1. 1 Emerging Therapies in MDS: A Focus on Epigenetics Click to edit Master subtitle style

2. 2 Myelodysplastic Syndrome (MDS) Epidemiology 10,000-15,000 estimated new cases/year in US (adults) 10,000-15,000 estimated new cases/year in US (adults) More common than acute myeloid leukemia (AML) More common than acute myeloid leukemia (AML) –8,000 new cases/year in US Predominantly a disease of the elderly Predominantly a disease of the elderly –Median age > 60 –Incidence greater in men than in women –Incidence increases with age Median survival 3 months to 6 years depending on risk category Median survival 3 months to 6 years depending on risk category Myelodysplastic syndromes detailed guide. American Cancer Society. Available at www.cancer.org. Accessed 6/20/06. Xie Y, et al. Cancer. 2003;97(9):2229-35; American Cancer Society, www.cancer.org; Aplastic Anemia and MDS International Foundation, www.aamds.org; Kurzrock R. Semin Hematol. 2002;39(3 Suppl 2):18-25; Steensma DP, Tefferi A. Leuk Res. 2003;27(2):95-120. Greenberg P, et al. Blood. 1997;89:2079-88.

3. 3 Risk Factors for MDS Greatest risk factor appears to be advancing age Greatest risk factor appears to be advancing age –80%  90% of all patients with these disorders > than 60 years Previous cancer therapy Previous cancer therapy –Mechlorethamine, procarbazine, chlorambucil, etoposide, teniposide (with or without concomitant radiation therapy) and other chemotherapy agents Exposure to environmental toxins Exposure to environmental toxins –Benzene, organic solvents, pesticides, radiation Tobacco smoke Tobacco smoke Cigarette smoking Cigarette smoking Congenital disorders Congenital disorders Familial disorder Familial disorder Male sex Male sex Myelodysplastic syndromes detailed guide. American Cancer Society. Available at www.cancer.org; accessed 6/20/06. Frogge MH, et al. CE monograph published by Oncology Education Services, Inc. Pittsburgh, PA, 2005. List AF, et al. Hematology. 2004;297-317.

4. 4 Symptoms of MDS Many patients have no apparent symptoms, but are diagnosed after routine laboratory tests uncover abnormalities in the circulating blood cells Many patients have no apparent symptoms, but are diagnosed after routine laboratory tests uncover abnormalities in the circulating blood cells Fatigue is the most common symptom of MDS Fatigue is the most common symptom of MDS Early symptoms of MDS may include: Early symptoms of MDS may include: –Bruising –Increased bleeding (ie, nose and gum bleeds) –Rash –Shortness of breath –Rapid heart rate –Weight loss –Fever –Loss of appetite None of these symptoms are specific to MDS, and may be attributable to other conditions None of these symptoms are specific to MDS, and may be attributable to other conditions Myelodysplastic syndromes detailed guide. American Cancer Society. Available at www.cancer.org. Accessed 6/20/06. Frogge MH, et al. CE monograph published by Oncology Education Services, Inc, Pittsburgh, PA, 2005.

5. 5 Diagnosis of MDS Key Features Evidence of ineffective hematopoiesis (anemia, neutropenia, thrombocytopenia) Evidence of ineffective hematopoiesis (anemia, neutropenia, thrombocytopenia) Hypercellular marrow (rarely, hypocellular marrow) Hypercellular marrow (rarely, hypocellular marrow) Evidence of dysplasia by bone marrow examination – typically in more than one lineage Evidence of dysplasia by bone marrow examination – typically in more than one lineage List AF, et al. Hematology. 2004;297-317. Myelodysplastic syndromes detailed guide. American Cancer Society. Available at www.cancer.org. Accessed 6/20/06.

6. 6 MDS Classification French-American-British (FAB) French-American-British (FAB) World Health Organization (WHO) World Health Organization (WHO) International Prognostic Scoring System (IPSS) International Prognostic Scoring System (IPSS) Bennett J, et al. Br J Haematol. 1982;51:189-99. Harris N, et al. Ann Oncol. 1999;10:1419-32. Greenberg P, et al. Blood. 1997;89:2079-88.

7. 7 MDS FAB (French-American- British) Classification Category % Blasts in Bone Marrow Survival in Months RA (Refractory anemia) RARS (Refractory anemia with ringed sideroblasts) RAEB (Refractory anemia with excess blasts) RAEB-T (Refractory anemia with excess blasts in transformation) CMMoL (Chronic myelomonocytic leukemia) < 5% 5-20%21-30%1-20%19–6421–767–155–128–60+ List AF, et al. The myelodysplastic syndromes. In: Wintrobe’s Hematology 2003. Bennett J, et al. Br J Haematol. 1982;51:189-99.

8. 8 MDS World Health Organization (WHO) Classification Revised MDS classification proposed in 2000 Revised MDS classification proposed in 2000 Changes included: Changes included: –Eliminated RAEB-T –Redefined AML as  20% blasts –Recognize prognostic impact of multilineage dysplasia in RA and RARS and isolated interstitial deletion of chromosome 5q –CMMoL = Myelodysplastic/myeloproliferative disorder May provide more uniform and accurate prognostic data May provide more uniform and accurate prognostic data Steensma DP, et al. Leuk Res. 2003;27:95-120. Harris N, Jaffe E, Diebold J, et al. Ann Oncol. 1999;10:1419-32.

