0. Howard A. Burris III, MD, FACP
Managing HER2- Positive Breast Cancer in the Metastatic Setting: The Evolution of Targeted Therapies
Howard A. Burris III, MD, FACP
Chief Medical Officer and Director of Drug Development
Sarah Cannon Research Institute
Memphis, TN
Lee Schwartzberg, MD
Medical Director, West Clinic
Chief, Division of Hematology/Oncology
Professor of Medicine
University of Tennessee Health Science Center

1. Breast Cancer Mortality
Breast cancer mortality has dropped by nearly one-third since 1990
Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) Lancet 1

2. HER2+ Breast Cancer Subtypes
Using the population-based California Cancer Registry, 114,786 incident cases of Stages 1-3 invasive breast cancer diagnosed between 2000 and 2006 were identified. Cases were assigned to Low, Intermediate, or High Risk categories. Five-year-relative survival was computed for the three St Gallen risk categories and for the ER/PR/HER2 subtypes for further differentiation. This study period was selected because it is prior to the era when trastuzumab was routinely administered to women with early breast cancer that overexpressed HER2
A tumor is considered to be ER negative and PR negative if less than 5% of tumor cell nuclei are immunoperoxidase positive in immunohistochemistry (IHC) assays. ER and PR status may also have been determined by examining cytosol protein (ER negative or PR negative if there are fewer than 3 or 5 fmol/mg of cytosol protein, respectively) HER2 was assessed through IHC or fluorescence in situ hybridization (FISH)
Bauer et al. BMC Cancer 2010, 10:228
HER2+ Breast Cancer Subtypes
N=114,786
~21% HER2+
~79% HER2-
7.1%
10.8%
Breakdown of the 21% HER2+
3.3%
ER+/PR+/HER2+
ER+/PR-/HER2+
ER-/PR+/HER2+
ER-/PR-/HER2+
0.5%
Bauer K., Cancer. 2010;10:228. 2 2

3. Survival for HER2+ Subtypes
Clinical and pathologic features and survival of the four subtypes were compared
In ER/PR+,HER2-, chemotherapy conferred significant overall survival advantages
Subtype comparison revealed statistically significant differences in outcomes
Onitilo A. Clin Med Res Opin. 2009;7(2):4-13. 3 3

4. Signal Transduction by the HER Family Promotes Proliferation, Survival, and Invasiveness
Receptor-specific
ligands
HER2
HER1, HER2,
HER3, or HER4
HER3
HER4
HER2
VEGF
HER1
(EGFR)
PI3K P
SOS
Plasma
membrane P
Tyrosine kinase
domains
The human epidermal growth factor receptor (HER) gene family. This image depicts the complex crosstalk between members of the HER family of receptor tyrosine kinases and intracellular signaling. Activated HER receptors can function to both stimulate and inhibit downstream signaling of members of other biologic pathways. Note that HER-2 has no activating ligands and HER-3 lacks a tyrosine kinase domain. HER-2–mediated signaling is associated with cell proliferation, motility, resistance to apoptosis, invasiveness, and angiogenesis. The figure shows the complexity of signaling pathways initiated by, and influenced by, HER family protein receptors at the cell surface. Abbreviations: Amp, amphiregulin; β-cel, β-cellulin; EGF, epidermal growth factor; Epi, epinephrine; HB-GF, heparin-binding growth factor; MAPK, mitogen-activated protein kinase; MEK, MAPK/extracellular signal–related kinase kinase; NRG, neuregulin; PI3K, phosphatidylinositol 3′ kinase; SOS, son of sevenless; TGFα, transforming growth factor α; VEGF, vascular endothelial growth factor. P
RAS
Akt
RAF
MAPK P
MEK
Cytoplasm
Cell proliferation
Cell survival
Cell mobility and invasiveness
Nucleus 4
Ross JS, et al. The Oncologist. 2009;14:
Transcription

5. Current Assays of HER2/neu
Immunohistochemistry
‘0’ (negative)
‘1+’ (negative)
‘2+’ (equivocal)
‘3+’ (positive)
Fluorescence in situ hybridization (FISH)
Online Reference:
HER2 gene no amplification FISH negative
HER2 gene amplification FISH positive
Murthy SS, et al. Indian J Pathol Microbiol. 2011;54(3): 5

6. Optimal Testing Algorithm Immunohistochemistry (IHC)
Breast Cancer Specimen (invasive component)
HER2 testing by validated IHC assay for HER2 protein expression
Positive for HER2 protein expression IHC 3+ (defined as uniform intense membrane staining of >30% of invasive tumor cells)
Negative for HER2 protein expression IHC 0 or 1+
Equivocal for HER2 protein expression IHC 2+
Test with validated assay for HER2 gene amplification
Positive for HER2 gene amplification
Negative for HER2 gene amplification
Equivocal HER2 gene amplification (Patients with HER2/CEP17 ratio ≥2.0 were eligible for the adjuvant trastuzumab trials) 6

7. Optimal Testing Algorithm FISH
Breast Cancer Specimen
HER2 gene amplification FISH positive
HER2 gene no amplification FISH negative
HER2 testing by validated FISH assay for HER2 gene amplification
Positive for HER2 gene amplification (FISH ratio >2.2 or HER2 gene copy >6.0)
Equivocal for HER2 gene amplification (FISH ratio or HER2 gene copy )
Negative for HER2 gene amplification (FISH ratio <1.8 or HER2 gene copy <4.0)
Count additional cells for FISH or retest, or test with HER2 IHC
Equivocal HER2 gene amplification result (Patients with HER2/CEP17 ratio ≥2.0 were eligible for the adjuvant trastuzumab trials) 7

8. HER2+ Metastatic Disease Case Review
Treatment of a 53-Year-Old Woman With HER2-Positive Metastatic Inflammatory Breast Cancer
A 53-year-old woman presents with T4 N2 M0 ER–/PR–/HER2+ (by fluorescence in situ hybridization) right inflammatory breast cancer
She is treated with preoperative doxorubicin/cyclophosphamide (AC) chemotherapy with minimal response in the breast and axilla and in the diffuse erythema in the skin of the left breast
Her disease is not operable with expectation of clear margins 8

