Personalizing Treatment for Non-Small Cell Lung Cancer Page 1. A transcription of an online webcourse presented by

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1 Personalizing Treatment for Non-Small Cell Lung Cancer Page 1 A transcription of an online webcourse presented by SURESH S. RAMALINGAM, MD Professor of Hematology and Medical Oncology Director, Division of Medical Oncology Emory University Winship Cancer Institute Atlanta, GA HEATHER WAKELEE, MD Associate Professor of Medicine Department of Medicine Division of Oncology Stanford University Palo Alto, CA Slide 1 Heather Wakelee, MD: Welcome to the webcourse Oncology Exchange: Personalizing Treatment for Non-Small Cell Lung Cancer. This activity is jointly sponsored by Potomac Center for Medical Education and Rockpointe Oncology. This activity is supported by an independent educational grant from Boehringer Ingelheim Pharmaceuticals, Incorporated. Slide 2 I m Dr. Heather Wakelee, Medical Oncologist and Associate Professor of Medicine at Stanford University and Stanford Cancer Institute. I am joined on this Program by my friend and colleague Dr. Suresh Ramalingam. Suresh S. Ramalingam, MD: Hello. I am Dr. Suresh Ramalingam, Professor at Emory University and the Winship Cancer Institute in Atlanta. It is my pleasure to join Dr. Wakelee on this educational activity. Slide 3 On this next slide, you will see our disclosures,

2 Personalizing Treatment for Non-Small Cell Lung Cancer Page 2 Slide 4 And now our educational objectives: At the conclusion of this activity, participants should be able to: demonstrate the ability to review molecular evaluation strategies for non-small cell lung cancer; discuss formulation of treatment plans for patients with non-small cell lung cancer based on biomarker expression; review quality measures associated with personalizing treatment for non-small cell lung cancer; and discuss emerging strategies for the management of non-small cell lung cancer. Slide 5 To remind everyone, lung cancer is the number one cause of cancer deaths in the United States, killing more patients annually than breast, colon, and prostate cancer combined. Slide 6 Lung cancer s major cause, of course, is cigarette consumption. And you can see on this graph, in green, cigarette consumption, when it started to go down in the 1960s after the Surgeon General report had come out showing the health hazards. This report was picked up by men who stopped smoking, and you can see with that there is a decline in cancer death rate for men. But, unfortunately, for women, cigarette smoking continued on the uptake in the 70s and 80s, and you can see that the rates of lung cancer deaths for women have only now started to plateau. Slide 7 Fortunately, we do have some hope on the horizon for detecting lung cancer earlier, and that comes from newest data looking at screening for patients with a smoking history. This slide shows data from the National Lung Screening Trial, or NLST, which recently led to recommendations from the US Preventive Task Force that screening for lung cancer with annual CT scans should be considered for people who are over 55 years old and have at least a 30 pack-year smoking history. The NLST Trial included patients ages 55 to 74 with at least a 30 pack-year smoking history. They were randomized 1:1 to get an annual chest X-ray or low-dose CT scan over a period of three years. They would get annual scans. Over 50,000 patients were screened and followed for the two years. Many of the CT scans did reveal abnormalities, 95% of which were false positives, and that is going to be one of the major challenges as screening becomes more widespread, is how do we follow those false positive scans appropriately without leading to too much alarm for patients? The results of the trial were that the total lung cancer deaths were lower in the group of patients getting CT scans. There were 354 lung cancer deaths versus 442 in those who got only the chest X-rays. This is a 20% relative mortality reduction. And putting it in another way, the number needed to screen in order to prevent one lung cancer death is about 320 people. Slide 8 The next slide shows some of the survival curves, showing an improvement in lung cancer mortality but also an all-mortality, perhaps related to other health issues that were discovered on the CT scans. But that is still being looked at. So screening at this time is now recommended by this US Preventive Task Force recommendation. However, how that is going to be covered and how it is going to be adopted on a widespread scale is still very much an area of debate.

3 Personalizing Treatment for Non-Small Cell Lung Cancer Page 3 Slide 9 So, with that, I am going to move into the first case, and this is looking at non-small cell lung cancer detected at an early stage in a patient with an EGFR mutation. Slide 10 So the case is a 45 year-old never-smoking woman, originally from India, who presents with an increasing cough. She has no response to antibiotics and, after a month, she is sent for a chest X-ray which reveals a left upper-lobe mass. A CT scan confirms a three-centimeter left upper-lobe mass. It does not show any anything else of abnormality. But, on the PET scan, there is uptake not only in the mass but also in the left hilum. The patient goes for a left upper lobectomy and has no complications. The final pathology confirms a 2.5-centimeter adenocarcinoma with three positive hilar lymph nodes but 0 out of 14 mediastinal nodes are involved, so the final stage is a T2bN1M0 stage IIA non-small cell lung cancer. Slide 11 At this time, would you obtain testing to guide choice of adjuvant chemotherapy? If so, which biomarkers would you test for: A) yes, ERCC1; B) yes, ERCC1 and RRM1; C) yes, ERCC1, RRM1, and thymidylate synthase (TS); or D) no? Slide 12 The correct answer here would be no. There have actually been some recent trials questioning the utility even further, though this was never clearly established. And, Ram, have you done any ERCC1 and RRM testing in the past, before we had these recent results in the past year? Suresh S. Ramalingam, MD: No, Heather. Our approach has been to treat patients based on histology and use that to select the appropriate treatment regimen. But the biomarkers listed in this slide are, in my view, still experimental and, therefore, we have not adopted them into practice. Heather Wakelee, MD: Right. Yeah, and that had been my practice, as well. These tests were commercially available and so I know they were starting to be looked at. And we did have some interesting, intriguing data that had come out in the years past. Slide 13 But, on this next slide, we go through some of the other markers that people have talked about. Again, all of these come from retrospective analyses. There has been a lot of work looking at gene signatures and, in my mind, the best was from the BR.10 Trial, which, again, found a 15- gene signature. That is not widely adopted yet and still being investigated. There are many other genes being looked at. Slide 14 And then, further on this slide, you see these predictive markers that have been studied. ERCC1 is a DNA repair enzyme, and when levels are low in the tumor, patients are felt to be more sensitive to the platinum and, conversely, if the levels are high, then there is felt to be a relative platinum resistance. RRM1 is similar only it is more focused on gemcitabine pathways. Thymidylate synthase when levels are low in the tumor, the patients are felt to be more sensitive to pemetrexed and, of course, if they re high, to be resistant. But, again, a lot of

