1. MammaPrint, the story of the 70-gene profile
René Bernards
Professor of Molecular Carcinogenesis
The Netherlands Cancer Institute
Amsterdam
Chief Scientific Officer
Agendia
Amsterdam

2. The breast cancer treatment dilemma

3. Of 100 women with breast cancer3

4. Only 25% will develop distant metastases4

5. But we treat over 75% of all patients
with chemotherapy 5

6. Which means that 50% of all breast cancer patients get a toxic chemotherapy that they did not need!6

7. MammaPrint: improved breast cancer diagnosis
Low risk
High risk
High risk
Low risk

8. Identification of the MammaPrint breast cancer prognosis profile
78 breast tumors (‘83-’94)
patients < 55 years
lymph node negative
no adjuvant therapy
Unbiased full genome
gene expression analysis
Prognosis Reporter Genes
distant metastases
< 5 years (n=34)
no distant metastases
in at least 5 years (n=44)

9. MammaPrint
Discovery:
Van ‘t Veer et al. (2002)
Nature 415,

10. MammaPrint prognosis Profile
“the 70 gene profile”
van´t Veer et al., Nature 415, p , 2002
70 significant prognosis genes
Tumor samples
threshold set at 10% false negatives
91 % sensitivity, 73% specificity

11. MammaPrint 70 genes are involved in all aspects of tumor cell biology
proliferation
angiogenesis
adhesion to extracellular matrix
local invasion
intravasation, survival, extravasation
proliferation
angiogenesis
adhesion to extracellular matrix
Genes of unknown function (25)

12. First validation: Van de Vijver et al. (2002)
New England J. Med. 347,
295 patients

13. MammaPrint:Improved Clinical Management
Profiling vs St Gallen selection
MammaPrint
St Gallen
MammaPrint
improved prediction
and more accurate
metastases-free
metastases-free
MammaPrint:
40% in good profile
60 % in poor profile
St Gallen:
15% in low risk
85% in high risk
NEJM 347, p , 2002

14. MammaPrint vs St Gallen guidelines
Gene profiling:
Reduction adjuvant chemotherapy selection
Avoiding both over- and undertreatment
Improved prognosis prediction
NEJM 347, p , 2002

15. Second validation: Buyse et al. (2006) JNCI. 98, 1183-1192.
302 patients

16. >30% Discordant cases!
Independent External Validation: Microarray outperforms all clinical risk assessment
High clinical risk
Adjuvant on line! N=222
73%
Low clinical risk
Adjuvant on line! N=80
27%
27%
microarray
Low risk
35%
microarray
High risk
Under-
treatment!
Over-
Buyse et al JNCI 2006
>30% Discordant cases!

17. MammaPrint predicts early metastases
Time to distant metastasis
Hazard Ratios highest in first 5 years
JNCI 98, p , 2006

18. Chemotherapy only reduces the early metastases
No effect of Chemotherapy
Effect of Chemotherapy
Courtesy: Peter Ravdin

19. High reproducibility of microarray experiments (99%)
Reproducibility; repeat of the experiment
Reproducibility; 2 samples, 7 month period
Glas et al, BMC Genomics 2007

20. MammaPrint: improved breast cancer diagnosis
First FDA approved molecular
Diagnostic test for cancer
2007
Time Magazine:
Invention of the year 2007 20

21. MINDACT study design ASSESS clinical RISK AND MammaPrint RISK
6000 patients, <70 YRS, 1-3 POS NODES
ASSESS clinical RISK AND MammaPrint RISK
(adjuvant!online & MammaPrint)
55%
10%
35%
BOTH HIGH RISK
DISCORDANT
RISK
BOTH LOW RISK
RANDOMIZE
decision-making
Use clinical risk
Use MammaPrint
high
low
high
low
Chemotherapy
No chemotherapy

22. Recent additional features of the MammaPrint test: Expanded indications: all ages

23. MammaPrint prognosis in postmenopausal
patients 5 10 15
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9 1
KM survival curve: Breast cancer > 55 year old
Time(year)
Survival Probability
Chi2 = P = 8.79e-005(wt power = 0)
Good prognosis profile
Metastases free probability
Poor prognosis profile
Poor
Good
150 patients
Overall survival HR 2.3, 0.95 CI [ ], p=0.0049

24. Recent additional features of the MammaPrint test: Expanded indications: patients with 1-3 positive lymph nodes

25. Validation of MammaPrint in patients with
1-3 positive lymph nodes
Milan and NKI series 241 patients
Milan EIO (B Viale):
NKI series:
80% treated adjuvant chemo and/or hormonal therapy
Median Follow Up:
Milan: 8.97 years (0-10.9)
NKI : 10.4 years ( )

26. MammaPrint performance in patients with 1-3 positive node(s)
N=241breast cancer patients with 1-3 positive lymph node(s)
Milan & NKI
Multivariate HR 6.59 (95% CI 1.71 to 25.45; p = 0.006)

27. Breast cancer with 1-3 positive node(s)
MammaPrint Distant metastases as first event
Multivariate analysis

28. TargetPrint: Quantification of ER, PR and HER2

29. MammaPrint: extensive regulatory approvals
MammaPrint is the first and only IVDMIA cleared for market by FDA
ISO accredited and CE mark for European market
CLIA registered to be able to test US patients
CAP Accredited
The College of American Pathologists

30. MammaPrint is only the “tip of the iceberg” of personalized medicine
Who needs treatment?
Which therapy will work best? 30

31. Personalized medicine: multiple answers on a single microarray chip
Prognosis?
Is there a hereditary
component?
Will tumor respond
to Herceptin?
Will tumor respond
to DNA damaging agents?

32. Poor quality biomolecules: poor quality biomarkers!
RNA integrity
Protein integrity
FFPE
Fresh

33. Thank you!