Investigations • Innovation • Clinical Application

Investigations • Innovation • Clinical Application
Evolving Paradigms for Optimizing Management of Metastatic Breast Cancer Focus on Novel Mechanisms of Action and Evidence-Based Therapies for Survival Prolongation in Heavily Treated Patients with MBC Program Chair Debu Tripathy, MD Professor of Medicine USC/Norris Comprehensive Cancer Center University of Southern California Los Angeles, CA

Welcome and Program Overview
CME-certified symposium jointly sponsored by the Postgraduate Institute for Medicine and CMEducation Resources, LLC Commercial Support: Sponsored by an independent educational grant from Eisai, Inc. Faculty disclosures: Listed in program syllabus This CME activity may include discussions of off-label or unapproved uses of specific agents

Program Faculty Sara Hurvitz, MD Assistant Clinical Professor of
Sara Hurvitz, MD Assistant Clinical Professor of Medicine Director, Breast Oncology Program David Geffen School of Medicine University of California, Los Angeles Los Angeles, CA Paraskevi Giannakakou, PhD Associate Professor of Pharmacology in Medicine Weill Cornell Medical College New York, NY Program Chair Debu Tripathy, M.D. Professor of Medicine USC/Norris Comprehensive Cancer Center University of Southern California Los Angeles, CA

CME Program Agenda Chairman’s Introduction
8:30 AM — 8:45 AM Chairman’s Introduction An Overview of Current Issues and Controversies Surrounding Management of Advanced and Metastatic Breast Cancer DEBU TRIPATHY, MD —Program Chair Professor of Medicine │ USC/Norris Comprehensive Cancer Center │ University of Southern California │ Los Angeles, CA 8:45 AM — 9:15 AM A Landscape Update on Metastatic Breast Cancer (MBC)— What Works? What Doesn’t? Strategies for Optimizing Survival: An Evidence-to-Practice Roadmap for MBC Professor of Medicine │ USC/Norris Comprehensive Cancer Center │ University of Southern California │ Los Angeles, CA 9:15 AM — 9:25 AM Question and Answer Session 5

CME Program Agenda 9:25 AM — 9:50 AM Microtubules as a Target for Anticancer Drugs —Multi-Mechanistic Approaches to Mitigating Metastatic Breast Disease Paraskevi Giannakakou, PhD Associate Professor of Pharmacology in Medicine │Weill Cornell Medical College │New York, NY 9:50 AM — 10:00 AM Question and Answer Session 10:00 AM — 10:30 AM Improving Overall Survival Prolongation in MBC: The Role of Nontaxane Microtubule Dynamics inhibitors—Evidence and Implications of Recent Clinical Studies Sara Hurvitz, MD Assistant Clinical Professor of Medicine │Director, Breast Oncology Program │ David Geffen School of Medicine │University of California, Los Angeles 6

CME Program Agenda Question and Answer Session
10:30 AM — 10:40 AM Question and Answer Session 10:40 AM — 11:05 AM Case Studies in Metastatic Breast Cancer DEBU TRIPATHY, MD —Program Chair Professor of Medicine │ USC/Norris Comprehensive Cancer Center │ University of Southern California │ Los Angeles, CA 11:05 AM — 11:15 AM 7

Evolving Paradigms and Optimizing Management of
Metastatic Breast Cancer An Overview of Current Issues and Controversies Surrounding Management of Advanced and Metastatic Breast Cancer Program Chair Debu Tripathy, MD Professor of Medicine USC/Norris Comprehensive Cancer Center University of Southern California Los Angeles, CA

Learning Objectives Understand the treatment options for metastatic breast cancer as first-line therapy and beyond Understand how breast cancer subtype influences treatment options and selection Understand the side effect profile associated with different agents

What are the Therapeutic Goals?
Survival prolongation Symptom palliation, delay, or preemption Response (surrogate for symptom relief) PFS, TTP, TTF (surrogates for symptom delay) Quality of life (QOL) instruments Achieve favorable tradeoff profile (ie, efficacy vs. toxicity) No consistent relationship between RR/PFS and QOL No clinically useful tool to measure QOL or tradeoffs Subjective assessment often made by clinicians based upon objective data from trials (RR, PFS, OS, toxicity) subjective data for individual patient (performance status)

Therapeutic Goals Live longer Live better Prolong survival
Symptom palliation or delay Favorable tradeoff profile Toxicity Convenience Cost Simple Objective Complex Subjective

Survival and FDA Approval of Oncology Drugs for Metastatic Breast Cancer
2003 (Johnson, Williams, Pazdur. J Clin Oncol 2003) “There is a common misperception that … FDA … requires a survival improvement for approval of oncology drug marketing applications.”” “Regular …approval …requires substantial evidence of efficacy…” “…prolongation of life, a better life, or an established surrogate for at least one of these.” 2008 (Cortesar. Proc ASCO 2008) “…survival is both a safety and efficacy parameter… “PFS may be an acceptable endpoint if measured properly and is of sufficient magnitude. “ “Survival also should be measured to ensure that any new therapy does not lead to a decrement.”

What are the Therapeutic Options?
Modality Selection Improvement in RR PFS OS Chemotherapy1,2 ER/PR-negative, visceral mets, failed endocrine therapy  Endocrine1,2 ER and/or PR-positive Trastuzumab, lapatinib1,2 Her2/neu-positive Bevacizumab3,4,5 Her2/neu-negative, first-line therapy  RANKL inibitors, bisphosphonates1,2 Osteolytic bone mets 1. National Cancer Institute. Breast Cancer Treatment (PDQ®) NCCN Clinical Practice guidelines in Oncology. Breast Cancer V Miller et al. N Engl J Med. 2007;357: Miles et al. Presented at the San Antonio Breast Cancer Symposium Abstract Robert N, et al. J Clin Oncol. 2009;27(15S). Abstract 1005. 13

What are the Toxicities Associated with Therapeutic Options?
Agent Non-hematologic toxicities Endocrine therapy Hot flushes, gynecologic symptoms Bevacizumab Hypertension, thromboembolic disease Trastuzumab Cardiac dysfunction Lapatinib Diarrhea Cytotoxic agents Anthracycllnes Paclitaxel Docetaxel Ixabepilone Eribulin Vinorelbine Capecitabine Gemicitabine Cardiomyopathy Neuropathy Fluid retention Obstipation, nueropathy Hand-foot syndrome Fever, dyspnea

Does Cytotoxic Chemotherapy Improve Survival?
Clinical trials Hundreds of trials, few show OS benefit Few that show benefit - play of chance? More positive trials in second or greater line setting Population-based studies Suggests that addition of modestly effective cytotoxic agents have produced incremental improvements in OS 1.0 0.8 0.6 0.4 0.2 0.0 Overall Survival Years Chia et al. Cancer 2007; 110:

Probability of Detecting Significant Difference in OS as a Function of Median OS Post-Progression (SPP) Median SPP (months) Probability of OS Statistical Significance (%) 80% power for PFS 85% power for PFS 90% power for PFS 100 80 60 40 20 Broglio, K. R. et al. J. Natl. Cancer Inst. 2009

Does Chemotherapy Palliate Symptoms ?
90 Complete/partial response 80 Stable disease Progressive disease 70 60 50 40 30 20 10 Pain CRF Pain QoL Shortness of breath CRF Shortness of breath QoL Mood CRF Worry QoL Depression QoL Geels P, et al. J Clin Oncol 2000;18:

Is Chemotherapy more Effective than Endocrine Therapy in ER-Positive Disease?
Methods Meta-analysis Randomized trials comparing chemotherapy alone with endocrine therapy alone in metastatic breast cancer Results (8 trials, N=817) No difference in OS: HR 0.94 (95%CI ,P=0.5) (heterogeneity P = 0.1) Higher RR for chemo OR 1.25 ( , P = 0.04) ((heterogeneity P= ) Two largest trials showed trends in opposite directions Toxicity Increased toxicity with chemotherapy (nausea, vomiting and alopecia) 3 of 7 mentioned aspects of QOL, with differing results - only one trial formally measured QOL, concluding that it was better with chemotherapy Authors' conclusions “In women with metastatic breast cancer and where hormone receptors are present, a policy of treating first with endocrine therapy rather than chemotherapy is recommended except in the presence of rapidly progressive disease.” Reference is available online at: et al. The Cochrane Database of Syst Rev 2003;(2):CD 18

What is the role for targeted agent as first line therapy or beyond?
Evolving Paradigms and Optimizing Management of Metastatic Breast Cancer What is the role for targeted agent as first line therapy or beyond? 19

Treatment Effect of Trastuzumab as First Line Therapy in HER2-Positive MBC
Chemotherapy alone Chemotherapy plus trastuzumab P< .0001 P = .0002 P< .001 P< .001 1. Slamon et al. N Engl J Med. 2001;344(11): Marty et al. J Clin Oncol. 2005;23(19):

Treatment Effect of Trastuzumab as First-Line Therapy in HER2-Positive MBC
Chemotherapy alone Chemotherapy plus trastuzumab P = .0325 P = .046 1. Slamon et al. N Engl J Med. 2001;344(11): Marty et al. J Clin Oncol. 2005;23(19):

Treatment Effect of Bevacizumab as First-line Therapy for MBC (Mainly HER2-Negative)
Chemotherapy alone/plus placebo Chemotherapy plus bevacizumab Response Rate P< .0001 † P = .0054 P< .0001 † * P = .0097 † E21001 AVADO2 RIBBON-13 * Chemotherapy alone vs chemotherapy plus 10 mg/kg bevacizumab † Chemotherapy plus placebo vs chemotherapy plus 15 mg/kg bevacizumab 1. Miller et al. N Engl J Med. 2001;357(26): Miles et al. J Clin Oncol May 24 [Epub ahead of Print]. 3. Robert et al. J Clin Oncol. 2009;27(15S). Abstract 1005.