4 Personalizing Treatment for Non-Small Cell Lung Cancer Page 4 controversy. There is a lot of different investigations looking at that with not any clear pattern really emerging. And then, of course, there are EGFR mutations and ALK translocations. And we all know how critical those are in determining therapy for patients with metastatic disease. But, for patients with early stage resected, I think there is still a lot of work that needs to be done to figure out the role there. This is data that came out on ERCC1 in the past year. This is from the IALT adjuvant trial which, of course, is the largest adjuvant trial to date and one of the main ones to really establish the utility of this platinum-based chemotherapy. So, what the investigators did here is, retrospectively, they initially looked at of the total of 1,867 patients, they had about 760 tumor samples that were assayed for the ERCC1, and that was the initial publication that came out in Then, this last year, they went back and reanalyzed almost 600 of those cases, and that is the 589 number in yellow. When they initially did this analysis in 2006, ERCC1 positivity was found in 44%, but, on the redo, it is now at 77%. So, again, the ERCC1-positive means patients should, theoretically, be resistant to platinum. And when this initial analysis was done, the hazard ratio was 1.2, kind of supporting that hypothesis, but on the new analysis, the hazard ratio was close to one, so saying that wasn t particularly useful at all. And then, with the ERCC1 negativity, implying platinum sensitivity, initially, that was 56% of the cases; now, it is down to only 23%. And, initially, the patients that had ERCC1 low -- hazard ratio was held up statistically significant even in long-term follow-up, indicating that, maybe, was a marker of who should get adjuvant chemo; but, on the new analysis, it was not statistically significant. There was a really nice New England Journal publication last spring, in 2013, which went through a very detailed look at maybe why this ERCC1 testing wasn t working, and what they showed was that the current antibodies available really couldn t distinguish between the isoforms of ERCC1, and only one of those isoforms the 202 is actually active. It went through a lot of other analyses, as well, but the take-home is that the ERCC1, at least, has really been brought into question, as utility has, and we had a couple of presentations at ASCO this year in the metastatic setting, which also sort of reinforced that idea. Slide 15 There are still some ongoing trials looking at ERCC1 as a potential marker in adjuvant, and this next slide has a table looking at those. Some of these trials have completed accrual; especially the SWOG 0720 and the C30506 which stopped accruing a while ago. There are a couple of European studies, also: the ITACA, TASTE, and SCAT trials. The ITACA Trial is moving along. The TASTE Trial we heard about at ASCO this year, and they decided not to pursue the full Phase III portion of the test. They did do the Phase II and showed that it was do-able, but because of the ERCC1 data, they decided to stop the study at that point. And then the SCAT Trial is using a different marker, and that is being done in Spain. Slide 16 So that brings us to our next question on this case. Which of the following chemotherapy options would not be appropriate for this patient: A) four cycles of cisplatin/vinorelbine; B) four cycles of cisplatin/pemetrexed; C) four cycles of cisplatin/docetaxel; or, D) four cycles of carboplatin/paclitaxel?

