National Medical Policy

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1 National Medical Policy The Medical Policy Department is no longer maintaining the Herceptin Policy. Please refer to the HNPS Prior Authorization Criteria Database which can be found at Subject: Policy Number: Her2/neu (formerly Her2/neu Herceptin) NMP155 Effective Date*: June 2004 Updated: June 2015 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link National Coverage Determination (NCD) National Coverage Manual Citation X Local Coverage Determination (LCD)* Cytogenetic Studies: Article (Local)* Other None Use Health Net Policy Instructions Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) Her2 neu and Herceptin Jun 15 1

2 If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Current Policy Statement I. Health Net, Inc. considers human epidermal growth factor receptor 2 testing (Her2/neu) medically necessary for all newly diagnosed invasive breast cancers, as the level of expression may be used to provide prognostic information regarding response to chemotherapy, including Herceptin. The American Society of Clinical Oncology and The College of American Pathologists (CAP) have developed the following guideline recommendations for HER2 testing, which include all of the following indications: 1. A testing algorithm that relies on accurate, reproducible assay performance, including newly available types of FDA approved IHC, Brightfield in-situ hybridization (ISH), or FISH assay is proposed; and 2. Elements to reduce assay variation (Eg. specimen handling, assay exclusion, and reporting criteria) are specified; and 3. An algorithm defining positive, equivocal, and negative values for both HER2 protein expression and gene amplification is recommended. This means: A positive HER2 result is IHC 3+ based on circumferential membrane staining that is complete and intense; or fluorescent in situ hybridization (FISH) result of > 6 HER2 gene copies per nucleus or a FISH ratio (HER2 gene signals to chromosome 17 centromere signals) ratio >2.2; An equivocal* HER2 result is defined as either immunohistochemistry (IHC) staining of 2+, based on circumferential membrane staining that is incomplete and/or weak/moderate and within >10% of invasive tumor cells; or complete and circumferential membrane staining that is intense and within < 10% of invasive tumor cells; or fluorescent in situ hybridization (FISH) ratio of <2.0 or average HER2 gene copy number >4 to <6 signals/cell; and dual probe HER/CEP17 ratio<2.0 with an average HER2 copy number > 4.0 signals/cell). (If testing is equivocal, reflex testing using the IHC method on the same specimen or repeating tests if a new specimen is available, to assign HER2 status. A negative result is an IHC 1+ defined by incomplete membrane staining that is barely perceptible and within >10% of the invasive tumor cells, or a FISH result of less than 1.8 or average HER2 gene copy number of <4 signals/nucleus for test systems without an internal control probe *Note - NCCN Panel on Breast Cancer agrees with the ASCO/CAP HER2 committee that this is the appropriate protocol with equivocal HER2 results. Equivocal results require additional action for final determination. It is recommended that to perform HER2 testing, labs show 95% condcordance with another validated test for positive and negative assay values. The panel strongly recommends validation of laboratory assay or modifications, use of standardized operating procedures, and compliance with new testing criteria to be monitored with the use of stringent Her2 neu and Herceptin Jun 15 2

3 laboratory accreditation standards, proficiency testing, and competency assessment. The panel recommends that HER2 testing be done in a CAP-accredited laboratory or in a laboratory that meets the accreditation and proficiency testing requirements set out by this document. (Arch Pathology Lab Med. 2007) II. Health Net, Inc. considers testing of tumor HER2-neu overexpression using immunohistochemistry*(ihc) or fluorescence in situ hybridization (FISH) medically necessary in individuals with inoperable locally advanced, recurrent, or metastatic adenocarcinoma of the stomach, esophagus or esophagogastric (GE) junction when traustuzumab therapy is being considered. *Note The NCCN Guidelines Panel recommends that cases showing 2+ expression of HER2-neu by IHC should be additionally examined by FISH or other in situ hybridization methods. Cases with 3+ overexpression by IHC or FISH positive (HER2:CPT17>2) are considered positive. Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Health Net National Medical Policies will now include the preliminary ICD-10 codes in preparation for this transition. Please note that these may not be the final versions of the codes and that will not be accepted for billing or payment purposes until the October 1, 2015 implementation date. ICD-9 Codes (may not be all-inclusive) V10.3 Personal history of malignant neoplasm, breast Malignant neoplasm of digestive organs and peritoneum Malignant neoplasm of female breast Malignant neoplasm of male breast ICD-10 Codes Z85.3 Personal history of malignant neoplasm of breast C15.3-C26.9 Malignant neoplasm of digestive organs C Malignant neoplasm of breast C Her2 neu and Herceptin Jun 15 3

