Methods for assessing selective glucocorticoid receptor modulation and methods for identifying and treating patients likely to benefit from glucocorticoid receptor modulation

Abstract

Co-administration of a selective glucocorticoid receptor modulator (SGRM; e.g., relaxolant or exicholant) with a cancer therapeutic agent (e.g., a taxane or antiandrogen) is useful for identifying elevated cortisol activity in cancer patients or patients with Cushing's syndrome and for treating cancer patients (e.g., ovarian, pancreatic, or prostate cancer). A change of at least 40% in RNA levels encoding CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, or CD86 indicates that the cancer patient is likely to benefit from the combination treatment (e.g., likely to survive longer than similar patients not receiving the combination treatment). An active SGRM dose is identified when RNA levels encoding CDKN1C, TNFRSF17, BRIP1, or PDK1 decrease by at least 40%, or RNA levels encoding CLEC10A, FPR3, CCR2, LILRB4, and CD86 increase by at least 40%. Altered levels of RNA encoding CLEC10A, FPR3, CCR2, LILRB4, and CD86 identify cancer or Cushing's syndrome patients with elevated cortisol activity.

Description

[Background technology]

[0001] Cortisol is the most abundant endogenous agonist of the glucocorticoid receptor (GR) in humans. Cortisol can be measured, for example, in blood, urine, saliva, or tear samples, but the cortisol levels measured in these different samples are different and do not correlate with each other. Urinary free cortisol (a measure of cortisol excreted in urine over a 24-hour period) is used to diagnose Cushing's syndrome. Furthermore, plasma cortisol (a measure of cortisol levels at the time the blood sample is taken) is used in the dexamethasone suppression test (which tests the patient's response to a rapid increase in glucocorticoid levels). Furthermore, cortisol levels can be measured in whole blood or serum samples according to methods known to those skilled in the art.

[0002] Cortisol levels fluctuate throughout the day, with higher levels in the morning and lower levels at night. Normal morning serum levels are sufficient to activate the GR systemically [Wang & Harris, Adv Exp Med Biol. (New York, NY: Springer New York). 2015; 2895-98.]. Research into GR physiology will be aided by selective glucocorticoid receptor modulators (SGRMs). GR-specific agonists, such as dexamethasone, can assess supraphysiological GR activation [Shen et al., Archives of Surgery, 141, 771 (2006)]. Although endogenous GR agonists (i.e., cortisol and corticosterone) are abundant in mammals, no natural GR antagonists exist, complicating interpretation of systemic SGRM effects on gene transcription. However, steroidal GR antagonists are limited to mifepristone and its analogs and are not specific for the GR [Rew et al., Journal of Medicinal Chemistry, 61, 7767-7784 (2018)]. Therefore, there is a need for GR-specific antagonists to elucidate the biological role of endogenous cortisol by specifically antagonizing cortisol activity at the GR.

[0003] Nuclear hormone receptors are one of the few examples of druggable transcriptional regulators [Frigo et al., Essays in Biochemistry, 65, 847-856 (2021)]. Selective androgen receptor modulators (SARMs and SERMs) are important pharmaceuticals in oncology and the treatment of endocrine disorders. SGRMs are a new class of promising drug candidates in oncology, endocrine disorders, and metabolic diseases [Munster et al., Clinical Cancer Research, 28, 3214-3224 (2022); Colombo et al., Journal of Clinical Oncology, 40, LBA5503-LBA5503 (2022)]. Thousands of target genes for GR have been reported in various contexts [Greenstein et al., Endocrine-Related Cancer, 28, 583-592 (2021)], and published studies generally report GR agonists and short-term effects on homogenous cell populations in vitro [McDowell et al., Genome Research, 28, 1272-1284 (2018); Arora et al., Cell, 155, 1309-132 2(2013); Stringer-Reasor et al., Gynecologic Oncology, 138, 656-662 (2015)]. Many of the reported GR-responsive genes are also AR and ER target genes, confirming the complexity of nuclear hormone signaling [Arora et al., Cell, 155, 1309-1322 (2013); and Isikbay et al., Hormones and Cancer, 5, 72-89 (2014)]. Previous studies have not systematically addressed the broader role of cortisol signaling in humans through the identification of GR-specific target genes.

[0004] Thus, there is a need for the identification of genes regulated by GR and for novel therapeutic options to modulate GR for the treatment of disorders of GR regulation and other disorders, including cancer and Cushing's syndrome. Summary of the Invention [Means for solving the problem]

[0005] Disclosed herein are novel methods for identifying patients likely to benefit from treatments involving the administration of a selective glucocorticoid receptor modulator (SGRM), novel methods for identifying active doses of such SGRMs in cancer patients, and novel methods for identifying cancer patients with relatively elevated cortisol activity compared to other similar cancer patients. In some embodiments, these methods include combination cancer therapies involving the administration of an SGRM and a cancer therapeutic agent, as well as methods for identifying patients likely to benefit from such combination therapies. In some embodiments, the SGRM inhibits GR activation. In some embodiments, the SGRM is a non-steroidal SGRM and may be a heteroaryl ketone-fused azadecalin or an octahydro-fused azadecalin. In some embodiments, the SGRM is selected from a relaxilant and an exicolant. The cancer therapeutic agent may be, for example, a taxane, an antiandrogen, or another cancer therapeutic agent. In some embodiments, the taxane is paclitaxel or nab-paclitaxel. In some embodiments, the antiandrogen is enzalutamide. In some embodiments, administration of the SGRM and the cancer therapeutic agent (e.g., a taxane or an antiandrogen) is effective to prolong patient survival (i.e., the patient survives for a longer period after combined treatment with the SGRM and the cancer therapeutic agent than would be expected for such patient receiving the cancer therapeutic agent alone). In some embodiments, a potential benefit of such combination therapy includes prolonged patient survival. In some embodiments, the cancer patient is afflicted with a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

[0006] Also disclosed herein are novel methods for identifying an active dose of an SGRM in patients with Cushing's syndrome. In some embodiments, the SGRM inhibits activation of the glucocorticoid receptor (GR). In some embodiments, the SGRM is a relaxant or an exicholant.

[0007] Disclosed herein are methods for assessing the pharmacodynamic effects of an SGRM and for identifying cancer patients likely to benefit from an SGRM-containing therapy, comprising administering an SGRM and a cancer therapeutic (e.g., a taxane, such as paclitaxel or nab-paclitaxel; an antiandrogen, such as enzalutamide, or other cancer therapeutic) and measuring a change in the patient's systemic RNA levels (e.g., as measured in a blood sample, e.g., a whole blood sample) of RNA encoding one or more of CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 compared to baseline. In some embodiments, the RNA levels are whole blood RNA levels. In some embodiments, a change of at least 40% in RNA levels in a cancer patient receiving an SGRM and a cancer therapeutic (compared to a similar cancer patient not receiving an SGRM and a cancer therapeutic) indicates that the patient is more likely to survive long-term than a similar cancer patient not receiving an SGRM and a cancer therapeutic. In some embodiments, a decrease of at least 40% in the level of RNA encoding CDKN1C, TNFRSF17, BRIP1, or PDK1, or an increase of at least 40% in the level of RNA encoding CLEC10A, FPR3, CCR2, LILRB4, or CD86 in a cancer patient receiving an SGRM and a cancer therapeutic agent (compared to a similar cancer patient not receiving an SGRM and a cancer therapeutic agent), indicates that the patient is more likely to survive for a longer period of time than a similar cancer patient not receiving an SGRM and a cancer therapeutic agent. In some embodiments, the cancer patient is afflicted with a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

[0008] In some embodiments, administration of the SGRM and the cancer therapeutic agent is effective to extend patient survival beyond the expected survival for the patient if the SGRM were not administered, where the expected survival for the patient administered the cancer therapeutic agent alone without the SGRM is the expected survival for the patient if the SGRM were not administered. In some embodiments, the cancer therapeutic agent can be a taxane (e.g., paclitaxel or nab-paclitaxel), the antiandrogen enzalutamide, or a different cancer therapeutic agent.

[0009] Applicant further discloses herein a method of using the change from baseline in RNA levels encoding one or more of CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 to identify an active dose of an SGRM to administer to a patient in need thereof. In some embodiments, an SGRM dose that causes a decrease in the level of RNA encoding CDKN1C, TNFRSF17, BRIP1, or PDK1, or an increase in the level of RNA encoding CLEC10A, FPR3, CCR2, LILRB4, or CD86 (compared to baseline), is identified as an active dose of the SGRM. In some embodiments, the decrease or increase that identifies an SGRM dose as an active dose is at least a 40% decrease or increase compared to baseline. In some embodiments, the identified active SGRM dose is administered to a patient in conjunction with a cancer therapeutic agent.

[0010] Applicant further discloses herein a method for identifying cancer patients with relatively elevated cortisol activity (compared to similar cancer patients) using baseline RNA levels encoding one or more of CLEC10A, FPR3, CCR2, LILRB4, CD86, FKBP5, GSK3B, PIK3CG, and MCL1. In one embodiment, the cancer patient is afflicted with a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

[0011] In one embodiment, a change in RNA level of at least 40% in a Cushing's syndrome patient receiving a dose of an SGRM (compared to the baseline level of that RNA in that Cushing's syndrome patient) indicates that the SGRM dose is an active dose.

[0012] In one embodiment, the SGRM is relacolinant (also known as CORT 125134) or exicholant (also known as CORT 125281). Relacolinant has the chemical name (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone, and is a heteroaryl-ketone-fused azadecalin compound having the following structure: [ka] Exicholant has the chemical name ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone and is an octahydrofused azadecalin compound having the following structure: [ka]

[0013] Accordingly, applicants disclose herein improved methods for identifying and treating cancer patients who would benefit from combination treatment with an SGRM and a cancer therapeutic agent; improved methods for identifying an active dose of an SGRM; improved methods for identifying and treating cancer patients with excess cortisol activity; improved methods for identifying an active SGRM dose for such treatment; improved methods for extending overall survival of cancer patients; methods for identifying an active SGRM dose for treating patients with Cushing's syndrome; methods for treating patients with Cushing's syndrome with said SGRM dose; and other useful diagnostic and therapeutic methods. [Brief explanation of the drawings]

[0014] [Figure 1A]

[0014] Figure 1 shows the design of a randomized, open-label, phase 2 ovarian cancer trial. Patients received nab-paclitaxel (NP) alone or with relacorilant (administered continuously or intermittently). Patients whose disease progressed on nab-paclitaxel alone were allowed to cross over to NP plus continuous relacorilant.

[0015] [Figure 1B] Figure 1 shows the design of a randomized, open-label, phase 2 ovarian cancer study. RNA sampling (red triangles) was performed pre-dose on days 1 and 15 of cycle 1. This captured the pharmacodynamic effect of relacorilant administration for 14 consecutive days in patients in the continuous group (not shown). Meanwhile, for patients in the intermittent group, this essentially represents sampling after washout (days 10-13) followed by a single relacorilant administration (day 14) (black diamonds represent relacorilant administration days). Granulocyte colony-stimulating factor (G-CSF) (gray bars) was required for all patients receiving relacorilant on days 2, 9, and 16 of each cycle.

[0016] [Figure 2A]FIG. 1 shows the scheme used to identify 444 target genes that distinguish between patients treated with relacorilant and those not treated with relacorilant.

[0017] [Figure 2B] Figure 2B shows genes identified to distinguish between patients treated with relacorilant and those not treated with relacorilant. Machine learning distinguished the pharmacodynamic effects between relacorilant + NP (combined continuous and intermittent treatment) and NP alone based on fold change in a panel of 444 genes. Genes were measured on C1D1 and C1D15, and fold change was calculated for each gene. Cross-validated random forest analysis identified a set of genes whose fold change consistently differed between the relacorilant + nab-paclitaxel group and the nab-paclitaxel alone group (Figure 2B, left). In contrast, baseline values ​​of these genes did not predict treatment group (Figure 2B, right).

[0018] [Figure 3] Figure 1 shows the fold changes of eight genes associated with relacorilant activity. The top genes that were important for distinguishing the study groups identified in Figure 2 were prioritized based on corrected significance in a t-test comparing the fold changes between relacorilant plus nab-paclitaxel and nab-paclitaxel alone. The fold change for each gene is represented for each subject as a data point after treatment with (A) continuous relacorilant plus NP, (B) intermittent relacorilant plus NP, or (C) NP alone.

[0019] [Figure 4] Figure 1 shows the fold changes of key genes before and after crossover from NP alone to relacorilant + NP. For patients who crossed over from nab-paclitaxel alone to continuous relacorilant + NP, changes in four key genes are shown before (left side of each graph) and after (right side of each graph) crossover.

[0020] [Figure 5A] Figure 5A shows a cross-study pharmacodynamic analysis of eight key genes. The same analysis of the log2 fold change of the eight genes identified in the randomized Phase 2 ovarian study was applied to other SGRM clinical trials. The study shown in Figure 5A is a trial of sequential relaxilant + NP in pancreatic ductal adenocarcinoma.

