Molecular genetic tests for access to targeted therapies in France in 2012

RESEARCH DECEMBER 2012 Molecular genetic tests for access to targeted therapies in France in 2012 C O L L E C T I O N Activity reports and assessments PREDICTIVE TESTS IN THE MOLECULAR GENETICS CENTRES: SUMMARY OF ACTIVITY IN 2011 PROGRAMME FOR EMERGING BIOMARKERS QUALITY ASSURANCE PROGRAMME DATABASES www.e-cancer.fr

2 MOLECULAR GENETIC TESTS FOR ACCESS TO TARGETED THERAPIES IN FRANCE IN 2012 As the medical and scientific agency of reference devoted to cancer, the French National Cancer Institute stimulates, supports and implements a coordinated policy in the fight against the disease. Created by the Public Health Act of 9 August 2004, INCa brings together approximately 150 staff in the following four operational units: Research and Innovation, Public Health and Cancer Care, Recommendations and Quality Control for Specialists, and Communication and Information This document can be consulted at the following sites: www.e-cancer.fr THE FOLLOWING PEOPLE PARTICIPATED IN THE PREPARATION OF THIS DOCUMENT: Étienne LONCHAMP, Department of Innovation, Research and Innovation Directorate Frédérique NOWAK, Manager, Department of Innovation, Research and Innovation Directorate THIS DOCUMENT IS PART OF THE IMPLEMENTATION OF THE 2009-2013 CANCER PLAN Measure 21: Guarantee equal access to treatments and innovations. action 21.2: Develop cancer molecular genetics hospital platforms This document must be referred to as follows : Molecular genetics testing for equal access to targeted therapies in France in 2012. Collection Activity reports and assessments, collective volume edited by INCa, Boulogne-Billancourt, 2012. It may be reproduced or distributed freely for personal non-commercial use or for short quotations. For other uses, permission must be sought from the INCa by filling out the reproduction application form available on the website www.e-cancer.fr or from the institutional communication department of INCa at the following address: diffusion@institutcancer.fr

CONTENTS SUMMARY AND HIGHLIGHTS... 4 INTRODUCTION... 5 METHOD... 7 TESTS PERFORMED IN 2011 FOR ACCESS TO TARGETED THERAPIES WITH MA... 8 1. List of predictive markers determining access to a targeted therapy... 8 2. BCR-ABL translocations in leukaemia prescription of imatinib, dasatinib or nilotinib... 9 2.1. Detection of the BCR-ABL fusion transcript... 9 2.2. BCR-ABL quantification... 10 2.3. ABL mutation testing... 11 2. Amplification of HER2 in breast cancer prescription of trastuzumab or lapatinib... 12 3. HER2 amplification in stomach cancer prescription of trastuzumab... 13 4. KRAS mutations in colorectal cancer prescription of cetuximab and panitumumab... 14 5. KIT and PDGFRA mutations in GIST prescription of imatinib... 16 6. EGFR mutations in lung cancer prescription of gefitinib or erlotinib... 17 7. Summary of predictive tests performed by centres since 2007... 19 PROSPECTIVE DETECTION OF EMERGING BIOMARKERS IN 2011... 20 1. Lung cancer... 20 2. Colorectal cancer... 22 3. Melanoma... 24 4. Impact of the emerging biomarkers programme on patients... 25 QUALITY ASSURANCE OF TESTS... 26 1. INCa publications... 26 2. Campaigns for external quality assessment... 26 DATABASES... 28 1. Database for lung cancer: the BIOMARQUEURS France project... 28 2. Database for melanoma: the MELBASE project... 28 CONCLUSION... 30 APPENDIX 1. CANCER MOLECULAR GENETICS HOSPITAL CENTRES... 31 3

SUMMARY AND HIGHLIGHTS SUMMARY AND HIGHLIGHTS Most of the new molecules with antitumour activity target a molecular event crucial to tumour development and present in specific patient subgroups. As a result, molecular characterisation of the tumour has become an indispensable criterion in the choice of treatment strategy. In 2012, 8 biomarkers determined the use of 11 molecules with marketing authorisation for 7 tumour locations, including lung cancer, colorectal cancer and breast cancer. In 2011, 55,000 patients underwent molecular genetic testing to determine access to targeted therapy with marketing authorisation (MA), including: - 6,500 tests to detect BCR-ABL translocations in leukaemia patients; - 17,000 tests to detect KRAS mutations in colorectal cancer; - 20,700 tests to detect EGFR mutations in lung cancer. The programme for prospective detection of emerging biomarkers established by INCa enabled 76,300 molecular genetic tests for the detection of molecular alterations in molecules at the clinical development phase including: - 58,400 tests on lung cancers from 20,750 patients - 12,500 tests on colorectal cancers from 17,000 patients - 5,400 tests on melanomas from 3,900 patients. A specific quality assurance programme has been established at national level by INCa. Two databases (BIOMARQUEURS France and MELBASE) are supported by INCa for the collection of molecular data and associated epidemiological, clinical, histological, treatment and follow-up data for patients with lung cancer and melanoma. 4

INTRODUCTION INTRODUCTION The identification of molecular alterations in cancerous cells has enabled identification of new molecular biomarkers. The identification of these biomarkers has helped to improve the description of the disease, to identify new therapeutic targets, and to develop targeted therapies. The original example is imatinib, used for the treatment of patients with chronic myeloid leukaemia or acute lymphoblastic leukaemia whose tumour cells carry a BCR-ABL translocation. Furthermore, the demonstration of other molecular alterations has provided an explanation for the resistance of some patients to targeted therapies, despite the presence of the target in their tumours. The KRAS mutation enabling prediction of non-response to panitumumab and cetuximab in colorectal cancer is an example. The molecular characterisation of the tumour has thus become a key criterion in the choice of treatment strategy, which no longer relies solely on the type or stage of the disease. It allows optimal access to targeted therapies, i.e., prescription of a treatment only to patients likely to benefit, and non-prescription of an ineffective, toxic and expensive treatment. Specific molecular alterations demonstrated in tumour cells may also help to guide or pinpoint the disease diagnosis, or to provide prognostic elements, guiding patient care. In this context, INCa established a specific programme to support the structuring of molecular genetics in 2006. There are 28 cancer molecular genetics centres distributed throughout the whole French territory, supported by INCa and the DGOS (General Healthcare Directorate) (Fig. 1). The centres bring together several laboratories that may belong to different facilities, enabling patients to be offered the entire set of core molecular genetic techniques for all pathologies concerned. Their purpose is to carry out innovative molecular tests for all patients in their region, regardless of treating facility university hospital (CHU), comprehensive cancer centre (CLCC), General hospital (CH) or private facility. The development of these centres is part of the implementation of Measure 21 of the 2009-2013 French Cancer Plan, Guarantee equal access to innovative and existing treatments. The activity of the centres may be categorised according to the use of markers in patient management: predictive markers determining access to a targeted therapy; markers that guide the diagnostic process; markers used for diagnosis as a complement to clinical, morphological and biological parameters; prognostic markers that guide the treatment strategy for the patient; markers that enable monitoring of residual disease. The present document focuses on predictive tests for access to targeted therapies. It presents a summary of the activity of the molecular genetics centres for 2011 for access to targeted therapies that already had marketing authorisation. This document also shows 2011 data for activities concerning the programme for prospective detection of emerging biomarkers, established to anticipate the arrival of new targeted therapies, and enabling the centres to be immediately operational once these therapies become available for patients. Finally, it describes actions led by INCa to ensure the quality of these predictive tests and collect the molecular, epidemiological and clinical data. This report is more especially directed at our supervisory bodies and at professionals with an interest in targeted therapies (clinicians, biologists, pathologists, industrialists involved in drugs and diagnostics, etc.). 5

