1. Lung Cancer Genotyping in Colombia Mauricio Lema Medina MD Clínica de Oncología Astorga - Medellín

2. Acknowledgments Dr. Andrés Felipe Cardona Zorrilla M.D

3. Globocan, 2008

4. Registro Poblacional de Cáncer, Cali – Colombia

5. Registro Poblacional de Cáncer, Antioquia – Colombia, 2007-2009

8. Colombia Creado por: Mauricio Lema Medina - LemaTeachFiles© - 2010 http://rpcc.univalle.edu.co/

9. Globocan, 2008

10. Cisplatin-based CT in advanced NSCLC Meta-Analysis Modest improvement in OS NSCLC Collaborative Group. BMJ 1995;311:899–909 Supportive care + CT Supportive care Cisplatin-Based chemotherapy for advanced NSCLC 100 80 60 40 20 0 Survival (%) 06121824 Time from randomisation (months)

11. Platinum-Based Doublets in Advanced NSCLC Schiller, et al. NEJM 2002 Meses 051015202530 0.0 0.2 0.4 0.6 0.8 1.0 Carboplatin / paclitaxel Cisplatin / docetaxel Cisplatin / gemcitabine Cisplatin / paclitaxel Probabilidad de supervivencia ECOG trial 1594 ECOG, Eastern Cooperative Oncology Group Schiller et al. N Engl J Med 346:92, 2002

12. NSCLC Outcomes in Bogotá, Colombia Cardona AF. Rev Venez Oncol 2010; 22(1):66-83 n=345 n=176 Stage IIIB / IV NSCLC Received anti cancer agents Male 64% Male 64% PS 0/1 45% PS 0/1 45% Adeno 60% Adeno 60% Squamous 24% Squamous 24% Weight loss 61.5% Weight loss 61.5% Platinum-doublets 71% Platinum-doublets 71% Gem/Vin mono 19% Gem/Vin mono 19% Erlotinib 4.5% Erlotinib 4.5% 1 st Line therapy

13. NSCLC Outcomes in Bogotá, Colombia Cardona AF. Rev Venez Oncol 2010; 22(1):66-83 PFS Cisplatin: 4.7 m Carboplatin: 3.2 m PFS Cisplatin: 4.7 m Carboplatin: 3.2 m 3.4 OS Median: 9.2 m 1-yr OS: 26% OS Median: 9.2 m 1-yr OS: 26%

14. Molecular subtypes of lung carcinoma PIK3CA HER2 EGFR EML4-ALK BRAF K-rasFGFR4 Recently described MEK1 ROS fusion gene PDGFR amp LKB1 ERK BIM MET

15. Lung cancer 2010 – USA 219,000 new cases KRAS-mutated NSCLC 36.000 cases/year EGFR-mutated NSCLC 18.000 cases/year EML4-ALK NSCLC 9.000 cases/year CML 5.000 cases/year Yearly incidence of cancers with driver mutations Small-cell lung cancer (13%) EGFR mutated (10% NSCLC ) KRAS mutated (25% of adenocarcinoma) Other NSCLC Pao W. ASCO 2010.

16. EGFR mutations around the world Overall 40% - 50% E19 51% E21 42% E20 2% Overall 17% E19 62% E21 37% E20 38% Overall 14% E19 60% E21 30% E20 8% - 38% Overall 32.8% E19 54.3% E21 44.5% E20 2.2% Overall 15.8% E19 64.3% E21 24.7%

17. IPASS: Carboplatin + Paclitaxel vs Gefitinib in metastatic NSCLC adenocarcinoma (very low smoking burden) Mok T, et al. ESMO 2008 Adenocarcinoma, Stage IV, PS 0-2, very low smoking burden (n=1217) Carboplatin + Paclitaxel (PC) (n=608) Gefitinib (n=609) Median OS (months)PCGefitinibP All17.318.6NS PC: Carboplatin AUC 5-6 d1 + Paclitaxel 200 mg/m 2 d1. q21 days x6. Gefitinib: 250 mg vía PO qd. Crossover allowed HR for progressionHRP Wild type EGFR2.850.0001 Mutated EGFR0.480.0001

18. EURTAC: CT vs Erlotinib in mEGFR NSCLC Chemo-naive metastastic NSCLC with mEGFR (n = 173) Chemotherapy (n = 87) Erlotinib 150 mg PO qd (n = 86) Rosell R, et al. ASCO 2011. Abstract 7503. Primary End-Point: Overall survival.

