1. Small and Large- Molecule Angiogenesis Inhibitors: Excitement and Disappointments Scott Kopetz, MD, PhD Gastrointestinal Medical Oncology University of Texas, M D Anderson Cancer Center CT-322 VEGFR2 Adnectin Cediranib VEGFR Kinase Inhibitor

2. Outline  Anti-Angiogenesis: Where are we now?  Overview of Agents Targeting VEGF  Disappointments:  VEGF Tyrosine Kinase Inhibitors  Excitement:  Large Molecule VEGF inhibitors  Beyond VEGF: Alternate angiogenesis inhibitors

3. Current Benefits of Anti-Angiogenic Therapy: Bevacizumab in Phase III Hurwitz et al NEJM 2004; Saltz et al JCO 2008; Giantonio et al JCO 2007 IFLIFL + Bev FOLFOX/XELOX FOLFOX/XELOX + Bev FOLFOXFOLFOX + Bev

4. Why the interest in alternate angiogenesis inhibitors?  There is clearly room to improve on anti- angiogenic therapy in CRC  VEGF and angiogenesis are known to be relevant in CRC  Anti-VEGF development is viewed as a lower risk than a completely novel target  Agents with oral bioavailability and lower production costs may have market advantage

5. Cell membrane VEGF-A VEGF-R1 (Flt-1) Migration Invasion Survival VEGF-R3 (Flt-4) Lymphangio- genesis VEGF-R2 (KDR/Flk-1) Proliferation Survival Permeability PlGF VEGF-B VEGF-C, VEGF-D Functions VEGF Biology

6. VEGF-A VEGF-R1 (Flt-1) Migration Invasion Survival VEGF-R3 (Flt-4) Lymphangio- genesis VEGF-R2 (KDR/Flk-1) Proliferation Survival Permeability PlGF VEGF-C, VEGF-D Functions Large molecule VEGF inhibitors BevacizumabVGX-100 Ramucirumab (IMC-1121B) CT-322 IMC-18F1 Aflibercept (VEGF Trap) TB403

7. Cell membrane VEGF-A VEGF-R1 (Flt-1) Migration Invasion Survival VEGF-R3 (Flt-4) Lymphangio- genesis VEGF-R2 (KDR/Flk-1) Proliferation Survival Permeability PlGF VEGF-B VEGF-C, VEGF-D Functions Small molecule VEGFR inhibitors VEGFR Tyrosine Kinase Inhibitors (TKIs)

8. Small Molecule VEGFR Inhibitors in CRC Agenta.k.amCRC TrialsCRC Patients CediranibAZD21712 Phase III3,194 SemaxinibSU54162 Phase III2,084 VatalanibPTK7872 Phase III2,050 SunitinibSU11248Phase III1,623 BrivanibBMS-582664Phase III926 RegorafenibBAY 73-4506Phase III730 SorafenibBAY 43-9006Phase IIB814 VandetanibZD6474Phase IIB356 AxitinibAG-013736Phase IIB299 LinifanibABT-869Phase IIB147 VargategBIBF 1120 Phase II166 TivozanibAV-951Phase II80 MotesanibAMG-706Phase IB148 PazopanibGW786034Phase IB94 Clinicaltrials.gov >10,000

9. “VEGF” TKIs Vary By Kinase Selectivity and PK Agent VEGFR2 IC 50 T1/2Other primary kinases Sorafenib90nM27hRaf, RET Sunitinib10nM44h Pazopanib30nM35h Vandetanib40nM120hRET (100nM), EGFR (500nM) Cediranib0.5nM~24hc-Kit (2M), PDGFR (5nM), FGFR (26nM) Vatalanib17nM~5h Axitinib0.2nM~3h Semaxanib100nM1.3h Regorafenib40nM?Tie2, PDGFR, FGFR, Kit, RET, Raf (69nM) Motesanib3nM~6hc-Kit (8nM), PDGFR (84nM), RET (59nM) Brivanib25nM3hFGFR (148nM) Vargatef21nM12h FGFR (70nM), PDGFR (60nM), Src (150nM) Linifanib4nM17hPDGFR (2nM), CSF-1R (7nM) Dovitinib10nM17hFLT3 (1nM), c-KIT (2nM), FGFR (8nM)

10. Outline  Anti-Angiogenesis: Where are we now?  Overview of Agents Targeting VEGF  Disappointments:  VEGF Tyrosine Kinase Inhibitors  Excitement:  Large Molecule VEGF inhibitors  Beyond VEGF: Alternate angiogenesis inhibitors

11. FOLFOX4 + PTK787 FOLFOX4 CONFIRM-1 Hecht, ASCO 2005; Pharmacia Press Release Feb 2002 5+ Years ago… “First Generation” VEGFR TKIs Vatalanib (PTK787) Negative Study 5-FU + SU5416 5-FU 0306090102050407080 0 25 50 75 100 Weeks Overall Survival Semaxinib (SU5416) Negative Study

12. Lessons Learned with “First Generation” VEGFR TKIs VatalanibSemaxinib  Continuous VEGF inhibition appears to be necessary  Pharmacokinetics matter  Phase III trials are too late to determine the optimal pharmacokinetics and biomarkers of activity  Don’t skip Phase II studies!

