1. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Combination and Sequential Chemotherapy of Metastatic Colorectal Cancer Daniel G. Haller, MD University of Pennsylvania Cancer Center

2. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Discussion topics What is the goal of administering combination vs sequential therapy?What is the goal of administering combination vs sequential therapy? What is the evidence for combination versus sequential therapy?What is the evidence for combination versus sequential therapy? What are the interim endpoints in studies of sequential therapy?What are the interim endpoints in studies of sequential therapy? How are new therapies incorporated into combination or sequential therapy?How are new therapies incorporated into combination or sequential therapy?

3. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Chemotherapy for Metastatic Colorectal Cancer What is the Goal of Combination vs Sequential Therapy? –Overall survival The gold standard for regulatory approvalThe gold standard for regulatory approval –Progression-free survival Surrogate of activity for clinical trialsSurrogate of activity for clinical trials Marker of clinical benefitMarker of clinical benefit –Response rate –Measures of quality of life Time to symptom worseningTime to symptom worsening

4. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Chemotherapy for Metastatic Colorectal Cancer Combination Chemotherapy (FU/LV With CPT-11 or Oxaliplatin) –RR: range from 34–51% –PFS: range from 6.7–9.3 m –OS:range from 14.8–19.4 m Statistical superiority for FU/LV/CPT-11 compared to first-line FU/LVStatistical superiority for FU/LV/CPT-11 compared to first-line FU/LV Incremental benefit achieved without marked increase in toxicity or negative impact on QOLIncremental benefit achieved without marked increase in toxicity or negative impact on QOL Effects of crossover and surgical therapyEffects of crossover and surgical therapy

5. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Chemotherapy for Metastatic Colorectal Cancer “There are only two tragedies in life: one is not getting what one wants, and the other is getting it.” Oscar Wilde

6. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC NCCTG Trial N9741 FU/LV/CPT-11 (Saltz) weekly FU/LV (de Gramont) + oxaliplatin Q2W Oxaliplatin + CPT-11 Q3W -Primary endpoint: Survival -No fixed crossover; no oxaliplatin available after progression on Saltz regimen R Chemotherapy for Metastatic Colorectal Cancer

7. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Chemotherapy for Metastatic Colorectal Cancer FRE-C97-3: FOLFIRI vs FOLFOX 113 patients/arm Primary endpoint: PFS No prior CT, >6mos from adjuvant Rx, no prior CPT-11 or oxaliplatin Oxaliplatin + de Gramont FU/LV R CPT-11 + de Gramont FU/LV Proc ASCO, abstract 949, 2000

8. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Duration of Chemotherapy MRC-CR06 Trial CIFU De Gramont FU/LV Tomudex R Patients are treated for 12 weeks; if stable or responding, a second randomization to 12 more weeks of therapy or discontinuation

9. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Sequence of Chemotherapy FOCUS Trial Modified de Gramont FU/LV CPT-11 Modified de Gramont FU/LV FU/LV+CPT-11 FU/LV/CPT-11 Modified de Gramont FU/LVFU/LV+oxaliplatin FU/LV/oxaliplatin R 2100 patients endpoints: PFS, OS, QOL

10. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Chemotherapy for Metastatic Colorectal Cancer Pivotal Trial of Oxaliplatin: EFC 4584 –Response rate in FU/LV and CPT-11 failures –Survival advantage in patients who have failed FU/LV/irinotecan infusional FU/LV(de Gramont) Roxaliplatin infusional FU/LV+oxaliplatin

11. D. Haller, CRC Symposium, 1.23.2001 Oncology Spectrums, NYC Chemotherapy for Metastatic Colorectal Cancer Oxaliplatin Trials in US –EFC 4584:in FU/LV/CPT-11 (Saltz) failures –EFC 4585: CPT-11 alone vs CPT-11 + oxaliplatin in FU/LV failures –EFC 4759: oxaliplatin in third-line therapy –EFC 4760: de Gramont FU/LV + oxaliplatin in third-line therapy