19. EURTAC: Response and Safety CT-treated patients had increased frequency of: – Grade 3/4 AEs (81% vs 45%) – Dose modification or interruption due to treatment-related AE (47% vs 23%) – Discontinuation due to treatment- related AE (14% vs 5%) – Treatment-related serious AEs (16% vs 7%) Response Outcome, % Erlotinib (n = 86) Chemo (n = 87) Objective response5815  CR20  PR5615 Disease control rate7966 SD2151 PD713 No response assessed 1422 Rosell R, et al. ASCO 2011. Abstract 7503. Clinical Care Options.

20. Rosell R, et al. ASCO 2011. Abstract 7503. Reprinted with permission. EURTAC: Erlotinib vs Chemo in EGFR Mutation-Positive, Stage IIIB/IV NSCLC Phase III; significant benefit in PFS and with erlotinib vs chemotherapy Erlotinib (n = 86) Chemotherapy (n = 87) HR: 0.37 (95% CI: 0.25-0.54; log-rank P <.0001) PFS Probability 1.0 0.8 0.6 0.4 0.2 0 03691215182124273033 Mos 5.29.7 Patients at Risk, n Erlotinib Chemo 86 87 63 49 54 20 32 8 21 5 17 4 9 3 7 1 4 0 2 0 2 0 0 0 Clinical Care Options.

21. EURTAC: OS and PFS Across Patient Subgroups No significant difference in OS at interim analysis; data immature with high rate of crossover (HR = 0.80; 95% CI: 0.47-1.37; P =.4170) No PFS benefit of erlotinib vs chemotherapy among former smokers Rosell R, et al. ASCO 2011. Abstract 7503. 0.10.20.40.60.81.01.52.04.0 Favors ErlotinibHRFavors Chemotherapy All < 65 yrs ≥ 65 yrs Male Female PS 0 PS 1 PS 2 Current smoker Former smoker Never smoker Exon 19 deletion L858R mutation HR (95% CI) 0.37 (0.25-0.54) 0.44 (0.25-0.75) 0.28 (0.16-0.51) 0.38 (0.17-0.84) 0.35 (0.22-0.55) 0.26 (0.12-0.59) 0.37 (0.22-0.62) 0.48 (0.15-1.48) 0.56 (0.15-2.15) 1.05 (0.40-2.74) 0.24 (0.15-0.39) 0.30 (0.18-0.50) 0.55 (0.29-1.02) n 173 85 88 47 126 57 92 24 19 34 120 115 58 Clinical Care Options.

22. Study design Between subjects factorial design 20 Target population Colombia incident cases of LAC Accesible population LAC cases analized in a centralized laboratory Study sample LAC cases with complete genotipification 10 EGFR + KRAS + KRAS/EGFR Wt Alk BRAF Her2 PI3K Random allocation Control Measurement of clinical outcomes Main objective To establish the frequency of driver mutations in NSCLC in LATAM population. Methods Direct sequencing in patients from Argentina, Colombia, Mexico, and Peru was performed at each site.

23. + N=1 + N=0 Main study schedule - Colombia Test for KRAS mutation - + Test for EGFR mutation No further molecular testing - + Test for ALK/ELM4 Translocation No further molecular testing + Test BRAF N=322 N=322 N=80 N=26 N=205 N=242 N=35 N=170 N=1 Test Her2 N=60 N=36 Patients with available data concerning the use of erlotinib (N=41) + N=1 Test PI3k N=20

