Embrace the change with confidence LONG-TERM endometrial and breast safety of a specific and standardised SOYA ISOFLAVONES extract (PHYTO SOYA®) INFOGYN 2010 – Tarbes – Pr. Palacios S.

Introduction Many women have chosen to not take HRT either because they have contraindication or because they wish to use a more natural treatment. Consequently, a number of women take phyto estrogens either advised by their doctor or also by themselves because phyto estrogens can be sold as a dietary supplement. Many clinical studies have studied the efficacy of phyto estrogens but questions of their safety on endometrium and on breast are raised.

E R a E R b Human Estrogen Receptors A and B AF-1 DNA Ligand / AF-2 A/B C D E F 1 180 263 302 552 595 E R a N- -C 1 144 227 255 504 530 E R b N- -C (18) (97) (30) (59) (18)  Different tissue / cell distributions  Different affinity for ligands  Different gene activations

Human Estrogen Receptors A and B Pearce, S. T.; Jordan, V. C. The biological role of estrogen receptors alpha and beta in cancer. Crit Rev Oncol Hematol 2004, 50, 3-22.

Phytoestrogen/RE/uterus Dominant in the uterus ER ERE TF P X Weak response to E2 Inactivation RE Greater increase in response to E2 Inactivation RE  Isoflavones: competition at receptor level Selective partial agonist: absence of E Selective partial antagonist: presence of E (Messina MJ 1994)

Kuiper G et al. Endocrinology 1998

Effects of phyto estrogens on endometrium and breast

Rationale Breast density (BD) is one of the strongest predictors of breast cancer BC risk. Women with BD > 50% are at three- to five-fold greater risk of breast cancer than women with < 25% dense area About 30% of PM women have high BD, a frequency that is greater than the frequency of most recognized risk factors (for example, a family history of breast cancer occurs in only 10% of women)

Rationale  A decrease of BD can be induced by several factors: increasing age, menopause, elevated BMI, pregnancy at an early age.  An increase is induced by some types of HRT, but SERM can decrease it and reduce the BC risk.

Breast density is associated with breast cancer risk Boyd N.F. et al., NEJM 356:227-236, 2007

Breast density is associated with breast cancer risk Epidemiologic studies have clearly shown an association between breast density and higher risk to develop breast cancer. The mechanisms by which density confers this increased risk remain unclear.

Clinical trials on endometrial effect of phyto estrogens Authors Isoflavones Quantity Treatment period & number of subjects Methodology Exams Results Balk (2002) 100 mg/j 6 months 27 patients Double blind vrs placebo Biopsy No histological modification Di Carlo (2003) 36 mg/j 12 months 70 patients open Ultrasound No increase of the thickness Penotti (2002) 72 mg/j 66 patients Han (2002) 4 months 80 patients Scambia (2000) 50 mg/j 3 months 39 patients Unfer* (2004) 150 mg/j 5 years 379 patients Increase of the impact of hyperplasies

1. Methodology 2. Results of endometrial SAFETY 3. Results of breast SAFETY 4. Tolerance 5. Conclusion

1. Study objective Evaluate the effects of administration of 70 mg of SOYA ISOFLAVONES (PHYTO SOYA®) on the endometrium and breasts 2. Study design International, multicentre, non-comparative study, open for a duration of 3 years 34 centres in 4 countries: - France, 30 centres: Pr MARES - Spain, 2 centres: Pr PALACIOS - Belgium, 1 centre: Dr PORNEL - Australia, 1 centre: Pr EDEN

- Specific, standardised ISOFLAVONE extract 3. Treatment - Specific, standardised ISOFLAVONE extract - Extract composition: 50% Daidzein, 30% Glycitein, 20% Genistein - 2 capsules of PHYTO SOYA® taken in the morning and at night, - 17.5 mg of ISOFLAVONES per gel cap (70 mg per day), - 3 years of treatment.

