Curis Highlights Publication in Nature Cell Biology Identifying Cancer-Causing Form of IRAK4 in Patients with AML and MDS

On June 12, 2019 Curis, Inc. (NASDAQ: CRIS), a biotechnology company focused on the development of innovative therapeutics for the treatment of cancer, reported a publication titled "U2AF1 mutations induce oncogenic IRAK4 isoforms and activate innate immune pathways in myeloid malignancies" in Nature Cell Biology (Press release, Curis, JUN 12, 2019, View Source [SID1234537035]).1 The study findings demonstrate that a cancer-causing splicing variant of IRAK4 (IRAK4-L) is dominant in the majority of cases of acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). Additionally, specific mutations of the U2AF1 splicing factor induce IRAK4-L, which has potential therapeutic targetability by CA-4948, the Company’s small molecule inhibitor of IRAK4. The findings present inhibition of IRAK4 as a potential option for the treatment of patients with myeloid malignancies expressing IRAK4-L and with U2AF1 mutations. Isoform-switching to the oncogenic form of IRAK4 is also present in a subset of breast, lung and colon cancers.

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"We are encouraged by these findings in Nature Cell Biology, which support that CA-4948’s unique target profile may be beneficial to patients with myeloid malignancies and, in particular, those with IRAK4-L and U2AF1 mutations," said Jim Dentzer, President and Chief Executive Officer of Curis. "There is a large unmet need for further treatment options among this patient subgroup and we look forward to assessing the potential of CA-4948 to address this significant medical issue."

The Company is currently evaluating CA-4948 in an ongoing Phase 1 trial in patients with non-Hodgkin lymphoma, including those with MYD88 alterations, with interim data expected in mid-2019. In addition, the Company is further investigating the potential of CA-4948 in patients with myeloid malignancies expressing IRAK4-L and with U2AF1 mutations.

About CA-4948, a small molecule inhibitor of IRAK4

Innate immune responses orchestrated through Toll-like receptors or certain interleukin receptors are important mediators of the body’s initial defense against foreign antigens, while their dysregulation is associated with certain inflammatory conditions. Toll-like receptor and interleukin receptor signaling through the adaptor protein MYD88, results in the assembly and activation of IRAK4, initiating a signaling cascade that induces cytokine and survival factor expression mediated by the transcription factor NFκB. More recently, components of this pathway are recognized to be genetically altered and have important roles in specific human cancers. MYD88 gene mutations are shown to occur in approximately 30% of Activated B-Cell (ABC) subtype of diffuse large B-cell lymphomas (DLBCL) and in over 90% of the B-cell malignancy Waldenstrom’s macroglobulinemia. Due to IRAK4’s central role in these signaling pathways, it is considered an attractive target for generation of therapeutics to treat these B-cell malignancies as well as certain inflammatory diseases.

Constellation Pharmaceuticals Presentation Highlights Enhanced EZH2 Target Engagement, Leading to Second-Generation EZH2 Inhibitor CPI-0209

On June 12, 2019 Constellation Pharmaceuticals, Inc. (Nasdaq: CNST) reported that Dr. Jacob Stuckey, Senior Scientist at Constellation Pharmaceuticals, gave an oral presentation titled Methods for Kinetic Assessment of High Affinity EZH2 Inhibitors: Identification of a 2nd Generation EZH2i with Improved Biological Activity and Extremely Long Residence Time at the Oxford Global Drug Discovery Summit in Berlin earlier today (Press release, Constellation Pharmaceuticals, JUN 12, 2019, View Source [SID1234537034]).

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Dr. Stuckey described detailed studies conducted by Constellation Pharmaceuticals to characterize molecules from the Company’s second-generation EZH2 inhibitor program. As outlined in Dr. Stuckey’s presentation, potent EZH2 inhibitors present a number of unique challenges for measurement of biochemical potency and residence time. To meet these challenges, the Company developed customized biochemical and binding assays to evaluate these parameters. A key structural modification was identified that bestows prolonged residence time on multiple known EZH2-inhibitor scaffolds. Optimized second-generation EZH2 inhibitors display sub-pM potencies that translate into enhanced cell killing of EZH2-inhibitor-sensitive preclinical models both in vitro and in vivo.

