Challenging the Dogma Questioning the Role of Anthracyclines

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer This program is supported by educational grants from

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The Role of Anthracyclines in the Adjuvant Treatment of Breast Cancer: Making Clinical Decisions Dennis Slamon, MD, Ph. D Chief, Division of Hematology/Oncology David Geffen School of Medicine at UCLA Los Angeles, California

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Molecular Diversity of Human Breast Cancers Biologic and Therapeutic Implications BRCA 1 HER 2 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Subtypes Are Associated With Disease Outcome Luminal A Luminal B Basal ERBB 2+ van’t Veer data set Norway/Stanford data set 1 1 0. 8 0. 6 0. 4 0. 2 xx x x xx xxxx x x x P <. 01 Probability x Censored 0 0 24 48 72 96 120 144 168 192 Time to Distant Metastasis (Months) Copyright (2003) National Academy of Sciences, U. S. A. Sørlie T, et al. PNAS. 2003; 100: 8418 -8423. x xxxxx x 0. 6 xxx xxxxx x x x 0. 4 x x 0. 2 0 xx x 0 x x P <. 01 24 48 72 96 Overall Survival (Months) clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer The HER-2 Gene Encodes a 185 kd protein that is a member of the type I receptor tyrosine kinase family which also contains EGFR, HER-3 and HER-4 Functions When Altered § Growth and proliferation increased § Differentiation decreased § Cell survival increased § Motility increased § Neoangiogenesis increased § Reduced dependency on estrogen and insensitivity to hormonal blockade clinicaloptions. com/oncology

The Meta-Analysis

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Breast cancer mortality, % Breast Cancer Mortality 50 40 30 22. 5 20 19. 5 10 0 CMF 35. 1% Anthracycline 30. 8% 10 yr gain 4. 3% (SE 1. 1) Logrank 2 P <. 00001 0 5 Years 10 Anthracycline Years 0 -4 4. 23 (4. 44 – 0. 21) Years 5 -9 3. 33 (3. 67 – 0. 34) Year 10+ 2. 25 (2. 88 – 0. 63) CMF 4. 82 (5. 01 – 0. 19) 3. 50 (3. 86 – 0. 36) 3. 46 (4. 27 – 0. 81) Rate ratio, from (O-E) / V 0. 83 SE 0. 04 -100. 2 / 554. 1 0. 89 SE 0. 07 -22. 6 / 186. 8 0. 64 SE 0. 18 -9. 0 / 20. 1 Peto R. Lancet. 2003; 356: 593. clinicaloptions. com/oncology

How Did This All Start? Attempts to Explain the Differential Prognosis of HER 2 -Positive Breast Cancers

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer CALGB 8541 Muss HB, et al. NEJM. 1994; 330: 1260. Copyright @ [1994] Massachusetts Medical Society. All rights reserved. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer NSABP-B 11 Copyright (1998) J Natl Cancer Inst. Paik S, et al. J Natl Cancer Inst. 1998; 90: 1361 -1370. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer NSABP-B 11 Copyright (1998) J Natl Cancer Inst. Paik S, et al. J Natl Cancer Inst. 1998; 90: 1361 -1370. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer NSABP-B 11 Outcome erb. B-2 Status RR: PAF vs PF 0. 05 1. 00 1. 50 P Value PAF vs PF P Value Interaction DFS Negative Positive + . 74. 001 . 02 OS Negative Positive + . 47. 01 . 15 RFS Negative Positive + . 37. 002 . 06 DDFS Negative Positive . 84. 003 . 02 + + + Copyright (1998) J Natl Cancer Inst. Paik S, et al. J Natl Cancer Inst. 1998; 90: 1361 -1370. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer NSABP-B 15 Copyright (1998) J Natl Cancer Inst. Paik S, et al. J Natl Cancer Inst. 1998; 90: 1361 -1370. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer NSABP-B 15 Copyright (1998) J Natl Cancer Inst. Paik S, et al. J Natl Cancer Inst. 1998; 90: 1361 -1370. clinicaloptions. com/oncology

HER-2 Negative MA. 5 Trial Pritchard KI, et al. NEJM. 2006; 354: 2103 -2111. Copyright @ [2006] Massachusetts Medical Society. All rights reserved. HER-2 Positive