9. Polling Question 1 Which Neoadjuvant Treatment Would You Recommend?
Please see the multiple answer options on the right and select an answer. Once you submit your
answer, your answer selection will be compared with your peers’ responses. The best answer(s)
will be discussed in the subsequent slides and commentary.
Taxane plus trastuzumab
Docetaxel/carboplatin/trastuzumab (TCH)
Taxane plus lapatinib/trastuzumab
TCH plus lapatinib
Lapatinib/trastuzumab 9

10. Case Review – Progression I
Discussion
Case Review – Progression I
Howard A. Burris III, MD, FACP
Lee Schwartzberg, MD

11. Case Review – Progression I
The patient is subsequently treated with 3 cycles of preoperative weekly paclitaxel/trastuzumab with no response, followed by worsening erythema extending onto her chest wall below her breast and ipsilateral and contralateral supraclavicular fossa. 11

12. Polling Question 2
Which Treatment Would You Recommend for Case Progression I ?
Please see the multiple answer options on the right and select an answer. Once you submit your answer, your answer selection will be compared with your peers’ responses. The best answer(s) will be discussed in the subsequent slides and commentary.
Trastuzumab/lapatinib
Capecitabine/lapatinib
Weekly paclitaxel plus lapatinib/trastuzumab 12

13. Case Review – Progression II
Discussion
Case Review – Progression II
Howard A. Burris III, MD, FACP
Lee Schwartzberg, MD

14. Case Review – Progression II
The patient is treated with capecitabine/lapatinib for 6 cycles, with improvement in the erythema and a 30% reduction in tumor volume in breast and all nodal metastatic disease
She undergoes a left modified radical mastectomy and has diffuse residual disease in her breast and axilla with diffuse skin and tumor lymphovascular invasion
The margins of resection are clear
She receives radiation therapy and resumes capecitabine/lapatinib postoperatively; however, she develops signs of coronary spasm that require discontinuation of capecitabine 14 14

15. Polling Question 3
Which Treatment Do You Recommend for Case Progression II?
Please see the multiple answer options on the right and select an answer. Once you submit your answer, your answer selection will be compared with your peers’ responses. The best answer(s) will be discussed in the subsequent slides and commentary.
Lapatinib alone until disease progression
One year of lapatinib/trastuzumab
Lapatinib/trastuzumab until disease progression
Trastuzumab alone until disease progression 15

16. Case Review – Progression III
Discussion
Case Review – Progression III
Howard A. Burris III, MD, FACP
Lee Schwartzberg, MD

17. Case Review – Progression III
The patient continues lapatinib/trastuzumab for 9 months and then develops progressive disease over the right chest wall as well as bilateral supraclavicular adenopathy
Restaging reveals new pulmonary metastases
Her physician is interested in enrolling her in a trial evaluating investigational HER2-targeted agents and refers her to the ongoing phase IB trial of trastuzumab emtansine (T-DM1)/paclitaxel/pertuzumab 17

18. Polling Question 4
Which of the Following Statements Regarding Novel HER2-Targeted Agents Is Correct?
Trastuzumab emtansine consists of trastuzumab conjugated to a potent topoisomerase inhibitor
Pertuzumab is a monoclonal antibody (MoAb) that works by targeting the HER2 protein but in a different way than trastuzumab
Combination trastuzumab emtansine/pertuzumab has demonstrated antitumor activity in patients previously treated with trastuzumab
Trastuzumab emtansine has not demonstrated improved antitumor activity compared with patients treated with lapatinib plus capecitabine
Please see the multiple answer options on the right and select an answer. Once you submit your answer, your answer selection will be compared with your peers’ responses. The best answer(s) will be discussed in the subsequent slides and commentary. 18

19. Howard A. Burris III, MD, FACP
Discussion
Howard A. Burris III, MD, FACP
Lee Schwartzberg, MD

20. Targeted Agents for HER2+ Breast Cancer
Trastuzumab
Bevacizumab
VEGF
T-DM1
EGFR
Pertuzumab
VEGFR
HER2 P P P P
PI3-K
Akt/PKB
Lapatinib
EGFR, epidermal growth factor receptor; VEGFR, vascular endothelial growth factor receptor.
This slide summarizes some of the targeted agents currently being evaluated in clinical trials for HER2-positive metastatic breast cancer.
The treatment of HER2-positive breast cancer has gone from a very effective, heavily used agent to a number of agents that target HER2, as well as rational combinations of agents based on other molecular changes that occur in HER2-positive tumors that may mediate resistance. Treatment of this disease has gone from having very few treatment options to now having among the most treatment options, and outcome data will likely continue to improve with further use of these various HER2-targeting combinations, as well as anti-HER2 therapy, with therapies directed at other pathways that facilitate the growth of these tumors.
PTEN
mTOR
Neratinib
4E-BP1
S6K1
elF-4E
Protein synthesis
Cell growth, proliferation, survival, metastasis, angiogenesis 20

21. Proposed Mechanisms of Action of Trastuzumab
Spector N., J Clin Oncol. 2009;27:5838.

22. HER2 Targeting With Trastuzumab Has Changed the Natural History of HER2-Positive Advanced Breast Cancer
Dawood S., et al. J Clin Oncol. 2009;28:92.

23. Polling Question 5
With which of the following statements regarding HER2+ MBC do you agree?
Please see the multiple answer options on the right and select an answer. Once you submit your answer, your answer selection will be compared with your peers’ responses. The best answer(s) will be discussed in the subsequent slides and commentary.
Chemotherapy is an essential component of therapy for this patient population
When there is disease progression on trastuzumab, adding a new agent to conventional therapy is generally a good strategy
Both of these
Neither of these 23