Treatment Effect of Bevacizumab as First-line Therapy for MBC (Mainly HER2-Negative)
Chemotherapy alone/plus placebo Chemotherapy plus bevacizumab Progression Free Survival P< .001 * P = .006 P = .0002 P = .0001 † † † E21001 AVADO2 RIBBON-13 No significant difference in median OS * Chemotherapy alone vs chemotherapy plus 10 mg/kg bevacizumab † Chemotherapy plus placebo vs chemotherapy plus 15 mg/kg bevacizumab 1. Miller et al. N Engl J Med. 2001;357(26): Miles et al. J Clin Oncol May 24 [Epub ahead of Print]. 3. Robert et al. J Clin Oncol. 2009;27(15S). Abstract 1005.

Bevacizumab: Meta-analysis
No bevacizumab Bevacizumab No. 1008 1439 ORR 32% 49% P<0.05 Median PFS 6.7 mo 9.2 mo. HR 0.64, p<0.0001 Median OS 26.4 mo 26.7 mo. P=0.56 1-year survival 77% 82% P<0.003 O’Shaughnessy et al. JCO 2010; 28; 152, abst 1005

Second or Greater Line Biologic Agents
Author & Population Experimental vs. Standard No. Median TTP/PFS (mo.) ORR OS Geyer et al. NEJM 2006 & Cameron ASCO 2007 HER2+, Trast. Resistant Lapatinib + Cap vs. Cap alone 324 HR 0.57 6.2 vs. 4.3 22% vs. 14%* HR 0.78 15.6 vs. 15.3 Brufsky et al. SABCS, 2009 HER2-, Prior chemo Bev vs. placebo Plus Chemotherapy 684 7.2 vs. 5.1 40% vs. 30% HR 0.90 18.0 vs. 16.1 O’Shaughnessy et al ASCO 2009 & SABSC 2010 Triple Negative Carbo/gem +/- BSI-201 123 HR 0.34 6.9 vs. 3.3 48% vs. 16% HR 0.50 12.2 vs. 7.7 * Statistically significant difference

Metastatic Breast Cancer Is combination cytotoxic therapy more effective than single agent therapy as first-line therapy or beyond? 26

Single Agent vs Combination Chemotherapy for Metastatic Breast Cancer
Methods Randomized trials single agent vs. combination chemotherapy Results - 43 eligible trials (N=9742 randomized) Overall survival HR 0.88 (95% CI= , P <0.0001) & no heterogeneity Results are similar if analysis is limited to first-line chemotherapy Time to disease progression HR (95% CI= , P < ) (heterogeneity (P = 0.002) Response rate Odds ratio 1.29 (95% CI= , P <0.0001) (heterogeneity P < ) – due to varying efficacy of the comparators Toxicity More neutropenia, alopecia, nausea/vomiting with combinations The survival benefit seen in older studies not evident in more contemporary studies with availability of numerous agents and targeted therapies Reference is available online at: Carrick S, et al. The Cochrane Database of Syst Rev 2009;(2):CD 27

First Line Cytotoxic Therapy for Metastatic Disease: Prior Adjuvant Anthracycline
Selected Trials Author Combination vs. Comparator Median TTP/PFS (months) ORR OS Albain et al JCO 2008 Gem + Paclitaxel vs. Paclitaxel HR 0.70 6.1 vs. 4.2* (TTP) 41% vs. 26%* HR 0.78 18.6 vs. 15.8* Sparano et al JCO 2009 PLD + Docetaxel vs. Docetaxel HR 0.65 9.8 vs. 7.0* 35% HR 1.01 20.5 vs. 20.6 * Statistically significant difference PLD – pegylated liposomal doxorubicin

Experimental vs. Standard
Second or Greater Line Cytotoxic Therapy: Prior Anthracycline/Taxane Exposure Selected Trials Author Experimental vs. Standard No. Median TTP/PFS (mo.) ORR OS O’Shaughnessy et al JCO 2002 Cap+ Docetaxel vs. Docetaxel 511 HR 0.65 6.1 vs. 4.2* (TTP) 42% vs. 30%* 0.78 14.5 vs. 11.5* Thomas et al JCO 2007 Ixabepilone+Cap vs. Capecitabine 752 HR 0.75 5.8 vs. 4.2* (PFS) 35% vs. 14%* 12.9 vs. 11.1 Sparano et al JCO 2010 1221 HR 0.79 6.2 vs. 4.2* 43% vs. 29%* HR 0.9 16.4 vs. 15.6 Twelves et al ACO 2010 Eribulin vs. Physician’s Choice 762 HR 0.87 3.7 vs. 2.2 12% vs.7%* 0.81 13.1 vs. 10.7* * Statistically significant difference

Combination Chemotherapy Versus Sequential Single-agent Chemotherapy
Both combinations of cytotoxic chemotherapy and single-agent chemotherapy are reasonable options as first-line systemic therapy NCCN guidelines & ESO-mBC task force, sequential single-agent chemotherapy should be the preferred choice In absence of rapid clinical progression Life-threatening visceral metastases or Need for rapid symptom and/or disease control Guidelines did not address use of biologics in combinations Cardoso et al. J Natl Cancer Inst. 2009;101(17):

Conclusions: Systemic Therapy for MBC
Treatment regimen should be individualized Identify and prioritize therapeutic goals Select least toxic option required to achieve therapeutic goals Decision based upon multiple factors including Disease-specific factors (Her2/neu, ER/PR status) ER/PR-positive: endocrine therapy Her2/neu-positive: anti-HER2 therapy Patient-specific factors Prior treatment history Performance status Age Co-morbidities (eg, cardiac disease) Patient preference (eg, avoid alopecia) 31

Conclusions: General Principles in Selecting Therapy
Cytotoxic therapy Usually reserved for ER-negative disease, or ER-positive disease resistant to endocrine therapy or associated with substantial symptom burden Use single agents rather than combinations whenever feasible Combination cytotoxic therapy may be indicated in selected circumstances Breast cancer subtypes ER-Positive Disease Use endocrine therapy (ET) as first line therapy whenever feasible Switch to alternative ET if prolonged benefit from first or second/greater lines of ET HER2-Positive Disease When chemotherapy indicated, always used in combination with anti-HER2 directed therapy Triple-negative disease or resistant to endocrine therapy Cytototoxic therapy

Metastatic Breast Cancer A Landscape Update on Metastatic Breast Cancer (MBC):— What Works? What Doesn’t? Strategies for Optimizing Survival: An Evidence-to-Practice Roadmap for MBC Program Chair Debu Tripathy, M.D. Professor of Medicine USC/Norris Comprehensive Cancer Center University of Southern California Los Angeles, CA

Principles of Systemic Therapy for Advanced Metastatic Breast Cancer
Evaluation includes careful history and examination with staging scans, biopsy and biomarkers (if possible) For ER or PR+, trial of salvage hormonal therapy Chemotherapy for hormone-insensitive or aggressive presentations Doublets of chemotherapy – higher response and time to progression , marginal effects on survival, ↑ toxicities Addition of HER2 blockade to hormonal or chemotherapy (trastuzumab, lapatinib) for HER2+ disease Addition of anti-angiogenic therapy improves time to progression, but not survival Newer targeted therapies in appropriate subgroups and combinations being actively studied

Key Issues Surrounding Chemotherapy for Advanced Breast Cancer
Are there specific chemotherapy agents that are superior in first or subsequent lines of therapy? Should chemotherapy breaks be given in patients with stable or responsive disease? Should chemotherapy combinations be given instead of single agents? If so when should combinations be used? What is the role of schedule and dose? Can drug delivery be improved (eg. nanoparticle, liposomes, immunotoxins)? Can one predict toxicities of single or combination therapy? What is the basis for individualizing treatment choices?