5 Personalizing Treatment for Non-Small Cell Lung Cancer Page 5 Slide 17 All right, so the incorrect answer or the answer that you would choose as not appropriate for this patient would be D) the four cycles of carboplatin/paclitaxel. Really, the trials, so far, have been with cisplatin/vinorelbine, but there is a lot of use of the other regimens, as well. In the adjuvant setting, those are included in NCCN Guidelines and were arms on the ECOG 1505 Trial, which has finished accrual, as options for patients getting adjuvant treatment. However, the carboplatin/paclitaxel there was only one randomized trial. It was a small trial. It was not, in the end, a positive study, and so we don t tend to use that as much. And I try to avoid carboplatin, myself, unless a patient really is not going to be able to handle cisplatin. So, Ram, do you have comments on this? Suresh S. Ramalingam, MD: I think your approach reflects what most of us do in our practice, which is to use cisplatin-based doublets in the adjuvant setting. Vinorelbine, obviously, is the drug that has been studied the most in the adjuvant therapy setting. However, I feel comfortable using the newer drugs like pemetrexed and docetaxel in my patients with early stage disease. We can all agree, I think, that this patient with the three lymph nodes-positive disease is at high risk for recurrence and requires the most aggressive therapy that we can give her to improve the cure rate. Heather Wakelee, MD: Yeah, I agree with that. We do have, of course, the one small trial from Germany the TREAT Trial that looked at the cisplatin/pemetrexed versus cisplatin/vinorelbine, and that was published this year. And they showed that you could get more platinum in if you were giving the cisplatin/pemetrexed, but they didn t really have outcomes data of note. The trial included a lot of patients who had squamous histology, because it was planned before we knew about the pemetrexed squamous issue, where it is not a good drug in that setting. So until 1505 data are out and we re able to analyze it, we re not going to have a big study really looking at these other regimens, but we will get that when 1505 data comes out. Slide 18 There are, of course, many, many adjuvant trials now. The LACE meta-analysis looked at the five largest trials that include cisplatin-based regimens. The overall survival hazard ratio was 0.89, statistically significant. However, if you look at it by stage: the Stage IA patients really no benefit, potential harm; the Stage IB patients not a statistically significant benefit; and the Stage II and III hazard ratio 0.83, highly statistically significant. So that is about a five- to 10% overall survival benefit at five years. Now, looking at that Stage IB group a little more, again, this was with the old AJCC and not the new one. In the old one, remember, the size didn t matter for the tumor, and anybody who had a big tumor at least three centimeters in size with no lymph nodes was a Stage IB. So this included a lot of patients that we would now classify as a Stage II based on the size of the tumor. But, in that in sub-analyses from those studies, the patients with tumors of at least four centimeters seem to benefit from adjuvant treatment, so that is just something to keep in mind. If a patient has lymph nodes involved, I almost always give adjuvant chemo. If there are no lymph nodes involved, then we look at the size of the tumor more. Slide 19 So what if this patient ended up having an EGFR mutation? And, in fact, she is going to as we get through this case. I do not yet routinely test the early stage patients for EGFR mutations, but there is going to be a big, international trial that is going to be looking at that, so we ll be starting

6 Personalizing Treatment for Non-Small Cell Lung Cancer Page 6 to do that. And my surgeons will sometimes send off the samples for that anyway, even without talking with me. So, Ram, are you guys sending off routinely for EGFR mutations at this time, in the early stage patients? Suresh S. Ramalingam, MD: Yeah, we continue to use chemotherapy for appropriate patients, even if they have an EGFR mutation. Heather Wakelee, MD: Mm-hmm. Suresh S. Ramalingam, MD: Clearly, it is a very difficult clinical issue, because patients have a target, and we have good experience with this class of agents in advanced-stage disease. But, as you point out, data from the Canadian trial raised caution and, therefore, we stay away from it outside of the clinical trial. Slide 20 OK, and so this next slide really just talks about the EGFR mutations. And, again, everyone, I m sure, is familiar that there are somatic mutations that occur in the epidermal growth factor receptor (EGFR). When this occurs in the tumor, those tumors are very, very responsive to EGFR tyrosine kinase drugs, and that is especially this in-frame deletion in exon 19 or the L858R point mutation in exon 21. That is 85% to 90% of EGFR mutation. There are other EGFR mutations, and we don t know as much about those, so whenever one of my comes back with a result that is something other than exon 19 or exon 21 L858R, I will go to mycancergenome.org to get a better sense of what data is out there with those mutations. I don t know if Ram, is that a resource you ve been using, also, for the rare mutations? Suresh S. Ramalingam, MD: I have done that, and I have also talked to colleagues who tend to see more of the EGFR-mutated tumors in their practices. Heather Wakelee, MD: Mm-hmm, yeah. Great. Slide 21 OK, and, again, just to remind everybody of the IPASS data, this trial was a large study done in Asia, taking patients who were light or never smokers, who had adenocarcinoma, and tended to be women, and before we knew about EGFR mutations, randomizing them to either start on gefitinib, the EGFR TKI, or to get chemotherapy with carboplatin/paclitaxel. And these were all metastatic patients who had not been previously treated. And what the trial showed us was that, when they went back, retrospectively, and tested the large percentage of patients for EGFR mutations, they had a very clear separation based on mutation status. And so, if you look at the progression-free survival, which is on the left, in yellow are the patients who got gefitinib. And you can see that the solid yellow line are patients who had an EGFR mutation and got gefitinib, and they do the best of everybody for PFS. But if you got gefitinib and you didn t have a mutation, even though you were never a smoker, in Asia, you most likely a woman, you did very poorly as far as PFS with gefitinib. And so this is our strongest data to tell us that, if you don t know mutation status, starting with an EGFR TKI is not a good idea, but, if you do, it is an excellent idea. In blue, we have the carboplatin/paclitaxel. And you can see there that, if you had an EGFR mutation, patients did a little better with carboplatin/paclitaxel than if you didn t have the EGFR mutation, but those curves didn t separate very much. So when I m thinking about a patient, if I know their EGFR mutation status makes it easy, I am going to start with an EGFR TKI; if I don t, I don t assume, and I start with chemo. And that is, I think, the most important message from my past. Ram, do you is that kind of the way you think about it, also?

