1. October 29, 2009 7:00 PM - 8:30 PM Arlington, Virginia Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum This program is supported by an educational donation from

2. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum About These Slides  Our thanks to the presenters who gave permission to include their original data  Users are encouraged to use these slides in their own noncommercial 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 Users are asked to honor this intent  These slides may not be published or posted online without permission from Clinical Care Options Disclaimer The materials published on the Clinical Care Options Web site reflect the views of the authors of the CCO material, 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.

3. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Bone Metastases: Scope of the Problem  Approximately 400,000 new patients per yr in the United States develop bone metastases

4. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Osteotropic Tumors and Bone Mets: Incidence and Median Survival 5-Yr World Prevalence, Thousands [1] Incidence in Advanced Cancers, % [2] Median Survival, Mos [2-5] Breast440665-7519-25 Prostate236965-7512-53 Lung136930-406-7 Bladder1110406-9 Melanoma64314-45< 6 Renal58620-2512 Thyroid5316048 1. Ferlay J, et al. IARC Globocan 2002. 2. Coleman RE. Cancer Treat Rev. 2001;27:165-176. 3. Coleman RE. Cancer. 1997;80:1588-1594. 4. Zekri J, et al. Int J Oncol. 2001;19:379-382. 5. Chiappori A, et al. Oncology. 2005;68:382-390.

5. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Pathogenesis of Osteolytic Bone Metastases  Tumor-derived osteoclast activating factors –Parathyroid hormone- related protein –Interleukin-6, -8, -11 –Tumor necrosis factor –Macrophage colony- stimulating factor  Bone-derived tumor growth factors –Transforming growth factor  –Insulin-like growth factors –Fibroblast growth factors –Platelet-derived growth factor –Bone morphogenic proteins Bone Tumor Cells in Bone Osteoclast (+) Derived from Roodman GD. N Engl J Med. 2004;350:1655-1664.

6. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Multiple myeloma* [2] 21 mos 37 34 5 3 Prostate [3] 24 mos 25 4 8 33 Skeletal Complications in Large, Randomized Trials: Placebo Arms Pathologic fracture Radiation therapy Surgical intervention Spinal cord compression Breast [1] 24 mos Cancer Type Patients With SRE (%) *21-mo data except for surgical intervention and spinal cord compression, for which only 9-month data are available. 52 11 3 43 0 10 20 30 40 50 60 NSCLC + other solid tumors [4] 21 mos 22 34 5 4 1. Lipton A, et al. Cancer. 2000;88:1082-1090. 2. Berenson JR, et al. J Clin Oncol. 1998;16:593-602. 3. Saad F, et al. AUA 2003. Abstract 1472. 4. Rosen LS, et al. Cancer. 2004;100:2613-2621.

7. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Bone Complications and Quality of Life 1. Groot MT, et al. Eur Urol. 2003;43:226-232. 2. Weinfurt KP, et al. ESMO 2002. Abstract 662P. 3. Weinfurt KP, et al. Med Care. 2004;42:164-175. 4. Saad F, et al. Eur Urol. 2004;46:731-740. 5. Oefelein MG, et al. J Urol. 2002;168:1005-1007. 6. Riggs BL, et al. Bone. 1995;17:505S-511S. Skeletal complications Negative impact on survival [5] Increased medical costs [1] Impaired mobility [6] Diminished quality of life [2-4]

8. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Prostate Solid tumors Lung cancer RCC 00.20.40.60.81.01.21.41.61.82.0 Relative Risk of SRE Breast Zoledronic Acid and Risk of SREs in Multiple Tumor Types 36%.002 31%.003 32%.016 58%.010 41%.019 Risk ReductionP Value In favor of ZOL In favor of placebo Kohno N, et al. J Clin Oncol. 2005;23:3314-332. Saad F, et al. J Natl Cancer Inst. 2004;96:879-882. Rosen LS, et al. Cancer. 2004;100:2613-2621. Lipton A, et al. Cancer. 2003;98:962-969.

9. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Osteonecrosis of the Jaw  Incidental finding of osteonecrosis in a patient complaining of a dislodged dental restoration. The patient underwent dental extraction in the region of the exposed bone 1 yr prior to presentation. She has no symptoms.

10. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum ABCSG-12 Trial Design  Accrual 1999-2006  1803 premenopausal breast cancer patients  Endocrine-responsive (ER and/or PgR positive)  Stage I & II, < 10 positive nodes  No chemotherapy except neoadjuvant  Treatment duration: 3 yrs  404 patients in bone subprotocol Randomize 1 :1:1:1 Surgery (+ RT) Tamoxifen 20 mg/day Goserelin 3.6 mg Q28D Anastrozole 1 mg/day + Zoledronic acid 4 mg Q6M Anastrozole 1 mg/day Tamoxifen 20 mg/day + Zoledronic acid 4 mg Q6M

11. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum First Event per Patient (n) Gnant M, et al. ASCO 2008. Abstract LBA4. No ZOL vs ZOL 10 41 29 10 6 9 20 0 2 0 10 20 30 40 50 60 70 80 90 No ZOL (n = 904) ZOL (n = 899) Death without previous recurrence Secondary malignancy Contralateral breast cancer Distant recurrence Locoregional recurrence

12. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum RANK Ligand: Key Mediator in “Vicious Cycle” of Bone Destruction RANK RANKL Bone resorption Osteoclast Cancer cells in bone Growth factors (TGF-β  IGFs, FGFs, PDGFs, BMPs) Cytokines and growth factors (IL-6, IL-8, IL-1β, PGE-2, TNFα, CSF-1, PTHrP) RANKL Direct effects on tumor? Adapted from Roodman GD. N Engl J Med. 2004;350:1655-1664. Bone Osteoblastlineage

13. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Denosumab: Monoclonal Antibody to RANKL  Fully human, high-affinity IgG2 antibody  No binding to TNF-α, TNF-ß, TRAIL, or CD40L  Administration via subcutaneous injection

14. Robert E. Coleman, MD, FRCP Professor and Honorary Consultant Medical Oncologist Cancer Research Centre Academic Unit of Clinical Oncology Weston Park Hospital Sheffield, England Current Approaches and Research Directions With RANKL Inhibitors in Optimizing Bone Health in Breast Cancer

15. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Global Burden of Breast Cancer: Incidence, Prevalence, and Mortality Globocan 2002 Adapted from http://www-dep.iarc.fr/. Breast Cancer Incidence 1,151,298 5-Yr Prevalence 4,406,080 Mortality 410,712

16. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Metastases to Bone Cause Significant Morbidity by Causing SREs  Pathological fractures –Nonvertebral –Vertebral compression  Spinal cord compression/collapse  Radiation therapy  Surgery to bone  Hypercalcemia  Bone pain  Use of analgesics  Quality-of-life effects  Survival Skeletal-related events

17. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Oral Clodronate 1600 mg Kristensen 1999 Paterson 1993 Tubiana-Hulin 2001 P Value Risk Reduction, % 00.20.4 0.6 0.81.01.21.41.61.82.0 Zoledronic acid 4 mg Kohno 2005 Pamidronate 90 mg Aredia study 18 and 19 Ibandronate IV 6 mg Body 2003 Ibandronate Oral 50 mg Body 2004.03 (pooled) Cochrane database comparing placebo-controlled trials in breast cancer setting. SRE Risk Reduction in Breast Cancer: Meta-analysis vs Placebo 0.77 0.82 0.86 0.69 0.83 0.92 0.59 41 31 23 18 14 8 17.001 <.001.04.08 Adapted from Pavlakis N, et al. Cochrane Database Syst Rev. 2005:CDC003474.

18. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Potential Mechanism of Action for Denosumab RANKRANKL Denosumab Adapted from Roodman GD. N Engl J Med. 2004;350:1655-1664. Cytokines and Growth Factors (IL-6, IL-8, IL-1β, PGE 2, TNF-α, CSF-1, PTHrP) Growth Factors (TGF-β, IGFs, FGFs, PDGFs, BMPs) Bone Resorption Ca 2+ RANK-Expressing Tumor Cells Direct Effects on Tumor?

19. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Hofbauer LC, et al. JAMA. 2004;292:490-495. Eghbali-Fatourechi G, et al. J Clin Invest. 2003;111:1221-1230. Hofbauer LC, et al. Endocrinology. 1999;140:4382-4389. Theriault RL. Oncology. 2004;18(suppl 3):11-15. Gravallese EM, et al. Arthritis Rheum. 2000;43:250-258. Roodman GD. N Engl J Med. 2004;350:1655-1664. Kong YY, et al. Nature. 1999;402:304-309 Kitazawa S, et al. J Pathol. 2002;198:228-236. Cancer-Related Bone Destruction Treatment-Induced Bone Loss Bone Erosion of RA Postmenopausal Osteoporosis RANK Ligand Plays a Key Role in Conditions of Bone Loss and Destruction Treatment-Induced Bone Loss Bone Erosion of Rheumatoid Arthritis Postmenopausal Osteoporosis Cancer-Related Bone Destruction

20. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Phase I Single Dose Study of Denosumab in Patients With Breast Cancer 9080706050403020100 0 20 40 80 Urine NTX (mmol BCE/mmol creatinine) 60 Days Values are expressed as absolute medians Pamidronate 90 mg Denosumab 3.0 mg/kg Denosumab 0.3 mg/kg Denosumab 0.1 mg/kg Denosumab 1.0 mg/kg Body JJ, et al. Clin Cancer Res. 2006;12:1221-1228. Reprinted with permission.

21. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Phase II Trial in Bisphosphonate-Naive Breast Cancer Patients 25 wks of treatment Denosumab 30 mg SC Q4W Denosumab 120 mg SC Q4W Denosumab 180 mg SC Q4W Denosumab 60 mg SC Q12W Denosumab 180 mg SC Q12W Bisphosphonate IV Q4W Study features 40 patients per group (n = 240) Blinded denosumab Patients naive to bisphosphonates ECOG = 0, 1, 2 Primary endpoint % change in uNTx at Wk 13 Follow-up at Wks 33, 45, 57 Screening/ randomization Lipton A, et al. J Clin Oncol. 2007;25:4431-4437.

22. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Phase II Bisphosphonate Naive, Percentage Change in uNTx From Baseline  40 patients in each group of the following treatments –IV bisphosphonates (largely zoledronic acid) –Denosumab 30 mg every 4 wks –Denosumab 120 mg every 4 wks –Denosumab 180 mg every 4 wks –Denosumab 60 mg every 12 wks –Denosumab 120 mg every 12 wks –Primary endpoint: median percent change in uNTx/Cr at 13 wks –Decrease similar in all groups, approximately 75% –Decrease maintained at 25 wks Lipton A, et al. Clin Cancer Res. 2008;14: 6690-6696. Reprinted with permission.

23. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Phase II Study in Patients Pretreated With Bisphosphonates uNTx > 50 despite IV bisphosphonates Denosumab 180 mg SC Q4W (n = 38) 25 wks of treatment with daily supplements of calcium and vitamin D Denosumab 180 mg SC Q12W (n = 36) IV BP Q4W (n = 37) Extension/ follow-up Study Design (20040114) Fizazi K, et al. J Clin Oncol. 2009;[Epub ahead of print].

24. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Phase II Pretreated With Bisphosphonates Estimated Median Time to uNTx < 50 Study Days Fizazi K, et al. J Clin Oncol. 2009;27:1564-1571. Reprinted with permission. © 2009 American Society of Clinical Oncology. All rights reserved.

25. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Phase II Pretreated Patients With Bisphosphonates Time to First SRE  Time to first SRE significantly longer in with denosumab vs IV bisphosphonate –Patients experiencing first SRE at Day 40 –1% of patients on denosumab –5% on bisphosphonate with –Patients experiencing first SRE at Day 200 –12% of patients on denosumab –20% on bisphosphonate *P =.038 vs IV BP. 1 patient was found to have experienced the SRE during the follow-up phase of the study. Fizazi K, et al. J Clin Oncol. 2009;27:1564-1571.

26. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Dose Selection Rationale for Phase III Oncology Program  Treatment goals for patients with bone metastases –Maximize suppression of osteoclasts and bone resorption (uNTx) –Minimize the number of subjects that “escape” suppression of bone resorption –Choose safe and convenient dose  Observations –120 mg Q4W dosing trended toward the greatest suppression of bone turnover –Q12W dosing had more “escape” from suppression, favoring dosing Q4W –More grade 2 and 3 calcium shifts with the 180-mg dose Selected dose = 120 mg Q4W

27. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Breast Cancer Phase III Study Primary Endpoint Secondary Endpoints  Time to first on-study SRE (noninferiority)  Time to first on-study SRE (superiority)  Time to first and subsequent on-study SRE (superiority) Key Inclusion  Adults with advanced breast cancer and confirmed bone metastases Key Exclusion  Current or previous IV bisphosphonate administration *IV product dose adjusted for baseline creatinine clearance and subsequent dose intervals determined by serum creatinine (per zoledronic acid label). Stopeck A, et al. ECCO/ESMO 2009. Abstract 2LBA. Zoledronic acid 4 mg IV* + SC Placebo every 4 wks (n = 1020) Denosumab 120 mg SC + Placebo IV* every 4 wks (n = 1026) Supplemental Calcium and Vitamin D

28. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum An Approximation of Incremental Benefits: Bone Targeted Agents in Breast Cancer 64% risk of skeletal complication with no bisphosphonate at 2 yrs ~ 33% risk reduction with pamidronate 64%43%34% Further 20% risk reduction with zoledronic acid 27% Additional 18% risk reduction with denosumab Lipton A, et al Cancer. 2000;88:3033-3037. Rosen LS, et al. Cancer. 2003;100:36-43. Stopeck A, et al. ECCO/ESMO 2009. Abstract 2LBA.

29. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Denosumab Oncology Program Overview Phase IPhase IIPhase III Breast cancer and MM: PK/PD Breast cancer: PK/PD (bisphosphonate naive) Breast cancer: Al bone loss Solid tumors and MM: PK/PD (bisphosphonate treated) Prostate cancer: ADT bone loss Giant cell tumor Prostate cancer: delay of bone mets MMBreast cancer: SRE Prostate cancer: SRE Solid tumors and MM: SRE

30. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Effect of Bisphosphonates on Vicious Cycle of Bone Destruction  Decrease activity of osteoclasts –Reduction in release of peptides –Slowed tumor-cell growth –Reduced production of PTHrP and other factors –Decrease in bone resorption PTHrP Tumor Cells IL-6 IL-8 PGE 2 TNF-  CSF-1 BMP PDGF FGFs IGFs TGF-β Osteoclast Bone Adapted from Mundy GR, et al. N Engl J Med. 1998;339:398-400.

31. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Clodronate Improves Survival in Patients With Breast Cancer  Bone metastasis-free survival: clodronate vs placebo –At 2 yrs, HR is 0.546 (95% CI: 0.312-0.954; P =.031) –At 5 yrs, HR is 0.692 (95% CI: 0.484-0.990; P =.043)  Overall survival: clodronate vs placebo –At 10.5 yrs, HR is 0.768 (95% CI: 0.591-0.999; P =.048) Powles T, et al. Breast Cancer Res. 2006;8:R13.

32. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum ABCSG XII: First DFS Events (ITT Population) First Event per Patient (n) No ZOL vs ZOL HR: 0.65; P =.017 No ZOL (n = 904) ZOL (n = 899) 10 20 30 40 50 60 70 80 90 0 Death without prior recurrence Secondary malignancy Contralateral breast cancer Distant recurrence Locoregional recurrence 2 10 41 20 0 9 6 29 10 Gnant M, et al. N Engl J Med. 2009;360:679-691.

33. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Number of Relapses in Postmenopausal Bone Protection Studies of 6-Mo ZA Eidtmann H, et al. SABCS 2008. Abstract 44. Brufsky AM, et al. SABCS 2008 Abstract 2067. ECCO/ESMO 2009. Zoledronic AcidControlHR (95% Cl) ZO-FAST (N = 602) 3253 0.59 (0.39-0.92) P =.0176 Z-FAST (N = 1065) 2226 0.80 (0.45-1.41) P = NS EZO-FAST (N = 527) 1911 1.76 (0.83-3.69) P = NS

34. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Summary  Bisphosphonates are an important component of breast cancer management –Reduce number and severity of skeletal complications –May prevent or interrupt the metastatic process and reduce recurrences  Denosumab is a new potential treatment for metastatic bone disease –Rapid and sustained reduction in bone resorption –Superiority over zoledronic acid in prevention of SREs –Well tolerated and convenient

35. Matthew R. Smith, MD, PhD Director, Genitourinary Medical Oncology Associate Professor of Medicine Massachusetts General Hospital Cancer Center Boston, Massachusetts Prostate Cancer: Beyond Bisphosphonates—Evolving Evidence Supporting RANKL Inhibition

36. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Treatment-Related Fractures Disease-Related Skeletal Complications Castrate-sensitive nonmetastatic Castrate-resistant nonmetastatic Castrate-resistant metastatic Spectrum of Bone Disease in Prostate Cancer

37. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Complications From Bone Metastasis in Prostate Cancer  Pain  Fractures  Spinal cord compression  Myelophthisis

38. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Pathogenesis of Osteoblastic Metastases Osteoblasts Sclerotic Metastasis Latent TGF-β, IGF Active TGF-β, IGF Tumor Cell Osteoclast Proteases ET-1, BMPs IGFs, OPG TGF-β EGF bFGF

39. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Cook RJ, et al. Clin Cancer Res. 2006;12:3361-3367. Reproduced with permission. Osteoblast (BAP) and Osteoclast (NTx) Markers in Men With mPC  Study of men with hormone refractory metastatic prostate cancer –Osteoblast activity measured by serum bone alkaline phosphatase (BAP) –Osteoclast activity measured by N-telopeptide (NTX)  Normal levels of both BAP and NTx in only 11% of men –Many subjects had markers elevated several fold greater than the upper limits of normal  Elevated markers of osteoblast and osteoclast activity are associated with adverse clinical outcomes including greater risk of skeletal complication and death

40. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Elevated NTx Is Associated With Greater Risk for SRE and Death  High NTx levels at baseline associated with an increased rate of first SRE –Increased rate of first SRE maintained throughout study  Markedly increased survival for patients with low NTx levels compared with those with high NTx levels –Median survival: 11.9 mos (95% CI: 8.1-16.0) for patients with high NTx levels at baseline –Median survival: 22.8 months (95% CI: 18.6 to infinity) for patients with high NTx levels at baseline Brown JE, et al. J Natl Cancer Inst. 2005;97:59-69. Reproduced with permission.

41. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Contemporary Phase III Trials for Castrate- Resistant Metastatic Prostate Cancer StudyPopulationTreatmentEndpoint NCIC Pr06 (N = 204) SymptomaticMitoxantrone/prednisone ± clodronate Palliative response 032/INT 05 (N = 350) SymptomaticIV pamidronate vs placebo Pain score analgesic use Zoledronic acid 039 (N = 643) AsymptomaticIV zoledronic acid vs placebo SRE

42. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Saad F, et al. J Natl Cancer Inst. 2002;94:1458-1468. Primary endpoint: SRE Zoledronic Acid Study 039 Design Castrate-resistant bone mets (N = 643) Placebo Q3W Zoledronic acid Q3W

43. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Saad F, et al. J Natl Cancer Inst. 2002;94:1458-1468. Zoledronic Acid Inhibits Urinary NTx, A Specific Marker of Osteoclast Activity  Urinary NTx statistically significantly decreased in patients who received zoledronic acid at either 4 mg or at 8/4 mg –P =.001 vs placebo at 15 mos  The NTx-to-creatinine ratio decreased within 1 mo after treatment with zoledronic acid –4 mg 70% (95% CI: -72.6% to -66.3%) vs placebo –8/4 mg 70% (95% CI: -75.9% to -69.5%) vs placebo  Remained suppressed for 18 mos

44. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Cumulative Incidence of Skeletal-Related Events  Statistically significantly lower in incidence of SREs with zoledronic acid vs placebo – P =.002  SREs –Radiation to bone –Pathologic fracture –Spinal cord compression –Surgery to bone –Change in antineoplastic therapy Major PP, et al. ASCO 2003. Abstract 3062.

45. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum CALGB 90202: Study Design Castrate-resistant or SRE Primary endpoint: SRE or death Newly diagnosed stage D2 prostate cancer (N = 680) Placebo Q4W Zoledronic acid Q4W Zoledronic acid Q3W ClinicalTrials.gov. NCT00079001.

46. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Intravenous Bisphosphonates: Adverse Effects  Acute phase reaction  Renal dysfunction  Osteonecrosis of the jaw

47. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Primary endpoint: SREs Accrual complete: 2008 Q4 Final analyses: 2010 Denosumab to Prevent SREs ClinicalTrials.gov. NCT00321620. Castrate-resistant, bone metastases, no previous BP (N = ~ 1900) Denosumab monthly Zoledronic acid monthly

48. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Metastasis Prevention Castrate-sensitive nonmetastatic Castrate-resistant nonmetastatic Castrate-resistant metastatic Spectrum of Bone Disease in Prostate Cancer

49. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Natural History of Castrate-Resistant Nonmetastatic Prostate Cancer  Zoledronic acid 704 trial aborted because of low event rate  201 men from placebo arm analyzed –At 2 yrs –33% of subjects had developed at least 1 bone metastasis –21% had died –42% had a bone metastasis or had died –Median bone metastasis–free survival was 907 days –Median OS was not reached Smith MR, et al. J Clin Oncol. 2005;23:2918-2925.

50. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum PSA and PSADT Are Associated With Shorter Bone Metastasis–Free Survival Smith MR, et al. J Clin Oncol. 2005;23:2918-2925. Reprinted with permission. ©2005 American Society of Clinical Oncology. All rights reserved 00.51.01.52.02.53.0 0.2 1.0 0.4 0.6 0.8 Proportion of Patients With Bone Metastases or Died Yrs Since Random Assignment PSA 24.0 ng/mL 00.51.01.52.02.53.0 0.2 1.0 0.4 0.6 0.8 Proportion of Patients With Bone Metastases or Died Yrs Since Random Assignment PSADT 18.8 mos 00

51. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Primary endpoint: bone metastasis–free survival Accrual complete: 2008 Q2 Final analyses: 2010 Denosumab to Prevent Metastases ClinicalTrials.gov. NCT00286091. Castrate resistant, no bone metastases, PSA > 8 or PSADT < 10 mos (N = ~ 1500) Denosumab monthly Placebo monthly

52. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Incidence/1,000,000 Person-Yrs Age (Yrs) 4000 3000 2000 1000 35-39 ≥ 85 Hip Spine MenWomen Melton LJ 3rd, et al. J Bone Miner Res. 1992;7:1005-1010. Fracture Risk by Sex and Age

53. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum 0 3 6 9 12 15 18 Any FractureFracture Resulting in Hospitalization Frequency (%) +2.8%; P <.001 +6.8%; P <.001 12.6 21 5.2 19.4 2.4 Shahinian VB, et al. N Engl J Med. 2005;352:154-164 Proportion of Patients With Fractures 1-5 Yrs After Cancer Diagnosis ADT (n = 6650) No ADT (n = 20,035)

54. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum P <.001 for each comparison 12-mo data Mittan D, et al. J Clin Endocrinol Metab. 2002;87:3656-3661. Reproduced by permission of the Endocrine Society. GnRH Agonists Decrease BMD in Men With Prostate Cancer GnRH agonist Control Lumbar Spine Total Hip Percent Change -5 -4 -3 -2 0 1 2

55. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Lumbar Spine Total Hip 12-mo data Greenspan SL, et al. Ann Intern Med. 2007;146:416-424. Alendronate Increases Bone Mineral Density During GnRH Agonist Therapy BMD Percent Change -3 -2 0 1 2 3 4 5 Placebo Alendronate

56. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum P <.005 for each comparison Final 12-mo data Michaelson MD, et al. J Clin Oncol. 2006;25:1038-1042. Annual Zoledronic Acid Increases BMD During GnRH Agonist Therapy Lumbar Spine Total Hip BMD Percent Change -6 -4 -2 0 2 4 6 Zoledronic acid Placebo

57. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Primary endpoints: bone mineral density, new vertebral fractures Denosumab Fracture Prevention Study Clinical Trials.gov. NCT00089674. Current androgen deprivation therapy for prostate cancer, older than 70 yrs of age or T score < -1.0 (N = 1468) Denosumab Q6M for 3 yrs Placebo Q6M for 3 yrs

58. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Denosumab Increased BMD at All Skeletal Sites Smith MR, et al. N Engl J Med. 2009;361:745-755. Reprinted with permission © 2009 Massachusetts Medical Society. 36 -6 2412630 Mo -4 -2 0 2 4 6 8 10 Percent Change in BMD From Baseline CFemoral Neck Denosumab Placebo Difference at 24 mos, 3.9 percentage points Difference at 24 mos, 6.7 percentage points Difference at 24 mos, 4.8 percentage points Difference at 24 mos, 5.5 percentage points Placebo Denosumab ALumbar Spine DDistal Third of Radius BTotal Hip 36 -6 241260 Mo -4 -2 0 2 4 6 8 10 Percent Change in BMD From Baseline 36 -6 241260 Mo -4 -2 0 2 4 6 8 10 Percent Change in BMD From Baseline 36 -6 241260 Mo -4 -2 0 2 4 6 8 10 Percent Change in BMD From Baseline 33 3

59. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Denosumab Decreased New Vertebral Fractures Smith MR, et al. N Engl J Med. 2009;361:745-755. Reprinted with permission © 2009 Massachusetts Medical Society. Mo 12 New Vertebral Fracture (%) 0 2 4 6 8 Mo 24Mo 36 Denosumab Placebo No. of Patients1322272610 1.9 0.3 1.0 3.3 P =.004 P =.006 3.9 1.5

60. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Castrate-sensitive nonmetastatic Castrate-resistant nonmetastatic Castrate-resistant metastatic Spectrum of Bone Disease in Prostate Cancer

61. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Summary: Treatment of Bone Metastases  Disease-related skeletal complications are common in men with metastatic prostate cancer  Zoledronic acid decreases risk of SRE in men with castrate-resistant disease and bone metastases  Role of bisphosphonates in castrate-sensitive disease has not been established  An ongoing RCT will compare efficacy of zoledronic acid and denosumab

62. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Summary: Prevention of Bone Metastases  Prevention of bone metastases is an important unmet clinical need  Failure of previous studies was related, at least in part, to previous limited information about the natural history of castrate-resistant nonmetastatic disease  An ongoing RCT in high-risk subjects will evaluate whether denosumab prevents metastases

63. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Summary: Prevention of Treatment- Related Fractures  Androgen deprivation therapy increases fracture risk  Bisphosphonates increase bone mineral density during androgen deprivation therapy –Not shown to prevent treatment-related fractures in men with prostate cancer  Denosumab increases bone mineral density and decreases fractures during androgen deprivation therapy

64. G. David Roodman, MD, PhD Professor of Medicine, Vice Chair for Research Department of Medicine/Hematology-Oncology University of Pittsburgh School of Medicine Director, Myeloma Program Department of Medicine/Hematology-Oncology University of Pittsburgh Cancer Institute VA Pittsburgh Healthcare System Pittsburgh, Pennsylvania Mitigating Bone Complications In Multiple Myeloma—What’s Current and What’s on the Horizon

65. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Bone Involvement in Different Tumor Types Disease Prevalence (US) (in Thousands) Incidence of Bone Metastases in Patients With Advanced Disease, % Median Survival of Patients With Bone Metastases, Mos Myeloma49.6 [1] 84 [2] 37-58 [4] Lung327 [1] 30-40 [3] 8-10 [5] Breast2051 [1] 65-75 [3] 19-25 [6] Prostate1477 [1] 65-75 [3] 30-35 [7] 1. National Cancer Institute. Available at: http://seer.cancer.gov/csr/1973-1999/prevalence.pdf. 2. Kyle RA, et al. Mayo Clin Proc. 2003;78:21-33. 3. Coleman RE. Oncologist. 2004;9(suppl 4):14-27. 4. Palumbo A, et al. Blood. 2004;104:3052-3057. 5. Smith W, et al. Semin Oncol. 2004;31(suppl 4):11-15. 6. Lipton A. J Support Oncol. 2004;2:205-213. 7. Tu SM, et al. Cancer Treat Res. 2004;118:23-46.

66. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Prevalence of Osteolytic Bone Destruction in Multiple Myeloma  Frequency of skeletal abnormalities and bone pain detected by x-ray (N = 824) 71 68 63 60 Lytic Lesions Bone Pain at Diagnosis OsteopeniaPathologic Fractures Patients (%) 0 10 20 30 40 50 60 70 80 90 100

67. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Melton LJ 3rd, et al. J Bone Miner Res. 2005;20:487-493 Fracture Incidence Myeloma Patients  Retrospective cohort study of 168 patients with myeloma  Approximately 20% present with pathologic fracture at diagnosis –1-yr rate of pathologic fracture is 40% –Even with disease control, rate of fracture continues to rise –Approximately 60% of patients will sustain a pathologic fracture during the course of their disease  Patients with fracture have 20% increased risk of death

68. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Bone Cell Stimulation in Malignancy Multiple Myeloma Osteolytic Solid Tumors Including Breast Cancer OsteoclastsOsteoblasts

69. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Bone Scans in Myeloma Can Underestimate Bone Involvement

70. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Current Treatment of MM Bone Disease  Bisphosphonates  Surgical procedures –Vertebroplasty –Balloon kyphoplasty  Radiotherapy  Treatment of myeloma

71. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Placebo Pamidronate Berenson JR, et al. N Engl J Med. 1996;334:488-493. Pamidronate Decreases Skeletal Related Events In Myeloma Patients 24 41 38 921 Patients (%) 0 10 20 30 40 50 60 Mos 51 P <.001.015

72. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Zoledronic Acid and Pamidronate in Multiple Myeloma  Patients with no SRE similar between pamidronate and zoledronic acid over the study period (13 wks)  Median time to first SRE approximately 1 yr for both pamidronate and zoledronic acid Rosen LS, et al. Cancer J. 2001;7:377-387. 44 46 0 20 40 60 Pamidronate 90 mg Zoledronic acid 4 mg All SREs Patients With SRE (%)

73. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Issues With BP Therapy  Renal toxicity  Osteonecrosis of the jaw  Decreases skeletal events by 50%; patients still progress but at a slower rate  No clear antitumor activity in myeloma

74. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Myeloma Bone Disease Myeloma cells Tumor-derived bone resorbing factors (+) Derived from Roodman GD. N Engl J Med. 2004;32:290-292. Bone-derived tumor growth factors IL-6 TGF-  Osteoclast Bone

75. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Myeloma Bone Disease Myeloma cells Tumor-derived osteoclast activating factors  Macrophage inflammatory protein  IL-3 Tumor-derived osteoblast inhibitory factors  Dickkopf1, IL-3, sFRP2, IL-7 Bone Osteoclast Osteoblasts (–) Stromal cells –RANKL –IL-6 Derived from Roodman GD. N Engl J Med. 2004;32:290-292. (+)

76. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum RANKL/OPG in Normal Bone Prevents Promotes OPGRANKL Osteoclast Formation

77. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum The RANK/RANKL/OPG Pathway in Osteolytic Bone Disease Prevents Promotes Increased Osteoclastic Activity and Decreased OPG OPGRANKL Adapted from Roodman GD. N Engl J Med. 2004;350:1655-1664.

78. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Inhibiting RANK in Bone Disease  High affinity human monoclonal antibody that binds RANKL  Specific: does not bind to TNF-α, TNF-β, TRAIL, or CD40L  Inhibits formation and activation of osteoclasts

79. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Effect of Denosumab vs Pamidronate on Urinary NTX in Patients With Myeloma 9080706050403020100 0 20 40 60 Urine NTX (mmol BCE/mmol creatinine) 50 30 Days Values are expressed as absolute medians Pamidronate 90 mg Denosumab 3.0 mg/kg Denosumab 0.3 mg/kg Denosumab 0.1 mg/kg Denosumab 1.0 mg/kg Body JJ, et al. Clin Cancer Res. 2006;12:1221-1228. Reprinted with permission.

80. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Phase II Study of Denosumab in Relapsed and Plateau-Phase MM  Effective for myeloma bone disease  Median changes in bone resorption markers were -70% and -52% for relapsed and PP patients Vij R, et al. ASH 2007. Abstract 3604.

81. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum DKK1 and sFRP-2 in Myeloma Bone Disease  Inhibitors of the WNT signaling pathway  WNT signaling is a critical pathway for OBL differentiation  Secreted by myeloma cells  Marrow plasma from patients with high levels of DKK1 or sFRP-2 inhibit murine OBL differentiation  DKK1 gene expression levels correlated with extent of bone disease in MM patients Tian E, et al. N Engl J Med. 2003;349:2483-2489. Oshima T, et al. Blood. 2005;106:3160-3165.

82. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Anti-DKK1 Increases Bone Formation in the SCID-Rab Multiple Myeloma Model Yaccoby S, et al. Blood. 2007;109:2106-2111.  Preclinical murine myeloma model –Implanted BMD in control hosts reduced by 10.9% ± 4.3% –Implanted BMD in DKK1 AB-treated hosts increased by 3.5% ± 3.4% from pretreatment levels (P <.001)

83. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Myeloma Cell Stromal Cell NF-κB p38 Adhesive Interactions Between Myeloma Cells and Marrow Stromal Cells  Increases NF-κB and p38 MAPK signaling

84. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Signaling Pathways Involved in Osteoclast Formation and Activity RANKL RANK TRAF6 aPKC IKK IκBIκB NF-κB NF-κB–dependent transcription TNF TNFR1 ASK1 TRADD RIP TRAF2 JNKK Raf MKK IL-1R IRAK IKK  Src PI3K PDK1 AKT JNK AP1 (fos/jun) P38 MAPK MEK ERK1/2 c-Fos MITF NFATc 1 -dependent transcription AP1-dependent transcription Growth/differentiationDifferentiation/survivalResorption/survival BAD IL-1 RelB/p52 Noncanonical NF-κB pathway p62

85. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum 0 200 400 600 800 1000 1200 1400 1600 1800 2000 IL-6 (pg/ml) p62 siRNA Transfer Reagent Control siRNA P <.01 Hiruma Y, et al. Blood. 2009;113:4894-4902. Knockdown of p62 Decreases VCAM-1 and IL-6 Expression by MM-Stromal Cells  In myeloma stromal cells transduced with p62 siRNA –p62 protein decreased by 90% –VCAM-1 protein decreased by 70%

86. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Hiruma Y, et al. Blood. 2009;113:4894-4902. p62 Is Important for Stromal Cell Support of Human Multiple Myeloma Cell Growth  Murine stromal cells can enhance growth of human myeloma cells in vitro  Marrow stromal cells of p62 -/- mice support significantly less growth than those of p62 +/- mice (P <.01)  In contrast to p62 +/- cells, coculture of p62 -/- stromal cells with human myeloma cells did not significantly increase expression of IL-6 and TNF-α

87. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Vehicle 100 150 TRAP Positive MNC/Culture 0 50 PTH-rp (10 -8 M) * TNF-  (100 pg/ml) * p62 +/- stromal cells p62 -/- stromal cells *P <.05 compared with WT stromal cells TNF-α or PTH-rp Decreases OCL Formation in p62 -/- Stromal Cell Coculture Hiruma Y, et al. Blood. 2009;113:4894-4902.

88. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum 1000 Control RANKL (pg/ml) 0 PTH-rp (10 -8 M) TNF-  (100 pg/ml) 3000 500 1500 2000 2500 * * * RANKL Production by p62 +/- and p62 -/- Stromal Cells p62 +/- stromal cells p62 -/- stromal cells *P <.01 compared with p62 +/- stromal cells Hiruma Y, et al. Blood. 2009;113:4894-4902.

89. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum New Agents for Treating Myeloma Thalidomide Lenalidomide Bortezomib

90. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Roodman GD. J Clin Invest. 2008;118:462-464. Bortezomib/Lenalidomide in MBD Myeloma Cells Bone OCL Osteoblasts OLC Precurser Lenalidomide OAFs Bzb BMP-2Runx-2 MSCs

91. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum IMiDs Inhibit OCL Formation  In a 21-day culture system, addition of thalidomide analogue CC-4047 (100 µM twice wkly) inhibited OCL formation in healthy donor bone marrow (HBM) and multiple myeloma bone marrow (MMBM) cultures Anderson G, et al. Blood. 2006;107:3098-3105. TreatmentOCL/Well, Mean ± SD HBM OCL/WellMMBM Control59.0 ± 13.057.0 ± 35.0 CC-0470 ± 02.8 ± 2.6 Thalidomide14.0 ± 1.910.0 ± 6.2

92. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Giuliani N, et al. Blood. 2007;110:334-338. Effect of Bortezomib on Bone Formation in Multiple Myeloma Patients  Analysis of in vivo effect of bortezomib in a cohort of MM patients –Significant increase in the number of osteoblastic cells x mm 2 of bone tissue observed in MM patients responding to bortezomib treatment –No significant increase in nonresponders –Osteoblastic cells x mm 2 of bone tissue in responder MM patients after therapy decreased compared with healthy bone from the control group –Significant increase in the number of Runx2/Cbfa1-positive osteoblastic cells in responder MM patients compared with nonresponders

93. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Activin decreases bone mineral density and strength Activin and Bone Growth Reduced bone formation Activin Activin inhibits osteoblasts Osteoblast Activin receptor type IIA Activin receptor type IIA Activin stimulates osteoclasts Increased bone resorption Osteoclast

94. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Activin A Levels Are Elevated in Patients With MM Activin A levels are increased in bone marrow plasma of MM patients Activin A is produced by the microenvironment, notably BMSCs and osteoclasts Median Levels in 72-hr Culture Supernatants: BMSCs: 2094 pg/ml OCs: 1396 pg/ml OBs: 200 pg/ml Average Levels of Activin A in BM Sera of MM Pts: MM: 119 ± 143 pg/ml Normal: 33 ± 14 pg/ml Vallet S, et al. 2008 AACR. Abstract 1521. MM 0 50 Normal 100 150 200 250 300 350 400 450 Activin A, pg/ml BMSC 0 OB 1000 2000 3000 4000 Activin A, pg/ml OC

95. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Normal MiceMice + Tumor + RAP-011 Croucher P, et al. 2007 International Myeloma Workshop. Abstract. RAP-011 Prevents Development of Myeloma Bone Lesions

96. clinicaloptions.com/oncology Novel Strategies for Bone-Directed Therapy Across the Cancer Continuum Novel Therapeutic Targets for MM Bone Disease TargetPotential Therapy RANKLAnti-RANKL MIP-1aCCR1 antagonist DKK1/sFRP-2Wnt Agonist, anti-DKK1, bortezomib Activin AACE-011

97. Go Online for More CCO Coverage of Bone Complications in Cancer! Treatment updates: including all the key data in breast cancer, multiple myeloma and prostate cancer Interactive virtual presentations: watch and listen to our experts review cases, vote on your treatment choiceand compare to the experts evidence-based recommendations Downloadable PowerPoint slides clinicaloptions.com/oncology