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Disease-Free Survival Study NSABP B 11 NSABP B 15 Brussels Milan DBCCG-89 -D NCIC MA-5 Total Overall HR 95% CI 0. 60 0. 96 0. 84 1. 02 0. 65 1. 35 0. 83 1. 22 0. 75 0. 79 0. 52 0. 91 0. 90 0. 71 1. 00 0. 44 -0. 82 0. 75 -1. 23 0. 65 -1. 08 0. 86 -1. 20 0. 34 -1. 27 0. 93 -1. 97 0. 46 -1. 49 0. 91 -1. 64 0. 53 -1. 06 0. 60 -1. 05 0. 34 -0. 80 0. 71 -1. 17 0. 82 -0. 98 0. 61 -0. 83 0. 90 -1. 11 heterogeneity c 25 = 5. 3; P =. 38 heterogeneity c 25 = 7. 6; P =. 18 Test for interaction chi 2 = 13. 7; P <. 001 Anthracycline Better Nonanthracycline Better P =. 01 P <. 0001 P = 1. 0 0. 4 0. 6 0. 9 1. 0 HER 2 positive Copyright (1998) J Natl Cancer Inst. Gennari A, et al. J Natl Cancer Inst. 2008; 100: 14 -20. 2. 0 5. 0 HER 2 negative clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Overall Survival Study NSABP B 11 NSABP B 15 GUN 3 Milan DBCCG-89 -D NCIC MA-5 Total Overall HR 95% CI 0. 66 0. 90 0. 82 1. 07 0. 85 1. 64 0. 61 1. 26 0. 73 0. 82 0. 65 1. 06 0. 91 0. 73 1. 03 0. 47 -0. 92 0. 69 -1. 18 0. 63 -1. 06 0. 88 -1. 30 0. 27 -2. 69 0. 85 -3. 15 0. 32 -1. 16 0. 89 -1. 79 0. 50 -1. 05 0. 59 -1. 13 0. 42 -1. 01 0. 80 -1. 40 0. 83 -1. 00 0. 62 -0. 85 0. 92 -1. 16 heterogeneity c 25 = 5. 2; P =. 39 heterogeneity c 25 = 5. 5; P =. 36 Test for interaction chi 2 = 12. 0; P <. 001 Anthracycline Better Nonanthracycline Better P =. 056 P <. 0001 P =. 86 0. 4 0. 6 0. 9 1 HER 2 positive Copyright (1998) J Natl Cancer Inst. Gennari A, et al. J Natl Cancer Inst. 2008; 100: 14 -20. 2 5 HER 2 negative clinicaloptions. com/oncology

Is this due to a unique and/or inherent sensitivity to anthracycline caused by HER 2 overexpression?

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Human Breast Cancer Cells MCF-7 Transfect HER 2/neu Single copy Low expressor MCF-7* Multiple copy High expressor Additional Human Breast Cancer Cells MDA-435 MDA-231 BT-20 Transfect HER 2/neu Single copy Low expressor MDA-435 MDA-231 BT-20 Multiple copy High expressor *Consistent results in 9 additional breast cancer cell lines. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Sensitivity of Human Breast Cells to Chemo Agents in Vitro IC 50 for DOX, µM MCF 7/NEO 0. 39 ± 0. 03 MCF 7/HER-2 0. 34 ± 0. 07 MDA-MB-435/NEO 0. 6 ± 0. 09 MDA-MB-435/HER-2 0. 6 ± 0. 07 MDA-MB-231/NEO 0. 3 ± 0. 03 MDA-MB-231/HER-2 0. 2 ± 0. 05 BT-20/NEO 0. 17 ± 0. 03 BT-20/HER-2 0. 15 ± 0. 02 [Peak plasma] achievable in humans 5. 6 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer The Topo IIα Gene Functions § Resolves topological problems in DNA § Is critical in RNA transcription from DNA § Makes transient protein-bridged DNA breaks on one or both DNA strands during replication § Plays critical roles in segregation, condensation, and superhelicity clinicaloptions. com/oncology

The Topo IIα Protein Is a Major Target of the Anthracyclines

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Mapping the HER 2 Amplicon HER 2 Core region TOPO II region Example 1 Example 2 Example 3 Example 4 Example 5 Example 6 Example 7 TOP 2 A HER 2 Normal Amplified Deletion clinicaloptions. com/oncology