[0021] [Figure 5B] 5B shows a cross-study pharmacodynamic analysis of eight key genes. The study shown in FIG. 5B is a study of continuous or intermittent relacorilant plus NP in various solid tumors.

[0022] [Figure 5C] 5C shows a cross-study pharmacodynamic analysis of eight key genes. The study shown in FIG. 5C is a study of sequential relaxilant plus enzalutamide in prostate cancer.

[0023] [Figure 5D] Figure 5D shows a cross-study pharmacodynamic analysis of eight key genes. The study shown in Figure 5D is a study of sequential exicholant plus enzalutamide in prostate cancer.

[0024] [Figure 5E] FIG. 1 shows CDKN1C expression levels at baseline and after 2 weeks of exicholant plus enzalutamide treatment in prostate cancer patients.

[0025] [Figure 6A] 1 shows that CLEC10A is suppressed by GR agonists. 25 mg of prednisone suppressed CLEC10A in healthy volunteers.

[0026] [Figure 6B]Figure 1 shows that CLEC10A is inhibited by GR agonists. Subjects with low baseline CLEC10A had higher 24-hour urinary free cortisol (UFC), and high baseline CLEC10A was associated with lower 24-hour UFC.

[0027] [Figure 7A] This study demonstrates that induction of CLEC10A by relacorilant is associated with improved overall survival in ovarian cancer. The fold change in CLEC10A from C1D1 to C1D15 was measured for all subjects in an ovarian phase 2 study receiving sequential relacorilant + NP. Patients in the top two tertiles of fold change (CLEC10A induced, black) experienced improved overall survival compared with patients in the bottom tertile (CLEC10A not induced, gold). Overall survival for all subjects treated with NP alone (regardless of CLEC10A induction) is shown as the control group (black).

[0028] [Figure 7B] Induction of CLEC10A by relaxant is associated with improved overall survival in ovarian cancer. In a large public database of ovarian cancer tumor gene expression, patients in the top two tertiles of baseline CLEC10A (red) had improved overall survival compared to patients in the bottom tertile (black). DETAILED DESCRIPTION OF THE INVENTION

[0029] Introduction The methods and discoveries disclosed herein include methods for identifying cancer patients who are likely to benefit from administration of an SGRM and a cancer therapeutic agent; methods for treating the identified patients; methods for identifying cancer patients as those with elevated cortisol activity and methods for treating the identified cancer patients; methods for identifying active doses of SGRMs in cancer patients; methods for identifying active doses of SGRMs in patients with Cushing's syndrome; and other useful diagnostic and therapeutic methods.

[0030] The methods disclosed herein can be used to identify and treat cancer patients who would benefit from a combination treatment of a selective glucocorticoid receptor modulator (SGRM) and a cancer treatment. Such cancer treatments can include taxane treatments (e.g., paclitaxel or nab-paclitaxel treatment); antiandrogen treatments (e.g., enzalutamide treatment); and other cancer treatments. Such cancer patients include those with excessive cortisol activity, such as those suffering from ovarian, pancreatic, or prostate cancer. The methods disclosed herein include methods for identifying an active SGRM dose for such treatment in cancer patients and methods for extending survival after treatment (compared to the expected survival for a patient not receiving such treatment; often referred to as "extending overall survival"). The active dose identified by the methods disclosed herein is considered to be an effective dose useful for treating cancer patients. Benefits for cancer patients receiving such a combination of SGRM and a cancer therapeutic agent include, for example, an increased survival time after treatment compared to similar cancer patients not receiving such treatment. SGRMs useful in these methods include heteroaryl-ketone fused azadecalin compounds (e.g., relacolinant) and octahydro-fused azadecalin compounds (e.g., exicolinant). In one embodiment, the SGRM is a selective glucocorticoid receptor antagonist (SGRA).

[0031] The methods disclosed herein further include identifying an active SGRM dose for treating a patient with Cushing's syndrome and treating the patient with Cushing's syndrome. The active dose identified by the methods disclosed herein is considered to be an effective dose useful for treating a patient with Cushing's syndrome. A patient with Cushing's syndrome may be suffering from Cushing's disease. SGRMs useful in these methods include heteroaryl-ketone fused azadecalin compounds (e.g., relacolinant) and octahydro-fused azadecalin compounds (e.g., exicolinant). In embodiments of these methods for treating a patient with Cushing's syndrome, the SGRM is an SGRA.

[0032] SGRM is a novel tool for investigating basic glucocorticoid receptor (GR) function and cortisol activity at the GR [Greenstein and Hunt, Oncotarget, 12, 1243-1255 (2021)]. Cortisol is the most abundant endogenous GR agonist in humans, and normal morning serum levels are sufficient to activate the GR systemically [Wang & Harris, Adv Exp Med Biol. (New York, NY: Springer New York). 2015; 2895-98.]. Steroidal GR antagonists, such as mifepristone and its analogs, lack specificity for the GR alone [Rew et al., Journal of Medicinal Chemistry, 61, 7767-7784 (2018)]. The compounds used in the examples disclosed herein, relacolinant and exicolinant, are nonsteroidal SGRMs that selectively inhibit GR activity without affinity for other hormone receptors [Hunt et al., Journal of Medicinal Chemistry, 60, 3405-3421 (2017)]. GR-specific agonists, such as dexamethasone, can probe supraphysiological GR activation [Shen et al., Archives of Surgery, 141, 771 (2006)]. Although endogenous GR agonists (i.e., cortisol and corticosterone) are abundant in mammals, there are no naturally occurring GR antagonists, complicating the interpretation of systemic SGRM effects on gene transcription.Although the established safety profile of SGRMs [Munster et al., Clinical Cancer Research, 28, 3214-3224 (2022); Pivonello et al., Frontiers in Endocrinology, 12, 1-12 (2021)] allows for administration over weeks to years, most existing reports have focused on the short-term effects of GR (hours to days) [Olnes et al., Scientific Reports, 6, 23002 (2016); and Stringer-Reasor et al., Gynecologic Oncology, 138, 656-662 (2015); Al-Hity et al., Communications Biology, 4, 781 (2021)]. SGRMs are therefore uniquely positioned to probe the biological role of endogenous cortisol by specifically antagonizing cortisol activity on GR.

[0033] Applicants herein disclose the specific transcriptional effects of SGRMs identified in whole blood. In an ovarian cancer study of ovarian cancer patients treated with nab-paclitaxel (NP) and relacorilant (relacorilant + NP), eight genes exhibiting SGRM activity were identified. The specificity of these genes is supported by their consistent performance across different tumor types, drug combinations, and even in patients receiving co-administration of selective androgen modulators (SARMs; e.g., enzalutamide). The CLEC10A gene is a component of this gene panel and is acutely induced by supraphysiological GR agonists and suppressed by GR antagonists in whole blood. Furthermore, CLEC10A induction by SGRMs predicts overall survival in cancer patients after administration of relacorilant + NP therapy. Bioinformatics analysis indicates that CLEC10A and its correlated genes (FPR3, CCR2, LILRB4, and CD86) are markers of a group of dendritic cells. Collectively, these data reveal novel, clinically relevant biological consequences of GR regulation in humans.

[0034] We found that SGRM administration not only increased the amount of mRNA encoding CLEC10A in whole blood, but also increased the amount of mRNA encoding FPR3, CCR2, LILRB4, and CD86. Therefore, the argument for increased CLEC10A expression by SGRM administration reflects not only an increase in CLEC10A mRNA levels, but also an increase in mRNA encoding FPR3, CCR2, LILRB4, and CD86.

[0035] SGRMs represent a clinically validated mechanism for enhancing chemotherapy sensitivity and efficacy and ameliorating the sequelae of hypercortisolism. GR reportedly controls the expression of approximately 3,000 genes, but it is unclear which of these are specific targets of systemic GR activity in humans. We established a robust assay to measure candidate GR target genes in human blood and evaluated them before and after treatment with an oral SGRM that specifically antagonizes GR. These genetic alterations were evaluated in a randomized phase 2 ovarian cancer trial (NCT03776812) after treatment with SGRM plus nab-paclitaxel (NP) (compared to NP alone to exclude changes due to disease state or NP therapy). Machine learning identified a gene set that accurately identified patients who received SGRM (ROC AUC 0.945 ± 0.038; "ROC" means receiver operating characteristic curve, and "AUC" means area under the ROC). In patients who crossed over from NP alone to SGRM+NP, these same genes were altered only after crossover within a given patient (paired t-test, P=0.0003). These genes have been shown to be reliable indicators of SGRM activity across clinical trials in pancreatic, prostate, and other solid tumors (NCT04329949, NCT03437941, NCT03674814), independent of concomitant medications or other hematologic confounders. CLEC10A appeared to be a particularly sensitive marker of GR activity, as its expression was induced by SGRM in patients with solid tumors (paired t-test, P<0.00010) and suppressed by prednisone in healthy volunteers (paired t-test, P<0.00010, NCT03335956), and was also suppressed in patients with elevated 24-hour urinary free cortisol (nonparametric t-test, P=0.037).Induction of blood CLEC10A by SGRM was associated with prolonged overall survival in ovarian cancer patients treated with SGRM plus NP (HR = 0.39, Cox PH, P = 0.0135), and high baseline tumor CLEC10A expression was associated with longer OS in a large tumor "omics" database (HR 0.8, log-rank test, P = 0.0008; "HR" indicates "hazard ratio"). CLEC10A and the genes correlated with its expression in these datasets are primarily expressed by specific subsets of dendritic cells. Analysis of CLEC10A and related SGRM-responsive genes confirmed that systemic GR activity can be pharmacologically modulated in patients with solid tumors, demonstrated that GR modulation can affect survival in ovarian cancer patients, and provided new insights into the systemic function of GR in humans.

[0036] Applicant herein discloses a method for evaluating the pharmacodynamic effects of an SGRM using a gene set in the whole blood of cancer patients, including cancer patients with ovarian, pancreatic, or prostate tumors. Applicant herein discloses a method for identifying patients likely to experience improved survival compared to untreated patients treated with an SGRM and a cancer therapeutic agent (e.g., a taxane or an antiandrogen). Applicant herein discloses a method for predicting which cancer patients are likely to benefit from an SGRM-containing therapy involving administration of an SGRM and a cancer treatment (e.g., a taxane, such as paclitaxel or nab-paclitaxel; an antiandrogen, such as enzalutamide; or other cancer treatment) by measuring early changes in the patient's systemic RNA levels (e.g., measured in a whole blood sample) of RNA encoding one or more of CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86. In some embodiments, the cancer patient is afflicted with a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer. In some embodiments, the SGRM is relacorilant. In some embodiments, the SGRM is hrelacorilant and the taxane is nab-paclitaxel (referred to as "relacorilant + nab-paclitaxel"). In some embodiments, the SGRM is exicholant. In some embodiments, the SGRM is exicholant and the taxane is nab-paclitaxel (referred to as "exicholilant + nab-paclitaxel").

[0037] Applicant discloses herein a method for identifying patients with elevated cortisol activity using baseline RNA levels encoding one or more of CLEC10A, FKBP5, GSK3B, PIK3CG, and MCL1. In one embodiment, the RNA levels are whole blood RNA levels. In one embodiment, patients with elevated cortisol activity include cancer patients and Cushing's syndrome patients.

[0038] The applicant herein discloses a method for using the change from baseline in RNA levels encoding one or more of CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 after administration of an SGRM as a pharmacodynamic biomarker for determining or assisting in the determination of an active dose of an SGRM to be administered to a patient in need thereof, wherein the baseline RNA levels are measured before administration of the SGRM. In one embodiment, the RNA levels are whole blood RNA levels. In one embodiment, patients in need of administration of an SGRM include cancer patients and patients with Cushing's syndrome (as used herein, "patients with Cushing's syndrome" and "Cushing's syndrome patients" include patients with Cushing's disease, subclinical Cushing's syndrome, and difficult-to-diagnose Cushing's syndrome). In one embodiment, administration of one dosage level of an SGRM results in a response indicating that the dosage level is an active dose. In some embodiments, one or more dose levels administered to a patient do not result in a response in the patient, and such dose levels are not active dose levels. In such cases, additional doses can be administered to the patient. For example, two or more additional doses of SGRM, each different from a previously administered dose level, are administered to identify an SGRM dose that results in a response in the patient.

[0039] Applicant discloses herein a method for using the change from baseline in RNA levels encoding one or more of CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 after administration of an SGRM as a predictive biomarker for identifying cancer patients who are more likely to benefit from treatment with an SGRM plus a cancer therapeutic compared to treatment with the cancer therapeutic alone. In some embodiments, the cancer treatment comprises administration of a cancer therapeutic that is a taxane or an antiandrogen, or administration of another cancer therapeutic or therapy. In some embodiments, the RNA levels are whole blood RNA levels. The baseline RNA levels are measured before administration of the SGRM. In some embodiments, the SGRM is a relaxant or an exicholant. In some embodiments, the taxane is paclitaxel or nab-paclitaxel. In some embodiments, the antiandrogen is enzalutamide. In some embodiments, the cancer patient is afflicted with a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

[0040] Applicant discloses herein a method for increasing RNA levels encoding one or more of CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a cancer patient, comprising administering an effective dose of an SGRM to the patient. Applicant discloses herein a method for decreasing RNA levels encoding one or more of CDKN1C, TNFRS17, BRIP1, and PDK1 in a cancer patient, comprising administering an effective dose of an SGRM to the patient. In some embodiments, the RNA levels are whole blood RNA levels. In some embodiments, the SGRM is selected from a relaxilant and an exicolant. In some embodiments, the cancer patient is afflicted with a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer. In some embodiments, the patient's survival is extended beyond the expected survival of the patient if the SGRM is not administered. In one embodiment, a cancer patient is administered an SGRM together with a taxane (e.g., paclitaxel or NP), and the expected survival for the patient in the absence of the SGRM is the expected survival for a patient administered only the taxane (e.g., paclitaxel or NP) without the concurrent SGRM.

