1. Genomics in the Treatment of Early Stage Breast Cancer Oncotype DX ™ Breast Cancer Assay ROSEMARY LEEMING, MD, FACS April 11, 2008

2. 22 Agenda Introduction Development of Oncotype DX Clinical Studies –Validation studies –Hormonal therapy benefit study (B-14) –Chemotherapy benefit study (B-20) ASCO Data (6/07) –Clinical Utility Studies Exploratory Studies –RS and local recurrence (SABCS 12-06) –Node Positive Data (ASCO 6/07) Other Gene Profiles –MammaPrint –“Invasiveness” gene signature TAILORx Clinical Summary

3. 33 Breast Cancer Treatment Planning: History Treatment planning for N–, ER+ disease is based on: –Traditional prognostic factors with limited predictive power (tumor size, patient age) or poor reproducibility (tumor grade) –IHC markers (eg, Ki-67) lacking standardization and validation –Limited insight into relative benefits of chemotherapy for different individuals Bundred. Cancer Treat Rev. 2001;27:137-142.

4. 44 Breast Cancer Treatment Planning: Not Optimized Chemotherapy treatment for N–, ER+ disease –Many women are offered chemotherapy, knowing that few benefit –Guidelines assume all patients benefit equally –Some patients are under-treated, many others are over-treated

5. 55 Oncotype DX ™ : Unmet Clinical Need for Better Markers Biopsy or Resection Optimize chemotherapy + local therapy + hormonal therapy Optimize local therapy and hormonal therapy Robust markers High risk/ Large chemo benefit Low risk/ Little chemo benefit

6. 66 Development and Validation of a 21-Gene Assay for N–, ER+, Tam+ Patients Develop real-time RT-PCR method for paraffin block Select candidate genes (250 genes) Model building studies (N = 447, including 233 from NSABP B-20) Commit to a single 21-gene assay Validation studies in NSABP B-14 and Kaiser Permanente YEAR 2001 2002 2003 Paik et al. N Engl J Med. 2004;351:2817-2826.

7. 77 Oncotype DX ™ Technology: Final Gene Set Selection Study SiteN Node Status ER Status Treatment NSABP B-20, Pittsburgh, PA 233N–ER+Tamoxifen (100%) Rush University, Chicago, IL 78 >10 positive nodes ER+/–Tamoxifen (54%) Chemotherapy (80%) Providence St. Joseph’s Hospital, Burbank, CA 136N+/–ER+/–Tamoxifen (41%) Chemotherapy (39%) 21 genes and Recurrence Score (RS) algorithm Paik et al. SABCS 2003. Abstract #16. Cobleigh et al. Clin Cancer Res. 2005;11(24 Pt 1):8623-8631. Esteban et al. Proc ASCO 2003. Abstract #3416. Objective Gene expression and relapse-free survival correlations across three independent studies – testing 250 genes in 447 patients

8. 88 Oncotype DX ™ 21-Gene Recurrence Score (RS) Assay PROLIFERATION Ki-67 STK15 Survivin Cyclin B1 MYBL2 ESTROGEN ER PR Bcl2 SCUBE2 INVASION Stromelysin 3 Cathepsin L2 HER2 GRB7 HER2 BAG1GSTM1 REFERENCE Beta-actin GAPDH RPLPO GUS TFRC CD68 16 Cancer and 5 Reference Genes From 3 Studies CategoryRS (0-100) Low riskRS <18 Int riskRS ≥18 and <31 High riskRS ≥31 Paik et al. N Engl J Med. 2004;351:2817-2826. RS =+ 0.47 x HER2 Group Score - 0.34 x ER Group Score + 1.04 x Proliferation Group Score + 0.10 x Invasion Group Score + 0.05 x CD68 - 0.08 x GSTM1 - 0.07 x BAG1

9. Oncotype DX ™ Clinical Validation: The NSABP B-14 Study* *Paik et al. N Engl J Med. 2004;351:2817-2826.

10. 10 Objective: Prospectively validate RS as predictor of distant recurrence in N–, ER+ patients Design –Multicenter study with prespecified 21-gene assay, algorithm, endpoints, analysis plan Oncotype DX ™ Clinical Validation: Genomic Health – NSABP B-14 Randomized Registered Placebo—not eligible Tamoxifen—eligible Paik et al. N Engl J Med. 2004;351:2817-2826.

11. 11 Oncotype DX ™ Clinical Validation: B-14 Results – Distant Recurrence-Free Survival (DRFS) DRFS Over Time – All 668 Patients 10-year DRFS = 85% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0246810121416 Years DRFS Paik et al. N Engl J Med. 2004;351:2817-2826.

