ASCO 2005 Adjuvant Breast Cancer Update Lori J. Goldstein, MD Director, Breast Evaluation Center Leader, Breast Cancer Research Program Fox Chase Cancer Center Philadelphia, PA

ASCO 2005 Breast Cancer Update Abstract #/ Session Title/ Subject 512 E2197: Adjuvant AT vs. AC 513 ECTO: A->CMF vs AT->CMF MoAB Ed N9831/ NSABP B31 Joint Analysis – Adjuvant Trastuzumab MoAB Ed N9831 – Adjuvant Trastuzumab MoAB Ed HERA: Adjuvant Trastuzumab MoAB Ed E2100: T +/- bevacizumab MBC

E2197: Phase III AT vs. AC in the Adjuvant Treatment of Node Positive and High Risk Node Negative Breast Cancer Goldstein LJ, O’Neill A, Sparano JA, Perez EA, Shulman LN, Martino S, Davidson NE. On behalf of ECOG and the US Intergroup, thank you for allowing me to present the first results of E2197, a randomized trial comparing adriamycin plus docetaxel to adriamycin plus cyclophosphamide for node positive and hi risk node negative breast cancer.

E2197 Rationale Phase II Studies Anthracyline + Taxane Study A/Por D mg/m2 RR % CHF % Gianni/ 60/P200 80-90 20 Dombernowsky Sledge E1193 50/P150 47 9.8 Sparano E4195 60/P200 57 6 Sparano E1196 60/D60 57 6 Cresta 60/D60 63 10 Misset 50/D75 81 0 Given their single agent activity, relative non-cross resistance, partially non-overalpping toxicities and different mechanisms of action, there was a clear rationale for combining the taxanes with doxorubicin. The encouraging results of the combination of doxorubicin and palcitaxel were associated with a risk of cardiac toxicity related to cumulative doxorubicin dose and alteration of doxorubicin pharmacokinetcs by paclitaxel which was highly sequence dependent Here are some of the Phase II trial s in metastatic breast cancer. The combination of doxorubicin and docetaxel was selected for E2197 based on the relative cardiac safety of this combination.

E2197 Rationale Phase III Studies:Anthracyline + Docetaxel MBC AT (50/75) AC (60/600) RR% 60 47 p=.012 TTPwk 37.1 31.9 p=.015 CHF % 2 4 FN% 33 10 No difference OS Nabholtz JCO 2003 TAC vs. FAC MBC Mackey ASCO 2002 Increase RR with TAC; no difference in TTP or OS TAC vs. FAC Adjuvant: Nabholtz ASCO 2002 TAC increase DFS/ OS Subsequent to the initiation of E2197 several randomized trials were published supporting the investigation of this combination in the adjuvant treatment of early stage breast cancer. Here one can see that AT resulted in an increased response rate and time to tumor progression compared to AC in metastatic breast cancer with a low incidence of CHF. As you can also see the AT combination is associated with significant febrile neutropenia when given without growth factor support. These data are also supported by the comparison of TAC vs FAC. While TAC resulted in an increased response rate there was no improvement in time to progression when compared to FAC in metastatic breast cancer. However, in the adjuvant setting, TAC was superior to FAC in terms of both disease free and overall survival.

E2197: Schema R A N D O M I Z E IV q 3wk x 4 Cipro 500mg po. bid D8 x 10d Adriamycin 60mg/m2 Docetaxel (T) 60mg/m2 T1-3 N0-1 M0 No then T> 1.0cm Adriamycin 60mg/m2 Cyclophosphamide 600mg/m2 IV q 3wk x 4 Tamoxifen 20mg daily x 5 years post chemotherapy for ER and/or PR positive tumor Stratified: Nodal Status HR Status (ER+PR+,ER+PR-, ER-PR+,ER- PR-,ER/PR unknown) Menopausal Status *G-CSF - per ASCO guidelines

E2197: Objectives To determine whether AT will improve DFS and OS To compare toxicity of AT vs. AC No difference in LVEF between AT and AC reported ASCO 2003. At ASCO 2003 we reported no difference in LVEF bewteen AT and AC.

E2197: Study Design Primary endpoint: DFS-recurrences, new breast primaries, or death without recurrence whichever comes first. Design: 83% power to detect a 25% reduction of the DFS failure hazard rate (5% absolute improvement in 5 yr DFS from 78% to 83% by using AT) Sample size: 2778 including an estimated 10% ineligible Primary Analysis: Intent-to-treat analysis on eligible patients. The primary endpoint was DFS defined a recurrence, new breast cancer, or death without recurrence. With 2778 patients (inlcuding 10% ineligible) this study had 83% power to detect a 25% reduction in DFS hazard rate using AT This was an intent to treat analysis. __________________________________________________________________________________________________________________ (assuming a 5 yr 78% DFS on the AC arm OR The ability to detect a 5% absolute improvement in 5 yr DFS from 78% to 83%. 2 interims and a final analysis planned (total information=420 DFS failures) The information time was defined by the number of eligible patients who recur, have a new breast cancer primary or die without recurrence whichever occurred first.