7 Personalizing Treatment for Non-Small Cell Lung Cancer Page 7 Suresh S. Ramalingam, MD: Yes, that is pretty much how I interpret those data. Heather Wakelee, MD: Right. So with the overall survival, which is on the right, you can see there really wasn t a distinction for patients. If they had an EGFR mutation, they did better regardless of whether they started first on the EGFR TKI or got it switched over a little bit later, and so that is reassuring to me. When I don t know a mutation status, I am not so anxious about starting the patient on chemo. Oftentimes, they can tolerate it pretty well, and then they can always get their EGFR TKI, and we re not dealing with a survival disadvantage by doing that. So that is reassuring news from that. But you do see that, the yellow dotted line, the patients who started on an EGFR TKI, who did not have the mutation perhaps didn t do quite as well, and so that, again, just reinforces the importance of knowing. Slide 22 Heather Wakelee, MD: The BR.19 Study, which is on this slide. That trial took patients who had received adjuvant chemotherapy or not -- but they were all completely resected, early stage patients, with or without the chemotherapy -- and then randomized them to either get adjuvant gefitinib or a placebo. And gefitinib, of course, is one of our other EGFR TKIs initially approved in the US and Canada, now predominantly outside of the US and in Asia. But, in this study, patients were not tested for EGFR mutation status, initially, overall. And the overall hazard ratio for the trial showed that it was, if anything, harmful to get the gefitinib as opposed to the placebo. When testing was done, looking for patients with known EGFR mutations, it actually showed that the gefitinib was not beneficial, even in patients with a known EGFR mutation. So there were a lot of issues with this trial. It was stopped early. Patients did not get the full two years of gefitinib. They were very, very small numbers who had EGFR mutations 40 on the placebo arm and 36 on the gefitinib arm -- and so a lot of people have said that we can t take anything away from this trial. The take away from it is just caution. It just tells me we do need to complete these bigger trials, randomizing patients to get an EGFR TKI or not, and not to just assume we should be doing that for patients with early stage disease. So that is my take-home from it. I don t know, Ram, it sounds like you have a similar idea about it, as well. Suresh S. Ramalingam, MD: Yes, I would agree. Heather Wakelee, MD: But there are trials being done, some of which are non-randomized, that are looking specifically in patients with known EGFR mutations, and looking at whether or not there is a benefit for them to get an EGFR drug. Slide 23 So one of these trials is the SELECT Trial, in which case these patients were treated and followed, and they had a 94% two-year disease-free survival for patients who were on this. Now, the study did not have a randomized arm. It was all patients were treated with adjuvant erlotinib. And so we can look at this, and it is intriguing, but it is hard to know exactly what this means for clinical practice. So their sample size at the time of presentation was 36, when this was presented by my colleague Joel Neal at ASCO in They ve now expanded it to 100 patients, and we ll be hearing more about that. But, again, without the randomization, it is a little harder to know what this means.

8 Personalizing Treatment for Non-Small Cell Lung Cancer Page 8 Slide 24 We are going to get some randomized data. This is the RADIANT Trial schema. This, again, took all comers with resected non-small cell lung cancer. They had to at least have immunohistochemistry or FISH demonstration of EGFR expression, but they did not have to have a mutation. And these patients were randomized after resection to either get erlotinib for two years or placebo in a 2:1 randomization. There were 974 patients enrolled, and they did present data saying that about 17% of those patients did have EGFR mutations. So we are going to have some good randomized data looking at those patients who either got erlotinib or placebo, and that is going to give us, I think, the best data to date about whether or not adjuvant erlotinib is a good approach. Slide 25 But it is still kind of small, kind of underpowered, which is why this next trial the ALCHEMIST Trial is going to be so critical. This, I think, is going to be practice-changing because it is really going to encourage all of us to think about looking for EGFR and ALK in resected tumor specimens, because if we re able to identify patients that either have an EGFR mutation or an ALK translocation in their resected tumors, they can enroll in this trial and then will be randomized to either get: if they are EGFRmutant, erlotinib versus placebo; if the tumor is ALK-/FISH-positive, to get crizotinib versus placebo. In each case, it is two years of therapy. And this trial is really going to give us a definitive answer about what we should do with patients like this. Any comments on this, Ram? Suresh S. Ramalingam, MD: This trial is presently being developed, and we anticipate that it will be up and running in the next few months, at least by the first quarter of Heather Wakelee, MD: Yeah, yeah, so a highly anticipated study. Slide 26 OK, let s keep going with our case. Again, this woman is 45. She receives four cycles of cisplatin/pemetrexed adjuvantly on the control arm of ECOG 1505, tolerates it reasonably well, and then does well for two years. But, unfortunately, two years later, she develops increasing dyspnea and is found to have a pleural effusion. Analysis of the effusion is consistent with recurrent adenocarcinoma. Slide 27 So she is now 47 at the time of the recurrence. She has a PET scan and a brain MRI, and disease that is limited to the left lung but with extensive pleural involvement, mediastinal adenopathy. Her EGFR testing is repeated, and she is now found to have an EGFR exon 19 deletion. So what would be your choice of therapy, assuming her effusion is controlled: A) erlotinib, B) afatinib, C) carboplatin/pemetrexed, D) carboplatin/paclitaxel/bevacizumab, or E) erlotinib or afatinib? Slide 28 And both erlotinib and afatinib are now FDA-approved in this setting for patients with known EGFR deletion mutations, especially exon 19 deletion or the L858R so they have to have one of those two activating mutations for afatinib. For erlotinib, also, ideally have an activating mutation and, in that setting, either erlotinib or afatinib are approved agents.