The MA. 5 Trial

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Probability (%) DFS by Treatment 100 Overexpression of Topo protein P =. 01 CEF 80 60 CMF 40 Probability (%) 0 100 5 10 Normal expression of Topo protein P =. 6 CEF CMF 80 60 40 0 Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. 5 Yrs 10 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer § These preclinical (in vitro and in vivo) as well as clinical data indicate that the increased anthracycline sensitivity is NOT due to HER 2 overexpression § Instead the current data indicate that it is the Topo IIα gene amplification and not HER 2 that is responsible for improved anthracycline sensitivity clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer BCIRG 006 4 x Docetaxel 4 x AC 100 mg/m 2 60/600 mg/m 2 AC T HER 2+ (central FISH) N+ or high-risk N- 4 x AC 4 x Docetaxel 2 60/600 mg/m 100 mg/m 2 AC TH (N = 3222) 1 year of Trastuzumab 6 x Docetaxel and Carboplatin 75 mg/m 2 AUC 6 TCH Stratified by nodes and hormonal receptor status Slamon D, et al. SABCS 2006. Abstract 52. 1 year of Trastuzumab clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HER 2 and Topo IIα in BCIRG 006 2990 of 3222 patients analyzed 17 q 12 17 q 21. 1 HER 2 Core region N = 2990 17 q 21. 2 Topo IIα region Topo IIα non- 1788 pts (60%) coamplified 145 pts (5%) Coamplified 1057 pts (35%) Most recent analysis Slamon D, et al. SABCS 2006. Abstract 52. Normal Amplified Deletion clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS: BCIRG 006 Second Interim Analysis 1. 0 93% Disease Free (%) 0. 9 0. 8 92% 87% 86% 83% 82% 81% 77% 0. 7 Patients 1073 1074 1075 0. 6 0. 5 0 Events 192 AC → T 128 AC → TH HR (AC → TH vs AC → T): 0. 61 (0. 48; 0. 76; P <. 0001) 142 TCH HR (TCH vs AC → T): 0. 67 (0. 54; 0. 83; P =. 0003) 1 2 3 Year From Randomization Slamon D, et al. SABCS 2006. Abstract 52. 4 5 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS Non-coamplified Topo IIα by Arm: BCIRG 006 Second Interim Analysis 1. 0 91% Disease Free (%) 0. 9 90% 0. 8 83% 85% 83% 84% 81% 78% 0. 7 71% Patients 643 642 618 0. 6 0. 5 0 Events 146 AC → T 87 AC → TH P <. 001 92 TCH P <. 001 1 2 3 Year From Randomization Slamon D, et al. SABCS 2006. Abstract 52. 4 5 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS Coamplified Topo IIα by Arm: BCIRG 006 Second Interim Analysis 1. 0 95% 89% Disease Free (%) 0. 9 94% 92% 0. 8 87% 83% 85% 0. 7 Patients 328 357 359 0. 6 0. 5 0 Events 42 AC → T 35 AC → TH P <. 336 42 TCH P <. 648 1 2 3 Year From Randomization Slamon D, et al. SABCS 2006. Abstract 52. 4 5 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer BCIRG 006: Cardiac Deaths and CHF as per Independent Review Panel First Analysis/Second Analysis AC → T (n = 1050) AC → TH (n = 1068) TCH (n = 1056) Cardiac-related death 0/0 Grade 3/4 cardiac left ventricular function (CHF) 3/4 17/20 4/4 P =. 0015 Slamon D, et al. SABCS 2006. Abstract 52. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer BCIRG 006: Patients With > 10% Relative LVEF Decline AC → T (n = 1012/1014) AC → TH (n = 1040/1042) TCH (n = 1029/1030) Patients, n 91/102 180/189 82/89 Patients, % 9/10 17. 3/18. 0/8. 6 First Analysis/ Second Analysis P =. 002 P <. 0001 P =. 5 Slamon D, et al. SABCS 2006. Abstract 52. P =. 5 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer BCIRG 006: Mean LVEF—All Obs: Second Interim Analysis AC→T (N = 1014) AC→TH (N = 1042) TCH (N = 1030) 66 65 TCH LVEF Points (%) 64 AC→T 63 62 AC→TH 61 60 59 58 0 100 200 300 400 500 600 700 Time Since Randomization (Days) Slamon D, et al. SABCS 2006. Abstract 52. 800 900 1000 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Therapeutic Index: Most Recent BCIRG 006 Data AC → TH TCH Breast cancer recurrence 93 98 Breast cancer deaths 44 47 Grade 3/4 CHF 20 4 Acute leukemia 4* 0 161 149 Total *In both anthracycline-based arms. clinicaloptions. com/oncology

In our recent analysis of > 1600 HER 2 negative patients in the BCIRG 005 study for Topo IIα amplification, there is not a single case of Topo IIα coamplification in the absence of HER 2 amplification

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Implications for HER 2 -Negative and HER 2 -Positive Breast Cancers § Superior efficacy benefits for anthracyclines (when present) derives from their effects on Topo IIα amplification and/or overexpression § To date, Topo IIα amplification occurs only in 35% of the 25% of breast cancer patients with HER 2 amplification, ie, a subset of a subclass (tested in > 4500 patients) § Data support their preferential use in a HER 2 -negative breast cancer population that is ~ 75% of all breast cancers § For HER 2 -positive breast cancers, trastuzumab and lapatinib appear to replace the gained efficacy of anthracyclines in the 1/3 of patients with coamplification of HER 2 and Topo IIα without risking their known and well-established toxicities clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Onset of Heart Failure: 66 -70 Years of Age Proportion Free of CHF 1. 0 0. 8 0. 6 0. 4 Adjuvant anthracycline Nonanthracycline No adjuvant chemotherapy 0. 2 0. 0 0 24 48 72 Months 96 Permission granted by author to print. Giordano S, et al. ASCO 2006. Abstract 521. 120 144 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer TC x 4 vs AC x 4 Reprinted with permission. © 2008 American Society of Clinical Oncology. All rights reserved. Jones SE, et al. J Clin Oncol. 2006; 24: 5381 -5387. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer TC x 4 vs AC x 4 (cont’d) Subgroup HR (95% CI) All patients (TC = 506, AC = 510) 0. 67 (0. 50 -0. 94) Age < 50 yrs (TC = 210, AC = 214) 0. 64 (0. 38 -1. 04) Age ≥ 50 yrs (TC = 296, AC = 296) 0. 73 (0. 48 -1. 10) ER-/PR- (TC = 137, AC = 157) 0. 64 (0. 38 -1. 04) ER+ or PR+ (TC = 369, AC = 383) 0. 71 (0. 47 -1. 08) Node neg (TC = 239, AC = 248) 0. 73 (0. 42 -1. 27) Node pos (TC = 267, AC = 262) 0. 0 0. 2 0. 67 (0. 45 -0. 98) 0. 4 0. 6 0. 8 HR Log Scale 1. 0 Reprinted with permission. © 2008 American Society of Clinical Oncology. All rights reserved. Jones SE, et al. J Clin Oncol. 2006; 24: 5381 -5387. 1. 2 1. 4 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Critical Question § Considering – The BCIRG 006 update with > 3200 patients (> 1000 patients/arm) shows that in HER 2 -positive breast cancer the difference in DFS efficacy events and breast cancer deaths in favor of AC → TH is statistically insignificant and is now exceeded by the number of critical adverse events including grade III/IV CHF and AC-related leukemia as well as a significant and sustained loss of LVEF for 18% (189 patients), both of which are highly statistically significant – The recently published data from US Oncology shows a highly statistically significant DFS superiority (HR: 0. 67) of TC over AC in terms of breast cancer efficacy (Jones S, et al. J Clin Oncol. 2006; 24: 5381 -5387). What is the role of anthracyclines in the adjuvant treatment of breast cancer? clinicaloptions. com/oncology

