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Targeting ATR in vivo using the novel inhibitor VE-822 results in selective sensitization of pancreatic tumors to radiation

Combined radiochemotherapy is the currently used therapy for locally advanced pancreatic ductal adenocarcinoma (PDAC), but normal tissue toxicity limits its application. Here we test the hypothesis that inhibition of ATR (ATM-Rad3-related) could increase the sensitivity of the cancer cells to radiation or chemotherapy without affecting normal cells. We tested VE-822, an ATR inhibitor, for in vitro and in vivo radiosensitization. Chk1 phosphorylation was used to indicate ATR activity, γH2AX and 53BP1 foci as evidence of DNA damage and Rad51 foci for homologous recombination activity. Sensitivity to radiation (XRT) and gemcitabine was measured with clonogenic assays in vitro and tumor growth delay in vivo. Murine intestinal damage was evaluated after abdominal XRT. VE-822 inhibited ATR in vitro and in vivo. VE-822 decreased maintenance of cell-cycle checkpoints, increased persistent DNA damage and decreased homologous recombination in irradiated cancer cells. VE-822 decreased survival of pancreatic cancer cells but not normal cells in response to XRT or gemcitabine. VE-822 markedly prolonged growth delay of pancreatic cancer xenografts after XRT and gemcitabine-based chemoradiation without augmenting normal cell or tissue toxicity. These findings support ATR inhibition as a promising new approach to improve the therapeutic ration of radiochemotherapy for patients with PDAC.

With a 5-year survival rate of 5%, pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies. 1,2 Most patients have locally advanced or metastatic disease at the time of diagnosis. 1 Chemoradiation was shown to increase resectability and to enhance local tumor control 3,4 at the cost of gastrointestinal toxicity. 5 Several trials with targeted agents such as inhibitors of angiogenesis, metastasis and oncogenic signaling had disappointing results. 6 Therefore, targeting factors mediating survival after DNA damage in cancer but not normal cells are highly relevant.
Radiation (XRT) and chemotherapy induce chromosomal DNA lesions resulting in activation of the ataxia telangiectasiamutated (ATM) and ATM-Rad3-related (ATR) protein kinases in response to double-strand DNA breaks (DSBs) and replication stress, respectively. [7][8][9] Defects in the DNA damage response (DDR) such as ATM and p53 deletion/ mutation are common in human tumors 10 and occur in up to 70% of patients with PDAC. 1,[11][12][13] They might lead to a differential response in DNA repair signaling between normal and tumor cells that could be exploited to increase killing of cancer cells with DNA-damaging agents without increasing normal cell toxicity. 7,14 Defects in one component of the DDR may result in tumor cells relying on the remaining intact DDR pathways, such as ATR, for survival upon DNA damage. [15][16][17][18][19][20][21][22] Additionally, oncogenic mutations that often occur in human malignancies induce replication stress that can create a selective sensitivity to inhibition of ATR in cancer cells. 18,[23][24][25] Finally, hypoxia may further drive dependence on ATR in tumors. 26 Thus, targeting ATR could markedly potentiate the efficacy of DNA-damaging agents without harming normal tissues.
Despite the great potential of ATR inhibitors, there is a paucity of potent, selective candidate pharmaceuticals due to of the difficulties in obtaining active ATR protein to support drug discovery efforts. We have recently described the in vitro biological profile of a highly selective ATR inhibitor (ATRi), VE-821; 15,27,28 in the present work, we present in vitro and in vivo data for VE-822, a close analog of VE-821 with a marked increase in potency against ATR and good pharmacokinetic (PK) properties. 29,30 With VE-822, we demonstrate that ATRi can profoundly sensitize tumors, both in vitro and in vivo, to radiation and radiochemotherapy with no evidence for potentiation of radiation-induced normal tissue damage.

Results
VE-822 inhibits Chk1 phosphorylation and sensitizes pancreatic cancer cells to XRT and gemcitabine in vitro. We recently described a highly selective ATRi, VE-821. 15 VE-822, a close analog of VE-821, has increased potency against ATR retaining the excellent ATR selectivity profile. 29 Furthermore, VE-822 has absorption, distribution, metabolism and excretion properties that support in vivo studies. Particularly, VE-822 has 4100-fold cellular ATR-selectivity over the closely related phosphatidylinositol 3-kinase-related kinases ATM/DNA-PK (Table  1,  Supplementary Table S1).