E2197:Results Opened 7/30/98; closed 1/21/00 2952 entered through the collaborative effort of ECOG, CALGB, NCCTG, SWOG and EPP. 3% Ineligibility rate 2885 eligible and analyzable

E2197: Patient Characteristics Balanced for age, HR, menopause, nodes, surgery, grade and size Age range 24-85 yo, Median age 51 64% ER + 65% LN- Grade: 10% low, 38% int., 46% high Size: 0.1 – 12.5 cm; Median – 2.0 cm The arms were balanced for age, hormone receptors, menopause, nodes, surgery, grade and size. The Age range was 24-85 , with a Median age of 51 64% were ER + 65% were LN- For Grade: 10% were low, 38% int., and 46% high For Size:the range was 0.1 – 12.5 cm; with a Median size of 2.0 cm

E2197: Toxicity Summary AT AC Feb/Infxn/N 28% 10% AML/MDS 7 7 Lethal Events Related 4 Unrelated 2 2 As noted in other studies of the AT combination, the neutropenia associated with fever and infection was significant at 28% compared to AC where the rate was 10%. Again noted is that growth factor was not given prophylactically, but rather by ASCO guidelines. There were 7 cases of AML/MDS on each arm. There were 7 deaths during or within 30 days of chemo and One death at 42 days. 4 were related to treatment with AT, one with visceral ishcemia( ischemic bowel), 2 secondary to sepsis and one cardiac in a patient with a cardiac history. Ages 62-70). AT Unrelated: Cardiac – h/o cardiac disease (77) Sudden death (60) AC Unrealted Angioedema of the larynx post endoscopy MI post chemo

E2197 Cardiac Safety AT AC Grade 3 4 5 3 4 CHF 15 2 1 10 Total 18 10 % .01 .006 No statistically significant difference There 18 and 10 cases of CHF on the AT and AC arms respectively, with no significant difference between the 2 arms.

E2197: DFS Fall 2004 DMC (409/ 420 DFS failures) O’Brien-Fleming boundary had not been crossed, there was not enough evidence to suggest a significant difference April 2005 - Median follow-up = 59 months 432/ 2885 (15%) recurred, developed second breast cancer or died. At the Fall 2004 DMC, the study was at full information and the ECOG DMC released the study for presentation and publication. The current data are as of April 2005. At 59 month median follow-up, 432 of 2885 patients recurred, developed second breast cancers or died.

E2197: DFS/OS Hazard Ratio HR > 1 favors AT HR (adjusted) DFS 1.03 (0.86-1.25), p=0.70 OS 1.09 (0.85-1.40), p=0.49 As of 4/4/05, 242 deaths With a Hazard ratio greater than 1 favoring AT there was no significant difference in disease free or overall survival between the 2 arms. The Hazard ratio was adjusted for age, nodes, ER, menopausal status, surgery, grade, size. The unadjusted HR’s were not significantly different.

E2197 Disease-Free Survival Percent 10 20 30 40 50 60 70 80 90 100 Months 12 24 36 48 72 AT AC 1444 213 1441 219 N Events 87 (1) 4-Yr % (S.E.) E2197 Disease-Free Survival The K-M curves are overlappiing for a disease free survival. The 4 year DFS was 87% for both arms.

Percent 10 20 30 40 50 60 70 80 90 100 Months 12 24 36 48 72 AT AC 1444 117 1441 125 N Events 94 (1) 93 4-Yr % (S.E.) E2197 Overall Survival Similarly, the curves overlap for overall survival with 94% survival at 4yrs.

E2197: DFS Subgroup Analysis No significant effect within any of the following subgroups : Nodes Size Age Menopausal Status Grade Type of Surgery Race No significant effect was observed within any of the following subgroups : Nodes Size Age Menopausal Status Grade Type of Surgery Race NB: There were no significant interactions between treatment and any of these variables.

E2197 Disease-Free Survival:ER-/PR- 10 20 30 40 50 60 70 80 90 100 100 90 80 70 60 Percent Percent 50 40 30 20 10 12 24 36 48 60 72 12 24 36 48 60 72 Months Months N Events 4-Yr % (S.E.) N Events 4-Yr % (S.E.) AT 454 85 83 83 83 (2) (2) (2) AT 52 14 77 (6) AC 463 109 79 79 79 79 79 79 79 79 (2) (2) (2) (2) (2) (2) (2) (2) AC 38 3 95 (4) E2197 Disease-Free Survival:ER+/PR- E2197 Disease-Free Survival:ER+/PR+ 100 100 90 90 80 80 70 70 60 The ER/PR subgroups were prespecified stratification groups at randomization designed to balance the treatment arms. And are not powered to detect differences between the subgroups. While there is no statistically significant difference in the ER+ and ER- tumors, these curves illustrate the 4 prespecified ER/PR subgroups. In the ER-/PR- and the ER+/PR – seen on the left side of the slide, there were fewer events in the AT arm. For the ER-/PR- group, the 4 yr DFS was 83% for AT and 79% for AC. For the ER+/PR- group, the DFS was 90 % and 83% respectively for AT and AC, acknowledging that this subgroup is quite small. On the top right, the ER-/PR+ subgroup was extremely small and may represent lab error for ER and therefore this curve could be collapsed into the ER+/PR+ curve below it showing no difference between the 2 arms, and this represents the majority of patients. 60 Percent 50 Percent 50 40 40 30 30 20 20 10 10 12 24 36 48 60 72 12 24 36 48 60 72 Months Months N Events 4-Yr % (S.E.) N Events 4-Yr % (S.E.) AT 162 22 90 (2) AT 767 91 90 90 90 90 90 90 90 (1) (1) (1) (1) (1) (1) (1) AC 164 34 81 83 81 (3) (3) (3) AC 770 73 92 92 92 92 92 92 92 (1) (1) (1) (1) (1) (1) (1)

Disease Free Survival ER-/PR- 1.30 (0.96, 1.70) ER-/PR+ 0.30 (0.10, 0.95) ER+/PR- 1.64 (0.96, 2.80) Here the same subgroup data are illustrated in this forest plot of DFS where anything to the right of 1 favors AT. Again the largest group is the ER+/PR+ group with the very small ER-/PR+ group likely collapsing into it. This again suggests that the PR – tumors may potentially benefit from AT but the study was not powered to statistically detect these differences. The same pattern is seen for OS, data not shown. These data support the hypothesis presented by Don Berry at San Antonio, that the in the ER positive tumors the large benefit provided by Tamoxifen, overwhelms the potential benefit to chemo, or that the prognosis of these tumors is so good it is difficult to detect a difference between the 2 chemotherapy arms. Taken together along with the Genomic Health data, this data supports the hypothesis that the biology of the tumor may predict the benefit to individual therapies. ER+/PR+ 0.79 (0.58, 1.10) 0.1 0.2 0.5 1 2 5 Favors AC Favors AT

E2197 Conclusions These results show a better than expected outcome for both regimens. 87%(obs) vs 78% (expected for AC) DFS at 4 yrs. At 59 mo median follow-up, there is no difference in DFS or OS between AT and AC. Prespecified stratifications at randomization: LN, menopause, ER/PR – no significant difference between the 2 treatment arms. In PR negative tumors, a potential benefit to AT may be suggested. These results show a better than expected outcome for both regimens. 87%(obs) vs 78% (expected for AC) DFS at 4 yrs. At 59 mo median follow-up, there is no difference in DFS or OS between AT and AC. Prespecified stratifications at randomization: LN, menopause, ER/PR – no significant difference between the 2 treatment arms. In PR negative tumors, a potential benefit to AT may be suggested.