9. 9 MDS International Prognostic Scoring System (IPSS) The first comprehensive prognostic scoring system adopted The first comprehensive prognostic scoring system adopted Patients are stratified into four well-defined risk groups according to survival and AML transformation Patients are stratified into four well-defined risk groups according to survival and AML transformation Scoring system based on percentage of bone marrow blasts, karyotype, and cytopenias Scoring system based on percentage of bone marrow blasts, karyotype, and cytopenias Greenberg P, et al. Blood. 1997:89(6):2079-88.

10. 10 MDS Subtypes IPSS Greenberg P, et al. Blood.1997:89(6):2079-88. *Good: Normal, -Y, del(5q), del(20q); Poor: Complex(>3abnl) or Chr 7 abnl; Intermediate: All others. Score Prognostic Variable00.51.01.52.0 Bone marrow blast (%) Karyotype*Cytopenias < 5 Good0/15-10Intermediate2/3–Poor11-2021-30 Prognosis ScoreIPSS Subgroup Median AML Transformation (yrs) Median Survival (yrs)00.5-1.01.5-2.0>2.5LowIntermediate-1Intermediate-2High9.43.31.10.25.73.51.20.4

11. 11 Causes of Death in MDS Greenberg P, et al. Blood. 1997;89:2079-2088. No. of Patients Who: Subgroups No. of PatientsDied (%) Died With Leukemia (%) Died Without Leukemia (%) Low235 113 (48) 22 (19) 91 (81) Int-1295 181 (61) 55 (30) 126 (70) Int-2171 147 (86) 49 (33) 98 (67) High58 51 (88) 23 (45) 28 (55) Total759 492 (65) 149 (30) 343 (70)

12. 12 Goals of Therapy in MDS Select the therapy best suited for the individual Select the therapy best suited for the individual –Performance status, disease classification, IPSS score (cytogenetics, cytopenias, BM blasts), and treatment tolerance Low/Int-1 IPSS: Improve blood counts (decrease transfusions and infections) Low/Int-1 IPSS: Improve blood counts (decrease transfusions and infections) Improve quality of life Improve quality of life Int-2/high-risk IPSS: Prolong survival and delay leukemic progression Int-2/high-risk IPSS: Prolong survival and delay leukemic progression –Possible cure of disease List AF, et al. Hematology (Am Soc Hematol Educ Program). 2004;297-317. Cheson BD, et al. Blood. 2000:96:3671. NCCN Myelodysplastic Panel Members. Available at: http://www.nccn.org/professionals/physician_gls/PDF/mds.pdf

13. 13 MDS Treatments MDS Treatments Best supportive care Best supportive care –Transfusions (RBCs, platelets) –Chelation therapy –Colony-stimulating factors (EPO ± G-CSF or GM-CSF) Chemotherapy Chemotherapy Anti-thymocyte globulin (ATG) ± cyclosporin in patients with hypocellular MDS Anti-thymocyte globulin (ATG) ± cyclosporin in patients with hypocellular MDS Stem cell transplant Stem cell transplant –Best candidates are younger patients with low % blasts and preserved platelet counts 1 –Median age at transplant (IBMTR data) = 38 yrs old 1 Hypomethylating agents Hypomethylating agents Immunomodulatory drugs Immunomodulatory drugs Other novel agents Other novel agents –HDAC inhibitors, farnesyl transferase inhibitors etc. 1 Sierra J, et al. Blood. 2002;100:1997-2004.

14. 14 IPSS CATEGORYTreatment Low, INT-1 Supportive care Anemia Serum Epo > 500 mU/ml Thrombocytopenia, neutropenia Clinically significant cytopenia(s) Serum Epo ≤ 500 mU/ml HLADR-15 + HLADR-15 - Epoetin alfa (EPO) ± G-CSF No response Azacitidine/ Decitabine or Clinical trial No response Clinical trial Antithymocyte Globulin (ATG), Cyclosporin A Azacitidine/ Decitabine or Clinical trial No response No response Clinical trial Azacitidine/ Decitabine No response ATG or Clinical trial NCCN Guidelines-Low Risk National Comprehensive Cancer Network (NCCN) guidelines v.4.2006. For more information see: http://www.nccn.org. del(5q) Lenalidomide No response Follow appropriate pathway below

15. 15 INT-2, HIGH Not intensive therapy candidate Intensive therapy Candidate * Donor available Yes No Hemopoietic stem cell transplant (HSCT) High intensity therapy r or Supportive care Azacitidine/Decitabine or Clinical trial or Supportive care * Based on age, performance status and absence of major comorbid medical conditions that would preclude high dose therapy. National Comprehensive Cancer Network (NCCN) guidelines v.4.2006. High-Intensity Therapy: Clinical Trials (preferred) Investigational therapy preferred. Standard induction therapy if investigational protocol unavailable or as a bridge to HSCT. (See text for more detail) Hemopoietic stem cell transplant (HSCT) allogeneic-matched sibling including standard and (experimental) reduced intensity preparative approaches or matched unrelated donor (MUD) IPSS CATEGORY Treatment NCCN Guidelines-High Risk

16. 16 Overview of Epigenetics and Its Role in MDS

17. 17 SAM SAH NH 2 H N NOH Cytosine NH 2 CH 3 N NOH 5-Methyl- Cytosine MTASE Cytosine DNA Methylation SAM = S-adenosyl methionine; SAH = S-adenosyl homocysteine. www.mdanderson.org/leukemia/methylation.