9 Personalizing Treatment for Non-Small Cell Lung Cancer Page 9 So, Ram, do you have a preference at this time, or, I think, do you just talk about both of them with the patients? Suresh S. Ramalingam, MD: Yeah, at this time, we have the luxury of having two drugs. All of this happened within the past five months, when the FDA approved erlotinib and, more recently, afatinib. Pre-clinically, afatinib has some advantages over erlotinib in EGFR-mutated cell lines, but how that translates into the clinic, for patients is something we don t have an answer for. We know that there are competitive trials that are ongoing, comparing afatinib with the earlier generation of EGFR inhibitors such as gefitinib but, in the clinic right now, we discuss both options with patients. Heather Wakelee, MD: Right, that is what I m doing, too, and getting more experience with the afatinib. And I think, as time goes on, we ll know more about that, but it is great that we do have both options now. Slide 29 OK, so this next slide shows all the trials so far that have looked at EGFR TKI versus chemo first-line. And in all of these, the message is the same, whether gefitinib, erlotinib, or afatinib. In all of these trials for patients with known mutations, the PFS is strikingly better with the EGFR TKI in those patients with known mutations. The response rates have been strikingly higher in all of the trials. But the overall survival we ve not seen a statistically significant improvement at this time. Slide 30 So getting to our case again, the patient starts on erlotinib. She does well for 14 months but then she has recurrence of her pleural effusion. After a biopsy, which of the following steps would be not appropriate: A) switch to a platinum doublet, with or without bevacizumab, and stop erlotinib; B) add a platinum doublet, with or without bevacizumab, to the erlotinib; C) switch to a second-generation EGFR TKI; or D) switch to a crizotinib? So which of these is not appropriate? Slide 31 And if you look at that, I think D) switching to crizotinib which, of course, is an ALK drug, is the only inappropriate for this patient with a known EGFR mutation. Ideally, we would get a second biopsy, which is done here, to know the mechanism of resistance. And then my preference, if I don t have a trial or another drug to switch them to that is EGFR-targeted, I usually stop the erlotinib and switch to chemo as opposed to continuing erlotinib and adding chemo. There are a couple of trials that are being developed right now, that really ask that question. Ram, what do you tend to do? Suresh S. Ramalingam, MD: Yeah, my approach outside of the clinical trial is also to stop erlotinib and start the patients on combination chemotherapy if they have not received it before. Heather Wakelee, MD: Mm-hmm. Suresh S. Ramalingam, MD: I am aware of the data that supports continuing erlotinib, though that is fairly small coming from very specific groups in the Country. So until we have some randomized evidence, continuing erlotinib is not supported by available data, is my interpretation. Heather Wakelee, MD: Mm-hmm.

10 Personalizing Treatment for Non-Small Cell Lung Cancer Page 10 Suresh S. Ramalingam, MD: Obviously, there are some exciting new drugs. The so-called T790-specific drugs that are being developed are not available through clinical trials, so if a trial is available, then I prefer that approach for patients with an EGFR mutation. Heather Wakelee, MD: Mm-hmm, yes, so me, too. I talk to my patients about the risk that they could have a flare when we stop the erlotinib, and tell them, you know, if they start feeling a lot worse within a couple of days, that they should call right away and perhaps restart. And so I ve got a few that I did keep on erlotinib, but mostly I stop it if they go to chemo. Slide 32 So this next slide shows some of the resistance mechanisms we know about, with the T790M gatekeeper mutation being the most common. And, Ram, you just mentioned some of the drugs being developed there. There is also this small-cell transformation which is rare but is definitely seen. And then some of the other mechanisms are still really being worked out. Slide 33 And then, on this next slide, we show some exciting data with a combination of afatinib plus cetuximab for patients who had progressed after doing well on erlotinib or gefitinib. And what was really exciting about this data was that we saw responses on this waterfall plot in patients whether or not they had the T790M, so some of the first data that really showed activity in the T790M population. And this is going to be further studied in an ECOG trial in development and in some other studies, as well. Slide 34 And then the last slide in the EGFR section is talking about this compound, the CO-1686, which is one of those drugs you just were alluding to, Ram, where there is preclinical activity in T790M. And, as presented, at ASCO this year, three of the four patients who had known T790M, who were on the highest dose this 900 b.i.d. responses were seen, so it is sort of the second published information on clinical activity in the T790M patient population. So exciting. And there are some other drugs, also, that are looking good, that are coming along. Slide 35 And so, with that, why don t we move on to your case, Ram. Suresh S. Ramalingam, MD: Sure. Heather, thank you so much for walking us through some very important data on early stage lung cancer and management of patients with EGFR mutations. I m going to switch gears and talk about a patient who has an EML4-ALK transformation. This is clearly a new and exciting area of targeted therapy for lung cancer. Slide 36 And we ll start with this case. This is a 55 year-old male who presented with chest pain, dyspnea, and cough. A CT scan revealed diffuse pleural-based lesions on the right hemithorax in addition to a right upper-lobe lung mass. Unfortunately, there were also lesions in the liver. At least one lesion measuring two centimeters was observed. The patient had a 10 pack-year smoking history. A biopsy was done of the pleural-based mass, and it was consistent with adenocarcinoma. And the amino stain showed that it was a TTF-1 positive tumor. The tumor was tested for EGFR mutation and was found to be a wild type. The patient had a good performance status with stable coronary artery disease and hypertension as the comorbid illnesses.