24. Trastuzumab in First-Line Treatment
Studies
Slamon et al,
20011
Vogel et al,
20022
Burstein et al, 20033
Marty et al, 20054
Kaufman et al, 20095
Valero et al 20116 N
469
114 54
186
207
263
Treatment
AC/EC + H or T+H vs chemo H VH
D+H vs D
Anas + H vs
Anas
DCbH vs
D+H
Response Rate
50% vs 32%*
35% (IHC 3+)
34% (FISH+)
68%
61% vs 34%*
20.3% vs 6.8%*
72% vs 72%
Median TTP
7.4 vs 4.6 mo*
3.8 mo (H at 4 mg/kg)
3.5 mo
(H at 2 mg/kg) NR
11.7 vs 6.1 mo*
4.8 vs
2.4 mo*
10.3 vs 11.1 mo
Median PFS
Median OS
25.1 vs 20.3 mo*
24.4 mo
31.2 vs 22.7 mo*
28.5 vs 23.9 mo
37.4 vs 37.1 mo
Have Slamon, vogel need to check
AC, anthracycline + cyclophosphamide; Anas, anastrozole; T, paclitaxel; D, docetaxel; EC, epirubicin + cyclophosphamide; H, trastuzumab; mo, months; PFS, progression-free survival; OS, overall survival; RR, response rate; TTP, time to progression; VH, vinorelbine + trastuzumab; *statistically significant
1. Slamon DJ, et al. N Engl J Med. 2001:344(11): ; 2. Vogel CL, et al. J Clin Oncol. 2002;20: ; 3. Burstein HJ, et al. J Clin Oncol. 2003;21(15): ; 4. Marty M, et al. J Clin Oncol. 2005;23(19): ; 5. Kaufman B, et al. J Clin Oncol. 2009;27(33): ; 6. Valero V, et al. J Clin Oncol. 2011;29: 24

25. NCCN Guidelines
Preferred agents for trastuzumab-exposed HER2 + disease
Lapatinib + capecitabine
Trastuzumab + other first-line agents
Trastuzumab + capecitabine
Lapatinib + trastuzumab
National Comprehensive Cancer Network (NCCN) Breast Cancer Guidelines, 2012 available at

26. Lapatinib: Targeting HER2 and EGFR
Lapatinib oral tyrosine kinase inhibitor of ErbB1 and ErbB2
Blocks signaling through EGFR and HER2 homodimers and heterodimers
May also prevent signaling between ErbB1/ErbB2 and other ErbB family members
PTEN
Lapatinib
P13K
pAkt
Ras
Raf
pErk
Shc
Grb2
So8
Phospholipid cell membrane
Lapatinib, a small molecule that is administered orally, inhibits the tyrosine kinase components of ErbB1 and ErbB2 receptors. Stimulation of ErbB1 and ErbB2 is associated with cell proliferation and with multiple processes involved in tumor progression, invasion, and metastases.
Overexpression of these receptors has been reported in a variety of human tumors and is associated with poor prognosis and reduced overall survival
Rusnak DW, et al. Mol Cancer Ther. 2001;1:85-94; Xia W, et al. Oncogene. 2002;21: 26

27. Randomized Phase III Study EGF10015
Progressive, HER2+ MBC or LABC
Previously treated with anthracycline, taxane, and trastuzumab*
No prior capecitabine R A N D O M I Z E
Lapatinib 1250 mg po qd continuously + Capecitabine 2000 mg/m2/d po days 1-14 q 3 wk
Stratification:
Disease sites
Stage of disease
Capecitabine 2500 mg/m2/d po days 1-14 q 3 wk
Patients on treatment until progression or unacceptable toxicity, then followed for survival
N=528
* Trastuzumab must have been administered for metastatic disease
Geyer C, et al. N Engl J Med. 2006;355: 27

28. Progression-Free Survival
Lapatinib + Capecitabine
100
Capecitabine
Cumulative Progression-Free Survival(%)
No. of pts
160
161 90
Progressed or died
45 (28%)
73 (45%) 80
Median PFS, wk
36.9
17.9
Hazard ratio (95% CI)
0.48 (0.33, 0.70) 70
P-value (log-rank, 1-sided) 60 50 40 30 20
Capecitabine
Lapatinib + Capecitabine 10 10 20 30 40 50 60 70
Time (weeks)
Geyer C, et al. N Engl J Med. 2006;355: 28

29. Overall Survival: Capecitabine ± Lapatinib
100
Cumulative Survival (%)
Capecitabine
Lapatinib + Capecitabine 90 80 70 60 50
Lapatinib + Capecitabine
Capecitabine 40
No. of pts
160
161 30
Deaths
29 (18%)
29 (18%)
Median OS NR NR 20
Hazard ratio (95% CI)
0.93 (0.55, 1.59) 10
P-value (log-rank, 2-sided)
0.800 10 20 30 40 50 60 70 80 90
Time (weeks)
Geyer C, et al. N Engl J Med. 2006;355: 29

30. OS With Lapatinib ± Trastuzumab in MBC
OS Outcome L
(n=145)
L + T
(n=146)
Died, n (%)
113 (78)
105 (72)
Median, mo
9.5 14
HR (95% CI)
0.74 ( )
Log-rank P-value
0.026
100
80% 80
56% 60
70%
Alive without Progression (Cumulative %)
6 Month OS 40
41%
CI, confidence interval; HR, hazard ratio; ITT, intent-to-treat; L, lapatinib; MBC, metastatic breast cancer; OS, overall survival; T, trastuzumab.
Surprisingly, overall survival was also statistically significantly different at 12 months. Lapatinib plus trastuzumab was associated with a median overall survival of 14.0 months compared with 9.5 months for lapatinib. This represents a 26% relative-risk improvement with the continued use of trastuzumab. This survival advantage observed in a metastatic setting confirms that the strategy of dual HER2 blockade and continuation of trastuzumab after progression on trastuzumab is correct. These data also confirm the biology behind the preclinical observation of a synergistic interaction between the 2 agents. Dual HER2 targeting has clinically translated into the metastatic setting and has also been evaluated in the early breast cancer setting in the Neo-ALTTO and ALTTO trials.[1,2]
For more information, go online to:
For more information, go online to:
Reference
1. Baselga J, Bradbury I, Eidtmann H, et al. First results of the NeoALTTO trial (BIG 01-06/EGF ): a phase III, randomized, open label, neoadjuvant study of lapatinib, trastuzumab, and their combination plus paclitaxel in women with HER 2-positive primary breast cancer. Program and abstracts of the 33rd Annual San Antonio Breast Cancer Symposium; December 8-12, 2010; San Antonio, Texas. Abstract S3-3.
2. ALTTO (Adjuvant Lapatinib and/or Trastuzumab Treatment Optimisation) Study; BIG 2-06/N063D (April 2011). L
L + T
12 Month OS 20 5 10 15 20 25 30 35
Patients at Risk, n
Months From Randomization L
L + T
148
121
102 88 65 64 47 43 28 25 13 1
Blackwell KL, et al. San Antonio Breast Cancer Symposium (SABCS) Abstract 61. 30