12. 12 Oncotype DX ™ Clinical Validation: B-14 Study Objectives First primary objective –Validate that 10-year DRFS in the low-risk group (RS <18) is larger than 10-year DRFS in the high-risk group (RS ≥ 31) Second primary objective –Determine whether Recurrence Score as a predictor of DRFS is more significant than age and tumor size Paik et al. N Engl J Med. 2004;351:2817-2826.

13. 13 Oncotype DX ™ Clinical Validation: B-14 Results – DRFS DRFS for the three distinct cohorts identified 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0246810121416 Years DRFS P <0.00001 Low Risk (RS <18) n = 338 Intermediate Risk (RS 18-30) n = 149 High Risk (RS  31) n = 181 Paik et al. N Engl J Med. 2004;351:2817-2826.

14. 14 Oncotype DX ™ Clinical Validation: B-14 Results – DRFS (cont.) Risk Group % of 10-yr Rate of Patients Recurrence 95% CI Low (RS <18) 51% 6.8% 4.0%, 9.6% Intermediate (RS 18-30) 22% 14.3% 8.3%, 20.3% High (RS ≥ 31) 27% 30.5% 23.6%, 37.4% Test for the 10-year DRFS comparison between the low-and high-risk groups: P <0.00001 Paik et al. N Engl J Med. 2004;351:2817-2826.

15. 15 Oncotype DX ™ Clinical Validation: B-14 Results Multivariate Analysis Confirms Power of RS Multivariate Cox Models: Age, Size Alone vs Age, Size + RS 0.058 (0.99, 2.11)1.44Size >2.0 cm 0.004 (0.39, 0.83)0.57Age ≥50 P value95% CIHazard RatioVariable <0.00001 (2.23, 4.61) 3.21 Recurrence Score 0.231 (0.86, 1.85)1.26Size >2.0 cm 0.084 (0.48, 1.05)0.71Age ≥50 P <0.00001 Age at surgery used as a binary factor: 0 = <50 yr, 1 = ≥50 yr. Clinical tumor size (CTS) used as a binary factor: 0 = ≤2 cm, 1 = >2 cm. Recurrence Score used as a continuous variable, with HR relative to an increment of 50 RS units. Paik et al. N Engl J Med. 2004;351:2817-2826.

16. 16 Oncotype DX ™ Clinical Validation: Conclusions – NSABP B-14 RS validated as predictor of recurrence in N–, ER+ patients RS performance exceeds standard measures (age, size) 50% of patients are reclassified by RS when compared to NCCN criteria RS (based on tumor gene expression) more accurately quantifies the risk of distant recurrence than do the NCCN guidelines (based on age, tumor size, and tumor grade)

17. Oncotype DX ™ Clinical Validation: The Kaiser Permanente Study Habel et al. Breast Cancer Res. 2006;May 31;8(3):R25.

18. 18 The Kaiser Permanente Study: Methods Study Design Study Population Data Sources Case-control Kaiser Permanente patients <75 yr in 14 Northern California hospitals diagnosed with node-negative BC 1985-94, no chemotherapy (N = 4964) Cases: Deaths from BC (n = 220) Controls: Randomly selected, matched on age, race, diagnosis year, KP facility, tamoxifen (n = 570) Cancer registry, medical records, archived diagnostic slides, and tumor blocks Habel et al. Breast Cancer Res. May 2006.

19. 19 The Kaiser Permanente Study: Risk of BC Death at 10 Years: ER+, Tam+ Patients % of % of 10-yr Cases Controls Absolute Risk Classifier (n = 55) (n = 150) Risk 1 Recurrence Score Low (<18)29% 63% 2.8% 2 Intermediate (18-30)40% 23%10.7% High (>31)31% 13%15.5% 1 Based on methods by Langholz and Borgan, Biometrics 1997;53:767-774. 2 Consistent with 3.0% absolute risk of breast cancer death in similar population of tamoxifen-treated patients in NSABP B-14. Habel et al. Breast Cancer Res. May 2006.

20. 20 The Kaiser Permanente Study: Conclusions “The RS has now been shown to be strongly associated with risk of breast cancer-specific mortality among LN–, ER+, tam-treated patients participating in a clinical trial and among similar patients from the community setting.” “Combining Recurrence Score, tumor grade, and tumor size provides better risk classification than any one of these factors alone.” Habel et al. Breast Cancer Res. May 2006.

21. Oncotype DX ™ Prediction of Tam Benefit: NSABP B-14 Placebo and Tamoxifen Arms* *Paik et al. ASCO 2004. Abstract #510.

