1. Case Study: A Young Patient with PV has a Major Thrombotic Event and Worsening Leukocytosis - Is she Progressing to Post-PV MF? Ruben A. Mesa, MD, FACP Chair, Division of Hematology & Medical Oncology Deputy Director, Mayo Clinic Cancer Center Professor of Medicine

2. Co-Presenters Jeffrey C. Bryan, PharmD, RPh Clinical Pharmacy Specialist, Leukemia Division of Pharmacy, University of Texas MD Anderson Cancer Center Houston, TX Otitolola Arterbery, MSN, RN, OCN Clinical Nurse MD Anderson Cancer Center Houston, TX

3. Case Study: Trisha K. Diagnosed with PV at the age of 32 years Disease features at diagnosis – Hb: 17.4 g/dL – Hematocrit: 56% – Leukocyte count: 9.2 x 10 9 /L – Platelet count: 520 x 10 9 /L – Suboptimal serum EPO – 0% circulating blasts on smear – Spleen not palpable; asymptomatic – JAK2V617F mutation No history of thrombosis or major bleeding events Mild hypertension

4. Case Study (cont.): Trisha K. Conventional risk stratification in PV is based on: A.Risk of progression to myelofibrosis B.Risk of leukemic transformation C.Risk of death D.Risk of thrombosis E.Risk of major hemorrhage

5. Case Study (cont.): Trisha K. Conventional risk stratification in PV is based on: A.Risk of progression to myelofibrosis B.Risk of leukemic transformation C.Risk of death D.Risk of thrombosis E.Risk of major hemorrhage

6. Risk Stratification in PV Based on Thrombotic Risk Risk CategoryRisk Variables Low Age < 60 years No thrombosis history High Age ≥ 60 years and/or Thrombosis history 1. Barbui T et al. J Clin Oncol. 2011;29(6):761-770; 2. Vannucchi AM. Blood. 2014 Oct 2. [Epub ahead of print]. Novel biomarkers of increased thrombosis risk include leukocytosis and JAK2V617F allele burden.

7. Rates of Thrombotic Events During The Clinical Course of PV All patients 3 (n=1543) Age >61 years (n = 743) Age ≤ 61 years (n=802) P-value Median follow-up, years (range) 6.9 (0-39)5.8 (0-22)8 (0-39) Arterial thrombosis184 (12%)86 (12%)98 (12%)NS Venous thrombosis137 (9%)63 (8%)74 (9%)NS Major hemorrhage24/572 (4%)13/281 (5%)11/291 (4%)NS Aspirin therapy1281/1535 (84%)599/739 (81%)682/796 (85%)0.02 Rate estimates for thrombosis in patients with PV range from 2.7 to 3.8 per 100 patients/year 1-3 1. Marchioli R, et al. J Clin Oncol. 2005;23(10):2224-32; 2. Marchioli R, et al. N Engl J Med. 2013;368(1):22-33; 3. Tefferi A et al. Leukemia 2013;27:1874-81.

8. Low-Dose Aspirin in Management of PV Persistently enhanced platelet activation contributes to the higher risk of thrombosis in patients with PV1,2 Placebo-controlled ECLAP trial (N= 518) demonstrated that low-dose aspirin can safely prevent thrombotic complications in patients with PV who have no contraindications to aspirin2 1. Patrono C, et al. Blood. 2013;121(10):1701-11; 2. Landolfi R, et al. N Engl J Med 2004;350: 114-24.

9. European Collaboration on Low-Dose Aspirin in Polycythemia Vera (ECLAP) Trial Landolfi R, et al. N Engl J Med 2004;350: 114-24. Incidence of major bleeding episodes was not significantly increased in the aspirin group (relative risk, 1.62; 95% CI, 0.27 to 9.71). Low-dose aspirin (100 mg) reduced the risk of nonfatal myocardial infarction, nonfatal stroke, pulmonary embolism, major venous thrombosis, or death from cardiovascular causes (relative risk, 0.40; 95% CI, 0.18 to 0.91; P = 0.03)

10. Estimated Rates of Upper GI Complications in Men Receiving Regular Treatment with Low-Dose Aspirin 1. Patrono C, et al. Blood. 2013;121(10):1701-11.