[0041] An increase in the level of whole blood RNA encoding CLEC10A is believed to indicate an increase in the number of a particular set of dendritic cells. Furthermore, an increase in the number of a particular set of dendritic cells is believed to indicate an enhanced immune response useful for treating cancer in a patient in need of cancer treatment. In one embodiment, the particular set of dendritic cells is dendritic cells that express CLEC10A. Accordingly, the applicant herein discloses a method for detecting an indication of an increase in the number of a particular set of dendritic cells (e.g., dendritic cells that express CLEC10A) in a cancer patient. Such an indication of an increase in the number of a particular set of dendritic cells (e.g., dendritic cells that express CLEC10A) is believed to indicate an enhanced immune response useful for treating cancer in the patient and to indicate a beneficial effect in cancer treatment. In one embodiment, the cancer patient is afflicted with a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

[0042] Applicant further discloses herein a method for using a change from baseline in the level of RNA encoding CLEC10A as a biomarker in cancer patients to identify patients who have an increased number of a particular set of dendritic cells (e.g., dendritic cells expressing CLEC10A) as a result of SGRM therapy. Applicant further discloses a method for using a change from baseline in whole blood CLEC10A RNA as a biomarker in cancer patients to indicate an increase in the number of a particular set of dendritic cells (e.g., dendritic cells expressing CLEC10A) in the patient, and to indicate that the patient is more likely to survive longer than other patients who do not show signs of an increase in the number of that particular set of dendritic cells. In one embodiment, the cancer patient is afflicted with a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

[0043] The selective glucocorticoid receptor modulator (SGRM) can be a non-steroidal compound containing a heteroaryl ketone-fused azadecalin structure. Compounds containing a heteroaryl ketone-fused azadecalin structure are described and disclosed in U.S. Patent No. 8,859,774, the entire contents of which are incorporated herein by reference. In some embodiments, the non-steroidal SGRM is a relacolinant, which is (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone, having the formula shown below. [ka]

[0044] The SGRM can be a non-steroidal compound containing an octahydro-fused azadecalin structure. Compounds containing an octahydro-fused azadecalin structure are described and disclosed in U.S. Patent No. 10,047,082, the entire contents of which are incorporated herein by reference. In some embodiments, the non-steroidal SGRM is an exicholant which is ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone, having the formula shown below. [ka]

[0045] Accordingly, Applicant provides herein a method for identifying cancer patients likely to benefit from administration of an SGRM and a cancer therapeutic agent, and for treating said identified cancer patients, comprising measuring a baseline level of RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a sample obtained from the cancer patient; administering an SGRM and a cancer therapeutic agent to said cancer patient; and measuring a baseline level of RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a sample obtained from said cancer patient after said administration of an SGRM and a cancer therapeutic agent, compared to said baseline level. and measuring a change in the level of the RNA encoding a gene selected from TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86, wherein an at least 40% change in the RNA level compared to the baseline level identifies the cancer patient as one who is likely to benefit from further administration of the SGRM and the cancer therapeutic; and continuing to administer the SGRM and the cancer therapeutic to the patient identified as likely to benefit from the treatment, thereby treating the identified cancer patient. In one embodiment, the benefit to the identified cancer patient includes extended survival.

[0046] Applicant further provides herein a method of identifying a cancer patient as a cancer patient with elevated cortisol activity, and treating said identified cancer patient, comprising measuring a baseline level of RNA encoding a gene selected from FKBP5, GSK3B, PIK3CG, MCL1, and CLEC10A in a sample obtained from the cancer patient; determining whether said baseline level of RNA encoding FKBP5, GSK3B, PIK3CG, or MCL1 is higher than a normal level of said RNA, wherein said normal level of RNA is determined from a mean level of said RNA in a cohort of at least 10 normal subjects; and determining whether said baseline level of RNA encoding CLEC10A is lower than the normal level of said RNA encoding CLEC10A, wherein said normal level of RNA is determined from a mean level of said RNA in a cohort of at least 10 normal subjects. The normal level of the RNA encoding C10A is determined from the average level of the RNA encoding CLEC10A in a cohort of at least 10 normal subjects; wherein the cancer patient is identified as having elevated cortisol activity if the baseline level of RNA encoding FKBP5, GSK3B, PIK3CG, or MCL1 is higher than the normal level, and the cancer patient is identified as having elevated cortisol activity if the baseline level of RNA encoding CLEC10A is lower than the normal level; and the cancer patient is identified as having elevated cortisol activity if the baseline level of RNA encoding CLEC10A is lower than the normal level. The method includes then administering a selective glucocorticoid receptor modulator (SGRM) and a cancer therapeutic agent to the cancer patient identified as having elevated cortisol activity, thereby treating the identified cancer patient.

[0047] Applicants disclose herein a further method, namely, a method for identifying an active dose of an SGRM in a cancer patient, comprising measuring a baseline level of RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a sample obtained from the cancer patient; administering a dose of an SGRM and a cancer therapeutic agent to the cancer patient; then measuring a baseline level of RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in the sample obtained from the patient compared to the baseline level. and measuring a change in the level of the RNA encoding a gene selected from CDKN1C, CLEC10A, FPR3, CCR2, LILRB4, and CD86; wherein a dose of the SGRM that results in a) at least a 40% decrease in the level of RNA encoding CDKN1C, TNFRSF17, BRIP1, or PDK1, or b) at least a 40% increase in the level of RNA encoding CLEC10A, FPR3, CCR2, LILRB4, and CD86, compared to the corresponding baseline level, identifies the SGRM dose as an active dose. In one embodiment, to identify an active SGRM dose, two or more SGRM doses are administered to the patient, each SGRM dose having a different amount of SGRM from the other SGRM doses. In one embodiment, the two or more SGRM doses include an initial SGRM dose having a first amount of SGRM and one or more subsequent SGRM doses having an amount of SGRM that is greater than the first amount of SGRM. In some embodiments, the two or more SGRM doses include: a) an initial SGRM dose having a first SGRM amount; and b) one or more subsequent SGRM doses having an SGRM amount less than the first SGRM amount. In some embodiments, the two or more SGRM doses include at least three SGRM doses, including: a) an initial SGRM dose having a first SGRM amount; b) a subsequent SGRM dose having an SGRM amount different from the first SGRM amount; and c) a third SGRM dose between the other SGRM doses (i.e., an SGRM dose having an SGRM amount greater than one of the other SGRM doses and less than the other).

[0048] The present applicant discloses herein a method for increasing RNA levels encoding one or more of CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a cancer patient, comprising administering an effective dose of an SGRM to the patient, or administering an effective dose of an SGRM and a cancer therapeutic agent to the patient. The present applicant further discloses herein a method for decreasing RNA levels encoding one or more of CDKN1C, TNFRSF17, BRIP1, and PDK1 in a cancer patient, comprising administering an effective dose of an SGRM to the patient, or administering an effective dose of an SGRM and a cancer therapeutic agent to the patient. In some embodiments, the SGRM inhibits GR activation. In some embodiments, the cancer patient is suffering from a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer. It is believed that such changes in RNA levels may benefit cancer patients. For example, cancer patients treated with an SGRM and a taxane who had increased CLEC10A levels experienced improved overall survival compared to cancer patients who received the same treatment but did not have increased CLEC10A levels. Furthermore, cancer patients who received an SGRM and a taxane and had increased CLEC10A had improved overall survival compared with cancer patients treated with a taxane alone (regardless of whether CLEC10A was altered in the taxane-treated population).

[0049] Applicant discloses herein a method for detecting an indication of an increase in the number of dendritic cells (e.g., dendritic cells expressing CLEC10A). Such an increase in the number of dendritic cells can be detected in a cancer patient and can indicate an enhanced immune response in the patient and a beneficial effect of cancer treatment. Such an increase in the number of dendritic cells (e.g., dendritic cells expressing CLEC10A) in a cancer patient administered an SGRM and a cancer therapeutic agent (e.g., a taxane or an antiandrogen) can indicate that the patient is likely to survive longer compared to other patients administered the same SGRM and cancer therapeutic agent who do not exhibit such an increase in the number of dendritic cells. In certain embodiments, the cancer patient is afflicted with a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

[0050] In an embodiment of the method for treating a cancer patient disclosed herein, the cancer patient may be suffering from a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer. In some embodiments, the sample obtained from the cancer patient is a blood sample, for example, a whole blood sample obtained from the cancer patient. In some embodiments, the cancer therapeutic agent is a taxane, an antiandrogen, or another cancer therapeutic agent. In some embodiments, the cancer therapeutic agent is a taxane selected from paclitaxel and nab-paclitaxel. In some embodiments, the cancer therapeutic agent is the antiandrogen enzalutamide. In some embodiments, the SGRM is a GR antagonist (GRA). In some embodiments, the SGRM is a relaxant or an exicolant.

[0051] Applicants disclose herein yet another method, namely, a method for identifying an active dose of a selective glucocorticoid receptor modulator (SGRM) in a Cushing's syndrome patient, comprising measuring a baseline level of RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a sample obtained from the Cushing's syndrome patient; administering a dose of the SGRM to the Cushing's syndrome patient; and then measuring the baseline level of RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a sample obtained from the Cushing's syndrome patient. and measuring a change in the level of the RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 using a serotonin receptor agonist (SAR) assay; wherein a dose of the SGRM that results in a) at least a 40% decrease in the level of RNA encoding CDKN1C, TNFRSF17, BRIP1, or PDK1, or b) at least a 40% increase in the level of RNA encoding CLEC10A, FPR3, CCR2, LILRB4, and CD86, compared to baseline levels, is identified as an active dose of the SGRM. In one embodiment, the method of identifying an active dose of an SGRM in a patient with Cushing's syndrome further comprises treating the patient with Cushing's syndrome, wherein the treatment comprises administering to the patient an additional active dose of an SGRM, the additional active dose consisting of the dose of the SGRM identified by the method as effective for treating the patient with Cushing's syndrome. In some embodiments, to identify an active SGRM dose, two or more SGRM doses, each having a different amount of SGRM from the other SGRM doses, are administered to the patient. In some embodiments, the two or more SGRM doses include an initial SGRM dose having a first SGRM amount and one or more subsequent SGRM doses having a greater SGRM amount than the first SGRM amount. In some embodiments, the two or more SGRM doses include a) an initial SGRM dose having a first SGRM amount, and b) one or more subsequent SGRM doses having a lesser SGRM amount than the first SGRM amount.In some embodiments, the two or more SGRM doses include at least three SGRM doses, including: a) an initial SGRM dose having a first SGRM amount; b) a subsequent SGRM dose having a different SGRM amount from the first SGRM amount; and c) a third SGRM dose between the other SGRM doses. In some embodiments, the sample obtained from the Cushing's syndrome patient is a blood sample, for example, a whole blood sample obtained from the Cushing's syndrome patient. In some embodiments, the sample obtained from the Cushing's syndrome patient is a saliva sample or a urine sample (e.g., a urine sample collected over a 24-hour period). In some embodiments, the SGRM is a relaxant or an exicholant.

[0052] B. Definition The term "about" denotes a range encompassing ±10% of the value to which it refers (eg, "about 100" denotes a value between 90 and 110).

[0053] As used herein, the terms "cancer therapeutic agent" and "chemotherapeutic agent," as well as their plural forms and grammatical variations, are used interchangeably and refer to agents that have the property of killing cancer cells, inhibiting cancer cell growth, reducing cancer growth, or reducing metastasis, or are otherwise useful in the treatment of cancer. Examples of such chemotherapeutic agents include those disclosed in U.S. Pat. No. 10,568,880 (see, e.g., columns 27-30), which is incorporated herein by reference in its entirety. These agents include, but are not limited to, microtubule inhibitors (e.g., taxanes and vinca alkaloids), topoisomerase inhibitors and antimetabolites (e.g., single-acting nucleoside analogs, e.g., gemcitabine), mitotic inhibitors, alkylating agents, antimetabolites, antitumor antibiotics, mitotic inhibitors, anthracyclines, intercalating agents, agents capable of interfering with signal transduction pathways, agents that promote apoptosis, proteosome inhibitors, and the like.