22. 22 Design Objective: Determine whether the 21-gene RS assay provides information on: 1) Prognosis (likelihood of recurrence) 2) Response to tamoxifen (change in likelihood of recurrence with tamoxifen) 3) Both Tamoxifen Benefit and Oncotype DX ™ NSABP B-14 Tam Benefit Study in N–, ER+ Patients Randomized Placebo-Eligible Tam-Eligible Paik et al. ASCO 2004. Abstract #510.

23. 23 All Patients (N = 645) 024681416 Years 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 DRFS Placebo Tamoxifen 12 10 B-14 Overall Benefit of Tamoxifen Paik et al. ASCO 2004. Abstract #510.

24. 24 B-14 Benefit of Tamoxifen By Recurrence Score Risk Category Low Risk (RS<18) N 171 142 Int Risk (RS 18-30) N 85 69 High Risk (RS≥31) N 99 79 Interaction P = 0.06 024681416 Years 0.0 0.2 0.4 0.6 0.8 1.0 DRFS Placebo Tamoxifen 12 10024681416 Years 0.0 0.2 0.4 0.6 0.8 1.0 DRFS Placebo Tamoxifen 12 10024681416 Years 0.0 0.2 0.4 0.6 0.8 1.0 DRFS Placebo Tamoxifen 12 10 Paik et al. ASCO 2004. Abstract #510.

25. 25 Analysis of Placebo and Tam-Treated Patients in NSABP B-14 Conclusions –RS combines prognostic and predictive factors into one assay report –RS performance is derived from measurement of expression of each of the 21 genes on a continuous scale with high precision and reproducibility Paik et al. ASCO 2004. Abstract #510.

26. Oncotype DX ™ Prediction of Chemo Benefit: NSABP B-20 Study* *Paik et al. J Clin Oncol. 2006;24:3726-3734

27. 27 Chemotherapy Benefit and Oncotype DX ™ Design Objective: Determine the magnitude of the chemo benefit as a function of the 21-gene RS assay Randomized Tam + MF Tam + CMF Tam NSABP B-20 Chemo Benefit Study in N–, ER+ Pts Paik et al. J Clin Oncol. 2006;24:3726-3734.

28. 28 B-20 Results 0 24681012 Years 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 All Patients Tam + Chemo Tam P = 0.02 N Events 424 33 227 31 DRFS Tam vs Tam + Chemo – All 651 Patients Paik et al. J Clin Oncol. 2006. 4.4% absolute benefit from tam + chemo

29. 29 B-20 Results: Tam vs Tam + Chemo 28% absolute benefit from tam + chemo Paik et al. J Clin Oncol. 2006. p = 0.61 N Events 218 11 135 5 p = 0.39 N Events 89 9 45 8 Low RS p < 0.0001 N Events 117 13 47 18 Int RS High RS

30. 30 Low RS <18 Int RS 18-30 High RS ≥31 0 10% 20% 30% 40% B-20 Results: Absolute % Increase in DRFS at 10 Years n = 353 n = 134 n = 164 % Increase in DRFS at 10 Yrs (mean ± SE) Paik et al. J Clin Oncol. 2006.

31. 31 Benefits of adjuvant treatment differ by Recurrence Score risk category –Benefits of tamoxifen are greater in patients with low-risk or intermediate-risk tumors –Benefits of chemotherapy are greater in patients with high-risk tumors RS and Breast Cancer Death in NSABP B-14 and B-20

32. 32 ASCO ABSTRACTS JUNE 2007 CLINICAL UTILITY OF ONCOTYPE DX –ABSTRACT #577: LOYOLA UNIVERSITY –ABSTRACT #576: MAYO CLINIC

33. Prospective multi-center study of the impact of the 21-gene Recurrence Score (RS) assay on medical oncologist (MO) and patient (pt) adjuvant breast cancer (BC) treatment selection. Shelly S. Lo 1, John Norton 1, Patricia B. Mumby 1, Jeffrey Smerage 2, Joseph Kash 3, Helen K. Chew 4, Daniel Hayes 2, Andrew Epstein 5, Kathy S. Albain 1 1 Loyola University, Maywood IL, 2 University of Michigan, AnnArbor MI, 3 Edward Hospital, Naperville IL, 4 UC Davis, Sacramento CA, 5 Mount Sinai Medical Center, New York NY

