Updated results, multivariate and subgroups analysis confirm improved activity and efficacy for FOLFOXIRI vs FOLFIRI in the G.O.N.O. randomized phase III study in metastatic colorectal cancer A.S.C.O. Annual Meeting Chicago (USA), June 1-5 A. Falcone 1,3, M. Andreuccetti 1, I. Brunetti 2, S. Ricci 2, C. Barbara 1, W. Evangelista 4, V. Passeri 5, S. Chiara 6, G. Allegrini 1, G. Masi 1 1 U.O. Oncologia Medica, Azienda USL-6, Livorno; 2 U.O. Oncologia Medica, Ospedale S. Chiara, Pisa; 3 Università degli Studi di Pisa, 4 Centro Oncologico ed Ematologico Subalpino, Ospedale S. Giovanni Battista Le Molinette, Torino, 5 Dipartimento di Medicina Sperimentale e Patologia, Oncologia Medica, Università la Sapienza, Roma, 6 Istituto Nazionale per la Ricerca sul Cancro, Genova ITALY

ABSTRACT Background: As previously reported (ASCO 2006) the G.O.N.O. conduced a phase III study comparing FOLFIRI to FOLFOXIRI in 244 patients (pts) with not resectable MCRC. At a median follow-up of 18.4 months (mos) we reported significant improvements in response-rate (RR), R0 resection of metastases (mts), PFS and OS for FOLFOXIRI. Methods: Results have been updated (median follow- up of 36.2 mos) and 14 variables were tested as possible prognostic factors for response, R0 resection, PFS and OS. Results: At this updated analysis 225 (111 vs 114) pts have progressed and 180 (84 vs 96) have died. Results confirm the significant improvements for FOLFOXIRI in terms of confirmed RR (60% vs 34% p 25%. Conclusions: FOLFOXIRI confirms to be the first combination demonstrated to be superior to an infusional 5FU containing doublet as FOLFIRI in terms of RR, R0 resections, PFS and OS. FOLFOXIRI represents a new treatment option in MCRC and its use and study is of particular interest in a neoadjuvant strategy, in pts with few chances to achieve a three-drug exposure in a sequential strategy and in combination with targeted agents. Partially supported by Fondazione ARCO.

RATIONALE Preclinical synergism between CPT-11, LOHP and 5FU and different dose-limiting toxicities (Fischel, BJC 2001) FOLFOXIRI can expose 100% of pts to all the 3 active agents (CPT- 11, LOHP and 5-FU) while in a sequential strategy 25-50% of pts does not receive II line CT and therefore is not exposed to all the 3 agents (Grothey, JCO 2004) FOLFOXIRI, if more active, may improve post-CT resection-rate of mts (Folprecht, Ann Oncol 2005) FOLFOXIRI RATIONALE FOLFIRI was a reference standard combination in MCRC (Douillard, Lancet 2000) FOLFOXIRI was a feasible regimen with manageable toxicities and promising activity in phase I-II studies (Falcone JCO 2002; Masi Ann Onc 2004) STUDY RATIONALE

STUDY DESIGN FOLFIRI* CPT mg/m 2 1-h d.1 L-LV100 mg/m 2 2-h d.1,2 5FU400 mg/m 2 bolus d.1,2 5FU 600 mg/m 2 22-h d.1,2 q. 2 wks x 12 cycles FOLFOXIRI** CPT mg/m 2 1-h d.1 LOHP 85 mg/m 2 2-h d.1 L-LV200 mg/m 2 2-h d.1 5FU 3200 mg/m 2 48-h CI d.1 q. 2 wks x 12 cycles Stratification Center PS 0/1-2 Adjuvant CT RANDOMRANDOM  In pts progressed after FOLFIRI a second-line CT with an LOHP containing regimen (FOLFOX) was recommended * Douillard Lancet 2000 ** Masi Ann Oncol 2004

FOLFOXIRI SCHEDULE 5FU flat continuous infusion 3200mg/m 2 L-LV 200 mg/m 2 Oxaliplatin 85 mg/m 2 2 hours Repeated every 14 days CPT mg/m 2 48 hours Day 1 Day 2 Day 3 1 hour

MAIN PATIENTS SELECTION CRITERIA Metastatic and unresectable colorectal cancer Measurable disease Age yrs ECOG PS 0-2 (ECOG PS=0 for pts yrs) Adjuvant CT ended > 6 mos Adequate renal, hepatic and bone-marrow functions No previous CPT-11 or LOHP No previous CT for metastatic disease