VE-822 disrupts DNA damage-induced cell-cycle checkpoints in vitro. VE-822 alone increased the G1-phase-fraction (Supplementary Figures S3A-D). XRT enriched G2/M-phase-fraction, and this was abrogated by co-treatment with VE-822. By contrast, gemcitabine-induced S-phase arrest that was not affected by VE-822.
VE-822 increases XRT-and gemcitabine-induced apoptosis in vitro. We analyzed apoptosis in PSN-1 cells by Annexin V-FITC/PI to differentiate necrotic from early apoptotic cells (Supplementary Figure S4). VE-822 had little effect, whereas XRT and gemcitabine increased apoptosis slightly in PSN-1 while combinations of VE-822, XRT and/or gemcitabine enhanced early and late apoptosis that was strongest in the triple combination.
Efficacy of VE-822 combined with radiotherapy in xenografts. We first investigated whether VE-822 efficiently blocks phosphorylation of the main downstream target of ATR, Chk1, in tumor xenografts, in response to DNA damage. For that purpose, PSN-1 xenografts were treated with VE-822 (60 mk/kg; d0, 1), gemcitabine (100 mg/kg; d0) and/or XRT (6 Gy; d1), as described in Materials and Methods. Tumors were then harvested 2 h post-XRT. In keeping with our in vitro observations, VE-822 inhibited phospho-Ser-345-Chk1 in xenografts after DNA-damaging agents (Figure 4a), establishing VE-822 as a potent inhibitor of ATR in vivo.
We then asked whether mice bearing PSN-1 xenografts would show a better response to radiotherapy when co-treated with VE-822 (Growth delay experiment I; Figures 4b and c). Subscripts in the text indicate day of treatment. The time for tumors to grow to 600 mm 3 (TV600) in the XRT 1 group was significantly longer than in the vehicle or VE-822 0-5 (Po0.001) treated groups. Although VE-822 alone had no effect on tumor growth at the dose used in this study, administration of XRT plus VE-822 for either 6 days (VE-822 0-5 XRT 1 ) or 4 days (VE-822 0-3 XRT 1 ) more than doubled the TV600 of XRT alone (Po0.001). Interestingly, the TV600 for the VE-822 0-5 XRT 1 group was significantly longer than the VE-822 0-3 XRT 1 group (Po0.001). No body weight loss was detected in any of the animals in this study (Supplementary Figure S4A). Taken together, these data demonstrate the marked radiosensitising potential of VE-822.
We next tested the efficacy of VE-822 in a different tumor xenograft, MiaPaCa-2 (Growth delay experiment III;  (Figure 4f). Radiation alone (XRT 1 ) resulted in a significant tumor growth delay compared with control (Po0.01). Strikingly in the combined group (VE-822 0-5 XRT 1 ; n ¼ 4) only 2/4 tumors regrew. The TV600 for the two regrowing tumors was significantly longer than the TV600 for the XRT 1 group (Po0.001). Again, no weight loss was recorded in any of the mice (Supplementary Figure S4C).