11. Low-Dose Aspirin in Management of PV Primary prevention with low-dose aspirin (81- 100 mg) is currently recommended for almost all patients with PV 1,2 Risks may include increased risk of bleeding, especially GI bleeds Benefit/risk balance depends on the level of thrombotic and hemorrhagic risks for the individual patient 1. Patrono C, et al. Blood. 2013;121(10):1701-11; 2. Barbui T et al. J Clin Oncol. 2011;29(6):761-770.

12. Hematocrit (Hct) Control is a Key Therapeutic Goal Maintaining Hct <45% significantly decreases the risk of cardiovascular death and major thrombotic events Marchioli R, et al. N Engl J Med. 2013;368(1):22-33.. Death from cardiovascular causes or thrombotic eventsTotal cardiovascular events Low Hct – target <45% High Hct – target 45 – 50%

13. Reducing the Risk of Vascular Complications: Lifestyle Interventions Weight control Physical exercise Adherence to antihypertension, antidiabetes, and/or antihypercholestrolemia/hyperlipidemia medications Avoidance of oral contraceptives Smoking cessation Avoidance of situations that carry a risk of bleeding Vannucchi AM. Blood. 2014 Oct 2. [Epub ahead of print]..

14. Risk-Adapted Management of Patients with PV 1,2 Risk CategoryRisk VariablesTherapy Low Age < 60 years No thrombosis history Phlebotomy, and Correction of CV risk factors, and Aspirin High Age ≥ 60 years and/or Thrombosis history Cytoreduction, and Correction of CV risk factors, and Aspirin, plus/minus Phlebotomy 1. Barbui T et al. J Clin Oncol. 2011;29(6):761-770; 2. Vannucchi AM. Blood. 2014 Oct 2. [Epub ahead of print]; 3. Marchioli R, et al. N Engl J Med. 2013;368(1):22-33; 4. Stein BL, et al. Ann Hematol. 2014; Oct 2 [Epub ahead of print].

15. Case Study (cont.): Trisha K. Classified as ‘Low-Risk’ at diagnosis (age <65 years; no history of thrombosis) Control of hypertension, reduction of CV risk factors Phlebotomies to maintain Hct < 45% plus low-dose aspirin – 9 phlebotomies over the first 3 months, every 1.5 -2 months thereafter – Fatigue related to iron deficiency (repeated phlebotomies) 6 years later, she experienced venous thromboembolism (DVT) in her right leg – Anticoagulation with low-molecular weight heparin (LMWH) was instituted at time of thrombosis followed by vitamin K antagonists – She had a good outcome

16. Case Study (cont.): Trisha K. Due to her DVT event and underlying PV, she is at high-risk for re-thrombosis. Q: Despite her younger age (38 years), Trisha is now at high risk for thrombosis (high-risk PV). What would you suggest for management? A.Continue with phlebotomy plus low-dose aspirin B.Maintain on oral anticoagulation instead of aspirin C.Combine oral anticoagulation and aspirin D.Institute oral anticoagulation plus cytotreductive therapy (hydroxyurea or interferon) E.Other strategy

17. Case Study (cont.): Trisha K. Due to her DVT event and underlying PV, she is at high-risk for re-thrombosis. Q: Despite her younger age (38 years), Trisha is now at high risk for thrombosis (high-risk PV). What would you suggest for management? A.Continue with phlebotomy plus low-dose aspirin B.Maintain on oral anticoagulation instead of aspirin C.Combine oral anticoagulation and aspirin D.Institute oral anticoagulation plus cytotreductive therapy (hydroxyurea or interferon) E.Other strategy

18. Risk-Adapted Treatment for Patients with High-Risk PV High risk  If prior thrombosis or age >60 years or poor compliance to phlebotomy  Or progressive myeloproliferation (splenomegaly, leukocytosis, thrombocytosis)  First-line cytoreductive therapy is hydroxyurea or interferon alfa. Busulfan in age >75 years Barbui T et al. J Clin Oncol. 2011;29(6):761-70; Trisha K. managed with oral anticoagulation plus interferon alfa therapy