PATIENTS CHARACTERISTICS * Accrual from November 2001 to April 2005 FOLFIRI (122 pts) FOLFOXIRI (122 pts) Age, median (range)64 (21-75)62 (27-75) Sex (M/F)69/5375/47 ECOG PS 0 / 1-261% / 39% Previous adjuvant CT24% Synchronous mts65% Multiple sites of disease45%47% Liver mts only34%32% Liver involvement ≥ 25%57%53% LDH >UNL25%23%

NON-HEMATOLOGICAL TOXICITY (NCI) GRADE 3-4 PER PATIENT (N=122) p < ** Grade 2-3 **

HEMATOLOGICAL TOXICITY (NCI) GRADE 3-4 PER PATIENT (N=122) p =0.0006

FOLFIRI 122 pts FOLFOXIRI 122 pts Complete6%8% Partial35%58% Complete + Partial41%*66%* 95% Confidence Interval Stable33%21% Progression24%11% Not evaluable2% *p = RESPONSES (ITT analysis) INVESTIGATORS’ ASSESSMENT INVESTIGATORS’ ASSESSMENT

FOLFIRI 122 pts FOLFOXIRI 122 pts Complete6%7% Partial28%53% Complete + Partial34%*60%* 95% Confidence Interval Stable34%21% Progression24%11% Not evaluable8% *p < EXTERNALLY REVIEWED EXTERNALLY REVIEWED RESPONSES (ITT analysis)

Logistic regression multivariate analysis of predictive factors for Response CovariateP valueHR(95% CI) Treatment FOLFIRI1.0 FOLFOXIRI< Variables tested: Treatment, sex, age, PS, primary, N. organs involv., sites of mts,% liver involv., time from diagnosis to mets, previous adjuvant CT, LDH, CEA, WBC, HB

FOLFIRI (122 pts) FOLFOXIRI (122 pts) R0 6%* (7 pts) 15%* (18 pts) R11%2% Explorative8%1% * p=0.033 POST-CT SURGICAL RESECTIONS (all patients) POST-CT SURGICAL RESECTIONS (all patients)

FOLFIRI (42 pts) FOLFOXIRI (39 pts) R0 12%* (5 pts) 36%* (14 pts) * p=0.017 POST-CT SURGICAL RESECTIONS (patients with liver mts only) POST-CT SURGICAL RESECTIONS (patients with liver mts only)

Logistic regression multivariate analysis of predictive factors for secondary R0-Surgery CovariateP valueHR(95% CI) Treatment FOLFIRI1.0 FOLFOXIRI Liver only metastases Yes1.0 No Variables tested: Treatment, Sex, age, PS, primary, N. organs involv., Sites of mts,% liver involv., Time from diagnosis to mets, previous adjuvant CT, LDH, CEA, WBC, HB

FOLFIRI 122 pts FOLFOXIRI 122 pts Progressed Median PFS6.9 m9.9 m HR: 0.65 (95%CI: ) log-rank P value = PROGRESSION FREE SURVIVAL

Cox’s multivariate analysis of prognostic factors for Progression Free Survival Covariatep valueHR(95% CI) Treatment FOLFIRI1.0 FOLFOXIRI< ECOG PS > Gender Female1.0 Male Variables tested: Treatment, sex, age, PS, primary, N. organs involv., sites of mts,% liver involv., time from diagnosis to mets, previous adjuvant CT, LDH, CEA, WBC, HB

Hazard ratios for risk of progression in subgroups (1) CaracteristcsTotal n Median n HR95% CI All Patients PS (ECOG) Age <65 yr ≥65 yr Gender Male Female Primary Colon Rectum Previous adjuvant CT Yes No Time from diagnosis to randomization < 3 months ≥ 3 months LDH ≤UNL >UNL n.a FOLFIRIFOLFOXIRI

CaracteristcsTotal n Median n HR95% CI All patients CEA <100 ≥100 n.a HGB <11 ≥11 n.a GB <8000 ≥8000 n.a Liver mts only yes no n° organ involvement 1 > Liver involvement <25% >25% n.a FOLFIRIFOLFOXIRI Hazard ratios for risk of progression in subgroups (2)

FOLFIRIFOLFOXIRI Progressed pts Second-line CT78% 73% FOLFOX87% 15% FOLFIRI5% 23% FOLFOXIRI1% 20% Mitomycin-C0% 17% Infusional 5FU3%11% Cetuximab1% 7% Bevacizumab0% Other3% 6% SECOND-LINE CHEMOTHERAPY