Are Genetic Variables Guiding Clinical Decisions? Kathleen I. Pritchard, MD, FRCPC Sunnybrook Odette Cancer Centre Senior Scientist, Sunnybrook Research Institute Professor, Department of Medicine/ Public Health Services University of Toronto, Ontario, Canada

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Are Genetic Variables Guiding Clinical Decisions? § Biomarkers may be able to help us select treatments for patients § But they must be used cautiously, and only when they have been validated in numerous studies and metaanalyses § HER 2/neu and Topo IIα may be a marker for selecting anthracycline-containing vs nonanthracycline-containing regimens clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer NCIC-MA 5: Study Design CMF 6 cycles every 4 weeks NCIC-MA. 5 Premenopausal node positive (N = 710) Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. § Cyclophosphamide 100 mg/m 2 PO x 14 days § Methotrexate 40 mg/m 2 IV Days 1, 8 § 5 -FU 600 mg/m 2 IV Days 1, 8 CEF 6 cycles every 4 weeks § Cyclophosphamide 75 mg/m 2 PO x 14 days § Epirubicin 60 mg/m 2 IV Days 1, 8 § 5 -FU 500 mg/m 2 IV Days 1, 8 Cotrimoxazole or Norfloxacin/ Ciprofloxacin clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer MA. 5 DFS Patients (%) 100 80 60 CEF 40 CMF P =. 005 20 0 0 No. at CEF 351 Risk: CMF 359 5 Yrs 10 212 193 84 80 Reprinted with permission. © 2008 American Society of Clinical Oncology. All rights reserved. Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer MA. 5 OS Patients (%) 100 80 CEF 60 CMF 40 P =. 047 20 0 0 No. at CEF 351 Risk: CMF 359 5 Yrs 10 269 253 98 106 Reprinted with permission. © 2008 American Society of Clinical Oncology. All rights reserved. Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Adverse Events § Congestive heart failure – CEF: 4 patients – CMF: 1 patient § Acute leukemia – CEF: 5 patients – CMF: 1 patient Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HER 2 as a Predictive Factor: DFS by Treatment for Those With HER 2 Amplification CEF 100 DFS by Treatment for Those With no HER 2 Amplification CMF 80 Patients (%) 80 60 40 20 0 CEF 100 HR = 0. 52; P =. 003 0 # At Risk CEF 75 CMF 88 5. 0 Yrs 10. 0 42 35 19 12 60 40 20 0 HR = 0. 91; P =. 49 0 5. 0 Yrs 10. 0 237 228 145 138 59 60 Pritchard KI, et al. NEJM. 2006; 354: 2103 -2111. Copyright @ [2006] Massachusetts Medical Society. All rights reserved. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HER 2 as a Predictive Factor: OS OS by Treatment for Those With HER 2 Amplification CEF 100 OS by Treatment for Those With no HER 2 Amplification CMF 80 Patients (%) 80 60 40 20 0 CEF 100 HR = 0. 65; P =. 060 0. 0 # At Risk CEF 75 CMF 88 5. 0 Yrs 10. 0 49 47 20 18 60 40 20 0 HR = 1. 06; P =. 91 0. 0 5. 0 Yrs 10. 0 237 228 184 175 71 78 Pritchard KI, et al. NEJM. 2006; 354: 2103 -2111. Copyright @ [2006] Massachusetts Medical Society. All rights reserved. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Adjusted* HRs by HER 2 Status (CEF vs CMF) DFS OS HER 2 HR 95% CI P Value Amplified 0. 52 0. 34 -0. 80 . 003 0. 65 0. 42 -1. 02 . 06 Not amplified 0. 91 0. 71 -1. 18 . 49 1. 06 0. 83 -1. 44 . 68 *Adjusted for age, nodal status, grade, ER status, surgical procedure, tumor size. Test for interaction: P =. 02 for DFS; P =. 01 for OS Pritchard KI, et al. NEJM. 2006; 354: 2103 -2111. Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HER 2/neu Overexpression: Predictive of Response Anthracycline vs nonanthracycline containing trials: HER 2/neu § 10 large studies § Each suggest that HER 2/neu overexpression/amplification is a positive factor for response to anthracycline § Each underpowered to test the question clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HER 2/neu Overexpression: Predictive of Response (cont’d) § All from published data – De Laurentiis et al – Gennari et al – Dhesy-Thind et al All support interaction between positive HER 2/neu status and advantage of anthracycline vs nonanthracycline containing regimen De Laurentiis M, et al. J Clin Oncol. 2008; 26: 44 -53. Gennari A, et al. J Natl Cancer Inst. 2008; 100: 14 -20. clinicaloptions. com/oncology Dhesy-Thind B, et al. Breast Cancer Res Treat. 2008; 109: 209 -229.

