Update on the Management of HER2+ Breast Cancer. Christian Jackisch, MD, PhD Sana Klinikum Offenbach Offenbach, Germany

Update on the Management of HER2+ Breast Cancer Christian Jackisch, MD, PhD Sana Klinikum Offenbach Offenbach, Germany

Outline Treatment strategies for HER2-positive metastatic breast cancer since First line Second line Third line and beyond Managing special situations Brain metastasis Cardiac morbidity Future directions

Targeting the HER2 Receptor In a period of 20 years HER2 was identified as a bad prognostic factor - Impact on DFS: early recurrences - Impact on OS: distant mets - Impact on treatment resistance: endocrine treatment and classical CMF HER2 was identified as a target for new treatment approaches - Definition of the target population: IHC and/or FISH - Definition of the treatment: humanized monoclonal antibody - Demonstration of the first clinical results: phase II-III trials - Demonstration of different modes of application (IV vs SC) Trastuzumab clearly changes the prognosis of HER2-positive MBC with a strong impact on OS in EBC & MBC

Approved Treatment Options in HER2 + MBC

Other Innovative Targeted Therapies in HER2-Positive Breast Cancer Pertuzumab* IGF-1R EGFR HER2 VEGFR Trastuzumab emtansine* FLT-3 c-kit Lapatinib* PDGFR- Tumor cell membrane PI3K PIP 2 Ras IP 3 DAG Afatinib/Neratinib Akt RAF Src Endothelial cell and pericyte membrane mtor PKC MEK MAPK Approved Under investigation Everolimus ERK *Not approved in all countries Cell differentiation Nucleus Transcription factors Angiogenesis Cell proliferation Cell survival (apoptosis inhibition) Cell adhesion/ penetration/metastasis Perez EA, et al. Cancer. 2012;118(12):3014-3025. Hernandez-Aya LF, et al. Oncologist. 2011;16(4):404-414.

Options for Dual Blockade of the HER2 Receptor Vertical dual blockade Horizontal dual blockade T Trastuzumab T P Pertuzumab 2 2 3 2 2 2 3 2 Lapatinib L L Downstream signaling pathways 1 Downstream signaling pathways 2 L, lapatinib; P, pertuzumab; T, trastuzumab. 1. Konecny GE, et al. Cancer Res. 2006;66(3):1630-1639; 2. Nahta R, et al. Cancer Res. 2004;64(7):2343-2346.

CLEOPATRA: Study Design Primary endpoint: PFS (independently assessed) Secondary endpoints: PFS (investigator assessment), ORR, OS, Safety Women with previously untreated, HER2-positive locally recurrent/metastatic breast cancer (N = 808) Trastuzumab 6 mg/kg q3w* + Docetaxel 75-100 mg/m 2 q3w + Pertuzumab (PTZ) 420 mg q3w (n = 402) Trastuzumab 6 mg/kg q3w* + Docetaxel 75-100 mg/m 2 q3w + Placebo q3w (n = 406) Treatment until disease progression or unacceptable toxicity *Trastuzumab 8 mg/kg loading dose given Minimum of 6 docetaxel cycles recommended; <6 cycles permitted for unacceptable toxicity or progressive disease (PD) Pertuzumab 840 mg loading dose given Baselga J, et al. Cancer Res. 2011;71(24 Suppl): Abstract S5-5.

Overall Survival, % CLEOPATRA Overall Survival 100 90 80 70 60 50 40 30 20 10 PTZ + TRAS + DOC 48 patients crossed over from placebo to PTZ arm after previous report of OS benefit Long-term cardiac safety profile maintained Swain SM, et al. New Engl J Med. 2015;372(8):724-734. Control, 221 events Hazard ratio, 0.68 (95% CI, 0.56-0.84) P<.001 Months Placebo + TRAS + DOC Pertuzumab, 168 events 0 0 10 20 30 40 50 60 70 80 No. at Risk Pertuzumab 402 371 318 268 226 104 28 1 0 Control 406 350 289 230 179 91 23 0 0 56.5 months 40.8 months HR = 0.68, P <.001

Other Options on the Forefront for First-Line?

T-DM1: Mechanism of Action HER2 T-DM1 Emtansine release Inhibition of microtubule polymerization Lysosome P P P Internalization Nucleus Adapted from LoRusso PM, et al. Clin Cancer Res. 2011;17(20):6437-6447.

First-Line MBC: TDM4450 Study Design HER2-positive, recurrent locally advanced breast cancer or MBC (N = 137) 1:1 Trastuzumab 8 mg/kg loading dose; 6 mg/kg q3w IV + Docetaxel 75 or 100 mg/m 2 q3w (n = 70) T-DM1 3.6 mg/kg q3w IV (n = 67) PD a PD a Crossover to T-DM1 (optional) Randomized, phase II, international, open-label study b Stratification factors: World region, prior adjuvant trastuzumab therapy, disease-free interval Primary endpoints: PFS by investigator assessment, and safety Data analyses were based on clinical data cut of Nov 15, 2010 prior to T-DM1 crossover Key secondary endpoints: OS, ORR, DOR, CBR, and QOL a Patients were treated until PD or unacceptable toxicity b This was a hypothesis-generating study; the final PFS analysis was to take place after 72 events had occurred DOR, duration of response; CBR, clinical benefit rate; QoL, quality of life Hurvitz SA, et al. J Clin Oncol. 2013;31(9):1157-1163.

Proportion Progression Free 1.0 0.8 TDM4450 PFS by Investigator: Randomized Patients TRAS+ DOC (n = 70) T-DM1 (n = 67) Median PFS, months Hazard ratio 9.2 14.2 0.594 95% CI 0.364-0.968 Log-rank P value.0353 0.6 0.4 0.2 0.0 0 2 4 6 8 10 12 14 16 18 20 Number of patients at risk Time, Months TRAS + DOC 70 66 63 53 43 27 12 4 2 2 0 T-DM1 67 60 51 46 42 35 22 15 6 3 0 Hazard ratio and log-rank P value were from stratified analysis Hurvitz SA, et al. J Clin Oncol. 2013;31(9):1157-1163.

Progression-Free Survival, Proportion TDM4450 Duration of Response (DOR): Randomized Patients 1.0 0.8 Median DOR n Months 95% CI HT 40 9.5 6.6 to 10.6 T-DM1 43 NR 0.6 0.4 0.2 0 2 4 6 8 10 12 14 16 18 Duration of Objective Response, Months No. at Risk HT 40 40 38 32 19 8 2 1 1 0 T-DM1 43 41 38 33 27 19 12 6 3 0 Hurvitz SA, et al. J Clin Oncol. 2013;31(9):1157-1163.

Outline Treatment strategies for HER2-positive metastatic breast cancer since First line Second line Third line and beyond Managing special situations Brain metastasis Cardiac morbidity

EMILIA Trial HER2-positive (central) LABC or MBC (N = 991) n = 495 T-DM1 3.6 mg/kg q3w IV PD Prior taxane and trastuzumab Progression on metastatic therapy or within 6 months of adjuvant therapy 1:1 n = 496 Lapatinib 1250 mg/day orally qd Capecitabine 1000 mg/m 2 orally bid, days 1 14, q3w PD Primary endpoint: independently assessed PFS, OS, safety Key secondary endpoints: investigator-assessed PFS, ORR LABC, locally advanced breast cancer; MBC, metastatic breast cancer; T-DM1, trastuzumab emtansine; IV, intravenous; PD, progressive disease; qd, once daily; bid, twice daily; PFS, progression-free survival; OS, overall survival; ORR, objective response rate. Verma S, et al. N Engl J Med. 2012;367(19):1783-1791.