The culmination of the Company’s second-generation EZH2 inhibitor program was the identification of CPI-0209, which reversibly binds to the PRC2 complex with sub-pM binding affinity and a residence time of >3 months. Constellation expects to file an Investigational New Drug (IND) application for CPI-0209 in June 2019.

Blue Earth Diagnostics Highlights Presentations on Axumin® (Fluciclovine F 18), 18F-Fluciclovine and 18F-rhPSMA at Upcoming Society of Nuclear Medicine and Molecular Imaging (SNMMI) Annual Meeting

On June 12, 2019 Blue Earth Diagnostics, a molecular imaging diagnostics company, reported upcoming presentations at the Society of Nuclear Medicine and Molecular Imaging Annual Meeting (SNMMI), from June 22 – 26, 2019 in Anaheim, Ca (Press release, Blue Earth Diagnostics, JUN 12, 2019, View Source [SID1234537033]). Highlighted presentations encompass clinical use of Axumin (fluciclovine F 18) injection; investigational use of 18F-fluciclovine; and initial clinical experience by the Technical University of Munich with 18F-rhPSMA-7, an investigational Prostate Specific Membrane Antigen-targeted radiohybrid PET imaging agent representative of the family of rhPSMA agents that Blue Earth Diagnostics exclusively licensed in 2018. Senior executives from Blue Earth Diagnostics will participate in sessions about advancing companies from concept to commercialization, and current and future approaches to molecular imaging and therapy. In addition, a special program led by SNMMI, "Fluciclovine Live Reader Training," will be held immediately prior to the Annual Meeting. Details of selected oral and poster presentations by Blue Earth Diagnostics and its collaborators are listed below.

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NOTE: Axumin (fluciclovine F 18) injection is FDA-approved for positron emission tomography (PET) imaging in men with suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following prior treatment. Presentations noted by "*" discuss results of investigational studies of an approved product that is not approved by the FDA for the specific use or purpose noted, or "*" denotes experience with an investigational agent for which the safety and efficacy have not been established by the FDA.

HIGHLIGHTED SCIENTIFIC PRESENTATIONS

Axumin (fluciclovine F 18) presentations

Date: Monday, June 24, 2019

Poster Title: [18F]-fluciclovine positivity rate is not affected by androgen deprivation therapy (ADT) in recurrent prostate cancer post-prostatectomy

Session Title: MTA I: Prostate/GU Imaging Posters

Presenter: Olayinka Abiodun-Ojo, MD, Emory University

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1576

Date: Monday, June 24, 2019

Poster Title: Comparison of 18F-Fluciclovine PET/CT and Technetium-99m MDP BS in Detection of Bone Metastasis in Prostate Cancer

Session Title: MTA I: Prostate/GU Imaging Posters

Presenter: Bo Chen, MD, MD Anderson Cancer Center

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1553

Investigational 18F-fluciclovine presentations

Date: Monday, June 24, 2019

Session Title: SS47: Brain PET/MRI

Presentation Title: Evaluation of glioma tumor volume with 18F-fluciclovine positron emission tomography interpreted in combination with MRI, compared with MRI alone: Results from a prospective phase 3 blinded image evaluation*

Presenter: Matthew P. Miller, PhD, Blue Earth Diagnostics

Session Time: 4:45 – 6:15 PM PT

Presentation Time: 5:25 – 5:35 PM PT
Location: Room 204B

Publication No: 394

Date: Tuesday, June 25, 2019

Session Title: SS58: Brain Imaging Reloaded II

Presentation Title: Safety and effectiveness of 18F-fluciclovine PET in adults with recurrent glioma: A retrospective observational study*