11 Personalizing Treatment for Non-Small Cell Lung Cancer Page 11 Slide 37 The question here is which of the following options would you do next: A) start the patient on chemotherapy; would you order testing for ALK; would you order testing for ROS1; would you order testing for ALK and ROS1? Slide 38 The correct answer in this situation is it is preferable to perform both ALK and ROS1 testing by the FISH method, if you have access to it. At least, we should have ALK testing done on patients such as the one that we just talked about. Heather, what sort of testing strategy do you use for your newly diagnosed advanced-stage lung cancer patients, particularly adenocarcinomas? Heather Wakelee, MD: So we actually have a snapshot panel, which is a multi-gene PCRbased assay, where we look for EGFR and a lot of other mutations. And then we also do FISH for both ALK and ROS1, routinely. And we have already found seven patients with ROS1, so we find that to be pretty important, at least for our patient population. Suresh S. Ramalingam, MD: That is remarkable that you have seven cases of ROS1, given that the prevalence of ROS1 positivity in adeno is less than 2%. So our institution also uses a snapshot where we screen patients for a variety of mutations and do FISH testing for ALK, ROS1, and RET. Heather Wakelee, MD: Mm-hmm. Slide 39 Suresh S. Ramalingam, MD: Moving on, let me briefly give you a background on ALK fusions. This was a discovery made in 2007 regarding the relevance of ALK fusion gene in non-small cell lung cancer. You see on this picture that ALK consists of a kinase domain that is not activated in lung cancers under normal circumstances. However, when there is a fusion gene, including EML4 or one of the other variants, the ALK kinase is apparently activated and becomes a driving event for patients who have this abnormality. This is seen in approximately 5% of lung cancers, particularly the adenocarcinomas. When you look at the clinical characteristics of these patients, they tend to be never smokers; they have adenocarcinoma; and, in particular, pathologists might describe some of these or many of these tumors as having a signet ring morphology. So when one looks at the pathology report, if you see the phrase signet ring morphology in the setting of adenocarcinoma, it obviously should clue us in as to the possibility of this being an ALK-positive situation. The FISH test is what we use for detecting ALK positivity. This is the test that is also approved by the FDA as a companion diagnostic for use, for patients who are candidates for crizotinib therapy. Slide 40 ROS1 rearrangement is also a relatively uncommon genetic abnormality that is seen in adenocarcinoma. About one percent of the patients harbor this. This rearrangement is also seen in certain patients with glioblastomas or cholangiocarcinomas. ROS1 rearrangement is also seen in never- or light smokers with adenocarcinoma histology. And, as with other common mutations, both ALK positivity and ROS1 positivity do not overlap with other driving mutations that are seen in lung cancer.

12 Personalizing Treatment for Non-Small Cell Lung Cancer Page 12 Slide 41 The reason we check for ROS1 positivity is that, even though there is no FDA-approved drug for this patient population, crizotinib appears to have significant activity in this patient population even though what you see on this waterfall plot are data from relatively small numbers of patients. The objective responses and disease stabilization seen in many patients are quite striking and provide us with an option to treat patients with ROS1 positivity. Slide 42 More recently, the International Association for Study of Lung Cancer, in collaboration with other major organizations, had come out with recommendations for molecular testing of newly diagnosed lung adenocarcinomas. Particularly, they addressed important issues about who should be tested and what criteria should be should we be using to test patients. And the bottom line here is that, for patients with non-squamous histology, testing for EGFR and ALK is recommended at the time of diagnosis of advanced-stage disease. Using clinical criteria is clearly not optimal. If one used the smoking status to look for EGFR mutation or ALK positivity, we would miss about a third of these mutations and, therefore, we would not recommend using clinical criteria histology. Adenocarcinoma, or even, more broadly, nonsquamous patients should be seen for EGFR and ALK in the advanced-stage disease. For early stage disease, as Heather mentioned earlier, in the setting of a clinical trial, it is appropriate to test them. But that is not information that would immediately translate into therapy in routine practice. Now, when you talk about using FISH for ALK-positive disease, there have been several efforts to look at something even simpler that can be done at the institutional level to detect ALKpositive lung cancer. Slide 43 On this slide, you see the use of immunohistochemistry to detect ALK-positive lung cancer. In this test, you re looking for the ALK protein, and it is easy enough to do in the pathology laboratory as the diagnostic samples are being evaluated. The nice thing that has come out from these data in studies are that immunohistochemistrynegative tumors tend to be FISH-negative. If a tumor is immunohistochemistry-positive, then you can subsequently see a higher likelihood of developing FISH or detecting FISH-positivity and, therefore, you could use immunohistochemistry as a screening tool to decide which patients should be tested for ALK by FISH technology. So, on the slide, you see three different antibodies that were screened, and, in this, you see a high degree of concordance in the IHC-negative and FISH-negative groups and, therefore, it could be a screening assay. In other words, you do the IHC. If it is negative, then one may not have to do FISH testing. I would say that this technology is emerging very rapidly but still not something that is being routinely deployed in most centers. Slide 44 So coming back to this patient, the patient was started, without waiting for markers, on treatment with carboplatin, paclitaxel, and bevacizumab and, following cycle one, the ALK screening test came back with positive results on the FISH test. So how would you approach this situation -- do you: A) continue chemotherapy or B) switch immediately to crizotinib? Heather, what would your approach be in this situation?