[0054] As used herein, the term "taxane" refers to a diterpene compound useful as a chemotherapeutic agent in cancer treatment. Exemplary taxanes include, but are not limited to, paclitaxel, nab-paclitaxel, cabazitaxel, and docetaxel. Nab-paclitaxel is nanoparticle albumin-bound paclitaxel (marketed as ABRAXANE® by Abraxis Bioscience). Other taxanes useful as chemotherapeutic agents in cancer treatment include docosahexaenoic acid-conjugated paclitaxel (DHA-paclitaxel, Taxoprexin, marketed by Protarga), polyglutamic acid-conjugated paclitaxel (PG-paclitaxel, paclitaxel poliglumex, CT-2103, XYOTAX, marketed by Cell Therapeutic), tumor-activated prodrug (TAP), ANG105 (Angiopep-2 conjugated to three molecules of paclitaxel, marketed by ImmunoGen), paclitaxel-EC-1 (paclitaxel conjugated to the erbB2-recognizing peptide EC-1; see Li et al., Biopolymers (2007) 87: 225-230), and glucose-conjugated paclitaxel (e.g., 2'-paclitaxel methyl 2-glucopyranosyl succinate, Liu et al., Bioorganic & Medicinal Chemistry Letters (2007) 17: 617-620).

[0055] As used herein, the term "antiandrogen" refers to a therapeutic agent that reduces or blocks the action of androgens or reduces the production or level of androgens in a subject. Antiandrogens are used, for example, in the treatment of prostate cancer. Androgen receptor antagonists are antiandrogens. Antiandrogens include, but are not limited to, enzalutamide (marketed as Xtandi®; also known as MDV-3100); cyproterone acetate; abiraterone acetate; spironolactone; flutamide; bicalutamide; darolutamide; nilutamide; goserelin; triptorelin; histrelin; and leuprolide. As used herein, the term "antiandrogen" also includes androgen deprivation therapy.

[0056] As used herein, "RNA" refers to ribonucleic acid and may refer to RNA that encodes a specific protein (i.e., messenger RNA (mRNA)). The terms "mRNA" and "RNA" are used interchangeably herein.

[0057] The RNA level can be determined from a sample obtained from the patient, for example, from a blood sample obtained from the patient. The blood sample can be a whole blood, serum, or plasma sample. For example, the expression levels of several genes in patients administered exicholant were measured using NanoString technology (NanoString Technologies, Inc., Seattle, WA).

[0058] As used herein, "nanostring," "nanostring technology," "nanostring technology," and the like refer to technology and its use for amplification-free measurement of the nucleic acid content of a sample by directly counting target molecules. Nanostring technology (Nanostring Technologies, Inc., Seattle, Washington) can be used to measure the levels of multiple nucleic acid (RNA or DNA) targets in a sample. Targets are detected using sequence-specific probes that hybridize to target nucleic acid sequences (e.g., RNA sequences). These probes carry fluorescent molecules that allow for target detection and quantification, including detection and quantification of each of multiple targets in a single sample.

[0059] Other methods for detecting nucleic acid targets include polymerase chain reaction (PCR) methods, such as those described in U.S. Pat. No. 4,683,195; and generally in Mullis et al., Cold Spring Harbor Symp. Quant. Biol. 51: 263 (1987); Erlich, ed., PCR Technology (Stockton Press, NY, 1989).

[0060] Methods for determining RNA levels include, but are not limited to, reverse transcription polymerase chain reaction (rt-PCR or RT-PCR). rt-PCR uses reverse transcriptase (RT) to generate complementary DNA (cDNA) from RNA, which is then amplified by PCR to generate multiple copies of DNA that are used to detect and / or amplify target polynucleotides. Requirements for RT-PCR include reverse transcriptase, a DNA polymerase (e.g., a thermostable DNA polymerase), deoxynucleotides (typically as deoxynucleotide triphosphates ("dNTPs"), such as dATP, dTTP, dGTP, and dCTP), and an appropriate buffer. See, e.g., U.S. Pat. Nos. 5,322,770 and 5,310,652, the entire contents of which are incorporated herein by reference.

[0061] As used herein, "real-time PCR" refers to a PCR amplification method in which the progress or extent of target amplification is monitored during the course of the assay (e.g., at each thermal cycle). The progress of the amplification reaction can be monitored, for example, by detecting the amount of fluorescence or absorbance of a reporter molecule. Suitable reporter molecules include intercalator dyes (e.g., ethidium bromide and SYBR Green dye, dyes that are detectable when bound to double-stranded DNA or the minor groove of DNA); fluorogenic probes (e.g., self-quenching dyes or dye pairs (pairs comprising a dye and a quencher) attached to primers) that fluoresce when the primer binds to the target but do not produce significant fluorescence when not hybridized to the target nucleic acid molecule); and other reporter molecules.

[0062] As used herein, "rRT-PCR" refers to reverse transcription real-time PCR. rRT-PCR is real-time PCR for RNA targets that uses reverse transcription PCR to amplify nucleic acids based on RNA target molecules and monitors amplification using real-time PCR. As used herein, "rRT-PCR" refers to reverse transcription real-time PCR. rRT-PCR is real-time PCR for RNA targets that uses reverse transcription PCR to amplify nucleic acids based on RNA target molecules and monitors amplification using real-time PCR. Reverse transcription PCR involves contacting a sample with a reverse transcriptase under appropriate conditions to produce cDNA copies of the RNA molecules in the sample, thereby providing the DNA substrate required for PCR.

[0063] The gene names and accession IDs for many of the genes are listed in the table below, along with some additional information about the genetic regions that were specifically measured by the labeled RNA probes. In the table below, gene names are listed in lowercase italics. However, when a gene name also refers to the RNA that encodes that gene, it is written in uppercase elsewhere in this application. [Table 1]

[0064] As used herein, "subject," "normal subject," and "control subject," including their plural forms and grammatical variations, refer to a healthy subject, i.e., a subject not suffering from a disease or disorder, e.g., not suffering from cancer or not suffering from Cushing's syndrome.

[0065] "Patient," "patient in need," and the like refer to a person having or suspected of having a disease or condition that can be treated by the administration of a therapeutic agent or combination of agents.

[0066] As used herein, the terms "Cushing's syndrome" and "Cushing's" refer to conditions caused by excessive production of the glucocorticoid cortisol by the adrenal cortex or by ectopic (non-adrenal) sources such as tumors. The term "Cushing's syndrome" includes endogenous Cushing's syndrome and ectopic Cushing's syndrome. This condition is often due to the presence of a tumor or hyperplasia that exhibits unregulated secretion of adrenocorticotropic hormone (ACTH) or cortisol itself. Cushing's syndrome exhibits some or all of a range of symptoms caused by excess cortisol. These symptoms include, for example, elevated blood pressure, elevated blood sugar, weight gain (typically in the central area and on the face, causing the characteristic "moon face"), immunosuppression, thinning of the skin, acne, depression, hirsutism, and other symptoms. Patients with Cushing's syndrome include those with Cushing's disease, those with subclinical Cushing's syndrome, and those with Cushing's syndrome that are difficult to diagnose.

[0067] The terms "Cushing Disease" and "Cushing's Disease" refer to pituitary Cushing's syndrome, i.e., a condition caused by excess cortisol due to a pituitary abnormality (typically a pituitary tumor). Examples include conditions in which the pituitary gland releases excess ACTH due to a tumor located in or near the pituitary or excessive growth (hyperplasia) of the pituitary gland. Cushing's Disease is a form of Cushing's syndrome.

[0068] The term "endogenous Cushing's syndrome" refers to a form of Cushing's syndrome in which excessive cortisol levels are caused by the body's own overproduction of cortisol.

[0069] As used herein, "patients suffering from Cushing's syndrome" refers to any patient suffering from Cushing's syndrome, including endogenous Cushing's syndrome; Cushing's disease; or conditions related to Cushing's syndrome. Conditions related to Cushing's syndrome may be, but are not limited to, hypercortisolism; hyperglycemia secondary to hypercortisolism; type 2 diabetes or impaired glucose tolerance; such conditions in patients with endogenous Cushing's syndrome who have not responded to surgery; such conditions in patients with endogenous Cushing's syndrome who are not candidates for surgery; and other conditions related to Cushing's syndrome.

[0070] As used herein, a "standard control" refers to a sample containing a predetermined amount of an analyte (such as an RNA of interest or cortisol) suitable for application in the present invention to serve as a comparison standard to provide an indication of the relative amount of the analyte present in a test sample. A sample serving as a standard control provides an average amount of the analyte, such as cortisol, representative of a defined sample type (e.g., plasma, serum, saliva, or urine) taken from an average individual at a defined time of day (e.g., 8:00 AM).

[0071] The term "measuring the level" in the context of cortisol, an RNA encoding gene, or other analyte refers to determining, detecting, or quantifying the amount, level, or concentration of the analyte in a sample obtained from a subject.

[0072] As used herein, a "sample" can be any bodily fluid or tissue obtained from a patient, including, for example, a blood sample, urine sample, saliva sample, or other sample.

[0073] As used herein, a "blood sample" may be a whole blood sample, a serum sample, a plasma sample, or a blood cell sample, as needed to measure the analyte level by methods known to those skilled in the art according to conventional usage. Similarly, the "blood level" of a particular analyte may be the level of the analyte in whole blood, serum, plasma, or blood cells. For example, the blood level of cortisol, or an RNA encoding gene, or other analyte may be the level of the analyte in a whole blood sample, a serum sample, or a plasma sample taken from the subject being tested.

[0074] The term "morning serum sample" refers to a serum sample obtained from a human subject in the morning, which may be from about 6:00 AM to about 12:00 PM, or from about 7:00 AM to about 11:00 AM, or any other time period considered to be in the morning.

[0075] The term "morning serum cortisol sample" refers to a morning serum sample in which the level (eg, concentration) of cortisol is measured.

[0076] The term "cortisol" refers to the naturally occurring glucocorticoid hormone (also known as hydrocortisone) produced by the zona fasciculata of the adrenal cortex. Cortisol has the structure shown below. [ka] The term "total cortisol" refers to cortisol bound to cortisol-binding globulin (CBG or transcortin) and free cortisol (cortisol not bound to CBG). The term "free cortisol" refers to cortisol not bound to cortisol-binding globulin (CBG or transcortin). As used herein, the term "cortisol" refers to total cortisol, free cortisol, and / or cortisol bound to CBG.

[0077] Cortisol levels can be determined, for example, by measuring cortisol in blood (e.g., serum or plasma), urine, saliva, tears, or other bodily fluids. In certain embodiments, cortisol levels can be measured in a serum sample obtained in the morning (morning serum cortisol). Plasma samples can be used in a similar manner to assess a subject's cortisol levels.

[0078] Cortisol levels can be measured in samples (such as whole blood, serum, plasma, saliva, urine, tears, or other biological fluids) using a variety of methods, including, but not limited to, immunoassays, such as competitive immunoassays, radioimmunoassays (MA), immunofluorescence enzyme assays, and ELISA; competitive protein-binding assays; liquid chromatography (e.g., HPLC); and mass spectrometry, such as high-performance liquid chromatography / triple quadrupole mass spectrometry (LC-MS / MS). In a preferred embodiment, cortisol levels are measured using LC-MS / MS, for example, as performed by Quest Diagnostics (Secaucus, NJ07094).

[0079] As used herein, the terms "baseline" and "baseline level," including their plural forms and grammatical variations, refer to the level of an analyte measured in a sample obtained from a subject or patient before the subject or patient receives treatment (e.g., before administration of an SGRM or cancer therapeutic agent to the subject or patient).

[0080] As used herein, "normal level" and "control level," including their plural forms and grammatical variations, refer to the average level of an analyte determined by measuring samples obtained from multiple normal subjects. For comparison, measurements of the same type (e.g., plasma or serum; saliva; or urine) must be compared. A normal or control level of an analyte can be measured in a sample or group of samples obtained from a healthy subject or group of healthy subjects who have not received any drug or treatment. For example, a normal level of an analyte, such as mRNA encoding a gene of interest, can be determined by obtaining blood samples from 10 or more healthy subjects, measuring the level of the analyte in each sample, and calculating the average of the measured analyte levels from these sample measurements. That average provides what is referred to as the "normal level" or "control level" of that analyte.

[0081] The term "normal cortisol level" refers to the average level of cortisol determined by measuring samples (e.g., serum samples) obtained from multiple normal subjects. Normal cortisol levels may be known or ascertainable by those skilled in the art. For example, as reported by Putignano et al. in a study of plasma cortisol in healthy women (European Journal of Endocrinology 145: 165-171 (2001)), normal plasma cortisol was approximately 420 nanomoles per liter (nmol / L) at 8:00 AM (morning); approximately 250 nmol / L at 5:00 PM (evening); and approximately 90 nmol / L at 12:00 PM (midnight). Salivary cortisol measurements were approximately 14 nmol / L at 8:00 AM (morning); approximately 7 nmol / L at 5:00 PM (evening); and approximately 5 nmol / L at 12:00 PM (midnight). Urinary free cortisol levels were approximately 130 nmol per 24 hours (nmol / 24 h). Cortisol levels are suppressed by the dexamethasone suppression test (DST), as indicated by plasma cortisol levels of approximately 24 nmol / L after the DST and salivary cortisol levels of approximately 4 nmol / L after the DST. Cortisol levels in healthy men are considered similar to those reported by Putignano et al.