34. 34 Background The 21-gene Recurrence Score (RS) assay (Oncotype DX TM ) has been validated to quantify the risk of distant recurrence in tamoxifen treated patients in lymph node negative, estrogen receptor (ER) positive breast cancer. The RS also predicts benefit from adjuvant chemotherapy. There is little data regarding the impact of the RS on medical oncologist (MO) and patient (pt) decision making. A multi-center study was designed to prospectively examine whether the RS affects MO and pt adjuvant treatment selection. ASCO 2007, Abstract #577

35. 35 Methods 17 MOs at 1 community and 3 academic practices participated in this study. Each participating MO consecutively offered enrollment to eligible women with node negative, ER positive breast cancer. Each participating MO and consenting patient completed pre- and post-RS assay questionnaires specifically developed for the study. MOs stated their adjuvant treatment recommendation and confidence in it pre and post RS assay. Pts indicated treatment choice pre and post RS assay. In addition, patients completed measures for quality of life, anxiety, and decisional conflict pre and post assay. RS assay results were returned to MO and shared with pt for routine clinical care. Frequency distributions and co-frequency tables are used to display categorical distributions of nominal variables; means and standard deviations are used to summarize continuous variables.

36. 36 Medical Oncologist Characteristics 17 medical oncologists from 4 institutions –University of Michigan: 6 –LUMC: 6 –Edward: 3 –UC Davis: 2 Length of time in practice <5 yrs: 29% Length of time in practice>5 yrs: 71% ASCO 2007, Abstract #577

37. 37 Change in Treatment Recommendation by RS Treatment Recomm. Pre-RSPost- RS Number (%)Mean RSNumber (%) Mean RS CHT42 (47.2%)2123 (25.8%)29 HT alone46 (51.7%)1860 (67.4%)16 Equipoise1 (1.1%)196 (6.7%)19 ASCO 2007, Abstract #577

38. 38 MO Treatment Recommendations Changed 31.5% of the Time MO Pre to Post-RS Assay Treatment Recommendation Number of Cases(%) CHT to HT20 (22.5) HT to CHT3 (3.4) CHT or HT to Equipoise5 (5.6) Treatment plan did not change61 (68.5) Total89 (100) Treatment recommendation changed in 28 (31.5%) after results of RS Assay known. The largest change was from a recommendation of CHT to HT in 22.5% of cases.

39. 39 Conclusions RS Assay changed physician adjuvant treatment recommendations in 31.5% of the cases RS Assay is used by patients in their adjuvant treatment decisions Results from the RS assay was associated with less adjuvant chemotherapy administration –The largest treatment recommendation change for MO was changing recommendation from CHT to HT

40. 40 How Well Do Standard Prognostic Criteria Predict Oncotype DX Scores? Kamal AH, Loprinzi CL, Reynolds C, Dueck AC, Geiger XJ, Ingle JN, Carlson RW, Hobday TJ, Winer EP, Perez EA, Goetz MP Mayo Clinic, Rochester, MN; Mayo Clinic, Jacksonville, FL; Stanford Comprehensive Cancer Center, Palo Alto, CA; Dana-Farber Cancer Institute, Boston, MA

41. 41 Methods Cases were presented to six academic oncologists, blinded to Recurrence Score Asked to predict RS (low, intermediate, or high) Asked to recommend chemo (yes/no) Then presented with actual Recurrence Score and asked chemo question again (yes/no) ASCO 2007, Abstract #576

42. 42 Mayo Clinic Study Methods: 31 patients with Oncotype DX scores available Slides reviewed for path, receptors and her-2 Cases presented to 6 “academic” oncologists, blinded to RS asked to predict RS and to recommend chemo given RS and asked chemo question again

43. 43 Mayo Clinic Study Results: RS: low – 18, int – 10, high – 3 Concordance between predicted and actual RS low/int vs. high >87% Easier to pick out high risk More important to identify low risk than low/int

44. 44 Mayo Clinic Study Results: Most frequent discrepancies: actual low RS predicted as intermed (31/80 discordant 39%) actual intermed RS predicted as low (29/80 discordant 36%) Treatment recommendations following Oncotype DX changed about 18.2% most frequent change from CHT to HT

45. 45 Mayo Clinic Study Conclusions: “Proper evaluation and interpretation of traditional prognostic criteria will identify most node negative, ER+ patients at high risk of recurrence (as predicted by RS), but poorly discriminate low vs. intermediate risk.” Recommendation for treatment was changed in about 20% of cases This study used expert pathologists and nationally known breast oncologists.