31. Neo-ALTTO: Study Design
Invasive operable
HER2+ BC
T>2 cm
(inflammatory BC
excluded)
LVEF50%
N=450
lapatinib
lapatinib
paclitaxel R A N D O M I Z E S U R
G E Y
FEC X 3
trastuzumab
trastuzumab
paclitaxel
Stratification:
T≤5 cm vs. T>5 cm
ER or PgR + vs. ER & PgR –
N 0-1 vs N≥2
Conservative surgery or not
lapatinib
lapatinib
trastuzumab
trastuzumab
paclitaxel
6 wks
+ 12 wks
34 weeks
52 weeks of anti-HER2 therapy
Baselga J, et al. SABCS 2010. 31 31

32. Neo-ALLTO: Pathologic Response10 20 30 40 50 60 70
P=0.34
P=0.0001
24.7%
29.5%
51.3%
pCR
Pathologic Complete Response L T
L+T
N=150*
N=145*
20.0%
27.6%
46.9%
P=0.13
P=0.001
tpCR
Locoregional (total) pCR
L, lapatinib; T, trastuzumab; L+T, lapatinib plus trastuzumab; pCR, pathologic complete response.
* Excludes 15 patients with non-evaluable nodal status
Baselga J, et al. SABCS 2010. 32 32

33. Investigational Anti-HER2 Agents

34. Polling Question 6
Which of the following have demonstrated benefit in patients with HER2+ MBC who experienced disease progression on trastuzumab?
Please see the multiple answer options on the right and select an answer. Once you submit your answer, your answer selection will be compared with your peers’ responses. The best answer(s) will be discussed in the subsequent slides and commentary.
Neratinib (single agent)
Pertuzumab (single agent)
Lapatinib plus capecitabine
Lapatinib plus trastuzumab
Trastuzumab-DM1 34

35. Polling Question 7 Which of the following is true of trastuzumab-DM1?
Please see the multiple answer options on the right and select an answer. Once you submit your answer, your answer selection will be compared with your peers’ responses. The best answer(s) will be discussed in the subsequent slides and commentary.
Retains the properties of trastuzumab
Inhibits HER2 signaling
Contains a cytotoxic agent
Adverse event profile resembles traditional chemotherapy
Not appropriate for patients who did not benefit from prior trastuzumab
Correct answer is C 35 35

36. Trastuzumab-DM1

37. T-DM1 Selectively Delivers a Highly Toxic Payload to HER2-Positive Tumor Cells
Trastuzumab-like activity by binding to HER2
Targeted intracellular delivery of a potent antimicrotubule agent, DM1
T-DM1 binds to the HER2 protein on cancer cells
Trastuzumab and DM1 are covalently linked via a thioether linker
DM1 is a highly potent derivative of antimicrotubule agent
T-DM1 specifically targets HER2 + tumor cells by antibody- dependent cellular cytotoxicity and inhibiting HER2 signaling.
A phase I study demonstrated that MTD was 3.6 mg/kg every 3 wks, and systemic DM1 exposure was low (5 ng/mL maximum plasma levels).
Receptor-T-DM1 complex is internalized into HER2-positive cancer cell
Potent antimicrotubule agent is released once inside the HER2-positive tumor cell 37

38. Trastuzumab-TDM1
Trastuzumab-DM1 (T-DM1) is a novel anti-HER2 antibody drug conjugate in development for treatment of HER2-positive metastatic breast cancer (MBC).T-DM1 combines the HER2-targeting properties of trastuzumab2 with targeted delivery of a highly potent anti-microtubule derivative, DM1
T-DM1 binds to HER2 with an affinity similar to that of trastuzumab.
It is hypothesized that after binding to HER2, T-DM1 undergoes receptor-mediated internalization, 7 resulting in intracellular release of DM1. 38

39. TDM1 Versus Trastuzumab + Docetaxel 1st line
HER2-positive, recurrent locally advanced BC or MBC (n=137)
T-DM1
3.6 mg/kg Q3W until PD
1:1
Trastuzumab
8 mg/kg dose; 6 mg/kg Q3W
+ Docetaxel
75 or 100 mg/m2 Q3W PD
Crossover
T-DM1
Randomized, phase II, international, open-label study
HER2-positive, measurable disease required
Stratification factors
World region, prior adjuvant trastuzumab therapy, disease-free interval
Primary endpoints: PFS by INV, safety
Key secondary endpoints: ORR, clinical benefit, OS, QOL, symptom control
Perez EA, et al. ESMO Abstract LBA3. 39

40. T-DM1 Versus Trastuzumab (T) + Docetaxel (D) in HER2-Positive MBC With No Prior Chemotherapy for MBC
Efficacy Summary
Overall response rate (ORR)
47.8%
41.4%
Safety Summary
Grade ≥3 adverse event (AE)†
37.3%
75.0%
† Most common AEs, any grade, T + D: alopecia: 66.2%, neutropenia: 57.4%, diarrhea: 45.6% — these were 1.5%, 7.5%, and 10.4% in pts receiving T-DM1.
Most common AEs, any grade, T-DM1: nausea: 47.8%, fatigue: 46.3%, pyrexia: 35.8% — these were 39.7%, 46.2%, and 20.6% in pts receiving T + D.
Perez EA, et al. Proc ESMO Abstract LBA3.

41. T-DM1 Activity: Improved PFS
Median Progression-Free Survival
(months)
trastuzumab + docetaxel
T-DM1
HER2+ locally advanced or metastatic 10 15 5
14.2
9.2
P=0.035
Treatment with T-DM1 reduced the probability of disease progression or death by 41% compared with Trastuzumab + Docetaxel
HR=0.59, P=0.035
Hurvitz S, et al. ECCO-ESMO Abstract 5001. 41

42. PD or unacceptable toxicity
EMILIA (TDM4370g) Phase III Study: T-DM1 Versus Lapatinib/Capecitabine in HER2+ MBC
PD or unacceptable toxicity
Patients with HER2+ locally advanced or metastatic breast cancer following treatment with a taxane and trastuzumab
(N=980)
T-DM1 q3w (n=490)
Lapatinib + Capecitabine q3w (n=490)
DOR, duration of response; IRF, independent review facility; MBC, metastatic breast cancer; PD, progressive disease; OS, overall survival; PFS, progression-free survival; QoL, quality of life.
The phase III EMILIA study is actively recruiting patients. This ongoing study is comparing T-DM1 vs lapatinib plus capecitabine in HER2-positive metastatic breast cancer patients who have received previous trastuzumab- and taxane-based therapy. The primary endpoint is progression-free survival, and this is the only study evaluating T-DM1 where overall survival is a coprimary endpoint.
Primary endpoint: PFS by IRF, OS, safety
Secondary endpoints: QoL (FACT B), DOR, PFS by investigator assessment
ClinicalTrials.gov. NCT 42