OVERALL SURVIVAL FOLFIRI 122 pts FOLFOXIRI 122 pts Died9684 Median OS16.7 m23.6 m HR: 0.74 (95%CI: ) log-rank P value = % 13% Median follow up: 36.2 months

Cox’s multivariate analysis of prognostic factors for Survival CovariateP valueHR(95% CI) Treatment FOLFIRI1.0 FOLFOXIRI Liver involvement > 25%1.0 < 25% no Variables tested: Treatment, Sex, age, PS, primary, N. organs involv., Sites of mts,% liver involv., Time from diagnosis to mets, previous adjuvant CT, LDH, CEA, WBC, HB

Hazard ratios for risk of OS in subgroups (1) CaracteristcsTot aln Median n HR95% CI All Patients PS (ECOG) Age <65 yr ≥65 yr Gender Male Female Primary Colon Rectum Previous adjuvant CT Yes No Time from diagnosis to randomization < 3 months ≥ 3 months LDH ≤UNL >UNL n.a FOLFIRIFOLFOXIRI

CaracteristcsTotal n Median n HR95% CI All patients CEA <100 ≥100 n.a HGB <11 ≥11 n.a GB <8000 ≥8000 n.a Liver mts only yes no N° organ involvement 1 > Liver involvement <25% >25% n.a FOLFIRIFOLFOXIRI Hazard ratios for risk of OS in subgroups (2)

Survival of pts radically resected after FOLFOXIRI in phasae II and III GONO’s trials N. of pts: 37 N. of events: 18 Median Follow up: 55 months Median Survival: months 5-years Survival: 40% Falcone at al. J Clin Oncol 2002; Masi et al. Ann Oncol 2004; Falcone et al. J Clin Oncol 2007

Grothey A, Sargent D. J Clin Oncol. 2005;23: Survival improves with availability of three active drugs * “GONO” FOLFOXIRI P=0.0001

Studies incl. selected pts. (liver metastases only, no extrahepat. disease) r=.96, p=.002 Studies incl. all patients with metastatic CRC (solid line) r=.74, p<.001 Phase III studies in metastatic CRC (dashed line) r=.67, p=.024 G Folprecht, A Grothey, S Alberts, HR Raab, and CH Köhne, Ann Oncol 2005 * * “GONO” FOLFOXIRI CORRELATION BETWEEN TUMOR RESPONSE AND RESECTION RATES

Doublet + 1 biologic or Triplet in phase III studies Doublet + 1 biologic or Triplet in phase III studies Treatment IFL + BV NEJM ‘04 FOLFOX or XELOX + BV ASCO-GI ‘07 FOLFOXIRI ASCO‘07 N pts RR (%)44.8%38.0%60.0 % R0 surgery< 2%?15% PFS (months) OS (months)20.3?23.6

CONCLUSIONS “GONO” FOLFOXIRI is the first studied combination, in a phase III study, that compared to an infusional doublet as FOLFIRI, although at the cost of a modest increase in toxicity, significantly improves ORR, post-CT resection of mts, PFS and OS “GONO” FOLFOXIRI represents a new first-line option in metastatic colorectal cancer patients with similar characteristics to those included in this study The study of FOLFOXIRI should be of particular interest in a neoadjuvant strategy, in pts with few chances to achieve a 3 drugs exposure in a sequential strategy and in combination with targeted agents

Thank you to all patients and investigators! Centro TrialM. Andreuccetti, C. Barbara, C. Orlandini AlbaG. Porcile, M. Boe BolognaL. Crinò, G. Benedetti, S. Bartolini, C. Calandri CaltanissettaS. Vitello CorreggioS. Bagnulo CuneoM. Merlano, C. Granetto, E. Fea FirenzeL. Fioretto, A. Ribecco GenovaR. Rosso, S. Chiara LivornoA. Falcone, G. Masi, G. Allegrini, S. Bursi, F. Loupakis NovaraO. Alabisio, S. Miraglia, L. Forti ParmaA. Ardizzoni, R. Camisa, F. Pucci PisaS. Ricci, I. Brunetti, R. Murr, E. Pfanner PistoiaM. Di Lieto, A. Chiavacci PontederaM. Filidei, S. Cupini RomaE. Cortesi, V. Picone, S. Ferraldeschi, G. D’Auria TorinoO. Bertetto, L. Fanchini, W. Evangelista Gruppo Oncologico Nord Ovest