibitor TAK-441, also known as NLM001, may be administered for 5 days at a dose of 800 mg / day (one dose less than the maximum dose previously administered) for 4 cycles. At the end of each cycle, administration is followed by administration of a checkpoint inhibitor. The combination is believed to demonstrate efficacy beyond that shown by either individual single agent.

[0097] In one aspect of the examples provided herein, the improvement to the patient is: metabolic response, positron emission tomography, Objective response according to criteria, progression-free survival, overall survival, response based on tumor marker levels, Toxicity, and Tumor elasticity This is evidenced by one or more of the following:

[0098] In this regard, metabolic response may be measured by fluorodeoxyglucose (FDG), PET may be assessed according to EORTC criteria, objective response may be assessed according to RECIST (Response Evaluation Criteria in Solid Tumors) criteria, progression-free survival may be as defined herein, overall survival may be as defined herein, response based on tumor marker levels may be assessed, for example, against CA 19.9, toxicity may be assessed, for example, according to the Common Toxicity Criteria for Adverse Events, National Cancer Institute, version 4.03 (NCI CTCAE v4.03), and tumor elasticity may be assessed by estography, defined as the "strain rate ratio" between tumor tissue and normal tissue.

[0099] All subjects will be included in the efficacy analysis according to the "intention-to-treat" principle. All subjects who received at least the first dose of the first treatment cycle will be included in the toxicity analysis.

[0100] The elasticity index is graphed for each subject and measurement time. For each patient, the variability of this parameter is calculated for each measurement point. Values ​​at different measurement points are compared using a paired sample non-parametric test. The variability of CA 19.9 is analyzed by the same method.

[0101] Objective responses by CT and / or MRI will be analyzed according to RECIST criteria, and responses will be attributed to each subject. Global data from the study will be summarized using descriptive statistics. Responses by PET will also be analyzed using EORTC criteria.

[0102] Biomarker analysis is presented graphically for each subject. Data are summarized using descriptive statistics for each collection point, including calculation of proportional change before and after treatment and nonparametric comparison of paired samples. Overall, we use methodologies previously published in GA studies.

[0103] Similarly, pharmacokinetic parameters are graphically visualized and summarized using descriptive statistics.

[0104] Adverse events characterized by type, frequency, severity (graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) version 4.03), timing, seriousness, and relationship to study treatment will be described using descriptive statistics.

[0105] Overall survival is defined as the time elapsed between the inclusion date and the date of death. Progression-free survival is defined as the time elapsed between the inclusion date and the date of start of second-line treatment without progression, documented progression, or death. Both variables will be studied using survival curves according to the Kaplan-Meier method.

[0106] Given the exploratory nature of the study design, correction for multiplicity of the studies used is not deemed necessary.

[0107] The level of significance used in all statistical tests was p-value = 0.05 two-sided.

[0108] Details of the analysis will be reflected in a statistical analysis plan that will be developed prior to closure of the study database.

[0109] All publications, patents, and patent applications cited herein are hereby incorporated by reference for the purposes of teaching the use of such citations.

[0110] Test compounds for the experiments described herein were used in free or salt form.

[0111] The particular response observed may vary according to and depending on the presence or absence of the particular active compound or carrier selected, as well as the type of formulation and mode of administration used, and such expected variations or differences in results are contemplated in accordance with the practice of the present invention.

[0112] Although specific embodiments of the present invention have been illustrated and described in detail herein, the present invention is not limited thereto. The above detailed description is provided as an example of the present invention and should not be construed as constituting any limitation of the present invention. Modifications will be apparent to those skilled in the art, and all modifications that do not depart from the spirit of the present invention are intended to be included within the scope of the appended claims.

Claims

1. A method of treating a subject having a cancerous tumor, comprising the temporary administration to the subject of a hedgehog inhibitor (HHI) in combination with one or more additional cancer therapies.

2. A method of temporarily administering a hedgehog inhibitor (HHI) to a cancer patient in combination with one or more additional cancer treatments, wherein administration of the HHI is discontinued before initiating clinically significant, harmful fibroblast depletion.

3. 3. The method of claim 1 or 2, wherein the HHI is administered prior to the administration of at least one additional cancer treatment.

4. 4. The method of any one of claims 1 to 3, wherein administration of the HHI is discontinued before discontinuation of at least one of the additional cancer treatments.

5. 5. The method of any one of claims 1 to 4, wherein at least one of the additional cancer treatments is a systemically delivered therapy.

6. 6. The method of claim 5, wherein the systemically delivered therapy is chemotherapy, targeted therapy, or immunotherapy.