13 Personalizing Treatment for Non-Small Cell Lung Cancer Page 13 Heather Wakelee, MD: I would continue to chemotherapy. These patients often do quite well with chemo for a period of time and, in particular, when they are on pemetrexed. So, not this case, but definitely notice that for both ALK and the ROS patients, pemetrexed is perhaps even better than the taxanes. But if you ve started a treatment, you need to know if it is working. You don t want to abandon this first-line chemotherapy just because there is something that might have a better response. Unfortunately, we re not curing people yet with the ALK-targeted drugs and, in the absence of that, you might as well utilize another treatment option that is good and get the full benefit from it before switching. Slide 45 Suresh S. Ramalingam, MD: That is very similar to how I approach the situation, as well. You do not want to abandon an FDA-approved or a proven front-line option before knowing whether it is working or not. And, clearly, giving crizotinib at the earliest sign of progression or even in the maintenance setting might be a better time to switch these patients. Slide 46 Now let me review the data that led to the approval of crizotinib in non-small cell lung cancer patients that have ALK-positive disease. This drug was originally developed as a MET inhibitor. The Phase I trials were ongoing when the paper describing ALK positivity in lung cancer was published. Given the knowledge that crizotinib was also ALK inhibitor in preclinical setting, the investigators when on to open a new cohort in the Phase I trial for patients with ALK-positive lung cancer. So this was an expansion cohort specifically based on screening for ALK and then positive patients being enrolled. They all received 250 milligrams twice a day of crizotinib. Slide 47 On this slide, you see the waterfall plot for 116 patients enrolled to this expansion cohort, and the response they had seen was 61%, and nearly 90% of the patients experience clinical benefit with crizotinib. If you look at the duration of response, it is nearly one year for those 60% of the patients. The median time to progression is approximately 10 months with crizotinib, not very different from what you see with EGFR TKIs in patients with EGFR mutations. Another important piece of information about crizotinib is the tolerability. This drug is tolerated well. The main side effects tend to be some ocular issues such as dark-to-light adaptation that can be seen in 30% to 40% of the patients; even this gets better with continuation of therapy and, therefore, patients adjust to it. Slide 48 So this patient had a CT scan after three cycles of therapy and, unfortunately, was found to have disease progression. And, at this point, what would you do? Would you switch the patient to A) pemetrexed, B) crizotinib, C) docetaxel, or D) erlotinib? Slide 49 The correct answer here is, as we just talked about, going to crizotinib at this first sign of progression, given that the patient has ALK-positive disease. Slide 50 The question also gives you the choice of using pemetrexed or docetaxel, which are proven second-line therapy options. And, thankfully, we now have comparative data of crizotinib versus

14 Personalizing Treatment for Non-Small Cell Lung Cancer Page 14 chemotherapy in the salvage therapy setting. And what you see here are the results from a randomized Phase III trial that gave patients either crizotinib or standard second-line therapy in advanced-stage setting, and the trial results clearly showed that crizotinib was superior to chemotherapy. The median PFS was 7.7 months with crizotinib compared to three months with chemotherapy. Now, in the chemotherapy, the physicians had a choice of using either docetaxel or pemetrexed. If you look at the results just on the chemotherapy arm, on the Kaplan-Meier curve on your right, you see that patients who received pemetrexed actually did better than patients who received docetaxel in this patient subpopulation. The median PFS was 4.2 months with pemetrexed compared to 2.6 months with docetaxel. And if you look at response rates, nearly 30% of the patients who received pemetrexed responded to this drug. Crizotinib had a response rate of 65%, and docetaxel had a response rate of only 7%. So this trial shows us that crizotinib is obviously the preferred option in the salvage therapy setting for patients with ALK-positive non-small cell lung cancer. However, among the chemotherapy agents, pemetrexed appears to be a preferred agent and can be considered for a patient who progresses on crizotinib, if no other good option exists in that situation that would be part of a clinical trial. The survival results for this trial are still early. And, obviously, as one can imagine, the crossover is an issue so patients in the control arm getting crizotinib would dilute the effects of any survival impact that second-line therapy with crizotinib might have. So this is something that should not surprise us, that superimposable overall survival curves and the hazard ratio of 1.02 when observed here. Slide 51 So the patient was started on crizotinib, had a near-complete response on the CT scan after two months, and the patient tolerated the treatment well. And the patient was continued on treatment. Unfortunately, after about 14 months, the patient was found to have three six- to eight-millimeter lesions in the brain, suggestive of metastases. The disease was stable elsewhere. In other words, there was no evidence of disease in the chest, abdomen, or the bones. The patient went on to receive stereotactic body radiotherapy to the brain lesions and was continued on crizotinib. Let me pause and ask Heather this question when you have a patient who is progressing, either in the brain or has slow progression, how do you approach them, whether you continue crizotinib or do you switch to something else? Can you help us with that? Heather Wakelee, MD: So I think the approach that you ve mentioned in this case is similar to what we would do. If the patient has progression in the limited sites, either a couple of places in the brain or even a limited site in the body, we will consider doing focused radiation and continuing on the crizotinib. And there is some data to support that approach. So that is what I would do. And it is only at the time where there is clear, more of a systemic progression picture that I would then switch to chemotherapy or, preferably, to another ALK inhibitor if we have a trial open. Slide 52 Suresh S. Ramalingam, MD: OK, so in this situation, the patient continued on crizotinib after the brain radiotherapy stereotactic radiotherapy and did well for another five months, after which, unfortunately, had disease progression both in the liver and the lungs.