Cell Cycle-Specific Activity of Cytotoxics
Vinca Alkaloids Vinorelbine Vinblastine Antimicrotubule agents Paclitaxel Docetaxel Epothilones Eribulin Cell CycleNon-Specific Agents Alkylating Agents Platinum Cyclophos-phamide Thiotepa Nitrosoureas Antibiotics Anthracycines Doxorubicin Epirubicin Mitoxantrone Podopyllotoxins Etoposide Camptothecins Irinotecan Antimetabolites 5-FU, fluoropyrimidines Gemcitabine Methotrexate

First-Line Second-Line Doxorubicin 40 - 50% 32 - 36%
Response Rates with Single-Agent Chemotherapy in Advanced Breast Cancer Pre – Year 2000 First-Line Second-Line Doxorubicin % % Epirubicin % ~28% Paclitaxel % % Docetaxel % % Capecitabine ~25% % Gemcitabine % % Vinorelbine % %

Docetaxel vs. Paclitaxel
Overall Survival Intention-to-Treat Population 1 Censored 0.8 Paclitaxel 175 mg/m2 Docetaxel 100 mg/m2 0.6 Proportion Alive 0.4 P=0.03 The analysis of the Overall Survival (in the ITT population) showed that the median overall survival was superior in the docetaxel treated patients. The difference was statistically significant. 0.2 20 40 60 80 100 Survival (Months) Jones SE, et al. J Clin Oncol 2005

Hematologic Toxicity There was more Grade 3/4 neutropenia in the patients receiving Docetaxel, and more patients receiving Docetaxel had at least one episode of febrile neutropenia (15 vs 2%). There was a trend toward more slightly more Grade 3/4 anemia and thrombocytopenia in the docetaxel treated patients. There were 3 treatment related deaths in this study in the Docetaxel arm due to infection and no such deaths in the Paclitaxel treated patients. There was one other treatment related death in this study related to a gastrointestinal bleed in a non-thrombocytopenic patient who had received Docetaxel. *For difference in grade 3 / 4 toxicities, p < 0.05 3 treatment related deaths in the docetaxel arm (due to infection) and 1 non-treatment related death (GI bleed); no treatment related deaths with paclitaxel Jones SE, et al. J Clin Oncol 2005

Maintenance Therapy for Advanced Hormonally Sensitive Breast Cancer
“Induction” Significant visceral involvement Significant symptoms Likely clinical sequelae with small degree of progression Chemotherapy For HER2+, Chemotherapy + HER2-directed therapy Maintenance Therapy Prior response/stability to hormonal therapy Low disease burden, minimal visceral involvement Low level of symptoms Hormonal therapy For HER2+, hormonal therapy plus HER2-directed therapy

Trials Examining Continuous vs. Interrupted/Fixed Therapy
Study Treatment Schedules N Med TTP (mo) p Med OS (mo) Coates A et al NEJM 1987 AC/CMF until PD 305 6 0.02 10.7 0.19 AC x 3 cycles 4 9.4 Harris AL et al Lancet 1990 Mitoxantrone until PD 43 5.5 NS 11 Mitoxantrone x 4 6.5 12 Muss H et al NEJM 1991 FAC x 6 → CMF x 12 145 <0.001 21.1 0.67 FAC x 6 3.2 19.6 Ejlertsen B Eur J Ca 1993 FEC + TAM x 18 254 14 < .003 23 0.03 FEC + TAM x 6 10 18 Gregory R et al Eur J Ca 1997 VAC/VEC x 6 → MMM x 6 100 0.01 13.0 0.3 VAC/VEC/MMM x 6 7 10.5 Falkson G et al JCO 1998 A x 6 → CMFPTH x 8 195 18.7 <0.0001 32.2 0.74 A x 6 7.8 28.7 Nooij M et al Eur J Ca 2003 CMF until PD 196 5.2 14.0 0.77 CMF x 6 3.5 14.4

Trials Examining Continuous vs. Interrupted/Fixed Therapy
Contemporary Regimens Study Treatment Schedules N Med TTP (mo) p Med OS (mo) Gennari A et al JCO 2006 E/A + P x 6-8 → P x 8 215 8.0* 0.817 26.0 0.547 E/A + P x 6-8 9.0* 29.0 Alba E ASCO 2007 A →T x 6 → PLD 155 13.2 8.4* 0.006* 0.005 A →T x 6 10.2 5.1* * From time of randomization to maintenance arm E = epirubicin; A = doxorubicin; P = paclitaxel; T = docetaxel; PLD = pegylated liposomal doxorubicin

Single vs. Combination vs. Sequential Chemotherapy
Doxorubicin + Paclitaxel 36% % % QOL Median TTF Response Paclitaxel Doxorubicin 6 mos mos mos. = = = 19 mos mos mos. Median Survival Crossover Responses: A T = 22% = 20% NS Sledge G et al. J Clin Oncol 2003

Finnish Randomized Comparison of Single Agents vs Combinations As First- and Second-Line Chemotherapy for Metastatic Breast Cancer First -Line 20 mg/m2 weekly E E E E E E E E E E E E E C 500 mg/m2 C C C C E 60 mg/m2 E E E E F 500 mg/m2 F F F F Weeks Second-Line MC 8 mg/m2 MC MC MC MC 8 mg/m2 MC MC MC V 6 mg/m2 V V V Weeks Joensuu H et al. J Clin Oncol 1998

Single Agents vs Combinations as 1st- and 2nd-Line Chemotherapy for MBC
Finnish Breast Cancer Group Study Regimen RR Response Duration CEF % mos E % mos MV % M % No significant difference in overall TTP for E M vs CEF MV (P = 0.28) No difference in overall survival for E M vs CEF MV (P = 0.96) or survival calculated from second-line Rx (P = 0.56) Less toxicity and better QOL with single agents Joensuu H et al. J Clin Oncol 1998

Combination vs. Monotherapy for MBC: No Survival Benefit (n=2,490)
APPH-1 ONLABEL Abraxane Slides Combination vs. Monotherapy for MBC: No Survival Benefit (n=2,490) 3/27/2017 9:33 PM Dox + Paclitaxel = Single Agents Sequentially (Sledge, J Clin Oncol 2003) FEC then MV = Epirubicin then Mitomycin C (Joensuu, J Clin Oncol 1998) Taxotere > Mitomycin C + Vinblastine (Nabholtz, J Clin Oncol 1999) Taxol > CMFP (Bishop, J Clin Oncol 1998) FEC = Mitoxantrone (Heidemann, Ann Oncol 2002) Dox + Vinorelbine = Doxorubicin (Norris, J Clin Oncol 2000) Epirubicin + Vinorelbine = Epirubicin In fact, there exists a high level of evidence-based medicine to support the approach of single agent chemotherapy for metastatic breast cancer. The 6 randomized trials listed here represent a larger number of patients than in the Fossati meta-analysis, and none showed a survival advantage for the use of combinations over single agents. In the interest of focusing on the 4 trials at hand, I will not examine these trials in detail here. Suffice it to say that in most of these trials, there were neither higher response rates nor longer time to progression for combinations versus the single agent strategy. Toxicities were generally greater for combination therapy, and where assessed, QOL for combination therapy was either equal to or inferior to that experienced during monotherapy. Ejlertsen, J Clin Oncol 2004

Gemcitabine + Paclitaxel (n=267)
Single vs Combination Chemotherapy: Recent Positive Trials in MBC - Overall Survival Capecitabine/docetaxel Docetaxel Events Median (CI) 100% 72% 14.5 (12.3–16.3) 79% (9.8–12.7) Survival Gemcitabine + Paclitaxel (n=267) Paclitaxel (n=262) 12 mo 70.7% 60.9% 18 mo 50.7% 41.9% Hazard ratio = 0.775 Log-rank p=0.0126 100% 15.8 18.5 Log rank P=0.018 HR 0.78 ( ) Incidence of febrile neutropenia, and grade ¾ anemia, thrombocytopenia, and fatigue were all higher with the paclitaxel-gemcitabine doublet, but uncommon Interestingly, qoL analysis showed superiority in GT. Conclusion: superiority of combination vs. sequential is not yet proven, yet the two recent studies of CT and GT suggest favoring combination in terms of OS. 11.5 14.5 10 20 Months 12 24 Months O'Shaughnessy J et al J Clin Oncol 2002 Albain K et al J Clin Oncol 2009