Overall Survival, % 1.0 EMILIA: OS 85.2% (95% CI, 82.0-88.5) Median, Months No. Events CAP + L 25.1 182 T-DM1 30.9 149 0.8 64.7% (95% CI, 59.3-70.2) 0.6 78.4% (95% CI, 74.6-82.3) 0.4 51.8% (95% CI, 45.9-57.7) 0.2 0.0 No. at risk: CAP + L 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 Time, Months 496 Stratified HR: 0.68; (95% CI, 0.55-0.85); P<.001 Efficacy stopping boundary, P =.0037 HR: 0.73 471 453 435 403 368 297 240 204 159 133 1 10 86 63 45 27 17 7 4 T-DM1 495 485 474 457 439 418 349 293 242 197 164 136 11 1 86 62 38 28 13 5 Verma S, et al. N Engl J Med. 2012;367(19):1783-1791.

TH3RESA Study Schema HER2-positive (central) advanced BC a (N = 600) 2 prior HER2-directed therapies for advanced BC Prior treatment with trastuzumab, lapatinib, and a taxane 2 1 T-DM1 3.6 mg/kg q3w IV (n = 400) Treatment of physician s choice (TPC) b (n = 200) PD PD T-DM1 c (optional crossover) Stratification factors: World region, number of prior regimens for advanced BC, d presence of visceral disease Co-primary endpoints: PFS by investigator and OS Key secondary endpoints: ORR by investigator and safety a Advanced BC includes MBC and unresectable locally advanced/recurrent BC b TPC could have been single-agent chemotherapy, hormonal therapy, or HER2-directed therapy, or a combination of a HER2-directed therapy with a chemotherapy, hormonal therapy, or other HER2-directed therapy c First patient in: Sep 2011. Study amended Sep 2012 (following EMILIA 2nd interim OS results) to allow patients in the TPC arm to receive T-DM1 after documented PD d Excluding single-agent hormonal therapy BC, breast cancer; IV, intravenous; ORR, objective response rate; PD, progressive disease; q3w, every 3 weeks Krop IE, et al. Lancet Oncol. 2014;15(7):689-699.

Overall Survival, % TH3RESA Overall Survival 100 Physician s choice Trastuzumab emtansine 80 60 Physician s choice (n = 198) Trastuzumab emtansine (n = 404) 40 Median OS (95% CI), months 14.9 (11.27-NE) NE 20 0 Number at risk Physician s choice Trastuzumab emtansine Events 44 61 Stratified HR 0.552 (95% CI 0.369-0.826); P<.0034 Efficacy stopping boundary; HR 0.370; P<.0000016 Unstratified HR* 0.570 (95% CI 0.386-0.840); P<.0040 0 2 4 6 8 10 12 14 16 198 404 169 381 125 316 Months since randomization 80 207 51 127 30 65 9 30 3 7 0 0 Krop IE, et al. Lancet Oncol. 2014;15(7):689-699.

EGF104900 trial HER2-positive MBC (central) (N = 296) Prior taxane, anthracyclines and trastuzumab Progression on trastuzumab within most recent regimen for MBC Patients were stratified by hormone receptor and visceral disease status 1:1 n = 148 n = 148 Lapatinib 1000 mg qd Trastuzumab 4 mg/kg load, then 2 mg/kg weekly Lapatinib * 1500 mg qd *Lapatinib is not approved for use as a single agent. Primary endpoint: PFS Key secondary endpoints: OS, ORR, CBR, safety MBC, metastatic breast cancer; qd, once daily; PFS, progression-free survival; OS, overall survival; ORR, overall response rate; CBR, clinical benefit rate. Blackwell KL, et al. J Clin Oncol. 2010;28(7):1124-1130.

Overall Survival, % Overall Survival in ITT 100 80 60 70% 80% 6-month OS 56% L n = 145 L + TRAS n = 146 Died, n (%) 113 (78) 105 (72) Median, months 9.5 14 HR (95% CI) 0.74 (0.57 to 0.97) Log-rank P.026 40 20 L + T L 41% 12-month OS 0 5 10 15 20 25 30 Time Since Random Assignment, months 35 Blackwell KL, et al. J Clin Oncol. 2012;30(21):2585-2592.

Probability of Progression, % Survival Probability, % Taking Care of CNS Metastases Postponing WBRT Time to Progression by CNS Response Survival (Dashed lines Are 95% CI) 100 90 80 70 60 50 40 30 20 Patients who did not respond to treatment Patients who responded to treatment 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 20 10 Number at risk Time, Months 0 No response 15 13 9 5 4 3 1 0 Time, Months Response 29 29 29 29 26 21 13 10 9 7 2 2 2 2 1 No. at risk 44 44 44 43 42 41 40 37 37 36 35 34 31 30 26 23 22 17 14 13 13 11 8 7 7 5 4 100 90 80 70 60 50 40 30 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Bachelot T, et al. Lancet Oncol. 2013;14:64-71.

Taking Care of CNS Metastases CEREBEL: Optimizing Systemic Therapy Key eligibility HER2+ MBC* Prior anthracyclines or taxanes Any line therapy No CNS metastases** Evaluable systemic dx Stratification Prior trastuzumab yes vs no Prior MBC tx 0 vs >1 R A N D O M I Z E D Phase III Planned N = 650 Lapatinib 1250 mg/day + Capecitabine 2000 mg/m 2 /day, days 1-14 q21 days Trastuzumab 6 mg/kg q21 days + Capecitabine 2500 mg/m 2 /day, days 1-14 q21 days *FISH+/IHC 3+ **No CNS metastases at baseline confirmed by independently reviewed MRI scan Pivot X, et al. J Clin Oncol. 2015 Jan 20 [Epub ahead of print].

Progression-Free Survival, % Overall Survival, % Taking Care of CNS Metastases CEREBEL: Optimizing Systemic Therapy Progression-Free Survival 100 80 60 40 Lap + Cap n = 271 Tras + Cap n = 269 Events, n 160 (59%) 134 (50%) PFS, months (95% CI) First quartile 3.9 (2.8 to 5.4) 5.5 (4.8 to 5.6) Median 6.6 (5.7 to 8.1) 8.1 (6.1 to 8.9) Third quartile 12.2 (9.0 to 13.8) 18.2 (12.0 to 25.1) Hazard ratio (95% CI) 1.30 (1.04 to 1.64) Stratified log-rank P.021 100 80 60 40 Survival Lap + Cap Tras + Cap Lap + Cap n = 271 Tras + Cap n = 269 Events, n 70 (26%) 58 (22%) OS, mos (95% CI) 1 st quartile 14.5 (12.8 to 15.4) 16.2 (14.3 to 19.7) Median 22.7 (19.5 to NR) 27.3 (23.7 to NR) 3 rd quartile NR 33.6 (33.6 to NR) HR (95% CI) 13.34 (1.04 to 1.64) Stratified log-rank P.095 20 Lap + Cap Tras + Cap 20 0 5 10 15 20 25 30 35 40 Time Since Random Assignment, Months Number at risk Lap + Cap 271 147 49 20 20 7 4 Tras + Cap 269 154 56 26 26 15 7 0 5 10 15 20 25 30 35 40 Time Since Random Assignment, Months Number at risk Lap + Cap 271 194 79 48 27 7 7 Tras + Cap 269 207 97 61 29 15 6 1 Trial was terminated early (n = 540/650) Incidence of CNS-mets as first site of relapse was 3% (Tras + Cap) vs 5% (Lap + Cap) PFS & OS & SAE were in favor of Tras + Cap over Lap + Cap Different result according to pretreatment with trastuzumab Pivot X, et al. J Clin Oncol. 2015 Jan 20 [Epub ahead of print].

Proportion Surviving Taking Care of CNS Metastases EMILIA: Retrospective Analysis of CNS-Mets 1.0 0.8 0.6 0.4 0.2 Survival 0.0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 Time, Months No. at Risk XL 50 47 45 41 36 30 21 15 13 7 6 5 4 1 0 0 0 0 0 T-DM1 45 43 42 40 38 34 32 27 21 18 16 11 8 6 4 2 2 1 1 In the EMILIA trial, 95/991 patients had CNS mets at baseline CNS progression: No CNS mets @ baseline (2% T-DM1; 0.7% XL) CNS mets @ baseline (22.2% T-DM1; 16.0% XL) Patients with CNS @ baseline had significantly improved survival (26.8 mos vs 12.9 mos) Krop IE, et al. Ann Oncol. 2015;26(1):113-119. Median, months XL n = 50 T-DM1 n = 45 12.9 26.8 Stratified HR =.382 (95% CI 0.184-0.795) P =.0081

Taking Care of CNS Metastases EMILIA: Retrospective Analysis Progression-Free Survival Survival Krop IE, et al. Ann Oncol. 2015;26(1):113-119.

Cardiac Dysfunction Secondary to HER2 Treatment Strategies in the Metastatic Setting Study, n Median Age, Years Previous Treatment LVEF Drop <50% and >10 20 Points Chronic Heart Failure Trastuzumab+ docetaxel 1 (First line) CLEOPATRA (406) 54 40% Anthracyclines 23% Taxanes 10% Trastuzumab 6.6% 0% Lapatinib + capecitabine 2 (Mainly second and third line) EMILIA (496) 53 61% Anthracyclines 100% Taxanes 100% Trastuzumab 1.6% NR T-DM1 2 (Mainly second and third line) EMILIA (495) 53 61% Anthracyclines 100% Taxanes 100% Trastuzumab 1.7% NR Trastuzumab+ pertuzumab+ docetaxel 1 (First line) CLEOPATRA (402) 54 37% Anthracyclines 23% Taxanes 12% Trastuzmab 3.8% <1% Lapatinib+ trastuzumab 3 (Second line onwards) EGF104900 (148) 52 100% Anthracyclines 100% Taxanes 100% Trastuzumab 2.5% <1% LVEF, left ventricular ejection fraction; NR, not reported; T-DM1, trastuzumab emtansine 1. Baselga J, et al. N Engl J Med. 2012;366(2):109-119; 2. Verma S, et al. N Engl J Med. 2012;367(19):1783-1791; 3. Tyverb Assessment Report. Available at http://www.ema.europa.eu/docs/en_gb/document_library/epar_-_assessment_report_- _Variation/human/000795/WC500147870.pdf. Accessed 10 March 2015.

MARIANNE trial Challenging first-line treatment (recruitment complete) HER2-positive locally recurrent or advanced breast cancer (N=1095) Blinded T-DM1 (3.6 mg/kg IV q3w) Pertuzumab (840 mg LD, 420 mg IV q3w) PD Stratified by: World region Neo/adjuvant therapy (Y/N) Trastuzumab- and/or lapatinib-based therapy (Y/N) Visceral disease (Y/N) 1:1:1 Blinded Open label T-DM1 (3.6 mg/kg IV q3w) Placebo Trastuzumab Taxane (docetaxel or paclitaxel) PD PD Primary endpoints: Key secondary endpoints: OS PFS, AEs T-DM1, trastuzumab emtansine; IV, intravenous; PD, progressive disease; LD, loading dose; PFS, progression-free survival; OS, overall survival. MARIANNE trial. Available at http://clinicaltrials.gov/ct2/show/nct01120184 (accessed March 2014). OF/LPD/0005/14. Date of preparation: March 2014.

Future Directions in HER2+ MBC for Biosimilars First line: Pertuzumab-Trastuzumab-Taxane Future: T-DM1+pertuzumab? Second line: T-DM1 Third line: Many options optimal timing unknown Lapatinib-trastuzumab Lapatinib-capecitabine Trastuzumab-other chemo