E2197: Issues for Discussion Would longer f/u change these results? Unlikely Observed DFS = 87% at 4 yrs. Expected DFS = 78% at 4yrs. Aromatase Inhibitor Affect: 60% on Tam; Median 41 mo; AI info collected; future analysis Subset analysis of prespecified ER/PR stratifications: Hypothesize that the biology of the primary tumor predicts outcome and benefit to specific therapies. Central review of ER/PR/Her 2 pending Genomic Health/ Sanofi-Aventis Analysis: Oncotype Genomic profiling Use as training set for validation with E1199 Pharmacogenomics PACCT- 1 Trial Would longer f/u change these results? Unlikely Observed DFS = 87% at 4 yrs. Expected DFS = 78% at 4yrs. The better than anticipated DFS may represent the continued improved prognosis over time that we have observed in Intergroup trials. In fact the predecessor to this trial, 9313, there was an 80% 5 yr DFS. What about the Aromatase Inhibitor Affect: 60% started Tam; About half have finished; with a Median of 41 mo on tamoxifen; AI info collected since 2004 for future analysis Subset analysis of prespecified ER/PR stratifications: lead to the Hypothesize that the biology of the primary tumor predicts outcome and benefit to specific therapies. Central review of ER/PR/Her 2 is ongoing With support from Genomic Health and Sanofi-Aventis we will perform the following analyses Oncotype Genomic profiling to Use these data as training set for validation with E1199 In addition to Pharmacogenomics In addition, These data support the design of the PACCT –1 trial Program for the assessment of clinical cancer tests – Phase III validation study of genomic profiling ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Intergroup 9313 AC vs. A->C; at median f/u of 5.3 yrs,, the estimated 5 yr DFS was 80%. Refer to NSABP studies of eight + years f/u to see differences in low risk population of tumors< 1 cm. B 13, 19, 14 and 20. Fisher at al. JNCI 93(2): 112-20. Jan 17, 2001 Prognosis and treatment of patient with breast tumors one cm or less and negative axillary nodes. ER - = 235: surgery +/- ctx ER + = 1024: surgery, tam +/- ctx 8yr RFS for ER -: Surgery = 81%; surgery + ctx = 90%; p=.06 Survival similar in both groups: 93 and 91%; p= .65. 8 yr RFS for ER+: Surgery = 86% Surgery/tam = 93%; p= .01 Surgery/tam/ctx = 95%; p= .07 compared with tam Survival was 90%, 92% ( p=,41). and 97% respectively. P=.01 in the latter 2 groups. Although the majority of tumor recurrences occur in the first decade of f/u, the proportion of recurrences that occur in the second decade of f/u increases in women with small tumors. Consequently a follow-up longer than 8 years is likely necessary to allow for a more meaningful assessment of the outcome of these patients. Mortality at 8 yrs f/up was 8% for t< 1 cm. I/2 of deaths were related to breast cancer. Therefore the findings in these patients with short follow-up should be viewed with caution. Would longer follow-up change these results? Statistically no, even though the entire group did better that anticipated compared to historical controls. PACCT-1 Program for the assessment of clinical cancer tests – Phase III validation study of genomic profiling

Anne O’Neill, Deborah Namande, Eric Ross Thank You Patients Data managers/ CRA’s CALGB, NCCTG, SWOG, EPP Anne O’Neill, Deborah Namande, Eric Ross

European Cooperative Trial in Operable Breast Cancer(ECTO): Improved freedom from progression from adding paclitaxel(T) to doxorubicin(A) followed by CMF Luca Gianni Abstract 513

ECTO: Schema Tumors > 2 cm randomized to : SURG ->A 75 mg/m2 x 4 -> CMF x 4 SURG ->AT 60/ 200 x 4 -> CMF x 4 AT 60/ 200 x 4 -> CMF x 4 -> SURG Tam for HR + Analysis: FFP A vs B B vs C

ECTO at 5 years Analysis A vs. B Pts. Events HR p A-CMF 453 91 .66 0.01* AT-CMF 451 63 Analysis B vs. C S-AT-CMF 451 63 1.22 0.24 AT-CMF-S 451 78 Data super imposable so far, no significant difference, however pCR had improved FFP.