[0082] The terms "excess," "excessive level," "elevated level," "elevated amount," or "elevated concentration" refer to a level or amount of the analyte that is higher than the normal or baseline value, and particularly to a level that is significantly higher than normal or baseline.

[0083] As used herein, the terms "excessive cortisol activity," "elevated cortisol activity," "elevated cortisol," "elevated cortisol levels," "cortisol excess," and the like refer to cortisol levels that are greater than about 1.5 times or greater than about 2 times normal cortisol levels, however measured. In a study of patients with castration-resistant prostate cancer, median urinary free cortisol (UFC) levels were measured as 17 μg / day (47 nmol / day). Thus, for example, in the studies disclosed herein, patients with UFC greater than 17 μg / day (47 nmol / day) were considered to have elevated cortisol activity.

[0084] The term "steroid backbone," in the context of glucocorticoid receptor antagonists containing it, refers to glucocorticoid receptor antagonists that are modified from the basic structure of the endogenous steroid glucocorticoid receptor ligand, cortisol. The basic structure of the steroid backbone is shown below: [ka]

[0085] As used herein, the phrase "non-steroidal backbone" in the context of an SGRM refers to an SGRM that does not share structural homology with, and is not a modified form of, cortisol, which has a steroidal backbone containing 17 carbon atoms joined by four fused rings.

[0086] The term "glucocorticosteroid" ("GC") or "glucocorticoid" refers to a steroid hormone that binds to the glucocorticoid receptor. Glucocorticosteroids are typically characterized by having 21 carbon atoms, an α,β-unsaturated ketone ring A, and an α-hydroxy group attached to ring D. These vary in the degree of oxygenation or hydroxylation at C-11, C-17, and C-19. See Rawn, "Biosynthesis and Transport of Membrane Lipids and Formation of Cholesterol Derivatives," in Biochemistry, Daisy et al. (eds.), 1989, pg. 567.

[0087] As used herein, the term "glucocorticoid receptor" ("GR") refers to type II GR, which belongs to a family of intracellular receptors that specifically bind cortisol and / or cortisol analogs (e.g., dexamethasone) (see, e.g., Turner & Muller, J. Mol. Endocrinol. October 1, 2005 35 283-292). Glucocorticoid receptors are also called cortisol receptors. This term includes GR isoforms, recombinant GRs, and mutant GRs.

[0088] The term "glucocorticoid receptor modulator" (GRM) refers to any compound that modulates the binding of GC to GR or modulates any biological response associated with the binding of GR to an agonist. For example, GRM acting as an agonist, such as dexamethasone, increases the activity of tyrosine aminotransferase (TAT) in HepG2 cells (human hepatocellular carcinoma cell line; ECACC, UK). GRM acting as an antagonist, such as mifepristone, decreases the activity of tyrosine aminotransferase (TAT) in HepG2 cells. TAT activity can be measured as reviewed in the literature by A. Ali et al., J. Med. Chem., 2004, 47, 2441-2452.

[0089] As used herein, the term "selective glucocorticoid receptor modulator" (SGRM) refers to any composition or compound that modulates the binding of GC to GR or modulates any biological response associated with the binding of GR to an agonist. By "selective," the drug binds preferentially to GR over other nuclear receptors, such as the progesterone receptor (PR), mineralocorticoid receptor (MR), or androgen receptor (AR). A selective glucocorticoid receptor modulator has a 10-fold higher affinity (1 / 10-fold K) than the affinity for MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR. d In a more preferred embodiment, the selective glucocorticoid receptor modulator binds to GR with an affinity that is 100-fold higher (1 / 100-fold lower K) than the affinity for MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR. d In another embodiment, the selective glucocorticoid receptor modulator binds to GR with an affinity that is 1000-fold greater (1 / 1000-fold lower K value) than its affinity for MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR. d It binds to GR at a specific agonist level (value). Relacorilants are SGRMs.

[0090] "Glucocorticoid receptor antagonist" (GRA) refers to any compound that inhibits the binding of GC to GR or inhibits any biological response associated with the binding of GR to an agonist. Thus, GR antagonists can be identified by measuring the ability of a compound to inhibit the effects of dexamethasone. TAT activity can be measured as reviewed in the literature by A. Ali et al., J. Med. Chem., 2004, 47, 2441-2452. GRAs are characterized by an IC 50(half-maximal inhibitory concentration) of less than 10 micromolar. See Example 1 of U.S. Patent No. 8,859,774, the entire contents of which are incorporated herein by reference.

[0091] As used herein, the term "selective glucocorticoid receptor antagonist" (SGRA) refers to any composition or compound that inhibits the binding of GC to GR or inhibits any biological response associated with the binding of GR to an agonist (where inhibition is determined relative to the response in the absence of the compound). By "selective," it is meant that the drug binds preferentially to GR over other nuclear receptors, such as the progesterone receptor (PR), mineralocorticoid receptor (MR), or androgen receptor (AR). A selective glucocorticoid receptor antagonist has a 10-fold higher affinity (1 / 10-fold K) than the affinity for MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR. d In a more preferred embodiment, the selective glucocorticoid receptor antagonist binds to the GR with an affinity that is 100-fold greater (1 / 100-fold lower K) than the affinity for the MR, AR, or PR, both the MR and PR, both the MR and AR, both the AR and PR, or the MR, AR, and PR. d In another embodiment, the selective glucocorticoid receptor antagonist binds to GR with an affinity that is 1000-fold greater (1 / 1000-fold lower K) than its affinity for MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR. d It binds to GR at a specific value. Relacorilant is an SGRA.

[0092] Non-steroidal GRA compounds, non-steroidal SGRA compounds, non-steroidal GRM compounds, and non-steroidal SGRM compounds include compounds containing a fused azadecalin structure (also referred to as a fused azadecalin backbone), compounds containing a heteroaryl ketone-fused azadecalin structure (also referred to as a heteroaryl ketone-fused azadecalin backbone), and compounds containing an octahydro-fused azadecalin structure (also referred to as an octahydro-fused azadecalin backbone). Exemplary non-steroidal GRA compounds, non-steroidal SGRA compounds, non-steroidal GRM compounds, and non-steroidal SGRM compounds containing a fused azadecalin structure include those described in U.S. Patent Nos. 7,928,237 and 8,461,172. Exemplary non-steroidal GRA compounds, non-steroidal SGRA compounds, non-steroidal GRM compounds, and non-steroidal SGRM compounds containing a heteroaryl ketone-fused azadecalin structure include those described in U.S. Patent No. 8,859,774. Exemplary nonsteroidal GRA compounds, nonsteroidal SGRA compounds, nonsteroidal GRM compounds, and nonsteroidal SGRM compounds containing an octahydro-fused azadecalin structure include those described in U.S. Pat. No. 10,047,082.

[0093] Exemplary heteroaryl-ketone-fused azadecalin compounds are described in U.S. Pat. Nos. 8,859,774; 9,273,047; 9,707,223; and 9,956,216, all of which are incorporated herein by reference in their entireties. In one embodiment, the SGRM is a heteroaryl-ketone-fused azadecalin. In one embodiment, the SGRA is the compound (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone, also known as "relacorilant" and "CORT125134" (Example 18 of U.S. Pat. No. 8,859,774), having the following structure: [ka]

[0094] In one embodiment, the heteroaryl-ketone-fused azadecalin SGRM is the compound (R)-(1-(4-fluorophenyl)-6-((4-(trifluoromethyl)phenyl)sulfonyl)-4,4a,5,6,-7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(thiazol-2-yl)methanone (referred to as "CORT122928"), having the following structure: [ka]

[0095] In one embodiment, the heteroaryl-ketone-fused azadecalin SGRM is the compound (R)-(1-(4-fluorophenyl)-6-((4-(trifluoromethyl)phenyl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1-H-pyrazoloP,4-g]isoquinolin-4a-yl)(pyridin-2-yl)methanone (dazcorilant; also known as "CORT113176"), having the following structure: [ka]

[0096] In some embodiments, the SGRM is an octahydro-fused azadecalin. In some embodiments, the octahydro-fused azadecalin is exicholant (also known as CORT125281), ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone, which has the formula: [ka]

[0097] As used herein, the terms "active amount," "active dose," "effective amount," and the like refer to an amount of a pharmacological agent effective to elicit a response in a subject or patient to which the agent is administered. Such a response can be, for example, a change in the level of an analyte (e.g., an RNA of interest, or cortisol levels) in a sample obtained from the subject or patient. Such a change can be, for example, at least a 40% change in the analyte level. Thus, an active dose elicits a response in a subject or patient to which the dose is administered. An active dose can be effective to treat, eliminate, or alleviate at least one symptom of the disease being treated. In some cases, an "effective amount" can refer to the amount of an agent or pharmaceutical composition useful to exhibit a detectable therapeutic or inhibitory effect. The effect can be detected by any assay method known to those of skill in the art.

[0098] As used herein, the terms "administer," "administering," "administered," "administration," and the like refer to administering a compound or composition (e.g., those described herein) to a subject or patient. Thus, for example, "administration to a patient" refers to the delivery of a drug or other therapeutic agent into the body of a patient in need of treatment with the drug or therapeutic agent, effective to achieve a therapeutic effect. Administration can be by any suitable route of administration, including, for example, oral administration; intravenous administration; subcutaneous administration; parenteral administration; intra-arterial administration; intranasal administration; topical administration; and other routes of administration.

[0099] "Treate," "treating," and "treatment" refer to any indication of success in treating or ameliorating a disease state or condition, including any objective or subjective parameter, such as remission; relief; reducing symptoms or making the disease state or condition more tolerable to the patient; slowing the rate of degeneration or decline; making the final stage of degeneration less debilitating; or improving the patient's physical or mental well-being. Treatment or amelioration of symptoms can be based on objective or subjective parameters, including results of a physical examination; histopathological examination (e.g., analysis of biopsy tissue); laboratory analysis of urine, saliva, tissue samples, serum, plasma, or blood; or imaging.

[0100] As used herein, the term "combination therapy" refers to the administration of at least two pharmaceutical agents to a subject to treat a disease. The two agents can be administered simultaneously or sequentially in any order during all or part of the treatment period. The at least two pharmaceutical agents can be administered according to the same or different dosing regimens. In some cases, one pharmaceutical agent is administered according to a set regimen, and the other pharmaceutical agent is administered intermittently. For example, in some embodiments, an SGRM is administered daily. In other embodiments, an SGRM is administered intermittently, for example, every two, three, or four days, or at other intervals. In some cases, both pharmaceutical agents are administered intermittently. In some embodiments, one pharmaceutical agent, e.g., an SGRM, is administered daily, and the other pharmaceutical agent, e.g., a chemotherapeutic agent, is administered every two, three, or four days, or at other intervals. In some embodiments, a chemotherapeutic agent is administered daily, and the other pharmaceutical agent, e.g., an SGRM, is administered every two, three, or four days, or at other intervals.

[0101] As used herein, the term "compound" is used to refer to a molecular moiety of a unique, identifiable chemical structure. A molecular moiety ("compound") may exist in the form of a free species, not associated with other molecules. A compound may also exist as part of a larger aggregate that is associated with other molecules but nonetheless retains its chemical identity. Salts and solvates (in which a molecular moiety ("compound") of a defined chemical structure is associated with molecules of a solvent) are examples of such associated forms. A hydrate is a solvate in which the associated solvent is water. A recitation of "compound" refers to the molecular moiety (of the recited structure) itself, whether it exists in free or associated form.

[0102] As used herein, the term "composition" is intended to encompass products comprising specified ingredients in specified amounts, such as the compounds disclosed herein, as well as tautomeric forms, derivatives, analogs, stereoisomers, polymorphs, deuterated species, pharmaceutically acceptable salts, esters, ethers, metabolites, mixtures of isomers, pharmaceutically acceptable solvates, and pharmaceutically acceptable compositions thereof, as well as any product that results directly or indirectly from combining specified ingredients in specified amounts. The pharmaceutical compositions discussed herein are intended to encompass any composition made by admixing the compounds discussed and their pharmaceutically acceptable carriers.

[0103] As used herein, the terms "pharmaceutically acceptable excipient" and "pharmaceutically acceptable carrier" are intended to include any and all solvents, surfactants, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, etc., compatible with pharmaceutical administration. These terms refer to any substance that aids in the administration of an active agent to and absorption by a subject and can be included in a pharmaceutical composition without causing significant adverse toxicological effects to the patient. Except insofar as any conventional media or agent is incompatible with the active compound, its use is contemplated in pharmaceutical compositions. Non-limiting examples of pharmaceutically acceptable excipients include water, NaCl, saline, lactated Ringer's solution, normal sucrose, normal glucose, binders, fillers, disintegrants, encapsulating agents, plasticizers, lubricants, coatings, sweeteners, flavoring agents, and coloring agents. Those skilled in the art will recognize that other pharmaceutical excipients may be similarly useful.