Figure 1: Cancer molecular genetics centres 6

METHOD METHOD Each year, INCa prepares a form to collect the following data for each test and for each tumour location: - the total number of tests performed; - the number of patients who underwent a test; - the source of the prescriptions for these patients, distinguishing between prescriptions from centre own facilities, from hospitals outside of centre, from private facilities and from other centres. - the number of patients with a molecular alteration, the number of patients showing no alteration, and the number of patients for whom the test result was not interpretable. This form is completed and returned to INCa by the 28 centres once a year. For tests conducted as part of the programme for prospective detection of emerging biomarkers, monitoring is done at three-month intervals to allow for the rapid development of the activity. For these tests, special attention is given to the choice of techniques in the centres and to the qualitative aspects. Thus, in addition to the data listed above, the following items are collected for each test: - the time taken to obtain results; - When a result cannot be given, a request was made to specify the cause of the failure to obtain a result between the 3 most common causes : a failure to amplify the DNA, a sample having a content of tumour cells below the detection threshold for the laboratory, or insufficient quantity of material; - the technique(s) used to conduct the tests. INCa collates the data returned by the centres and calculates the indicators that enable monitoring of the activity at national level, especially the following: the evolution of the annual number of tests performed, and the number of patients involved; the overall percentage of patients on a national scale for whom a molecular anomaly has been detected. This indicator enables an estimation of compliance with the indications on prescriptions. Monitoring its evolution enables the demonstration of any broadening or restriction on prescriptions. the percentage of patients for whom a result could not be obtained. They are indicators of the quality of the preanalytical phases of the test. A more detailed analysis of the causes of failure to obtain results was carried out for several tests; the distribution of activity between centres; the source of prescriptions. The activity associated with external hospitals and private facilities enables monitoring of the regional coverage of a centre. The last item enables monitoring of referral activity that the centres perform extraregionally for some markers. Following the merge of the Institut Curie and the Hôpital René Huguenin/CH de Versailles, the activity data of these two centres were treated as a single entity. 7

Tests performed in 2011 for access to targeted therapies with MA TESTS PERFORMED IN 2011 FOR ACCESS TO TARGETED THERAPIES WITH MARKETING AUTHORISATION 1. List of predictive markers determining access to a targeted therapy Since 2001, several targeted therapies have received marketing authorisation (MA) restricted to a patient group showing specific molecular alterations (Table 1). Table 1. Targeted therapies with MA and associated molecular markers Pathology Biomarker Molecule prescribed Date of MA Chronic myeloid leukaemia (CML)/ Acute lymphoblastic leukaemia (ALL) 1. BCR-ABL translocation at diagnosis 2. Detection of BCR-ABL to monitor residual disease 3. ABL mutation 1. Prescription of imatinib, dasatinib and nilotinib 2. Resistance to imatinib/prescription of a second-line treatment 3. Resistance to imatinib/prescription of a second-line treatment Imatinib: 2001 Dasatinib: - 2006 (2 nd line) 1st - 2010 ( line) Nilotinib: - 2007 (2 nd line) - 2010 ( 1st line) GIST KIT mutation PDGFRA mutation Prescription of imatinib Imatinib: 2002 Breast cancer HER2 amplification Prescription of trastuzumab for metastatic breast cancer and as adjuvant therapy for early stage breast cancer Prescription of lapatinib for metastatic breast cancer Trastuzumab: 2000 Lapatinib: 2008 Stomach cancer HER2 amplification Prescription of trastuzumab for metastatic stomach cancer Trastuzumab: 2009 Metastatic colorectal cancer KRAS mutations Prescription of panitumumab and cetuximab Panitumumab: 2007 Cetuximab: 2008 Lung cancer EGFR mutations Prescription of gefitinib and erlotinib Gefitinib: 2009 Erlotinib: 2011 ALK translocation Prescription of crizotinib Crizotinib: 2012 Melanoma BRAF V600 mutations Prescription of vemurafenib Vemurafenib: 2012 8

2. BCR-ABL translocations in leukaemia prescription of imatinib, dasatinib or nilotinib Chronic myeloid leukaemia (CML) is a disease of the haematopoietic stem cells responsible for the proliferation of the myeloid cell line. In 95% of cases, it is characterised by the t(9;22)(q34;q11) translocation, with the appearance of a BCR-ABL gene fusion on the Philadelphia chromosome. The BCR-ABL translocation is also found in some patients with acute lymphoblastic leukaemia (ALL). Imatinib is a tyrosine kinase inhibitor (TKI), directly targeting the BCR-ABL fusion protein, and has revolutionised the management of CML since the beginning of the 2000s. It is the standard treatment for patients with BCR-ABL translocation. It has been possible to show a 6-year overall survival rate of 88% with imatinib 1. Since December 2010, dasatinib and nilotinib have also had an MA for the first-line treatment of patients with BCR-ABL translocation. Detection of the BCR-ABL transcript at the time of diagnosis immediately allows an estimation of the response to treatment with TKIs and then allows monitoring of residual disease. A diminution or increase in this level provides early evidence of resistance to treatment, thereby allowing its modification as soon as possible. BCR-ABL quantification must therefore be carried out at regular intervals for the duration of treatment. Point mutations have been described in the tyrosine kinase domain of the ABL protein which confer TKI resistance. Where there is primary or secondary resistance to treatment, early detection of these mutations provides an opportunity for adjusting the dose or offering treatment with another tyrosine kinase inhibitor. The type of mutation detected may guide the choice of second-line treatment, in order to prescribe a molecule effective against the patient's mutated form of BCR-ABL 2. 2.1. Detection of the BCR-ABL fusion transcript In 2011, 6,497 3 patients were tested for BCR-ABL. Testing for BCR-ABL translocation was performed by all centres. Since expression of the BCR-ABL transcript is sufficient in itself to determine prescription of a TKI, testing is carried out very early in the diagnostic process for suspected ALL or CML. The number of tests performed has been relatively stable since 2008, and should not vary in future since testing will be carried out routinely for all patients concerned from now on (Fig. 2). Figure 2. Evolution of the number of tests for BCR-ABL translocations in leukaemia 2 Number of patients 8,000.00 4,000.00 0.00 6,171 6,235 6,569 6,497 2008 2009 2010 2011 A BCR-ABL transcript was detected in 18.9% of patients (results obtained from 5,500 patients). It can be estimated that approximately 1,500 patients with leukaemia were identified as having BCR-ABL translocation, and may benefit from TKI treatment. The percentage of uninterpretable results was 1.7%. 66% of the prescriptions came from the centre own facilities, and 23% from non-centre hospitals (CHs) (Fig. 3). This proportion was little changed from the previous year. 1 Hochhaus et al, Leukemia 2009; 23(6): 1054-61 2 Preudhomme et al, NEJM 2010; 363(26):2511-21 3 Estimates from data provided, since not all centres reported the number of patients. 9

