Safety and efficacy of oxaliplatin – fluoropyrimidine regimens with or without bevacizumab as first-line treatment of metastatic colorectal cancer (mCRC): Final analysis of the TREE study HS Hochster H. S. Hochster, L. L. Hart, R. K. Ramanathan, J. D. Hainsworth, S. Griffing, R. D. Mass, Y. Nagarwala, G. Jirau-Lucca, A. Shpilsky, B. H. Childs

Background Oxaliplatin – fluoropyrimidine regimens: standard combination chemotherapy for stage III and IV CRC TREE-1 trial: comparison of three different oxaliplatin – fluoropyrimidine regimens (mFOLFOX, bFOL, CapeOx) for toxicity Bevacizumab: promising results in mCRC when added to first-line chemotherapy (bIFL or 5-FU – LV) 1,2 TREE-2 trial: TREE-1 trial modified to include bevacizumab 1. Hurwitz H, et al. N Engl J Med 2004; 2. Kabbinavar F, et al. J Clin Oncol 2003

Study design mFOLFOX CapeOx R bFOL (n=50) Nov 2002 – Oct 2003 mFOLFOX + bevacizumab bFOL + bevacizumab CapeOx (reduced dose) + bevacizumab (n=75) (n=74) Nov 2003 – Apr 2004 R TREE-1 TREE-2 n=150 n=223

mFOLFOX6: 14-day cycle bFOL: 28-day cycle LV (350 mg IV, 2 h) OX (85 mg/m 2 IV, 2 h) 5-FU (400 mg/m 2, IV bolus) 5-FU (2400 mg/m 2 IV, 46 h) Day 1 CapeOx: 21-day cycle OX (130 mg/m 2 IV, 2 h) Day 1Days 1 – 15 CAPE (1000 mg/m 2 orally bid a ) a 28 doses in total Day 1 Day 8 OX (85 mg/m 2 IV, 2 h) 5-FU (500 mg/m 2, IV bolus) LV (20 mg/m 2, IV bolus) Day 15 Day 2 OX (85 mg/m 2 IV, 2 h) Treatment regimens: TREE-1

mFOLFOX6 + bev: 14-day cycle bFOL + bev: 28-day cycle LV (350 mg IV, 2 h) OX (85 mg/m 2 IV, 2 h) 5-FU (400 mg/m 2, IV bolus) 5-FU (2400 mg/m 2 IV, 46 h) Day 1 CapeOx + bev: 21-day cycle OX (130 mg/m 2 IV, 2 h) Day 1Days 1 – 15 CAPE (850 mg/m 2 orally bid a ) a 28 doses in total; 650 mg/m 2 bid for patients with creatinine clearance 30–50 mL/min Day 1 Day 8 OX (85 mg/m 2 IV, 2 h) 5-FU (500 mg/m 2, IV bolus) LV (20 mg/m 2, IV bolus) Day 15 Day 2 OX (85 mg/m 2 IV, 2 h) Treatment regimens: TREE-2 BEV (5 mg/kg IV, 30–90 min) BEV (7.5 mg/kg IV, 30–90 min)

Inclusion criteria Histologically documented adenocarcinoma of the colon or rectum Inoperable metastatic disease No prior chemotherapy for metastatic/recurrent disease Age ≥18 years; ECOG performance status 0 – 1 At least 1 unidimensional measurable lesion

Exclusion criteria Prior treatment with oxaliplatin or bevacizumab Myocardial infarction within 6 months, current clinical evidence of congestive heart failure, or non-stable coronary artery disease Blood pressure >160/110 mmHg on medication; symptomatic peripheral vascular disease a Peripheral neuropathy a TREE-2 cohort only

Objectives Primary:  Incidence of grade 3/4 toxicity during initial 12 weeks of therapy Secondary:  Response rate (RECIST)  TTP (censored for second-line treatment)  TTF (treatment discontinuation, progression, or death)  Survival