13. Strategies Being Employed in “Second Generation” VEGFR TKI studies  Frontline chemo + Bevacizumab vs. VEGFR TKI  Testing superiority of VEGFR TKI  Frontline chemo +/- VEGFR TKI  Demonstrate benefit in “easier” setting  Approval outside of US  Bevacizumab-refractory: Second-line chemo +/- VEGFR TKI  Testing benefit of continued VEGF inhibition  Evaluating relevance of alternate VEGF signaling after bevacizumab  Dual Inhibition: Bevacizumab + VEGF TKI *  More “complete” inhibition of VEGF pathway * Grothey et al ASCO 2010 GI (Colorectal) Poster Session #3549

14. “Second Generation” VEGFR TKIs: Disappointing Recent Results  Sunitinib  Phase III: First line FOLFIRI +/- Sunitinib  Cediranib  Phase II: Second Line FOLFOX Bev vs. Cediranib  Phase III: First Line FOLFOX Bev vs Cediranib  Phase III: First Line FOLFOX +/- Cediranib  Vandetanib  Phase IIB: Second Line FOLFOX +/- Vandetanib

15. Phase III: Frontline Sunitinib 1 st Line Met CRC N=720 patients Primary endpoint: PFS 1 st Line Met CRC N=720 patients Primary endpoint: PFS R FOLFIRI + Placebo FOLFIRI + Sunitinib Europe/S.America/Asia study Failed to meet interim analysis and was closed for futility Phase IIB: First line FOLFOX Bev vs Sunitinib Hecht et al, ASCO 2010 #127 (Tues Poster Disc)

16. Phase IIB: FOLFOX Bevacizumab vs. FOLFOX Cediranib  Toxicities: Thrombocytopenia, fatigue  More frequent dose reductions in oxaliplatin in cediranib arms 2 nd Line mCRC with PD on FOLFIRI N=215 patients No prior anti- VEGF 2 nd Line mCRC with PD on FOLFIRI N=215 patients No prior anti- VEGF R FOLFOX + Bevacizumab FOLFOX + Cediranib 20mg/d FOLFOX + Cediranib 30mg/d Cunningham, ASCO 2008 Abs 4028

17. Phase III: Cediranib (HORIZON III) 1 st Line Met CRC N=1600 patients Primary endpoint: PFS R FOLFOX + Bevacizumab FOLFOX + Cediranib 20mg/d Europe/US study Failed to meet primary endpoint Press release 3/10/10

18. Phase III: Cediranib (HORIZON II) 1 st Line Met CRC N=1050 patients Co-primary endpoint: PFS, OS R FOLFOX + Placebo FOLFOX + Cediranib 20mg/d Europe/Asia study “Met PFS endpoint”, but … Press release May 2010 failed to meet OS endpoint. Development in CRC halted. failed to meet OS endpoint. Development in CRC halted.

19. Phase IIB: FOLFOX +/- Vandetanib  Once daily oral VEGFR + EGFR TKI  Added toxicities of thrombocytopenia (+15%), diarrhea (+20%) 2 nd Line mCRC with PD on FOLFIRI N=106 patients No prior bevacizumab R FOLFOX + Placebo FOLFOX + Vandetanib 100mg FOLFOX + Vandetanib 300mg Yang, ASCO 2009 Abs 4084

20. AgentFOLFOX Irinotecan FOLFIRI EGFRi + Irinotecan Other Bevacizumab Phase III Phase IIB Sunitinib Phase IIBPhase IIIPhase I/II Vandetanib Phase IIB Phase I Cediranib Phase II/IIIPhase IIBPhase I Vatalanib Phase IIIs Axitinib Phase IIBBevacizumab Semaxinib Phase III5-FU, phase III Motesanib Phase I Sorafenib Phase IIB Phase I/IIBevacizumab Pazopanib Phase I Brivanib Phase I/IICetux, Phase III Vargatef Phase I/II Regorafenib Phase I Alone, Phase III Linifanib Phase IIB Negative Positive Ongoing Negative studies across multiple regimens

21. Summary of VEGF TKI Activity  Is there activity of VEGF TKI therapies?  In contrast to HCC, RCC, minimal activity seen in CRC  Are they equivalent to bevacizumab?  No evidence  Are they superior to bevacizumab?  Increasingly unlikely  Does the same hold for large-molecule VEGF inhibitors?  Too early Why are VEGF TKIs failing?  Compliance? Possible Toxicities? Unlikely  Failing to understand the difference between targeting VEGF receptor and ligands  The benefit of VEGF inhibition by any method may be less than we think with current chemotherapy regimens

22. Lessons from “Second Generation” of VEGF TKI Studies  Don’t ignore phase II study results  Biomarker development is still lagging clinical development  Phase II is also too late  Added toxicities are non-trivial  TKIs inhibiting multiple kinases beyond VEGF have not yet shown greater activity

23. Outline  Anti-Angiogenesis: Where are we now?  Overview of Agents Targeting VEGF  Disappointments:  VEGF Tyrosine Kinase Inhibitors  Excitement:  Large Molecule VEGF inhibitors  Beyond VEGF: Alternate angiogenesis inhibitors

