Stereotactic Radiotherapy: What We Can Do For Pets

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Ambrose Adams
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large mass in right shoulder Biopsy-confirmed liposarcoma

2 Revolutionizing Cancer Care for Lexi 10-year old FS German Shepherd Presents for evaluation of right forelimb lameness and large mass in right shoulder Biopsy-confirmed liposarcoma Pulmonary nodules Copyright All rights reserved. PetCure Oncology

Revolutionizing Cancer Care for Lexi Planning CT

Revolutionizing Cancer Care for Lexi 3 month re-check CT

Revolutionizing Cancer Care for Lexi Post-SRS

7 Cancer diagnosis now what? Staging Complete blood count, biochemistry profile Urinalysis Chest radiographs 3-view metastasis check Evaluation of local/draining lymph nodes Submit to pathologist Consider abdominal ultrasound Tumors with high risk for spread to abdominal organs and lymph nodes Subjective: breeds at high-risk for liver/splenic tumors

8 Cancer Treatment Options Chemotherapy Systemic treatment Microscopic/metastatic disease Blood-born cancers Can result in side effects IV or oral

9 Cancer Treatment Options Surgery Local therapy Ideal treatment when clean margins can be achieved Curative intent For localized tumors

10 Cancer Treatment Options Radiation Therapy Local therapy Consider when surgery not feasible or is unlikely to achieve clean margins Can result in side effects to healthy tissues

11 Cancer Treatment Options Palliative Treatments Used to alleviate clinical signs and improve quality of life Commonly used when long-term control cannot be achieved

12 Cancer The Conversation Know the diagnosis and options we can help Look the pet owner in the eye Be direct Acknowledge how hard this is Be quiet and listen Ask what is most important to them Offer options Develop a plan with them that keeps what is most important to them in the forefront Copyright 2017 All rights reserved. PetCure Oncology

13 What is Radiation Therapy?

14 What is Radiation Therapy? Electromagnetic energy Light waves, radiowaves, microwaves X-rays!

15 What is Radiation Therapy? The Physics: X-rays! Absorption in tissue two primary processes Photoelectric effect Dominant for low energy (diagnostic radiology) Differential absorption pretty radiographs Compton process Dominant for high energy x-rays (therapeutic radiation) Even absorption in bone, soft tissue, etc

16 What is Radiation Therapy? The Biology: X-rays damage DNA of cells Cells die when attempting to replicate Interference with replication growth inhibition Non-invasive, pain-free therapy Localized treatment

17 Indications for referral: When there is residual microscopic disease Post-surgery dirty margins (mast cell tumor, soft tissue sarcoma) Bulky disease, where a good surgical option does not exist Location Ability to achieve clean margins High morbidity Advanced stage disease Palliative radiation addresses local/clinical disease

Radiation Therapy (IMRT) Stereotactic Radiosurgery (SRS,

18 Radiation Therapy The Evolution Conventionally Fractionated Radiation Therapy (CFRT) Intensity Modulated Radiation Therapy (IMRT) Stereotactic Radiosurgery (SRS, SRT, SBRT, SABR) Volumetric Modulated Arc Therapy (VMAT, RapidArc )

19 Radiation Therapy The Evolution Conventionally Fractionated Radiation Therapy (CFRT) Most common Widely available treatments ( fractions ) and anesthetic events Large treatment fields include tumor + margins for microscopic disease large volume of healthy tissue radiated Healthy tissue will repair over time, but dose per fraction must remain low to avoid severe toxicity

20 Conventional Radiation: Point-and-shoot approach Tumor Eyes Brain Large treatment fields spare normal tissues by fractionation

21 Targeting tumors: Multi-leaf collimator Allows better conformity to decrease normal tissue damage Individual computer-controlled leaves to shape radiation beam Sparing by avoidance

Intensity Modulated Radiation Therapy (IMRT) Dynamic

steep dose gradient Inverse treatment planning

$reproducible patient positioning 15-20 fractions Radiation$

22 Intensity Modulated Radiation Therapy (IMRT) Dynamic multi-leaf collimator non-uniform fluence Multiple beams steep dose gradient Inverse treatment planning Patient-specific, CT-based identification of tumor target and organs at risk Requires accurate, precise and highly reproducible patient positioning fractions Radiation Therapy The Evolution

Sub-millimeter accuracy, avoiding healthy tissue Only 1-3 treatments Can target tumors