43. Phase III MARIANNE Study: T-DM1 ± Pertuzumab in HER2+ MBCPD
Trastuzumab + Taxane
(n=364)
Patients with HER2+, previously untreated MBC
(N=1092)
T-DM1 + Pertuzumab
(n=364)
T-DM1 + Placebo
(n=364)
AE, adverse event; CBR, clinical benefit rate; DOR, duration of response; IRF, independent review facility; MBC, metastatic breast cancer; ORR, overall response rate; OS, overall survival; PD, progressive disease; PFS, progression-free survival; TTF, time to treatment failure.
An ongoing phase III study, the MARIANNE study, is comparing T-DM1 with or without pertuzumab in the first-line treatment of HER2-positive metastatic breast cancer.
Primary endpoints: PFS as assessed by IRF, AEs
Superiority design with a noninferiority analysis
Interim futility analysis: option to drop experimental arm
Secondary endpoints: OS, TTF by IRF, ORR, CBR, DOR
ClinicalTrials.gov. NCT 43 43

44. HER2-Targeted Therapy With Pertuzumab
Monoclonal antibody and pan-HER inhibitor
Binds to a distinct epitope on the HER2 extracellular domain
Prevents dimerization
Pertuzumab is a humanized monoclonal antibody which binds to the extracellular domain of HER2.
However unlike trastuzumab which binds at domain IV, pertuzumab binds domain II of the receptor and is thus able to disrupt HER2 dimerization and ligand-activated signaling with other growth factor receptors, including other HER family members.
Animal model studies using HER2 positive breast cancer xenografts have shown a synergistic antitumor activity for pertuzumab in combination with trastuzumab
Pertuzumab
Trastuzumab
Fisher, et al. J. Mol. Biol. 2010;402: 44

45. Ligand-binding domain
Pertuzumab Recognizes Different Epitopes
HER2
Ligand-binding domain
(inactive)
Pertuzumab
Trastuzumab
Omnitarg (pertuzumab) recognizes different epitopes in HER2 hetero-dimerization and prevents EGFR-HER2
Cell membrane
Tyrosine kinase domain 45

46. Pertuzumab Demonstrates Synergistic Activity With Trastuzumab
HER2 receptor
Pertuzumab
Trastuzumab
Dimerization domain of HER2
Subdomain IV of HER2
Reference
Junttila TT, Akita RW, Parsons K, et al. Ligand-independent HER2/HER3/PI3K complex is disrupted by trastuzumab and is effectively inhibited by the PI3K inhibitor GDC Cancer Cell 2009; 15:353–355.
Preferentially inhibits ligand-independent HER2 signaling
Prevents shedding of HER2 ECD
Flags cells for destruction by the immune system
Inhibits formation of HER2 dimer pairs
Suppresses multiple HER signaling pathways, leading to a more comprehensive blockade of HER2-driven signaling
Flags cells for destruction by the immune system
Junttila, et al. Cancer Cell 46

47. HER2:HER3 Dimers May Provide an Escape Mechanism From Trastuzumab
Homodimers
Heterodimers
HER4:HER4
HER1:HER2
HER1:HER3
HER1:HER4
HER3:HER3
HER2:HER3
HER2:HER2
HER2:HER4
HER1:HER1
HER3:HER4 + + + + + + + + + + + +
Inhibition of HER2:HER2 dimerization may provide a more comprehensive blockade of HER2-driven signaling
References
Tzahar E, Waterman H, Chen X, Levkowitz G, Karunagaran D, Lavi S, et al. A hierarchical network of interreceptor interactions determines signal transduction by Neu differentiation factor/neuregulin and epidermal growth factor. Mol Cell Biol 1996;16:5276–5287.
Sergina NV, Rausch M, Wang D, et al. Escape from HER-family tyrosine kinase inhibitor therapy by the kinase-inactive HER3. Nature 2007; 445:437–441. + + +
Signaling activity
Tzahar E., et al. Mol Cell Biol Sergina NV, et al. Nature. 445: 47

48. CLEOPATRA: Phase III Trial Evaluating Adding Pertuzumab
N=808 HER2-positive Metastatic Breast Cancer
Primary Outcome: Progression-Free Survival
First-Line MBC
Could have received prior adjuvant trastuzumab
Treatment A: 400 patients
Docetaxel* + Trastuzumab + Pertuzumab R
Treatment B: 400 patients
Docetaxel* + Trastuzumab + Placebo 
First-Line
HER2-positive
MBC
1:1 randomization
stratification by (1. pretreated or de novo, 2. region)
* At least 6 cycles of docetaxel
Baselga J, et al. N Engl J Med. 2012;366:

49. CLEOPATRA: Response Data
100
5.5
4.2 90 80 70
ORR: 69.3%
ORR: 80.2% CR
65.2 60
74.6 PR
Patients (%) 50 SD 40 PD 30
Not evaluable 20
20.8
CR, complete response; ORR, overall response rate; PD, progressive disease; PR, partial response; SD, stable disease.
There was also an advantage in response associated with the pertuzumab and trastuzumab combination compared with trastuzumab.
The objective response rates increased from 69% with trastuzumab to 80% with the pertuzumab/trastuzumab combination, and this increase was statistically significant (P = .001).
14.6 10
1.5
1.5
8.3
3.8
Trastuzumab + Docetaxel + Pertuzumab
(n=343)
Trastuzumab +
Docetaxel + Placebo
(n=336)
Baselga J, et al. N Engl J Med. 2012;366: 49

50. CLEOPATRA: Independently Assessed PFS
100
Ptz + T + D: median 18.5 months
Pbo + T + D: median 12.4 months 90 80 70 60
PFS (%) 50 40
(HR: 0.62;
95% CI: ;
P<0.0001) 30 20
CI, confidence interval; D, docetaxel; HR, hazard ratio; Pbo, placebo; PFS, progression-free survival; Ptz, pertuzumab; T, trastuzumab.
Kaplan–Meier estimates of progression free survival in the intention-to-treat population, stratified according to prior treatment and region. The median progression-free survival was longer by 6.1
months in the pertuzumab group (pertuzumab plus trastuzumab plus docetaxel) than in the control group placebo plus trastuzumab plus docetaxel). tTe addition of pertuzumab to trastuzumab therapy was associated with a statistically significant increase in median progression-free survival (PFS).The improvement in median PFS was a little more than 6 month is both statistically and clinically meaningful. An interim analysis of overall survival (43% of the prespecified total number for the final analysis) suggests there might be a benefit to the addition of pertuzumab. 10 5 10 15 20 25 30 35 40
Months
Pts at Risk, n
Ptz + T + D
Pbo + T + D
402
406
345
311
267
209
139 93 83 42 32 17 10 7
Stratified by previous treatment status and region
Baselga J, et al. N Engl J Med. 2012;366: 50

51. CLEOPATRA: OS Curve Baselga J, et al. N Engl J Med. 2012;366:109-119.
The interim analysis of overall survival was performed after 165 events (43% of the prespecified total number for the final analysis) had occurred. More deaths occurred in the control group than in the pertuzumab group (96 [23.6%] vs. 69 [17.2%])The hazard ratio was 0.64 (95% CI, 0.47 to 0.88; P = 0.005), which did not meet the O’Brien– Fleming stopping boundary of the Lan–DeMets alpha spending function for this interim analysis of overall survival (hazard ratio, ≤0.603; P≤0.0012) and was therefore not significant. However, the data showed a strong trend toward a survival benefit with pertuzumab–trastuzumab–docetaxel therapy.
Baselga J, et al. N Engl J Med. 2012;366: 51 51

52. Trastuzumab + Docetaxel + Pertuzumab Trastuzumab + Docetaxel + Placebo
CLEOPATRA: Safety
Adverse Events (%)
Trastuzumab + Docetaxel + Pertuzumab
(n=407)
Trastuzumab + Docetaxel + Placebo
(n=397)
All Grades
Grade 3/4
Diarrhea
66.8
7.9
46.3
5.0
Alopecia
60.9 NR
60.5
Neutropenia
52.8
48.9
49.6
45.8
Nausea
42.3
41.6
Fatigue
37.6
36.8
Rash
33.7
24.2
Decreased appetite
29.2
26.4
Mucosal inflammation
27.8
19.9
Asthenia
26.0
30.2
Peripheral edema
23.1
30.0
Constipation
15.0
24.9
Febrile neutropenia
13.8
7.6
Dry skin
10.6
4.3
Leukopenia
12.3
14.6
NR, not reported.
An increase in efficacy was observed with combination therapy, and there was no excess in toxicity associated with the addition of pertuzumab to trastuzumab. Importantly, there was no substantial increase in cardiac toxicity, which is a concern with trastuzumab or other HER2-targeted agents.
Baselga J, et al. N Engl J Med. 2012;366: 52

53. CLEOPATRA: Conclusions
Adding pertuzumab to first-line trastuzumab/docetaxel in HER2+ locally recurrent or MBC improves PFS vs trastuzumab/docetaxel alone
Median PFS prolonged 6.1 months according to independent review
PFS improvement consistent across nearly all patient subgroups
ORR higher with addition of pertuzumab to trastuzumab/docetaxel
Pertuzumab associated with increased incidence of mild and manageable diarrhea, rash, mucosal inflammation, febrile neutropenia, and dry skin
Incidence of cardiac toxicities comparable between treatment arms
Symptomatic LVSD: Ptz + T + D (1.0%) vs Pbo + T + D (1.8%)
D, docetaxel; LVSD, left ventricular systolic dysfunction; MBC, metastatic breast cancer; ORR, overall response rate; Pbo, placebo; PFS, progression-free survival; Ptz, pertuzumab; T, trastuzumab.
 Based on these data, if pertuzumab is approved by the US Food and Drug Administration for use in this setting, I think that this combination merits strong consideration as first-line therapy for HER2-positive metastatic breast cancer. The question may be how these data apply to the average patient as the majority with HER2-positive disease will get trastuzumab, and only 10% of these patients had received previous trastuzumab.
Clearly, this clinical trial did not provide any insight as to whether patients would experience similar outcomes by using these agents sequentially. Approximately 10% of patients in this study had previous trastuzumab therapy, and the median PFS was 16.9 months in the combination arm compared with 10.4 months in the trastuzumab arm (hazard ratio: 0.62; 95% confidence interval: ). Nevertheless, until there are more data showing efficacy with the pertuzumab/trastuzumab combination in previously trastuzumab-treated patients, it will be hard not to consider pertuzumab/trastuzumab combination as the preferred first-line therapy for HER2-positive metastatic breast cancer.
Baselga J, et al. SABCS Abstract S5-5. 53

54. Neratinib Inhibitors of EGFR-receptors
Online reference:
Gajria D Chandarlapaty S. Expert Rev Anticancer Ther. 2011;11(2): Review. 54

55. Neratinib Description
Neratinib is an oral, multi-targeted, irreversible tyrosine kinase inhibitor 
In preclinical studies, has been shown to target the ErbB1 (EGFR), ErbB2 (HER2), and ErbB4 (HER4) kinases
Mechanism: covalently binds to ErbB2 at ATP binding site and inhibits tyrosine kinase activity resulting in G0/G1 cell cycle arrest

56. Randomized Phase II: Neratinib Versus Lapatinib + Capecitabine in Locally Advanced or MBC
Progression-Free Survival n
Median PFS
95% CI
P-value
Neratinib
117
4.5 mo
3.1–5.7 mo
0.231
L + C
116
6.8 mo
5.9–8.2 mo
L, lapatinib; C, capecitabine; PFS, progression-free survival; CI, confidence interval.
Overall Survival n
Median OS
95% CI
P-value
Neratinib
117
19.7 mo
18.2 mo–NE
0.280
L + C
116
23.6 mo
18.0 mo–NE
L, lapatinib; C, capecitabine; OS, overall survival; CI, confidence interval; NE, not estimable.
Most Common Adverse Events
Most frequently observed severe adverse events in the trial were diarrhea and hand-foot syndrome; 28% of the patients in the neratinib arm and 10% of the patients in the L/C arm of the trial experienced rade 3/4 diarrhea.