Presenter: Tore Bach-Gansmo, MD, PhD, Oslo University Hospital

Session Time: 10:00 – 11:30 AM PT

Presentation Time: 11:20 – 11:30 AM PT

Location: Room 201B

Publication No. 496

Date: Tuesday, June 25, 2019

Poster Title: PET imaging of recurrent brain tumors using 18F-FACBC*

Session Title: MTA II: Neurology & Psychiatry Imaging Posters

Presenter: Laure Michaud, MD, Memorial Sloan-Kettering Cancer Center

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1506

Date: Monday, June 24, 2019

Poster Title: [18F]-fluciclovine PET/CT is superior to conventional imaging in preoperative nodal staging in patients with high-risk prostate cancer*

Session Title: MTA I: Prostate/GU Imaging Posters

Presenter: Olayinka Abiodun-Ojo, MD, Emory University

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1580

Date: Monday, June 24, 2019

Poster Title: Preoperative staging in high-risk prostate cancer patients using [18F] fluciclovine PET/CT*

Session Title: MTA I: Prostate/GU Imaging Posters

Presenter: Akinyemi A. Akintayo, MD, Emory University

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1554

Date: Monday, June 24, 2019

Poster Title: [18F] Fluciclovine PET/MRI for Initial Staging of High-Risk Prostate Cancer*

Session Title: MTA I: Prostate/GU Imaging Posters

Presenter: Samuel J. Galgano, MD, University of Alabama at Birmingham

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1561

Date: Tuesday, June 25, 2019

Poster Title: Using dynamic PET/CT imaging to explore the kinetics of 18F-fluciclovine (anti-(18)F-FACBC) in invasive breast cancer*

Session Title: MTA II: Data Analysis & Management Posters

Presenter: Nathaniel P. Scott, MSc, MPhys, University of Oxford

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1194

Date: Tuesday, June 25, 2019

Session Title: SS65: Gynecological Cancers

Presentation Title: Feasibility of Fluciclovine PET-CT Imaging of Endometrial, Cervical and Ovarian Cancers: Preliminary Findings*

Presenter: Funmilayo Tade, MD, MPH, Loyola University Medical Center

Session Time: 12:30 – 2:00 PM PT

Presentation Time: 1:50 – 2:00 PM PT

Location: Room 202AB

Publication No.: 558

Presentations on initial clinical experience with 18F-rhPSMA-7 at Technical University of Munich

Date: Monday, June 24, 2019

Poster Title: Preclinical dosimetry and human biodistribution of 18F-rhPSMA-7 and 18F-rhPSMA-7.3*

Session Title: MTA I: Prostate/GU Imaging Posters

Presenter: So Won Oh, MD, PhD, Seoul National University Boramae Hospital

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1635

Date: Monday, June 24, 2019

Poster Title: Quantitative and qualitative analysis of biodistribution and PET image quality of novel radiohybrid PSMA ligand, 18F-rhPSMA-7, in patients with prostate cancer *

Session Title: MTA I: Prostate/GU Imaging Posters

Presenter: So Won Oh, MD, PhD, Seoul National University Boramae Hospital

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1557

Date: Monday, June 24, 2019

Poster Title: Histologically-confirmed diagnostic efficacy of 18F-rhPSMA-7 positron emission tomography for N-staging of patients with high risk primary prostate cancer*

Session Title: MTA I: Prostate/GU Imaging Posters

Presenter: Markus Kroenke, Technical University of Munich

Presentation Time: 3:00 – 4:30 PM PT

Location: Exhibit Hall C

Publication No.: 1567

Date: Tuesday, June 25, 2019

Session Title: SS69: Prostate Diagnosis I

Presentation Title: 18F-rhPSMA-7 positron emission tomography (PET) for the detection of biochemical recurrence of prostate cancer following curative-intent radiation therapy*

Presenter: Harun Ilhan, MD, Ludwig-Maximilian-University (LMU), Munich

Session Time: 12:30 – 2:00 PM PT

Presentation Time: 1:30 – 1:40 PM PT

Location: 204B

Publication No.: 592

Date: Tuesday, June 25, 2019

Session Title: SS76: Prostate Cancer Diagnosis II

Presentation Title: 18F-rhPSMA-7 positron emission tomography (PET) for the detection of biochemical recurrence of prostate cancer following radical prostatectomy*