Capecitabine plus Docetaxel: Most Common (>5%) Grade 3/4 Treatment-Related Toxicities
Capecitabine/docetaxel (n=251) Grade 3 Grade 4 30 25 20 15 10 5 Docetaxel (n=255) Patients (%) 17. Xeloda® plus docetaxel: most common (>5%) grade 3/4 treatment- related toxicities The spectrum of grade 3/4 toxicities was similar to the profile described for all grades in both treatment arms.1 Overall, 78% of patients in the combination arm and 64% of patients in the monotherapy arm experienced grade 3/4 treatment-related adverse events. However, a smaller proportion of patients receiving the combination regimen experienced life threatening (grade 4) treatment-related adverse events (25% vs 30% with the monotherapy regimen). The number of treatment-related hospitalisations was similar in the two treatment groups (92 vs 96 patients in the combination and monotherapy arms, respectively). Of the patients who required hospitalisation in the combination arm, only one was hospitalised owing to a primary diagnosis of hand-foot syndrome. More patients in the monotherapy arm were hospitalised for neutropenia and neutropenic complications than in the combination arm. 1. O’Shaughnessy J, Vukelja S, Moiseyenko V et al. Results of a large phase III trial of Xeloda®/Taxotere® combination therapy vs Taxotere® monotherapy in metastatic breast cancer (MBC) patients. Poster presented at the San Antonio Breast Cancer Symposium, San Antonio, USA, 2000 (Abstract 381). Hand-foot syndrome Diarrhea Stomatitis Nausea Fatigue/ asthenia Neutropenic fever O'Shaughnessy J, et al J Clin Onocol 2002

(combination:single agent)
Combination vs. Single-Agent Therapy for MBC: Meta-Analysis of Randomized Trials Regimens Hazard ratio of death (combination:single agent) Combination Single agent AV A A + DBD A A + MMC A VAC A CF + P ± V A A + ETO A AV + MMC A E + VDS E FEC 75 E FEC 50 E Subtotal (deaths/patients) 619/738 649/747 0.87 (0.78–0.97) CMF + VBL C CMF PAM CMFV + P F CF + P ± V CCNU CF + P ± V I Subtotal (deaths/patients) 206/252 225/249 0.70 (0.59–0.84) Total (deaths/patients) 825/990 874/996 0.82 (0.75–0.90) Combination better Single agent better Efficacy: c (p= ) Fossati R et al. J Clin Oncol 1998

APPH-1 ONLABEL Abraxane Slides
3/27/2017 9:33 PM Paclitaxel: Dose/Schedule Comparison CALGB 9840 (n=171; HER2 unknown) q3wP+T q1wP+T (n=406; HER2 known) H E R 2 (+) (-) q3w P q1w P The first 171 patients who entered the initial phase of this trial were not required to have known tumoral HER2 status, nor baseline assessment of left ventricular function. By design, the first 116 patients received paclitaxel at 100 mg/m2 for the first 6 infusions, then continued at 80 mg/m2. After the integration of trastuzumab into the trial design, known HER2 status was required for study entry, and baseline LVEF had to exceed 45%. Again (animate), patients with HER2 positive metastatic breast cancer, defined as a 3+ score by immunohistochemistry or 2+ by IHC with evidence of HER2 gene amplification by fluorescent in situ hybridization testing, were randomized to receive (point) weekly paclitaxel plus trastuzumab or standard paclitaxel plus trastuzumab, and patients whose tumors tested negative for HER2 were randomized for trastuzumab or not, as well as for paclitaxel schedule. *first 116 pts at 100 mg/m2/wk x 6, then all pts 80 mg/m2 q wk = paclitaxel 80 mg/m2* qw vs 175 mg/m2 q 3w = trastuzumab 4mg/kg load, 2 mg/kg/w Seidman A, et al. J Clin Oncol 2008

APPH-1 ONLABEL Abraxane Slides
Paclitaxel: Dose/Schedule Comparison CALGB 9840 3/27/2017 9:33 PM The first 171 patients who entered the initial phase of this trial were not required to have known tumoral HER2 status, nor baseline assessment of left ventricular function. By design, the first 116 patients received paclitaxel at 100 mg/m2 for the first 6 infusions, then continued at 80 mg/m2. After the integration of trastuzumab into the trial design, known HER2 status was required for study entry, and baseline LVEF had to exceed 45%. Again (animate), patients with HER2 positive metastatic breast cancer, defined as a 3+ score by immunohistochemistry or 2+ by IHC with evidence of HER2 gene amplification by fluorescent in situ hybridization testing, were randomized to receive (point) weekly paclitaxel plus trastuzumab or standard paclitaxel plus trastuzumab, and patients whose tumors tested negative for HER2 were randomized for trastuzumab or not, as well as for paclitaxel schedule. Seidman A, et al. J Clin Oncol 2008

Pegylated Liposomal Doxorubicin (PLD)
Prolonged half life (>55 hours) Pegylation reduced uptake by reticuloendothelial system Preferential tumor penetration Compromised vasculature in tumor tissue Reduced volume of distribution Limited exposure to normal tissue, e.g. heart. Pegylated liposomal doxorubicin, which I will refer to as PLD, is encapsulated by a bilayer liposome membrane, and by polyethylene glycol, which is anchored in the bilipid layer. These changes contributed to the long half of the drug of over 55 hours, which is due to reduced uptake by the reticuloendothelial system. This also results in preferential tumor penetration at sites of disrupted vascular channels which characterize tumors. This also resluts in reduced volume of disbtibution, there limiting exposure to normal tissues, such as the heart. Gabizon A et al. Clin Pharmacokinet 2003

Phase III trial: Pegylated liposomal doxorubicin (PLD) plus Docetaxel vs. Docetaxel
Alone in Advanced Breast Cancer PLD (30 mg/m2) + Docetaxel (60 mg/m2) day 1 every 21 days Randomi ze Eligibility: - Advanced breast cancer Relapsed ≥1 year following neo/adjuvant anthracyclines (≥180 and ≤360 mg/m2) N=378 Docetaxel (75 mg/m2) day 1 every 21 days N=373 N=751 Primary endpoint: TTP Secondary endpoints: OS, ORR, overall safety, cardiac safety Sparano J et al. JCO 2009 53

PLD plus Docetaxel vs. Docetaxel Alone in Advanced Breast Cancer
PLD + Docetaxel HR P-Value Median TTP 7.0 months 9.8 months 0.65 ORR 26% 35% - .0085 Median OS* 20.7 months 20.6 months 1.03 .75 Select Grade 3/4 Adverse Events Docetaxel (N=373) PLD + Docetaxel (N=377) Neutropenia 59% 57% Febrile Neutropenia 6% 7% Hand-Foot syndrome 24%* Stomatitis 1% 11% * 20% patients discontinued due to HFS generally managed by dose modification Grade ≥2 cardiac AEs: similar for Doc vs. Doc + PLD (4% vs. 5%) Sparano J et al. JCO 2009 54

Randomized nab-Paclitaxel Trial Design: CA012
APPH-1 Slides Albumin-bound paclitaxel 260 mg/m2 iv over 30 min q3w No standard premedication MBC with prior anthracycline and no prior taxane for MBC Randomisation (1:1) n = 460 Paclitaxel 175 mg/m2 iv over 3 hrs q3w Standard premedication with dexamethasone and antihistamines Gradishar et al. J Clin Oncol 2005 56 56

Randomized nab-Paclitaxel Trial Response Rates
APPH-1 Slides P = 0.001 P = 0.029 P = 0.006 P = 0.002 P = 0.002 42.3% 33.2% 34.1% 33.5% 27.0% 26.5% ORR (± 95% CI) 18.7% 18.3% 18.7% 13.2% Albumin-bound paclitaxel Paclitaxel n 229 225 97 89 132 136 176 175 176 182 Gradishar et al. J Clin Oncol 2005 57 57

Nab-Paclitaxel: Different Dose/Schedules vs. Docetaxel
Response Rates 300 mg/m2 q3w n = 76 100 mg/m2 qw 3/4 n = 76 150 mg/m2 qw 3/4 n = 74 100 mg/m2 q3w n = 74 Nab-Paclitaxel Docetaxel Gradishar W et al. JCO 2009 58

Capecitabine ± Ixabepilone in Taxane and Anthracyline-Resistant MBC
% Response Investigator Independent Radiology Review Ixabepilone + Capecitabine (N=375) Capecitabine (N=377) ORR (CR + PR) 42 23 35 14 P < P <0.0001 Stable Disease 36 38 41 46 Median Progression-Free Survival: by IRR (95% CI) Ixabepilone + capecitabine: 5.8 months ( ) Capecitabine: 4.2 months ( ) Hazard ratio: 0.75 ( ); P=0.0003 Vahdat L et al. JCO 2007