ECTO: Main Treatment Outcomes A(%) B(%) C(%) Total FFP pCR 89 no pCR 75 N - 81 89 86 N + 1-3 79 86 71 N +>3 58 65 59 OS 82 91 90 No significant difference in OS. No significant difference in cardiac toxicity

Combined Analysis of NSABP-B31/NCCTG-N9831 Doxorubicin and Cyclophosphamide Followed by Paclitaxel with or without Trastuzumab as Adjuvant Therapy for Patients with HER-2 Positive Operable Breast Cancer Romond EH, Perez EA, Bryant J, Suman V, Geyer CE, Davidson N, Tan-Chiu E, Martino S, Swain SM, Kaufman P, Fehrenbacher L, Pisansky T, Vogel V, Kutteh LA, Yothers G, Visscher D, Brown AM, Jenkins R, Seay TE, Mamounas E, Abrams J, Wolmark N Combined Analysis of NSABP-B31/NCCTG-N9831

NSABP B-31 NCCTG N9831 Control: ACT Arm 1 Arm 2 Arm A Arm B Arm C Investigational: ACT+H Arm B Arm C = doxorubicin/cyclophosphamide (AC) 60/600 mg/m2 q 3 wk x 4 = paclitaxel (T) 175 mg/m2 q 3 wk x 4 = paclitaxel (T) 80 mg/m2/wk x 12 = trastuzumab (H) 4mg/kg LD + 2 mg/kg/wk x 51

Patient Eligibility HER-2 positive by FISH or +++ by IHC verified centrally (N9831) or by approved reference lab (B-31) Normal left ventricular ejection fraction No past or active cardiac disease including: History of myocardial infarction History of congestive heart failure Angina pectoris requiring medication Arrhythmia requiring medication Clinically significant valvular disease Uncontrolled hypertension LVH Cardiomegaly on CXR

LVEF Evaluation Schedule B-31 Arm 2 / N9831 Arm C AC Paclitaxel + Trastuzumab mo. 3 mos. 6 mos. 9 mos. 18 mos. B-31 Arm 1 / N9831 Arm A AC Paclitaxel mo. 3 mos. 6 mos. 9 mos. 18 mos.

Relationship of LVEF to LLN Asymptomatic Patients Rules for Trastuzumab Continuation Based on Serial LVEFs Relationship of LVEF to LLN Absolute Decrease of < 10% Absolute Decrease of 10 - 15% Absolute Decrease of  16% Within Normal Limits 1- 5 % below LLN  6 % below LLN Cont. Cont.* Cont. Hold * Hold * Once the patients start Herceptin, they will be monitored at set intervals by MUGA scan. The above criteria must be followed for continuing or stopping Herceptin in patients who are asymptomatic. If a repeat MUGA scan is indicated, that MUGA scan must fall into one of the categories labeled “continue” (above) before the patient can proceed with further weekly Herceptin doses. * Repeat LVEF assessment after 4 weeks - If criteria for continuation met – resume trastuzumab - If 2 consecutive holds, or total of 3 holds occur – discontinue trastuzumab

B-31: Trastuzumab Discontinuation Due to Asymptomatic or Symptomatic Cardiac Dysfunction by Quarter

Patient and Tumor Characteristics (%) AC  Paclitaxel + Trastuzumab 872 B-31 807 N9831 864 808 Age <50 50-59 ≥60 52 34 15 51 32 16 50 18 No. Pos Nodes 1-3 4-9 10+ 57 29 14 13 48 25 11 Hormone Receptors ER+ ER- PR+ PR- 53 47 41 58 46 39 60 Tumor Size ≤2.0 cm. 2.1-4.0 cm. >4.0 cm. 43 40 37 44 17 38

Statistical Analysis Median follow-up: 2.0 years (2.4 years on B-31/1.5 years on N9831) Primary endpoint: DFS analyzed by intent-to-treat Secondary endpoints: OS and Time to 1st Distant Recurrence Definitive analysis after 710 DFS events First interim analysis after 355 DFS events Stop trials only if equivalence is rejected at p=0.0005 (2p=0.001)

Disease-Free Survival ACTH 87% 85% ACT 75% % 67% N Events ACT 1679 261 ACTH 1672 134 HR=0.48, 2P=3x10-12 Years From Randomization B31/N9831

Forest Plot For Disease-Free Survival ALL DATA Age ≥60 50-59 40-49 ≤39 Hormone Receptor Positive Negative Tumor Size ≥ 4.1cm 2.1- 4.0 cm <2.0 cm No. Positive Nodes 10+ 4-9 1-3 Protocol N9831 NSABP B-31 0.2 0.4 0.6 0.8 1.0 1.2 1.4 Hazard Ratio

Disease-Free Survival 1 2 3 4 5 50 60 70 80 90 100 B-31 N9831 ACTH ACTH 87% 87% 85% ACT 86% ACT 78% 74% % 68% 66% N Events N Events ACT 807 90 ACT 872 171 ACTH 808 51 ACTH 864 83 HR=0.55, 2P=0.0005 HR=0.45, 2P=1x10-9 Years From Randomization

Time to First Distant Recurrence 100 ACTH AC->T+H 90% 90% 90% 90% 90% 90% 90 ACT AC->T 80 81% 81% 81% % 74% 74% 70 74% N Events N Events ACTH 1672 96 ACT 1679 194 AC->T 1679 194 60 AC->T+H 1672 96 HR=0.47, 2P=8x10-10 HR=0.47, 2P=8x10-10 50 1 2 3 4 5 Years From Randomization B31/N9831

Hazard of Distant Recurrence 120 100 ACT 80 Rate per 1000 Women /Yr 60 40 ACTH 20 1 2 3 4 Years From Randomization B31/N9831

B-31/N9831 Survival ACTH 94% 91% ACT 92% 87% N Deaths ACT 1679 92 HR=0.67, 2P=0.015 Years From Randomization B31/N9831

B-31: Post-AC LVEF and Age Are Independent Predictors of Trastuzumab-Associated CHF P(Age)=0.04 P(LVEF)<0.0001

Conclusions For high risk HER-2 positive breast cancer, trastuzumab given concurrently with paclitaxel following AC chemotherapy, reduces the risk of a first breast cancer event at 3 years by 52%. The relative risk reduction benefit was present and of similar magnitude in all subsets of patients analyzed. There is not, however, statistical power to establish efficacy in the node negative subset. The addition of trastuzumab reduced the probability of distant recurrence by 53% at 3 years, and the hazard of developing distant metastases appears, thus far, to decrease over time.

Conclusions 4. Results at a median follow-up of 2 years show a statistically significant survival advantage with a relative risk reduction of 33%. 5. The combination of trastuzumab and chemotherapy has a notable risk of cardiac toxicity. Careful monitoring of cardiac function is of vital importance if trastuzumab is to be used in the adjuvant setting.

