2013 ASCO Annual Meeting Chicago, 31 May – 4 Jun 2013 FOLFOXIRI/bevacizumab (bev) versus FOLFIRI/bev as first-line treatment in unresectable metastatic colorectal cancer patients: Results of the phase III TRIBE (TRIplet+BEva) trial by GONO group. A. Falcone, C. Cremolini, G. Masi, S. Lonardi, V. Zagonel, L. Salvatore, P. Trenta, G. Tomasello, M. Ronzoni, L. Ciuffreda, A. Zaniboni, G. Tonini, A.Buonadonna, C. Valsuani, S. Chiara, C. Carlomagno, C. Boni, L. Marcucci, L. Boni, F. Loupakis on behalf of the GONO Investigators

DISCLOSURES Amgen Merck Serono Roche Advisory Role, Honoraria, Research funding: Amgen Merck Serono Roche

Background Doublets plus bev are a standard of care in the first-line treatment of mCRC Hurwitz et al. NEJM ‘04, Saltz et al. JCO ‘08 FOLFOXIRI triplet demonstrated superior RR, PFS and OS compared to LV5FU2+CPT11 doublet in a previous phase III trial by the GONO group Falcone et al. JCO ‘07 FOLFOXIRI plus bev achieved promising results (median PFS 13.1 mos, RR 77%), with a safe toxicity profile in a phase II study (N=57) Masi et al. Lancet Oncol ‘11

Objective To confirm the superiority in the 1st- line treatment of unresectable mCRC of FOLFOXIRI triplet compared to FOLFIRI doublet also when bevacizumab is associated to chemotherapy

TRIBE Study Design R FOLFIRI+bev FOLFOXIRI+bev INDUCTION 5-FU/LV +Bev PD 508 mCRC pts 1st line unresectable stratified by center PS 0/1-2 adjuvant CT FOLFIRI+bev (up to 12 cycles) 5-FU/LV +Bev R FOLFOXIRI+bev (up to 12 cycles) 5-FU/LV +Bev INDUCTION MAINTENANCE

Experimental ARM : FOLFOXIRI + bev FOLFOXIRI+Bev schedule Experimental ARM : FOLFOXIRI + bev bev 5 mg/Kg irinotecan 165 mg/sqm oxaliplatin 85 mg/sqm L-LV 200 mg/sqm 5FU flat continuous infusion 3200 mg/sqm 48h 30 min 1 hour 2 hours 48 hours Repeated every 2 weeks No prophylatic G-CSF recommended

End-points / Statistics Primary end-point Progression free survival to detect a HR for PFS of 0.75 in favour of FOLFOXIRI + bev with a 2-sided type 1 error= 0.05; power= 80% 379 events required (approx. 450-500 patients to be rand.) Secondary end-points Response Rate Secondary R0-resection rate Overall survival Safety profile Biomarkers evaluation

Key Eligibility Criteria Histologically proven adenocarcinoma Unresectable (locally assessed) mCRC not pre-treated for mets Measurable disease according to RECIST 1.0 Age 18-75 ECOG PS ≤ 2 (ECOG PS = 0 if age = 71-75 years) Adjuvant oxa-containing chemotherapy allowed if more than 12 months elapsed between the end of adjuvant and first relapse Adequate bone marrow, liver and renal functions

Patients’ characteristics – ITT population Characteristic, % patients FOLFIRI + bev N = 256 FOLFOXIRI + bev N = 252 Sex (M / F) 61 / 39 60 / 40 Median Age (range) 60 (29 – 75) 61 (29 – 75) ECOG PS (0 / 1-2) 89 / 11 90 / 10 Synchronous Metastases (Y / N) 81 / 19 79 / 21 Prior Adjuvant CT (Y / N) 13 / 87 Primary Tumor Site (right / left / NR) 24 / 70 / 6 35 / 60 / 5 Number Metastatic Sites (1 / >1) 24 / 76 31 / 69 Liver Only Disease (Y / N) 18 / 82 23 / 77 Resected Primary (Y / N) 65 / 35 69 / 31 Kohne score (low / interm / high / NE) 41 / 44 / 11 / 4 43 / 44 / 7 / 6

Induction treatment duration and management FOLFIRI + bev N = 254 FOLFOXIRI + bev N = 250 Induction CT cycles, median (range) 12 (1-25) 11 (1-21) Delayed cycles 6% 16% Cycles with dose reduction 8% 21% 5-FU relative dose intensity 83% 73% Irinotecan relative dose intensity 84% 74% Oxaliplatin relative dose intensity NA 75%

Overall Safety – Safety population Patients, % FOLFIRI + bev N = 254 FOLFOXIRI + bev N = 250 Serious AEs 19.7% 20.4% Fatal AEs 3.5% 2.8% Treatment-related deaths 1.6% 2.4% Early deaths (within 60 days from random) 2.3% 3.2%

Toxicity Profile – Safety population G3/4 adverse events, % patients FOLFIRI + bev N=254 FOLFOXIRI + bev N=250 p Nausea 3 1.000 Vomiting 4 0.492 Diarrhea 11 19 0.012 Stomatitis 9 0.048 Neutropenia 20 50 <0.001 Febrile neutropenia 6 0.315 Neurotoxicity 5 Hypertension 2 0.157 Venous Thrombosis 7 0.593 Arterial Thrombosis 1 Bleeding

Primary endpoint: PFS (updated) – ITT population FOLFIRI + bev FOLFOXIRI + bev Median follow up: 32.3 mos FOLFIRI + bev: N = 256 / Progressed = 226 FOLFOXIRI + bev: N = 252 / Progressed = 213 FOLFIRI + bev, median PFS : 9.7 mos FOLFOXIRI + bev, median PFS : 12.1 mos Unstratified HR: 0.77 [0.64-0.93] p=0.006 Stratified HR: 0.75 [0.62-0.90] p=0.003 Progression-free survival probability F-up time (months) FOLFIRI/bev 256 203 94 46 26 14 7 3 FOLFOXIRI/bev 252 208 125 74 35 21 11 5 2 1