4 CPT Codes Serum assay, Oncoprotein (HER2/neu microtiter ELISA) Molecular cytogenetics: DNA probe, each (eg FISH) Interphase in situ hybridization, analyze cells Immunocytochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure (Code revised in 2015) Tissue in situ hybridization, (eg. FISH) per specimen; initial single probe stain procedure (Code revised in 2015) Morphometric analysis, in situ hybridization (quanitative or semiquantitative) using computer-assisted technology, per specimen; initial single probe stain procedure (Code revised in 2015) Morphometric analysis, in situ hybridization (quanitative or semiquantitative), manual, per specimen; initial single probe stain procedure (Code revised in 2015) HCPCS Codes N/A Scientific Rationale Update June 2015 Perez et al. (J. Clin Oncol. 2014) Positive interim analysis findings from four large adjuvant trials evaluating trastuzumab in patients with early-stage human epidermal growth factor receptor 2 (HER2) -positive breast cancer were first reported in One of these reports, the joint analysis of North Central Cancer Treatment Group NCCTG N9831 (Combination Chemotherapy With or Without Trastuzumab in Treating Women With HER2-Overexpressing Breast Cancer) and the National Surgical Adjuvant Breast and Bowel Project NSABP B-31 (Doxorubicin and Cyclophosphamide Plus Paclitaxel With or Without Trastuzumab in Treating Women With Node-Positive Breast Cancer That Overexpresses HER2), was updated in The authors now report the planned definitive overall survival (OS) results from this joint analysis along with updates on the disease-free survival (DFS) end point. In all, 4,046 patients with HER2-positive operable breast cancer were enrolled to receive doxorubicin and cyclophosphamide followed by paclitaxel with or without trastuzumab in both trials. The required number of events for the definitive statistical analysis for OS (710 events) was reached in September Updated analyses of overall DFS and related subgroups were also performed. Median time on study was 8.4 years. Adding trastuzumab to chemotherapy led to a 37% relative improvement in OS (hazard ratio [HR], 0.63; 95% CI, 0.54 to 0.73; P<.001) and an increase in 10-year OS rate from 75.2% to 84%. These results were accompanied by an improvement in DFS of 40% (HR, 0.60; 95% CI, 0.53 to 0.68; P<.001) and increase in 10-year DFS rate from 62.2% to 73.7%. All patient subgroups benefited from addition of this targeted anti-her2 agent. The addition of trastuzumab to paclitaxel after doxorubicin and cyclophosphamide in early-stage HER2-positive breast cancer results in a substantial and durable improvement in survival as a result of a sustained marked reduction in cancer recurrence. Scientific Rationale Update June 2014 The National Comprehensive Network (NCCN, Version ), notes the following addition: Laboratory must participate in a quality assurance accreditation program for HER2 testing. Otherwise, tissue specimen should be sent to an accredited laboratory for testing. Health care systems and providers must cooperate to ensure the highest quality testing. Her2 neu and Herceptin Jun 15 4