Perez EA, Suman VJ, Davidson N, Martino S, Kaufman P, on Behalf of NCCTG N9831 May 2005 Update Perez EA, Suman VJ, Davidson N, Martino S, Kaufman P, on Behalf of NCCTG, ECOG, SWOG, CALGB

Radiation and/or hormonal therapy as indicated NCCTG N9831 Schema Paclitaxel qw x 12 Arm A: AC q3w x 4 RANDOMI Z E Arm B: AC q3w x 4 Paclitaxel qw x 12 H qw x 52 Paclitaxel qw x 12 + H qw x 12 Arm C: H qw x 40 AC q3w x 4 Radiation and/or hormonal therapy as indicated Perez E. Protocol NCCTG-N9831. H=trastuzumab (4mg/kg loading dose, followed by 2mg/kg); doxorubicin dose 60mg/m2; cyclophosphamide, 600mg/m2; paclitaxel, 80mg/m2 q3w=every 3 weeks; qw=weekly

Statistical Plan Addition of H to AC  T Two pairwise comparisons Goal To detect a 33% increase in median DFS from 6.3 to 8.4 years Final analysis At 663 events for A vs C comparison At 789 events for A vs B comparison Sequential AC  T  H vs Control: AC  T Concurrent AC  T + H  H Control: AC  T vs T=paclitaxel; DFS=disease free survival

Statistical Plan Timing of H Initiation Pairwise comparison Goal To detect a 29% increase in median DFS from 7.3 to 9.4 years Final analysis At 590 events for B vs C comparison Sequential AC  T  H Concurrent AC  T + H  H vs

No H if symptoms or LVEF ↓ >15% or ↓ to <LLN Cardiac Testing RANDOMI Z E  Arm A: AC x 4 Paclitaxel   Arm B: AC x 4 Paclitaxel H   Arm C: AC x 4 Paclitaxel + H H Time (months) 3 6 9 18–21 LVEF measurement No H if symptoms or LVEF ↓ >15% or ↓ to <LLN Pre-AC Post-AC LVEF=left ventricular ejection fraction; LLN=lower limit of normal

Impact of Joint Analysis on N9831 April 2005 Joint analysis with B-31: Concurrent approach DMC asked for an unplanned interim analysis comparing Arm B (sequential) vs Arm C (concurrent) to assist in patient management AC  T + H  H significantly improves disease-free and overall survival vs control: AC  T DMC=data monitoring committee

Patient/Event Status at Time of Joint Analysis April 2005 Patients Enrollment goals met (n: >3300) 700 patients on chemotherapy 2701 patients entered prior to 1/1/2005 Median follow up: 1.5 years Total disease-free survival events A and B: 220 (of 789 needed) B and C: 147 (of 590 needed)

Results Disease-Free Survival Joint Analysis *Stratified – nodal status and receptor status N9831 Analysis A B B C *Stratified – nodal status and receptor status **for patients randomized before 1/1/2005

Disease-Free Survival: A vs B N9831 100 90 80 70 60 50 40 30 20 10 AC → T → H Events=103 AC → T Events=117 % Hazard ratio=0.87 Stratified logrank 2P=0.2936 0 1 2 3 4 Years Number of patients followed A 979 629 353 168 15 B 985 637 403 169 20

Disease-Free Survival: B vs C N9831 AC → T + H → H Events=53 100 90 80 70 60 50 40 30 20 10 AC → T → H Events=84 % Hazard ratio=0.64 Stratified logrank 2P=0.0114 0 1 2 3 4 Years Number of patients followed B 842 501 285 162 20 C 840 520 285 178 17

Joint Analysis Results Overall Survival Joint Analysis Results *Stratified – nodal status and receptor status N9831 Analysis Results A B B C *Stratified – nodal status and receptor status

Other Relevant Factors for Patient Management HER2 testing Cardiac tolerability comparisons based on planned analyses

HER2 Testing in N9831 Modest level of concordance between local and central laboratories for both IHC and FISH With HercepTest™: 81% (78-83%) With FISH: 87% (84-90%) High level of agreement between central and reference laboratory results for HER2 94.5% for IHC (0, 1+, 2+) 95.1% for FISH (not amplified) Accurate HER2 testing is critical given the degree of trastuzumab benefit as a component of adjuvant therapy Conclusions: There was high level of discordance by either IHC or FISH between local and central laboratories: 20% for protein analysis when Herceptest was used locally, and 15% with FISH. When the discordant cases were retested there was a high level of agreement between central and the independent reference laboratory – for both IHC and FISH. Updated from Perez EA, et al. ASCO 2004 (abstract 567)

Cardiac Monitoring Plan Monthly formal review of LVEF, clinical data Interim analyses after 100, 300, and 500 patients per arm completed AC and followed at least 6 months ~ 9 months from registration Perez EA, et al. ASCO 2005 (abstract 556)

Effect of the Introduction of H on Cardiac Tolerability Difference in the incidence of cardiac events (CHF and cardiac deaths) between non-H and H arms is <4% 9 month analysis; 500 per arm with nl LVEF or LVEF decrease  15% from baseline (after AC) 0.0% (95% CI,0.0-0.7%) for control 2.2% (95% CI,1.1-3.8%) for control vs sequential 3.3% (95% CI,2.0-5.1%) for control vs concurrent* therapy with paclitaxel * at month 9, concurrent pts have received 3 additional months of H compared to sequential Perez EA, et al. ASCO 2005 (abstract 556)

Effect of Introduction of H on Disease Recurrence Conclusions 52% decreased recurrence with concurrent vs control treatment (P=3X10-12) (joint analysis finding) 13% decreased recurrence with sequential vs control treatment (P=0.2936) 36% decreased recurrence with concurrent vs sequential treatment (P=0.0114) More follow up is needed to determine whether this trend continues

NCCTG N9831 Next Steps Pre-specified interim analyses at 50%, 67%, and 75% of events still planned Continued exploration of predictive factors for cardiac toxicity Continued patient follow up

FIRST RESULTS OF THE HERA TRIAL ASCO, Scientific Session, May 16, 2005 FIRST RESULTS OF THE HERA TRIAL A randomized three-arm multi-centre comparison of: 1 year Herceptin® 2 years Herceptin® or no Herceptin® in women with HER-2 positive primary breast cancer who have completed adjuvant chemotherapy Martine J. Piccart-Gebhart, MD, PhD on behalf of: The Breast International Group (BIG), NON-BIG participating groups, Independent sites, F. Hoffmann – La Roche Ltd.