7. The method of claim 5, wherein the additional cancer treatment is administration of a chemotherapy agent (CTA), and the HHI is administered before administering the CTA.

8. 8. The method of claim 7, wherein administration of the HHI is discontinued before discontinuation of the CTA.

9. 9. The method of any one of claims 1 to 8, wherein the tumor is a fibrous tumor.

10. 10. The method of any one of claims 1 to 9, wherein the tumor is a solid tumor.

11. 11. The method of any one of claims 1 to 10, wherein the tumor has a high tumor mass.

12. 12. The method of claim 1, wherein the HHI reduces interstitial mass.

13. 13. The method of any one of claims 1 to 12, wherein the HHI induces angiogenesis within or around the tumor.

14. 14. The method of any one of claims 1 to 13, wherein the HHI improves tumor uptake of a subsequently administered CTA.

15. 15. The method of any one of claims 1 to 14, wherein administration of the HHI is discontinued such that further reduction of interstitium is stopped or is not clinically significant.

16. 16. The method of any one of claims 1 to 15, wherein administration of the HHI is discontinued such that further depletion of tumor fibroblasts is stopped or is not clinically significant.

17. 17. The method of any one of claims 1 to 16, wherein administration of the HHI improves the efficacy of additional cancer therapy but is discontinued before promoting clinically significant tumor growth.

18. 18. The method of any one of claims 1 to 17, wherein administration of the HHI is discontinued such that administration of the HHI does not subsequently initiate clinically significant HHI-induced metastasis.

19. 19. The method of any one of claims 1 to 18, wherein administration of the HHI is discontinued such that administration of the HHI does not significantly increase the likelihood of subsequent tumor metastasis.

20. 20. The method of any one of claims 1 to 19, wherein administration of the HHI improves the efficacy of a subsequent cancer treatment.

21. Improvements, A) metabolic response, B) Positron emission tomography, C) objective response according to criteria; D) progression-free survival; E) overall survival; F) Response based on tumor marker levels; G) toxicity, and H) Tumor elasticity 21. The method of claim 20, wherein the method is evidenced by one or more of:

22. 21. The method of claim 20, wherein the improvement is evidenced by increased survival or increased time to progression.

23. 21. The method of claim 20, wherein the improvement is evidenced by progression-free survival.

24. 24. The method of any one of claims 1 to 23, wherein the cancer is pancreatic cancer, esophageal cancer, squamous cell carcinoma, prostate cancer, colon cancer, breast cancer, hepatocellular carcinoma, renal cancer, or cholangiocarcinoma.

25. 25. The method of any one of claims 1 to 24, wherein the cancer is pancreatic ductal adenocarcinoma (PDAC).

26. 25. The method of any one of claims 1 to 24, wherein the cancer is hepatocellular carcinoma.

27. 26. The method of any one of claims 1 to 25, wherein the HHI is a Smo antagonist.

28. 28. The method of claim 27, wherein the Smo antagonist is selected from the group consisting of TAK 441, glasdegib, taladegib, sonidegib, salidegib, pachidegib, BMS833923, LEQ506, and combinations thereof.

29. 29. The method of any one of claims 1 to 28, wherein the HHI is TAK 441.

30. 30. The method of any one of claims 26 to 29, wherein the CTA is selected from the group consisting of gemcitabine, nab-paclitaxel, taxol, irinotecan, temozolomide, capecitabine, topotecan, cisplatin, oxaliplatin, carboplatin, camptothecin, cytarabine, fluorouracil, cyclophosphamide, etoposide phosphate, teniposide, doxorubicin, daunorubicin, and pemetrexed.

31. 31. The method of claim 30, wherein the CTA is one or more of nab-paclitaxel, gemcitabine, and cisplatin.

32. 31. The method of claim 30, wherein the CTA is one or more of nab-paclitaxel and gemcitabine.

33. 33. The method of any one of claims 1 to 32, wherein the route of administration of the HHI is selected from the group consisting of intravenous, oral, and topical.

34. 34. The method of any one of claims 1 to 33, wherein the route of administration of the additional cancer treatment is selected from the group consisting of intravenous, oral, and topical.

35. 35. The method of any one of claims 1 to 34, wherein the doses of the HHI and the additional cancer treatment are administered between a biologically effective dose and a maximum tolerated dose.

36. 36. The method of any one of claims 1 to 35, wherein the patient undergoes treatment cycles and the additional cancer treatment is a CTA and is administered during all or substantially all of the treatment cycles.

37. 37. The method of claim 36, wherein the patient receives an additional treatment cycle of the cancer therapy and the HHI is administered during less than the entire treatment cycle.