18. 18 MMM MMMMMMMMM Expressed (or ready for expression) Silenced Imprinted genes, Inactive X Ectopically Silenced Genes (e.g. tumor suppressor genes) Hypermethylation and Silencing Courtesy of Issa, JP

19. 19 Tumor Suppressor Gene Methylation p15 INK4b p15 INK4b –Inhibitor of the cyclin-dependent kinases CDK4 and CDK6 –Plays a role in transforming growth factor-  (TGF-  )-mediated growth inhibition –Inactivated by hypermethylation in hematopoietic neoplasms (AML, ALL, MDS, and Burkitt’s lymphoma) Quesnel, et al. Blood. 1998;91:2985.

20. 20 Association Between Survival and p15 Methylation Status in MDS Quesnel B, et al. Blood. 1998;91:2985-90. Methylated Unmethylated P =.049

21. 21 Hypomethylating Agents

22. 22 Hypomethylating Cytosine Analogs Santini V, et al. Ann Intern Med. 2001;134(7):573-86. N O NH 2 N N O N CH 3 N O NH 2 N N Ribose N O NH 2 N N Deoxyribose 5-aza-cytidine5-aza-2′-deoxycytidine5-methyl-cytosineCytosine (azacitidine) (decitabine)

23. 23 How Hypomethylating Agents Work Act as cytosine nucleoside analogs that reverse aberrant DNA methylation Act as cytosine nucleoside analogs that reverse aberrant DNA methylation Incorporate into DNA and trap DNA- methyltransferase, depleting cells of DNA- methyltransferase Incorporate into DNA and trap DNA- methyltransferase, depleting cells of DNA- methyltransferase Decitabine contains deoxyribose and is incorporated into DNA while azacitidine, which contains ribose, is incorporated into both RNA and DNA Decitabine contains deoxyribose and is incorporated into DNA while azacitidine, which contains ribose, is incorporated into both RNA and DNA –10-20% azacitidine incorporation into DNA Leone G, et al. Haematologica. 2002;87:1324-41; Kuykendall JR. The Annals of Pharmacotherapy.2005;39:1700-1709.

24. 24 Mechanism of Epigenetic Therapy STOP Fully methylated DNA Silencing DNA replication Mtase Epigenetic Therapy STOP Maintained Silencing Fully methylated DNA Unmethylated DNA Reactivated Gene Expression Hemi-methylated DNA CH 3 Differentiation - Apoptosis - Senescence - Enhanced Immune Response Courtesy of Issa JP.

25. 25 Phase 3 Clinical Experience with Decitabine in Advanced MDS

26. 26 Decitabine Phase 3 Study Design (D-0007) Open-label, 1:1 randomized, multicenter study in US and CA Open-label, 1:1 randomized, multicenter study in US and CA Schedule: 3-hour infusion of 15 mg/m 2 q 8 hrs x 3 days Schedule: 3-hour infusion of 15 mg/m 2 q 8 hrs x 3 days Eligible Patients (n = 170) Decitabine + Supportive Care* (n = 89) RANDOMIZEDRANDOMIZED Supportive Care* (n = 81) Stratification IPSS classification Prior chemotherapy Study center *Antibiotics, growth factors, and/or transfusions. Kantarjian, et al. Cancer. 2006;106:1794-1803.

27. 27 Decitabine Phase 3 Patient Eligibility and Study Design Patient population Patient population –de novo or secondary MDS –IPSS  0.5; all FAB subgroups Primary endpoints Primary endpoints –Overall response rate (CR + PR), IWG criteria –Time to AML transformation or death In the primary endpoint analysis, a P value less than.024 was required to achieve statistical significance In the primary endpoint analysis, a P value less than.024 was required to achieve statistical significance Secondary endpoints Secondary endpoints –Duration of response, cytogenetic response rate, transfusion requirements, QOL, survival, febrile neutropenia, toxicity Kantarjian HM, et al. Cancer. 2006;106:1794-1803.

28. 28 Decitabine Phase 3 IWG Response Criteria Independent review of bone marrow and best response Independent review of bone marrow and best response Complete response (CR) Complete response (CR) –<5% blasts in bone marrow –Hgb  11, ANC  1500, platelets > 100,000, no blasts –No dysplasia –No transfusions or growth factors –Minimum duration 8 weeks Partial response (PR) Partial response (PR) –50% decrease in marrow blasts –Other response criteria same as CR IWG = international working group; Hgb = hemoglobin; ANC = absolute neutrophil count. Kantarjian HM, et al. Cancer. 2006;106:1794-1803. Cheson BD. Blood. 2000;96:3671-74.

29. 29 Decitabine Phase 3 Demographics (ITT Population) Parameters Decitabine n = 89 (%) Supportive Care n = 81 (%) Sex (male) 59 (66) 57 (70) Median Age 7070 Median Time From Diagnosis (months) 7.38.8 Type of MDS De novo Secondary 77 (87) 12 (13) 70 (86) 11 (14) Previous MDS Therapy 20 (22) 16 (20) IPSS High risk High risk Intermediate-2 Intermediate-2 Intermediate-1 Intermediate-1 23 (26) 38 (43) 28 (31) 21 (26) 36 (44) 24 (30) ITT = intent to treat. Kantarjian HM, et al. Cancer. 2006;106:1794-1803.