Presenter: Matthias Eiber, MD, Technical University of Munich

Session Time: 10:00 – 11:30 AM PT

Presentation Time: 11:20 – 11:30 AM PT

Location: Room 204B

Publication No.: 649

PANEL PRESENTATIONS

Date: Saturday, June 22, 2019

Session Title: Concept to Commercialization and Funding Along the Way

Panel Title: Emerging Technologies, Funding, M&A

Panel Participant: Jonathan Allis, D.Phil., CEO, Blue Earth Diagnostics

Session Time: Saturday 3:30 – 5

Location: Room 303AB

Date: Sunday, June 23, 2019

Session Title: CMIIT Emerging Technologies – Emerging Technologies – A Look into the Future of Molecular Imaging and Therapy

Presentation Title: Molecular Imaging and Therapy – Current and Future Approaches*

Presenter: David Gauden, D.Phil., CSO, Blue Earth Diagnostics

Session Time: 4:30 – 6:00 PM PT

Presentation Time: 4:30 – 4:50 PM PT
Location: Room 201D

In addition, the following presentations will be part of independent continuing education programs at SNMMI.

Date: Saturday, June 22, 2019

Session Title: SNMMI Special Programming

Presentation Title: Fluciclovine Live Training Session

Session Time: 9:00 AM PT – 12:00 PM PT

Location: Registration required: View Source

Date: Saturday, June 22, 2019

Session Title: CE08: Prostate Cancer Nuts and Bolts: Diagnosis and Therapy

Presentation Title: Prostate Cancer Diagnostic: Fluciclovine F18 PET/CT

Presenter: David M. Schuster, MD, Emory University

Session Time: 3:15 – 4:45 PM PT

Presentation Time: 3:15 – 3:45 PM PT

Location: Room 211AB

Date: Sunday, June 23, 2019

Session Title: CE29: New PET Radiopharmaceuticals – Read with the Experts

Presentation Title: Fluciclovine F18 PET/CT

Presenter: David M. Schuster, MD, Emory University

Session Time: 4:45 – 6:15 PM PT

Presentation Time: 4:45 – 5:05 PM PT

Location: Room 212AB

Blue Earth Diagnostics invites participants at this year’s SNMMI Annual Meeting to attend the presentations above and to visit the company at Exhibit Booth 720.

U.S. Indication and Important Safety Information About Axumin

INDICATION

Axumin (fluciclovine F 18) injection is indicated for positron emission tomography (PET) imaging in men with suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following prior treatment.

IMPORTANT SAFETY INFORMATION

Image interpretation errors can occur with Axumin PET imaging. A negative image does not rule out recurrent prostate cancer and a positive image does not confirm its presence. The performance of Axumin seems to be affected by PSA levels. Axumin uptake may occur with other cancers and benign prostatic hypertrophy in primary prostate cancer. Clinical correlation, which may include histopathological evaluation, is recommended.
Hypersensitivity reactions, including anaphylaxis, may occur in patients who receive Axumin. Emergency resuscitation equipment and personnel should be immediately available.
Axumin use contributes to a patient’s overall long-term cumulative radiation exposure, which is associated with an increased risk of cancer. Safe handling practices should be used to minimize radiation exposure to the patient and health care providers.
Adverse reactions were reported in ≤ 1% of subjects during clinical studies with Axumin. The most common adverse reactions were injection site pain, injection site erythema and dysgeusia.

To report suspected adverse reactions to Axumin, call 1-855-AXUMIN1 (1-855-298-6461) or contact FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Full Axumin prescribing information is available at www.axumin.com.

About Axumin (fluciclovine F 18)

Axumin (fluciclovine F 18) injection is a novel product indicated for use in positron emission tomography (PET) imaging to identify suspected sites of prostate cancer recurrence in men. Recurrence of prostate cancer is suspected by an increase in prostate specific antigen (PSA) levels following prior treatment. PET imaging with Axumin may identify the location and extent of such recurrence. Axumin was developed to enable visualization of the increased amino acid transport that occurs in many cancers, including prostate cancer. It consists of a synthetic amino acid that is preferentially taken up by prostate cancer cells compared with surrounding normal tissues and is labeled with the radioisotope F 18 for PET imaging. Fluciclovine F 18 was invented at Emory University in Atlanta, Ga., with much of the fundamental clinical development work carried out by physicians at Emory University’s Department of Radiology and Imaging Sciences. Axumin was approved by the U.S. Food and Drug Administration in May 2016, following Priority Review, and is the first product commercialized by Blue Earth Diagnostics, which licensed the product from GE Healthcare. The molecule is being investigated by Blue Earth Diagnostics for other potential cancer indications, such as glioma.