Progression-free Survival by Independent Radiologic Review
1.0 0.8 0.6 0.4 0.2 Median 95% CI Ixabepilone + Capecitabine 5.8 mo (5.5–7.0) Capecitabine 4.2 mo (3.8–4.5) HR: 0.75 (0.64–0.88) Proportion Progression Free P=0.0003 Looking at the primary endpoint: progression free survival in this heavily pretreated population with a large disease burder, As you can see, PFS was statistically significantly improved with the combination of ixa bepilone and capecitabine over capecitabine alone. The median PFS for the combination was 5.8 months and for the capecitabine arm 4.2 months.The hazards ratio for progression was 0.75 and the p value was Months Vahdat L et al. JCO 2007

Gene Expression Profiling Reveals Distinct Clusters
HER2+ subtype % of tumors 2. prognostic/predictive 2. proliferation 3. two types (ER -/+) Basal subtype % of tumors 2. ER/PR/HER2-negative 3. very proliferative 4. EGFR, c-kit, c-myc + 5. includes BRCA1 mutations Luminal A and B (ER+) 1. continuum 2. prognostic/predictive 3. ER-GATA3-HNF3a-XBP1 4. proliferation (mutant p53) 5. cyclin D1 and BCL2 + Ki-67, STK6, Survivin, Cyclin B1 and MYBL2 Sorlie T et al. PNAS 2003

p <0.0001 p <0.001 Sorlie T et al. PNAS 2003

Where are We Today with Chemotherpy for Advanced Breast Cancer ?
No clear single agent stands out as superior, but certain comparisons have been noted First line (eg. docetaxel > paclitaxel) Late line (eg. eribulin > several single agents after 2 or more chemotherapy regimens for MBC) Combinations are superior for response and TTP, so may be indicated for symptoms or high visceral burden Dose and schedule matter, particularly for taxanes Certain combinations may be synergistic in preclinical models, but difficult to prove in the clinic Molecular diagnostics and pharmacogenomics may point the way to individualizing chemotherapy for efficacy and toxicity

Metastatic Breast Cancer Microtubules as a Target for Anticancer Drugs —Multi-Mechanistic Approaches to Mitigating Metastatic Breast Disease The Role of Nontaxane Microtubule Dynamics Inhibitors – Evidence and Implications of Recent Clinical Studies Paraskevi Giannakakou, PhD Associate Professor of Pharmacology in Medicine │Weill Cornell Medical College │New York, NY

Improving Overall Survival in Metastatic Breast Cancer
Evolving Paradigms and Optimizing Management of Metastatic Breast Cancer Improving Overall Survival in Metastatic Breast Cancer The Role of Nontaxane Microtubule Dynamics Inhibitors – Evidence and Implications of Recent Clinical Studies Sara Hurvitz, MD Assistant Clinical Professor of Medicine Director, Breast Oncology Program David Geffen School of Medicine University of California, Los Angeles Los Angeles, CA

Microtubule Targeting Agents
Taxanes Docetaxel, paclitaxel, nab-paclitaxel Vinca alkaloids Vinorelbine, vinflunine Epothilones Ixabepilone, KOS 862 (EPO D), ZK-EPO, patupilone Halichondrin B analogue Eribulin (E7389)

Microtubules Key component of cell cytoskeleton made of dynamic filamentous protein polymers arranged in specific formation essential to cell division Mitosis (mitotic spindle) Chemotaxis/locomotion Intracellular transport Secretory processes Receptor anchorage Receptor signaling

Mitotic spindle formation blocked
Mechanisms of action of microtubule-targeted agents Vinca alkaloids Taxanes/Epothilones Destabilizers Stabilizers This slide summarizes the two classes into which the currently available microtubule-targeting drugs may be categorized according to their effect at high concentrations. The microtubule-destabilizers, e.g., the vinca alkaloids, act to inhibit tubulin polymerization. The microtubule-stabilizers, e.g., the taxanes and epothilones, enhance tubulin polymerization. Agents that disrupt the process of microtubule polymerization and depolymerization cause cell cycle arrest, resulting in the induction of apoptosis. Paclitaxel binds in a cavity formed by beta tubulin  Polymerization  Polymerization Mitotic spindle formation blocked MT Bundling Multipolar spindles Graphic courtesy of Harold J. Burstein, MD, PhD. 68

Sorangium cellulosum Myxobacteria
Secondary metabolites (epothilones/fungicides) Epothilones are Natural macrolides produced by myxobacterium Sorangium cellulosum; compete for tubulin binding Zambezi river

Ixabepilone (BMS ) Semisynthetic analog of epothilone B (aza-epothilone B) Molecular difference between ixabepilone and epothilone because of amine vs ester moiety Ixabepilone Epothilone B

Conclusions: Preclinical
Ixabepilone Semisynthetic analog of epothilone B Bind specifically and uniquely to beta-tubulin Tubulin polymerizing activity 2-10 x greater than paclitaxel Have activity in tumors that use MDR as a resistance mechanism Active in multiple in vivo tumor models Similar mechanism of action (G2/M arrest, Bax conformational change) Linear pharmacology Ixabepilone + other agents Synergy with capecitabine, cetuximab, trastuzumab Greater in vivo synergy with bevacizumab than paclitaxel

Ixabepilone: Preclinical Activity
Capecitabine Synergy Activity in Paclitaxel Resistance 1000 N = 8 Control Ixabepilone Capecitabine Combination 2500 250 mg/kg (MTD) 2000 10 mg/kg (MTD) Median Tumor Weight (mg) 100 Ixabepilone Paclitaxel Control 1500 Median tumor weight (mg) 10 1000 Paclitaxel Rx (36 mg/kg/inj) Ixabepilone Rx (10 mg/kg/inj) 500 (P=0.0001) 10 30 50 Days Post-Tumor Implant Pat-21 Xenograft Days post-tumor implant Trastuzumab Synergy Bevacizumab Synergy 1000 10000 750 1000 Control Bevacizumab Ixabepilone Combined Control Trastuzumab Ixabepilone Combined 500 Median Tumor Weight (mg) 100 Median tumor weight (mg) 250 10 Rx Bevacizumab IP 4 mg/kg Ixabepilone IV 1 20 40 60 15 35 55 75 Days Post-Tumor Implant L2987 Human Lung Carcinoma Days Post-Tumor Implant HER2 receptor positive KPL4 Human breast Carcinoma Xenografts Data on file. Bristol Myers Squibb Company; Princeton, NJ

Ixabepilone in Metastatic Breast Cancer: Summary of Single-Agent Phase II Trials
Roche H et al. J Clin Oncol ;23: ; Denduluri N et al. J Clin Oncol. 2007;23: ; Low et al. J Clin Oncol 2005;23:2726–2734; Thomas E et al. J Clin Oncol. 2007;23:

Phase II Study 081: Ixabepilone in Triple Refractory MBC
[Perez 2007/2/ 1/3 and 5] Prior therapy with anthracycline, taxane, and capecitabine (N=126) Ixabepilone 40 mg/m2 IV q3w1 PD or unacceptable toxicity Max 18 cycles [Ixa PI/27/1] [Ixa PI/28-29/ Table 9] Primary end point: ORR Resistance Criteria Neoadjuvant or Adjuvant: ≤ 6 months of last dose Metastatic: ≤ 8 weeks of last dose Progression during or after discontinuation of trastuzumab in HER2+ patients Perez E, et al. J Clin Oncol ;23: 1. IXEMPRA® (ixabepilone) [package insert]. Princeton, NJ; Bristol-Myers Squibb Company; 2007. 2. Perez et al. J Clin Oncol E-pub ahead of print.

Phase II Study 081: Ixabepilone in Triple Refractory MBC
Characteristic Patients, no. (%) (N=126) Median age (min-max) in years 51 (30–78) Visceral disease (liver and/or lung) 108 (86) No. of disease sites: 3–4 ≥5 62 (49) 19 (15) ER-, PR-, HER2- 42 (33) Prior neoadjuvant/adjuvant chemotherapy 95 (75) No. of prior chemotherapy regimens for metastatic disease 1 2 3 15 (12) 51 (40) 60 (48) No. of prior taxane-containing regimen Any ≥2 ≥3 126 (100) 38 (30) 7 (6) Perez E, et al. J Clin Oncol ;23:

Phase II Study 081: Efficacy
Outcome Response-Evaluable (n=113) Tumor response rate, % (95% CI) IRR assessment 12.4 ( ) Investigator assessment 18.6 ( ) Median response duration, mo (95% CI) 6.0 ( ) Stable disease rate, % Median duration of stable disease, mo (95% CI) 49.6 4.5 (3.7–6.0) Treated Patients (n=126) Median PFS, mo (95% CI) 3.2 ( ) Median survival, mo (95% CI) 9.0 ( ) [Ixa PI/29/Table 10] IRR = independent radiology review. Perez E, et al. J Clin Oncol ;23: 1. IXEMPRA® (ixabepilone) [package insert]. Princeton, NJ; Bristol-Myers Squibb Company; 2007. 2. Perez et al. J Clin Oncol E-pub ahead of print.