30. 30 Decitabine Phase 3 Response to Decitabine (ITT) IWG Response Rate, Onset, and Duration* Decitabine (n = 89) Supportive Care (n = 81) Overall Response Rate (CR+PR) Complete response (CR) Partial response (PR) Hematologic improvement (HI) 15 (17%) † 8 (9%) 7 (8%) 12 (13%) 0 (0%) 0 (0%) 0 (0%) 6 (7%) † † P value <.001 from two-sided Fisher’s exact test Onset and Duration of Response (Months) Median time to response (CR+PR) Median duration of response (CR+PR) 3.3 (2.0 – 9.7) 10.3 (4.1 - 13.9) ‡ N/A Best response observed after 2 cycles (median number of cycles = 3) *Cheson BD. Blood. 2000 96:3671-74. ‡ Kantarjian HM, et al. Cancer. 2006;106:1794-1803. ‡ For patients with a confirmed date of progression.

31. 31 Response in Patients with AML at Baseline *IWG AML Response Criteria. † One patient was a CRi (morphologic complete remission with incomplete blood count recovery). Cheson et al. J Clin Oncol. 2003;21:4642-49; Kantarjian HM, et al. Cancer. 2006;106:1794-1803; Data on File, MGI PHARMA. Decitabine n = 9 (%) Supportive Care n = 3 (%) Overall Response* 5 (56) 3 (33) 2 (22) Complete Response † 0 (0) Partial Response 0 (0)

32. 32 Decitabine Phase 3 Median Time to AML or Death MDS Group Decitabine Months (range) Supportive Care Months (range) Log-rank P Value All Patients 12.1 (0.3*-22.3) n = 89 7.8 (0.3-21.0*) n = 81.160 Treatment Naive 12.3 (0.3*-20.1*) n = 69 7.3 (0.3-21.0*) n = 65.082 Int-2/ High Risk 12.0 (0.4*-22.3) n = 61 6.8 (0.3-21.0*) n = 57.028 High Risk 9.3 (0.4*-19.9) n = 23 2.8 (0.3-13.5) n = 21.010 * * Censored data. Kantarjian HM, et al. Cancer. 2006;106:1794-1803; Data on File, MGI PHARMA.

33. 33 Decitabine Phase 3 Survival by Response 0 50100150200250300350400450500550600650700750800 Days 0 10 20 30 40 50 60 70 80 90 100 Percent Alive Analyzed population = All patients Nonresponders (N=155) Responders (N=15) Kantarjian HM, et al. Cancer. 2006;106:1794-1803. P =.007

34. 34 Decitabine Phase 3 Cytogenetic Evaluations Patients Evaluable for Cytogenetic Evaluations Decitabine n = 26 (%) Supportive Care n = 21 (%) Cytogenetic responses Major Response Minor Response 9* (35) 1 (4) 2 (10) – *1 additional patient who was randomized to supportive care crossed over to decitabine and had a major cytogenetic response and clinical CR. Kantarjian HM, et al. Cancer. 2006;106:1794-1803.

35. 35 Decitabine Phase 3: Percent of Patients RBC Transfusion-Free Per Cycle % of Patients RBC Transfusion-Free 0 10 20 30 40 50 60 70 80 90 100 0123456 Decitabine Supportive Care Note: Last cycles less than 35 days long with 0 transfusions are not considered in this analysis. Kantarjian HM, et al. Cancer. 2006;106:1794-1803. Decitabine N=89836444372623 Supportive Care N=81756340282315

36. 36 Quality of Life Measure Percent Change from Baseline for Global Health Status -25 -15 -5 5 15 25 35 45 % Change From Baseline * * Cycle 1Cycle 2Cycle 3Cycle 4Cycle 5Cycle 6 * P <.05 Decitabine Supportive Care Kantarjian HM, et al. Cancer. 2006;106:1794-1803.

37. 37 Decitabine Phase 3 Adverse Events (>10% Incidence) Decitabine (n = 83)* Supportive Care (n = 81) Grade 3Grade 4Grade 3Grade 4 Hematologic Neutropenia10%77%25% Thrombocytopenia22%63%27%16% Anemia11%1%14%1% Febrile neutropenia17%6%4%0% Nonhematologic Pneumonia13%2%7%2% Kantarjian et al. Cancer. 2006;106:1794-1803. *Exposed to decitabine.

38. 38 Decitabine Phase 3 Summary and Conclusions Decitabine therapy was superior to supportive care Decitabine therapy was superior to supportive care –Response rate 17% (CR 9%, PR 8%) –Durable responses (median 10.3 months) –Responders remained or became transfusion independent and symptoms improved Delayed time to AML progression or death Delayed time to AML progression or death Responders had longer survival Responders had longer survival –24 months responders vs 14 months in non- responders (P =.007) Well tolerated with manageable toxicity profile Well tolerated with manageable toxicity profile Kantarjian et al. Cancer. 2006;106:1794-1803.