46. 46 Conclusions of clinical utility studies Oncotype DX TM directly changes treatment recommendations approx. 20 – 30+% of the time Physicians and patients alike find the RS useful Even when treatment decisions are not altered, the RS can increase confidence in the decision

47. 47 ONCOTYPE DX EXPLORATORY STUDIES: ONCOTYPE DX AND LOCAL RECURRENCE ONCOTYPE DX AND NODE POSITIVE PATIENTS ONCOTYPE DX AND NEO-ADJUVANT CHEMOTHERAPY

48. 48 Association Between Recurrence Score and Risk of Local-regional Failure in N─, ER+ Breast Cancer: Results from NSABP B-14 and NSABP B-20 E. Mamounas, G. Tang, J. Bryant, S Paik, S Shak, J Costantino, D Watson, D. L Wickerham, and N Wolmark

49. 49 Study Objectives To examine the relationship between RS and Risk of Loco-Regional Failure (LRF) in Node-Negative, ER-Positive, Patients from NSABP B-14 and NSABP B-20:To examine the relationship between RS and Risk of Loco-Regional Failure (LRF) in Node-Negative, ER-Positive, Patients from NSABP B-14 and NSABP B-20: –Placebo treated patients from B-14 –Tamoxifen treated patients from B-14, B-20 –Chemo-TAM treated patients from B-20

50. 50 Study Population Patients with RS Assay from NSABP node- negative, ER-positive adjuvant trials:Patients with RS Assay from NSABP node- negative, ER-positive adjuvant trials: – B-14 Placebo: 355 pts – B-14/B-20 Tamoxifen: 895 pts B-14: 668B-14: 668 B-20: 227B-20: 227 – B-20 Chemo + Tamoxifen: 424 pts

51. 51 SurgeryTypeB-14Placebo(n=355)B-14TAM(n=668)B-20TAM(n=227)B-20TAM+Chem(n=424) Lumpectomy32%42%48%39% Mastectomy68%58%52%61% Patient Characteristics Surgery Type All lumpectomy patients received breast XRTAll lumpectomy patients received breast XRT Post-mastectomy chest wall XRT was not allowedPost-mastectomy chest wall XRT was not allowed Regional nodal XRT was not allowed irrespective of surgical procedureRegional nodal XRT was not allowed irrespective of surgical procedure

52. 52 1.6 2.7 7.8 Chemo + TAM n=424 P=0.028 4.3 7.2 15.8 TAM n=895 P<0.0001 10.8 20 18.4 Placebo n=355 P=0.0220 10 20 30 40 % 10 Year LR Failure Rates According to Treatment and RS Category RS < 18 RS >31 RS 18-30

53. 53 Variable P-value HR HR 95% CI for Recurrence Score 0.0052.16 (1.26, 3.68) Age (> 50 vs. 50 vs. < 50)0.00020.40 (0.25, 0.65) Mastectomy vs. Lumpectomy + XRT 0.0470.62 (0.39, 0.99) CTS ( >2 cm vs. 2 cm vs. < 2 cm)0.9330.98 (0.61, 1.59) Grade (Mod vs. Well) 0.9661.10 (0.54, 1.92) Grade (Poor vs. Well) 0.1051.76 (0.89, 3.48) Multivariate Cox Proportional Hazard Models TAM-Treated Pts (n=895)

54. 54 AgeRS LRF Rate 95% CI P- value Events <50 < 18 1.5% (0, 4.5%) 0.0012/73 18 - 30 7.6% (0, 17.6%) 2/31 ≥ 31 23.8% (9.4%, 38.1%) 9/49 ≥ 50 < 18 2.6% (0.1%, 5%) 0.0056/189 18 - 30 3.8% (0, 8.1%) 3/82 ≥ 31 12.8% (4.3%, 21.3%) 9/81 10-Year Loco-Regional Failure Rates TAM-Treated Pts with Mastectomy (n=505)

55. 55 Exploratory Analysis 10-Year Loco-Regional Failure Rates TAM-Treated Pts with Mastectomy (n=505) RS correlated with 10-year LRF rates in patients 50 –High (23.8%) LRF rate in pts <50 with a high RS –However, small sample size of pts <50 who had high RS and mastectomy (49 pts) Subset analysis - hypothesis-generating ONLY

56. 56 AgeRS LRF Rate 95% CI P- value Events <50 < 18 12.5% (4.4%, 20.7%) 0.05710/72 18 - 30 27.7% (8.8%, 46.6%) 7/23 ≥ 31 26.5% (12.2%, 40.8%) 12/45 ≥ 50 < 18 3.6% (0.1%, 7.1%) 0.6636/139 18 - 30 3.7% (0, 8.7%) 4/58 ≥ 31 4.8% (0, 11.2%) 3/53 10-Year Loco-Regional Failure Rates TAM-Treated Pts with Lumpectomy/XRT (n=390)