19. PV is a Progressive Disease Estimated probability of evolution to post-PV MF (N=116): 16% at 10 years and 34% at 15 years 1 Events During the Clinical Course (N=1543) 2 1. Alvarez-Larran A, et al. Br J Haematol. 2009;146(5):504-509; 2. Tefferi A et al. Leukemia 2013;27:1874-81. All patients (n=1543) Age >61 years (n = 743) Age ≤ 61 years (n=802) P-value Median follow-up, years (range)6.9 (0-39)5.8 (0-22)8 (0-39) Progression to myelofibrosis138 (9%)50 (7%)88 (11%)0.004 Leukemic transformation50 (5%)25 (3%) NS Deaths347 (23%)237 (32%)110 (14%)< 0.0001 Most common causes of death (>10 pts) 2 ─Acute leukemia - 36 ─Second malignancy - 36 ─Thrombotic complications – 32 ─Heart failure – 13 ─Non-leukemic progressive disease – 12

20. Adverse Prognostic Factors in Patients with PV Tefferi A et al. Leukemia 2013;27:1874-81. Adverse Prognostic Factors Age > 67 yrs (5 points) Age 57-66 yrs (2 points) Leukocyte count >15 x 10 9 /L (1 point) Venous thrombosis (1 point) Low risk – 0 points Intermediate risk - 1 or 2 points High risk - >3 points Based on this prognostic model, Trisha K is ‘Intermediate Risk’ Leukocyte count >15 x 10 9 /L (1 point) Venous thrombosis (1 point)

21. Case Study (cont.): Trisha K. Managed with oral anticoagulation plus interferon alfa therapy. Two years later: – Increasing constitutional symptoms (esp. pruritus) – Unintentional weight loss of 5% in past 4 months; full on smaller meals – Worsening leukocytosis (22 x 10 9 /L) and thrombocytosis – Newly palpable spleen (3 cm)

22. Case Study (cont.): Trisha K. Q: How can we tell if the patient has progressed to post-PV MF? A.Re-evaluate PV risk status B.Assess JAK2 allele burden C.Perform bone marrow biopsy D.Obtain cytogenetic profile

23. Case Study (cont.): Trisha K. Managed with oral anticoagulation plus interferon alfa therapy. Two years later: – Increasing constitutional symptoms (esp. pruritus) – Unintentional weight loss of 5% in past 4 months; full on smaller meals – Worsening leukocytosis (22 x 10 9 /L) and thrombocytosis – Newly palpable spleen (3 cm) Q: How can we tell if the patient has progressed to post-PV MF? A.Re-evaluate PV risk status B.Assess JAK2 allele burden C.Perform bone marrow biopsy D.Obtain cytogenetic profile

24. IWG-MRT Criteria for the Diagnosis of Post-PV-MF 3 of 4 additional criteria 1 of 2 required criteria Diagnosis of PPV-MF requires at least two additional criteria beyond the two main criteria. According to the European classification (scale 0-3) or standard classification (scale 0-4) ** Below the reference range for appropriate age, sex, gender, and altitude considerations.

25. European Classification (scale 0-3) on Grading of Bone Marrow Fibrosis in MF* O1 23 GradeDescription MF - 0Scattered linear reticulin with no intersections consistent with normal bone marrow MF - 1Loose meshwork of thin reticulin fibers with many intersections MF - 2Diffuse and dense increase in reticulin with extensive intersection, occasionally with only focal bundles of collagen and/or focal osteosclerosis MF - 3Diffuse and dense increase in reticulin with extensive interaction with coarse bundles of collagen, often associated with significant osteosclerosis Silver impregnation after Gomori ; x180 Thiele J et al. Haematologica 2005; 90:1128-1132. *Grade 2 or 3 required for post PV-MF criteria

26. Standard Classification (scale 0-4) on Grading of Bone Marrow Fibrosis in MF* 0-4: Reticulin silver stain; x200. *Grade 3 or 4 required for post PV-MF criteria O1 23 Kuter DJ et al. Br J Haematol. 2007; 139: 351–362. 4 Collagen fibers (blue) – Mason’s trichrome stain GradeDescription 0Staining of small vessel walls (confirms stain was successful); no staining in the surrounding bone marrow. 1Short, thin reticulin fibers, but these do not intersect to form a network. 2Network of thin reticulin fibers with numerous intersections. 3Network of reticulin fibers, including thick and reduplicated fibers. 4Dense network of thick reticulin fibers throughout the bone marrow.

