1. Lee S. Rosen, MD Premiere Oncology, California Affiliated with the John Wayne Cancer Institute and St John’s Health Center Santa Monica, California Multitargeted Tyrosine Kinase Inhibitors: When Are More Targets Necessary? This program is supported by an educational donation provided by

2. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies About These Slides Disclaimer The materials published on the Clinical Care Options Web site reflect the views of the authors, not those of Clinical Care Options, LLC, the CME providers, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.  Users are encouraged to include these slides in their own presentations, but we ask that content and attribution not be changed. Users are asked to honor this intent.  These slides may not be published or posted online or used for any other commercial purpose without written permission from Clinical Care Options.  We are grateful to Lee S. Rosen, MD, of Premiere Oncology, California, who aided in the content creation of these slides.

3. Role of VEGF in Cancer

4. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies bFGF, basic fibroblast growth factors; EGF, epidermal growth factor; IGF, insulin-like growth factor; IL, interleukin; PDGF, platelet-derived growth factor; VEGFR, VEGF receptor. 1. Dvorak HF. J Clin Oncol. 2002;20:4368-4380; 2. Ebos JM, et al. Mol Cancer Res. 2002;1:89-95; 3. Ferrara N, et al. Nat Med. 2003;9:669-676. Genes implicated in tumorigenesis (p53, p73, src, ras, vHL, bcr-abl) Growth factors, hormones (EGF, bFGF, PDGF, IGF-1, IL-1 , IL-6, estrogen) Environmental factors (hypoxia, pH) Increased VEGF levels VEGF: A Key Mediator of Angiogenesis

5. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies P P P P ANGIOGENESIS SurvivalProliferation Migration PLCFAKPI3-KRas IP3PKCAKTPaxillinMAPK ANGIOGENESIS SurvivalProliferation Migration PLCFAKPI3-KRas IP3PKCAKTPaxillinMAPK VEGF VEGFR binding and activation Endothelial cell activation VEGF: A Key Mediator of Angiogenesis

6. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies The VEGF Family and Its Receptors Neufeld G, et al. FASEB J. 1999;13:9-22. VEGFR-3 (Flt-4) VEGFR-2 (Flk-1/KDR) VEGFR-1 (Flt-1) AngiogenesisLymphangiogenesis Angiogenesis Lymphangiogenesis PIGFVEGF-AVEGF-BVEGF-CVEGF-D

7. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Summary of Anti-VEGF Proposed MOAs Based on Preclinical Models  May regress existing microvasculature 1,2  May normalize surviving mature vasculature 3-5  May inhibit vessel regrowth and neovascularization 2,3,6

8. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Targeting VEGF: The Bevacizumab Story P P P P VEGF Bevacizumab

9. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies VEGF Bevacizumab P P P P VEGF Activation BLOCKED Targeting VEGF: The Bevacizumab Story

10. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies TumorStudyComparisonBev DoseDFSOS CRC 1st lineAVF2107 [1] IFL vs IFL + Bev5 mg/kg Q2W  CRC 1st linePoor KPS [2] 5-FU/LV vs 5-FU/LV + Bev 5 or 10 mg/kg Q2W  CRC 2nd lineE3200 [3] FOLFOX vs FOLFOX + Bev 10 mg/kg Q2W  Breast 2nd lineMiller et al [4]z Capecitabine vs Cape + Bev 15 mg/kg Q3W== Breast 1st lineE2100 [5] Paclitaxel vs Pac + Bev10 mg/kg D1, 15  ? NSCLCE4599 [6] Carbo-Pac vs Carbo-Pac + Bev 7.5 or 15 mg/kg Q3W  PancreasC80303 [7] Gem vs Gem + Bev10 mg/kg D1, 15== OvarianNCT00262847 [8] Carbo-Pac vs Carbo-Pac + Bev NA 1. Hurwitz H, et al. N Engl J Med. 2004;350:2335-2342. 2. Kabbinavar F, et al. J Clin Oncol. 2003;21:60- 65. 3. Giantonio B, et al. ASCO 2005. Abstract 2. 4. Miller KD, et al. J Clin Oncol. 2005;23:792-799. 5. Miller KD. SABCS 2005. Abstract 3. 6. Sandler AB, et al. ASCO 2005. Abstract LBA4. 7. Kindler HL, et al. ASCO GI 2007. Abstract 108. 8. Available at: http://www.clinicaltrials.gov. Bevacizumab Phase III Trials

11. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies ResponsePlacebo + IFL (n = 411) Bevacizumab + IFL (n = 402) P ValueHR Median OS, mo15.620.3<.001*0.66 PFS, mo6.210.6<.001*0.54 ORR, %34.844.8<.01 † -- DOR, mo7.110.4.001*0.62 *By stratified log-rank test. † By chi-square test. Hurwitz H, et al. N Engl J Med. 2004;350:2335-2342. Bevacizumab in First-Line CRC: Which Endpoints Matter?

12. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Bevacizumab in CRC: What Don’t We Know?  First-line metastatic disease –IFL/bevacizumab –FOLFOX/bFOL/CapOX plus bevacizumab (?) –5FU/LV/BEV in “poor KPS” patients  Second-line metastatic disease –FOLFOX/bevacizumab (a higher dose?)  Subsequent-line disease? –5FU/LV/bevacizumab  Combinations with cetuximab –Irinotecan/cetuximab –Irinotecan/cetuximab/bevacizumab

13. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies VEGF Trap P P

14. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies P P VEGF Trap

15. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies VEGF Trap

16. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies VEGF Trap F c portion P P P P VEGF

17. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies VEGF Trap F c portion P P P P VEGF

18. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies P P P P VEGF Trap VEGF Activation BLOCKED VEGF Trap VEGF

19. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Tyrosine Kinase Inhibition and VEGF TKI (Tyrosine Kinase Inhibitor) P P P P VEGF

20. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies P P P P Tyrosine Kinase Inhibition and VEGF TKI Downstream phosphorylation BLOCKED VEGF

21. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Anti-VEGF Class Toxicities  Hypertension  Fatigue  Increased clotting events  Bleeding (epistaxis, pulmonary hemorrhage, tumor associated)  Headache  Neurologic events  Increased LFTs  Pain at tumor sites  Proteinuria  Hypothyroidism?

22. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies True or Not? Avoid bevacizumab in patients with  Cardiac disease  Hypertension  CNS lesions  Coagulopathy (on anticoagulation?)  Peritoneal metastases  Recent surgery  “Central” or “large” chest lesions

23. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Bevacizumab: GI Perforation in Metastatic CRC 1. Avastin [package insert]. South San Francisco, Calif: Genentech; October 2006. 2. Sugrue M, et al. ASCO GI 2006. Abstract 345.  Incidence in patients with colorectal cancer: 2.4% (prescribing information) [1]  Patients in BRiTE community-based bevacizumab mCRC treatment registry (N = 1953): [2] 1.7%  Patients < 65 years: 2.3%  Patients ≥ 65 years: 1.1%  Phase II/III studies: [2]  AVF2107 (IFL + bevacizumab): 2.0%  AVF2192 (5-fluorouracil + bevacizumab): 2.0%

24. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Bevacizumab: Remaining Questions  Which tumors?  With which cytotoxic chemotherapy?  What dose?  How long to continue? Past progression?  Include/exclude which subgroups of patients?  Predictive factors?  Toxicity management?  With other VEGF inhibitors? Other targeted agents?  Adjuvant/neoadjuvant use?

25. Multitargeted Agents (“VEGF-Plus”): Increasing Activity? Increasing Toxicity?

26. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Combining Targeted Therapies  Bevacizumab + erlotinib: RCC, NSCLC [1-3] –Successfully combined in number of phase II trials  Bevacizumab + erlotinib + imatinib: RCC [4]  Bevacizumab + trastuzumab: intriguing activity in phase II [5]  Combinations with chemotherapy: results not always clear –PACCE (FOLFOX or FOLFIRI + panitumumab/ bevacizumab) [6] 1. Hainsworth JD, et al. J Clin Oncol. 2007;25:1747-1752. 2. Herbst RS, et al. J Clin Oncol. 2005;23:2544-2555. 3. Hainsworth JD, et al. J Clin Oncol. 2005;23:7889-7896. 4. Thompson DS, et al. ASCO 2006. Abstract 4594. 5. Pegram M, et al. SABCS 2006. Abstract 3039. 6. Amgen press release. March 22, 2007. Available at: http://www.amgen.com.

27. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies VEGFR-1 VEGFR-2 FLT4 Fms Split Kinase Domain RTKs Sunitinib (SU11248): A Multitargeted Receptor Tyrosine Kinase Inhibitor  IC50 (  M) [1] –VEGFR2:4 –PDGFRβ: 39 –KIT: 1 –FLT3 (WT): 8 –EGFR: >10,000 Chow LQ, et al. J Clin Oncol. 2007;25:884-896. PDGFR-  PDGFR-  CSF1R KIT FLT3  Effective against VEGFR, PDGFR, KIT and FLT3 at  M concentration  Targets receptors involved in both tumor cell proliferation and angiogenesis  No significant activity against other RTKs (ie, EGFR); tested against > 40 other RTKs and protein kinases  Activity in GIST, renal, breast, etc

28. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Sorafenib (BAY 43-9006): A Signal Transduction Inhibitor  Inhibits both Raf kinase and VEGFR  Inhibits tumor cell proliferation and angiogenesis  Activity in various cancers  Approved by FDA to treat renal cell carcinoma Molecule IC 50,  M ± SD Raf-16 ± 3 VEGFR-290 ± 15 VEGFR-320 ± 6 PDGFR-ß57 ± 20 C-kit68 ± 21 Flt358 ± 20 EGFRInactive at 10,000 Wilhelm SM, et al. Cancer Res. 2004;64:7099-7109.

29. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Motesanib Diphosphate (AMG 706): Multitargeted RTK Inhibitor  47 other kinases are not inhibited by AMG 706 at < 1  M Receptor Kinase IC 50,  M VEGFR-12 VEGFR-23 VEGFR-36 Kit8 PDGFR84 Ret59 Rosen L, et al. ASCO 2005. Abstract 3013.

30. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Tumor Angiogenesis: Bevacizumab and Multitargeted Agents Tumor cell Pericyte Angiogenic growth factors O2O2 Endothelial cell

31. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Ras Raf MEK ERK p38MAPK PI3K Akt Caspase-9eNOS CELL ACTIVATION / SURVIVAL MIGRATION PROLIFERATION MIGRATION ANGIOGENESIS VASCULOGENESIS LYMPHANGIOGENESIS VEGF-B VEGF-A VEGF-C VEGF-D Endothelial Cell VEGF-R1 (Flt-1) VEGF-R2 (KDR) VEGF-R3 (Flt-4)

32. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Ras Raf MEK ERK p38MAPK PI3K Akt Caspase-9eNOS CELL ACTIVATION / SURVIVAL MIGRATION PROLIFERATION MIGRATION ANGIOGENESIS VASCULOGENESIS LYMPHANGIOGENESIS VEGF-B VEGF-C VEGF-D VEGF-R2 (KDR) VEGF-A Bevacizumab VEGF-R3 (Flt-4) VEGF-R1 (Flt-1) MIGRATION PROLIFERATION MIGRATION ANGIOGENESIS VASCULOGENESIS

33. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies LYMPHANGIOGENESIS VEGF-R2 (KDR) VEGF-B VEGF-A VEGF-C VEGF-D Sorafenib Bevacizumab PTK/ZK Sunitinib Motesanib MIGRATION PROLIFERATION MIGRATION ANGIOGENESIS VASCULOGENESIS MIGRATION PROLIFERATION MIGRATION ANGIOGENESIS VASCULOGENESIS CELL ACTIVATION SURVIVAL Raf MEK ERKp38MAPK CELL ACTIVATION SURVIVAL Raf MEK ERKp38MAPK VEGF-R3 (Flt-4) VEGF-R1 (Flt-1) Vandetanib Ras PI3K Akt Caspase-9eNOS LYMPHANGIOGENESIS

34. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Tumor Angiogenesis: Bevacizumab and Multitargeted Agents Tumor cell Pericyte PDGF O2O2 Endothelial cell

35. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Pericyte PDGF-B PDGF-Rβ Ras Raf MEK ERKp38MAPK PI3K Akt Caspase-9eNOS CELL ACTIVATION VESSEL MATURATION

36. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies PDGF-B PDGF-Rβ Pericyte PTK/ZK Sunitinib Sorafenib Motesanib Vandetanib CELL ACTIVATION VESSEL MATURATION Ras Raf MEK ERKp38MAPK PI3K Akt Caspase-9eNOS

37. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Tumor Angiogenesis: Bevacizumab and Multitargeted Agents Tumor cell Pericyte Paracrine factors O2O2 SOURCE: Angiogenesis Foundation Endothelial cell

38. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Tumor Cell KITMultiple Growth Factors RETFlt-3 CELL PROLIFERATION SURVIVAL PI3K Akt Ras Raf MEK ERKp38MAPK Src Rac1 JNK

39. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies KITMultiple Growth Factors RETFlt-3 Tumor Cell Src Rac1 JNK Ras CELL PROLIFERATION SURVIVAL PI3K Akt Raf MEK ERKp38MAPK Sorafenib PTK/ZK Sunitinib Vandetanib Motesanib Src Rac1 JNK Ras CELL PROLIFERATION SURVIVAL PI3K Akt Raf MEK ERKp38MAPK

40. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Tumor Angiogenesis: Cells and Pathways Tumor cell Pericyte Angiogenic growth factors O2O2 Endothelial cell Paracrine factors PDGF

41. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Multitargeted Agents: Trade-off Between Toxicity and Efficacy?  Increasing inhibition of each kinase: unknown effect Toxicity Efficacy High toxicity, low efficacy Low toxicity, high efficacy

42. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Multitargeted TKI Toxicities  Hypertension  Fatigue  Increased clotting events  Bleeding (epistaxis, pulmonary hemorrhage, tumor associated)  Headache  Neurologic events  Increased LFTs  Pain at tumor sites  Proteinuria  Hypothyroidism? And…  Skin rash  Myelosuppression  Nausea/vomiting  Diarrhea  Others

43. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Reduction of Tyrosine Kinase Activity by Multitargeted TKIs Kinase Inhibition Sunitinib (IC 50,  M) [1,5] Motesanib (IC 50,  M) [2] Sorafenib (IC 50,  M) [3] PTK/ZK (IC 50,  M) [4] Vandetanib (IC 50,  M) [5] Pazopanib (IC 50,  M) [5,6] VEGFR-122-77160010 VEGFR-24#4# 390374030 VEGFR-317620*62011047 PDGFR-84-- PDGFR-β39 # -57 * 580110084 Raf-9163600 [7] -- c-Kit1#1# 868730> 20,00074 FLT38-58-- EGFR> 10,000> 3000> 10,000 500- RET224 [8] 5947 [9] -130 [10] - AssayIn vitro biochemical kinase assay, except where indicated as # (cellular assay) *Murine-based protein used. 1. Mendel DB, et al. Clin Cancer Res. 2003;9:327-337. 2 Herbst et al. Presented at 16th EORTC-NCI-AACR Symposium on Molecular Targets and Cancer Therapeutics. Sept 28- Oct 1, 2004. 3 Wilhelm SM, et al. Cancer Res. 2004:64;7099-7109. 4 Wood JM, et al. Cancer Res. 2000;60:2178- 2189. 5 Chow L and Eckhardt G, J Clin Oncol 2007;25:884-896. 6 Podar K, et al. Proc Natl Acad Sci USA 2006;103:19478-19483. 7 Hess-Stumpp H, et al. ChemBioChem 2005;6: 550–557. 8 Kim D, et al. J Clin Endocrinol Metab. 2006;91:4070-4076. 9 Carlomagno F. et al. J Natl Cancer Inst 2006;98:326 – 334. 10 Carlomagno F. et al. Cancer Res 2002;62:7284-7290.

44. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Multitargeted Kinase Inhibitors  Are these just “combination studies” using 1 pill?  Can/should they be combined with other agents still? Cytotoxics? Other biologics?  Are they not “broad” enough?  Long-term tolerability?  Can another in the class be used when one fails?  Why are we not curing all cancers with them?

45. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Motesanib Diphosphate Phase I: Tumor Assessment by CT (Best Response) Rosen L, et al. J Clin Oncol. 2007. In press.  Results –PD: 23 (32%) –SD: 40 (56%) –PR: 3 (4%) sarcoma, RCC, thyroid  Range of time on study: 6 to > 566 days

46. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Sunitinib vs IFN in mRCC: PFS (Independent Central Review) Motzer RJ, et al. N Engl J Med. 2007;356:115-124.  Sunitinib –Median 11 months (95% CI: 10-12)  IFN-  –Median 5 months (95% CI: 4-6)  Hazard ratio: 0.415 (95% CI: 0.320-0.539) –P <.001

47. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies RCC: Can We Compare? How to Interpret?  No head-to-head comparison –Clinician still has to choose –Will we ever know which is “better”? Drugs Compared NORR, %Median PFS, mos Median OS, mos Sunitinib vs interferon alfa [1] 750 31 vs 6 P <.001 11 vs 5 HR: 0.42; P <.001 NR (median duration treatment: 6 vs 4 mo) 13% vs 17% died Sorafenib vs placebo [2] 90310 vs 2 5.5 vs 2.8 HR: 0.44; P <.001 19.3 vs 15.9 HR: 0.77; P =.02 1. Motzer RJ, et al. N Engl J Med. 2007;356:115-124. 2. Escudier B, et al. N Engl J Med. 2007;356:125-134.

48. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies GIST: When One Targeted Agent Fails... Second- Line Agent Phase III Trial NORR, % PFSMedian OS Motesanib diphosphate (AMG 706) Study 20040110 [1] 138 33* at Wk 8 27% † at 26 wks 59.3 wks † SunitinibCasali et al [2] 361--28.4 wks ‡ ~ 35% at ~ 100 wks § *Choi criteria. † Kaplan-Meier estimate. ‡ P <.0001 vs placebo. § P =.107 vs placebo group (88% of whom crossed over). Ongoing Clinical Trial: AMN107 vs Current Treatment Options in Patients With GIST Who Have Failed Both Imatinib and Sunitinib (ClinicalTrials.gov identifier: NCT00471328) 1. Benjamin R, et al. CTOS 2006. 2. Casali PG, et al. ASCO 2006. Abstract 9513.

49. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies Mechanisms of Resistance  How/why do tumors become resistant?  Can one come back to the same drug?  Can one switch to other drugs in the same class?  Is there a role for symptom palliation even in the setting of disease progression?  Is it true that tumors grow faster once they have stopped “antiangiogenic” therapy?  Lesson: study failures/resistance as closely as successes/responses

50. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies We Are Clearly Now Beyond Phase I  Is phase II a better place to test biomarkers?  Are any of the known biomarkers or imaging techniques established enough to make reliable development decisions?  How should we select combinations? –With cytotoxics? Other biologics? Others in the same class?  When to take something to phase III?  Will a “me-too” drug be approved unless it is compared directly with its competitor?  Are there any more “orphan diseases”?

51. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies ASCO 2007  Sunitinib  Sorafenib  Vandetanib (ZD6474)  Pazopanib (GW786034)  Vatalanib (PTK787)  Motesanib diphosphate (AMG 706)  Others

52. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies 10 Years of Trials: Where Are We?  Some wonderful successes!  Data are still limited, although clinicians are racing ahead of the science  Indeed class-related toxicities (some beneficial, some used as biomarkers?)  Toxicity is variable across seemingly similar agents, potentially influencing schedule and use in combination regimens  Efficacy and toxicity will affect use in various disease settings (emerging information about long-term effects)  Mechanisms of resistance just as important as success

53. clinicaloptions.com/oncology Navigating Multiple Pathways: Targeted Therapies 10 Years of Trials: Where Are We? (cont’d)  Imperative to pool data across studies, across disease types, across agents  Consensus conference to agree on trial design/endpoints, assessment of biomarkers, areas for further development

54. Download Slidesets including PowerPoint Animations illustrating key concepts in Targeting EGFR, Multikinase Inhibition, and the Tumor Microenvironment Earn CME Credit: Read Online Modules addressing these important topic areas in detail clinicaloptions.com/oncology Go Online for More Content From “Navigating Multiple Pathways”