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HER 2/neu Overexpression: Predictive of Response (cont’d) Topoisomerase IIα gene (Topo IIα) § Located close to HER 2/neu on the 17 q chromosome § Integrally involved in the antitumor action of anthracyclines § Topo IIα is essential for DNA replication and recombination § Anthracyclines target Topo IIα enzyme clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Topo IIα (not HER 2) Amplification Predictor of Anthracycline Response § Since 2002, at least 7 studies have been published demonstrating the association between Topo IIα amplification and improved anthracycline response Study Yr N Park et al 2006 284 Tanner et al 2006 525 Knoop at al 2005 805 Park et al 2003 188 Coon et al 2002 35 Di Leo et al 2002 354 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Topo IIα as a Predictive Factor CEF vs CMF § Patients with Topo IIα amplification or deletion increased RFS (HR = 0. 43; 0. 63) and OS (HR = 0. 57; 0. 56) if treated with CEF vs CMF § Topo IIα vs treatment interaction was negative Knoop AS, et al. J Clin Oncol. 2005; 23: 7483 -7490. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS Non-coamplified Topo IIα by Arm: Second Interim Analysis 1. 0 91% Disease Free (%) 0. 9 90% 0. 8 83% 85% 83% 84% 81% 78% 0. 7 71% Patients 643 642 618 0. 6 0. 5 0 Events 146 AC → T 87 AC → TH P <. 001 92 TCH P <. 001 1 2 3 Year From Randomization Slamon D, et al. SABCS 2006. Abstract 52. 4 5 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS Coamplified Topo IIα by Arm: Second Interim Analysis 1. 0 95% 89% Disease Free (%) 0. 9 94% 92% 0. 8 87% 83% 85% 0. 7 Patients 328 357 359 0. 6 0. 5 0 Events 42 AC → T 35 AC → TH P <. 336 42 TCH P <. 648 1 2 3 Year From Randomization Slamon D, et al. SABCS 2006. Abstract 52. 4 5 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HER 2 and Topo IIα 17 q 12 17 q 21. 2 HER 2 Core region Topo IIα region 23% to 50% 13% to 43% Normal Amplified Deletion clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer MA. 5 Clinical Trial § Tissue microarrays constructed – 480 patients (67% entire cohort) § Topo IIα gene alterations (FISH) – FISH results available on 443/480 (92%) Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Topo IIα FISH Results § Amplified: 48 (10. 8%) § Deleted: 27 (6. 1%) § Normal: 368 (83. 2%) Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Baseline Characteristics for Patients With Topo IIα FISH Measurements Characteristic, n (%) HER 2/neu Amplified Not amplified Topo IIα Gene Status Amplified Deletion (n = 48) (n = 27) 28 (60) 19 (40) Pritchard KI, et al. NEJM. 2006; 354: 2103 -2111 18 (67) 9 (33) Normal (n = 368) P* Value 73 (20) 288 (80) <. 0001 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS by Treatment for Patients With Topo IIα Amplified or Deleted Tumors 100 CEF 60 40 CMF 20 80 Patients (%) 80 0 CEF 60 CMF 40 20 Unadjusted P =. 07 Adjusted P =. 01 0 DFS by Treatment for Patients With Normal Topo IIα 5. 0 Yrs O'Malley FP, et al. ASCO 2006. Abstract 533. 10. 0 Unadjusted P =. 75 Adjusted P =. 56 0 0 5. 0 10. 0 Yrs clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer OS by Treatment for Patients With Topo IIα Amplified or Deleted Tumors 100 80 60 40 CMF 20 0 60 CMF 40 20 Unadjusted P =. 06 Adjusted P =. 01 0 CEF 80 CEF Patients (%) OS by Treatment for Patients With Normal Topo IIα 5. 0 Yrs O'Malley FP, et al. ASCO 2006. Abstract 533. 10. 0 Unadjusted P =. 41 Adjusted P =. 60 0 0 5. 0 10. 0 Yrs clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HRs* by Treatment (CEF vs CMF) and Topo IIα Status DFS OS HR 95% CI P Value HR 95%CI P Value Amp/del 0. 42 0. 21 -0. 83 . 01 0. 38 0. 18 -0. 80 . 01 Norm 0. 93 0. 68 -1. 25 . 56 1. 10 0. 77 -1. 56 . 60 *Adjusting for age, nodal status, grade, ER status, surgical procedure, tumor size, HER 2 status. Test for interaction: (adjusted) P =. 09 for DFS; P =. 04 for OS O'Malley FP, et al. ASCO 2006. Abstract 533. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Topo IIα Protein IHC § No. positive cells/500; expressed as a percentage § Initial analysis used Topo IIα protein as a continuous variable § Final analysis used 13% as a cutoff (28. 5% over-expression) clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Topo IIα Status by FISH and IHC FISH Topo IIα Gene Status IHC Topo IIα Protein Status, n (%) Amplified (n = 44) Deleted (n = 23) Normal (n = 351) Overexpression 13 (30) 7 (30) 97 (28) Normal 31 (71) 16 (70) 254 (72) P Value*. 93 *Chi-square test for association. Pritchard KI, et al. NEJM. 2006; 354: 2103 -2111 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer § Earlier work has also shown that Topo IIα protein expression and Topo IIα gene amplification status are not correlated Mueller, Parkes, Andrulis, O’Malley. Genes, Chromosomes & Cancer. 2004. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Probability (%) DFS by Treatment 100 Overexpression of Topo IIα protein P =. 01 CEF 80 60 CMF 40 Probability (%) 0 100 5 10 Normal expression of Topo IIα protein P =. 6 CEF CMF 80 60 40 0 Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. 5 Yrs 10 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Probability (%) OS by Treatment 100 Overexpression of Topo IIα protein P =. 02 CEF CMF 80 60 40 Probability (%) 0 100 5 10 Normal expression of Topo IIα protein P =. 8 CEF CMF 80 60 40 0 Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. 5 Yrs 10 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Adjusted* HRs by Topo IIα Protein Overexpression (CEF vs CMF) DFS Topo IIα protein HR OS 95% CI P Value HR 95% CI P Value Over 0. 49 expression 0. 28 -0. 85 . 01 0. 51 0. 28 -0. 93 . 03 Normal 0. 66 -1. 23 . 50 0. 98 0. 68 -1. 41 . 91 0. 90 *Adjusted for age, nodal status, grade, ER status, surgical procedure, tumor size, HER 2 status. Test for interaction: P =. 04 for DFS; P =. 03 for OS Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Which Is the Best Predictive Factor for CEF vs CMF in MA. 5? § Regression adjustment is not an appropriate technique 1 § Needs new statistical methodology § Can use “ranked” P value as a rough estimate 1. Simon R. J Natl Cancer Instit. 2006. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Which Is the Best Predictive Factor for CEF vs CMF in MA. 5? (cont’d) DFS P Value OS P Value HER 2/neu . 01 . 02 Topo IIα protein* . 04 . 03 Topo IIα gene . 09 . 04 *Exploratory analysis. Levine MN, et al. J Clin Oncol. 2005; 23: 5166 -5170. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Conclusions § Strong theoretical underpining for Topo IIα gene and Topo IIα protein and anthracycline efficacy § More robust data supporting role of HER 2/neu and anthracycline efficacy § Topo IIα analyses not routinely available § HER 2/neu analyses available in most centers, quality assured clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Conclusions (cont’d) § Individual trials and 3 meta-analyses support HER 2/neu amplification as a predictor of response to anthracycline vs nonanthracycline chemotherapy § HER 2/neu amplified or overexpressed: candidates for anthracyclines clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Conclusions (cont’d) § HER 2/neu nonamplified or non-overexpressed may do equally well with nonanthracycline combinations such as CMF § Topo IIα may be better predictor but more data and more robust and widely used testing are required before this can be concluded or applied to clinical practice clinicaloptions. com/oncology

