1. Novel Biologics in the Treatment of Colorectal Cancer Howard S. Hochster, MD Professor of Medicine, NYU School of Medicine Director, GI Program NYU Cancer Institute

2. Current Therapies  Fluoropyrimidines  Oxaliplatin  Irinotecan  Bevacizumab; anti-angiogenic MoAB  Cetuximab; anti-growth factor MoAB

3. 5-Fluorouracil: History

4. Concept of “All-3-Drugs” - Update 2005 11 Phase III Trials, 5768 Patients OS (mos) = 13.2 + ([%3drugs] x 0.1), R^2 = 0.85 Grothey & Sargent, JCO 2005 0 10 20 30 40 50 60 70 80 Infusional 5-FU/LV + irinotecan Infusional 5-FU/LV + oxaliplatin Bolus 5-FU/LV + irinotecan Irinotecan + oxaliplatin Bolus 5-FU/LV LV5FU2 22 21 20 19 18 17 16 15 14 13 12 Median OS (mo) Patients with 3 drugs (%) P =.0001 First-Line Therapy Multivariate analysis: Effect on OS P First-line doublet 0.69 All 3 drugs 0.005 Source: Grothey A, Sargent D. Overall survival of patients with advanced colorectal cancer correlates with availability of fluorouracil, irinotecan, and oxaliplatin regardless of whether doublet or single-agent therapy is used first line. J Clin Oncol 2005;23(36):9441-2. Adapted with permission from the American Society of Clinical Oncology.

5. NOVEL MOLECULAR TARGETS 2006  Angiogenesis Pathway –VEGFR-TKIs –Trap  IGF-IR MoAB  Src-TKIs  TRAIL

6. Functions of Cell Surface Receptors ProliferationInvasionMigrationSurvivalAngiogenesis EGFR√√√√ √ IGFR√√√√ √ c-MET√√√√√ VEGFR1 √√√ uPAR√√√√ Integrins√√√ √ The best targeted therapies may be those that mediate cell survival

7. AN INTERESTING DILEMMA: Bevacizumab studied with bIFL; how will it be used with oxaliplatin-based Rx?

8. THE TREE TRIAL (2 cohorts) comparing oxaliplatin schedules  Given that: –5-FU may be administered as an infusion, a bolus, or as an oral prodrug formulation –3 oxaliplatin-fluoropyrimidine regimens would have:  Similar efficacy, if there were equivalent dose intensities  Variant AE profiles, related to the mode of fluoropyrimidine administration TREE-1 Rationale

9. TREE-1 and TREE-2: Treatment Schema RANDOMIRANDOMIZATZATIONIONRANDOMIRANDOMIZATZATIONION mFOLFOX6 (q14 days) Oxaliplatin-85 mg/m 2 LV-350 mg (fixed dose) 5-FU-400 mg/m 2 IV bolus followed by 2400 mg/m 2 IV infusion over 46 hrs on D1 CapeOx (q21days) Oxaliplatin-130 mg/m 2 over 2 hours on D1 Capecitabine-1000 mg/m 2 twice daily on Days 1-15 bFOL (every 28 days) Oxaliplatin - 85 mg/m 2 IV x 2 hrs days 1,15 LV - 20 mg/m 2 IV bolus on Days 1,8,15 5-FU - 500 mg/m 2 IV bolus on Days 1,8,15 TREE-1 (N=150) (Nov 2002-Oct 30, 2003) mFOLFOX6 + Bevacizumab (5 mg/kg q14 days) CapeOx Capecitabine 850 mg/m2 bid day 1-5 + Bevacizumab (7.5 mg/kg q21days) bFOL + Bevacizumab (5 mg/kg q 2 weeks) TREE-2 (N=223) (Nov 2003 – April 2004) RANDOMIRANDOMIZATZATIONIONRANDOMIRANDOMIZATZATIONION

10. TREE-1TREE-2 mFOLFOX n=50* bFOL n=50* CapeOx n=50* mFOLFOX-B N=75* bFOL-B N=74* CapeOx-B N=74* Median age (range) 61 (35-79) 62 (31-84) 62.5 (32-84) 64 (31-83) 57.5 (30-85) 62 (32-82) Gender(%): Male/Female 58/4262/38 61/3949/5160/40 ECOG PS: 0/1 % 62/3858/4250/5059/4155/4566/34 Prior adjuvant therapy (%) 441626233231 * ITT population TREE-1 vs. TREE-2 : Demographics