[0104] The dosing regimen also takes into account pharmacokinetic parameters known to those skilled in the art, such as absorption rate, bioavailability, metabolism, clearance, etc. (see, e.g., Hidalgo-Aragones (1996) J. Steroid Biochem. Mol. Biol. 58: 611-617; Groning (1996) Pharmazie 51: 337-341; Fotherby (1996) Contraception 54: 59-69; Johnson (1995) J. Pharm. Sci. 84: 1144-1146; Rohatagi (1995) Pharmazie 50: 610-613; Brophy (1983) Eur. J. Clin. Pharmacol. 24: 103-108; Remington's, supra, most recently). Prior art techniques allow the clinician to determine the dosing regimen for each individual patient, GR modulator, and disease or condition being treated.

[0105] SGRMs can be used in combination with other active agents known to be useful for modulating the glucocorticoid receptor, or with adjuvants that are not effective alone but may contribute to the effectiveness of the active agent.

[0106] In some embodiments, simultaneous administration includes administering the SGRM within 0.5 hours, within 1 hour, within 2 hours, within 4 hours, within 6 hours, within 8 hours, within 10 hours, within 12 hours, within 16 hours, within 20 hours, or within 24 hours of the second active agent (e.g., a cancer therapeutic agent). Simultaneous administration includes administering the two active agents simultaneously, nearly simultaneously (e.g., within about 1 minute, within about 5 minutes, within about 10 minutes, within about 15 minutes, within about 20 minutes, or within about 30 minutes of each other), or sequentially in any order. In some embodiments, simultaneous administration can be achieved by co-formulation, i.e., preparing a single pharmaceutical composition containing both active agents. In other embodiments, the active agents can be formulated separately. In another embodiment, the active agents and / or adjuncts can be linked or conjugated to each other.

[0107] After a pharmaceutical composition containing an SGRM discussed herein has been formulated in an acceptable carrier, it can be placed in an appropriate container and labeled for treatment of a target disorder. In the case of administration of an SGRM, such labeling would include, for example, instructions regarding the amount, frequency, and method of administration.

[0108] Pharmaceutical compositions can be formed with many acids, including, but not limited to, hydrochloric acid, sulfuric acid, acetic acid, lactic acid, tartaric acid, malic acid, succinic acid, and the like. Salts tend to be more soluble in aqueous or other protic solvents than the corresponding free base forms. In other cases, the preparation may be a lyophilized powder in 1 mM to 50 mM histidine, 0.1% to 2% sucrose, 2% to 7% mannitol, at a pH range of 4.5 to 5.5, which is combined with a buffer solution prior to use.

[0109] I. Combination Therapy Various combinations of a GRM or SGRM and another agent (or combination of such agent and compound) can be used to treat a patient's Cushing's syndrome, Cushing's disease, or cancer. The terms "combination therapy" or "in combination" do not imply that the therapeutic agents must be administered simultaneously and / or formulated for delivery together, although these delivery methods are within the scope described herein. The GRM or SGRM and chemotherapeutic agent can be administered according to the same or different dosing regimens. In some embodiments, the GRM or SGRM and chemotherapeutic agent are administered sequentially in any order during all or part of the treatment period. In some embodiments, the GRM or SGRM and anti-cancer agent are administered simultaneously or nearly simultaneously (e.g., within about 1 minute, about 5 minutes, about 10 minutes, about 15 minutes, about 20 minutes, or about 30 minutes of each other). Non-limiting examples of combination therapy involving the administration of a GRM or SGRM and a chemotherapeutic agent are as follows: For example, the GRM or SGRM is designated "A" and the anti-cancer agent or compound administered as part of the chemotherapy regimen is designated "B." A / B / AB / A / BB / B / AA / A / BA / B / BB / A / AA / B / B / BB / A / B / B B / B / B / AB / B / A / BA / A / B / BA / B / A / BA / B / B / AB / B / A / A B / A / B / AB / A / A / BA / A / A / BB / A / A / AA / B / A / AA / A / B / A

[0110] Administration of therapeutic compounds or agents to patients will follow standard protocols for the administration of such compounds, taking into account the toxicity, if any, of the treatment. Surgical intervention may also be applied in combination with the treatments described herein. [Example]

[0111] The following examples are illustrative only and not intended to be limiting. Those of ordinary skill in the art will readily recognize a variety of non-critical parameters that could be changed or modified to yield essentially similar results.

[0112] Example 1. Assessment of glucocorticoid receptor modulation Ovarian Cancer Trials The methods and results disclosed herein are obtained from studies including a phase 2 randomized trial of relacorilant plus nab-paclitaxel (rela+nab-pac) in patients with ovarian cancer (Clinical Trial NCT03776812).

[0113] method Test Design This phase 2, open-label, randomized, three-arm study was conducted in accordance with the principles of the Declaration of Helsinki, the International Council for Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use guidelines for good clinical practice, and local regulatory requirements. The protocol was approved by the Institutional Review Board or Independent Ethics Committee at each study site. All patients or their legal representatives provided written informed consent.

[0114] Patients were randomized 1:1:1 to one of three treatment groups: a) nab-paclitaxel (80 mg / m 2) + intermittent relacorilant (150 mg; administered orally the day before [except day -1 of cycle 1], on the day of, and the day after nab-paclitaxel; "intermittent group"); b) nab-paclitaxel (80 mg / m 2 ) + continuous relacorilant (100 mg orally once daily; "continuous group"); and c) nab-paclitaxel monotherapy (100 mg / m 2 ; "nab-paclitaxel alone group"). (As used herein, "+" indicates "and"). In all groups, nab-paclitaxel was administered on days 1, 8, and 15 of each 28-day cycle. Study arms were stratified by treatment-free interval from the most recent taxane (relapse within 6 months vs. relapse greater than 6 months; i.e., patients who experienced a relapse within 6 months of the most recent taxane treatment were placed in a different group from patients who relapsed greater than 6 months after the most recent taxane treatment) and the presence or absence of ascites (yes / no). Prophylactic G-CSF was required in the relacorilant + nab-paclitaxel group and optional in the nab-paclitaxel alone group. Patients who progressed in the nab-paclitaxel monotherapy group (27 patients in total) were allowed to crossover to the nab-paclitaxel + continuous relacorilant group (Figure 1).

[0115] Patient population Female patients (aged 18 years or older) with a histological diagnosis of recurrent high-grade serous or endometrioid epithelial ovarian cancer, primary peritoneal cancer, fallopian tube cancer, or ovarian carcinosarcoma, for whom nab-paclitaxel was deemed appropriate treatment in the investigator's opinion, were eligible to participate. Patients with clear cell, mucinous, and borderline histological subtypes were excluded. Patients with a platinum-free interval of 6 months or less or disease progression during or immediately following platinum therapy were required to have received at least one line of platinum-based chemotherapy. Patients with primary platinum-resistant or primary platinum-refractory disease were also eligible to participate. Measurable or nonmeasurable disease by RECIST v1.1 and ≤4 lines of chemotherapy or myelosuppressive therapy (excluding maintenance therapy) were permitted. Patients were required to have an Eastern Cooperative Oncology Group (ECOG) status of 0 or 1 and adequate organ and bone marrow function.

[0116] evaluation Radiation tumor assessments (computed tomography or magnetic resonance imaging with contrast) were performed within 28 days prior to Cycle 1 Day 1 and every 8 weeks (±7 days) from Cycle 1 Day 1 until disease progression, including in patients who discontinued treatment early. Tumor response was assessed by the investigator or a local radiologist using RECIST v1.1.

[0117] Sample collection Blood was collected on Day 1 of Cycle 1, prior to administration of either relacorilant or nab-paclitaxel. Blood was also collected in the morning of Day 15 of Cycle 1, prior to administration. For patients who progressed in the nab-paclitaxel monotherapy group and subsequently crossed over to the nab-paclitaxel + continuous relacorilant group, specimens were collected on Day 1 of Cycle 1 and Day 15 of Cycle 1 in both groups. Blood (2.5 mL) was collected into PAXGene RNA collection tubes (Qiagen) using a butterfly needle. The tubes were sealed and gently inverted 10 times. The tubes were frozen on dry ice and stored at -80°C until RNA extraction.

[0118] Pancreatic Cancer Trials An open-label, single-arm study of relacorilant plus nab-paclitaxel in patients with metastatic pancreatic ductal adenocarcinoma (mPDAC) (NCT04329949) This was a multicenter, open-label, single-arm study to evaluate the safety and efficacy of relacorilant in combination with nab-paclitaxel in patients with mPDAC. Patients with mPDAC received relacorilant and nab-paclitaxel starting on day 1 of cycle 1 until disease progression, unacceptable toxicity, or other treatment discontinuation criteria were met. Relacorilant (starting dose 100 mg, escalating by 25 mg per cycle to a potential maximum of 150 mg) was administered once daily at a dose of 80 mg / m 2 Nab-paclitaxel was administered on days 1, 8, and 15 of each 28-day cycle.

[0119] Patient population The study included male and female patients (aged 18 years or older) with histologically confirmed mPDAC who had received at least two lines of PDAC therapy, including at least one gemcitabine-based therapy and one fluoropyrimidine-based therapy. Patients must not have received more than four lines of cytotoxic or myelosuppressive therapy for PDAC and must have had measurable disease at baseline based on Response Evaluation Criteria in Solid Tumors v1.1 (RECIST v1.1).

[0120] Sample collection Blood was collected into PAXgene RNA collection tubes on Day 1 of Cycle 1 prior to administration of relacorilant or nab-paclitaxel. Blood was collected in the morning of Day 15 of Cycle 1 prior to administration.

[0121] Prostate Cancer Trials A trial of exicholant plus enzalutamide in metastatic castration-resistant prostate cancer (NCT03437941) This was a phase 1 / 2a study evaluating the safety, tolerability, and PK of exicholant in combination with enzalutamide in patients with metastatic castration-resistant prostate cancer (mCRPC). The objectives of the study were to identify the pharmacologically active dose and exposure range, characterize the PK of exicholant in combination with enzalutamide, evaluate potential drug-drug interactions, and select an appropriate dose of exicholant plus enzalutamide for further development.

[0122] Dose-finding was conducted in two segments. In Segment 1, patients with mCRPC, defined as progressive disease by PSA or imaging, were enrolled in three sequential dose-finding cohorts to evaluate exicolilant twice daily under fasting conditions in combination with enzalutamide 160 mg / day (with or without enzalutamide lead-in). Segment 2 was randomized and double-blind dose-escalation of exicolilant was conducted in combination with enzalutamide (80 mg to 160 mg / day). All patients received a starting dose of 240 mg exicolilant once daily under fed conditions. Patients in segment 2 had to have a rising PSA and be taking a stable dose of enzalutamide and were randomized 3:1 to receive the established dose of enzalutamide plus exicolant in one of two dosing regimens: 240 mg of exicolant once daily with dose escalation in 40 mg increments to a maximum of 320 mg / day, or 240 mg of exicolant once daily with placebo (no active dose escalation).

[0123] Sample collection Blood was collected into PAXgene RNA tubes on Day 1 of Cycle 1 prior to administration of exicholant or enzalutamide. Blood was also collected in the morning of Day 15 of Cycle 1 prior to administration. Urine was collected over a 24-hour period the day before the Cycle 1 Day 1 visit.

[0124] A trial of relacorilant plus enzalutamide in metastatic CRPC cancer (NCT03674814) This was a phase 1 study evaluating the safety, tolerability, and PK of relacorilant in combination with enzalutamide in patients with mCRPC. The objectives of the study were to identify the pharmacologically active dose and select an appropriate relacorilant plus enzalutamide dose for further development.

[0125] Sample collection Blood was collected on Day 1 of Cycle 1, prior to administration of relacorilant or enzalutamide. Blood was also collected in PAXgene RNA collection tubes in the morning of Day 15 of Cycle 1, prior to administration.

[0126] A Study of Prednisone in Healthy Volunteers (Part of the Exicholant SAD / MAD Trial NCT03335956) This was a Phase 1 single ascending dose (SAD) and multiple ascending dose (MAD) study to evaluate the safety and pharmacological activity of exicholant. The pharmacological activity of exicholant was established by coadministration of exicholant with 25 mg prednisone and comparison with the effects of prednisone alone. Only samples collected after administration of prednisone alone were analyzed for the studies described below.

[0127] Sample collection Blood was collected into PAXgene RNA collection tubes in the morning before dosing, and again 4 hours after administration of 25 mg of prednisone.

[0128] Biomarker analysis RNA isolation and quantification Paired baseline and post-dose samples were thawed and processed in the same batch. RNA was isolated using the PAXgene Blood RNA Kit (Qiagen) according to the manufacturer's recommended protocol. RNA yield was quantified using a NanoDrop ND-2000 spectrophotometer (ThermoFisher Scientific). After mRNA sample preparation and hybridization using the NanoString nCounter XT Assay according to the NanoString Preparation Station and Digital Analyzer instructions, RNA was assessed using a custom panel containing 444 genes. Specific RNA transcripts were quantified using a Nanostring nCounter FLEX instrument (NanoString Technologies) and analyzed using nSolver 4.0 (Nanostring Technologies, Seattle, WA, USA).