About rhPSMA

Blue Earth Diagnostics acquired exclusive, worldwide rights to radiohybrid Prostate Specific Membrane Antigen (PSMA)-targeted technology (rhPSMA) from Scintomics in 2018. rhPSMA originated from the Chair of Pharmaceutic Radiochemistry at the Technical University of Munich, Germany, by Alexander Wurzer and Hans Juergen Wester, and has been utilized clinically under German legislation at the Department of Nuclear Medicine for the diagnostic imaging of men with both primary and recurrent prostate cancer. 18F-rhPSMA consists of a prostate-specific membrane antigen (PSMA) receptor ligand, which attaches to and is internalized by prostate cancer cells, and is labeled with the 18F radioisotope for PET imaging. rhPSMA compounds can also be labeled with radioisotopes such as 177Lu and 225Ac for therapeutic use. 18F-rhPSMA, 177Lu-rhPSMA and 225Ac-rhPSMA have not received regulatory approval.

Alkermes Advances ALKS 4230 into Monotherapy Expansion Phase of ARTISTRY-1 in Patients With Renal Cell Carcinoma or Melanoma

On June 12, 2019 Alkermes plc (Nasdaq: ALKS) reported the initiation of the monotherapy expansion stage of its ARTISTRY-1 clinical trial to evaluate the efficacy, safety and tolerability of ALKS 4230 in treating patients with renal cell carcinoma or melanoma (Press release, Alkermes, JUN 12, 2019, View Source;p=RssLanding&cat=news&id=2401218 [SID1234537031]). Initiation of this portion of the ongoing study follows the identification of 6 µg/kg/day administered intravenously as the recommended monotherapy dose of ALKS 4230 to evaluate in these select tumor types. The maximum tolerated dose of ALKS 4230 has not yet been reached, and the dose-escalation stage of the ARTISTRY-1 study is continuing. ALKS 4230 is a novel, engineered fusion protein designed to selectively expand tumor-killing immune cells while avoiding the activation of immunosuppressive cells by preferentially binding to the intermediate-affinity interleukin-2 (IL-2) receptor complex.

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"At the 6 µg/kg/day dose, data from the dose-escalation stage of ARTISTRY-1 demonstrated the tolerability profile we set out to achieve for ALKS 4230, along with desired lymphocyte cell expansion without corresponding Treg activation. This validates our design rationale for ALKS 4230, and we now look forward to progressing into the expansion stage to evaluate ALKS 4230 as monotherapy in select tumor types," said Craig Hopkinson, M.D., Chief Medical Officer and Senior Vice President of Medicines Development and Medical Affairs at Alkermes. "We plan to present the first efficacy data from across the ALKS 4230 development program at a medical meeting later this year, pending conference acceptance."

Selection of the recommended phase 2 dose of ALKS 4230 as monotherapy was made following the completion of five dose-escalation cohorts, spanning a dose range of 0.1 µg/kg/day to 6 µg/kg/day, in 36 patients who were refractory to prior administered therapies known to demonstrate clinical benefit. Data from the completed cohorts demonstrated dose-dependent pharmacodynamic effects on circulating natural killer (NK) cells and CD8+ T cells, and minimal and non-dose dependent effects on immunosuppressive regulatory T cells (Tregs). The newly initiated monotherapy expansion stage will assess objective efficacy measures of ALKS 4230 administered intravenously daily for five consecutive days in up to 105 patients refractory to prior administered therapies with renal cell carcinoma or melanoma, two tumor types for which high-dose IL-2 has demonstrated durable anti-tumor responses as a monotherapy treatment.1