Nonanthracycline Adjuvant Regimens: Changing the Standard of Care? Stephen E. Jones, MD Medical Director, US Oncology Research Houston, Texas Director, Breast Cancer Research Baylor Charles A. Sammons Cancer Center Texas Oncology, PA Dallas, Texas

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Nonanthracycline Options § L-PAM (L-phenylalanine mustard) § CMF: cyclophosphamide, methotrexate, 5 -FU § TC: docetaxel/cyclophosphamide § TCH: docetaxel/carboplatin/trastuzumab clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer The Story of 2 Modern Nonanthracycline Regimens § TC: docetaxel/cyclophosphamide § TCH: docetaxel/carboplatin/trastuzumab clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer History of AC § First human studies using AC were conducted at the University of Arizona in 1973 § Based on laboratory conclusions of synergy between A and C § Initial trials in 1973 in metastatic breast cancer moved into the adjuvant setting in 1974 in both node-positive (N+) and node-negative (N-) disease § First publication of AC in 1975[1] 1. Jones SE, et al. Cancer. 1975; 36: 90 -97. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Original AC Publication: 1975 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer History of AC (Why AC Remains a Standard of Care) § Series of NSABP trials defined the dose of C – NSABP B-22 and NSABP B-25 § CALGB studies (8541 and 9344) tested doses of A from 30 mg/m 2 to 90 mg/m 2 and found that 60 mg/m 2 was the optimal dose of A § Thus, AC 60/600 was the optimal dose of both agents § NSABP compared AC with CMF in NSABP B-15 and NSABP B-23 and 4 cycles of AC became “standard” § Until now, no treatment of 4 cycles in length was superior to AC § AC has been the backbone for addition of taxanes clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer USON 9735: Study Design N = 1016 71% ER+ 48% N- 4 x TC Q 3 W Docetaxel 75 mg/m 2 + Cyclophosphamide 600 mg/m 2 n = 506 4 x AC Q 3 W Doxorubicin 60 mg/m 2 + Cyclophosphamide 600 mg/m 2 n = 510 § Eligibility: stage I, II, or III disease § Median follow-up: 5. 5 years § Chemotherapy doses based on actual body surface area (no cap) § Chemotherapy given before radiation § Tamoxifen for all ER+ patients after chemotherapy ± radiation Jones SE, et al. J Clin Oncol. 2006; 24: 5381 -5387. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer USON 9735: Patient Characteristics Characteristic TC (n = 506) AC (n = 510) 72 69 § 1 -3 41 42 § 4 12 9 Negative nodes, n 47 51 ER+ and/or Pg. R+, % Positive nodes, n Jones SE, et al. J Clin Oncol. 2006; 24: 5381 -5387. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Extended Follow-up and Analysis of USON 9735: Demographics TC (n = 506) AC (n = 510) < 65 (n = 428) ≥ 65 (n = 78) < 65 (n = 428) ≥ 65 (n = 82) ER+, % 70 67 64 71 Pg. R+, % 63 60 60 60 § 0 50 36 51 38 § 1 -3 41 45 41 46 § 4+ 10 19 9 16 Median age, yrs 50 69 49 68 27 -64 65 -77 Nodes, % § Range, yrs Jones SE, et al. Breast Cancer Res Treat. 2007; 106(suppl 1): S 5. Abstract 12. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS by Treatment and Age 1. 00 1. 0 0. 95 0. 9 < 65 yrs TC TC 0. 85 81% P =. 033 HR = 0. 74 0. 80 AC 0. 75 75% Proportion DFS 0. 90 < 65 yrs AC 0. 8 0. 7 ≥ 65 yrs TC 0. 6 ≥ 65 yrs AC 0. 70 0. 5 0. 60 0 12 24 36 48 60 72 84 96 0. 4 0 12 24 Mos Jones SE, et al. Breast Cancer Res Treat. 2007; 106(suppl 1): S 5. Abstract 12. 36 48 60 72 84 96 Mos clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer OS by Treatment and Age 1. 00 1. 0 0. 90 87% 0. 85 AC P =. 032 HR = 0. 69 0. 80 < 65 yrs TC 0. 9 TC 82% 0. 75 0. 70 Proportion Surviving 0. 95 < 65 yrs AC 0. 8 ≥ 65 yrs TC 0. 7 ≥ 65 yrs AC 0. 6 0. 5 0. 60 0 12 24 36 48 60 72 84 96 0. 4 0 12 24 Mos Jones SE, et al. Breast Cancer Res Treat. 2007; 106(suppl 1): S 5. Abstract 12. 36 48 60 72 84 96 Mos clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HER 2+ HER 2 - (n = 46/170; 27%) (n = 124/170; 73%) 1. 0 0. 9 0. 8 Proportion DFS DFS by HER 2 0. 7 0. 6 TC 0. 5 0. 4 AC HR = 0. 73 0. 7 0. 5 0. 3 0. 1 0. 0 24 36 48 Mos 60 72 84 96 HR = 0. 