15 Personalizing Treatment for Non-Small Cell Lung Cancer Page 15 So, at this point, what are your treatment choices: A) do you switch to pemetrexed, B) do you obtain a tumor biopsy to understand the mechanism of resistance, or C) do you continue crizotinib? Slide 53 The correct answer here would be to switch to pemetrexed. Heather, would you agree with that choice? Heather Wakelee, MD: Absolutely. I mean, it is great to be able to get a tumor biopsy and look at mechanisms of resistance, but I think, with ALK, we re still not that far along, and our understanding is a little bit different than with the EGFR story. So I would think about switching to pemetrexed. Suresh S. Ramalingam, MD: Yes. So if you had a clinical trial that requires a tumor biopsy, that might inform us as to what might be an appropriate way to treat; it would be reasonable. At this point, we re still early. Slide 54 And that leads us to the next slide, which describes the mechanisms of resistance of having reported in ALK-positive patients with crizotinib therapy. Now, I would say that these are based on a relatively small number of patients. We re talking about 30 to 40 patients tested here. These are patients who progressed on crizotinib and then underwent a tumor biopsy. And what you see here are a variety of mechanisms of resistance coming into play. In approximately a third of the patients, alternative ways by which ALK pathway is activated are observed. In other words, they may develop a secondary mutation in ALK, just like what Heather talked about as the case with EGFR-mutated tumors. And, also, some patients develop increased copy numbers of ALK that lead to activation of the ALK signaling. In about a third of patients, alternative pathways outside of ALK are activated. This could involve EGFR mutation or a KRAS mutation. And, in another third of the patients, we are yet to uncover a mechanism of resistance. So, basically, this slide shows that there are a number of mechanisms of resistance a number of mechanisms by which one could become resistant to crizotinib. And our treatment approaches, based on specific mutations or the resistance mechanism is still a bit far away from where we are. And it might be very variable, unlike in the situation of EGFR, where nearly half the patients have a single mechanism of resistance. Slide 55 Now, I m going to switch gears and talk about a situation with squamous cell histology. Slide 56 This is a patient who is 72 years old and had a 40 pack-year smoking history, and presented with increasing dyspnea and cough. This patient s CT scan revealed a right upper-lobe lung mass with extensive mediastinal adenopathy and bilateral pulmonary nodules. The patient underwent a transbronchial biopsy of the right paratracheal lymph node, and it was consistent with squamous cell cancer. Immunostains were positive for P63, which is indicative of squamous cell histology. The patient had COPD, hypertension, and diabetes but still had a good performance status. And as we always do, the patient was recommended smoking cessation and did not get any further molecular testing.

16 Personalizing Treatment for Non-Small Cell Lung Cancer Page 16 Slide 57 Now, when we talk about molecular testing in squamous cell cancer, it is still in its infancy. What we know is that squamous cell tumors have a totally different set of molecular drivers compared to adenocarcinoma. On this slide, you see the molecular drivers in adenocarcinoma and squamous cell carcinoma displayed side by side, and we know that EGFR, ALK, KRAS are some of the more commonly seen events in adenocarcinoma. In squamous cell cancer, amplification of FGFR, or the fibroblast growth factor receptor gene, is seen in approximately 10% to 20% of the patients. There is also a good subpopulation of patients who have the PI3-kinase mutation, nearly 15%. And some of the less common events, such as DDR mutation, are also seen. So, at this point, people are investigating specific targeted agents that might work against each of these subpopulations, but that is still in a clinical trial setting, and we are therefore not recommending routine molecular testing for squamous cell histology. Slide 58 So, for this patient, which of the following regimens would you not recommend: A) platinumgemcitabine, B) platinum-pemetrexed, C) platinum-nab-paclitaxel, and D) platinum-paclitaxel? In this situation, when I saw platinum, it could either be cisplatin or carboplatin based on your own individual treatment preference. Slide 59 So the treatment option you would not recommend in this situation is pemetrexed-based combinations, given that this drug is no longer recommended or approved for use in squamous cell histology. Slide 60 This was based on the large Phase III trial that compared cisplatin-gemcitabine to cisplatinpemetrexed in the front-line treatment of non-small cell lung cancer. This trial was designed to show non-inferiority for cisplatin and pemetrexed in the overall patient population. And you see the survival curve on the left, which shows that both of these regimens have similar median overall survival and response rates. So cis-pemetrexed was non-inferior to cis-gemcitabine in the overall patient population. However, in the pre-specified subset analysis, patients with non-squamous histology experienced an improved survival of cisplatin-pemetrexed compared to cisplatin-gemcitabine. They had a median overall survival with cisplatin-pemetrexed of 11.8 months compared to 10.4 months with cisplatin and gemcitabine. Based on this, pemetrexed was approved for non-squamous histology. What also became evident in this trial is that, for squamous cell histology, cisplatin-gemcitabine was superior to cisplatin-pemetrexed. This and other such observations from other trials led to the restriction of pemetrexed label to non-squamous histology only. Slide 61 Another drug that has implications for squamous cell histology that was approved by the FDA last year is nab-paclitaxel. This drug is approved in combination with carboplatin in patients with non-small cell lung cancer in the front-line setting. In a large randomized trial, the carboplatin-nab-paclitaxel combination was compared to carboplatin-paclitaxel combination, and you see the results of this trial. Response rate was the