23 Radiation Therapy The Evolution Stereotactic Radiosurgery (SRS) Intensity-modulated delivery Advanced patient immobilization On-board imaging position verification Sub-millimeter accuracy, avoiding healthy tissue Only 1-3 treatments Can target tumors in complex locations previously not considered radiation candidates Custom immobilizers for each patient

24 Radiation Therapy The Evolution Volumetric Modulated Arc Therapy (VMAT or RapidArc ) Radiation delivered while the gantry is rotating and while the leaves are in simultaneous, continuous movement Decreases dose to normal tissues by spreading dose evenly across irradiated volume Treatment delivered in single arc as opposed to 5-10 static fields Decreases treatment/anesthetic time Treatments last just 5-7 minutes CBCT for position verification

25 Radiation Therapy The Evolution VMAT Technology Static gantry IMRT or SRT SRS with VMAT

26 Radiation Therapy The Evolution VMAT facilitates sparing by avoidance

27 What is Stereotactic Radiosurgery (SRS)? Planning that revolves around patient-specific tumor targeting and identification of organs at risk Utilizes advanced patient immobilization to ensure accurate positioning of the target and organs at risk On-board imaging at the time of treatment (cone beam CT) to confirm tumor targeting

28 What is Stereotactic Radiosurgery (SRS)? More Precision We can treat tumors in locations previously thought untreatable Lung, liver, kidney, prostate, adrenal gland, heart base, etc. Fewer Treatments Treatments given in 1-3 consecutive days (instead of 15-20) Fewer anesthetic events and trips to the hospital Fewer Side Effects Radiation side effects happen when healthy tissue is exposed to radiation more precision means those side effects are greatly reduced

29 In Summary: PetCure Oncology and Varian relationship brings great excitement and innovation to radiation therapy The collaboration strengthens PetCure s commitment to clinical excellence by improving treatment and operational efficiency Elevates PetCure s industry-leading combination of clinical care, technology, and QA Offers the potential to impact cancer research for humans and pets over time with a goal of statistically verifiable results and publishing in the peer-reviewed journals

30 Tumors where radiation therapy should be considered

31 PRELIMINARY DATA ANALYSIS*

32 PetCure Preliminary Data: * Patients with incomplete datasets not included in this analysis Censored = Alive Lost to follow-up Death from unrelated cause All analysis NCSS v11.0 Study power suboptimal in many cases

33 Tumors commonly treated with radiation therapy canine nasal tumors Canine nasal tumors MST no treatment = 95 days MST surgery = 3-6 months MST CFRT/IMRT = months Stage 4 (cribriform lysis) = 6.7 months MST SRS experience = months

34 Revolutionizing Cancer Care for Pita 6-year old FS Yorkie mix Presented to discuss treatment options for diagnosed nasal carcinoma Mandibular lymph nodes prominent cytology confirmed metastasis Elected to proceed with SRS Copyright All rights reserved. PetCure Oncology

Revolutionizing Cancer Care for Pita Copyright

36 Revolutionizing Cancer Care for Pita 2-weeks post-srs Resolution or oral mass Resolution of epistaxis Lymph nodes palpate normal No ocular side effects No medical intervention for pain Copyright All rights reserved. PetCure Oncology

38 Revolutionizing Cancer Care for Sam

39 Revolutionizing Cancer Care for Sam

40 Tumors commonly treated with radiation therapy - CNS Canine brain tumors presumed meningioma MST no treatment = 2-3 months MST surgery + CFRT = months SRS experience = 18 months (Griffin, CSU 2014)

Tumors commonly treated with radiation therapy - CNS * Glial Origin: 26 total cases; 21 censored 15-1049 days Meningioma 70 total cases, 56 censored 28-1728 70%

41 Tumors commonly treated with radiation therapy - CNS * Glial Origin: 26 total cases; 21 censored days Meningioma 70 total cases, 56 censored % Quantile Estimate Glial 622 Days (20 months) Meningioma 669 Days (22 months) Image characteristic diagnosis only Some tumors may be mischaracterized/misdiagnosed on this basis

42 Revolutionizing Cancer Care for Maple

43 Tumors commonly treated with radiation therapy OSA Canine OSA MST palliative care only (pain meds) = 1-3 months MST amputation alone = 3-6 months MST amputation + chemotherapy = ~1 year (8-12 months) SRS experience = Bisphosphonate therapy prior to treatment Chemotherapy indicated following SRS MST = ~12-15 months Fracture rate varying reports; 10-40%