57. Combination Treatments of Novel Anti-HER2 Agents57

58. Phase II Trial of Trastuzumab + Pertuzumab in HER2-Positive MBC Patients Progressing During Trastuzumab-Based Therapy
HER2-positive MBC Progressed on trastuzumab + chemotherapy (Cohorts 1 and 2, n=66)
Pertuzumab + trastuzumab (n=66)
Cohorts 1 and 21
HER2-positive MBC Progressed on trastuzumab + chemotherapy (n=29)
Pertuzumab (n=29)
Pertuzumab + trastuzumab (n=15)
Cohort 32
References
Baselga J, Gelmon KA, Verma S, et al. Phase II trial of pertuzumab and trastuzumab in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer that progressed during prior trastuzumab therapy. J Clin Oncol 2010:28;1138–44.
Baselga J, Cortés J, Fumoleau P, et al. Pertuzumab and trastuzumab: re-responses to 2 biological agents in patients with HER2-positive breast cancer which had previously progressed during therapy with each agent given separately – a new biological and clinical observation. Poster 5114 presented at SABCS, 9–13 December, 2009.
Primary objectives
Safety and efficacy
Population
≤3 prior lines cytotoxic therapy (including adjuvant treatment)
1. Baselga J, et al. J Clin Oncol ; 28; Baselga J, et al. SABCS 2009. 58

59. Pertuzumab/Trastuzumab Combination Therapy More Active Than Treatment With Either Agent Alone
Cohorts 1 and 2
(P+H) (n=66)
Cohort 3 (P)
(n=27)
Cohort 3
(P&H)
CR (%)
7.6
0.0
PR (%)
16.7
3.4
21.4
ORR (%)
24.2
SD (%)
25.8
6.9
CBR (CR+PR+SD> 6 months)
50.0
10.3
37.5
PD (%)
82.8
57.1
CR, complete response; PR, partial response; SD, stable disease
* n=27, as at data cut-off 2/29 patients had not reached overall best response endpoint (8 cycles of assessment during this phase); †n=11, as at data cut-off 4/15 patients had not reached overall best response endpoint (8 cycles of assessment during this phase); ‡at data cut-off, 21 (31.8%) patients had not experienced PD
1. Gelmon, et al. ASCO 2008; 2. Baselga, et al. JCO. 2010; 3. Baselga, et al. SABCS 2009. 59

60. Phase IB/II Trial of T-DM1 + Pertuzumab in Patients With Locally Advanced and MBC Who Were Previously Treated With Trastuzumab
Dose escalation phase (completed)
Expansion phase
(completed)
Phase IB/II: HER2-positive MBC
in all therapeutic lines (n=67)
T-DM1 + pertuzumab (n=9)
T-DM1 + pertuzumab (n=58, including 22 first line)
Primary endpoints
Safety
ORR by RECIST 1.0
Secondary endpoints
PFS
DoR
Phase IB: 3+3 dose escalation
Cohort I: T-DM1 3.0 mg/kg; pertuzumab (840 mg loading dose, 420 mg maintenance dose)
Cohort II: T-DM1 3.6 mg/kg; pertuzumab (840 mg loading dose, 420 mg maintenance dose)
Phase II
Expansion at dose level established in Phase Ib
Reference
A study of trastuzumab-Mcc-DM1 (T-DM1) in combination with pertuzumab administered to patients with HER2-positive locally advanced or metastatic breast cancer who have previously received trastuzumab. ClinicalTrials.gov [Website].
Updated August 7, Accessed October 19, 2009.
Heavily pretreated population
Median of 6 prior therapeutic agents in the metastatic setting
Miller K, et al. ASCO 2010. 60

61. T-DM1 + Pertuzumab Shows Promising Efficacy in Patients Pretreated With Trastuzumab + Lapatinib
Results
Total, n (%) (n=28) PR
10 (35.7) SD
13 (46.4) PD
4 (14.3)
Missing
1 (3.6)
Reference
Miller K, Giani L, Andre F, et al. A phase Ib/II trial of trastuzumab-DM1 (T-DM1) with pertuzumab for women with HER2-positive locally-advanced or metastatic cancer who were previously treated with trastuzumab. Poster 1012 presented at ASCO, 4–8 June, 2010.
ORR was 35.7% (10/28 patients), per investigator assessment
All responses were confirmed PRs
1/13 patients with SD had an unconfirmed response
Miller K, et al. ASCO 2010. 61

62. T-DM1 + Pertuzumab Has an Encouraging Safety and Tolerability Profile
Key AE (%)
Grade 3 (%)
Grade 4 (%)
Total (all grades) (%)*
Any Events
36.4
4.5
100
Fatigue
13.6
52.3
Nausea
5 .0
Thrombocytopenia
6.8
27.3
Diarrhea
2.3
25.0
Vomiting
22.7
AST increase
20.5
Dyspnea†
Reference
Miller K, Giani L, Andre F, et al. A phase Ib/II trial of trastuzumab-DM1 (T-DM1) with pertuzumab for women with HER2-positive locally-advanced or metastatic cancer who were previously treated with trastuzumab. Poster 1012 presented at ASCO, 4–8 June, 2010.
AST, aspartate aminotransferase
* One Grade 5 AE was reported (pneumonia) in a patient who died before her first tumor assessment. This AE was considered to be unrelated to study treatment; †Primarily attributed to pneumonia or the disease under study (lung metastases and pleural effusions).
Miller K, et al. ASCO 2010 Poster 1012. 62

63. NEOSPHERE: Study Design
TH (n=107) docetaxel + trastuzumab S U R G E Y
FEC q3w x 3
trastuzumab q3w cycles 5–17
Patients with operable or locally advanced /inflammatory* HER2-positive BC
Chemo-naïve and primary tumors >2 cm (N=417)
THP (n=107) docetaxel + trastuzumab + pertuzumab
FEC q3w x 3
trastuzumab q3w cycles 5–17
HP (n=107) trastuzumab + pertuzumab
docetaxel q3w x 4→FEC q3w x 3
trastuzumab q3w cycles 5–17
TP (n=96) docetaxel + pertuzumab
FEC q3w x 3
trastuzumab q3w cycles 5–21
Study dosing: q3w x 4
BC, breast cancer; FEC, 5-fluorouracil, epirubicin and cyclophosphamide; H, trastuzumab; P, pertuzumab; T, docetaxel
* Locally advanced=T2-3, N2-3, M0 or T4a-c, any N, M0; operable=T2-3, N0-1, M0; inflammatory=T4d, any N, M0
Gianni L, et al. SABCS 2010. 63 63