Finally, intermittent VE-822 dosing (days 0, 2 and 4) at three different doses (15,30 and 60 mg/kg) was tested for radiosensitisation, and the time for tumors to grow to 400 mm 3 (TV400) was analyzed (Growth delay experiment IV; Supplementary Figures S6A and B). A clear dose-dependent radiosensitisation response to VE-822 was observed, with 60 mg/kg the most efficacious dose (Supplementary Figures  S6A and B). No weight loss was observed in any of the mice (Supplementary Figure S6C). Collectively, growth delay experiments I-IV reveal that ATRi using VE-822 can safely Efficacy of VE-822 in combination with chemoradiotherapy in pancreatic tumor xenografts. Above, we investigated the potential of VE-822 to enhance response of PDAC xenografts to radiotherapy. As gemcitabine-based chemoradiation is frequently used in patients with PDAC, 3,4 we tested gemcitabine in combination with VE-822 plus XRT (Growth delay experiment V; Figures 5a and b). Gemcitabine (100 mg/kg) was given at day 0 (Gem 0 ), XRT on d1 (XRT 1 ) and VE-822 (60 mg/kg) on d1, 3 and 5 (VE-822 1,3,5 ). XRT led to a significant increase in TV400 (Po0.05) compared with control. Gem 0 at this dose did not alter tumor growth significantly. Adding gemcitabine to VE-822 (Gem 0 VE-822 1,3,5 ) did not significantly increase TV400 compared with gemcitabine alone (P40.05) under the conditions of this experiment. Adding XRT to gemcitabine (Gem 0 XRT 1 ) increased tumor growth delay compared with Gem 0 (Po0.05). Similarly, the tumor growth delay in the VE-822 1,3,5 XRT 1 group was significantly longer compared with the XRT 1 group (Po0.05). VE-822 added to the combination of gemcitabine þ XRT (Gem 0 XRT 1 VE-822 1,3,5 ) substantially prolonged the tumor growth delay compared with the Gem 0 XRT 1 group (Po0.001). In addition, no weight loss was observed throughout the experiment (Figure 5c). These results As the tolerance of XRT in PDAC is restricted by the small bowel, we assessed the effect of VE-822 on intestinal morphology. 32,33 VE-822 combined with abdominal XRT did not significantly increase the number of TUNEL-positive apoptotic jejunal cells compared with XRT alone (Figure 5d). Furthermore, VE-822 administered with XRT did not increase villus tip loss or villi shortening when compared with XRT alone (Figures 5e and f). In keeping with these findings, equivalent body weight loss was observed in the combination and XRT-only groups (Figure 5g). Thus, in our model, we found no evidence for enhancement of XRT-induced gastrointestinal damage by VE-822.
Effect of VE-822 on tumor vessel density and proliferation. We used CD31 immunostaining to assess the effect of VE-822 on tumor angiogenesis (Supplementary Figure S7). In growth delay experiments I-III, VE-822 therapy, alone or with XRT, did not alter vessel density ( Supplementary Figures S7A and B). In growth delay experiment V, a significantly reduced vessel density was observed after therapy with gemcitabine, whereas addition of VE-822 and/or XRT to gemcitabine did not alter vessel density significantly. There was no significant difference in the proportion of Ki67-positive cells following any combination of agents, indicating that proliferation had not been affected (Supplementary Figures S8A-D). In vivo imaging of DNA DSBs following radiation and VE-822. In vitro, VE-822 led to persistent gH2AX foci after XRT. To examine persistence of gH2AX in vivo, we used a SPECT probe, which we have recently developed, that binds to phosphorylated gH2AX. 34 We have shown that anti-gH2AX antibody, coupled to the Tat peptide DTPA, allows radiolabelling with 111 In and can be used for specific imaging of DNA damage in live animals. 34 We performed SPECT/CT at 24 h post-XRT to non-invasively image DNA damage, as induced by XRT (6 Gy; day 1). We administered VE-822

Discussion
In the present study, we investigated the potential of VE-822, a potent ATRi, to sensitize PDAC cells and xenografts to XRT and gemcitabine. ATRi by VE-822 resulted in profound sensitization of PDAC cells to radiotherapy both in vitro and in xenografts, to the extent that the combination of VE-822 and XRT prevented MiaPaCa-2 tumor regrowth in some mice. VE-822 is a close analog of the previously reported selective ATRi, VE-821 with excellent potency against ATR (Ki 200pM) and 4100-fold cellular selectivity for ATR over ATM and DNA-PK (Table 1, Supplementary Table S1). The selectivity of VE-822 for ATR is also supported by the lack of inhibition of DNA-PK, ATM or Chk2 protein phosphorylation by VE-822 after irradiation of PDAC cells. VE-822 blocked XRT and gemcitabine-induced Chk1 Ser345 phosphorylation in PDAC cells and tumors, as well as in normal cell fibroblasts, confirming its ability to disrupt ATR signaling. Of most relevance to the clinical setting, VE-822 sensitized tumors to fractionated XRT. In addition to sensitizing tumors to XRT, VE-822 profoundly sensitized tumors to gemcitabine-based chemoradiation. Here, VE-822 remained effective even with doses of gemcitabine that alone had no effect on tumor growth. In accordance to previous reports, [35][36][37] addition of VE-822 to XRT and/or gemcitabine resulted in increased early and late apoptosis in PDAC cell cultures.