* Palliative: 19 total cases, 10 censored 4-739 days Median = 7-9 months SRS 26 total cases, 18 censored 21-878 50% Quantile Estimate CFRT 251

44 * Palliative: 19 total cases, 10 censored days Median = 7-9 months SRS 26 total cases, 18 censored % Quantile Estimate CFRT 251 days SRS 579 days (19 months) P=0.04 Tumors commonly treated with radiation therapy OSA Multiple systemic protocols 11% Pathologic Fracture Rate

45 Tumors commonly treated with radiation therapy Oral tumors Prognosis dependent on histotype Local control generally good (>12-18 months) Call before performing dental procedures!

46 Revolutionizing Cancer Care for Cooper

47 Revolutionizing Cancer Care for Cooper 3 months post-srs 5 weeks post-srs weeks post-srs

48 Revolutionizing Cancer Care for Beauty

49 Revolutionizing Cancer Care for Beauty

50 Revolutionizing Cancer Care for Beauty

51 Revolutionizing Cancer Care for Beauty

52 Tumors commonly treated with radiation therapy canine soft tissue sarcoma * SRS 43 total cases, 38 censored days 75% Quantile estimate: 944 days (31 months) All had gross disease No systemic therapy in this group Tumors confined to the skin/subq

53 Revolutionizing Cancer Care for Brownie 3 months post-srs

54 Revolutionizing Cancer Care for Annie 3 months post-srs

55 Tumors commonly treated with radiation therapy canine soft tissue sarcoma Clinical Trial Nanovi PetXMark Marginally resected grade II sarcoma with a linear scar <15cm Liquid fiducial used to define a surgical scar Other tumors of the skin/subq can be treated off protocol PetCure will retreat in the event of early local failure or geographic miss

56 Revolutionizing Cancer Care for Lola 3 months post-srs

57 Revolutionizing Cancer Care for Lola 3 months post-srs 3 weeks post-srs 3 months post-srs

58 Revolutionizing Cancer Care for Chauncey 3 months post-srs 3 weeks post-srs 4 months post-srs

59 Tumors commonly treated with radiation therapy Lung Alternative to surgery for primary lung tumors SRS experience local control >12 months Human experience: SRS achieves similar or better outcome compared to surgery as primary treatment for nonsmall cell lung cancer Currently enrolling canine patients for prospective clinical trial of SRS for primary lung tumors

60 Canine Lung Tumor Clinical Trial Solitary lung tumor No life threatening comorbidities SOC1 = 3x20Gy SOC2 = 1x24Gy Subsidized cost of treatment Cost for follow-up CT at 3 and 12 months covered

61 Revolutionizing Cancer Care for Saffee 3 months post-srs

62 Preliminary data: AGASACA * CFRT: 10 total cases, 7 censored days SRS 14 total cases, 12 censored % Quantile Estimate CFRT 192 days (6.5 months) SRS 570 days (19 months) P=0.11 All received some chemotherapy

63 * SRS 19 total cases, 10 censored days 50% Quantile Estimate: 736 days (24 months) Multiple systemic protocols Preliminary data: Prostatic Carcinoma/TCCa

64 Tumors where radiation therapy should be considered

Here are some of the most common: Oral mucositis Skin irritation, coat color change, and change in pigmentation GI nausea,

65 Side Effects with SRS Acute toxicity is significantly reduced with SRS, but patients may still experience side effects in the location of the treatment. If we never saw side effects, it would mean we weren t treating the cancer aggressively enough. Here are some of the most common: Oral mucositis Skin irritation, coat color change, and change in pigmentation GI nausea, diarrhea, colitis Transient demyelination 3-6 months following brain/spinal tumor treatment Steroid-responsive Acute tumor necrosis can lead to abscess

Side Effects of Radiation Therapy Acute (early) effects Days-weeks after treatment Correlates with short life span of mature cell population Rapidly dividing tissues Skin, mucosa

66 Side Effects of Radiation Therapy Acute (early) effects Days-weeks after treatment Correlates with short life span of mature cell population Rapidly dividing tissues Skin, mucosa (oral, GI), bone marrow Moderate-severe with CFRT Mild-moderate with SRS None-mild with palliative radiation Should resolve without intervention, though supportive care may be required