56 0. 4 0. 2 12 AC 0. 6 0. 2 0 TC 0 12 24 Jones SE, et al. Breast Cancer Res Treat. 2007; 106(suppl 1): S 5. Abstract 12. 36 48 60 Mos 72 84 96 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Exploratory Analysis of DFS HRs (CI) for Key Subgroups Overall HR for DFS = 0. 74 HER 2 - (TC = 55, AC = 69) 0. 56 (0. 30 -1. 05) HER 2+ (TC = 28, AC = 18) 0. 73 (0. 33 -1. 70) ER- or PR- (TC = 136, AC = 158) 0. 70 (0. 44 -1. 10) ER+ or PR+ (TC = 368, AC = 351) 0. 79 (0. 56 -1. 13) Age ≥ 65 (TC = 78, AC = 82) 0. 70 (0. 40 -1. 24) Age < 65 (TC = 428, AC = 428) 0. 76 (0. 55 -1. 04) 0 0. 2 0. 4 0. 6 0. 8 1 1. 2 1. 4 1. 6 1. 8 HR Log Scale Jones SE, et al. Breast Cancer Res Treat. 2007; 106(suppl 1): S 5. Abstract 12. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Results: Grade 3/4 Hematologic Toxicity Adverse Events, % TC n = 506 AC n = 510 < 65 yrs (n = 428) ≥ 65 yrs (n = 78) < 65 yrs (n = 428) ≥ 65 yrs (n = 82) Anemia < 1 1 5 Neutropenia 60 52 54 59 Thrombocytopenia < 1 0 1 < 1 Febrile neutropenia 4 8 2 4 Jones SE, et al. Breast Cancer Res Treat. 2007; 106(suppl 1): S 5. Abstract 12. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Additional* Long-term Fatalities All on AC arm: § CHF (45 yrs old) § Myelodysplastic syndrome (63 yrs old) § Myelofibrosis (66 yrs old) *With 2 more years of follow-up Jones SE, et al. Breast Cancer Res Treat. 2007; 106(suppl 1): S 5. Abstract 12. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Conclusions § At 7 years, 4 cycles of TC compared with 4 cycles of AC was associated with – Superior DFS (P =. 033) – Superior OS (P =. 032) – Efficacy in HER 2+ as well as HER 2 - disease (limited sample) – Efficacy established in older as well as younger patients Jones SE, et al. Breast Cancer Res Treat. 2007; 106(suppl 1): S 5. Abstract 12. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Conclusions (cont’d) § Overall toxicity similar in both treatment groups – In older patients, numerically slightly more febrile neutropenia with TC but more anemia with AC § Less long-term toxicities with TC, particularly bone marrow and cardiac related § TC should be considered one of several standard regimens for the treatment of early breast cancer and deserves further study in new clinical trials Jones SE, et al. Breast Cancer Res Treat. 2007; 106(suppl 1): S 5. Abstract 12. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer What Does This Mean in Clinical Practice? § First study to report a significant DFS and OS advantage for docetaxel vs an anthracycline in adjuvant breast cancer § Findings of this trial fundamentally significant, particularly for node-negative patients and those with 1 -3 positive nodes § Risk reduction similar to other anthracycline-taxane regimens (without using an anthracycline) clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Risk Reduction DFS: ITT Analyses Regimen HR: DFS AC → T (CALGB 9344) 0. 83 AC → T (NSABP B-28) 0. 83 AC → T (NSABP B-27) 0. 86 TAC (BCIRG 001) 0. 72 FEC → T (PACS-001) 0. 83 TC (USON) 0. 74 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer What Does an Anthracycline Do for You? § Significant cardiac toxicity, some of it appearing late § Increased nausea and vomiting, some delayed § Rare, but real, risk of leukemia § Who benefits from the use of anthracyclines? clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer BCIRG 006: SABCS 2006 and 2007 § Late-breaking abstract presented by Dennis Slamon, MD, Ph. D[1] § Topo IIα and significance[2] 1. Slamon D, et al. SABCS 2006. Abstract 52. 2. Slamon DJ, et al. SABCS 2006. Abstract 13. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer BCIRG 006 4 x AC 60/600 mg/m 2 4 x T 100 mg/m 2 AC T HER 2+ (central FISH) N+ or high-risk N- AC TH (N = 3222) 6 x T and C 75 mg/m 2 AUC*6 Stratified by nodes and hormonal receptor status 1 yr H TCH *AUC: area under the concentration vs time curve Slamon D, et al. SABCS 2006. Abstract 52. 1 yr H clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS: 2 nd Interim Analysis 1. 0 Patients Disease Free (%) 93% 0. 