INCLUSION CRITERIA Women ages 45-65 Intact uterus No normal period for at least 2 years Status of menopause confirmed by hormone levels (>30 IU/l) and estradiol levels (<35 ng/l). BMI < 30 kg/m2 "Wash-out" period: 3 months: hormone therapy, tibolone, raloxifene… 2 months: isoflavones 1 months: local hormonal treatment

INCLUSION CRITERIA Undiagnosed vaginal bleeding Polyps Hyperplasia Cancer Biopsy of endometrium: Thickness >4mm Submucosal fibroids Severe endometriosis Hyperplasia or cancer Transvaginal ultrasound: ACR3: benign anomalies to monitor ACR4: indeterminate or suspicious anomalies ACR5: anomalies suggesting the presence of cancer Mammography:

317 patients finished year 1 192 usable biopsies (smlTT) DISTRIBUTION OF WOMEN THROUGHOUT THE STUDY 499 selected patients 395 admitted patients 317 patients finished year 1 235 patients admitted for the extension phase 197 available biopsies (mlTT) 6 final visits (biopsies) were performed in time 305 evaluable patients 301 usable biopsies 3 with no tissue 1 with insufficient tissue (endometrial thickness >5 mm) 193 evaluable patients 1 simple hyperplasia 192 usable biopsies (smlTT) 78 premature exits 35 premature exits Phase I Phase II

DEMOGRAPHIC AND CLINICAL CHARACTERISTICS Number of women: 235 Age: 55.90 ± 3.93 years Average age of menopause: 49.40 ± 3.31 years Duration of menopause: 6.49 ± 3.92 years Body mass index (kg/m2): 24.58 ± 3,22

Effects of PHYTO SOYA on endometrium

BIOPSY RESULTS Total biopsies 235 197 192 3 - 19 25 24 1 213 167 Classification Admission (Sample population of safety of the extension) Biopsies analysed during the extension phase) (mITT population) Final visit (smITT population) No tissue 3 - Insufficient tissue. Endometrial thickness <5 mm 19 25 24 1 Atrophic/inactive 213 167 Proliferative Secretory/menstrual Hyperplasia Cancer Total biopsies 235 197 192

ENDOMETRIAL THICKNESS Average endometrial thickness at inclusion: 2.20 mm Average endometrial thickness at the end of treatment (3 years): 2.17 mm No significant change from a statistical point of view in terms of endometrial thickness was observed between admission and end of treatment. Endometrial thickness of 8.3 mm was recorded for one patient 24 months after the start of treatment. The patient's histology revealed simple hyperplasia without atypical cytology.

Assessment of Breast Safety in women treated during 3-year with Phyto Soya®

ACR BI-RADS classification for breast density Type 1 :< 25 % breast is almost entirely fat Type 2 : 25 - 50 % there are scattered fibroglandular densities Type 4 > 75 % breast is extremely dense Type 3 : 50 – 75% Breast is heterogenously dense

MAMMOGRAPHY RESULTS Mammographies Admission (Sample population of safety of the extension) Population mITT smITT Numbers 235 191 189 Missing 43 42 ACR1: number of normal mammographies 111 (47,2%) 81 (42,4 %) (42,9%) ACR2: number of mammographies with benign anomalies 122 (51,9%) 108 (56,5%) 106 (56,1 %) ACR3: number of mammographies with anomalies that are likely benign 2 (0,9 %) (1,0%) (1,1%) ACR4: number of mammographies with indeterminate or suspicious anomalies ACR5: number of mammographies with anomalies suggesting the presence of cancer ACR: American College of Radiology

MAMMOGRAPHY RESULTS Results of mammographies were similar to those observed during admission visit. No patients were classified as ACR4 or ACR5. There were no patients or populations whose category changed from ACR1, 2 or 3 to ACR4 or 5. No significant change from a statistical point of view in terms of ACR classification was observed between admission and end of treatment.

OVERALL TOLERANCE The only adverse recurring product-related side effects were gastrointestinal problems observed in 4.3% of women. Overall safety after 3 years was observed as "EXCELLENT” or "GOOD" by 99.1% of examiners and by 99.0% of patients from the mITT sample.

STUDY CONCLUSION ENDOMETRIUM BREAST These statistics fulfil the conditions for safety evaluations of the endometrium specified in the new European regulatory guidelines, which require a frequency of hyperplasia/cancer of the endometrium ≤ 2% 1 year after treatment. BREAST The results of this study support the hypothesis that states that this specific extract of isoflavones does not increase breast density 3 years after treatment.

STUDY CONCLUSION This study was carried out with PHYTO SOYA® specific and standardised extract of SOYA ISOFLAVONES: 50% daidzein 30% glycitein 20% genistein This clinical study therefore should not be extrapolated to other SOYA ISOFLAVONE extracts

Menopause. 2007 Nov-Dec;14(6):1006-11.

Climacteric. 2010 Aug;13(4):368-75.

STUDY CONCLUSION Daily administration of 70 mg of specific and standardised ISOFLAVONE extract from PHYTO SOYA® for 3 years can be considered a safe treatment for both the endometrium and the breast