67 Side Effects of Radiation Therapy Treat symptomatically! Will resolve with time, prevention of self-trauma and appropriate supportive care Skin desquamation: ~10-14 days post-srs; resolves in ~10-14 days Pain medication Prevention of self-trauma Keep clean/dry But don t encourage owners to clean/groom/etc Do not bandage Antibiotics for secondary infections

68 Side Effects of Radiation Therapy Treat symptomatically! Will resolve with time, prevention of self-trauma and appropriate supportive care Mucositis ~10-14 days post-srs; resolves in ~7-10 days Anti-inflammatory dose of steroids Magic mouthwash compounding pharmacies +/- pain medication as needed Consider softening food or providing canned food Avoid hard chew toys

69 Side Effects of Radiation Therapy Treat symptomatically! Will resolve with time, prevention of self-trauma and appropriate supportive care Colitis ~5-7 days post-srs; resolves in ~3-5 days Metronidazole owners are sent home with this if anticipated Ocular changes refer to ophthalmologist Dry eye Conjunctivitis

70 Side Effects of Radiation Therapy Early-delayed/transient demyelination 2-4 months (some say up to 6 months) post-srs Reported in 20-40% of patients Recurrence of initial clinical signs Steroid-responsive Treatment = aggressive supportive care and steroid therapy SLOW steroid taper following recovery 25% every 4 weeks if no relapse

71 Side Effects of Radiation Therapy Late effects Months-years after treatment Slowly proliferating tissues Brain, spinal cord, heart, liver, lung, bone May improve, but never completely repaired Goal = minimize risk 5% risk acceptable

A Few Things We ve Learned Many pet owners are uncomfortable with surgery or CFRT and elect not to treat Pet owners choose SRS because: Fewer anesthetic events

72 A Few Things We ve Learned Many pet owners are uncomfortable with surgery or CFRT and elect not to treat Pet owners choose SRS because: Fewer anesthetic events Non-invasive Curative intent Setting Expectations Keeping pet owners involved and informed Letting them know that we won t give up on them Giving realistic expectations

73 Who is PetCure Oncology? A national network of radiation therapy facilities offering clinical and technological expertise: Strong commitment to technology IGRT, VMAT, Halcyon Eclipse 15, Aria 15, Rapidplan Data mining Radiologica Full Access Clinical team with experience in all forms of radiation therapy Scientific Advisory Board Clinical Protocols Committee Copyright All rights reserved. PetCure Oncology

75 PetCure Oncology PetCure Oncology National Network Dr. Neal Mauldin, Chief Medical Officer Triple-boarded in Internal Medicine, Medical and Radiation Oncology Oversees all clinical operations, treatment planning, and the PetCure Scientific Advisory Board Has treated over 1,500 pets with SRS in the last seven years PetCure Radiation Oncology Specialists (PROS) Network of board-certified radiation oncologists Responsible for development and review of all treatment plans Available to all PetCure sites and referring veterinarians

76 PetCure Scientific Advisory Board and Quality Assurance Scientific Advisory Board (SAB) Created to ensure independent, analytical and science-driven approach Well-respected clinical experts in veterinary & human radiation oncology Established first set of treatment protocols for veterinary SRS Standardized Quality Assurance Protocols Implemented at all PetCure Oncology locations Every treatment plan touched by at least two board-certified radiation oncologists QA protocols include both computer and human checks

77 What next? Clinical Trials SRS for canine primary lung tumors Candidates to receive significantly subsidized SRS treatment Any canine patient with a primary lung tumor is potentially eligible Evaluation of CT will determine eligibility Lack of histopathology not exclusionary SRS for grade II, incompletely excised soft tissue sarcomas Candidates to receive SRS for cost of CFRT If patient experiences early local recurrence/treatment failure, PetCure will cover cost of additional local treatment SRS for canine appendicular osteosarcoma Joint Varian/PetCure Oncology proposal pending funding Evaluation of Treg and T effector cell populations following SRS ClinicalTrials@PetCureOncology.com for more information

78 What next? Published Outcomes Data Very little published data currently exists regarding SRS for pets Now that more pets have access to SRS, toxicity and outcomes data can be collected, aggregated and published

79 A Few Patients We ve Helped

80 The PetCure Promise We understand. We commit. We will help.

PetCure Oncology: Our First 1,000 Patients. A life-saving new treatment for pets with cancer

2017 PetCure Oncology: Our First 1,000 Patients A life-saving new treatment for pets with cancer PURPOSE OF THIS REPORT In 2017, 12 million cats and dogs will be diagnosed with cancer. [1] Of the estimated