Demographic and baseline characteristics a TREE-1TREE-2 mFOLFOX (n=49) bFOL (n=50) CapeOx (n=48) mFOLFOX + bev (n=71) bFOL + bev (n=70) CapeOx + bev (n=72) Median age (years) [range] 62 [35 – 79] 62 [31 – 84] 62 [32 – 84] 64 [31 – 83] 57 [30 – 85] 62 [32 – 82] Male (%) ECOG PS 0 (%) Prior adjuvant chemotherapy (%) a With the exception of tumor response, all data are presented for the as-treated population, defined as all patients who received at least one dose of treatment

Grade 3 /4 adverse events during first 12 weeks Patients (%) TREE-1TREE-2 (primary endpoint) mFOLFOX (n=49) bFOL (n=50) CapeOx (n=48) mFOLFOX + bev (n=71) bFOL + bev (n=70) CapeOX + bev (n=72) Related event a [95% CI] 59 [44 – 73] 36 [ 23 – 51] 67 [52 – 80] 59 [47 – 71] 51 [39 – 64] 56 [43 – 67] All events [95% CI] 76 [61 – 87] 44 [30 – 59] 73 [58 – 85] 65 [53 – 76] 60 [48 – 72] 58 [46 – 70] a Determined by the investigator to be related (possibly or probably) to study drug

Grade 3 /4 adverse events occurring in ≥5% of patients Patients (%) TREE-1TREE-2 mFOLFOX (n=49) bFOL (n=50) CapeOx (n=48) mFOLFOX + bev (n=71) bFOL + bev (n=70) CapeOX + bev (n=72) Neutropenia Dehydration a Diarrhea a Hypertension TE, arterial TE, other Nausea Vomiting Neurotoxicity Hand – foot Any grade 3/ a The high incidence of dehydration and diarrhea in the CapeOx arm in TREE-1 was effectively reduced by capecitabine dose reduction in TREE-2. TE, Thromboembolic events

Adverse events of special interest Adverse event (all grades), n (%) of patients TREE-1TREE-2 mFOLFOX (n=49) bFOL (n=50) CapeOx (n=48) mFOLFOX + bev (n=71) bFOL + bev (n=70) CapeOX + bev (n=72) Sepsis0 (0) 2 (4.2)3 (4.2)3 (4.3)1 (1.4) Bowel perforation 0 (0) 03 (4.2)2 (2.9)2 (2.8) Impaired wound healing 0 (0) 1 (2.1)4 (5.6)1 (1.4)4 (5.6) Treatment- related death 0 (0)1 (2.0)3 (6.3)0 (0)3 (4.3)3 (4.2)

Best confirmed tumor response (per-protocol population) a Tumor response (RECIST) (% patients) TREE-1TREE-2 mFOLFOX (n=46) bFOL (n=45) CapeOx (n=37) mFOLFOX + bev (n=70) bFOL + bev (n=63) CapeOX + bev (n=69) CR PR SD PD NE ORR (CR+PR) [95% CI] 43 [29 – 59] 22 [11 – 37] 35 [20 –53 ] 53 [41 – 65] 41 [29 – 54] 48 [36 – 60] a All patients who received at least 1 treatment with oxaliplatin  fluoropyrimidine ± bevacizumab and who have sufficient data to allow assessment of response

Time to treatment failure Probability 0510 Time to treatment failure (months) Probability 0510 Time to treatment failure (months) TREE-1TREE-2 mFOLFOX bFOL CapeOx mFOLFOX + bevacizumab bFOL + bevacizumab CapeOx + bevacizumab CapeOx (n=48) bFOL (n=50) mFOLFOX (n=49) Median (months) 3.0–5.83.5–6.15.4–8.395% CI mFOLFOX + bev (n=71) 4.9– bFOL + bev (n=70) 4.0– CapeOx + bev (n=72) 4.7– Median (months) 95% CI

Time to tumor progression a a With censoring for second-line treatment CapeOx + bev (n=72) bFOL + bev (n=70) mFOLFOX + bev (n=71) 8.6– –9.97.9–11.795% CI Median (months) CapeOx (n=48) bFOL (n=50) mFOLFOX (n=49) 5.1– – –9.8 95% CI Median (months) Time to tumor progression (months) Probability Time to tumor progression (months) Probability TREE-1TREE-2 mFOLFOX bFOL CapeOx mFOLFOX + bevacizumab bFOL + bevacizumab CapeOx + bevacizumab