39. 39 Decitabine Exposure in Phase 2 and 3 Studies Multiple cycles of decitabine therapy may be required for optimal response Multiple cycles of decitabine therapy may be required for optimal response Phase 2Phase 3 91-0195-1197-19D-0007 N29668789 ORR (CR + PR)13 (45%)17 (26%)23 (26%)15 (17%) CR8 (28%)14 (21%)19 (22%)8 (9%) PR5 (17%)3 (5%)4 (5%)7 (8%) Median # cycles4443 Saba HI, et al. Blood. 2005;106:706a [abstract 2515]. Kantarjian HM, et al. Cancer. 2006;106:1794-1803. Saba HI, et al. Semin Hematol. 2005;42(3 suppl 2): S23-S31. Wijermans PW, et al. Leukemia. 1997;11:1-5. Wijermans PW, et al. J Clin Oncol. 2000;18:956-962.

40. 40 Alternative Dosing with Decitabine

41. 41 Decitabine Reduced-Dose Schedule (100 mg/m 2 /course): 3-Arm Dosing Study 3 decitabine treatment arms: 3 decitabine treatment arms: –10 mg/m 2 IV over 1 hr daily x 10 days –20 mg/m 2 IV over 1 hr daily x 5 days –20 mg/m 2 SQ (10 mg SQ BID) daily x 5 days Preferential randomization to arm with higher CR started after 45 th patient Preferential randomization to arm with higher CR started after 45 th patient Courses were given every 4 weeks Courses were given every 4 weeks Total = 100 mg/m 2 /course (75% of phase 3 MDS trial dose) Total = 100 mg/m 2 /course (75% of phase 3 MDS trial dose) Study group Study group –95 patients treated (77 MDS, 18 CMML) –65% patients Int-2/High Risk –69% male, 65% were  60 yrs of age SQ = subcutaneous; CR = complete response. Kantarjian H, et al. Blood. 2006;108(in press). First Edition Paper, prepublished online Aug 1, 2006; DOI 10.1182/blood-2006-05-021162.

42. 42 3-Arm Dosing Study: Overall Response Responsen = 95 (%) Complete Response (CR) 32 (34) Partial Response (PR) 1 (1) Marrow CR 10 (11) Marrow CR + other HI 13 (14) Hematologic Improvement (HI) 13 (14) Single lineage Single lineage 9 (9) 2 or 3 lineage 2 or 3 lineage 4 (4) Objective Response 69 (72%) Kantarjian H, et al. Blood. 2006;108(in press). First Edition Paper, prepublished online Aug 1, 2006; DOI 10.1182/blood- 2006-05-021162.

43. 43 Comparison of outcome and side effects by dose schedule Parameter5 Day IV5 Day SQ10 Day IV n641417 4 (24) 9 Median duration of therapy in mos (range) 5.4 (1.0 – 20.4+) 9.7 (0.5 – 22.9+) 10.8 (1.9 – 17.7+) Median days to granulocytes recovery* 241427 Median days to platelet recovery † 203127 Median days to delivery of subsequent courses 353540 No. courses requiring hospitalization (%) 50 (12) 14 (14) 23 (23) CR / treated (%) 25 (39) 3 (21) Median no. courses 58 o 10 9 /L or aboveTo 50 x 10 9 /L or above *To 10 9 /L or above; † To 50 x 10 9 /L or above; Kantarjian H, et al. Blood. 2006;108(in press). First Edition Paper, prepublished online Aug 1, 2006; DOI 10.1182/blood-2006-05-021162.

44. 44 3-Arm Dosing Study Data Summary Low-dose schedules of decitabine have significant activity Low-dose schedules of decitabine have significant activity –34% complete response rate* and a 73% objective response rate † across all 3 arms The optimal dose was 20 mg/m 2 IV x 5 days (CR = 39%) The optimal dose was 20 mg/m 2 IV x 5 days (CR = 39%) Primary toxicity across all arms was myelosuppression Primary toxicity across all arms was myelosuppression –Lower frequency vs. higher dose regimen The dose of 10 mg/m 2 IV x 10 days was associated with higher incidence of myelosuppression and hospitalization The dose of 10 mg/m 2 IV x 10 days was associated with higher incidence of myelosuppression and hospitalization A dose schedule of 20 mg/m 2 IV x 5 days represents an excellent therapeutic option and offers an alternative dosing schedule A dose schedule of 20 mg/m 2 IV x 5 days represents an excellent therapeutic option and offers an alternative dosing schedule * Response criteria for CR and PR were as for AML but required response durability for at least 4 weeks (PR also requiring that blasts decrease by >50%). † CR + PR + marrow CR + HI. Kantarjian H, et al. Blood. 2006;108(in press). First Edition Paper, prepublished online Aug 1, 2006; DOI 10.1182/blood-2006-05-021162.

45. 45 Phase 3 Clinical Experience with Azacitidine in MDS

46. 46 Azacitidine Phase 3 Study Design (CALGB 9221) RANDOMIZED Supportive Care Eligible Patients (n = 191) ASSESSASSESS HI: Continue Azacitidine + Supportive Care NR: Off study CR: 3 Cycles Silverman LR, et al. J Clin Oncol. 2002;20:2429-40. SC: Pts worsening azacitidine Randomized, crossover trial Schedule: 75 mg/m 2 /day SQ x 7 days q 28 days (n = 92) (n = 99)

47. 47 Azacitidine Phase 3 Patient Eligibility and Study Design Patient population Patient population –FAB classification for MDS –Symptomatic cytopenia requiring active therapy –Cancer-free for 3 years with no radiation or chemotherapy for 6 previous months Endpoints Endpoints –Analysis of response (CR, PR, improved) –Time to treatment failure –Effects on RBC and platelets –Quality of life –Overall survival Silverman LR, et al. J Clin Oncol. 2002;20:2429-40.