ACCRUAL: 5090 WOMEN 478 centers from 39 countries (2002-2005) NORDIC COUNTRIES EASTERN EUROPE:  11% CANADA 71.5% EU JAPAN  12% ASIA PACIFIC CENTRAL & SOUTH AMERICA 5.5% AUSTRALIA – NEW ZEALAND SOUTH AFRICA

HERA TRIAL DESIGN Women with HER2 POSITIVE invasive breast cancer IHC3+ or FISH+ centrally confirmed Surgery + (neo)adjuvant chemotherapy (CT)  radiotherapy Stratification Nodal status, adjuvant CT regimen, hormone receptor status and endocrine therapy, age, region Randomization Trastuzumab 8 mg/kg  6 mg/kg 3 weekly x 2 years Trastuzumab 8 mg/kg  6 mg/kg 3 weekly x 1 year Observation

KEY INCLUSION CRITERIA Centrally confirmed HER-2 overexpression or amplification Node-positive or (sentinel) node-negative with  T1c Completed  4 cycles of approved (neo)adjuvant chemotherapy regimen Baseline LVEF  55% (Echo or MUGA) Known hormone receptor status

ENDPOINTS AND ANALYSIS PLAN Target accrual: 4482 HR = 0.77 (power 80% 2 sided  = 0.025) for each pairwise test (1y vs nil or 2y vs nil) SAFETY EFFICACY Tolerability Incidence of cardiac dysfunction. Primary endpoint: DFS Secondary endpoints: RFS, DDFS, OS, 2 years vs 1 year trastuzumab Three interim analysis of cardiac endpoints after n = 300 n = 600 n = 900 pts Stopping rule:  4% absolute increase in primary cardiac events One interim efficacy analysis (n = 475 events) One primary core analysis (n = 951 events)

HERA FLOW CHART 5090 Women enrolled 5081 with available data 1 year median follow-up Efficacy Analysis N=3387 2y trastuzumab N=1694 1y trastuzumab N=1694 Observation N=1693 N=20 N=3 N=26 Safety Analysis N=3413 N= 1677 1y trastuzumab N=1736 Observation

PATIENT/TUMOR CHARACTERISTICS Age (%) Observation (n = 1693) 1 year trastuzumab (n = 1694) 7.3 7.6 < 35 y 35- 49 y 50 - 59 y  60 y missing 43.7 44.3 32.7 31.8 16.2 16.2 0.2 0.2 Adjuvant chemotherapy (%) 6.1 6.2 68.3 67.9 25.5 26.0 No anthracyclines, no taxane Anthracyclines missing 0.1 0.2 Anthracyclines + taxanes

PATIENT/TUMOR CHARACTERISTICS Menopausal status at randomization (%) Observation (N=1693) 1 year trastuzumab (N=1694) 15.4 Prem 16.1 37.2 Uncertain 37.9 47.1 Postmenopausal 50.0

PATIENT/TUMOR CHARACTERISTICS Observation (N=1693) 1 year trastuzumab (N=1694) Nodal Status (%) Any (neoadjuvant) 10.2 11.1 Node neg. 32.9 32.1 1-3 + nodes 28.9 28.5  4 + nodes 27.9 28.3 missing 0.1 0.2 Hormone Receptor (%) HR negative 49.9 49.0 49.0 HR positive 50.0 50.9

ADJUVANT ENDOCRINE THERAPY Observation 1 year trastuzumab TAM 64% AI TAMAI 9% 11% LHRH ± TAM 16% TAM 66% 8% 17% AI TAMAI LHRH ± TAM

OVERVIEW OF ADVERSE EVENTS Observation (N=1736) 1 year trastuzumab (N=1677) N % N % Patients with at least one grade 3 or 4 AE 75 4.3 132 7.9 Patients with at least one SAE 81 4.7 117 7.0 3 (a) 6 (b) Fatal AE Treatment withdrawals 143 (c) 8.5 Cardiac failure, suicide, unknown Cerebral hemorrhage, cerebrovascular accident, sudden death, appendicitis, two unknown Reason: safety in 6%, refusal in 2.5%

SAFETY ANALYSIS POPULATION Cardiotoxicity Observation N=1736 1 year trastuzumab N=1677 Decrease by  10 EF points and LVEF < 50% 2.2 % 7.1 % 0 % (95% CI: 0.00-0.21) 0.5% (95% CI: 0.25-1.02) Same LVEF criteria and symptomatic CHF NYHA class III/IV, confirmed by cardiologist Cardiac death 0.1% 0%

DISEASE-FREE SURVIVAL % alive and disease free

DISEASE-FREE SURVIVAL Type of First Event Observation n= 220 events 1 year trastuzumab n= 127 events Distant event 70% n=154 n= 85 67% Loco regional event 23% n=50 n=27 21% 3% n=7 n=6 5% Contralateral breast Ca 3% n=6 n=3 2% Second non breast malignancy Death as first event 1% n=3 n=6 5%