11. TREE-1: 5-FU/Capecitabine Dose Reductions FOLFOX (149 cycles) bFOL (82 cycles) CapeOX (88 cycles) 5-FU or capecitabine dose reductions: cycles (%) 171250  DSMB recommended that the capecitabine dose be reduced (to 850 mg/m 2 b.i.d. x 14 days) in the CapeOX arm (30/10/03)

12. TREE-1 vs. TREE-2 Comparative Grade 3/4 toxicities –First 12 weeks of treatment Events TREE 1TREE 2 mFOLFOX n=49* bFOL n=50* CapeOx n=48* mFOLFOX-B n=71* bFOL-B n=70* CapeOx-B n=72* Vomiting 86191117 Dehydration 410216118 Diarrhea 22 27102617 Neutropenia 35141335134 Febrile neutropenia 002310 Hand-foot syndrome 6213007 Neurotoxicity 4419347 Hypertension 0009410 Bleeding 042041 Thrombosis (arterial) 002001 Proteinuria 000001 Any Grade 3 or 4 764473656058

13. TREE-1 vs. TREE-2 Comparative Grade 3/4 toxicities -Overall Events TREE1TREE 2 mFOLFOX n=49* bFOL n=50* CapeOx n=48* mFOLFOX-B n=71* bFOL-B n=70* CapeOx-B n=72* Vomiting 12101931310 Dehydration 812276138 Diarrhea 332833132720 Neutropenia 552017451710 Febrile neutropenia 402310 Hand-foot syndrome 82190010 Neurotoxicity 181223141115 Hypertension 0029714 Bleeding 042441 Thrombosis(arterial) 202004 Proteinuria 000111 Any Grade 3 or 4 967685 7375

14. TREE-2: Grade 3/4Toxicities during the First 12 Weeks of Rx

15. mFOLFOX+Bev n=71 (%) bFOL+Bev n =70(%) CapeOx+Bev n=72(%) GI Perforation3 (4.2)2 (2.9)2(2.8) Impaired Wound Healing 4 (5.6)1 (1.4)4 (5.6) Treatment- related Deaths 0 3 (4.3) (2 sepsis, 1 peritonitis) 3 (4.2) (1 arrhythmia, 1 CVA, 1 SBO) TREE-2: Absolute Number of Patients with Specific Treatment-related Toxicities

16. TREE-2: Overall Incidence of Grade 3/4Toxicities

17. TREE-1 vs. TREE-2 Comparative Response Rate (p<0.004, from the pooled logistic regression analysis, likelihood ratio test) FOLFOX bFOL CapeOX

18. TREE-1 vs. TREE-2 Comparative Analysis FOLFOXCapeOxbFOL - BEV N=49 + BEV N=71 - BEV N=48 + BEV N=72 - BEV N=49 + BEV N=71 Conf. RR (%) 415227462035 TTF (mo) 5.75.84.25.54.85.5 TTP (mo) 8.49.95.910.36.98.3 Hochster et al., ASCO 2005 and GI ASCO 2006

19. TREE-2 Conclusions  Two sequential cohorts within same protocol, same investigators  CapeOX not tolerated at 1000 mg/m2 bid x 14 days; good tolerance at 850 mg/m2 bid  Addition of Bevacizumab to oxaliplatin plus fluoropyrimidines is safe with expected toxicities and overall gr 3-4 rates  Addition of Bevacizumab increases RR by approximately 10% –Also improves TTP –TTF is increased less by bevacizumab

20. Chemical differences PK differences Differences in spectrum of activity –VEGFR and other receptors  Differences in toxicity All TKIs Are Not the Same

21. Small Molecule Inhibitors 1st Generation PTK787 /ZK 22854 SU5416 SU6668 SU11248  Newer Inhibitors AAL993 CEP-7055 CP-547,632 GW654652 AMG 706 AZ 2171 Combined Inhibitors ZD6474 AEE788 BAY 43-9006

22. PTK787/ ZK 225846 (Vatalanib)  Aminophthalazine  Well tolerated oral inhibitor of VEGFR- 1,2,3  Also inhibits c-kit and PDGFR  Promising phase I, II data  Inhibits blood flow on DCE-MRI  CONFIRM 1-2 trials

23. Phase III Trial of Vatalanib in First-Line MCRC (CONFIRM-1)  Primary end point: PFS, OS  Secondary end points: TTP, TTF, ORR FOLFOX4 + placebo n=585 PD n=583 PD Previously untreated MCRC WHO PS 0-2 FOLFOX4 + Vatalanib 1250 mg po qd RANDOMIZATIONRANDOMIZATION Hecht et al. ASCO, 2005. Abstract 3. Updated from oral presentation.