24. VariableN (%) Number of pts treated with erlotinib (follow-up available data) 41 (51%) Mean age (SD)63 yrs (±12) Stratified age >65 yrs <65 yrs ND 13 (31.7) 58.5 24 (58.5) 4 (9.8) Sex Male Female 9 (22.0) 78.0 32 (78.0) Tobacco exposure Never smoker Former smoker Current smoker 73.2 30 (73.2) 10 (24.4) 1 (2.4) Main metastasis (site) Pleuropulmonary Brain Liver Bone ND 26 (63.4) 4 (9.8) 3 (7.3) 2 (4.9) 6 (14.6) Hormonal receptor status (tumor tissue) Positive Negative ND 53.7 22 (53.7) 11 (26.8) 8 (19.5) TTF1 status Positive Negative ND 53.7 22 (53.7) 11 (26.8) ND 8 (19.5) Mutation type delE19 L858R 63.4 26 (63.4) 15 (36.6) T790M basal Positive Negative ND 4.9 2 (4.9) 23 (56.1) 16 (39.0) Line of treatment 1 2 3 ND 17 (41.5) 14 (34.1) 9 (22.0) 1 (2.4) Response Stable disease Partial response Complete response Progressive disease ND 17.1 7 (17.1) 73.2 30 (73.2) 4.9 2 (4.9) 1 (2.4) Overall response rate32 (78.1) Clinical benefit39 (95.2) Main characteristics of EGFR mutant population

25. Colombia (ONCOLGroup study) Cardona AF, et al. ASCO 2011. Colombia IC95% (11.8-17.6) México IC95% (8.8-13.1) P = 0.093 Time (months) Survival Progresion free survival Time (months) Median 14.7 mo IC95% (11.8-17.6)

26. Outcomes in Latin American NSCLC patients harboring wild-type or activating mutations of EGFR (CLICaP Registry) - submitted to ASCO 2012 Arrieta O, Cardona AF, Bramuglia G, Campos AD, Becerra H, Martín C, Richardet E, Serrano S, Y powazniak, Rosell R, on behalf of the CLICaP. Stage IV NSCLC - CLICaP Registry - (n=589) mEGFR Non-EGFR (n=175) (n=414) PFS: 13 months OS: 36 months PFS: 3 months PFS: 14 months RR: 70% RR: 29% mEGFR% Female57% Adenocarcinoma89% Exon 19 mutations58% L858R mutation36%

27. + N=1 + N=0 Main study schedule - Colombia Test for KRAS mutation - + Test for EGFR mutation No further molecular testing - + Test for ALK/ELM4 Translocation No further molecular testing + Test BRAF N=322 N=322 N=80 N=26 N=205 N=242 N=35 N=170 N=1 Test Her2 N=60 N=36 Patients with available data concerning the use of erlotinib (N=41) + N=1 Test PI3k N=20

28. ALK/ELM4 MET ALK   Y Y Y Y P P P P Y Y Y Y P P P P TM Y Y P P Y Y P P Y Y Y Y P P P P Y Y Y Y P P P P SEMA TM Extracellular Intracellular Y Y P P Y Y P P Kinase Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P TM Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Extracellular Intracellular Y Y Y Y P P P P Y Y Y Y P P P P Kinase Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Y Y Y Y P P P P Cytoplasmic Fusion Variants of ALK NPM-ALK EML4-ALK Soda S, et al. Nature 2007.; Perner, et al. Neoplasia 2009.; Soda S, et al. PNAS 2008. Juxtaposed the 5’ end of the EML4 gene with the 3’end of the ALK gene

29. ALK/EML4 mutation around the world 4.2%4.2% 2.7%2.7% 8.0%8.0% 3.7%3.7% J Clin Oncol 2009;27:4232–4235. J Thorac Oncol.2009;4:1450-1454.

30. 30 Tumor responses to crizotinib by patient Median time to response: 8 wk 1. Camidge et al., ASCO 2011; Abs #2501. 2. Riely et al., IASLC 2011; Abs #O31.05. PROFILE 1005 2 PROFILE 1001 1

31. 31 Survival in ALK-positive NSCLC with crizotinib versus crizotinib-naive controls 0 0% 20% 40% 60% 80% 100% Overall survival (years) 1234 Shaw et al., ASCO 2011; Abs #7507. ALK Crizotinib (n=30) ALK Control (n=23) Median Survival, mo NR 6 1-yr Survival, % 70 44 WT/WT Control (n=125) 11 47 From 2 nd /3rd line crizotinib 2-yr Survival, % 55 12 32 HR = 0.49, p=0.02