DFS BENEFIT IN SUBGROUPS HR: 1 year trastuzumab vs observation Hazard Hazard ratio ratio n n All All 3387 3387 0.54 0.54 Nodal Nodal status status Any, neo Any, neo - - adjuvant chemotherapy adjuvant chemotherapy 358 358 0.53 0.53 0 pos, no neo 0 pos, no neo - - adjuvant chemotherapy adjuvant chemotherapy 1100 1100 0.52 0.52 1 1 - - 3 pos, no neo 3 pos, no neo - - adjuvant chemotherapy adjuvant chemotherapy 972 972 0.51 0.51 ³ ³ 4 pos, no neo 4 pos, no neo - - adjuvant chemotherapy adjuvant chemotherapy 953 953 0.53 0.53 Adjuvant chemotherapy regimen Adjuvant chemotherapy regimen No anthracycline or taxane No anthracycline or taxane 203 203 0.64 0.64 Anthracycline, no taxane Anthracycline, no taxane 2307 2307 0.43 0.43 Anthracycline + taxane Anthracycline + taxane 872 872 0.77 0.77 Receptor status/endocrine therapy Receptor status/endocrine therapy Negative Negative 1674 1674 0.51 0.51 Pos + no endocrine therapy Pos + no endocrine therapy 467 467 0.49 0.49 Pos + endocrine therapy Pos + endocrine therapy 1234 1234 0.68 0.68 Age group Age group <35 yrs <35 yrs 251 251 0.47 0.47 35 35 - - 49 yrs 49 yrs 1490 1490 0.52 0.52 50 50 - - 59 yrs 59 yrs 1091 1091 0.53 0.53 ³ ³ 60 yrs 60 yrs 549 549 0.70 0.70 Region Region Europe, Nordic, Canada, SA, Aus, NZ Europe, Nordic, Canada, SA, Aus, NZ 2430 2430 0.58 0.58 Asia Pacific, Japan Asia Pacific, Japan 405 405 0.42 0.42 Eastern Europe Eastern Europe 364 364 0.31 0.31 Central + South America Central + South America 188 188 0.90 0.90 Favors Favors 1 1 Favors Favors 2 2 trastuzumab trastuzumab observation observation

SECONDARY EFFICACY ENDPOINTS Intent-to-treat Analysis RFS DDFS OS 0.50 0.51 0.76 No of events 209 113 179 98 37 29 95% CI p value (logrank) 2y outcome (%) 0.40-0.63 < 0.0001 78.6 vs 87.2 0.40-0.66 < 0.0001 81.8 vs 89.7 0.47-1.23 <0.26 95.0 vs 96.0 Observation 1 year trastuzumab

CONCLUSIONS At one year median follow-up: Trastuzumab given every 3 weeks for one year following adjuvant chemotherapy significantly prolongs DFS and RFS for women with HER-2 positive early breast cancer Trastuzumab significantly reduces the risk of distant metastases Trastuzumab’s clinical benefits are independent of patients’ baseline characteristics (nodal status, hormone receptor status, ...) and of type of adjuvant chemotherapy received

CONCLUSIONS Trastuzumab therapy is associated with a low incidence of severe symptomatic congestive heart failure; longer follow-up is needed to better quantify this risk All patients continue to be followed for long-term safety: patients in the observation arm will be offered trastuzumab (guidelines in preparation) Results regarding optimal trastuzumab duration (1 versus 2 years) should be available by 2008

HERA Study Design Elements Randomized following ctx DFS was primary endpoint Most patients did not receive taxane In contrast to the Joint analysis, HERA included a large percentage of node negative pts(About 1/3). Very short median follow-up

Adjuvant Trastuzumab Summary and Conclusions Does adjuvant trastuzumab improve DFS? YES! Should we give trastuzumab with or following CTX? What is the appropraite duration of trastuzumab? What is the price of trastuzumab?

Should we give Trastuzumab before or after CTX? Preclinical data suggest that trastuzumab may amplify ctx’s pro-apoptotic effects. Synergistic activity in preclinical models for some ctx Cardiotoxicity concerns when trastuzumab is given in proximity to anthracyclines.

What is the appropriate duration of Trastuzumab? Unknown (HERA 1 vs. 2 yr pending) Current data supports one year of therapy Current data supports initiation of therapy for up to 6 months following completion of chemotherapy or radiation therapy Could we get by with less trastuzumab? ( ie. only with chemo?)

What is the price of Trastuzumab? Cardiac Toxicity(CHF) can be consequence of using trastuzumab Rate = 3.3-4.3% AC-TH vs. 0-0.5% AC-T (B31/ N9831) Rate = 0.5-2.2% post ctx (HERA/N9831) Degree of reversibility uncertain and requires further follow-up Long term effects unknown While benefit far outweighs the risks, the price is real and should be discussed with patients

Adjuvant Breast Cancer Node Positive and High Risk Node Negative BCIRG 006 Adjuvant Breast Cancer Node Positive and High Risk Node Negative 4 x AC 60/600 mg/m2 4 x Docetaxel 100 mg/m2 ACT HER2 + FISH ACTH 1 Year Trastuzumab N=3150 480 centres 6 x Docetaxel and Platinum salts 75 mg/m2 75 mg/m2 or AUC 6 TCH 1 Year Trastuzumab

BCIRG 006 LVEF Decline by NYHA Class AC-T AC-TH TCH >10 < LLN 9 34 7 >15%< LLN 6 25 4 Grade 3-4 CHF 1 18 1 Implication: Trastuzumab by itself is not cardiotoxic; it becomes so when it keeps company with doxorubicin.

Intergroup Guidelines for N9831 For women receiving trastuzumab, continue until 1 year is completed. For women randomized to 1 yr TH, continue as planned For women on Arm A: AC-T and are at most 6 months from completion of paclitaxel, begin weekly trastuzumab and continue until you have completed 1 yr of trastuzumab with cardiac testing.

Intergroup Guidelines for N9831 For women on Arm A: AC-T and have not started paclitaxel, begin weekly trastuzumab with paclitaxel and continue until 1 yr of trastuzumab is completed, with cardiac testing. For women on Arm B: AC-T-H, and you have not begun trastuzumab, begin trastuzumab with paclitaxel and continue for 1 yr. with cardiac testing. If ctx completed > 6 mo. and have not received trastuzumab, discuss risks and benefits.

E2100 A Randomized Phase III Trial of Paclitaxel versus Paclitaxel plus Bevacizumab as First-Line Therapy for Locally Recurrent or Metastatic Breast Cancer KD Miller, M Wang, J Gralow, M Dickler, MA Cobleigh, EA Perez, TN Shenkier, NE Davidson Indiana University Cancer Center, Dana Farber Cancer Institute, Pudget Sound Oncology Consortium, Memorial Sloan Kettering Cancer Center, Rush-Presbyterian-St. Luke’s Medical Center, Mayo Clinic, British Columbia Cancer Agency, Vancouver Cancer Center, Johns Hopkins Oncology Center

Rationale Tumor growth is dependent on angiogenesis Bevacizumab is a humanized monoclonal antibody directed against VEGF Recognizes all VEGF-A isoforms Active in patients with refractory MBC 9% response rate as monotherapy Increases ORR but not PFS in combination with capecitabine Greater activity expected in less heavily pre-treated patients

Study Design Stratify: DFI < 24 mos. vs. > 24 mos. < 3 vs. > 3 metastatic sites Adjuvant chemotherapy yes vs. no ER+ vs. ER- vs. ER unknown RANDOMI ZE Paclitaxel + Bevacizumab Paclitaxel 28-day cycle: Paclitaxel 90 mg/m2 D1, 8 and 15 Bevacizumab 10 mg/kg D1 and 15

Key Eligibility Criteria Locally recurrent or metastatic breast cancer HER2+ only if prior treatment with trastuzumab or contraindication No prior chemo regimens for MBC Adjuvant taxane allowed if DFI > 12 months ECOG PS 0 or 1 No anti-tumor therapy within 21 days No CNS mets (head CT or MR required) No significant proteinuria (> 500 mg/24 hr) No therapeutic anticoagulation

Statistical Design - Efficacy Primary endpoint: Progression-Free Survival 85% power for a 33% improvement 6 vs. 8 months One-sided type I error  2.5% Requires 650 eligible patients Final analysis after 546 PFS events Interim analyses after 270 and 425 events Asymmetric boundaries to stop early either for demonstrated benefit or for lack of benefit O-Brien-Fleming boundaries and repeated confidence interval analyses at each interim

Statistical Design - Safety Type I event: Grade 4 hemorrhage or HTN Acceptable rate: 1% Type II event: Grade 3/4 thrombosis or embolism Acceptable rate: 5%

Current Analysis Study activated Dec 21, 2001 Closed March 24, 2004 715 eligible patients First planned interim analysis Data cut-off February 9, 2005 355 events Progression – 291 Death without documented progression - 64

Patient Characteristics Paclitaxel (n=350) Pac. + Bev. (n=365) Treated 346 365 Median age 55 (27-85) 56 (29-84) DFI < 24 months 41% > 3 sites 29% 28% Adjuvant chemo. 64% 65% ER+ 63%

Response P<0.0001 P<0.0001 34.3% 28.2% 16.4% 14.2% 316 330 250 236

Progression Free Survival HR = 0.498 (0.401-0.618) Log Rank Test p<0.001 Months 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 PFS Proportion 10 20 30 Pac. + Bev. 10.97 months Paclitaxel 6.11 months

Overall Survival OS Proportion Months Pac. + Bev. Paclitaxel 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 10 20 30 40 Months OS Proportion Pac. + Bev. Paclitaxel HR = 0.674 (0.495-0.917) Log Rank Test p=0.01

Bevacizumab Toxicity NCI-CTC Grade 3 and 4 Paclitaxel (n=330) Pac. + Bev. (n=342) % Grade 3 Grade 4 HTN* 13 0.3 Thromboembolic 0.9 1.2 Bleeding 0.6 Proteinuria** 1.5 *p<0.0001; **p=0.0004 NCI-CTC v3.0, worst per patient

Other Toxicities NCI-CTC Grade 3 and 4 Paclitaxel (n=330) Pac. + Bev. (n=342) % Grade 3 Grade 4 Neuropathy* 13.6 0.6 19.9 Fatigue 2.7 4.7 0.3 Neutropenia 3 0.9 4.4  LVEF *p=0.01 NCI-CTC v3.0, worst per patient

Ongoing Correlative Studies Quality of Life (FACT-B) Circulating markers Serum VCAM-1 Urine VEGF Analysis of primary tumor samples VEGF expression

Conclusions and Future Directions Addition of bevacizumab to paclitaxel Significantly prolongs progression free survival Increases objective response rate Longer follow-up required to assess impact on OS Further studies should Explore the role of Bevacizumab in the adjuvant setting Develop methods to identify patients who are most likely to benefit from VEGF-targeted therapies

Adjuvant Pilot Trial Rationale Most successful use of anti-angiogenic therapy predicted to be in adjuvant setting Require large trial for proof of concept Limitations of metastatic trials Chronic therapy in only a few patients Different tolerance for toxicity Different metabolism (?) Less concern for rare but potentially fatal toxicities

E2104 Schema Arm A: ddBAC >BT >B Arm B: ddAC >BT >B R E G I S T Doxorubicin 60 mg/m2 plus Cyclophosphamide 600 mg/m2 Bevacizumab 10 mg/kg every 14 days x 4 Paclitaxel 175 mg/m2 Bevacizumab 10 mg/kg every 14 days x 4 Bevacizumab 10 mg/kg every 14 days x 18 Doxorubicin 60 mg/m2 plus Cyclophosphamide 600 mg/m2 every 14 days x 4 Paclitaxel 175 mg/m2 Bevacizumab 10 mg/kg every 14 days x 4 Bevacizumab 10 mg/kg every 14 days x 22 Arm B: ddAC >BT >B *Hormone therapy and radiation per standard care