57. 57 Exploratory Analysis Summary 10-Year Loco-Regional Failure Rates TAM-Treated Pts with Lumpectomy/XRT (n=390) Women < 50: RS associated with LRF (p = 0.057) –LRF is high with intermediate/high RS Women > 50: RS NOT associated with LRF (p = 0.663) However, as a subset analysis these findings should be hypothesis-generating ONLY

58. 58 Summary The 21-Gene Recurrence Score was found to predict risk of LRF in node-negative, ER-positive, pts treated with tamoxifen.The 21-Gene Recurrence Score was found to predict risk of LRF in node-negative, ER-positive, pts treated with tamoxifen. In this group of pts, RS was an independent predictor of LRF along with age and surgery type.In this group of pts, RS was an independent predictor of LRF along with age and surgery type. RS also predicted risk of LRF in node-negative, ER-positive pts treated with chemotherapy + tamoxifen and to a lesser extent in those treated without adjuvant therapyRS also predicted risk of LRF in node-negative, ER-positive pts treated with chemotherapy + tamoxifen and to a lesser extent in those treated without adjuvant therapy

59. 59 Conclusions Conclusions The present study demonstrates a similar association between RS and risk for LRF as the one previously shown for RS and risk of distant failure.The present study demonstrates a similar association between RS and risk for LRF as the one previously shown for RS and risk of distant failure. This information has biologic implications and may have clinical implications relative to loco-regional therapy decisions in patients with node-negative, ER-positive breast cancer.This information has biologic implications and may have clinical implications relative to loco-regional therapy decisions in patients with node-negative, ER-positive breast cancer.

60. 60 Can Oncotype DX be used for node positive patients?

61. Prognostic Utility of the 21-Gene Assay in Hormone Receptor (HR) Positive Operable Breast Cancer and 0-3 Positive Axillary Nodes Treated with Adjuvant Chemohormonal Therapy (CHT): An Analysis of Intergroup Trial E2197 Goldstein LJ 1, Gray R 1, Childs B 2, Watson D 3, Yoshizawa C 3, Rowley S 2, Shak S 3, Badve S 1, Davidson NE 1, Sledge GW 1, Sparano JA 1 From the Eastern Cooperative Oncology Group 1, sanofi aventis 2, & Genomic Health, Inc. 3

62. 62 ASCO 2007 - Abstract #526

63. 63 Objectives Specific: 1.To evaluate the prognostic utility of Oncotype DX Recurrence Score (RS) in patients with HR-Pos treated with adjuvant chemotherapy 2.To perform an exploratory analysis for individual genes associated with prognosis in patients with HR-Pos and HR- Neg disease treated with adjuvant chemotherapy ( analysis ongoing) 3.To perform an exploratory analysis to identify individual genes associated with differential sensitivity to AC versus AT (analysis ongoing)

64. 64 Outcomes by Nodal Status

65. 65 Outcomes by Recurrence Score

66. 66 Recurrence Rates Are Very Low (< 5%) if the RS < 18 Irrespective of Axillary Lymph Node Status 5-Year Event Rates by Nodal Status & RS Recurrence Rates Are Very Low (< 5%) if the RS < 18 Irrespective of Axillary Lymph Node Status RSNodesRFI (%)DFS (%)OS (%) Low <18 Neg969395 Pos959197 Int 18-30 Neg868797 Pos877786 High ≥ 31 Neg878092 Pos756172 ASCO - Abstract #526

67. 67 For HR-Pos Disease with 0-3 Pos Axillary Lymph Nodes Conclusions For HR-Pos Disease with 0-3 Pos Axillary Lymph Nodes Low RS (< 18) predictive of excellent outcomes at 5 yrsLow RS (< 18) predictive of excellent outcomes at 5 yrs including patients with 1-3 positive axillary lymph nodes when adjusted for centrally determined tumor grade Low RS (< 18) commonLow RS (< 18) common ~ 46% of patients with HR-positive disease in this study, of whom 49% had 1-3 positive axillary lymph nodes ASCO - Abstract #526