[0129] Data normalization and analysis Pairwise correlations of housekeeping genes were calculated using nSolver 4.0 (NanoString Technologies). Normalization was performed for test genes based on the housekeeping genes HPRT1, PPIB, TRAP1, EEF1A1, and TBP. A water blank sample was used to determine the background signal for each probe. A reference standard (Agilent, catalog number 750500) was used to ensure consistent batch-to-batch assay performance. Baseline and post-dose RNA counts were used to calculate fold change from baseline according to the following formula: Fold change = log2(post-treatment / baseline) Prior to assessment of correlation coefficients or statistical significance, log2 changes from baseline were calculated. In baseline-only analyses, gene abundances are reported as normalized counts.

[0130] Data were analyzed, and adjusted p-values ​​(using Benjamini-Yekutieli false discovery rate correction) were calculated using nSolver 4.0 (NanoString Technologies, Seattle, WA). A cross-validated random forest technique was used to derive a gene signature that could distinguish the relacorilant + nab-paclitaxel group from the nab-paclitaxel alone group (Ardigen SA, Krakow, Poland, Study WO5). Genes were ranked by p-value, and the genes with the most significant fold change differences between the nab-paclitaxel alone group and the relacorilant + nab-paclitaxel group were identified. The resulting top four relacorilant-repressed genes and top four relacorilant-induced genes were included in a set of eight genes for further analysis.

[0131] Bioinformatics analysis CLEC10A RNA levels associated with overall survival in ovarian cancer were calculated using KM Plotter [Nagy et al., Scientific Reports, 11, 6047 (2021)] without filtering (such as histology, stage, grade, CA-125, or treatment). Cell-type expression data were collected from the EBI expression atlas [Papatheodorou et al., Nucleic Acids Research, 46, D246-D251 (2018)] and normalized. Normalization was performed by determining the total counts of single genes across all cell types and then calculating the counts for each cell type as a fraction of that total count.

[0132] Quantitative determination of 24-hour urinary free cortisol Cortisol was extracted from urine with 2-butanol:ethyl acetate:hexane (25.0:300:675, v / v / v), dried, and reconstituted in water:methanol (500:500, v / v). Quantitation was performed by LC-MS / MS. Analytes were separated on a Kinetex Biphenyl (Phenomenex) column with a gradient of water:propionic acid:1.25% citric acid (800:2.40:0.173, v / v / v) and methanol:acetonitrile:propionic acid:1.25% citric acid monohydrate (400:approximately 400:2.40:0.173, v / v / v / v). HPLC (1200 Series Binary SL, Agilent) was used coupled to a tandem quadrupole mass spectrometer (Triple Quad 5500, AB Sciex).

[0133] result Discovery of genes altered by SGRM in ovarian cancer patients To determine whether changes in the gene set were associated with relacorilant activity, the fold change for each gene from Cycle 1 Day 1 to Cycle 1 Day 15 was calculated and log2 transformed. The resulting data were analyzed using machine learning to determine whether there were differences in gene changes between the relacorilant + NP group (combined) and the NP alone group. A cross-validated random forest analysis confirmed that gene changes, rather than just baseline gene values, were able to distinguish between groups with a receiver operating characteristic curve (ROC) area under the normalized control (AUC) of 0.945 + / - 0.038 (Figure 2). Genes were then ranked based on the significance of a t-test for the difference in fold change between the relacorilant + nab-paclitaxel group and the nab-paclitaxel alone group. If the median fold change for a gene was greater in the nab-paclitaxel alone group than in the relacorilant + nab-paclitaxel group, the gene was considered nab-paclitaxel-responsive and was not further analyzed. From the resulting list, the top four induced genes and the top four repressed genes were identified in the continuous relacorilant + NP group (Figure 3(A)). The intermittent relacorilant + nab-paclitaxel group in the phase 2 randomized ovarian trial showed a similar pattern with smaller effect sizes (Figure 3(B)), likely due to the SGRM washout on days 10-13 of cycle 1 and the administration of only a single dose of relacorilant on day 14 of cycle 1 prior to pharmacodynamic sampling. These genes were affected by relacorilant, whereas the effects of nab-paclitaxel were either in the opposite direction or minimal (i.e., significantly smaller) (Figure 3(C) and Table 2). [Table 2]

[0134] The median log2 fold change value for each gene in each arm of the ovarian phase 2 study is shown. p-values ​​represent adjusted T-tests comparing the fold change between the intermittent and continuous relacorilant + nab-paclitaxel arms and the nab-paclitaxel arm.

[0135] To validate this gene set, we determined whether these genes changed after crossover from nab-paclitaxel alone to nab-paclitaxel plus continuous relaxant, but not before crossover. Eight key genes were identified based on changes within each treatment group in separate subjects. Crossover analysis assessed the changes for each gene within each study subject before and after crossover. Paired t-tests (per subject) were performed to identify the most differentially regulated genes between before and after crossover in the 13 subjects. The top genes were FPR3 (adj P=0.00015), CLEC10A (adj P=0.00027), TNFRSF17 (adj P=0.00047), and BRIP1 (adj P=0.0029) (Figure 4). (Here, the term "adj" means that the Benjamini-Yekutieli false discovery correction was applied.) Furthermore, the direction of change was consistent with previous analyses. Specifically, BRIP1 and TNFRSF17 were repressed after crossover, whereas FPR3 and CLEC10A were induced after crossover.

[0136] Gene sets are consistently modified by SGRM across different clinical trials The eight genes identified above were evaluated in additional clinical trials of SGRM to determine whether they represent robust markers of SGRM activity (Figure 5). Individual trials inevitably involve confounding variables, such as disease-specific events, concomitant medications, and unique toxicities (including hematological toxicities, such as neutropenia, that may affect gene expression in whole blood). Therefore, the identification of alterations in these eight genes across multiple trials with different disease types, different combinations, and different cytotoxic drug combinations provides strong support for their regulation by GR. First, we evaluated a nonrandomized phase 2 trial of sequential relacorilant plus nab-paclitaxel in metastatic pancreatic ductal carcinoma (mPDAC). Compared to the phase 2 ovarian cancer trial from which this gene panel was identified, this PDAC trial shared similar combinations (i.e., G-CSF was required on days 2 and 9 of cycle 1 for patients receiving relacorilant in both trials) and the combination drug (nab-paclitaxel). Across a panel of eight genes, we observed a similar pattern of repression / induction as in the ovarian cancer study, confirming that these genetic alterations are not specific to ovarian cancer patients (Figure 5A). Similarly, similar genetic alterations were observed in a phase 1 dose-escalation study of relacorilant plus nab-paclitaxel (Figure 5B). Furthermore, alterations in the same eight key genes were also observed in two metastatic castration-resistant prostate cancer studies evaluating the combination of sequential exicholant plus enzalutamide or sequential relacorilant plus enzalutamide (Figure 5C, Figure 5D). This provides further evidence that these genetic alterations are not driven by nab-paclitaxel, indicating that these genetic alterations may be useful for assessing the activity of related SGRM drug candidates. Figure 5E shows CDKN1C expression levels at baseline and after 2 weeks of exicholant treatment in prostate cancer patients treated with enzalutamide and exicholant. CDKN1C is a well-established glucocorticoid-inducible gene that plays an important role in regulating cell proliferation.The expression level of CDKN1C was suppressed after 2 weeks of exicholant 240 mg + enzalutamide 160 mg treatment (paired T test, P < 0.0001).

[0137] CLEC10A is a marker of glucocorticoid receptor activity To determine whether the eight identified genes are more broadly associated with GR activity, we assessed the effect of a GR agonist (prednisone) on these genes. This was important to rule out off-target effects associated with the chemical series (condensed azadecalins) to which relacorilant and exicorilant belong. The effect of prednisone (fold change = 0.37, adj P = 6.4 × 10) was significantly greater than that of exicorilant. -8 ) was greater than the other seven identified genes, so CLEC10A was selected for further analysis (Figure 6C). Repression of CLEC10A by an agonist (prednisone) contradicted its induction by an antagonist (SGRM).

[0138] Because cortisol is the primary endogenous GR agonist in humans, we evaluated the relationship between cortisol and CLEC10A expression. While serum cortisol is difficult to interpret due to its diurnal and microdiurnal variations, pooled cortisol from urine collected over a 24-hour period (i.e., 24-hour urinary free cortisol [UFC]) is a more reliable way to assess systemic cortisol levels. In an exicholant plus enzalutamide mCRPC trial, 24-hour baseline urine was collected before Day 1 of Cycle 1, and 24-hour UFC was quantified. In subjects for whom both baseline CLEC10A and 24-hour UFC were available, high and low CLEC10A groups were defined based on the median baseline CLEC10A count. Subjects with low baseline CLEC10A showed significantly higher 24-hour UFC (P = 0.037) (Figure 6D). Conversely, subjects with high baseline CLEC10A showed lower 24-hour UFC. These findings suggest that cortisol suppresses CLEC10A. Accordingly, CLEC10A expression in whole blood was induced by relaxant, unaffected by nab-paclitaxel, and suppressed by the GR agonist prednisone and cortisol.

[0139] Induction of CLEC10A by relacolinant is associated with improved overall survival in patients with ovarian cancer Because CLEC10A induction by relacorilant was significant in the ovarian phase 2 study, we next investigated whether this induction correlated with overall survival. The sequential relacorilant + NP group was selected for this analysis because the timing of pharmacodynamic sampling was optimal for assessing relacorilant-induced genetic changes. Within this treatment group, the CLEC10A fold change (log2 fold change of 0.63) was divided into two groups: the lowest tertile and the top two tertiles. Subjects who showed CLEC10A induction after relacorilant plus NP treatment had significantly longer overall survival than subjects who did not (median 17.2 months and 6.6 months, respectively, HR = 0.39, Cox PH P = 0.0135) (Figure 7A) ("PH" stands for "proportional hazard"; Cox, (1972) "Regression Models and Life-Tables". Journal of the Royal Statistical Society, Series B. 34(2): 187-220). Overall survival of all subjects treated with NP alone (with or without CLEC10A induction) is shown as the control group (Figure 7A). Subjects who showed CLEC10A induction after relacorilant plus NP also had significantly longer overall survival than all subjects who received NP alone (median 17.2 months and 12.2 months, respectively, HR = 0.55, Cox PH P = 0.028).

[0140] To better understand the functional role of CLEC10A and its relevance in ovarian cancer, we analyzed publicly available databases for the association between tumor CLEC10A expression and prognosis [Nagy et al., Scientific Reports, 11, 6047 (2021)]. In a large set of ovarian tumors (N = 1656), CLEC10A counts ranged from 1 to 1173. In this analysis, the bottom tertile (<44 counts) was again defined as "low" CLEC10A. Consistent with previous reports, high baseline tumor expression of CLEC10A was associated with a favorable prognosis and prolonged OS in ovarian cancer (HR = 0.8, log-rank P = 0.00084) (Figure 7B).

[0141] Expression of CLEC10A in dendritic cells To understand the source of CLEC10A expression in our whole blood RNA profiling and ovarian tumor database, we next investigated the cell types associated with CLEC10A expression. We compared the relative expression of each of the eight genes included in our GR-regulated gene set across common cell types (Table 3) [Papatheodorou et al., Nucleic Acids Research, 46, D246-D251 (2018)]. CLEC10A expression was most pronounced in dendritic cells. In our whole blood analysis, the four genes most positively correlated with log2-transformed CLEC10A expression were FPR3 (Spearman's R = 0.72), CCR2 (Spearman's R = 0.57), LILRB4 (Spearman's R = 0.53), and CD86 (Spearman's R = 0.47). FPR3, CCR2, and LILRB4 were also highly expressed in dendritic cells (Table 3). CD86 (not shown), which correlated with CLEC10A but was not consistently GR-regulated in our dataset, is a well-known marker of dendritic cells [Collin et al., Immunology, 140, 22-30 (2013)]. [Table 3]

[0142] For each of the eight GR target genes identified in the whole blood analysis, normalized expression in each blood cell type is listed and colored (green indicates high relative expression, uncolored indicates low relative expression).

[0143] Consideration We identified a set of eight genes that provide reliable markers of SGRM activity, and demonstrated that combining the levels of two or more of these genes further improved their reliability as markers of SGRM activity. Furthermore, the CLEC10A gene is inversely regulated by GR agonists and GR antagonists (i.e., prednisone decreases CLEC10A levels, while SGRMs increase CLEC10A levels). Baseline CLEC10A also correlates with endogenous cortisol levels. Induction of CLEC10A in whole blood is associated with prolonged overall survival (OS) in patients treated with relaxant plus NP combination therapy. Therefore, changes from baseline in whole blood CLEC10A RNA are a useful pharmacodynamic biomarker for determining the active dose of SGRMs, as well as a useful predictive biomarker for identifying patients likely to experience improved survival after SGRM plus NP therapy. Baseline whole blood CLEC10A RNA may be useful for identifying patients with elevated cortisol activity, and baseline tumor CLEC10A may be a prognostic indicator in multiple solid tumors.

