1. HER2 pos. Disease Supportive care Hans Wildiers University Hospitals Leuven

2. HER2 pos. Disease HER2 pos. Disease – Adjuvant Trastuzumab: HERA (2y vs 1y) Phare (6 mo vs 1y) NSABP B-31 and NCCTG N9831 (1y vs nil) – Metastatic Pertuzumab: Cleopatra – HER2 Translational Supportive care Supportive care – MDS/AML after breast cancer – Neurocognitive impact of adjuvant chemotherapy – Bone

3. OBSERVATION n=1698 OBSERVATION n=1698 Women with locally determined HER2- positive invasive early breast cancer Surgery + (neo)adjuvant CT ± RT Centrally confirmed IHC 3+ or FISH+ and LVEF ≥ 55% Randomization 1 year Trastuzumab 8 mg/kg – 6 mg/kg 3 weekly schedule n=1703 1 year Trastuzumab 8 mg/kg – 6 mg/kg 3 weekly schedule n=1703 2 years Trastuzumab 8 mg/kg – 6 mg/kg 3 weekly schedule n=1701 2 years Trastuzumab 8 mg/kg – 6 mg/kg 3 weekly schedule n=1701 After ASCO 2005, option of switch to Trastuzumab After ASCO 2005, option of switch to Trastuzumab HERA TRIAL UPDATE at 8 y FUP Accrual 2001 – 2005 (n=5102) CT, chemotherapy; RT, radiotherapy S5-2 Final analysis planned for 725 disease-free survival (DFS) events to obtain 80% power to detect a true hazard ratio of 0.80. HER2 adjuvant

4. Disease-free survival (%) Years from randomization 89.1% 86.7% 81.0% 81.6% 75.8% 76.0% DFS FOR 2 YEARS VS. 1 YEAR TRASTUZUMAB AT 8 YRS MFU 100 80 60 40 20 0 0123456789 No. at risk Trastuzumab 2 years1553 144213611292122311531051633194 Trastuzumab 1 year1552 141313191265121411801071649205 Trastuzumab 1 year Trastuzumab 2 years PtsEventsHR (2 vs 1)95% CIp-value 2 years15533670.99(0.85-1.14)0.86 1 year1552367 S5-2 HER2 adjuvant

5. Hormone receptor negative 2.8% received endocrine therapy Hormone receptor positive 92.6% received endocrine therapy Years from randomization Disease-free survival (%) Trastuzumab 2 years Trastuzumab 1 year DFS BY HORMONE RECEPTOR STATUS AT 8 YRS MFU No. at risk Trastuzumab 2 years 798 74771067364259754432197 Trastuzumab 1 year 790 736691663634617559337106 100 80 60 40 20 0 0123456789 PtsEventsHR (2 vs 1)95% CIp-value 2 years7981851.05(0.85-1.29)0.67 1 year790175 90.3 % 89.6% 83.1% 82.9% 76.1% 77.2% Years from randomization Disease-free survival (%) Trastuzumab 2 years Trastuzumab 1 year 100 80 60 40 20 0 0123456789 PtsEventsHR (2 vs 1)95% CIp-value 2 years7551820.93(0.76-1.14)0.51 1 year762192 No. at risk Trastuzumab 2 years 755 69565161958155650731297 Trastuzumab 1 year 762 67762860258056351231299 87.8% 83.8% 80.1% 78.9% 75.4% 74.7% S5-2 HER2 adjuvant

6. Overall Survival (%) Years from randomization No. at risk Trastuzumab 2 years1553 152514851438138213171193708208 Trastuzumab 1 year1552 151314611413 1364 13291218732225 100 80 60 40 20 0 0123456789 OS FOR 2 YEARS VS. 1 YEAR TRASTUZUMAB AT 8 YRS MFU 97.4% 96.5% 91.4% 92.6% 86.4% 87.6% Trastuzumab 1 year Trastuzumab 2 years PtsEventsHR (2 vs 1)95% CIp-value 2 years15531961.05(0.86-1.28)0.63 1 year1552186 S5-2 HER2 adjuvant

7. ObservationTrastuzumab Only1 Year2 Years N=1744N=1682N=1673 ≥ 1 grade 3 or 4 AE8.2%16.3%20.4% Secondary Cardiac 1 0.9%4.1%7.2% Primary Cardiac 2 0.1%0.8%1.0% Fatal adverse event0.4%1.1%1.2% ADVERSE EVENTS (SAFETY ANALYSIS POPULATION) 1 LVEF < 50% and ≥ 10% below baseline confirmed by repeat assessment, excluding patients with a primary cardiac endpoint. 2 NYHA class III or IV, confirmed by a cardiologist, and LVEF < 50% and ≥ 10% below baseline, OR cardiac death. S5-2 HER2 adjuvant

8. Median follow-up (% follow-up time after selective crossover) No. of DFS events 1 year trastuzumab vs observation 127 vs 220 P<0.0001 218 vs 321 P<0.0001 369 vs 458 P<0.0001 DFS benefit Favours 1 year trastuzumabFavours observation 012 HR (95% CI) 1 YEAR TRASTUZUMAB VS. OBSERVATION: DFS ITT ANALYSES Extended from Gianni et al. Lancet Oncol. 2011. 2005 (0%) 2006 (4.3%) 2008 (33.8%) 1 yr MFU 4 yrs MFU 2 yrs MFU 0.54 0.64 0.76 471 vs 570 P<0.0001 2012 (48.6%) 8 yrs MFU 0.76 S5-2 HER2 adjuvant

9. Favours 1 year trastuzumabFavours observation 012 HR (95% CI) OS benefit 1 YEAR TRASTUZUMAB VS. OBSERVATION: OS ITT ANALYSES Extended from Gianni et al. Lancet Oncol. 2011. Median follow-up (% follow-up time after selective crossover) No. of deaths 1 year trastuzumab vs observation 29 vs 37 P=0.26 59 vs 90 P=0.0115 182 vs 213 P=0.1087 2005 (0%) 2006 (4.1%) 2008 (30.9%) 0.76 0.66 0.85 1 yr MFU 4 yrs MFU 2 yrs MFU 278 vs 350 P=0.0005 2012 (45.5%) 0.76 8 yrs MFU S5-2 HER2 adjuvant

10. PHARE* Trial results of subset analysis comparing 6 to 12 months of trastuzumab in adjuvant early breast cancer Protocol of Herceptin ® Adjuvant with Reduced Exposure *lighthouse in French Xavier Pivot, Gilles Romieu, Marc Debled, Jean-Yves Pierga, Pierre Kerbrat, Thomas Bachelot, Alain Lortholary, Marc Espié, Pierre Fumoleau, Daniel Serin, Jean-Philippe Jacquin, Christelle Jouannaud, Maria Rios, Sophie Abadie-Lacourtoisie, Nicole Tubiana-Mathieu, Laurent Cany, Stéphanie Catala, David Khayat, Iris Pauporté, Andrew Kramar. S5-3 HER2 adjuvant

11. Study design trastuzumab 6 months trastuzumab up to 12 months stop trastuzumab Clinical exam LVEF 3 Mammography 69121518212430 mos … 0 R R R: Randomization after informed consent Up to 60 mos… Stratification 1. ER pos / neg 2. Chemo: conco/ seq S5-3 HER2 adjuvant

12. Statistical Methods Non inferiority randomized trial – 2% variation in terms of absolute difference of recurrence – The 95% CI HR margins should not cross the 1.15 boundary – 1040 DFS events required for 80% power at 5% level or 4 years of accrual and at least 2 years of follow-up – HR were estimated from the stratified Cox model Accrual target: 3400 patients S5-3 HER2 adjuvant

13. Treatment Characteristics 12 months n=1690 6 months n=1690 Type of Chemotherapy No Anthracyclines Anthracyclines no taxanes Anthracyclines and Taxanes 10.2% 15.9% 73.9% 11.8% 15.5% 72.7% Concomitant Chemotherapy Sequential Chemotherapy 57.8% 42.2% 57.7% 42.3% Radiotherapy87.7%88.2% Hormonotherapy50.6%50.2% Trastuzumab duration, mean (sd)11.8 (2.03)6.3 (1.46) S5-3 HER2 adjuvant

14. DFS Events 12 mos (n=1690) 6 mos (n=1690) DFS Events (n=394)10.4%13.0% Local Recurrence Regional Recurrence Distant Recurrence Controlateral Breast Cancer 2 nd Primary Malignancy Death 1.1% 0.6% 6.4% 0.4% 1.5% 0.4% 1.4% 0.5% 8.3% 0.7% 1.5% 0.5% 42.5mos. median Follow-up S5-3 HER2 adjuvant

15. Disease Free Survival * Cox model stratified by ER status and concomitant chemotherapy 95.5 91.2 87.8 84.9 97.0 93.8 90.7 87.8 Events HR 95%CI p-value T 12m 176 T 6m 219 1.28 (1.05 – 1.56) 0.29 S5-3 HER2 adjuvant

16. Equivalent Superior Non Inferior Inferior A B C D E.8511.151.31.451.6 HR Primary endpoint scenarios PHARE trial X Pivot et al, ESMO 2012, LBA5_PR S5-3 HER2 adjuvant

17. Subanalysis S5-3 HER2 adjuvant

18. Trastuzumab plus Adjuvant Chemotherapy for HER2-positive Breast Cancer: Final Planned Joint Analysis of Overall Survival from NSABP B-31 and NCCTG N9831 San Antonio Breast Cancer Symposium – December 4-8, 2012 Abstract #S5-5 S5-5 Median follow-up: 8.4 years Definitive survival analysis at 710 OS events HER2 adjuvant

19. N9831/B-31 Disease-Free Survival A  P AC  P+H N Events AC→P 2018 680 AC→P+H 2028 473 HR adj =0.60 (95% CI: 0.53-0.68) P<0.0001 62.2% 73.7% 64.9% 76.8% 81.4% San Antonio Breast Cancer Symposium, December 4-8, 2012 S5-5 HER2 adjuvant

20. B-31/N9831 Overall Survival AC  P 87.0% 89.8% 79.4% 84.3% N Events AC→P 2018 418 AC→P+H 2028 286 90.3% ∆=2.9%∆=5.5%∆=7.6%∆=8.8% San Antonio Breast Cancer Symposium, December 4-8, 2012 S5-5 HER2 adjuvant

21. 1. Baselga J, et al. SABCS 2011 (Abstract S5-5); 2. Baselga J, et al. N Engl J Med 2012; 366: 109–119. CLEOPATRA: update * 6 cycles allowed at investigator discretion HER2, human epidermal growth factor receptor 2; PD, progressive disease Patients with HER2-positive MBC Centrally confirmed (N = 808) Placebo + trastuzumab n = 406 Primary endpoint: Independently-assessed progression-free survival (PFS) Collection of tumor tissue (archival in >90%) and serum samples was mandatory Study dosing q3w: − Pertuzumab/placebo:840 mg loading dose, 420 mg maintenance − Trastuzumab:8 mg/kg loading dose, 6 mg/kg maintenance − Docetaxel:75 mg/m 2, escalating to 100 mg/m 2 if tolerated 1:1 n = 402 Docetaxel* ≥ 6 cycles recommended PD Pertuzumab + trastuzumab Docetaxel* ≥ 6 cycles recommended PD P5-18-26 HER2 metastatic

22. CLEOPATRA: overall survival 22 Stopping boundary for concluding statistical significance at this second interim analysis was p ≤0.0138 D, docetaxel; Pla, placebo; Ptz, pertuzumab; T, trastuzumab 0510152025303540 0 10 20 30 40 50 60 70 80 90 100 n at risk 0Ptz + T + D 0Pla + T + D Time (months) Overall survival (%) 455055 0 0 9 4 33 22 84 67 143 128 230 198 317 285 342 324 371 350 387 383 402 406 89% 94% 1 year 2 years 69% 81% 3 years 66% 50% Ptz + T + D: 113 events; median not reached Pla + T + D: 154 events; median 37.6 months HR=0.66 95% CI 0.52−0.84 p=0.0008 P5-18-26 HER2 metastatic

23. CLEOPATRA: PFS D, docetaxel; PFS, progression-free survival; Pla, placebo; Ptz, pertuzumab; T, trastuzumab 0510152025303540 0 10 20 30 40 50 60 70 80 90 100 Time (months) Progression-free survival (%) 4550 0 0 0 0 8 8 34 26 67 42 108 72 178 110 218 148 284 223 341 329 402 406 Ptz + T + D: median 18.7 months Pla + T + D: median 12.4 months HR=0.69 95% CI 0.58−0.81 ∆=6.3 months n at risk Ptz + T + D Pla + T + D P5-18-26 HER2 metastatic

24. 0 10 20 30 40 50 60 70 80 90 100100 05101520253035 Progression-free survival (%) Time (months) Ptz + T + D <65Pla + T + D <65 Ptz + T + D ≥65Pla + T + D ≥65 CLEOPATRA PFS according to age D, docetaxel; PFS, progression-free survival; Pla, placebo; Ptz, pertuzumab; T, trastuzumab 24 P5-18-01 HER2 metastatic

25. CLEOPATRA PFS according to age: Exposure to docetaxel treatment <65 years≥65 years Placebo + trastuzumab + docetaxel (n=332) Pertuzumab + trastuzumab + docetaxel (n=346) Placebo + trastuzumab + docetaxel (n=65) Pertuzumab + trastuzumab + docetaxel (n=61) Median number of cycles administered (range) 8.0 (1−41)8.0 (1−35)6.5 (1−26)6.0 (1−16) Median dose intensity, mg/m 2 /week 24.824.524.8 Dose escalation to 100 mg/m 2, n (%) 53 (16.0)41 (11.8)8 (12.3)7 (11.5) Dose reduction to <75 mg/m 2, n (%) 72 (21.7)85 (24.6)17 (26.2)19 (31.1) 25 P5-18-01 HER2 metastatic

26. CLEOPATRA PFS according to age: Ten most common grade ≥3 adverse events overall <65 years≥65 years n (%) Placebo + trastuzumab + docetaxel (n=332) Pertuzumab + trastuzumab + docetaxel (n=346) Placebo + trastuzumab + docetaxel (n=65) Pertuzumab + trastuzumab + docetaxel (n=61) Neutropenia156 (47.0)174 (50.3)26 (40.0)25 (41.0) Leukopenia51 (15.4)44 (12.7)7 (10.8)6 (9.8) Febrile neutropenia26 (7.8)51 (14.7)4 (6.2)5 (8.2) Diarrhea16 (4.8)23 (6.6)4 (6.2)9 (14.8) Anemia9 (2.7)10 (2.9)5 (7.7)0 (0.0) Fatigue9 (2.7)7 (2.0)4 (6.2)2 (3.3) Peripheral neuropathy6 (1.8)6 (1.7)1 (1.5)5 (8.2) LVSD8 (2.4)4 (1.2)3 (4.6)1 (1.6) Asthenia4 (1.2)10 (2.9)2 (3.1)0 (0.0) Granulocytopenia9 (2.7)4 (1.2)0 (0.0)2 (3.3) 26 LVSD, left ventricular systolic dysfunction P5-18-01 HER2 metastatic

27. The HER2 signalling pathway Selection of biomarkers ER Nucleus c-myc Raf MEK 1/2 MAPK Akt GSK3BAD Cell-cycle progression PTEN mTOR p27 Cyclin D1, E FKHR Grb2 Sos Cell survival Ras Shc Sos Grb2 PI3K Cell proliferation Y ER HER2 EGFRHER2HER3IGF1R Y sHER2 HER ligands (AREG, EGF, TGFα) NO RESULTS (except HER2) HER2 translational S5-7

28. Neosphere: associaton between pCR and immune biomarkers S6-7 Lapatinib decreases Ki67 by 27% in HER2 neg tumors in a ‘window of opportunity’ study (mainly if also high HER3 expression) PD07-07 New techniques for HER2 determination – Next generation sequencing is highly concordant with FISH for HER2, and uncovers actionable genomic alterations PD02-07 – MPLA PD02-03, – RNA scope analysis PD02-04 – AQUA: predicts trastuzumab benefit in BCIRG-005/6 PD02-01 HER2 translational

29. Activating HER2 mutations in HER2 Gene Amplification Negative Breast Cancers HER2 mutations predominantly occur in HER2 gene amplification negative patients. The majority of HER2 mutations are activating events that cause oncogenic transformation, thus they are highly likely to be driver events in these breast cancers. Neratinib is a highly potent, irreversible pan- ErbB tyrosine kinase inhibitor for all of the HER2 mutations (clinical trial has been launched) HER2 translational S5-6

30. MDS/AML after BC diagnosis Previous reports: – NSABP trials: 0,27% after AC at 8y  if RT after lumpectomy or CSF use. – An “environmental” cancer AML/MDS S3-5

31. AML/MDS S3-5

32. Characteristics of Leukemia cohort AML/MDS S3-5

33. Cumulative incidence of Leukemia Chemo vs no chemo: HR 2,5 p0,007 AML/MDS S3-5

34. Conclusions Adjuvant chemotherapy was associated with a cumulative 10-year incidence of leukemia of ~ 0.5% Almost half of the events occurred beyond year 5 Radiation alone appears to be a risk factor, but may not add much to patients already treated with chemotherapy Leukemia risk was not limited to MDS/AML, and cases of high risk lymphoid leukemia were observed This study highlights the challenges of studying infrequent but important clinical events AML/MDS S3-5

35. Neurocognitive Impact in Adjuvant Chemotherapy for Breast Cancer Linked to Fatigue: A Prospective Functional MRI Study Prospective non-randomized comparative trial chemobrain S6-3 n=28 n=37 n=32

36. Frontal Brain Activation by group and time chemobrain S6-3

37. Neurocognitive alterations in working memory processes and greater fatigue were evident before any adjuvant chemotherapy. Pre-adjuvant treatment brain alterations during working memory task predict severity of fatigue post-treatment. Greater fatigue across all groups was related to reduced cognitive function over time. chemobrain S6-3 Results and conclusion

38. Vitamin D, But Not Bone Turnover Markers, Predict Relapse In Women With Early Breast Cancer: An AZURE Translational Study. Bone S6-4 And 25HO VitD

39. Prognostic effect S6-4 only for 25HO VitD Bone

40. Predictive effect S6-4 * CTX, PINP : ZOL benefit NOT predicted by higher bone turnover * 25HO Vit D Bone

41. Population: 157 pts, 92% continued ZOL only 37% received per label (q3-4w) SRE: - SRE rate 0,13 per person year during 18 month study (vs 0,13 in 18 months before inclusion) - 83% SRE free at 18 months - persistent ZOL therapy per label ≈ lower SRE rate (HR 0,26 p 0,009 ) Safety: - renal deterioration in 6 pts - No symptomatic hypoCa (but only 16% taking supplements!) - Acute phase reactions 9,5% - ONJ in 7 pts (4,5%) LOTUS trial: Prospective study of treatment pattern, effectiveness, and safety of Zoledronic acid (ZOL) beyond 2y: subgroup analysis of pts with metastatic breast cancer. S3-13-01 Bone

42. Neoadj FEC-paclitaxel +/- ZOL. PD07-05 – randomized trial (n= 182) – pCR 14,9 vs 7,9% (p 0,16) – in postmenopauzal 18,4 vs 5,4% (p 0,15) iv ZOL vs po ibandronat PD09-07 – randomized trial (n=1405) – MBC with bone metastases – SRE rate per year lower for ZOL (0,44 vs 0,54, p 0,02 ) Bisphosphonates Bone

43. Conclusions HER2 HER2 adjuvant: – HERA and NSABP B-31/NCCTG N9831 results at 8 yrs FUP show sustained and statistically significant DFS and OS benefit for 1 year trastuzumab versus observation in ITT analyses despite selective crossover. No benefit for extension to 2 years in HERA. – PHARE failed to show that 6 months of trastuzumab is non inferior to 12 months. Subgroup analysis suggested that Sequential modality for ER negative tumors impacted the overall results. Results in other groups seemed compatible with non-inferiority hypothesis – 1 year of trastuzumab remains the standard of care as adjuvant therapy for patients with HER2-positive early breast cancer. HER2 metastatic: – Addition of pertuzumab to trastuzumab and docetaxel improves OS and PFS significantly in HER2-positive first-line without important toxicity aspects.

44. Conclusions supportive care Adjuvant chemotherapy is associated with a cumulative 10-year incidence of leukemia of ~ 0.5% Neurocognitive alterations in working memory processes and greater fatigue are present before any adjuvant chemotherapy. Low baseline VitD is associated with increased risk of bone and distant recurrence