24. Dr. Dimitris Voliotis #24 Phase III Renal Cell Cancer  Interim analysis positive Filed for market approval in RCC  July 2005 Phase III Hepatocellular Carcinoma  Started March 2005 Phase II/III Malignant Melanoma  Started May 2005 Sorafenib (BAY 43-9006)

25. Dr. Dimitris Voliotis #25 *Placebo patients who progressed could cross over to sorafenib Randomized Discontinuation Design represents an innovative approach for studying novel anticancer drugs Bayer and Onyx were the first to apply this design in a major oncology setting Randomized Discontinuation Study – Treatment Plan Sorafenib 12-week run-in Tumor shrinkage ≥25% Tumor growth/ shrinkage <25% Tumor growth ≥25% Off study Placebo* 12 weeks Sorafenib 12 weeks Sorafenib open label % Progression free at 24 weeks Ratain MJ, et al. Presented at: ASCO; May 13-17, 2005; Orlando, Fla. N=202 N= 166 N=32 N=33 N= 79

26. Dr. Dimitris Voliotis #26 Tumor Size Changes After 12 Weeks of Treatment as Measured by Radiographic Measurements ≥25% growth <25% change ≥25% shrinkage -100 -75 -50 -25 0 25 50 75 100 125 % change from baseline in bidimensional tumor measurement Patients with increase in tumor size Patients with decrease in tumor size Source: With permission. Ratain MJ et al. Presentation. ASCO 2005. Abstract 4544

27. Dr. Dimitris Voliotis #27 0.00 0.25 0.50 0.75 1.00 Proportion of patients progression-free 0100200300400500 Days from randomization Sorafenib (n=32) Placebo (n=33) Censored 12-week run-in period -84 Median progression-free survival from randomization: Placebo=6 weeks Sorafenib=24 weeks p=0.0087 Median Progression-Free Survival for Patients with Renal Cell Cancer Randomized to Placebo or Sorafenib Source: With permission. Ratain MJ et al. Presentation. ASCO 2005. Abstract 4544

28. AZD2171 Clinical Data  Extensive and innovative phase I program in a number of tumours: –253 patients treated in monotherapy and combination studies  Program has led to a clear view of: –Pharmacokinetics –Evidence of inhibition of VEGF signalling in man –Initial evidence of anti-tumour activity –Tolerability profile –Dosing strategy

29. Changes in DCE-MRI correlated with exposure to AZD2171 Relationship between change in MRI (iAUC60) and AUC ss after 28 days’ dosing (Parts A and B, 0001) AUC ss (ng·h/ml) % Change in iAUC60 -100 -90 -80 -70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 05001000150020002500 Source: With permission. Dreus J et al. Presentation. ASCO 2005. Abstract 3002

30. VEGF Trap (AVE0005) A novel potent VEGF inhibitor in Oncology

31. VEGF Trap Phase I experience  Phase I SQ administration –25 ug/kg  800 q week  800 ug sq biw –8/10 stable at 800 ug/kg q wk or biw; one PR in refractory BAL NSCLC –Toxicity: HTN, proteinuria –T ½ = 25 + 3 days  Phase I IV administration –0.3  5 ug/kg iv q 2 wks –Usual toxicities –PR: ovarian (ascites), thymoma; 2 MRs

32.  VEGF Trap is a novel and potent anti-VEGF angiogenesis inhibitor with unique features that may yield antiangiogenic and antitumor activity:  Neutralizes all VEGF-A isoforms and PlGF  Binds VEGF-A 100 to 1000 fold more tightly than antibodies  VEGF Trap has been well tolerated at doses up to 5.0 mg/kg  VEGF Trap has demonstrated activity as single-agent in early clinical trials  Development program is progressing rapidly  VEGF Trap is a novel and potent anti-VEGF angiogenesis inhibitor with unique features that may yield antiangiogenic and antitumor activity:  Neutralizes all VEGF-A isoforms and PlGF  Binds VEGF-A 100 to 1000 fold more tightly than antibodies  VEGF Trap has been well tolerated at doses up to 5.0 mg/kg  VEGF Trap has demonstrated activity as single-agent in early clinical trials  Development program is progressing rapidly VEGF Trap (AVE0005) Conclusion Data on File