68. 68 Prognostic and Predictive Value of the 21-Gene Recurrence Score Assay in Postmenopausal, Node-Positive (N+), ER- Positive (ER+) Breast Cancer SWOG 8814, TBCI 0100 Oral Presentation #10 Prognostic and Predictive Value of the 21-Gene Recurrence Score Assay in Postmenopausal, Node-Positive (N+), ER- Positive (ER+) Breast Cancer SWOG 8814, TBCI 0100 Oral Presentation #10 K. Albain, W. Barlow, S. Shak, G. Hortobagyi, R. Livingston, I. Yeh, P. Ravdin, C. Yoshizawa, F. Baehner, N. Davidson, G. Sledge, E. Winer, C. Hudis, J. Ingle, E. Perez, K. Pritchard, L. Shepherd, C. Allred, K. Osborne, and D. Hayes for The Breast Cancer Intergroup of North America K. Albain, W. Barlow, S. Shak, G. Hortobagyi, R. Livingston, I. Yeh, P. Ravdin, C. Yoshizawa, F. Baehner, N. Davidson, G. Sledge, E. Winer, C. Hudis, J. Ingle, E. Perez, K. Pritchard, L. Shepherd, C. Allred, K. Osborne, and D. Hayes for The Breast Cancer Intergroup of North America

69. 69 SWOG 8814/TBCI 0100 Correlative Science Rationale The 21-gene Recurrence Score assay (RS) is prognostic for women with node(-), ER+ breast cancer on 5 years of tamoxifen* A high RS predicts large benefit from chemotherapy in node(-) disease, but no improvement if the RS is low** There are no RS data in a N+ population with a tamoxifen-alone control SWOG 8814 is an ideal trial to explore this question Albain, SABCS 2007, Abstract #10 *Paik, et al. NEJM, 2004 **Paik, et al. J Clin Oncol, 2006

70. 70 Phase III SWOG 8814 (TBCI 0100) Postmenopausal, N+, ER+ RANDOMIZE n = 1477 tamoxifen x 5 yrs CAF x 6, then tamoxifen CAF x 6, with concurrent tam Superior Disease-Free Survival (DFS) and Overall Survival (OS) over 10 Years (n = 361) (n = 550) (n = 566) Albain, SABCS 2007, Abstract #10 Albain, et al. Breast Cancer Res Treat 2005

71. 71 SWOG 8814/TBCI 0100 Correlative Science Study 1)Provides prognostic information for women with N+ disease treated only with tamoxifen, and 2)Allows prediction of a N+ group that does not derive benefit from chemotherapy Two co-primary objectives were to determine if the RS: Albain, SABCS 2007, Abstract #10

72. 72 Outcomes in RS Subset Mirror Those Reported in Main Trial: Superiority of CAF-T Albain, SABCS 2007, Abstract #10

73. 73 SWOG 8814/TBCI 0100 21-Gene Recurrence Score is Prognostic for DFS and OS in Tamoxifen Arm 10-yr: 60%, 49%, 43%10-yr: 77%, 68%, 51% Albain, SABCS 2007, Abstract #10

74. 74 Albain, SABCS 2007, Abstract #10

75. 75 CAF Benefit Greatest in Higher RS for Both Nodal Subsets, with No Benefit in Lower RS Albain, SABCS 2007, Abstract #10

76. 76 NEOADJUVANT DATA Milan and Baylor Studies

77. 77 Chemotherapy Response: Exploratory Studies in Stage 3 neoadjuvant setting confirm the findings from NSABP B20 Study Milan Study Baylor Study –Independent & Exploratory Studies in Stage 3 patients –Nearly identical trends with neoadjuvant & CR rates –Consistent with B20 Neoadjuvant anthracyline-taxane treatment Neoadjuvant docetaxel therapy

78. Gene Expression Profiles in Paraffin-Embedded Core Biopsy Tissue Predict Response to Chemotherapy in Women With Locally Advanced Breast Cancer L. Gianni, M. Zambetti, K. Clark, J. Baker, M. Cronin, J. Wu, G. Mariani, J. Rodriguez, M. Carcangiu, D. Watson, P. Valagussa, R. Rouzier, W. Symmans, J. Ross, G. Hortobagyi, L. Pusztai, and S. Shak Gianni et al. J Clin Oncol. 2005;23(29):7265-7277.

79. 79 Study Design Istituto Nazionale Tumori – Milan Core biopsy Primary chemotherapy DOX/TAX  3  w TAX  12 Surgery Adjuvant chemotherapy IV CMF q 4 wks  4 RT  TAM for RT-PCR analysis for pathology determination of pCR Nonrandomized in women with LABC 89 evaluable patients Gianni et al. J Clin Oncol. 2005;23(29):7265-7277.

80. 80 Results – Chemotherapy Response 89 evaluable patients –11 patients with pathologic complete response (pCR) 4 pts ER+ by IHC –pCR rate in ER+ pts = 8% (95% CI 1%-15%) 7 pts ER– by IHC –pCR rate in ER– pts = 23% (95% CI 8%-37%) –Overall pCR rate = 12% Gianni et al. J Clin Oncol. 2005;23(29):7265-7277.