9 92% Absolute DFS Benefits (From Years 2 to 4): 87% AC TH vs AC T: 6% TCH vs AC T: 5% 0. 8 87% 83% 86% 82% 81% 77% 0. 7 Patients 1073 1074 1075 0. 6 0. 5 0 Events 192 AC T 128 AC TH HR (AC TH vs AC T) = 0. 61 (0. 48; 0. 76; P <. 0001) 142 TCH HR (TCH vs AC T) = 0. 67 (0. 54; 0. 83; P =. 0003) 1 2 3 Year From Randomization Slamon D, et al. SABCS 2006. Abstract 52. 4 5 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Cardiac Deaths and CHF as per Independent Review Panel First Analysis/Second Analysis AC → T (n = 1050) AC → TH (n = 1068) TCH (n = 1056) Cardiac-related death 0/0 Grade 3/4 cardiac left ventricular function (CHF) 3/4 17/20 4/4 P =. 0015 Slamon D, et al. SABCS 2006. Abstract 52. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer HER 2 and Topo IIα in BCIRG 006 2120 of 3222 patients analyzed 2990 of 3222 patients analyzed 17 q 12 N = 2120 N = 2990 17 q 21. 1 HER 2 Core region 17 q 21. 2 Topo IIα region 1285 patients (60%) 1788 patients (60%) Topo IIα non- coamplified 91 patients (4%) 145 patients (5%) Coamplified 744 patients (35%) 1057 patients (35%) 1 st interim analysis 2 nd interim analysis Slamon D, et al. SABCS 2006. Abstract 13. Normal Amplified Deletion clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS Non-Coamplified Topo IIα by Arm: 2 nd Interim Analysis Patients Disease Free (%) 1. 0 91% 0. 9 90% 0. 8 83% 84% 81% 78% 0. 7 71% Patients Events 643 146 AC T 643 87 AC TH P <. 001 618 92 TCH 0. 6 0. 5 85% 0 1 2 3 Year From Randomization Slamon D, et al. SABCS 2006. Abstract 13. 4 5 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer DFS Coamplified Topo IIα by Arm: 2 nd Interim Analysis 1. 0 Patients Disease Free (%) 95% 89% 0. 9 94% 92% 0. 8 87% 83% 85% 0. 7 Patients 328 357 359 0. 6 0. 5 0 Events 42 AC T 35 AC TH P =. 336 42 TCH P =. 648 1 2 3 Year From Randomization Slamon D, et al. SABCS 2006. Abstract 13. 4 5 clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Who Benefits From Anthracyclines? § Only Topo IIα–amplified patients benefit from anthracyclines § One third of HER 2+ disease overexpress Topo IIα ~ 8% of all breast cancer patients § HER 2 - disease rarely overexpress Topo IIα § The best marker currently available for Topo IIα amplification is HER 2/neu amplification (might be a surrogate for Topo IIα) clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Who Benefits From Anthracyclines? § In a recent analysis of more than 1800 patients in the BCIRG 005 study for Topo IIα gene amplification, there was a single case of Topo IIα amplification § All cases were HER 2 - by FISH; Topo IIα amplification does not occur without HER 2 amplification § Value of Topo IIα protein expression independent of gene overexpression is still an ongoing controversy § Targets other than Topo IIα for anthracyclines? High proliferation, other targets unknown at this time Slamon D. Press, M: Personal communication; 2007 and 2008. clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer Who Can Be Treated Today? § TC better than AC and ACTH = TCH § Patients with cardiac history (or cardiac fear) § HER 2 -: invasive cancer regardless of receptor status with negative nodes or 1 -3 positive nodes; for higher risk, can give TC x 6 (no data) § HER 2+: TCH (including neoadjuvant setting) § For the oncologists who remain unconvinced, a study will be needed clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer TAC vs TC in HER 2/neu Nonamplified Early-Stage Breast Cancer: USON 06090 § Large randomized clinical trial (2000 patients) § Ongoing study of TC x 6 vs TAC x 6 § Biologic correlates § 500 patients currently accrued clinicaloptions. com/oncology

Challenging the Dogma: Questioning the Role of Anthracyclines in Early Breast Cancer More Hematology/Oncology Available Online § Medical Meeting Coverage: key data plus Expert Analysis panel discussions exploring clinical implications § Treatment Updates: comprehensive programs covering the most important new concepts § Interactive Cases: test your ability to manage patients clinicaloptions. com/oncology