Phase II Study 081: Safety Grade 3/4 Toxicity % of Patients (n=126)
Hematologic Neutropenia 54 Febrile neutropenia 2 Leukopenia 49 Anemia 8 Thrombocytopenia 7 Nonhematologic Peripheral sensory neuropathy 14 Fatigue 13 Myalgia/arthralgia Stomatitis 6 [Ixa PI/11-12/ Table 5; 14/Table 6] Perez E, et al. J Clin Oncol ;23: 1. IXEMPRA® (ixabepilone) [package insert]. Princeton, NJ; Bristol-Myers Squibb Company; 2007. 2. Perez et al. J Clin Oncol E-pub ahead of print.

Conclusions Median PFS 3.2 months Median overall survival 9 months
This is the first large prospective trial in triple therapy refractory metastatic breast cancer Ixabepilone demonstrates efficacy in patients with anthracycline-taxane and capecitabine refractory MBC Overall population Median PFS 3.2 months Median overall survival 9 months Response rate 18% (investigator assessment) Safety profile is acceptable In summary, ixabepilone represent a new choice in patients with patients with triple-therapy refractory MBC

Minimum cumulative dose
Capecitabine  Ixabepilone Study 046: Clinical Eligibility Criteria for Resistance Strict definition: patients whose tumors rapidly progressed in the adjuvant or metastatic setting after receiving both anthracyclines and taxanes [Thomas 2007b/ 6/1/1] Setting Anthracycline Taxane Metastatic ≤3 months of last dose ≤4 months of last dose Neo/adjuvant ≤6 months of last dose ≤12 months of last dose Any Minimum cumulative dose Doxorubicin: 240 mg/m2 Epirubicin: 360 mg/m2 Perez E, et al. J Clin Oncol ;23: Thomas et al. J Clin Oncol draft manuscript, 5/15/07. [Thomas 2007b]

046/048 Phase III MBC Trials: Ixabepilone and Capecitabine Combination
Pivotal trial CA Patients prospectively defined using a strict definition of resistance to previous anthracycline and taxane therapy Confirmatory trial CA Patients with metastatic disease who were pretreated with or resistant to an anthracycline and a taxane 50% met strict resistance criteria in pivotal trial

046/048 Phase III MBC Trials: Study Design
Ixabepilone (40 mg/m2 IV over 3 hr d1 q3wk) + Capecitabine (2000 mg/m2/day BID 14 days q3wk) Metastatic / locally advanced breast cancer pretreated with or resistant to taxanes and anthracyclines Capecitabine (2500 mg/m2/day BID 14 days q3wk) Hortobagyi GN et al ASCO Breast 2008

046/048 Phase III Trials: Progression Free Survival
Outcome Study 046 Study 048 Ixa + Cape N=375 Cape N=377 N=480 Median PFS, months 5.26 3.81 6.24 4.40 Hazard ratio (95.17% CI) 0.78 (0.67 – 0.91) 0.79 (0.69 – 0.90) Stratified log-rank P-value 0.0011 0.0005 Is the PFS data compelling enough to promote standard use of Ixempra in appropriate taxane- and anthracycline-refractory patients? Are there other treatments/combinations that would be preferentially used before Ixempra in these patients? Will this differ by patient sub-type? Roche et al. BCRT 2010

046/048 Phase III Trials: Objective Response Rate
Outcome Study 046* Study 048 Ixa + Cape N=375 Cape N=377 N=462 Objective response rate, % 42.1 22.5 43.3 28.8 95% CI 37.1 – 47.3 18.4 – 27.1 38.7 – 47.9 24.7 – 33.2 Best Response, N (%) Complete response 12 (3) 3 (1) 16 (3) 11 (2) Partial response 146 (39) 82 (22) 184 (40) 122 (26) Stable disease 136 (36) 144 (38) 170 (37) 182 (39) Progressive disease 51 (14) 109 (29) 57 (12) 111 (24) Unable to determine 30 (8) 39 (10) 35 (8) 36 (8) *ORR in 046 presented by investigator assessment. Roche et al. BCRT 2010

046/048 Phase III Trials: Overall Survival
Outcome Study 046 Study 048 Ixa + Cape N=375 Cape N=377 N=609 N=612 Median overall survival, months 12.9 11.1 16.4 15.6 No. of events 318 321 430 450 Hazard ratio (95.17% CI) 0.90 (0.77 – 1.05) (0.78 – 1.03) Stratified log-rank P-value 0.1936 0.1162 Roche et al. BCRT 2010

046/048 Planned Subset Analyses
Evolving Paradigms and Optimizing Management of Metastatic Breast Cancer 046/048 Planned Subset Analyses

Pooled Subgroup Analyses: Objective Response Rates
Patients With Ixa + Cape, % Cape, % Triple negative tumors 31 15 Taxane resistant tumors 39 22 Poor KPS (70-80) 35 19 Roche et al. BCRT 2010

Pooled Subgroup Analyses: Median Progression Free Survival
Patients With Ixa + Cape, months Cape, months P value Triple negative tumors 4.2 1.7 .0005 Taxane resistant tumors 5.1 3.7 .0003 Poor KPS (70-80) 4.6 3.1 .0007 Roche et al. BCRT 2010

046/048 Phase III Trials: Summary
Ixabepilone + capecitabine demonstrated clinically meaningful efficacy (increase in PFS and ORR) in a large heavily pretreated patient population (~2000) with limited treatment options The difference in median overall survival favored the combination: this difference did not reach statistical significance Ixabepilone plus capecitabine treatment showed consistent clinical benefit in difficult to treat sub-populations, including triple receptor MBC Study 048 reinforced the manageable safety profile of ixabepilone Similar profile as study 046 Low frequency of toxicity related deaths (<1%) in both arms Roche et al. BCRT 2010

Metastatic Breast Cancer Halichondrin B Analogue (E7389) after Anthracyclines, Taxanes and Capecitabine:

Eribulin (E7389): Mechanism of Action
Microtubule dynamics Polymerize De-polymerize E7389-induced formation of tubulin aggregates No drug µM E µM E7389 M.A. Jordan et al, Mol Cancer Ther 4:1086, 2005 Paclitaxel Eribulin Inhibits Microtubule Assembly Microtubule stabilization Non-productive aggregates

Eribulin: Tubulin-based Antimitotic Mechanism
G2/M cycle blocks Inhibition of tubulin polymerization in vitro 0 μM 1.5 μM 3 μM 5 μM 7.5 μM 15 μM U937 cells, 100 nM Disruption of mitotic spindles (DAPI/β-tubulin) Control Eribulin DU 145 cells, 20 h Towle et al., Cancer Research, 61: , 2001 Eisai Confidential

Eribulin: Preclinical Activity Across a Range of Models
Human tumor xenografts ( mg/kg) MDA-MB-435 Human Breast Cancer MWFx4, i.v. 500 1000 1500 14 28 42 56 70 Control ER mg/kg ER mg/kg Paclitaxel 20 mg/kg Average tumor volumes (µl) Day COLO 205 Human Colon Cancer MWFx4, i.p. OVCAR-3 Human Ovarian Cancer MWFx3, i.v. LOX Human Melanoma Q1Dx5[x2], i.p. Control Average tumor volume (mm3) Average tumor volume (mm3) Eribulin Average tumor volume (mm3) Average tumor volume (mm3) Towle et al., Cancer Research, 61: , 2001 LOX melanoma Towle MJ unpublished results, ERI, 2007

Summary of Eribulin Phase II Studies in Breast Cancer
Assessments 201 Study[1] (N = 103) Prior anthra & taxane Tx* Eribulin IV 1.4 mg/m2 (n = 70) over 2-5 mins on Days 1, 8, 15 q4w ORR with independent review Response duration, PFS, and OS Adverse events Eribulin IV 1.4 mg/m2 (n = 33) over 2-5 mins on Days 1, 8 q3w 211 Study[2] (N = 299) Prior anthra, taxane, & cape Tx* Eribulin IV 1.4 mg/m2 over 2-5 min on Days 1, 8 q3w *MBC patients with progression of disease ≤ 6 mos of last chemotherapy, if present, preexisting neuropathy ≤ grade 2. 1. Vahdat LT, et al. J Clin Oncol. 2009;27: Vahdat LT, et al. ASCO Abstract 1084.