27. Case Study (cont.): Trisha K. Clinical findings (review) – Increasing constitutional symptoms (esp. pruritus and night sweats) – Spleen is now palpable (3 cm) – Worsening leukocytosis (32 x 10 9 /L); reduced need for phlebotomy – No peripheral blasts Bone marrow biopsy findings: Grade 1 fibrosis (0-3 scale) (ie, loose meshwork of thin reticulin fibers with many intersections) Megakaryocyte proliferation, atypia Increased JAK2 allele burden vs baseline assessment (at diagnosis)

28. Case Study (cont.): Trisha K. Q: Which of the below best describes this patient’s clinical picture? A.Adequately controlled PV B.Uncontrolled/advancing PV C.Progression to post-PV myelofibrosis D.Transformation to leukemia

29. Case Study (cont.): Trisha K. Q: Which of the below best describes this patient’s clinical picture? A.Adequately controlled PV B.Uncontrolled/advancing PV – Grade 1 BM fibrosis is not sufficient for post-PV MF diagnosis C.Progression to post-PV myelofibrosis D.Transformation to leukemia

30. Case Study (cont.): Trisha K. Diagnosis of PPV-MF requires at least two additional criteria beyond the two main criteria. According to the European classification (scale 0-3) or standard classification (scale 0-4) ** Below the reference range for appropriate age, sex, gender, and altitude considerations. IWG-MRT Criteria for the diagnosis of Post-PV-MF 3 of 4 additional criteria 1 of 2 required criteria

31. Case Study (cont.): Trisha K. Interferon therapy was stopped and she was started on hydroxyurea (HU) to manage cytopenias and splenomegaly (with continued oral anticoagulation) 6 Phlebotomy + low-dose aspirin 8 IFN-alfa + oral anticoagulation HU + oral anticoagulation 0 Years from PV diagnosis To date, no therapeutic used to treat PV has been proven to prevent transformation to post-PV MF

32. HU Resistance and/or Intolerance in PV 20-25% of patients will become resistant and/or intolerant to HU 1,2 – Increased complications and symptom burden – Worsening disease transformation – Reduced survival Criteria 3 HU Resistance - After 12 weeks of HU, at a total dose ≥2 g/day: – Need for phlebotomy to maintain Hct at <45% – Elevated platelet and WBC counts or – <50% reduction in splenomegaly or failure to completely relieve splenomegaly symptoms HU Intolerance – Leg ulcers or other unacceptable HU-related toxicity – ANC <1 x 10 9 /L or Hgb <10 g/dL 1. Sever M et al. Leuk Lymphoma. 2014; Early Online: 1-6; 2. Stein BL, et al. Ann Hematol. 2014; Oct 2 [Epub ahead of print]; 3. Barbui T et al, J Clin Oncol 2011;29(6):761–70.

33. Ruxolitinib (JAK1/JAK2 Inhibitor) in the Treatment of MPNs IndicationUS Approval Date Patients with intermediate or high-risk myelofibrosis, including primary myelofibrosis, post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis 2011 Patients with polycythemia vera who have had an inadequate response to or are intolerant of hydroxyurea * Dec 2014 * For PV, the approved starting dose is 10 mg orally twice daily. Jakafi (ruxolitinib) prescribing information, 2014.

34. Phase III Study of Ruxolitinib vs BAT (RESPONSE) Primary endpoint (composite): % of patients who achieved both Hct control and spleen response at week 32 – Hct control: No phlebotomy eligibility from week 8 to 32, with no more than 1 post- randomization phlebotomy eligibility up to week 8 Phlebotomy eligibility was defined as Hct > 45% and ≥ 3% higher than baseline or > 48% – Spleen response : ≥ 35% reduction from baseline in spleen volume by MRI BAT Week 32 (primary endpoint) Week 80 n = 110 n = 112 Crossover to ruxolitinib Resistance to or intolerance of HU (modified ELN criteria) Phlebotomy requirement Splenomegaly Pre-randomization (day −28 to day −1) Hct 40%-45% Randomized (1:1) Extended treatment phase Ruxolitinib 10 mg BID Week 208 Week 48 Verstovsek S et al. J Clin Oncol 2014;32 (5s): Abstract 7026.

35. RESPONSE (Primary Response at Week 32) Phase 3 study of ruxolitinib in PV patients resistant to or intolerant of HU (N = 222) SV, spleen volume. P <.0001 OR, 28.64 (95% CI, 4.50-1206) Primary EndpointIndividual Components of Primary Endpoint To achieve Hct control, patients could not be eligible for phlebotomy based on protocol-defined Hct values –Phlebotomy eligibility defined as Hct > 45% and ≥ 3% higher than baseline or a Hct > 48% 91% of patients who achieved the primary endpoint had a confirmed response at week 48 Verstovsek S et al. J Clin Oncol 2014;32 (5s): Abstract 7026.

36. RESPONSE: Improvement in Symptoms Percentage of Patients With a ≥ 50% Improvement in MPN-SAF Symptom Score at Week 32 a a In patients with scores at both baseline and week 32. MPN-SAF, Myeloproliferative Neoplasm Symptom Assessment Form. MPN-SAF Total Symptom Score Cytokine Symptom Cluster Hyperviscosity Symptom Cluster Splenomegaly Symptom Cluster Tiredness Itching Muscle ache Night sweats Sweating while awake Headache Concentration problems Dizziness Skin redness Vision problems Ringing in ears Numbness/tingling in hands/feet Fullness/early satiety Abdominal discomfort n = 7481 7480 7180 6371 Verstovsek S et al. J Clin Oncol 2014;32 (5s): Abstract 7026.

37. RESPONSE: Thromboembolic Events to Week 32 Patients, n (%) Ruxolitinib (n = 110) BAT (n = 111) All gradeGrade 3/4All gradeGrade 3/4 All thromboembolic events1 (0.9) 6 (5.4) a 2 (1.8) a Portal vein thrombosis1 (0.9) 00 Myocardial infarction001 (0.9) Deep vein thrombosis002 (1.8)1 (0.9) Pulmonary embolism001 (0.9) Splenic infarction001 (0.9)0 Thrombophlebitis001 (0.9)0 Thrombosis001 (0.9)0 A higher proportion of patients in the ruxolitinib arm had a history of prior thromboembolic events at baseline than in the BAT arm (35.5% vs 29.5%) There was 1 additional event in the ruxolitinib group over the course of randomized treatment (median exposure 81 weeks) a 1 patient in the BAT group had both myocardial infarction and pulmonary embolism. Verstovsek S et al. J Clin Oncol 2014;32 (5s): Abstract 7026.

38. RESPONSE: Nonhematologic Adverse Events to Week 32 (Regardless of Causality) Patients, % Ruxolitinib (n = 110) BAT (n = 111) All GradesGrade 3/4All GradesGrade 3/4 Headache16.40.918.90.9 Diarrhea14.507.20.9 Fatigue14.5015.32.7 Pruritus13.60.922.53.6 Dizziness11.809.90 Muscle spasms11.80.94.50 Dyspnea10.02.71.80 Abdominal pain9.10.911.70 Asthenia7.31.810.80 Events occurring in at least 10% of patients in either treatment group. When adjusted for exposure (per 100 patient-years), the rates of adverse events and grade 3/4 adverse events over the entire course of treatment were lower in patients randomized to ruxolitinib compared with those randomized to BAT (64.7 vs 145.6 and 28.8 vs 44.0) Rate of herpes zoster infection was higher in the ruxolitinib group (6.4% vs 0; all grade 1-2) Verstovsek S et al. J Clin Oncol 2014;32 (5s): Abstract 7026.

39. RESPONSE: New or Worsening Hematology Laboratory Values to Week 32 Patients, % Ruxolitinib (n = 110) BAT (n = 111) All GradesGrade 3/4All GradesGrade 3/4 Hemoglobin (low)43.61.830.60.0 Platelets (low)24.55.518.93.6 Neutrophils (low)1.80.98.10.9 No patients discontinued treatment because of anemia or thrombocytopenia Verstovsek S et al. J Clin Oncol 2014;32 (5s): Abstract 7026.

40. Case Study (conclusion): Trisha K. Trisha’s case illustrates a clinical course for a typical PV patient (i.e., high thrombotic risk as well as progressing underlying PV disease) She has taken JAK inhibitor therapy (ruxolitinib) for 2 months – Good spleen response and symptom improvement – We monitor CBC every 2-4 weeks – Treatment-related cytopenias managed with dose modifications

41. Conclusions Contemporary treatment for patients with PV combines: – Modification of CV risk factors – Antiplatelet therapy – Phlebotomy – Cytoreduction (HU, IFN-alfa, busulfan) Recently, ruxolitinib demonstrated benefit in PV patients resistant or intolerant to HU (RESPONSE trial)