32. ALK/EML4+ NSCLC NPA (Female/53 yo) Adenocarcinoma de pulmón en mujer no fumadora T 3 N 2 (multinivel)M 1 (hueso) G 2 L x V x Lung adenocarcinomaT 3 N 2 (multilevel)M 1 (bone) G 2 L x V x Stage IV Diagnosis 24.10.09 1 st line Cis/Pem x 6 cycles 02.12.09 d+ RT 6.000 cGy Manteinance Pem x 4 cycles 27.05.10 PD 25.06.10 (one lesion brain) Radiosurgery 02.07.10 2 nd line CBP/Gem/Bev 21.07.10 Manteinance Bev x 13 cycles 27.05.10 PD 14.06.11 (Pleural) 3 rd line Doc x 3 cycles 03.07.11 PD 22.08.11 (Pericardial) 4 th line Crizo x 1 cycles 13.10.11 8 months14 months3 months OS OS 2.4 years EGFR 19 - L858R - T790M basal Wt/BCRA1 (T 1 )/RAP80 (T 1 )/ERCC1 (bajos niveles)/NKX2 (T 1 )/ ALK/ELM4 (V 1+ )

33. NSCLC in Colombia Outcomes with CT ALK/EML4 and others have been found They hold the promise of individualized care At first glance (and with very limited data): Similar to other countries Other mutations Relatively low incidence compared to other countries: 15/100.000 High letality In mEGFR enriched samples: 32% PFS/OS with 1st-line anti EGFR TKI appear to be non-inferior to other cohorts EGFR mutations

34. At progressionNever EGF/ALK Mutation At diagnosis SCENE 4 When should we perform genotyping in NSCLC? Different sub-types of NSCLC

35. At progressionNever EGFR/ALK Mutations At diagnosis When should we perform genotyping in NSCLC Different sub-types of NSCLC

36. Never...  All patients are candidates to anti-EGFR therapy  1 st Line (EURTAC)  Maintenance (Saturn-trial)  2 nd / 3 rd Line (BR.21)  No proven increase in OS with 1 st Line TKI in mEGFR  Likelihood of driver mutations other than EGFR, low  No anti ALK/EML4 therapy in Colombia (at this time)  All patients are candidates to anti-EGFR therapy  1 st Line (EURTAC)  Maintenance (Saturn-trial)  2 nd / 3 rd Line (BR.21)  No proven increase in OS with 1 st Line TKI in mEGFR  Likelihood of driver mutations other than EGFR, low  No anti ALK/EML4 therapy in Colombia (at this time) Never When should we perform genotyping in NSCLC Different sub-types of NSCLC

37. Post-progression  After chemotherapy progression  To define anti EGFR vs 2 nd Line Chemotherapy  To identify other driver mutations (ie, ALK+ NSCLC)  Not supported by clinical evidence  May be reasonable  Whom?  All  EGFR/ALK enriched populations?  After chemotherapy progression  To define anti EGFR vs 2 nd Line Chemotherapy  To identify other driver mutations (ie, ALK+ NSCLC)  Not supported by clinical evidence  May be reasonable  Whom?  All  EGFR/ALK enriched populations? Progression When should we perform genotyping in NSCLC? Different sub-types of NSCLC.

38. At diagnosis  In mEGFR patients may delay Chemotherapy initiation  No benefit in OS for mEGFR (non-asiatic) patients with 1 st Line TKIs  May help identify other driver mutations (ie, ALK+)  But, should we treat those 1 st or after conventional Rx?  Whom?  Restrict to non/light-smokers with adenocarcinoma?  In mEGFR patients may delay Chemotherapy initiation  No benefit in OS for mEGFR (non-asiatic) patients with 1 st Line TKIs  May help identify other driver mutations (ie, ALK+)  But, should we treat those 1 st or after conventional Rx?  Whom?  Restrict to non/light-smokers with adenocarcinoma? Diagnosis When should we perform genotyping in NSCLC? Different sub-types of NSCLC.