48. 48 Azacitidine Phase 3 Response Criteria Complete response (CR) Complete response (CR) –Normal bone marrow or < 5% blasts in the bone marrow –Normal peripheral blood counts –No blasts –No transfusions Partial response (PR) Partial response (PR) –≤ 50% initial bone marrow blasts –Trilineage response –No blasts –No transfusions Improved Improved –Monolineage or bilineage response –Transfusions ≤ 50% of baseline Silverman LR, et al. J Clin Oncol. 2002;20:2429-40.

49. 49 Azacitidine Phase 3 Demographics (ITT Population) Parameters Azacitidine n = 99 (%) Supportive Care n = 92 (%) Sex (male) 72 (73) 60 (65) Median Age 6967 Median Time From Diagnosis (days) 7787 Previous MDS therapy 16 (16) 17 (18) FAB RA RA RARS RARS RAEB RAEB RAEB-T RAEB-T CMMoL CMMoL Other* Other* 17 (17) 5 (5) 32 (32) 27 (27) 7 (7) 11 (11) 20 (22) 3 (3) 34 (37) 18 (20) 7 (8) 10 (11) Silverman LR, et al. J Clin Oncol. 2002;20:2429-40. *Includes 19 AML, one classifiable acute leukemia, and one undefined MDS.

50. 50 Azacitidine Phase 3 Response Rates Azacitidine (n = 99) Supportive Care (n = 92) Overall Response (CR + PR) Complete response Partial response Hematologic improvement 16 (16.2%)* 6 (6.1%) 10 (10.1%) 19 (19%) 0% 6% *P <.0001 (CR + PR) Median Duration of Response (CR + PR + improved) (months) 15 † N/A † 95% CI, 11 to 20 months Kaminskas E. Clin Cancer Res. 2005;11:3604-8. Silverman LR, et al. J Clin Oncol. 2002;20:2429-40.

51. 51 Azacitidine Phase 3 Duration of Response Silverman LR, et al. J Clin Oncol. 2002;20:2429-40. Median duration of response (CR + PR + improved) = 15 months (95% CI, 11- 20 months) Azacitidine Supportive Care 1.0 0.8 0.6 0.4 0.2 0.0 06121824303642 Probability of Continuing in Remission Months Number of Patients at Risk Azacitidine6051342515821 Observation51111000

52. 52 Azacitidine Phase 3 Time to AML Transformation or Death Silverman LR, et al. J Clin Oncol. 2002;20:2429-40. Median time to AML or death: azacitidine – 21 months (95% CI, 16-27 months) and supportive care – 12 months (95% CI, 8-15 months) 1.0 0.8 0.6 0.4 0.2 0.0 06121824303642 Probability of Remaining Event-Free Months 4854 Azacitidine Supportive Care Azacitidine8969553928169200 11Observation82513822151083 Number of Patients at Risk P =.007

53. 53 Azacitidine Phase 3 Effects on RBC and Platelets RBC transfusions decreased over the course of the study with azacitidine treatment – transfusions remained stable or increased on supportive care RBC transfusions decreased over the course of the study with azacitidine treatment – transfusions remained stable or increased on supportive care Patients treated with azacitidine: Patients treated with azacitidine: –51% had an RBC lineage response –47% had a platelet lineage response –41% had a WBC lineage response Silverman LR, et al. J Clin Oncol. 2002;20:2429-40.

54. 54 Azacitidine Phase 3 Quality of Life Azacitidine patients had significantly greater improvement over time in: fatigue (P =.001), physical functioning (P =.002), dyspnea (P =.0014), psychosocial distress (P =.015), and positive affect (P =.0077) Azacitidine patients had significantly greater improvement over time in: fatigue (P =.001), physical functioning (P =.002), dyspnea (P =.0014), psychosocial distress (P =.015), and positive affect (P =.0077) Patients on supportive care experienced declining QOL, but significant improvements were noted in fatigue (P =.0001), physical functioning (P =.004), dyspnea (P =.0002), and general well-being (P =.016) after crossover to azacitidine treatment Patients on supportive care experienced declining QOL, but significant improvements were noted in fatigue (P =.0001), physical functioning (P =.004), dyspnea (P =.0002), and general well-being (P =.016) after crossover to azacitidine treatment Silverman LR, et al. J Clin Oncol. 2002;20:2429-40.

55. 55 Azacitidine Phase 3 Overall Survival Silverman LR, et al. J Clin Oncol. 2002;20:2429-40. Median survival: azacitidine – 20 months (95% CI, 16-26 months) and supportive care – 14 months (95% CI, 12-14 months) 1.0 0.8 0.6 0.4 0.2 0.0 06121824303642 Probability of Survival Months 4854 Azacitidine Supportive Care Azacitidine998271524230211120 21Observation927358382519126 Number of Patients at Risk P =.10

56. 56 Azacitidine Phase 3 Adverse Events For azacitidine patients, the most common treatment-related toxicity was myelosuppression For azacitidine patients, the most common treatment-related toxicity was myelosuppression –Grade 3 or 4 leukopenia = 43% –Grade 3 or 4 granulocytopenia = 58% –Grade 3 or 4 thrombocytopenia = 52% Toxicity was transient – recovery by the next treatment cycle Toxicity was transient – recovery by the next treatment cycle Silverman LR, et al. J Clin Oncol. 2002;20:2429-40.