33. IV VEGF Trap Program: Summary of Ongoing Phase I and Phase II Studies Phase I Single-Agent IV Study Phase Ib Combination-Agent Studies  Phase Ib combination with oxaliplatin/5-FU/LV (FOLFOX4)  Phase Ib combination with LV5FU2-CPT11  Phase Ib combination with docetaxel/cisplatin/ fluorouracil  Phase Ib combination with docetaxel, then docetaxel/cisplatin  Phase Ib combination with gemcitabine, then GEMOX Phase II Single-Agent Studies  3rd Line Non-Small-Cell Lung Adenocarcinoma  3rd-Line Advanced Ovarian Cancer  Advanced Ovarian Cancer with Symptomatic Malignant Ascites

34. Properties Cetuximab/IMC-C225  IgG1 (chimerized antibody)  Exclusive for EGFR and its heterodimers  Prevents ligand binding to EGFR  Binds to EGFR with high affinity (K d = 2.0 x 10 –10 M) = ONE log higher than the natural ligand  Stimulates receptor internalization  Blocks receptor dimerization, tyrosine kinase phosphorylation, and signal transduction

35. Cetuximab ± Irinotecan in CRC Patients with CRC progressed on or within 3 months of irinotecan-based chemotherapy RANDOMIZATION Irinotecan dose and schedule used during progression Cetuximab 400 mg/m 2 1st infusion, then 250 mg/m 2 /week Cetuximab 400 mg/m 2 1st infusion, then 250 mg/m 2 /week Irinotecan dose and schedule used during progression Cetuximab 400 mg/m 2 1st infusion, then 250 mg/m 2 /week PD Schema n=111 n=218 Cunningham D, et al. Proc Am Soc Clin Oncol. 2003;22:252. Abstract 1012 and oral presentation (slide 6).

36. Combination Antibody Therapy MCRC NCI 5844 (“BOND-2”) Patients with MCRC who progressed with irinotecan (N=150) Bevacizumab + cetuximab + irinotecan Bevacizumab + cetuximab At: http://ctep.cancer.gov/forms. Primary end point: Response rate

37. Efficacy Comparison (Historical Controls) Cetux-Irino (historical) Cetux-Irino + Bev Resp Rate23%38% TTP4 m8.5 m Cetux alone (historical) Cetux + Bev Resp Rate11%23% TTP1.5 m6.9 m “BOND” “BOND-2”

38. CALGB/SWOG Intergroup Trial 80405 Bevacizumab Cetuximab Bevacizumab + Cetuximab FOLFOX or FOLFIRI “Dealer’s Choice” R N=2289 Primary endpoint: OS HR 1.25 (22 vs 27.5 months)

39. PACCE Trial* Bevacizumab Bevacizumab + Panitumumab FOLFOX or FOLFIRI “Dealer’s Choice” N=1000 Primary endpoint: PFS R PACCE: Panitumumab Advanced Colorectal Cancer Evaluation; opened April 2005

40. Strategies for future developments  “Pile-on” Approach –Combo-chemo+bev –Combo-chemo + bev + cetuximab –Combo-chemo + bev + TKI + cetuximab –Combo-chemo + bev + cetuximab + novel biologic 1 + novel biologic 2  Semi-STOP and GO –Biologic interludes  Avoid cytotoxics altogether

41. CONCLUSIONS  Combination Chemotherapy –Effective; “all 3-drugs” OS plateau –Platform for biologics  Angiogenesis Pathway –Validated target for combination with chemotherapy –Multiple approaches –Combinations of VEGF inhibitors?  Growth Factor Pathway –EGFR inhibitors validated –Can we use EGFR-TKIs in colorectal cancer

42. CONCLUSIONS  Studies underway combining dual-blockade with two antibodies plus chemotherapy  Future goals –Improved survival, decreased toxicity –Identifying the correct target –Confirming adequate inhibition of target