5 The following guidelines (October 2013) was developed through a collaboration between the American Society of Clinical Oncology and the College of American Pathologists and has been published jointly by invitation and consent in both Journal of Clinical Oncology and the Archives of Pathology & Laboratory Medicine: HER2 status (HER2 negative or positive) be determined in all patients with invasive (early stage or recurrence) breast cancer on the basis of one or more HER2 test results (negative, equivocal, or positive). Testing criteria define HER2-positive status when (on observing within an area of tumor that amounts to evidence of protein overexpression (IHC) or gene amplification (by ISH based on counting at least 20 cells within the area). If results are equivocal (revised criteria), reflex testing should be performed using an alternative assay (IHC or ISH). Repeat testing should be considered if results seem discordant with other histopathologic findings. Laboratories should demonstrate high concordance with a validated HER2 test on a sufficiently large and representative set of specimens. Testing must be performed in a laboratory accredited by CAP or another accrediting entity. Scientific Rationale Update June 2013 Goldhirsch et al. (2012) completed the HERA Trial. One year (yr) of trastuzumab (T) significantly improves disease-free (DFS) and overall survival (OS) in patients with HER2-positive early breast cancer (EBC) and is considered the standard of care. HERA is the only randomized trial investigating whether longer duration of T can further improve efficacy outcome. HERA (BIG 01 01) is an international, multicenter, phase III randomized trial involving 5102 women with HER2-positive EBC. Pts were randomized, after completion of primary therapy [surgery, chemotherapy and radiotherapy as indicated], to T every 3 weeks for 1 yr, 2 years (yrs), or observation. This landmark efficacy analysis compares the outcome of pts randomized to either 2 yrs or 1 yr of T who were disease-free at 1 yr after randomization (N = 1553 for 2 yrs, and N=1552 for 1 yr). The primary endpoint is DFS and secondary endpoints are OS and time to distant recurrence (TTDR). Updated efficacy analyses of the T arms vs. observation at 8-yrs of median followup (FU) are also presented. On April 12, 2012, HERA reached the target number of 725 DFS events needed for 80% power to detect a true hazard ratio (HR) of 0.80 for the comparison of 2 yrs vs. 1 yr of T. The unadjusted HR for an event in the 2- yr vs. 1-yr T arms was 0.99 (95% CI ; p = 0.86). OS in the two arms was comparable [HR=1.05 (95% CI ; p = 0.63)]. TTDR results were similar. The primary cardiac endpoint* was comparable (1.0% vs. 0.8% for 2-yr and 1-yr arms, respectively), but the secondary cardiac endpoint** was higher in the 2-yr arm (7.2% vs. 4.1%). Importantly, the durable benefit in DFS and OS for both 1 yr and 2 yrs of T compared with observation remains stable at 8 yrs of median FU. Subgroup analyses including by hormone receptor status will be available for the meeting. These results confirm that 1 yr of adjuvant T remains the standard of care for HER2-positive EBC pts. It is also reassuring that the significant improvement in DFS and OS persists over time and that the incidence of cardiac endpoints remains low at a median FU of 8 yrs. Lindstrom et al. (2012) completed a study, to investigate whether hormonal receptors and human epidermal growth factor receptor 2 (HER2) change Her2 neu and Herceptin Jun 15 5

6 throughout tumor progression, because this may alter patient management. The study cohort included female patients with breast cancer in the Stockholm health care region who relapsed from January 1, 1997, to December 31, Either biochemical or immunohistochemical (IHC)/immunocytochemical (ICC) methods were used to determine estrogen receptor (ER), progesterone receptor (PR), and HER2 status, which was then confirmed by fluorescent in situ hybridization for IHC/ICC 2+ and 3+ status. Results ER (459 patients), PR (430 patients), and HER2 (104 patients) from both primary tumor and relapse were assessed, revealing a change in 32.4% (McNemar's test P <.001), 40.7% (P <.001), and 14.5% (P =.44) of patients, respectively. Assessment of ER (119 patients), PR (116 patients), and HER2 (32 patients) with multiple (from two to six) consecutive relapses showed an alteration in 33.6%, 32.0%, and 15.7% of patients, respectively. A statistically significant differential overall survival related to intraindividual ER and PR status in primary tumor and relapse (log-rank P <.001) was noted. In addition, women with ER-positive primary tumors that changed to ER-negative tumors had a significant 48% increased risk of death (hazard ratio, 1.48; 95% CI, 1.08 to 2.05) compared with women with stable ER-positive tumors. Patients with breast cancer experience altered hormone receptor and HER2 status throughout tumor progression, possibly influenced by adjuvant therapies, which significantly influences survival. Hence, marker investigations at relapse may potentially improve patient management and survival. Hechtman et al. (2012) Amplification of the human epidermal growth factor receptor 2/neu (HER2/neu) gene and overexpression of the HER2 protein (HER2) have been shown to occur in gastric and gastroesophageal junction adenocarcinoma in a number of studies. With a dismal survival rate, patients with these cancers stand to benefit from the identification of possible molecular targets such as HER2 for both prognostic and therapeutic purposes. Although these and other carcinomas that overexpress HER2 may have a poorer prognosis and exhibit resistance to conventional chemotherapy, they have also recently been shown to respond to targeted therapy with the anti-her2 antibody trastuzumab. The Summary of ASCO/CAP HER2 Guideline Recommendations was updated in 2011 with the following information: Optimal FISH testing requirements Fixation for fewer than 6 hours or longer than 48 hours is not recommended. Optimal IHC testing requirements Fixation for fewer than 6 hours or longer than 48 hours is not recommended Test is rejected and repeated if: Test is rejected and repeated if: Controls are not as expected Controls are not as expected Observer cannot find and count at least Artifacts involve most of sample. two areas of invasive tumor. Sample has strong membrane staining >25% of signals are unscorable due to of normal breast ducts (internal weak signals controls). >10% of signals occur over cytoplasm Interpretation follows guideline recommendation Nuclear resolution is poor Positive HER2 result requires homogeneous, dark circumferential (chicken wire) pattern in >30% of invasive tumor Autofluorescence is strong Interpreters have method to maintain consistency and competency Interpretation is done by counting at Sample is subjected to confirmatory least 20 cells; a pathologist must FISH testing if equivocal based on initial Her2 neu and Herceptin Jun 15 6