57. 57 Azacitidine Phase 3 Summary and Conclusions Responses occurred in 35% of patients treated with azacitidine (6% CR, 10% PR, 19% improved) compared with 5% (improved) of supportive care patients Responses occurred in 35% of patients treated with azacitidine (6% CR, 10% PR, 19% improved) compared with 5% (improved) of supportive care patients Median time to AML or death was significantly increased with azacitidine treatment (21 months compared with 13 months for supportive care) Median time to AML or death was significantly increased with azacitidine treatment (21 months compared with 13 months for supportive care) Survival increased with azacitidine treatment (20 months compared with 14 months for supportive care) Survival increased with azacitidine treatment (20 months compared with 14 months for supportive care) Significant improvements in QOL criteria were noted Significant improvements in QOL criteria were noted Kaminskas E. Clin Cancer Res. 2005;11:3604-8; Silverman LR, et al. J Clin Oncol. 2002;20:2429-40.

58. 58 Comparison of Decitabine/D-0007 and Azacitidine/9221 Phase 3 Trials 1 Kantarjian et al. Cancer. 2006;106:1794-1803.; 2 Silverman LR, et al. J Clin Oncol. 2002;20:2429-40; 3 Kaminskas E. Clin Cancer Res. 2005;11:3604-8; 4 Cheson BD. Blood. 2000;96:3671-74. NA = Not available. Parameters Decitabine D-0007 1 Azacitidine CALGB 9221 2,3 Crossover Response Criteria < 5% IWG 4 53% CALGB % of IPSS Int-2/High % of prior therapy Median duration of MDS (months) Median number of treatment cycles 69 22 7.3 3 NA 16 2.8 9 Response Rates CR + PR = 15 (16.9%) CR = 8 (9.0%) CR = 8 (9.0%) PR = 7 (7.8%) PR = 7 (7.8%) CR + PR = 14 (16.2%) CR = 6 (6.1%) PR = 10 (10.1%) Differences in study design make it difficult to compare efficacy

59. 59 Alternative Dosing with Azacitidine

60. 60 Azacitidine Alternative Dosing Schedules 3-Arm Dosing Study Phase 2, multicenter, randomized, open-label trial Phase 2, multicenter, randomized, open-label trial Objective: treatment response in schedules that do not require weekend injections Objective: treatment response in schedules that do not require weekend injections 3 azacitidine treatment arms: 3 azacitidine treatment arms: –75 mg/m 2 /day x 5 days, followed by 2 days of no treatment, followed by 75 mg/m 2 /day x 2 days –50 mg/m 2 /day x 5 days, followed by 2 days of no treatment, followed by 50 mg/m 2 /day x 5 days –75 mg/m 2 /day x 5 days Eligible patients must have a life expectancy of  7 months and ECOG grade of 0-3 Eligible patients must have a life expectancy of  7 months and ECOG grade of 0-3 FAB classification of RA, RARS, RAEB, RAEB-T, CMML FAB classification of RA, RARS, RAEB, RAEB-T, CMML Anthony S, et al. J Clin Oncol. 2006;24(abstr 6574).

61. 61 3-Arm Dosing Study Data Summary of Preliminary Results 75 patients were randomized at the time of presentation; 49 were evaluable 75 patients were randomized at the time of presentation; 49 were evaluable 61% male, median age 74.5 yrs 61% male, median age 74.5 yrs RA and RARS were the most common subtypes RA and RARS were the most common subtypes Of 24 patients RBC transfusion dependent at baseline, 13 (54%) became independent Of 24 patients RBC transfusion dependent at baseline, 13 (54%) became independent –AZA 5-2-2: 8/14 (57%) –AZA 5-2-5: 3/5 (60%) –AZA 5: 2/5 (40%) 2 patients were platelet transfusion dependent at baseline; both became independent 2 patients were platelet transfusion dependent at baseline; both became independent Anthony S, et al. J Clin Oncol. 2006;24(abstr 6574).

62. 62 Considerations When Using Hypomethylating Agents

63. 63 Azacitidine for Injectable Suspension Indications Indications –For treatment of the following MDS subtypes: RA, RARS,* RAEB, RAEB-T, and CMMoL Preparation Preparation –Cytotoxic drug, caution should be used in handling Stability Stability –Reconstituted azacitidine may be stored for up to 1 hour at 25  C or up to 8 hours between 2  and 8  C *If accompanied by neutropenia or thrombocytopenia or requiring transfusions. Vidaza [package Insert]. Boulder, CO: Pharmion Company; 2004.

64. 64 Decitabine for Injection Indications Indications –Previously treated and untreated, de novo and secondary MDS of all French- American-British subtypes (RA, RARS, RAEB, RAEB-T, and CMMoL) and Int-1, Int-2, and high-risk IPSS groups Preparation Preparation –Cytotoxic drug, caution should be used in handling –Aseptically reconstituted with 10 mL of Sterile Water for Injection (USP); immediately after reconstitution, the solution should be further diluted with 0.9% sodium chloride injection, 5% dextrose injection, or lactated Ringer’s injection to a final drug concentration of 0.1 – 1.0 mg/mL Stability Stability –Unless used within 15 minutes of reconstitution, the diluted solution must be prepared using cold (2°C - 8°C) infusion fluids and stored at 2°C - 8°C (36°F - 46°F) for up to 7 hours Dacogen TM [package insert]. Bloomington, Minn; MGI Pharma; 2006.