81. 81 Higher Recurrence Score Associated With Higher Likelihood of pCR (P = 0.005) to neoadjuvant anthracyline-taxane treatment Gianni et al. J Clin Oncol. 2005;23(29):7265-7277. N=89 P=0.005 Milan Study

82. Gene expression profiles in paraffin-embedded core biopsies predict docetaxel chemosensitivity J. Chang, A. Makris, SG. Hilsenbeck, J. Hackett, J Jeong, M Liu, J Baker, K Sexton, K Osborne, S Shak

83. 83 Methods Patients identified from 3 phase II clinical trials who received neoadjuvant docetaxel (100 mg/m2 q3wks) for 4 cycles before surgery Diagnostic biopsies: 10-micron sections x 3 98 clinically eligible patients 81 (83%) of 98 with adequate tumor tissue (≥5% tumor) 80 (99%) of 81 with adequate RNA and expression signal 72 (90%) of 80 with response data (RECIST) Chang, ASCO 2006, Abstract #538

84. 84 Correlation between RS and clinical complete response Likelihood of correlation between RS and clinical complete response (CR) is not significant among all 3 categories (P = 0.3792) Recurrence CategoryComplete Response Yes No Low Risk 0 (0%)8 (100%) Intermediate Risk 3 (13.6%)19 (86.4%) High Risk 9 (21.4%)33 (78.6%) Chang, ASCO 2006, Abstract #538

85. 85 ≥1.7-fold increase in the odds of CR to neoadjuvant docetaxel therapy for high vs. low RS Chang, ASCO 2006, Abstract #538 N=72 Baylor Study

86. 86 Exploratory Studies Summary RS is associated with LRF Associated with response to modern Neoadjuvant Chemotherapy Prognostic in Node Positive Disease 86

87. 87 Other Gene Profiles MammaPrint –70-gene signature –Netherlands–based Agendia “Invasiveness” Gene Signature –186-gene signature –University of Michigan, Ann Arbor Wound Response Signature

88. 88 MammaPrint and Oncotype DX Distinctions MammaPrint Fresh Tissue by Microarray 81% Microarray success rate for RNA extraction Binary result (low risk vs. high risk) Patients all <61 years old 302 untreated patients (LN-, ER+, ER-) Clinical Utility Not Yet Established –Patients not representative of those diagnosed and treated today Insurance Coverage TBD Oncotype DX FPET by RT-PCR 99% FPET success rate for RNA extraction Continuous Predictor Curve (Individual Recurrence Score) No age barriers Multiple, reproducible studies in >2,600 treated patients with ER+, LN- disease Provides Clinical Utility for adjuvant treatment decisions –>20,000 patients, 4,500 physicians Over 100 million lives insured

89. TAILORx (PACCT-1 Trial) Sponsored by NCI Administered by ECOG Participating cooperative groups include ECOG, SWOG, NCCTG, CALGB, NCIC, ACOSOG, and NSABP

90. 90 Trial Assigning IndividuaLized Options for Treatment (Rx) (TAILORx) Premise – Integration of a molecular profiling test (Oncotype DX ™ ) into the clinical decision-making process Implications – Reduce chemotherapy overtreatment in those likely to be optimally treated with hormonal therapy alone – Reduce inadequate treatment by identifying individuals who derive great benefit from chemotherapy – Evaluate benefit of chemotherapy where uncertainty still exists about its utility

91. 91 Schema: TAILORx Node-Neg, ER-Pos Breast Cancer RS <10 Hormone Therapy Registry RS <10 Hormone Therapy Registry RS 11-25 Randomize Hormone Rx vs Chemotherapy + Hormone Rx RS 11-25 Randomize Hormone Rx vs Chemotherapy + Hormone Rx RS >25 Chemotherapy + Hormone Rx RS >25 Chemotherapy + Hormone Rx Oncotype DX ™ Assay Register Specimen banking Primary study group

92. 92 Study Design: Primary Objectives To determine whether adjuvant hormonal therapy (ie, experimental arm) is not inferior to adjuvant chemohormonal (standard arm) for patients in the “primary study group” (Oncotype DX ™ RS 11-25) To create a tissue and specimen bank for patients enrolled in this trial to learn more about breast cancer

93. 93 Study Design: Secondary Objectives Low RS group (<11) –To determine risk of recurrence with hormonal therapy prospectively Comparison with clinical models (Adjuvant! Online) Refine estimates of Oncotype DX ™ RS in contemporary practice Evaluate individual gene groups –Proliferation gene group –HER2 gene group –ER gene group –Invasion gene group –Other genes

94. 94