Figure 3. Source of prescriptions for BCR-ABL translocation testing in leukaemia 3.8% 7.0% Patients managed in the centre's own facilities 23.1% Patients managed in general hospitals outside of centres Patients managed in private facilities 66.1% Prescriptions coming from another centre 2.2. BCR-ABL quantification In 2011, 28,607 4 BCR-ABL quantifications were carried out on a total of 13,757 patients, corresponding to an average of 2.1 tests per patient per year (Fig. 4). This test was performed by all centres. Since most patients remain on TKI treatment for several years, and undergo regular follow-up for the remainder of their lives, the number of prescriptions for this test is set to increase steadily. Figure 4. Evolution of the number of BCR-ABL quantifications in leukaemia 3 30,000 20,000 10,000 19,717 20,751 22,128 6,700 7,410 8,196 23,849 11,014 28,607 13,757 Number of patients Number of testss 0 2007 2008 2009 2010 2011 Non-centre facilities accounted for 23% of BCR-ABL quantifications (Fig. 5). The source of prescriptions for BCR-ABL was unchanged compared with 2010. 4 Estimates from data provided, since not all centres reported the number of patients. 10

Figure 5. Source of prescriptions for BCR-ABL quantification in leukaemia 12.6% 2.9% 7.9% Patients managed in the centre's own facilities Patients managed in general hospitals outside of centres Patients managed in private facilities 76.7% Prescriptions coming from another centre 2.3. ABL mutation testing The level of activity with regard to ABL mutation testing decreased slightly in 2011 (-10%), returning to the level of preceding years (Fig. 6). Figure 6. Evolution of the number of tests for ABL mutations in leukaemia Number of patients 1,000 500 0 856 888 950 861 2008 2009 2010 2011 The frequency of mutation detection was 23.4%. The percentage of uninterpretable results was 5.4%. The main reasons given were the quality and quantity of RNA in samples. Half of the prescriptions come from the centre own facilities and 15% from other establishments in the region (Fig. 7). Referral activity for this test was substantial, since a third of activity was carried out for patients being cared for in other regions. 11

Figure 7. Source of prescriptions for ABL mutation testing in leukaemia 33.7% 51.1% Patients managed in the centre's own facilities Patients managed in general hospitals outside of centres 2.9% 12.3% Patients managed in private facilities Prescriptions coming from another centre 2. Amplification of HER2 in breast cancer prescription of trastuzumab or lapatinib Approximately 15% of breast cancers are associated to an overexpression of HER2, which is associated with a less favourable prognosis. Trastuzumab is an antibody that targets the HER2 receptor. This molecule, developed for the treatment of metastatic breast cancer, is also effective in preventing the recurrence of this type of cancer. Only those patients that overexpress HER2 or show an increase in the number of copies of the gene (score of 3+ in immunohistochemistry (IHC) or positive FISH/CISH) are likely to benefit from trastuzumab treatment. HER2 amplification is demonstrated by immunohistochemistry as a first measure. Where a tumour shows a score of 2+ in IHC, a complementary test for amplification of the gene using FISH or CISH is required to know if the patient is eligible for treatment with trastuzumab. Since February 2010, lapatinib, an oral drug of the anti-egfr family that inhibits tyrosine kinase activated by HER2, also has marketing authorisation for the first-line treatment of patients with metastatic breast cancer overexpressing HER2. National activity In 2011, 8,545 patients benefited from testing for HER2 amplification by FISH, i.e. a 10% increase compared with 2010 (Fig. 8). All centres carried out testing for HER2 amplification. In situ hybridisation (ISH) testing for HER2 in breast cancer was added to the list of reimbursement of medical procedures in 2009, and may therefore be done by all pathologists, regardless of their place of practice. Since then, a certain number of tests have also been performed outside of centres, and are not reported here. Despite this, and although trastuzumab has had an MA for metastatic breast cancer since 2000 and as an adjuvant treatment since 2004, this activity therefore continues to increase. The PrevHER 5 report on the assessment of HER2 prevalence in breast cancer showed an evolution in the results of IHC analyses between 2007 and 2010. This is especially reflected in an increase in the number of patients with a score of 2+: 5% of patients were IHC2+ in 2007, compared with 11% in 2010. This development might explain the increase in the number of FISH analyses observed here. 5 PrevHER : survey of pathologists to assess the prevalence of HER2 in breast cancer for patients on adjuvant treatment. 12

Figure 8. Evolution of the number of ISH tests for HER2 amplification in breast cancer Number of patients 6,000 4,000 2,000 0 5,345 3,821 4,126 3,233 2008 2009 2010 2011 The frequency of patients showing an amplification of the HER2 gene was 21.3%, a slight increase on that observed in 2010 (17.6%). The frequency of uninterpretable results was 2.2%, and was mainly due to inappropriate samples fixation. A little over half of tests prescribed for the detection of HER2 amplification came from the centres own facilities, and a quarter came from private facilities (Fig. 9). Figure 9. Source of prescriptions for HER2 amplification testing in breast cancer 27.1% 48.9% Patients managed in the centre's own facilities Patients managed in general hospitals outside of centres 6.1% 17.9% Patients managed in private facilities Prescriptions coming from another centre 3. HER2 amplification in stomach cancer prescription of trastuzumab The ToGA phase III clinical trial compared the addition of trastuzumab to treatment with cisplatin and fluoropyrimidine for patients with stomach cancer and showing HER2 amplification. The addition of trastuzumab was beneficial in terms of response rate (47.3% vs 34.5%, p = 0.0017), and the median duration of overall survival (13.8 months vs 11.1 months, p = 0.0046). In December 2009, based on these data, trastuzumab received an extension of its MA for the treatment of patients with metastatic stomach cancer and a tumour overexpressing HER2 (score of 3+ by IHC or score of 2+ by IHC confirmed by amplification of the HER2 gene as measured by ISH). National activity In 2011, 443 patients were tested for HER2 amplification by ISH (Fig.10). This activity was strongly increased compared with 2010, when 330 patients were tested. This test was performed by 18 centres in 2011. We recorded 7 regions where this test is not performed (Auvergne, Bourgogne, Centre, Haute-Normandie, Nord-Pas-de-Calais and Poitou-Charentes). It is possible, however, that some centres did not distinguish this activity from HER2 tests in breast cancer, and these data must therefore be interpreted with caution. 13