65. 65 Safety Considerations of Decitabine and Azacitidine –Nausea –Anemia –Thrombocytopenia –Vomiting –Pyrexia –Leukopenia –Diarrhea Vidaza TM [package Insert]. Boulder, CO: Pharmion Company; 2004. DacogenTM [package insert]. Bloomington, Minn; MGI Pharma; 2006. Kantarjian HM, et al. Cancer. 2006;106:1794-1803. –Fatigue –Injection site erythema –Constipation –Neutropenia –Ecchymosis –Cough –Petechiae –Hyperglycemia Most commonly occurring adverse reactions: Most commonly occurring adverse reactions: Patients should be premedicated for nausea and vomiting Patients should be premedicated for nausea and vomiting Blood and platelet counts should be performed at a minimum before each dosing cycle; dose adjustment or delay should be made based on hematology laboratory values Blood and platelet counts should be performed at a minimum before each dosing cycle; dose adjustment or delay should be made based on hematology laboratory values Consider need for early institution of growth factors and/or antimicrobial agents Consider need for early institution of growth factors and/or antimicrobial agents

66. 66 Future Directions for Hypomethylating Agents Other hematologic malignancies: AML, CML Other hematologic malignancies: AML, CML Solid tumors Solid tumors Further studies Further studies –Alternative dose schedules –Mechanisms and targets –Decitabine combinations with: Histone deacetylase inhibitors Histone deacetylase inhibitors Colony-stimulating factors Colony-stimulating factors Immunomodulators Immunomodulators

67. 67 Other Emerging Therapies in MDS: Lenalidomide

68. 68 Lenalidomide Overview An immunomodulatory drug derived from thalidomide An immunomodulatory drug derived from thalidomide Encouraging data have been presented in lower risk MDS patients Encouraging data have been presented in lower risk MDS patients Recently approved by FDA for treatment of MDS patients with del(5q) Recently approved by FDA for treatment of MDS patients with del(5q) Careful monitoring of the patients’ blood counts during the treatment period is necessary, particularly in patients with renal dysfunction Careful monitoring of the patients’ blood counts during the treatment period is necessary, particularly in patients with renal dysfunction Further studies are required to determine the efficacy of this drug and other agents for non-del(5q) MDS patients Further studies are required to determine the efficacy of this drug and other agents for non-del(5q) MDS patients

69. 69 Phase 2 Trial of Lenalidomide Study design Study design –Multicenter phase 2 trial –Lenalidomide administered 10 mg/day for 21 days or 10 mg/day –148 anemic RBC transfusion-dependent MDS patients with del(5q), with or without additional cytogenetic abnormalities Results Results –RBC TI at 24 weeks in 67% of patients in an ITT analysis –Median TI duration not reached after 104 weeks’ median follow-up –Cytogenetic responses in 73% of patients; 45% complete cytogenetic response –Common adverse events (in ~50% of patients) required treatment interruption or dose reduction for potentially serious but generally transient neutropenia and/or thrombocytopenia TI = transfusion independence; ITT = intention-to-treat List AF, et al. Proc ASCO. 2005;23[suppl 16S]:2S [abstract 5].

70. 70 Summary Hypomethylating agents: Hypomethylating agents: –Provide a new and exciting treatment option for an underserved MDS population –Offer encouraging response rates, transfusion-independence (TI), and delayed time to AML or death compared with supportive care –Are well tolerated with manageable adverse events –Can be considered the treatment of choice for Int-2/high-risk patients who are not transplant candidates –Future directions for hypomethylating agents include alternative dosing regimens that may help to optimize response Lenalidomide is effective in lower-risk patients with del(5q), inducing TI and cytogenetic responses in a high proportion of patients Lenalidomide is effective in lower-risk patients with del(5q), inducing TI and cytogenetic responses in a high proportion of patients

71. 71 Program Evaluation Form and Post Test Exam Go back to website to download and print out the post- activity program evaluation form and post-test exam or click here: http://www.dwrite.com/Files/TELECONFERENCES/TELECONFERENCES3/Download%20Material s_01/Post-Activity%20Evaluation%20Form%20&%20Post-Test%20Exam.pdf Go back to website to download and print out the post- activity program evaluation form and post-test exam or click here: http://www.dwrite.com/Files/TELECONFERENCES/TELECONFERENCES3/Download%20Material s_01/Post-Activity%20Evaluation%20Form%20&%20Post-Test%20Exam.pdf http://www.dwrite.com/Files/TELECONFERENCES/TELECONFERENCES3/Download%20Material s_01/Post-Activity%20Evaluation%20Form%20&%20Post-Test%20Exam.pdf http://www.dwrite.com/Files/TELECONFERENCES/TELECONFERENCES3/Download%20Material s_01/Post-Activity%20Evaluation%20Form%20&%20Post-Test%20Exam.pdf Return forms to address provided Return forms to address provided Questions: Contact Andy Beloff of DesignWrite at 609-436- 2412, abeloff@dwrite.com Questions: Contact Andy Beloff of DesignWrite at 609-436- 2412, abeloff@dwrite.comabeloff@dwrite.com To receive credit for today’s program: