Anti-HER2 Epitope Map Herceptin (4D5) (aa ) TK CRD-2 CRD-1 data from L. Bald & B. Fendly Extracellular Domain Intracellular Domain CB11

C alone C + H FISH- 38% 38% FISH+ 31% 54% n=451 (25-50%)(24-52%) (24-38%) (47-61%) FISH/Clinical Outcome Analysis H0648g Response Rate

Number of Patients FISH+FISH- Total patients evaluable17336 CR80 PR250 CR + PR33 (19%)0 (0%) (95% CI: 14%–26%)(95% CI: 0%–10%) CR + PR + SD > 6 mo 41 (24%) 0 (0%) FISH/Clinical Outcome Analysis H0649g-Response Rate IHC 2+/3+ combined

Number of Patients FISH+FISH- Total patients evaluable8229 CR70 PR221 CR + PR29 (35%)1 (3%) (95% CI: 25%–47%)(95% CI: 0%–20%) CR + PR + SD > 6 mo 41 (50%) 1 (3%) FISH/Clinical Outcome Analysis H0650g-Response Rate IHC 2+/3+ combined

Use Herceptin ® upfront *2/3 subsequent Herceptin ®

FISH versus IHC 0/1+ in the Herceptin ® plus weekly paclitaxel trial Fornier, personal communication Seidman A, et al. J Clin Oncol 2001;19:2587–95 *3 partial responses; 3 stable disease  6 months

Intergroup Real World IHC vs Central Test OUT = Outside Lab % False (+) (3+) OUT vs Central 27 (3+) OUT vs FISH 31 (3+) Central vs FISH 7

NSABP B-31 Central Review (104 cases) * cases whose eligibility was determined by FISH were excluded from analysis

Summary Clinical outcomes data in patients with prospective FISH and IHC testing  IHC 3+/FISH+  IHC 2+/FISH+  IHC 3+/FISH-  IHC 0 and 1+/FISH+ Cardiac incidence in 1000 patients Exploratory comparison of Herceptin plus Taxol vs Herceptin plus Taxotere    Gabriel N. Hortobagi, MD, FACP and Pamela N. Klein, MD HER-First

Recent Cardiac Data H = Herceptin Pamela M. Klein, MD Cardiac Dysfunction 

Herceptin and Chemotherapy: In-vitro Activity Pegram et al. Oncogene. 1999; 18: Pietras et al. Oncogene. 1998; 17: Synergistic (CI < 1) Additive (CI = 1) Antagonistic (CI > 1)

Taxotere + Herceptin Abstracts

Weekly Docetaxel* + Herceptin MDACC ( First or 2 nd Line) (30 pts) 63% RR 67% FISH (+) 76% ECD (+) 9 mo Med. TTP * 35 mg/m 2 /wk x 3/course (med D.I. = 24 mg/m 2 /wk) JCO 20: 1800, 2002

Toxicity Weekly Docetaxel + Herceptin (30 pts) Dexamethasone 4 mg x 3 doses 23% DC d Tox 5 pleural effusion 1 fatigue 1 fungal infection 1 bleeding ulcer JCO 20: 1800, 2002

Toxicity Weekly Docetaxel + Herceptin MDACC - 30 pts 93% Epiphora - Stenosis 12 Pts Cannalicular Intubation 10% Gr 1 LVEF 16% Gr 2 LVEF 1 case CHF (LVEF = 48%) JCO 20: 1800, 2002  

Clinical Activity of Trastuzumab and Vinorelbine in Women with Her2- Overexpressing Metastatic Breast Cancer: JCO May 2001: Burstein et. Al

ResponseNRR (%) CR38 PR2768 CR + PR3075* SD > 6 m25 PD820 *Conditional corrected 95% confidence interval 57%-89%. Response Rates: Overall

Phase II Trial of Weekly Vinorelbine and Trastuzumab as First-Line Therapy in Patients With HER2-Positive Metastatic Breast Cancer: SABCS 2001; Jahanzeb et. Al.

Navelbine + Herceptin 20 Pts. RR = 60% Jahanzeb - Asco Abst 1986

TRastuzumab And VInorelbine Or Taxane (TRAVIOTA) Eligibility: 1st line chemo HER2+ RECIST Multicenter n=250 Endpoints: RR, TTP X-over RR, TTP HER2 + MBC First-line Chemo & Trastumuzab Trastuzumab & Vinorelbine Trastuzumab & Weekly Taxane (paclitaxel or docetaxel) Progressive Disease

Xeloda ® plus Herceptin ® : activity against BT474 breast cancer xenografts Ouchi KF et al. Cancer Chemother Pharmacol (in press) 1, * * * Tumour volume (mm 3 ) Control Xeloda Herceptin Xeloda + Herceptin Days after inoculation *p<0.05

Xeloda ® plus Herceptin ® : the German experience 18 patients with anthracycline and taxane-pretreated HER2+ MBC received 21-day cycle of standard-dose Herceptin, weekly Xeloda 1,125mg/m 2 twice daily, days 1–14 47% ORR in 13 patients Median response duration of 10 months (range 7–18) Minimal side effects Bangemann N et al. Ann Oncol 2000; 11:143 (Abst 653P)

Gemzar + Herceptin 3 + Overexpression Population = Heavily Pretreated (64 Pts.) R.R. = 45% T.T.P (medium) = 5.8 mo. San Antonio 2001 (Abst 523)

Coley (CpG 7909) (+) Herceptin Herceptin acts by modulating signal transduction pathways and through ADCC CpG stimulates ADCC In a mouse model CpG as active as Herceptin Markedly synergistic Clin. Trial in Herceptin Resistant Pts.

Schema of Administration Taxotere Platinum Salt Every 3 weeks At least 6 cycles Herceptin weekly until PD Premedication Standard Taxotere premed Standard CDDP hydration

TCH - Response Rates First Line Patients 7/17 (41%) [19-67] 23/36 (64%) [46-79] 23/36 (64%) [46-79] FISH negative** FISH positive** Overall ORR 95% CI ORR 95% CI 31/55 (56%) [40-69] ORR 95% CI ORR 95% CI 49/62 (79%) [66-88] 49/62 (79%) [66-88] 27/35 (77%) [59-90] 27/35 (77%) [59-90] 16/19 (84%) [60-96] 16/19 (84%) [60-96] UCLA carbo UCLA carbo BCIRG cis BCIRG cis

TCarboH – Time to Progression First Line Patients by FISH Result * FISH +FISH - Patients3819 Median TTP (mos) % CI[9.1-NE*][ ] Events15 Censored Still responding Further Therapy Lost to Follow-up NE* = Not Estimable * 3 patients were treated in second line, 2 patients did not have tumor samples available for FISH testing

Dana - Farber Preoperative Trastuzumab & Paclitaxel: Tumor Response Rates

Schema Reevaluate (Week 17) Reevaluate ProgressionProgression StableStable Stop Herceptin Begin Pac / Carbo Stop Herceptin Begin Pac / Carbo Continue 8-week courses until PD or 12 months CR, PR, MR Continue Weekly Herceptin for 8 addt’l weeks (weeks 9-16) Begin weekly Herceptin / Pac / Carbo --- Continue 8-wk courses until progression or total 12 mos. treatment Begin weekly Herceptin / Pac / Carbo --- Continue 8-wk courses until progression or total 12 mos. treatment Herceptin Weekly x 8 Herceptin ReevaluateReevaluate

Herceptin / Paclitaxel / Carboplatin Response to Herceptin induction (58 pts.) ¬ ORR 19%; SD or better 60% Response to H / P / C (34 pts.) ¬ ORR 68%; SD or better 73% Response to P/C (18 pts. with PD on Herceptin) ¬ ORR 50%

Neoadjuvant Cisplat + Taxotere + Herceptin U of Miami (16 Pts.) PRE Herceptin Std. Dose T/C 70 mg/m 2 each q 21 d POST AC x 4 Asco Abst % RR 25 % pCR

Herceptin Q 3 Wks. 8 mg./kg. Loading -> 6 mg. /kg. Q 3 wk. Taxol 175 mg./m 2 Q 3 wk. x 8 1/2 Life > 3 Wks. AUC and Peak (? More Tox ?) Trough Levels Therapeutic ( > 20 ng./ml ) After 2 Doses Reanalysis Pivotal Trials - T1/2 = 25 Days Time to Steady State = 18 Wks. Proc Asco Abst. 271 

Trough levels - weekly vs q3w Week Number Herceptin (ug/mL) Week Number Herceptin (ug/mL) Weekly AdministrationQ-3 Weekly Administration

Summary Herceptin administered q3w is safe with no unexpected toxicity. No interaction of Taxol and Herceptin pharmacokinetics was observed. Trough levels for q3w Herceptin were similar to those seen with weekly dosing. Peak and average serum concentrations were higher than those seen with weekly Herceptin. Half-life of Herceptin was 21 days. This suggests that it could take approximately 18 weeks after discontinuing Herceptin to clear the drug from the body. Karen A. Gelmon, MD, FRCPC Herceptin + Taxol q3w

Adjuvant Herceptin Q3 Wk 2001 Hera Intergroup BCIRG - Maintenance

Should Herceptin be continued in patients with disease progression on Herceptin? Limited clinical data Depends on mechanism of action of Herceptin - ? Alters sensitivity of breast cancer cells to cytotoxic therapy - ? Interferes with anti-apoptotic pathways Clinical anecdotes suggest some activity   

Herceptin + Vinorelbine Study Design (MDACC) Progressive disease after Herceptin + Taxane-based Therapy (HER2 +) Vinorelbine (Single Agent) Vinorelbine + Herceptin

(q3w x 4) Adjuvant Taxol ® + Herceptin ® (T+H)  AC, Then Continued Herceptin (Trial E-2198): Schema Hypothesis: T + H  AC is less cardiotoxic than AC  T + H Patients: node+, HER2 positive (IHC 2+/3+*); no prior CHF or recent MI; LVEF > 50% (n = 234) (qw x 10) LVEF testing Taxol 175 mg/m 2 q3w Herceptin 4 mg/kg first wk, then 2 mg/kg qw Doxorubicin 60 mg/m 2 + cyclophosphamide 600 mg/m 2 q3w (3-wk break) (qw x 52) 6 mo 1 y (qw x 10)

Adjuvant Taxol  + Herceptin  (T + H)  AC, Then Continued Herceptin (E-2198): Cardiotoxicity Primary end point: rate of clinical CHF Secondary end point: > 10% absolute decrease in LVEF from baseline  Patients to go off Herceptin for LVEF drop of > 20%, LVEF drop below LLN, or CHF Results through immediate post-AC evaluation  CHF in 4 patients (< 2%), 3 post-AC  LVEF below LLN: 2.8% post-T + H, 6% post-AC  LVEF drop of > 10%: 9% post-T + H, 13.2% post-AC Update of Sledge et al. Breast Cancer Res Treat. 2001;69:209. Abstract 4.

Adjuvant Therapy With Herceptin ® in the NSABP B-31 Trial Patient characteristics: node+, HER2 positive (IHC 3+* or FISH+ † ) *HercepTest TM. † PathVysion TM or INFORM ® (>5 copies/cell). (q3w x 4) Taxol ® 175 mg/m 2 q3w Herceptin 4 mg/kg first wk, then 2 mg/kg qw Doxorubicin 60 mg/m 2 + cyclophosphamide 600 mg/m 2 q3w Adjuvant tamoxifen for ER+ or PR+ patients. Romond. Protocol NSABP-B-31. Activation: March 2000 (n = 2700) (q3w x 4) (qw x 52)

(n = 3000) (qw x 52) Adjuvant Therapy With Herceptin ® in the Intergroup Trial (N9831): Schema Patient characteristics: node+, HER2 IHC 3+ or FISH+ (> 5 copies/cell) (q3w x 4) (qw x 12) (qw x 52) Taxol ® 80 mg/m 2 qw Herceptin 4 mg/kg first wk, then 2 mg/kg qw Doxorubicin 60 mg/m 2 + cyclophosphamide 600 mg/m 2 q3w Radiotherapy for all pts  5 wks after Taxol, with tamoxifen for all ER+ pts at initiation of therapy. Perez. Protocol NCCTG-N9831. Horton. Cancer Control. 2001;8:103.

(n = 3150) Node+/ High Risk Node–/ FISH+ Adjuvant Therapy With Herceptin ® : Breast Cancer International Research Group Trial (BCIRG 006) (q3w x 4) (qw x 12)(q3w x 14) (q3w x 6) (q3w x 12)(qw x 18)  Herceptin 4 mg/kg first wk, then 2 mg/kg qw  Herceptin 6 mg/kg q3w Taxotere ® 100 mg/m 2 q3w A 60 mg/m 2 + C 600 mg/m 2 q3w Carboplatin AUC 6 + Taxotere 75 mg/m 2 q3w

Randomize Primary Management (chemotherapy, local or locoregional radiation) Stratify Surgery Herceptin ® q3w x 12 mo N=1100 Herceptin q3w x 24 mo N=1100 Observation N=1100 HER2 Adjuvant (HERA) Trial: Schema Patients HER2 IHC 3+/FISH+ Courtesy of Clifford Hudis.

Number of Patients in Adjuvant Herceptin Trials Accrual (~June ’02) Target NSABP720 (27%)2700 Intergroup781 (26%)3000 BCIRG (22%)3150 HERA 50 (2%)3300 Total2230 (18%)12150