In France, the number of stomach cancers at the metastatic stage is evaluated at 4,400 a year, and it is estimated that 10% of IHC analyses result in a score of 2+, requiring confirmation by ISH or FISH. On this basis, we expect an annual number of approximately 450 tests for HER2 amplification for this cancer. Figure 10. Evolution of the number of ISH tests for HER2 amplification in stomach cancer 500 443 Number of patients 250 65 330 0 2009 2010 2011 The percentage of stomach tumours with HER2 amplification was 26.1%, a little higher than in 2010 (22.5%). The frequency of uninterpretable results was 5.3%. Half of prescriptions came from the centres own facilities (49.4%) (Fig. 11). We do, however, note an increase in the proportion of prescriptions coming from private facilities since 2009: 38% in 2011 as against 33% in 2010 and 22% in 2009. Referral activity (3.8% of patients) remained low regarding the number of centres conducting this activity. Despite substantial activity overall, the low referral activity suggests that the coverage of the territory for this test is still incomplete and does not fulfil the needs for the 7 regions where the test is not performed. Figure 11. Source of prescriptions for HER2 amplification testing in stomach cancer 3.8% 49.4% Patients managed in the centre's own facilities 37.9% Patients managed in general hospitals outside of centres Patients managed in private facilities 9.0% Prescriptions coming from another centre 4. KRAS mutations in colorectal cancer prescription of cetuximab and panitumumab Mutations in the KRAS gene are frequently observed in cancer. Thus approximately 37% of colorectal cancers carry an activating mutation in the KRAS gene that leads to constitutive activation of the EGFR signalling pathway. Most of the mutations are found in codon 12 of the gene (82% of mutations). The other mutations are generally found in exons 13 and 2 6. Since this gene is located downstream of the EGFR signalling pathway, mutations are associated with inefficacy of anti- EGFR treatments. Several studies have shown that only those patients with tumours that did not show mutations in the 6 Amado et al, J Clin Oncol 2008; 27(5):672-80 14

KRAS gene were likely to benefit from this treatment 7. The presence or absence of mutations in the KRAS gene has thus become an important criterion in the choice of appropriate therapy, and it s now established that only patients with a tumour carrying a wild type KRAS gene are likely to benefit from anti-egfr treatment. In this context, the European Medicines Agency has authorised the use of cetuximab and panitumumab solely for those patients whose tumours carry the non-mutated form of the KRAS gene. National activity In 2011, testing for KRAS mutations was carried out for 17,003 patients (Fig. 12). The KRAS test was performed by all centres. The number of tests performed has been stable since 2009. Considering the incidence of colorectal cancer in France (40,250 new cases in 2011), and the proportion of patients at the metastatic stage for this type of tumour (between 40 and 60%), it seems that the majority of patients likely to benefit from cetuximab or panitumumab treatment were indeed tested for KRAS mutations in 2011. Figure 12. Evolution of the number of tests for KRAS mutations in colorectal cancer Number of patients 20,000 15,000 10,000 5,000 0 10,012 17,246 16,581 17,003 2008 2009 2010 2011 The frequency of mutation detection was 40.0%, and the frequency of uninterpretable results was 3.0%. This indicates a continuous improvement in the last two years (4.8% of uninterpretable results in 2009 and 4.1% in 2010). The source of prescriptions has not varied since 2010, i.e: 28.6% of patients tested for KRAS were managed by the centres own facilities, whereas 25.5% were managed by CHs outside centres, and 42.1% were managed in private facilities (Fig. 13). Figure 13. Source of prescriptions for KRAS mutation testing in colorectal cancer 42.1% 3.8% 28.6% Patients managed in the centre's own facilities Patients managed in general hospitals outside of centres Patients managed in private facilities 25.5% Prescriptions coming from another centre 7 Karapetis et al, 2008; 359(17):1757-65 15

5. KIT and PDGFRA mutations in GIST prescription of imatinib Gastrointestinal stromal tumours (GIST) are mesenchymal tumours of the digestive tract. They mainly develop starting from the stomach (60-70%) and the small intestine (20-30%) and are most often associated with a mutation in the KIT gene or the PDGFRA gene. There are approximately 900 cases of GIST each year in France. Mutations or short deletions in the KIT gene, observed in 50-90% of GISTs, are responsible for spontaneous activation of KIT. These mutations are most often located on exon 11, more rarely on exon 9, and exceptionally on exons 13, 17, 14 and 15. Mutations in PDGFRA, more rare, are generally seen in tumours carrying a wild-type KIT gene. Simultaneous mutation of both genes has never been seen. Diagnosis of GIST is initially done by histology and detection of KIT expression by IHC. In cases where this expression is not detected and where GIST continues to be suspected, as well as in some difficult cases, testing for KIT or PDGFRA mutations is required to make the diagnosis. Imatinib, which is an inhibitor of KIT, has revolutionised the prognosis of locally advanced inoperable and/or metastatic GIST, in that the one-year survival rate has gone from 30% to 90%. The antitumour response to imatinib seems to correlate with the type and presence of these mutations. This response is better where the mutation is on exon 11 than when it is on exon 9, or where there is no mutation. Conversely, the D842V mutation on exon 18 of PDGFRA is believed to confer primary resistance to imatinib. Finally, the presence of mutations on exon 9 of KIT is an indication for doubling the dose of imatinib. Testing for these alterations thus now enables the optimisation of care for patients with GIST. National activity Testing for KIT mutations was performed for 944 patients in 2011, and testing for PDGFRA mutations was carried out for 880 patients (Fig. 14). The number of tests performed remained unchanged from 2010 to 2011. Eighteen centres performed testing for KIT mutations, and 17 tested for PDGFRA mutations. Figure 14. Evolution of the number of tests for KIT and PDGFRA mutations in GIST Number of patients 1,000 500 0 982 944 831 829 701 891 880 784 770 701 KIT PDGFRA 2007 2008 2009 2010 2011 The frequency of mutation detection was 56.4% for KIT and 12.6% for PDGFRA. The frequency of uninterpretable results was 6.1% for KIT mutation testing, lower than for 2010 (9.7%). With respect to testing for mutations in the PDGFRA gene, the frequency of uninterpretable results was 6.6%, and was unchanged. The source of prescriptions varied little between 2010 and 2011, in that half of prescriptions for these tests came from the centres own facilities, whereas 23% of requests were extraregional (Figs. 15 and 16). This demonstrates the existence of referral activity for all patients in the territory. 16

Figure 15. Source of prescriptions for KIT mutation testing in GIST 23.2% 50.2% Patients managed in the centre's own facilities Patients managed in general hospitals outside of centres 17.6% 9.0% Patients managed in private facilities Prescriptions coming from another centre Figure 16. Source of prescriptions for PDGFRA mutation testing in GIST 23.6% 45.9% Patients managed in the centre's own facilities Patients managed in general hospitals outside of centres 19.8% 10.8% Patients managed in private facilities Prescriptions coming from another centre 6. EGFR mutations in lung cancer prescription of gefitinib or erlotinib Non-small cell lung cancers have a poor prognosis (20% 5-year survival), and are currently the leading cause of cancer deaths in men. Published data make a clear association between the existence of an alteration in the EGFR gene and the efficacy of targeted anti-egfr treatments 8 (gefitinib, erlotinib). According to the results of a study published in June 2010 9, gefitnib has a better response rate compared with chemotherapy alone for non-small cell lung cancer with EGFR mutation (73.7% compared with 30.7%, p < 0.001) and also doubles the median survival without progression (10.8 months compared with 5.4 months, p < 0.001). In April 2009, the EMA (European Medicines Agency) granted marketing authorisation for gefitinib restricted to patients with an advanced or metastatic form, where the tumour carries an activating EGFR mutation. Since 2011, erlotinib has also had a European MA for monotherapy of patients carrying an activating EGFR mutation. Mutations have been found in exons 18 to 21, which encode the kinase domain of the receptor; the most frequent are deletions within exon 19 and a point mutation in exon 21 (L858R). These mutations are most often found in patients with adenosarcoma, women, people of Asian origin and non-smokers. However, the frequency of the mutations is never sufficiently high to enable the clinical factors alone to predict the presence of an activating EGFR mutation and to replace the determination of EGFR status. Furthermore, INCa recommends that the EGFR test be carried out for any patient with non-squamous non-small cell lung carcinoma and showing a locally advanced or metastatic tumour. 8 INCa, March 2010, Mutations of EGFR in lung cancer: evidence of a molecular target for specific access to targeted therapies, INCa 9 Maemondo M et al. N Engl J Med 2010; 362:2380-8 17

National activity Testing for activating EGFR mutations was carried out for 20,750 patients in 2011, compared with 16,834 in 2010 (Fig. 17). After a strong increase in workload in 2010, and in light of the number of patients with metastatic stage nonsquamous non-small cell lung cancer, activity with respect to this test should stabilise from now on. All centres performed the EGFR test in 2011. Figure 17. Evolution of the number of tests for EGFR mutations in lung cancer. Number of patients 25,000 20,000 15,000 10,000 5,000 0 20,750 16,834 1,269 2,667 2008 2009 2010 2011 The frequency of mutation detection was 10.0% (10.5% in 2010). The variability in the mutation frequency reported by laboratories tends to lessen with time, and now ranges from 5.1% to 13.5%. The homogenisation of results observed by the centres may be due to an improvement in the techniques employed, but also to the harmonisation of the indications for prescriptions on INCa's recommendation. Analysis of uninterpretable or indeterminate results shows that: - in 3.7% of cases, the DNA was impossible to amplify due to bad quality specimen fixation; - in 1.5% of cases, there was insufficient material left to carry out the test; - in 5.2% of cases, the percentage of tumour cells in the sample was below the detection threshold of the test used by the laboratory. In this case, it is possible to demonstrate a mutation in the EGFR gene, but the risk of a false negative is very high if a mutation is not detected. This percentage is highly variable from one laboratory to another, depending on the techniques employed (0%; 17.3%); In 2011, 59.9% of prescriptions came from non-centre facilities (Fig. 18). This proportion has not changed since 2010, and shows that access to this test is possible for all patients involved, regardless of where they are being cared for. 18

Figure 18. Source of prescriptions for EGFR mutation testing in lung cancer 1.7% 39.1% Patients managed in the centre's own facilities 29.9% Patients managed in general hospitals outside of centres Patients managed in private facilities 29.2% Prescriptions coming from another centre 7. Summary of predictive tests performed by centres since 2007 Pathology Biomarkers Number of patients 2007 2008 2009 2010 2011 Chronic myeloid leukaemia/acute lymphoblastic leukaemia BCR-ABL detection (abnormal karyotype) BCR-ABL quantification nd 6,171 6,235 6,569 6,497 6,700 (19,717*) 7,410 (20,751*) 8,196 (22,128*) 11,014 (23,849*) 13,757 (23,849*) ABL mutations nd 856 888 950 861 Breast cancer HER2 amplification nd 5,416 6,748 7,798 8,545 Stomach cancer HER2 amplification / / 65 330 443 Colorectal cancer KRAS mutations 1,100 10,012 17,246 16,581 17,003 Lung cancer GIST EGFR mutations nd 1,269 2,667 16,834 20,750 ALK translocation** nd nd nd nd 4,543 KIT mutations 701 831 829 982 944 PDGFRA mutations 701 784 770 891 880 1. Melanoma BRAF V600 mutation*** nd nd nd nd 3,479 TOTAL OF PREDICTIVE TESTS FOR ACCESS TO A TARGETED THERAPY WITH MA nd 19,139 27,930 50,044 55,043 *number of tests **for access to crizotinib, on a nominative ATU (Temporary authorisation of use of case-by-case approval), and then under an cohort ATU since March 2012 **for access to vemurafenib, on an nominative ATU basis, and then under an cohort ATU since April 2011 19

PROSPECTIVE DETECTION OF EMERGING BIOMARKERS IN 2011 PROSPECTIVE DETECTION OF EMERGING BIOMARKERS IN 2011 Many molecules that target specific molecular alterations are currently in the clinical development phase. As a result, the choice of treatment for patients is increasingly guided by the result of measurement of a panel of biomarkers specific for each tumour location. Detection of these molecular alterations by the molecular genetics centres is not without difficulty as regards validation of the technique employed, as well as the constraints of samples quality and the quantity of material available. It must be done under optimised quality assurance conditions, while providing a time to result that is in keeping with clinical management. The measurement of a biomarker panel, sometimes using different techniques, will increase the difficulty of completion, and may make the management of small specimens more crucial (especially for lung cancer). An implementation and validation phase is therefore necessary for new molecular tests, and may be relatively long for some tests. Moreover, in order to anticipate the arrival of new molecules and make them available as early as possible, INCa has conducted a programme of prospective detection for these emerging biomarkers for lung cancer, colorectal cancer and melanoma since 2010. The centres received allocations of 3.5 million and 2.8 million for this purpose in 2010 and 2011, respectively. Thus, patients with lung adenocarcinoma who have to be tested each year for EGFR mutation are also tested for mutations of the KRAS, BRAF, PI3KCA and HER2 genes, as well as for the ALK gene translocation. In colorectal cancer, patients under 60 years are also tested for BRAF gene mutation and microsatellite instability (MSI) in addition to KRAS gene mutations. In melanoma, testing is performed for mutations in the BRAF and KIT genes. This programme aims to enable the centres to be immediately functional from the day therapies targeted against these alterations become available to patients. Furthermore, patients identified as carrying these molecular alterations may be guided toward clinical trials of these new targeted therapies, and thereby benefit from anticipated access to these innovative molecules. Since the beginning of the programme in January 2011, the following two molecules have been granted MA or a cohort ATU (temporary authorisation of use): vemurafenib obtained an MA in February 2012 for the treatment of patients with metastatic melanoma carrying mutation(s) in codon V600 of the BRAF gene; crizotinib obtained a cohort ATU in March 2012, and a positive decision from CHMP (Committee for Medicinal Products for Human Use) in July of the same year, thereby opening the way for the obtention of an MA in Europe for lung cancer patients with a tumour showing translocation of the ALK gene. 1. Lung cancer Table 2 summarises overall activity performed in 2011. Table 2. Number of tests performed in 2011 Number of patients Mutation frequency Activating EGFR mutations 20,750 10.0% EGFR resistance mutations 13,720 1.2% KRAS mutation 17,153 25.4% BRAF mutation 10,017 1.8% HER2 mutation 7,731 0.9% PI3KCA mutation 5,329 2.1% ALK translocation 4,543 4.8% 20

Figure 19. Evolution of the number of tests for lung cancer in France in 2011 Number of patients 6,000 5,000 4,000 3,000 2,000 1,000 EGFR activating EGFR resistance KRAS BRAF HER2 PI3KCA ALK 0 T1 T2 T3 T4 The number of tests performed increased steadily during the year 2011 for all markers involved (Fig. 19). By the end of 2011, testing for mutations conferring resistance to anti-egfr tyrosine kinase inhibitors had become quasi-routine, whereas testing for KRAS, BRAF and HER2 mutations had become highly developed. The centres established testing for PI3KCA and ALK later, and the activity with respect to these tests remains relatively low, since only 40% of patients had access to PI3KCA testing and 30% to ALK testing by the 4th quarter. The difficulty of establishing ALK testing is mostly due to the present requirement to perform the analysis by FISH, a technique that is time-consuming and difficult to implement on a wide scale. Alternative techniques using IHC or RT-PCR are presently being evaluated and may provide a solution to this problem. The obtaining of a cohort ATU at the beginning of 2012 for crizotinib in the treatment of lung cancer patients with ALK translocation makes this test indispensable for patients from now on. As mutations in different genes are most often described as being mutually exclusive (except for PI3KCA), several centres choose for a sequential analysis strategy. In this case, only patients that do not show EGFR mutations are tested for KRAS. Likewise, BRAF and HER2 tests may be carried out for patients whose tumours carry wild type EGFR and KRAS genes. Although the sequential analysis strategy allows a reduction in the number of tests to be carried out, it also has the disadvantage of increasing the time to result for patients requiring the last-run tests. Frequency of uninterpretable results For mutation testing, the causes of uninterpretability of results were similarly distributed for all tests (Fig. 20). However, we note that the percentage of patients for whom analyses could not be carried out was higher for the tests conducted last. 21

Figure 20. Frequency of uninterpretable or indeterminate results in lung cancer 14.0% 12.0% 10.0% 8.0% 6.0% % of tumour cells below the laboratory's sensitivity treshold sample depleted DNA unamplifiable 4.0% 2.0% 0.0% EGFR act EGFR res KRAS BRAF PI3KCA HER2 The percentage of uninterpretable results was higher (12%) for ALK translocation testing: - in 8.6% of cases, the probe did not hybridise correctly; - in 1.4% of cases, the number of labelled cells was small, and did not provide conclusive results; - in 2.0% of cases, there was insufficient material left to carry out the test (Fig. 21). Figure 21. Frequency of uninterpretable results for the ALK test 10.0% 8.6% 5.0% 1.4% 2.0% 0.0% Non-hybridization of the probe Too few cels labelled Sample depleted 2. Colorectal cancer In 2011, 12,500 patients with colorectal cancer were tested for BRAF mutation (Table 3). Table 3. Number of tests carried out in 2011 Number of patients KRAS mutations 17,003 BRAF mutations 12,500 22

Figure 22. Evolution of the number of tests for colorectal cancer in France in 2011 5,000 Number of patients 4,000 3,000 2,000 1,000 KRAS BRAF 0 T1 T2 T3 T4 The activity profile (Fig. 22) shows a steady increase in the number of BRAF tests during 2011, whereas KRAS activity remained stable overall. At the end of 2011, BRAF testing in colorectal cancer was being performed by all centres. Most of them were conducting BRAF testing as a first measure, in parallel with KRAS testing. Centres with the lowest activity had almost all opted for a sequential analysis strategy. In this case, BRAF testing was carried out for patients without a mutation in the KRAS gene, i.e. approximately 60% of patients. At the end of the year, 84% of patients who had undergone KRAS testing had also has access to BRAF testing, indicating that this test is being done routinely from now on. Table 4. Observed mutation frequency and rate of indeterminate results for each test in 2011 Mutation frequency Frequency of uninterpretable results KRAS mutations 40.0% 3.0% BRAF mutations 8.6% 3.9% KRAS mutations were observed for 40% of tumours tested, whereas a BRAF mutation was reported for 8.6% of patients (Table 4). The frequency of uninterpretable results was 3.0% for KRAS testing, and 3.9% for BRAF testing (Table 4). The main cause of uninterpretable results was poor tissue fixation, effectively rendering the DNA unamplifiable. 23

3. Melanoma In 2011, 3,479 patients underwent BRAF testing, and 1,936 underwent KIT testing (Table 5). The number of BRAF and KIT tests carried out increased steadily throughout 2011 (Fig. 23). Activity for BRAF testing progressed very rapidly. The activity was lower for KIT mutation testing, but progressed rapidly from the second quarter of 2011. Moreover, some laboratories only carried out KIT testing for patients with an acral or mucosal melanoma. At the end of the year, all centres had these two tests in place. Table 5. Number of tests performed in 2011 Number of patients BRAF mutations 3,479 KIT mutations 1,936 Figure 23. Evolution of the number of tests carried out on melanomas in France in 2011 1,500 Number of patients 1,000 500 BRAF KIT 0 T1 T2 T3 T4 The frequency of mutation detection for the BRAF gene was 37.6%. Mutations in codon V600 of the gene were observed for 36.6% of patients. V600E and V600K mutations were the most common, but rarer mutations in codon 600 were found among 0.3% of patients (Fig. 24). Figure 24. Frequency of BRAF gene mutations 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 37.6% 34.7% 1.6% 0.3% TOTAL V600E V600K other V600 The mutation frequency observed for the KIT gene was 3.8%, and the percentage of uninterpretable results was 10.7% (Table 6). The most frequently occurring mutation was L576P, located on exon 11 of the gene, and was found in 0.9% of patients. 24

Table 6. Observed mutation frequency and rate of indeterminate results for each test in 2011 Mutation frequency Frequency of uninterpretable results BRAF mutations 37.6% 5.1% KIT mutations 3.6% 10.7% 4. Impact of the emerging biomarkers programme on patients The programme for the prospective detection of emerging biomarkers was established in order to improve access to therapeutic innovations in the area of targeted therapies. Since the launch of the programme, the following two molecules have become widely available for patients: - Vemurafenib obtained a cohort ATU for treatment of patients with metastatic melanoma carrying a V600E BRAF mutation in April 2011. Vemurafenib obtained a broader MA, covering all mutations of codon V600, in February 2012. The second periodic summary report on the ATU for vemurafenib 10, published by ANSM (The French National Agency for Medicines and Health Products Safety) indicated that 263 patients benefited from an ATU between 7 April and 5 October 2011. During the same period, the molecular genetics centres identified V600E BRAF mutations in 603 patients with metastatic melanoma. These data suggest that nearly half of patients carrying V600E mutations might indeed benefit from vemurafenib treatment. - Crizotinib obtained a nominative ATU for the treatment of patients with advanced lung cancer with an ALK translocation in November 2010, followed by a cohort ATU from March 2012. From 13 October 2011 to 12 January 2012, 35 patients benefited from a nominative ATU approval for crizotinib. As an indication, during the same period, the molecular genetics centres identified 86 patients carrying ALK translocations. From November 2010 to January 2012, 75 patients benefited from a nominative ATU for crizotinib 11. During the same period, the molecular genetics centres identified 208 patients carrying ALK translocations. These data confirm the interest of the scheme for patients, since it enabled a segment of them to access the molecules under ATU in 2011. 10 Résumé du 2 ème du rapport de synthèse périodique RO5185426 (vemurafenib). ANSM, novembre 2011 11 Résumé du 2 ème rapport périodique sur l ATU nominative sur le crizotinib. ANSM, mai 2012 25

QUALITY ASSURANCE OF TESTS QUALITY ASSURANCE OF TESTS By contributing decisive information on the choice of treatment, tests determining access to targeted therapy have a major therapeutic impact. It is therefore vital to ensure their quality in order to avoid as far as possible any false positives or false negatives that could limit the patient s chances or expose him to unnecessary side effects. To this end, INCa is developing a quality assurance programme based on the following two main axes: The publication of documents defining good practice; The organisation of a quality control campaign for tests that have a major therapeutic impact on patients. These actions are intended to support the molecular genetics centres toward certification according to ISO standard 15189, which will ultimately be compulsory, as a result of the ordinance for reform of medical biology of 13 January 2010. To this end, INCa established a working group to assist with certification of the centre laboratories in 2012. 1. INCa publications In 2010, INCa published a good practice guide for the detection of somatic mutations in solid tumours 12. This is an attempt to describe good practice in relation to prescription and specimen-taking (specimen quality, type of fixative employed, etc.) and the list of mutations tested for in the context of the MAs involved, for each tumour type. Recommendations were also made with respect to validation of the analytical method, together with reporting of results (report and time to result). In 2011, a charter for the molecular genetics centres was published, defining the conditions for implementation of 13 molecular tests, and setting out the routes for prescriptions, specimens and results. It will thus contribute to better coordination of the professionals involved. In 2012 a proposal for an analysis report fulfilling the minimal requirements with a view to laboratory certification was 14 published. This is mainly an effort to collect and organise all of the elements that should appear in reports. It also defines the guidelines for interpretation of results with respect to treatments associated with the mutations being tested for and that have MA. All these documents are available on the INCa website ( www.e-cancer.fr). 2. Campaigns for external quality assessment A programme of external quality assessment (EQA) was established in 2012. This involves the 28 centres for the analytical phase of testing, and enabled, in 2012, the quality control of EGFR testing in lung cancer, KRAS testing in colorectal cancer, and BCR-ABL testing in CML. A campaign of external quality assessment for BRAF testing in melanoma is also being prepared and will be effective from 2013. The structures responsible for coordinating the EQA campaigns were selected by a competitive procedure in the context of a call for tenders organised by INCa. The EQA campaigns for mutation testing in the EGFR and KRAS genes are carried out by a group that includes the Institut Curie, the AFAQAP (French Association for Quality Assurance in Pathologic Anatomy and Cytology) and a laboratory specialising in quality assurance at the Université Catholique de Louvain. The objective of this programme is to assess mutation testing in the EGFR gene in 6 pulmonary adenocarcinoma biopsies and for the KRAS gene in 6 colorectal tumour biopsies. It must allow assessment of part of the preanalytical stages (histological validation) and of the analytical and post-analytical phases (quality of reports and time to results). Furthermore, the molecular status of the samples employed will be systematically validated by a reference laboratory (Nijmegen laboratory). 12 INCa document: Guidelines for theranostic testing for somatic mutations in solid tumours 13 INCa document: Code of practice for molecular genetics centres for cancer 14 INCa document: Model molecular genetics report for somatic mutation testing in solid tumours 26

The second EQA programme is organised by the GBMHM (Malignant Haemopathy Molecular Biology Group), and is aimed at assessing the quality of tests for quantification of BCR-ABL transcripts in malignant haemopathies (CML and ALL). Checks are done on 5 to 10 samples of cells from CML patients diluted in leukocytes from healthy subjects. The design of this campaign allows assessment of the three quantification steps, i.e. nucleic acid extraction, quantification of BCR-ABL transcripts and the alignment of laboratories at international level (EUTOS programme). To complete the assessment of the analytical stages, evidence in writing is envisaged in order to check compliance with the recommendations concerning the stages of analytical and biological validation of results. Debriefing meetings were organised with the participants at the end of each campaign in order to allow sharing of experiences and to contribute to quality improvement in participating laboratories. A general report summarising results from the three campaigns will also be published. 27

Databases DATABASES The national organisation established for molecular testing countrywide is a unique opportunity to generate data of great scientific value through the collection of molecular data combined with epidemiological, clinical, histological and therapeutic data and data from patient follow-up. For this purpose, two databases for lung cancer and melanoma are supported and funded by INCa. 1. Database for lung cancer: the BIOMARQUEURS France project The BIOMARQUEURS France project is led by the IFCT (French Intergroup for Thoracic Oncology) in close association with representatives from the molecular genetics centres. The objective is to carry out a descriptive analysis of the prevalence of molecular anomalies the systematic analysis of which has been funded by INCa as part of a programme for the prospective detection of emerging biomarkers (mutations conferring sensitivity and resistance to EFGR TKI, mutations in KRAS, BRAF, HER2 and PI3KCA and ALK translocation) and the related clinical characteristics. This project involves the collection of these data for all patients tested for EGFR mutations and the associated emerging biomarkers in the course of a year. The secondary objectives are as follows: Analysis of the number of patients in receipt of a personalised therapy based on a molecular anomaly identified by the centres Correlation of the molecular alterations between the centres (in order to validate or otherwise the concept of exclusive mutations) Correlations between molecular alterations and treatment decision (real individualisation of treatment?) Correlations between molecular alterations and survival data The project began at the end of 2011. A pilot phase was first established with the participation of 3 centres to validate the feasibility of the project and was complete in February 2012. The national phase began in April 2012, with the submission by the centres of all reports following that date. The centres include each patient for whom a request has been made for molecular analysis by submitting the analysis report to the IFCT via a Fax number or secure e-mail service. Trained dedicated staff enter the data from the reports into a secure BIOMARQUEURS France extranet database. A postal mailing and an email where necessary inform the patient's doctor of the existence of the study, of the requirement for his/her participation in the collection of clinical data, as well as the practical procedures for submission of data (connection to the secure extranet for clinical data entry at recruitment and at 3-month and 12-month follow-up). 2. Database for melanoma: the MELBASE project The MELBASE project is led by the group GMFmel (a multidisciplinary French group working on cutaneous melanoma). It involves the creation in a prospective manner of a cohort of patients with non-resectable stage III melanoma with lymph-node involvement, and patients with metastatic stage IV melanoma. The project was funded in 2011 in the context of an INCa call for proposals, Clinical and Biological Databases. One thousand patients will be recruited prospectively for one year, with follow-up for 3 years, from 26 consenting centres in France. A clinical and biological database, MELBASE, will be created on the basis of this cohort. The objective is to link a database that includes the clinical, biological and radiological follow-up of these patients to a virtual tumour bank. This database also includes the molecular results obtained by the molecular genetics centres. The objective is to collect in MELBASE, in a standardised fashion, data on constitutional factors, factors related to the primary melanoma, factors related to lymph node involvement prior to recruitment, tumour kinetics, the AJCC (American joint Committee on Cancer) stage at recruitment and after the different therapeutic interventions, serum markers, genotyping of the metastatic tumour (one or several tumour sites, one or several sequential time-points), therapeutic interventions 28

(medical, surgical, radiotherapy and palliative strategies) with assessment of the response, tolerance, impact on quality of life, direct costs, psycho-socio-economic aspects with a specific questionnaire, date and cause of death, and date of latest news. 29

Conclusion CONCLUSION In 2011, 55,000 patients underwent a test determining access to a targeted therapy with MA. After a steady increase in activity from 2008 to 2010, the activity for most markers reached a plateau. These data show that companion testing very soon becomes widespread, thereby allowing targeted therapies to be made available to most patients who might benefit from them. For some tests, such as the quantification of BCR-ABL in leukaemia or testing for amplification of HER2 by in situ hybridisation, activity continues to increase steadily. This is explained by the requirement to monitor a growing number of patients being treated with targeted therapy for several years for leukaemia, but is more difficult to explain for the determination of HER2 status. The programme for the prospective detection of emerging biomarkers that began at the start of 2011 allowed a rapid increase in activity for most of the biomarkers involved. Thus, one year after its launch, most patients with colorectal cancer who underwent KRAS testing also benefited from BRAF mutation testing. Likewise, BRAF and KIT testing in melanoma was also widely carried out in 2011. Data are more disparate for lung cancer: although the majority of patients who had to be tested for EGFR mutation also had access to KRAS and BRAF testing, testing for PI3KCA and HER2 mutations was not yet being carried out in all centres and was not available to all patients. Likewise, testing for ALK translocations, which presents more technical difficulties, was still insufficiently developed at the end of 2011. With respect to this last marker, alternative techniques using immunohistochemistry are presently being evaluated. The emerging biomarkers programme has thus enabled a rapid increase in services offered by laboratories for the tests involved, and helped make the new targeted therapies available as soon as they were on the market. The interest of this programme has been demonstrated in the case of vemurafenib, which obtained an MA for the treatment of melanoma patients with mutations in codon V600 of BRAF in the beginning of 2012, and crizotinib, which has had an ATU since the end of 2011. In both cases, the anticipated arrival of these molecules enabled these novel therapies to be made available to patients immediately. Thus 6 months after the granting of a cohort ATU to vemurafenib, 263 patients were able to benefit from this treatment. The list of biomarkers used in clinical practice is set to increase steadily with the growing number of targeted therapies undergoing development for patient populations defined according to the molecular characteristics of their tumours. This steady increase in the number of tests to be carried out for each patient will quickly lead the centres to turn toward technologies allowing multiplex analysis in an all-in-one approach. Thus the arrival of Next Generation Sequencing technologies (NGS) might answer these needs in the near future. To this end, in 2012 INCa began an evaluation of the needs and constraints related to the arrival of NGS in the laboratories. These developments will translate into farreaching reorganisation within the laboratories and will force them to acquire new skills in the preparation of samples and analysis of results. Apart from these quantitative aspects, it is also vital to ensure the quality of tests in order to avoid as far as possible any false positives or false negatives that could limit the patient s chances or expose him/her to unnecessary side effects. For this reason, INCa has continued to develop a quality assurance programme intended to prepare the molecular genetics centres for certification according to ISO standard 15189, which will ultimately become compulsory. For this purpose, working groups dealing with specific questions (reports and certification) have been piloted by INCa. Moreover, three external quality assessment campaigns were conducted in 2012 for EGFR, KRAS and BCR-ABL testing. 30

APPENDIX 1. CANCER MOLECULAR GENETICS HOSPITAL CENTRES APPENDIX 1. Cancer molecular genetics hospital centres Alsace CHU* - CLCC** de Strasbourg - CH de Mulhouse CH*** de Colmar Coordinators: Marie-Pierre Gaub and Jean-Pierre Ghnassia Aquitaine CHU - CLCC de Bordeaux Coordinator: Jean-Philippe Merlio Auvergne CHU - CLCC de Clermont-Ferrand Coordinator: Andreï Tchirkov Basse Normandie CHU - CLCC de Caen Coordinator: Marie-Laure Kottler Bourgogne CHU - CLCC de Dijon Coordinator: Laurent Martin Bretagne CHU de Brest Coordinator: Valérie Ugo CHU - CLCC de Rennes Coordinators: Thierry Fest and Nathalie Rioux-Leclercq Centre CHRU de Tours CH d Orléans Coordinator: Jean-Christophe Pagès Champagne Ardenne CHU - CLCC de Reims Coordinator: Christine Clavel Franche-Comté CHU de Besançon Coordinator: Christiane Mougin Haute Normandie CHU - CLCC de Rouen Coordinator: Jean-Christophe Sabourin Île-de-France Institut Gustave Roussy Coordinator: Jean-Michel Bidart Institut Curie Centre René Huguenin CH de Versailles Coordinators: Olivier Delattre and Ivan Bièche Île-de-France Public Assistance-Paris Hospitals (AP-HP) Coordinators: Michel Marty, Pierre Laurent-Puig, Thierry Molina and Nathalie Rheims Languedoc Roussillon CHU - CLCC de Montpellier - CHU de Nîmes Coordinator: Thierry Maudelonde Limousin CHU de Limoges Coordinators: François Labrousse and Jean Feuillard Lorraine CHU - CLCC de Nancy Coordinator: Philippe Jonveaux Midi-Pyrénées CHU - CLCC de Toulouse Coordinator: Eric Delabesse Nord-Pas-de-Calais CHU - CLCC de Lille Coordinator: Nicole Porchet Pays de la Loire CHU - CLCC de Nantes Coordinator: Marc Denis CHU - CLCC d Angers Coordinator: Alain Morel Poitou-Charentes CHU de Poitiers Coordinators: Lucie Karayan-Tapon Provence- Alpes- Côte d Azur CHU - CLCC de Nice Coordinator: Florence Pedeutour CHU - CLCC de Marseille Coordinator: Jean Gabert Rhône-Alpes CHU - CLCC de Lyon Coordinator: Jean-Yves Scoazec CHU de Grenoble Coordinator: Dominique Leroux CHU de Saint-Etienne Coordinator: Lydia Campos *CHU: University Hospital **CLCC: Comprehensive Cancer Centre ***CH: General Hospital CHRU: Regional University Hospital 31

NOTES 4

MOLECULAR GENETIC TESTS FOR ACCESS TO TARGETED THERAPIES IN FRANCE IN 2012 Edited by the Institut National du Cancer Design/production: Institut National du Cancer All right reserved Siren: 185512777 DUTY COPY DEPOSITED DECEMBER 2012

For more information please consult www.e-cancer.fr All the information on the 2009-2013 Cancer Plan www.plan-cancer.gouv.fr RÉF : BILPTFMOLANG12 Institut National du Cancer 52, avenue André Morizet 92100 Boulogne-Billancourt France Phone +33 (1) 41 10 50 00 Fax +33 (1) 41 10 50 20 diffusion@institutcancer.fr www.e-cancer.fr