1. www.OncologyEducation.com ESMO 2011 Lung Cancer AVAPERL Study Authors: Dr. Sunil Verma Date posted: September 28 th, 2011

2. www.OncologyEducation.com AVAPERL Background:There is evidence for the use of bevacizumab in combination with chemotherapy in the first line treatment of advanced non-small cell lung cancer. Cisplatin and Pemetrexed has previously been shown to be associated with superior overall survival compared to Cisplatin and Gemcitabine in patients with non-squamous non small cell lung cancer. This study was designed to evaluate the benefit of maintenance pemetrexed in addition to bevacizumab compared to bevacizumab alone in patients who have received induction therapy with Cisplatin+Pemetrexed and Bevacizumab.

3. www.OncologyEducation.com R Treatment A: Bevacizumab and Pemetrexed Treatment B: Bevacizumab Patient Population All patients received four cycles of treatment with Cisplatin + Bevaciuzmab + Pemetrexed and those who didn't progress after this induction treatment were randomized AVAPERL N= 253 Primary Outcome: Progression Free Survival, assessed from the beginning of the first line chemo

4. www.OncologyEducation.com RESULTS Treatment A Treatment B p-value PFS (median, months) 10.26.6 <0.001 OS (median, months) OS data is immature Progression Free Survival, assessed from the beginning of the first line chemo, and after a median follow-up of 11.0 months

5. www.OncologyEducation.com AVAPERL Key Conclusion Maintenance pemetrexed in combination with bevacizumab is associated with improvement in progression free survival for patients who have had first line treatment with Cisplatin+Pemetrexed and Bevacizumab.

6. www.OncologyEducation.com BOTTOM LINE FOR MEDICAL ONCOLOGISTS Improved outcomes in the setting of bevacizumab based induction and maintenance therapy Confirms the benefit seen from the PARAMONT pemetrexed maintenance study The data that we have to date for continued maintenance strategy (i.e. continuing one of the agents used in induction therapy) has only shows improvement in progression free survival, so we need to make sure that such an improvement is clinically meaningful and cost-effective- the cost-effectiveness of such a strategy needs to evaluated and studied further Should the control arm been pemetrexed alone as there is more single agent activity associated with this agent