ITT Efficacy Summary of Phase II Eribulin Breast Cancer Studies
Characteristic/Response 201 Trial1 (N = 103) 211 Trial2 (N = 269) Previous regimens, median n 4 Response rate,* % 13.6 9.0 Clinical benefit rate,† % 20.4 17.1 Duration of response, median mos 5.6 4.1 *CR + PR. †CR+ PR + SD for ≥ 6 mos. 1. Vahdat LT, et al. J Clin Oncol. 2009;27: Vahdat LT, et al. ASCO Abstract 1084. 94

Summary of Eribulin Phase II Study Grade 3/4 Adverse Events
201 Trial[1] (N = 103) 211 Trial[2] (N = 291) Neutropenia 64 54 Febrile neutropenia 4 6 Thrombocytopenia 2 1 Mucositis Peripheral neuropathy 5 1.Vahdat l, et al. J Clin Oncol. 2009;27: Vahdat LT, et al. ASCO Abstract 1084. 95

Additional Studies of Eribulin in Metastatic Breast Cancer
Primary endpoints: Eribulin IV on Days 1, 8, q21 Days EMBRACE Study (305)* Phase III OS ASCO 2010 Physicians choice (monotherapy) Eribulin 301 Study† Phase III PFS, OS completed Capecitabine Eribulin IV on Days 1, 8, q21 Days Development of peripheral neuropathy MBC Phase II Ixabepilone 40 mg/m2 IV q3w *Third-line breast cancer treatment. †Second-line breast cancer treatment. ClinicalTrials.gov. NCT ; NCT ; NCT 96

EMBRACE A Phase III study (EMBRACE*) of eribulin mesylate vs. treatment of physician’s choice in patients with locally recurrent or metastatic breast cancer previously treated with an anthracycline and a taxane Dr Chris Twelves Professor of Clinical Cancer Pharmacology and Oncology University of Leeds & St James’s University Hospital, Leeds, UK On behalf of the abstract co-authors and EMBRACE investigators *Eisai Metastatic Breast Cancer Study Assessing Physician's Choice Versus Eribulin (E7389)

EMBRACE Study Design Global, randomized, open-label Phase III trial (Study 305) Eribulin mesylate 1.4 mg/m2, 2-5 min IV Day 1, 8 q21 days Patients (N=762) Primary endpoint Locally recurrent or MBC 2-5 prior chemotherapies Progression ≤6 months of last chemotherapy Neuropathy ≤grade 2 ECOG ≤2 Overall survival ≥2 for advanced disease Prior anthracycline and taxane Randomization 2:1 Secondary endpoints Treatment of Physician’s Choice (TPC) Any monotherapy (chemotherapy, hormonal, biological)* or supportive care only† PFS ORR Safety Stratification: Geographical region, prior capecitabine, HER2/neu status * Approved for treatment of cancer †Or palliative treatment or radiotherapy administered according to local practice, if applicable ECOG, Eastern Cooperative Oncology Group; IV, intravenous; PFS, progression-free survival; HER2/neu, human epidermal growth factor receptor 2

EMBRACE Patient Characteristics
Eribulin (n=508) TPC (n=254) TOTAL (n=762) Median age (range) 55 (28-85) 56 (27-81) 55 (27-85) ECOG, % 1 2 Missing 43 48 8 1.6 41 50 9 42 49 Geographic region, % I North America, Western Europe, Australia II Eastern Europe, Russia, Turkey III Latin America, South Africa 64 25 11 Prior capecitabine, % Yes No 73 27 74 26 Median no. prior chemotherapy regimens (range) 4 (1-7) 4 (2-7) ITT population

EMBRACE Disease Characteristics
Eribulin (n=508) TPC (n=254) TOTAL (n=762) ER positive, % 66 67 PR positive, % 50 48 HER2/neu status, % Positive 16 Negative 73 76 74 Unknown 10 9 Triple (ER/PR/HER2) negative, % 18 21 20 No. organs involved, % ≤2 51 46 49 >2 54 Sites of disease,* % Liver 58 63 61 Lung 39 37 38 Bone 60 62 ITT population; *Clinically relevant sites of disease; ER, estrogen receptor; PR, progesterone receptor

EMBRACE: Demographic and Baseline Characteristics
Hormone Therapy Eribulin (n=508) TPC (n=254) Overall (n=762) Previous hormone therapy 430 (85%) 210 (83%) 640 (84%) Number of previous hormone regiments 1 220 (43%) 96 (38%) 316 (41%) 2 109 (21%) 65 (26%) 174 (23%) 3 60 (12%) 23 (9%) 83 (11%) >4 41 (8%) 26 (10%) 67 (9%) Cortes J, et al. The Lancet, Early Online Publication, 3 March 2011

EMBRACE TPC Treatment Received
96% of patients treated with chemotherapy Total patients = 247 % of patients n=61 n=46 n=44 n=38 n=24 n=25 n=9 No patient received best supportive care or “biological” therapies only ITT population; Taxanes: paclitaxel, docetaxel, abraxane, (ixabepilone) Anthracyclines: doxorubicin, liposomal doxorubicin, mitoxantrone 102

EMBRACE Best Overall Response
Independent review Investigator review Eribulin (n=468) TPC (n=214) ORR (CR+PR), % 12 5 13 7 p-value 0.002 0.028 SD, % 44.4 44.9 46.8 PD, % 40.6 49.1 37.6 45.3 NE, % 2.6 1.4 2.4 2.3 Clinical benefit rate (CR + PR + SD ≥6 months),% 22.6 16.8 27.8 20.1 Response evaluable population CR, complete response; PR, partial response; SD, stable disease; PD, progressive disease; NE, non-evaluable 103

EMBRACE: ITT Progression-Free Survival by Independent Review
PFS 3.7 vs 2.2 mos p=0.137 Cortes J, et al. The Lancet, Early Online Publication, 3 March 2011 104

EMBRACE: Per-Protocol Population Progression-Free Survival by Independent Review
Cortes J, et al. The Lancet, Early Online Publication, 3 March 2011 105

EMBRACE Overall Survival
TPC (n=254) Eribulin (n=508) 53.9% 1 year survival 43.7% 1.0 0.8 Eribulin Median months 0.6 Survival probability HR* 0.81 (95% CI 0.66, 0.99) p-value†=0.041 0.4 TPC Median months 0.2 2.47 months 0.0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 Overall survival (months) ITT population; *HR Cox model including geographic region, HER2/neu status, and prior capecitabine therapy as strata †p value from stratified log-rank test (pre-defined primary analysis); HR, hazard ratio; CI, confidence intervals 106

EMBRACE: Overall Survival in an Updated Analysis

EMBRACE: Exploratory Subgroup Analysis of Overall Survival
Cortes J, et al. The Lancet, Early Online Publication, 3 March 2011

EMBRACE Overall Incidence of AEs
Adverse event (AE), % Eribulin (n=503) TPC (n=247) All AEs 98.8 93.1 Serious AEs 25.0 25.9 AEs leading to Interruption 5.0 10.1 Discontinuation 13.3 15.4 Dose reduction 16.9 15.8 Dose delay 35.2 32.4 Fatal AEs 4.0 7.3 Fatal AEs (treatment-related) 1.0 0.8 109

EMBRACE Grade 3 and 4 AEs* Adverse Events Grade 3 Grade 4
Eribulin (n=503) TPC (n=247) Hematologic events, % Neutropenia 21.1 14.2 24.1 6.9 Leukopenia 11.7 4.9 2.2 0.8 Anemia 1.8 3.2 0.2 0.4 Febrile neutropenia 3.0 1.2 Non-hematologic events, % Asthenia / fatigue 8.2 10.1 0.6 Peripheral neuropathy† 7.8 2.0 Nausea 2.4 Dyspnea 3.6 Mucosal inflammation 1.4 Hand-foot syndrome *>2% incidence; † Neuropathy peripheral, neuropathy, paresthesia, peripheral motor neuropathy, polyneuropathy, peripheral sensory neuropathy, peripheral sensorimotor neuropathy, demyelinating polyneuropathy 110

Phase 3 Trials in MBC Patients Previously Treated with an Anthracycline and a Taxane

EMBRACE: Conclusions EMBRACE is the first Phase III single-agent study in heavily pre-treated MBC to meet its primary endpoint of prolonged overall survival Eribulin demonstrated a statistically significant improvement in overall survival Improvement of median overall survival was 2.5 months (23%) Clinically meaningful in heavily pretreated patients Overall response rate and progression-free survival also favored eribulin These benefits were achieved with a manageable safety profile 112