24. Phase III VEGF Trap (Aflibercept) after Bevacizumab 2 nd line CRC (after treatment with oxaliplatin-based therapy) N=1200 patients Primary endpoint: OS R FOLFIRI + Placebo FOLFIRI + Aflibercept 4mg/kg Results expected Dec 2010 “VELOUR” Study

25. Phase IIB ECOG 7208 : Anti-VEGFR2 Monoclonal Antibody after Bevacizumab 2 nd line CRC (after oxaliplatin and bevacizumab) KRAS Wild type N=147 patients Primary endpoint: PFS 90% power to detect difference between 4.5 months for control vs. 7.65 months for experimental arm (α = 0.10, β = 0.10) R Cetuximab + Irinotecan Cetuximab + Irinotecan + Ramucirumab (IMC-1121B) Courtesy of H. Hochster, PI

26. Comparing Anti-VEGFR2 or Anti-VEGFR1 Monoclonal Antibodies after Bevacizumab 2 nd line CRC (after irinotecan +/- bevacizumab) N=150 patients Primary endpoint: PFS Phase IIB R mFOLFOX6 mFOLFOX6 + IMC-18F1 (Anti-VEGFR1) Results Summer 2012 mFOLFOX6 + IMC-1121B (Anti-VEGFR2)

27. Outline  Anti-Angiogenesis: Where are we now?  Overview of Agents Targeting VEGF  Disappointments:  VEGF Tyrosine Kinase Inhibitors  Excitement:  Large Molecule VEGF inhibitors  Beyond VEGF: Alternate angiogenesis inhibitors

28. Angiogenic Factors Beyond VEGF Folkman, Nat Rev Drug Discovery 2007

29. Areas of Excitement: Alternate Angiogenesis Targets Tumors have an inherent or acquired upregulation of one of the redundant pro- angiogenic pathways PathwayTargetAgents in development Angiopoietins/Tie-2Ang-1,2AMG-386, Regorafinib Fibroblast growth factorFGFRAZD4547, Brivinib, Dovitinib Platelet-derived growth factorPDGFRABT-869, Imatinib Hepatocyte growth factorHGF/cMetARQ-197, AMG-102 Notch/DLL/Jaggedγ-secretaseRO4929097 Placental Growth FactorVEGFR1All VEGF TKIs, IMC-18F1

30. Angiogenic Factors Beyond VEGF Folkman, Nat Rev Drug Discovery 2007

31. Angiopoietins and Tie2 in Angiogenesis 2 nd line CRC (after treatment with oxaliplatin- based therapy) N=138 patients Primary endpoint: PFS R FOLFIRI + Placebo FOLFIRI + AMG-386 Results expected late 2010, early 2011 Phase IIB AMG-386 (Ang 1/2 neutralizing peptibody) Yu, Fut Oncol 2005 Angiogenesis VEGF

32. Single Agent VEGFR + Tie2 TKI: Regorafenib (BAY 73-4506) Phase III Refractory CRC N=690 patients Primary endpoint: OS R Regorafenib 160 mg PO 3 weeks on, 1 week off Placebo “CORRECT” Study Initiated Spring 2010 See Kies et al ASCO 2010 poster 7585 Also inhibits PDGFR, FGFR, Kit, RET, Raf

33. Angiogenic Factors Beyond VEGF Folkman, Nat Rev Drug Discovery 2007

34. Example: bFGF and Restored Angiogenesis Despite VEGF Inhibition VEGFR2 resistance can be reversed by targeting FGF Casanovas et al. Cancer Cell ‘05 Kopetz, et al JCO 2010 FGF-2 Levels are Increased in Patients at Progression on FOLFIRI + Bevacizumab

35. Example: Translating FGF Research to the Clinic FOLFOX + Bevacizumab- Refractory CRC N=100 screened Primary endpoint: non- comparative PFS HIGH plasma bFGF (n=30): Irinotecan 180mg/m2 Brivanib 800mg PO qd Low/normal bFGF (n=30): Irinotecan 180mg/m2 Brivanib 800mg PO qd Plasma bFGF Levels Opening Fall 201MDACC: Lieu, Overman PI’s Enrichment Phase II Trial: Inhibition of FGFR + VEGFR after Bevacizumab-failure Kopetz, et al JCO 2010 Heterogeneous Elevations in bFGF in the clinic

36. Ongoing Phase III: NCIC Brivanib Refractory CRC KRAS Wild type N=750 patients Primary endpoint: OS R Cetuximab Cetuximab + Brivanib Phase III Studies: Opportunities for Retrospective Evaluation of Plasma Markers NCIC study, Lillian Siu, PI

37. Conclusions  No evidence yet that anti-angiogenesis agents besides bevacizumab provide meaningful benefit  despite >10,000 enrolled patients  Recommendations for Path Forward:  Look Beyond VEGF: Understanding the mechanisms of acquired and inherent resistance to bevacizumab  Incorporate biomarker-driven enrichment studies  Utilize correlatives from completed randomized trials “Insanity is repeating the same mistakes and expecting different results” Albert Einstein