64. NEOSPHERE: pCR Rates P=0.0198 P=0.0141 P=0.003 50 40 45.8 30
pCR, %  95% CI
The main therapeutic result showed a very high rate of tumor eradication in th breast when pertuzumab was added to the conventional trastuzumab and docetaxel combination: 46.8 % for the triplet regimen and 29 % for the comparator arm. pCR accounted for 16.8% in women receiving the two monoclonals without chemotherapy, and 24% when pertuzumab and docetaxel were used 20
29.0
24.0 10
16.8 TH
THP HP TP
H, trastuzumab; P, pertuzumab; T, docetaxel
Gianni L, et al. SABCS 2010. 64 64

65. Summary: Pertuzumab and T-DM1 Are Promising New Therapeutic Agents for HER2-Positive MBC
First HER2 dimerization inhibitor
Has demonstrated encouraging clinical efficacy and tolerability in combination with trastuzumab
Offers a more comprehensive approach to blocking HER2-driven signaling than trastuzumab alone
T-DM1
First HER2-directed ADC delivering cytotoxic drug specifically to HER2-positive tumor cells while retaining the biological activity of trastuzumab
Has demonstrated encouraging clinical efficacy and tolerability in heavily pretreated patients
Clinical trials of both agents are ongoing, including pertuzumab and T-DM1 in combination 65

66. AVEREL: Study Design
Women with previously untreated HER2-positive locally recurrent/metastatic breast cancer
(N=424)
Trastuzumab 6 mg/kg† +
Docetaxel 100 mg/m2 +
Bevacizumab 15 mg/kg, all given q3w
(n=216)
Trastuzumab 6 mg/kg† +
Docetaxel 100 mg/m2,
both given q3w
(n=208)
Stratified by previous (neo)adjuvant taxane,
adjuvant trastuzumab, hormone receptor status, measurable disease
ORR, overall response rate; OS, overall survival; PFS, progression-free survival; TTF, time to treatment failure.
Gianni and colleagues reported the results of the AVEREL study, which was a randomized phase III trial that evaluated the addition of bevacizumab to first-line treatment with trastuzumab and docetaxel in patients with HER2-positive advanced breast cancer.
Cancer cells that overexpress HER2 also produce higher levels of vascular endothelial growth factor (VEGF) compared with cells that have low levels of HER2 expression. So the rationale for this study was to test a hypothesis that dual targeting of VEGF (with bevacizumab) and HER2 (with trastuzumab) pathways would be associated with greater efficacy than targeting HER2 alone. many of these patients were naive to previous HER2-targeted therapy with only approximately 12% having received neoadjuvant HER2-targeted therapy.
Treatment until disease progression or unacceptable toxicity*
Primary endpoint: PFS (investigator assessed)
Secondary endpoints: OS, ORR, duration of response, TTF, safety
* Planned minimum of 6 docetaxel cycles administered; †Trastuzumab 8 mg/kg loading dose given.
Gianni L, et al. SABCS Abstract S4-8. 66

67. AVEREL: PFS, Interim OS Analysis, and Response
Outcome, Months
T + Doc + Bev
(n=216)
T + Doc
(n=208)
HR (95% CI)
P Value
Median PFS (Investigator assessment)
16.5
13.7
0.82 ( )
0.0775
Median PFS (IRC assessment)
16.8
13.9
0.72 ( )
0.0162
Median OS
38.5
38.3
1.01 ( )
(unstratified)
0.9543
0.94 ( )
(stratified)
0.7078
Bev, bevacizumab; CI, confidence interval; Doc, docetaxel; HR, hazard ratio; IRC, independent review commitee; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; T, trastuzumab.
In the AVEREL study, the median PFS was numerically higher among the patients given bevacizumab combined with trastuzumab and docetaxel for both the investigator and central reviews. However, the difference in the median PFS between treatment arms was 2.8 months with investigator review and 2.9 months with central review, which was enough for a statistically significant difference in PFS with central review only. The median overall survival was nearly identical between the treatment groups.
ORR similar between T + Doc + Bev and T + Doc in investigator assessment (74.3% vs 69.9, respectively; P=0.3492)
ORR significantly higher with addition of Bev in IRC assessment (76.5% vs 65.9, respectively; P=0.0265)
Gianni L, et al. SABCS Abstract S4-8. 67

68. AVEREL: Conclusions
Addition of bevacizumab to first-line treatment with trastuzumab and docetaxel in patients with HER2-positive advanced breast cancer may prolong PFS
Findings not significant according to investigator-assessed PFS (primary endpoint; P=0.0775)
Findings significant according to independent review of PFS (exploratory endpoint; P=0.0162)
Bevacizumab-associated AEs led to higher incidence of discontinuation of any study drug
AEs, adverse events; PFS, progression-free survival.
data from the AVEREL study suggest that bevacizumab may add a benefit to trastuzumab therapy in patients with HER2-positive metastatic breast cancer, but they are not convincing enough to change practice in the community. This trial also demonstrates the importance of time and context in our interpretation. Had these results been available 3 or 4 years ago, they likely would have been viewed as quite encouraging and potentially practice changing. However in light of the CLEOPATRA data, they simply won’t and shouldn’t impact the treatment of patients with metastatic disease. The underlying biologic rationale for combined HER2 and VEGF inhibition remains strong and the ongoing BETH trial[1], which is investigating the addition of bevacizumab to chemotherapy plus trastuzumab in patients with resected node-positive or high-risk node-negative, HER2-positive breast cancer, may help to provide more insight into the role of bevacizumab in HER2-positive metastatic breast cancer.[1]
Reference
1. ClinicalTrials.gov. BETH study: treatment of HER2 positive breast cancer with chemotherapy plus trastuzumab vs chemotherapy plus trastuzumab plus bevacizumab. Available at: Accessed January 23, 2012.
Gianni L, et al. SABCS Abstract S4-8. 68

69. Howard A. Burris III, MD, FACP
Discussion
Thank You!
Howard A. Burris III, MD, FACP
Lee Schwartzberg, MD