Data from the initial four cohorts of the dose-escalation stage of ARTISTRY-1 were presented at the 2018 Society for Immunotherapy of Cancer (SITC) (Free SITC Whitepaper) Annual Meeting. Treatment with ALKS 4230 at 3 µg/kg/day resulted in a dose-dependent increase in circulating NK cells and CD8+ T cells with a near 4-fold and 2-fold expansion, respectively, and minimal, non-dose-dependent change in Tregs. Further effector-cell expansion was observed in cohort 5 at the 6 µg/kg/day dose, with minimal increase in circulating Tregs. No dose-limiting toxicities were observed in cohort 5. Fever and chills were the most common treatment-related adverse events (AEs) for ALKS 4230 across all cohorts, and the safety profile observed with ALKS 4230 was consistent with the known profile of cytokine therapy.

About ALKS 4230
ALKS 4230 is a novel, engineered fusion protein designed to selectively expand tumor-killing immune cells while avoiding the activation of immunosuppressive cells by preferentially binding to the intermediate-affinity interleukin-2 (IL-2) receptor complex. The selectivity of ALKS 4230 is designed to leverage the proven anti-tumor effects of existing IL-2 therapy while mitigating certain limitations.

About the ARTISTRY Clinical Program
ARTISTRY is an Alkermes-sponsored clinical program evaluating ALKS 4230 in patients with advanced solid tumors. ARTISTRY-1 is an ongoing phase 1/2 study in which ALKS 4230 is administered as an intravenous infusion daily for five consecutive days. ARTISTRY-1 has three distinct stages: an ongoing monotherapy dose-escalation stage, the newly initiated monotherapy expansion stage and an ongoing combination therapy stage with the PD-1 inhibitor KEYTRUDA (pembrolizumab) in patients with select advanced solid tumors.

ARTISTRY-2 is an ongoing phase 1/2 study of ALKS 4230 administered subcutaneously as monotherapy and in combination with pembrolizumab in patients with advanced solid tumors. ARTISTRY-2 is designed to explore the safety, tolerability and efficacy of ALKS 4230 administered subcutaneously and assess once-weekly and once-every-three-week dosing schedules.

Debiopharm and Ipsen extend their strategic Decapeptyl® (triptorelin) partnership for another 15 years

On June 12, 2019 Debiopharm (Debiopharm – www.debiopharm.com) and Ipsen (www.ipsen.com) reported renewal of their Decapeptyl agreement, which extends and strengthens their strategic partnership through 2034 for the development, manufacturing and distribution of Decapeptyl across Europe and certain Asian and African markets (Press release, Ipsen, JUN 12, 2019, View Source [SID1234537019]). Having established their collaboration in the 1980s, this extension represents a long-term commitment to patients, offering the benefits of Decapeptyl in the treatment of metastatic and non-metastatic patients with locally advanced prostate cancer, endometriosis, uterine fibroids, central precocious puberty and endocrine-responsive early-stage breast cancer.

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Under the renewed agreement, both parties will co-develop novel formulations and explore additional indications for other patient populations with high unmet needs.

"Our continued partnership remains critical to ensure that patients maintain access to Decapeptyl therapy for their various conditions. Furthermore, this renewed agreement represents an opportunity to refine and refocus our collaboration by further exploring our co-development capacity to potentially identify how Decapeptyl can respond to more unmet patient needs."

Thierry Mauvernay, President & Delegate of the Board Group, Debiopharm

"We are delighted to renew and extend this partnership with Debiopharm. This collaboration has been – and continues to be – a testament to our commitment to patients and our shared passion with strategic partners."

Ivana Magovčević-Liebisch, Executive Vice-President, Chief Business Officer

About Decapeptyl

Decapeptyl (triptorelin pamoate) is an agonist analogue of the natural gonadotropin-releasing hormone (GnRH), currently available in three sustained-release formulations (1, 3 and 6 months). First registered in France in 1986, triptorelin is currently marketed in more than 80 countries, being the market leader in many territories worldwide. The alliance between Debiopharm and Ipsen for Decapeptyl has successfully delivered sustained market growth with €372.6 million total sales in 2018, representing 8.1% annual growth.