Subgroup analyses of PFS (updated) – clinical characteristics Factor N HR p 0.5 1 1.5 2 Experimental better Control Better

* Patients whose samples were centrally analyzed Molecular characteristics – centralized analyses Characteristic, % patients FOLFIRI + bev N = 201* FOLFOXIRI + bev N = 205* KRAS (wt / mut / not evaluable) 49 / 48 / 3 46 / 51 / 3 BRAF (wt / mut / not evaluable) 91 / 6 / 3 89 / 8 / 3 * Patients whose samples were centrally analyzed KRAS codon 12, 13 and 61 and BRAF codon 600 mutations were assessed by pyrosequencing

Subgroup analyses of PFS – molecular characteristics Factor N HR p 0.4 0.6 0.8 1 Experimental better Control Better

Masi et al. Lancet Oncol ‘10 Salvatore et al. ASCO Ann Meet ‘12 Previous evidences of FOLFOXIRI+Bev in BRAF mut Phase II prospective trial of FOLFOXIRI plus bev in BRAF mutant mCRC patients Median PFS: 9.2 months (95%CI 5.1-13.3) Masi et al. Lancet Oncol ‘10 Salvatore et al. ASCO Ann Meet ‘12

Secondary endpoint: Response rate (updated) - ITT population Best Response, % FOLFIRI + bev N = 256 FOLFOXIRI + bev N = 252 p Complete Response 3% 5% Partial Response 50% 60% Response Rate 53% 65% 0.006 Stable Disease 32% 25% Progressive Disease 11% 6% Not Assessed 4%

Secondary endpoint: Resection of Metastases FOLFIRI + bev Arm A N = 256 FOLFOXIRI + bev Arm B N = 252 p Secondary surgery with radical intent 21% 26% 0.210 R0 secondary surgery 12% 15% 0.327 Liver-only subgroup N = 46 N = 59 41% 39% 1.000 28% 32% 0.823

Overall Survival: estimated power for the analysis Based on the present number of events (deaths= 286), accrual duration (34 mos) and median follow-up (32 mos) Assuming an expected median OS for FOLFIRI+Bev of 24 mos With a 2-sided type I error = 0.05 the power of the analysis to demonstrate a significant reduction in the risk of death in the range of 20-25% is approximately 35-55%

Secondary endpoint: OS (preliminary) – ITT population FOLFIRI + bev FOLFOXIRI + bev Median follow up: 32.3 mos FOLFIRI + bev: N = 256 / Died = 155 FOLFOXIRI + bev: N = 252 / Died = 131 FOLFIRI + bev, median OS : 25.8 mos FOLFOXIRI + bev, median OS : 31.0 mos Unstratified HR: 0.83 [0.66-1.05] p=0.125 Stratified HR: 0.79 [0.63-1.00] p=0.054 Overall survival probability F-up time (months) FOLFIRI/bev 256 233 216 172 109 69 36 15 5 FOLFOXIRI/bev 252 234 205 175 119 70 35 4

Summary FOLFOXIRI plus bev compared to FOLFIRI plus bev: significantly reduced the risk of progression (HR=0.77, p=0.006) (with a significant interaction with the prior exposure to adjuvant CT) significantly increased response rate (65% vs 53%, p=0.006), but not R0 resection rate (15% vs 12%, p=0.327) in this unselected population for conversion (see OLIVIA study abst. #3619) significantly increased the incidence of grade 3-4 neurotoxicity, diarrhea, stomatitis and neutropenia, but not of febrile neutropenia, serious AEs and treatment related deaths may reduce the risk of death, but OS data are still immature

Conclusions The trial achieved its primary objective of confirming the superiority of FOLFOXIRI vs FOLFIRI in terms of PFS, also in combination with bev FOLFOXIRI moderately increases specific side effects, but the overall safety profile remains acceptable Based on these results FOLFOXIRI plus bev represents a new standard option in the treatment of mCRC pts selected according to the eligibility criteria of this study (particular interest in BRAF mut) Finally these results support the hypothesis that an upfront intensive approach for few months associated with a greater tumor shirinkage (followed by maintenance) may have a favourable impact in later PFS, and perhaps OS, also in a palliative setting independently from an increase in resections

REGGIO EMILIA: Boni ROMA GEMELLI: Barone ROMA UMBERTO I: Cortesi Acknowledgements PATIENTS Roche INVESTIGATORS and THEIR 33 CENTERS all over Italy ANCONA: Cascinu AOSTA: Numico AREZZO: Bracarda AVIANO: Frustaci BRESCIA: Zaniboni CALTANISSETTA: Vitello CREMONA: Passalacqua CUNEO: Merlano FIRENZE: Ribecco GENOVA IST: Chiara GENOVA GALLIERA: De Censi LECCE: Lorusso LEGNAGO: Bonetti LIVORNO: Cappuzzo LUCCA: Baldini MILANO NIGUARDA: Siena MILANO HSR: Villa MIRANO: Vinante MONZA: Bidoli NAPOLI: Tortora PARMA: Ardizzoni PADOVA: Zagonel PISA: Falcone, Ricci PIOMBINO: Dargenio PONTEDERA: Allegrini PRATO: Di Leo REGGIO EMILIA: Boni ROMA GEMELLI: Barone ROMA UMBERTO I: Cortesi ROMA Campus Biomedico: Tonini SONDRIO: Bertolini TORINO: Ciuffreda VERSILIA: Amoroso