Survival: TREE-1 CapeOx mFOLFOX bFOL Survival time (months) Probability CapeOx (n=48) bFOL (n=50) mFOLFOX (n=49) 12.5– – – % CI Median (months)

Survival: TREE-2 CapeOx + bevacizumab mFOLFOX + bevacizumab bFOL + bevacizumab Survival time (months) Probability CapeOx + bev (n=72) bFOL + bev (n=70) mFOLFOX + bev (n=71) 21.8–NE18.8– – NE 95% CI Median (months) NE, not evaluable

Survival: chemotherapy regimens combined TREE-1 (n=147) TREE-2 (n=213) Patients who have died, n (%)101 (69)111 (52) Patients alive at last follow-up, n (%)46 (31)102 (48) Median survival time, months [95% CI] 18.2 [14.5 –21.6] 24.4 [21.4 –26.8] Survival probability, % [95% CI] 12 months 18 months 24 months 67.3 [58.9 – 74.3] 50.1 [41.5 – 58.1] 35.8 [27.6 – 44.1] 79.1 [73.0 –84.0] 64.7 [57.8–70.8] 50.7 [43.6–57.4]

Survival: oxaliplatin-based regimens combined a 21.4– –21.695% CI Median survival (months) TREE-2 (n=213) TREE-1 (n=147) Survival time (months) Probability TREE-1 TREE-2 a Sequential cohorts without (TREE-1) and with bevacizumab (TREE-2)

Efficacy summary TREE-1TREE-2 ORR a (% patients)22 – 4341 – 53 TTP b (months)6.1 – – 10.3 TTF (months)4.4 – – 5.8 Median survival time (months) c a Per-protocol population. b Censored for second-line therapy. c All three treatment arms combined

Conclusions (1) Oxaliplatin, in combination with bolus, infusional, or oral fluoropyrimidine regimens, is active and well tolerated in previously untreated mCRC No major differences in activity were observed between the three fluoropyrimidine regimen, but bFOL may be the least efficacious (response and TTP in both cohorts) With dose reduction a of capecitabine, CapeOx with bevacizumab was tolerated much better (compared with CapeOX in TREE-1)  equivalent activity to FOLFOX with bevacizumab a From 1000 mg/m 2 (TREE-1) to 850 mg/m 2 orally bid (TREE-2),

Conclusions (2) Bevacizumab, when added to oxaliplatin –f luoropyrimidine regimens results in increased efficacy with the expected toxicity profile  Addition of bevacizumab did not change TTF but improved TTP Overall survival was improved with the addition of bevacizumab (sequential historical cohorts)  Median survival time was: 18.2 months in TREE-1 a (95% CI:14.5–21.6 months) 24.4 months in TREE-2 a (95% CI: 21.4–26.8 months) a All three treatment arms combined

Acknowledgment Investigators  Lowell Hart, Florida Cancer Specialists  R. Ramanathan, Univ Pittsburgh  John Hainsworth, Sarah Cannon Cancer Center  Louis Fehrenbacher, Kaiser Permanente  Yusif Abubakr, Florida Oncology  Lee Schwartzberg, West Cancer Clinic  Peter Eisenberg, California Cancer Care  James Atkins, Southeastern Medical Oncology  Maunuel Modiano, Arizona Clinical Research Center  Marshall Levine, Greater Baltimore Medical Center  Joaquina Veranda, Kansas City VA Hospital  Gladys Rodriguez, South Texas Oncology  Michael Wertheim, Treasure Coast  George Geils, Charleston Hematology Oncology  Margaret Deutsch, Raleigh Hematology Oncology  Renato LaRocca, Kentuckiana Cancer Institute  David Mintzer, Pennsylvania Hematology Oncology  Other investigators sanofi aventis  Gilbert Jirau-Lucca, MS  Arkady Shpilsky, PhD  Yasir Nagarwala  Lauri Wells, MD  Barry Childs, MD Genentech  Robert Mass, MD  Eric Hedrick, MD  David Emanuel, MD OTHERS  Nursing personnel  Data Personnel  Research Staff  PATIENTS