38. 38. The method of any one of claims 1 to 37, wherein the patient is receiving additional cancer therapy treatment during the cycle, and one or more doses of the HHI are administered only before and during the initial treatment cycle.

39. 39. The method of claim 37 or 38, wherein the one or more doses of HHI are administered only 1 to 10 days before 1 to 5 cycles of chemotherapy.

40. 40. The method of claim 39, wherein one or more doses of HHI are administered up to the third cycle.

41. 41. The method of any one of claims 37 to 40, wherein each cycle is 28 days, and the HHI is administered on days -4 to -1 and days 10 to 13 of each cycle of cycles 1 to 3, and the CTA is administered on days 1, 8, and 15 every 28 days.

42. 42. The method of claim 41, wherein the HHI is an 800 mg dose of TAK 441.

43. CTA is 1000 mg / m 2 of gemcitabine and 125 mg / m 2 43. The method of claim 41 or 42, wherein the agonist is selected from one or more of the following: nab-paclitaxel;

44. 44. The method of any one of claims 1 to 43, wherein the one or more doses of additional cancer therapy are followed by one or more doses of a checkpoint inhibitor (CI).

45. 30. The method of any one of claims 1 to 29, wherein the CTA is a checkpoint inhibitor (CI) administered in one or more doses.

46. 46. ​​The method of claim 44 or 45, wherein the route of administration of the CI is selected from the group consisting of intravenous, oral or topical.

47. 47. The method of any one of claims 44 to 46, wherein one or more doses of CI are administered between a biologically effective dose and a maximum tolerated dose.

48. 48. The method of any one of claims 44 to 47, wherein the CI is a CTLA 4 inhibitor, a PD1 inhibitor or a PDL1 inhibitor.

49. 49. The method of claim 48, wherein the CI is tremelimumab, ipilimumab, durvalumab, nivolumab, pembrolizumab, atezolizumab, cemiplimab, AGEN1884, AGEN2034 or AGEN1181.

50. 50. The method of claim 49, wherein the CI is ipilimumab.

51. 51. The method of any one of claims 44 to 50, wherein the patient receives treatment in cycles and one or more doses of CI are administered only near the end or beginning of a treatment cycle.

52. 52. The method of claim 51, wherein one or more doses of CI are administered only within 7 days of the end of a treatment cycle.

53. 52. The method of claim 51, wherein one or more doses of CI are administered only after at least 1, 2, or 3 treatment cycles.

54. 52. The method of claim 51, wherein the cycle is 28 days and the CI is administered on days 1 and 21 of each cycle starting with cycle 4.

55. 55. The method of claim 54, wherein the CI dose is a 3 mg / kg IV dose of ipilimumab.

56. A method for treating or ameliorating cancer or the effects of cancer in a subject in need thereof, comprising administering to the subject an effective amount of a hedgehog inhibitor (HHI) or a pharmaceutically acceptable salt thereof, and a chemotherapeutic agent (CTA).

57. 57. The method of claim 56, wherein the HHI is TAK 441.

58. 58. The method of claim 56 or 57, wherein the CTA is nab-paclitaxel.

59. 58. The method of claim 57, wherein the CTA is a checkpoint inhibitor (CI).

60. 59. The method of claim 58, further comprising administration of a checkpoint inhibitor (CI).

61. 61. The method of any one of claims 56 to 60, wherein the cancer has a fibrous stroma.

62. 62. The method of any one of claims 56 to 61, wherein the cancer is pancreatic cancer, esophageal cancer, squamous cell carcinoma, prostate cancer, colon cancer, breast cancer, hepatocellular carcinoma, renal cancer, or cholangiocarcinoma.

63. 63. The method of any one of claims 56 to 62, wherein the cancer is pancreatic ductal adenocarcinoma (PDAC).

64. 63. The method of any one of claims 56 to 62, wherein the cancer is hepatocellular carcinoma.

65. 65. The method of any one of claims 56 to 64, wherein the efficacy of treatment is measured by tumor regression.

66. The effect of the treatment is A) Metabolic response measured by fluorodeoxyglucose (FDG); B) PET according to EORTC standards; C) Objective response according to RECIST (Response Evaluation Criteria in Solid Tumors) criteria; D) progression-free survival; E) overall survival; F) Response based on tumor marker (e.g., CA 19.9) levels; G) Toxicity (e.g., according to the Common Toxicity Criteria for Adverse Events Terminology, National Cancer Institute, version 4.03 (NCI CTCAE v4.03)); and H) Tumor elasticity 66. The method of any one of claims 56 to 65, wherein the tumor growth inhibition factor is measured in a tumor growth inhibition model selected from one or more of the group consisting of:

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