Previous work has shown that HRR-deficient cells are more radiosensitive compared with HRR-proficient cells, 38 although enhancing HRR by overexpression of Rad51, a major mediator of HRR, is associated with resistance to radiation. 39 VE-822 decreased Rad51 foci in irradiated tumor cells, showing that VE-822-mediated radiosensitivity was associated with inhibition of HRR. Furthermore, VE-822 caused increased persistence of residual gH2AX expression after XRT both in PDAC cells and tumor xenografts. By promoting a strong S-phase arrest, the addition of gemcitabine to XRT may further enhance dependence on ATR-mediated HRR for DSB repair and cancer cell survival. This model would be consistent with the dramatic anticancer effects we observed for the triple combination of VE-822, XRT and gemcitabine in vivo. VE-822 additionally led to abrogation of the XRTinduced G2 checkpoint in vitro, which could also contribute to the radiosensitization effect.
VE-822 did not sensitize normal cells to XRT or gemcitabine, despite inhibiting XRT-or gemcitabine-induced Chk1 phosphorylation, similarly to the findings with VE-821 in vitro 15 and was well tolerated from animals. Furthermore, as damage to the small intestine is commonly dose-limiting during radiotherapy for PDAC, 5,40 we specifically quantified the effect of VE-822 on bowel radiosensitivity. Notably, addition of VE-822 to XRT did not further enhance the jejunal apoptosis or villus damage observed with XRT alone, in agreement with a recent study showing that ATR suppression minimally affects normal tissue homeostasis. 41 Collectively, these data indicate that ATRi by VE-822 is not cytotoxic to normal tissue and, furthermore, we failed to find any evidence of enhanced gastrointestinal epithelial tract damage associated with XRT.
Approximately 50-70% of PDAC harbor mutations in ATM and p53-mediated signaling. 1,11 ATR depletion can strongly enhance DNA damage-induced tumor cell killing and suggest that the frequent loss of ATM-p53 signaling may be an important determinant of this finding. 15,[42][43][44] Moreover, prolonged disruption of the ATR pathway can exacerbate the levels of replication stress in oncogene-driven murine tumors to promote cell killing. 18,[23][24][25] These observations provide an explanation for the tumor selective effects of ATRi by VE-822.
PDAC is an incurable disease and survival remains poor. 1,2 Gemcitabine-based radiochemotherapy can increase local control rates and improve progression-free survival but is associated with normal tissue toxicity, which limits its therapeutic utility. 5,40 Our data show that VE-822 can dramatically sensitize PDAC cancer cells to radiochemotherapy both in vitro and in vivo. Thus ATRi, and specifically VE-822, represents a very promising candidate for combination with radiation and gemcitabine.

Conclusion
In the present work, we demonstrate that ATRi by VE-822 profoundly radiosensitizes PDAC cells and xenografts and increases the growth delay induced by XRT combined with gemcitabine in PDAC xenografts. VE-822 did not enhance toxicity to normal cells and tissues. The tumor selectivity shown by VE-822 provides strong evidence that ATRi represents a promising new approach to markedly increase the efficacy of the current therapies for PDAC. were obtained and cultured as previously described. 15,31,46 HDMECs (Lonza, Slough, UK) were cultured as reported. 47 ATR inhibitor preparation and treatment. The ATRis, VE-821 and VE-822, were obtained from Vertex Pharmaceuticals (Europe) Ltd (Abingdon, UK) in solution in dimethyl sulfoxide for in vitro studies. Vehicle controls were equal volumes of the same concentration of dimethyl sulfoxide. For the in vivo studies, VE-822 was dissolved in 10% Vitamin E d-alpha tocopheryl polyethylene glycol 1000 succinate and administered by gavage, in 200 ml.

Biochemical and cellular inhibition of ATR and related kinases.