[0144] The reported effects on CLEC10A and its correlated genes (FPR3, CCR2, LILRB4, and CD86) likely reflect changes in abundance of a subset of dendritic cells. An alternative interpretation of such RNA changes is that the cellular composition of the biospecimens remained consistent after treatment, resulting in uniform induction or repression of genes across most or all of these cells. CLEC10A (also known as type II GalNAc-specific C-type lectin domain family 10 member A, CD301, macrophage galectin-type lectin, or MGL) is a marker for DC2A and DC2B dendritic cell (DC) subsets [Heger et al., Frontiers in Immunology, 9, 1-16 (2018); Hoober et al., Frontiers in Immunology, 10, 1-8 (2019)]. CLEC10A is not expressed by CD16+ DCs, CD141+ DCs, or pDCs [Heger et al., Frontiers in Immunology, 9, 1-16 (2018)]. These findings provide further detail to previous reports demonstrating a clear role for GR agonists in systemic suppression of dendritic cells [Olnes et al., Scientific Reports, 6, 23002 (2016); Shodell et al., Lupus, 12, 222-230 (2003)].

[0145] The association between CLEC10A induction and prolonged OS after relacorilant + NP treatment confirms an important link between systemic SGRM activity and tumor response. CLEC10A is known to bind glycosylated antigens, such as Tn antigen [Zizzari et al., Journal of Immunology Research, 1-8 (2015)]. Therefore, increased CLEC10A may reflect either increased antigen release by apoptotic tumor cells or an enhanced immune response to that antigen. Previous reports have suggested that high tumor expression of CLEC10A is associated with prognostic benefit [He et al., Journal of Cellular and Molecular Medicine, 25, 3391-3399 (2021); Zhou et al., Cellular Immunology, 372, 104472 (2022); Tang et al., PREPRINT (Version 1) available at Research Square. Downloaded from https: / / doi.org / 10.21203 / rs.3.rs-895659 / v1 (2021)]. These findings suggest that CLEC10A-expressing cells are beneficial in limiting tumor growth under various conditions and treatments. Our new findings from SGRM demonstrate that increased systemic CLEC10A is also associated with a survival benefit in ovarian cancer patients treated with relaxant plus NP.

[0146] Systemic biomarkers of SGRMs have multiple applications. First, pharmacodynamic assays can guide the selection of active doses of SGRMs. This is particularly useful for competitive antagonists, where the endogenous competitor (cortisol) is dynamic (e.g., its levels may fluctuate over time). The pharmacodynamics of cortisol synthesis inhibitors (i.e., metyrapone, mitotane, or ODM-208) can be assessed by measuring cortisol, but SGRMs do not directly alter cortisol levels, necessitating the need for biomarkers downstream of the GR. Second, such biomarkers could help identify patients with elevated cortisol activity, including those with subclinical Cushing's syndrome or those that are part of Cushing's syndrome, which are difficult to diagnose. More broadly, they could elucidate specific functions of the GR systemically and potentially define new subsets of GR-targeted dendritic cells. While the effects of glucocorticoids were first described in 1924, our findings provide new, clinically relevant insights into the effects of GR on the human body.

[0147] All patents, patent publications, publications, and patent applications cited herein are incorporated by reference in their entirety, as if each individual publication or patent application was individually and expressly indicated to be incorporated by reference. Moreover, while the foregoing description has been described in some detail by way of illustration and example, for purposes of clarity of understanding, it will be readily apparent to those skilled in the art in light of the teachings herein that certain changes and modifications can be made without departing from the spirit or scope of the appended claims.

Claims

1. 1. A method of identifying a cancer patient who is likely to benefit from administration of a selective glucocorticoid receptor modulator (SGRM) and a cancer therapeutic agent, and treating said identified cancer patient, comprising: measuring a baseline level of RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a sample obtained from the cancer patient; administering an SGRM and a cancer therapeutic agent to said cancer patient; measuring a change in the level of the RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a sample obtained from the cancer patient after the administration of an SGRM and a cancer therapeutic agent compared to the baseline level, wherein an at least 40% change in the RNA level compared to the baseline level identifies the cancer patient as one who is likely to benefit from further administration of the SGRM and the cancer therapeutic agent; and and continuing to administer the SGRM and the cancer therapeutic agent to the patient identified as likely to benefit from the treatment, thereby treating the identified cancer patient. The method comprising:

2. 10. The method of claim 1, wherein the benefit to the identified cancer patient comprises increased survival.

3. The method of claim 1 or claim 2, wherein the identified cancer patient is suffering from a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

4. The SGRM is a) A relacolinant having the chemical name (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone and having the following structure: 【Chemical 1】 or b) An exicholant having the chemical name ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone and having the following structure: 【Chemistry 2】 The method according to any one of claims 1 to 3, wherein

5. The method of any one of claims 1 to 4, wherein the cancer therapeutic agent is a taxane selected from paclitaxel and nab-paclitaxel.

6. 6. The method of claim 5, wherein the SGRM is relacorilant and the taxane is nab-paclitaxel.

7. 6. The method of claim 5, wherein the SGRM is an exicholant and the taxane is nab-paclitaxel.

8. The method according to any one of claims 1 to 4, wherein the cancer therapeutic agent is an antiandrogen drug.

9. 9. The method of claim 8, wherein the antiandrogen is enzalutamide.

10. 10. The method of claim 9, wherein the SGRM is a relacorilant.

11. 10. The method of claim 9, wherein the SGRM is an exicholant.

12. The method according to any one of claims 1 to 11, wherein the sample obtained from the cancer patient is a whole blood sample.

13. The method of any one of claims 1 to 12, wherein the RNA encodes CLEC10A.

14. 1. A method of identifying a cancer patient as having elevated cortisol activity and treating said identified cancer patient, comprising: measuring a baseline level of RNA encoding a gene selected from FKBP5, GSK3B, PIK3CG, MCL1, and CLEC10A in a sample obtained from the cancer patient; determining whether the baseline level of RNA encoding FKBP5, GSK3B, PIK3CG, or MCL1 is higher than a normal level of said RNA, wherein said normal level of RNA is determined from a mean level of said RNA in a cohort of at least 10 normal subjects; determining whether the baseline level of RNA encoding CLEC10A is lower than a normal level of the RNA encoding CLEC10A, wherein the normal level of RNA encoding CLEC10A is determined from a mean level of the RNA encoding CLEC10A in a cohort of at least 10 normal subjects; wherein the cancer patient is identified as a cancer patient with elevated cortisol activity if the baseline level of RNA encoding FKBP5, GSK3B, PIK3CG, or MCL1 is higher than the normal level; and if the baseline level of RNA encoding CLEC10A is lower than the normal level, the cancer patient is identified as a cancer patient with elevated cortisol activity. then administering to said cancer patient identified as having elevated cortisol activity a selective glucocorticoid receptor modulator (SGRM) and a cancer therapeutic agent, thereby treating said identified cancer patient; The method comprising:

15. 15. The method of claim 14, wherein the baseline level of RNA encoding FKBP5, GSK3B, PIK3CG, or MCL1 is more than 1.5 times the normal level.

16. 16. The method of claim 14 or claim 15, wherein the sample obtained from the cancer patient is a whole blood sample.

17. The method according to any one of claims 14 to 16, wherein the cancer patient is suffering from a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

18. The SGRM is a) A relacolinant having the chemical name (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone and having the following structure: 【Chemistry 3】 or b) An exicholant having the chemical name ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone and having the following structure: 【Chemistry 4】 The method according to any one of claims 14 to 17, wherein

19. The method of any one of claims 14 to 18, wherein the cancer therapeutic agent is selected from paclitaxel and nab-paclitaxel.

20. 20. The method of claim 19, wherein the SGRM is relacorilant and the cancer therapeutic agent is nab-paclitaxel.

21. 20. The method of claim 19, wherein the SGRM is an exicholant and the cancer therapeutic agent is nab-paclitaxel.

22. The method of any one of claims 14 to 18, wherein the cancer therapeutic agent is an antiandrogen drug.

23. 23. The method of claim 22, wherein the antiandrogen is enzalutamide and the SGRM is relacorilant.

24. 23. The method of claim 22, wherein the antiandrogen is enzalutamide and the SGRM is exicholant.

25. 25. The method of any one of claims 14 to 24, wherein the baseline RNA level is measured in a whole blood sample obtained from the cancer patient.

26. The method of any one of claims 14 to 25, wherein the RNA encodes CLEC10A.

27. 1. A method for identifying an active dose of a selective glucocorticoid receptor modulator (SGRM) in a cancer patient, comprising: measuring a baseline level of RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a sample obtained from the cancer patient; administering to said cancer patient a dose of an SGRM and a cancer therapeutic agent; then measuring in the sample obtained from the patient a change in the level of said RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 compared to said baseline level; wherein a dose of the SGRM that results in a) at least a 40% decrease in the level of RNA encoding CDKN1C, TNFRSF17, BRIP1, or PDK1, or b) at least a 40% increase in the level of RNA encoding CLEC10A, FPR3, CCR2, LILRB4, and CD86, compared to the corresponding baseline level, identifies the SGRM dose as an active dose. The method comprising:

28. 28. The method of claim 27, comprising administering a plurality of doses of the SGRM and the cancer therapeutic agent to the cancer patient, wherein each of the plurality of SGRM doses has a different amount of SGRM than other SGRM doses.

29. 28. The method of claim 27, wherein the SGRM dose of the plurality of SGRM doses containing the lowest amount of the SGRM that results in a) at least a 40% decrease in the level of RNA encoding CDKN1C, TNFRSF17, BRIP1, or PDK1, or b) at least a 40% increase in the level of RNA encoding CLEC10A, FPR3, CCR2, LILRB4, and CD86, compared to the corresponding baseline level, is identified as the active SGRM dose.

30. 30. The method of any one of claims 27 to 29, wherein the cancer therapeutic agent is a taxane.

31. 30. The method of any one of claims 27 to 29, wherein the cancer therapeutic agent is an antiandrogen drug.

32. The method according to any one of claims 27 to 31, wherein the cancer patient is suffering from a cancer selected from ovarian cancer, pancreatic cancer, and prostate cancer.

33. The SGRM is a) A relacolinant having the chemical name (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone, and having the following structure: 【Chemistry 5】 or b) An exicholant having the chemical name ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone and having the following structure: 【Chemistry 6】 The method according to any one of claims 27 to 32, wherein

34. 31. The method of claim 30, wherein the taxane is selected from paclitaxel or nab-paclitaxel.

35. The method of any one of claims 27 to 34, wherein the SGRM is relacorilant and the cancer therapeutic agent is nab-paclitaxel.

36. 35. The method of any one of claims 27 to 34, wherein the SGRM is an exicholant and the cancer therapeutic agent is nab-paclitaxel.

37. The method of any one of claims 27 to 36, wherein the RNA level is measured in a whole blood sample obtained from the patient.

38. The method of any one of claims 27 to 36, wherein the RNA encodes CLEC10A.

39. 39. The method of any one of claims 27-38, further comprising treating the cancer patient comprising administering to the cancer patient an additional dose of the cancer therapeutic agent and an additional active dose of the SGRM, wherein the additional active dose consists of an SGRM dose having an amount of SGRM equal to or greater than the SGRM dose identified by the method as effective to treat the cancer patient.

40. 1. A method for identifying an active dose of a selective glucocorticoid receptor modulator (SGRM) in a patient with Cushing's syndrome, comprising: measuring a baseline level of RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 in a sample obtained from a patient with Cushing's syndrome; administering a dose of an SGRM to said patient with Cushing's syndrome; then measuring in the sample obtained from the Cushing's syndrome patient a change in the level of said RNA encoding a gene selected from CDKN1C, TNFRSF17, BRIP1, PDK1, CLEC10A, FPR3, CCR2, LILRB4, and CD86 compared to the baseline level; wherein a dose of the SGRM that results in a) at least a 40% decrease in the level of RNA encoding CDKN1C, TNFRSF17, BRIP1, PDK1, or b) at least a 40% increase in the level of RNA encoding CLEC10A, FPR3, CCR2, LILRB4, and CD86, compared to the baseline level, is identified as an active dose of the SGRM. The method comprising:

41. 41. The method of claim 40, comprising administering multiple doses of the SGRM to the Cushing's syndrome patient, each of the multiple SGRM doses having a different amount of SGRM than other SGRM doses.

42. 41. The method of claim 40, wherein the SGRM dose of the plurality of SGRM doses containing the lowest amount of the SGRM that results in a) at least a 40% decrease in the level of RNA encoding CDKN1C, TNFRSF17, BRIP1, or PDK1, or b) at least a 40% increase in the level of RNA encoding CLEC10A, FPR3, CCR2, LILRB4, and CD86, compared to the corresponding baseline level, is identified as the active SGRM dose.

43. 43. The method of any one of claims 40-42, further comprising treating said Cushing's syndrome patient comprising administering to said Cushing's syndrome patient an additional active dose of said SGRM, wherein said additional active dose consists of an SGRM dose having an amount of SGRM equal to or greater than the SGRM dose identified by said method as effective to treat said Cushing's syndrome patient.

44. The method of any one of claims 40 to 43, wherein the Cushing's syndrome patient is suffering from Cushing's disease.

Images