Conclusions Ixabepilone and eribulin are new therapeutic options for metastatic breast cancer Approved for pretreated breast cancer Neutropenia and neuropathy are most common adverse events

Case Study 1 43-year-old Army wife and mother of 5 children presents with a 6 cm, 5/12 + LN, ER+, PR+, Her2 nonamplified breast cancer in early 2007. No PMH other than postpartum depression No medications Staging studies including a bone scan, CT/PET scan and cardiac echo are within normal limits

Case Study 1 Patient receives 6 cycles of TAC followed by tamoxifen at an outside institution. Tolerates well. One year after completing her chemotherapy, patient develops midthoracic pain. Bone scan reveals metastatic disease at T8 and L1. CT scan reveals no visceral disease. Bone biopsy confirms ER+ and HER2- recurrence

Case Study 1 Patient receives radiation to L1 spine with good pain relief. Undergoes laparascopic oophorectomy followed by enrollment on a clinical trial of Exemestane and a IGFR mAb. Zoledronic acid is initiated. Does well until early 2009 when staging studies reveal new bony mets. LFTs remain normal. Bone scan is stable. Patient receives fulvestrant.

Case Study 1 Patient does well until late 2009 when staging studies reveal multiple new liver lesions. LFTs remain normal. Bone scan is stable.

Case Study 1 Capecitabine is initiated at 900 mg/m2, po, bid. Patient requires dose reduction to 700 mg/m2, po, bid secondary to diarrhea and hand foot syndrome after first cycle. Initial scans show a near complete response in the liver

Case Study 1 In the middle of 2010, patient demonstrated progression within the liver on single agent Capecitabine after 8 months and Bevacizumab was added. Restaging after 6 weeks of combination therapy demonstrated further progression. LFTs still normal. Patient wants additional therapy.

Case Study 1 Patient was placed on single agent eribulin. Her scans have shown a near complete response in the liver after 3 cycles. Last cycle, patient reported an increase in peripheral neuropathy and she was dose reduced per package insert.

Case Study 2 64-year-old retired bookkeeper
Stage II ER+, PR-, HER2- breast cancer, dose dense AC-T Developed cough 5 years later on anastrazole Bilateral pulmonary nodules CT guided biopsy positive ER+, PR-, HER2- disease Bone scan positive Lytic lesions on CT No symptoms Other factors ECOG PS 1 Non-insulin dependent diabetes Hypertension

What will you recommend?
Your choice for initial systemic therapy is: Chemotherapy Chemotherapy plus bevacizumab Endocrine therapy

Received fulvestrant with SD for 9 months, then develops increasing cough and bone pain. What chemotherapy regimen do you recommend? Single agent capecitabine Single agent taxane Paclitaxel or docetaxel + bevacizumab Paclitaxel + gemcitabine Docetaxel + capecitabine Carboplatin + gemcitabine Other

Received paclitaxel with bevacizumab with response, then progression 12 months later. What chemotherapy regimen do you recommend? Single agent capecitabine Ixabepilone Ixabepilone + capecitabine Eribulin

Case Study 3 44-year-old unemployed investment banker with T3N2M0 “triple negative” invasive breast cancer In 2006, received adjuvant docetaxel/doxorubicin/ cyclophosphamide Abdominal cramping and distention. CT scan: omental “caking”, peritoneal nodularity and a moderate amount of ascites; the ovaries and adnexae appeared normal. 6 bilateral pulmonary nodules, and a small right pleural effusion was noted. Serum CA-125: normal. Serum CA 15-3: elevated at 235. Abdominal paracentesis: straw colored fluid Cytologic examination: adenocarcinoma cells morphologically similar to her prior primary invasive breast cancer.

Single agent capecitabine Single agent taxane Paclitaxel or docetaxel + bevacizumab Paclitaxel + gemcitabine Docetaxel + capecitabine Carboplatin + gemcitabine Other

Received paclitaxel with bevacizumab with response and then PD at 12 months, then capecitabine with progression at 6 months. What chemotherapy regimen do you recommend? Carboplatin + gemcitabine Ixabepilone Ixabepilone + capecitabine Eribulin Other

Case Study 4 A 62-year-old woman is treated with modified radical mastectomy 5 years prior, for a T2N0M0 ER/PR/HER- negative infiltrating ductal cancer. She is treated with doxorubicin and cyclophosphamide for four cycles. She now is noted on a routine chest x-ray to have 4 pulmonary nodules in the right and left lungs, with CT and bone scans showing no other disease other than several rib metastases. A CT-directed biopsy of the lung shows infiltrating ductal cancer, ER/PR/HER-negative, and TTF-1-negative. She has no symptoms and ECOG performance score of 0.

At this point, which strategy would you recommend? Single agent paclitaxel every 3 weeks Single agent paclitaxel weekly Docetaxel plus gemcitabine Ixabepilone

Case Study 5 This patient is treated with docetaxel plus capecitabine for 3 cycles and exhibits a response, but subsequently required dose reductions of both drugs do to fatigue, delayed count recovery and hand-foot syndrome. After 6 months, scans show progression in the lung and three new liver metastases, 1-2 cm in size Apart from fatigue, she has no symptoms, but has reduced her work to part time. Blood work and serum chemistries are normal except for a mild anemia. ECOG performance score is 1

At this point, which strategy would you recommend? Paclitaxel plus gemcitabine Albumin-bound paclitaxel plus gemcitabine Albumin-bound paclitaxel alone Ixabepilone

Case Study 6 Patient M.C., 61 years old, female
No Family Hx for cancer No hormone replacing therapy Annual screening mammography, always negative 2004: during self palpation, she notices a non-tender mass in her left breast No skin changes, no palpable adenopathies in the omolateral axilla Mammography: presence of a 2,3 cm density, with irregular edges Courtesy of Giuseppe Galletti, MD Weill Cornell Medical College

Case Study 6 FNA of the lesion: Invasive Ductal Carcinoma
No evidence of metastatic disease at PET/CT scan April 2004: lumpectomy and SLN (positive) followed by omolateral axillary lymph node dissection Pathology results: Invasive Ductal Carcinoma pT2 (2,7 cm) pN1a (3/18 positive nodes) M0 Stage IIB Courtesy of Giuseppe Galletti, MD Weill Cornell Medical College

Case Study 6 May-June 2004: adjuvant chemotherapy Doxorubicin 60 mg/m2 + Cyclophosphamide 600 mg/m2 x 4 → Docetaxel 75 mg/m2 x 4 → Trastuzumab for 1 year Left breast irradiation (50 Gy + 10 Gy boost) NCCN Guideline Version Clinical

Case Study 6 June 2009: increase of Ca 15-3 levels; a CT scan revealed the presence of liver and bone metastases 1st line metastatic chemotherapy: weekly paclitaxel 80 mg/m² + Zoledronic Acid 4 mg every 28 days Side effects: two episodes G2 neutropenia After 8 weeks of treatment, Partial Response at CT scan She continued paclitaxel for further 16 weeks and experienced G2-3 peripheral neuropathy (paresthesia) as main side effect. December 2009: stable disease at CT scan; she stopped chemo and started Examestane as hormonal therapy Courtesy of Giuseppe Galletti, MD Weill Cornell Medical College

Case Study 6 July 2010: onset of dispnea and headaches; evidence of right pleural effusion, increase in size of liver mets and presence of brain lesions at CT scan July-August 2010: stereotactic radiation therapy on brain mets followed by complete regression of the two lesions on subsequent MRI August 2010: patient started Ixabepilone 40 mg Thomas E et al. JCO 2007; 25(33):

Case Study 6 After the 2nd cycle, a Total Body CT scan showed stable disease Chemotherapy continued for further 4 cycles At the end of the 3rd administration, patient referred G3 peripheral neuropathy (paresthesia and sensory loss tp lower limbs), partially recovered December 2010: A total body CT scan confirmed the stable disease Currently relapse free and under 3rd line Courtesy of Giuseppe Galletti, MD Weill Cornell Medical College

Case Study 6 Microtubule targeting agents as backbone of breast cancer chemotherapy in the adjuvant and metastatic setting Taxanes fundamental to improve disease free survival and overall survival in the adjuvant strategies Ixabepilone still active against a very taxane-resistant disease Neurological toxicitiy as main side effects of almost all microtubule targeting agents (eribulin seems to better tolerated) Courtesy of Giuseppe Galletti, MD Weill Cornell Medical College

Investigations • Innovation • Clinical Application

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Investigations • Innovation • Clinical Application

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