Broad kinase selectivity profiling and analysis of biochemical and cellular inhibition of ATR and related kinases were assessed as previously described. 15 Immunoblotting. Cells were treated with VE-822 (80 nM) and/or gemcitabine (20 nM) for 1 h before XRT (6 Gy). After rinsing with cold PBS, lysates were obtained at 2 h post-XRT using reducing Triton lysis buffer. Tumor lysates were obtained from female Balb/c nude mice bearing PSN-1 xenografts (volumeB300 mm 3 ) treated with VE-822 (60 mg/kg; days 0 and 1) and/or gemcitabine (100 mg/ kg; day 0) and/or XRT (6 Gy; day 1). Gemcitabine (day 0) was administered 24 h before XRT. VE-822 was administered 2 h after gemcitabine (day 0) and 2 h before XRT (day 1). Tumors were harvested 2 h post-XRT, snap frozen, homogenized and prepared in the same buffer used in cells. Immunoblotting was performed as described. 46 Proteins were detected using antibodies to phospho-Chk1 Ser345, phospho-Chk2 T68, total Chk2 (Cell Signalling, Hitchin, UK), total Chk1 (New England Biolabs, Hitchin, UK), phospho-ATM S1981 (Epitomics, Inc, Burlingame, CA, USA), total ATM (Epitomics, Inc.), DNA-PKcs phospho Ser2056 (Abcam, Cambridge, UK), total DNA-PK (BD Pharmigen, Oxford, UK) at (1 : 1000 dilution) and b-actin clone AC-15 (Sigma, Gillingham, UK; 1 : 4000 dilution). Cells were irradiated as described before. 46 Selective radiosensitisation by ATR inhibition E Fokas et al Clonogenic survival assay. VE-822 (80 nM) was administered 1 h before XRT and was washed away 17 h after XRT. For chemotherapy, cells were exposed to gemcitabine (10, 20 or 50 nM) for 24 h before addition of VE-822 (80 nM) for another 18 h. Gemcitabine was washed away immediately before addition of VE-822. The clonogenic survival of cells was assessed as reported. 46 Knock down of Chk1 by siRNA. Cells were transfected using either Chk1 siRNA carried out with the following sequence (5 0 -3 0 ): GGCUUGGCAACAGUAUU UCGGUAUA or with stealth RNAi negative control (Invitrogen, Paisley, UK). In total, 2 Â 10 5 MiaPaca-2 cells or 2.5 Â 10 5 PSN-1 cells were seeded per well 24 h before transfection. Two reaction mixtures were set up per transfection. Mixture 1 contained 3.125 ml of 20 mM siRNA, 121.875 ml diethylpyrocarbonate water and 125 ml of Dulbecco's Modified Eagle Medium (DMEM; serum-free) per well. Mixture 2 contained 5 ml Dharmafect transfection reagent and 245 ml DMEM (serum-free) per well. Each mixture was incubated for 5 min at room temperature, then combined and left to incubate for a further 20 min at room temperature. The final reaction mixture (500 ml) for each well was then diluted by adding 2 ml DMEM plus FBS. The old media was aspirated from cells and 2 ml of the transfection mixture was added. Twenty-four hours post-transfection, the old media was aspirated from cells and 2 ml of fresh DMEM plus FBS media was added. Finally, cells were harvested and processed for immunobloting blotting (for total Chk1 and b-actin, as described above) or processed for clonogenic assay (as described above) after incubation at 37 1C for 48 h.
Immunohistochemical analysis of cH2AX, 53BP1 and Rad51 foci. VE-822 (80 nM) was added 1 h before XRT (6 Gy). The residual DNA damage was assessed by 53BP1 and gH2AX in PSN-1 and MiaPaCa-2 cells at 24 h post-XRT with 6 Gy. HRR was analyzed by Rad51 focus formation at 6 h post-XRT. The analysis for residual gH2AX, 53BP1 and Rad51 foci was as described. 46 Cell-cycle assay. Cells were treated with VE-822 (80 nM) for 1 h before XRT (6 Gy) until cells were harvested. Gemcitabine (10 nM) was added for 24 h pre-XRT and was removed before addition of VE-822. Cell-cycle distribution was investigated at 12 h and 24 h after XRT as described elsewhere. 46,47 Data represent three independent experiments.
Apoptosis in vitro assay. Gemcitabine (10 nM) was added 24 h pre-XRT and was replaced with fresh medium before addition of VE-822. PSN-1 cells were treated with VE-822 (80 nM) for 1 h before, through to 18 h after, XRT (6 Gy). Apoptosis was analyzed 48 h after XRT by flow cytometry using an Annexin V-FITC kit with PI. 47 Capillary tube formation. HDMECs were exposed to VE-822 (80 nM) for 1 h pre-XRT (6 Gy). Cells were trypsinized immediately after XRT, plated onto 24-well plates that was previously coated with Matrigel (300 mL per well; BD Biosciences, Oxford, UK) and tube formation was analyzed 8 h post-XRT. HDMECs were also pretreated with 50 nM gemcitabine for 24 h, gemcitabine was washed away, 80 nM VE-822 was added and tube formation was assessed 9 h later. Tube formation was analyzed as described. 47 Xenograft studies. Animal experiments involving mice were performed according to the limits and guidelines of University of Oxford and the Home Office, UK. 48 MiaPaCa-2 cells and PSN-1 cells (10 6 in 50 ml serum-free medium mixed with 50 ml of Matrigel) were inoculated subcutaneously in female Balb/c nude mice (Harlan, Wolverhampton, UK). When the xenograft tumors reached B80 mm 3 , the mice were randomized. Tumor xenografts were irradiated and volumes were measured as we recently described. 49 VE-822 (60 mg/kg) was administered by oral gavage on one of three alternate schedules; either daily on days 0-5 (total of six days dosing), daily on days 0 through to 3 (total of 4 days dosing) or on days 1, 3 and 5. XRT (6 Gy) was given either on days 0 or 1 or days 1-5 (total of 5 days dosing; 2 Gy). Gemcitabine was dosed at 100 mg/kg by intraperitoneal injection on day 0. XRT to the tumor was given 2 h after initiation of VE-822 treatment. The gemcitabine at 100 mg/kg does not itself lead to tumor growth delay (data not shown).
Vessel density was quantified as the number of blood vessels/field in five random viable fields (10 Â objective) per tumor (n ¼ 4-5 per group). Proliferation was measured as the percentage of Ki67-positive area in relation to the DAPI-positive signal (tumor surface area) in five random viable fields (10 Â objective) per tumors (n ¼ 4-5 per group) using ImageJ software (version 1.38; NIH, Bethesda, MD, USA). Immunofluorescent images were acquired using the Leica DMRBE microscope with a Hamamatsu camera (Leica Microsystems Ltd, Milton Keynes, UK).
The effects of XRT and/or VE-822 on gut epithelium was determined by measuring changes in morphology 33 and apoptosis 32 of small intestine. Balb/c nude mice bearing PSN-1 tumors xenografts were treated with either vehicle or 60 mg/kg VE-822 p.o. at days 0, 2 and 4. Mice (n ¼ 3) were irradiated at day 0 using abdominal XRT (6 Gy), 2 h after initiation of VE-822. At day 5, mice were killed, and the small intestine was removed, washed and fixed in 3% formalin/PBS. Crosssections of the small intenstine were stained for hematoxylin and eosin and TUNEL (apoptosis), according to the manufacturer's instructions (Apoptag, Millipore, Watford, UK). Villus length was measured using ImageJ software (version 1.38). The loss of villus tip loss and the number of apoptotic cells were measured manually. Approximately 100 crypt-villus units were scored per group (n ¼ 2).
SPECT imaging of cH2AX in pancreatic tumor xenografts. We recently established a non-invasive method for live animal imaging to detect phosphorylated gH2AX in response to DNA damage. 34 This is based on administration of 111 In conjugated to an anti-gH2AX antibody coupled to the cell penetrating peptide, Tat, to allow nuclear localization. SPECT imaging then reveals location and extent of gH2AX foci. 34 Mice bearing PSN-1 tumor xenografts were treated with VE-822 (60 mg/Kg; days 0 and 1) and XRT (6 Gy; day 1), approximately 2 h after the second dose of VE-822. The radioimmunoconjugate 111 In-DTPA-anti-gH2AX-Tat was administered 2 h before radiation and SPECT was conducted at 24 h post-XRT as reported. 34 Following this, mice were euthanized and selected organs were removed, weighed and counted for radioactivity. Volume of interest analysis was performed on reconstructed SPECT images using the Inveon Research Workplace software package (Siemens Medical Solutions, Surrey, UK). Results were expressed as a percentage of the injected dose per gram of tissue (%ID/g).
Statistical analyses. The significance of differences between the means was measured by two-tailed t-test or one-way ANOVA (Bonferroni test) using the GraphPad Prism program version 4.0 (GraphPad Software, La Jolla, CA, USA). The values were expressed as means ± S.D. A P-valueo0.05 was considered statistically significant.
Conflict of Interest JRP, PMR and PAC are full time employees of Vertex Pharmaceuticals (Europe), Ltd. and hold equity in Vertex Pharmaceuticals, Inc.