7 Optimal FISH testing requirements confirm that counting involved invasive tumor. Sample is subjected to increased counting and/or repeated if equivocal; report must include guideline-detailed elements. Optimal IHC testing requirements results. Report must include guidelinedetailed elements. The summary of ASCO/CAP HER2 guideline recommendations for optimal tissue handling requirements was also revised per the 2011 ASCO/CAP Clinical Notice on HER2 and ER/PgR. This information is available at: commendations.pdf Per the 2013 NCCN guidelines on Esophageal and Esophagogastric Junction Cancers, unlike breast cancer, the prognostic significance of HER2-neu in patients with esophageal cancer is not clear. It has been demonstrated that HER2-neu overexpression correlates with tumor invasion and lymph node metastasis, and thus indicates a poor prognosis.her2-neu overexpression seems to be associated with poorer survival, especially in patients with SCC of the esophagus. Per the 2013 NCCN guidelines on Breast Cancer, samples scored as 2+ by the IHC method are designated as equivocal (borderline). These samples should by subjected to reflex testing by an ISH method to assign HER2 status. Similarly, samples with equivocal results by an ISH assay (for example, scores of 1.8-<2.0 HER2 genes/chromosomes 17/cell or scores of >4 to <6 HER2 genes/ cell depending on the test used) must be confirmed by counting additional cells or repeating the ISH assay. If the results continue to be equivocal, then reflex testing with IHC is recommended to assign HER2 status. Scientific Rationale Update June 2011 According to the National Comprehensive Care Network (NCCN), upper gastrointestinal (GI) tract cancers originating in the esophagus, gastroesophageal (GE) junctions and stomach constitute a major health problem around the world. They estimated 37, 600 new cases of and 25,150 deaths from upper gastrointestinal (GI) tract cancers will occur in the United States in They note that by some estimates, gastric cancer is the fourth most common cancer worldwide, whereas, esophageal cancer is the eighth most common cancer worldwide. Surgery is the primary treatment for early stage gastric and esophageal cancer, however, they are both often diagnosed at an advanced stage. Complete resection with adequate margins (4 cm or greater) is widely considered as a standard goal for gastric cancer, however, the type of resection is controversial. In esophageal cancer, surgery may be performed with a curative intent or as part of palliative care. The NCCN states that radiation therapy (RT) may be an integral part of the treatment of upper GI tract cancers. This may include preoperative, postoperative or palliative RT. The NCCN notes that post-operative chemoradiation is standard of care in individuals with resected gastric cancer who have not received preoperative therapy. Preoperative chemotherapy is an option as standard of care for individuals with resectable gastric cancer. Primary chemoradiation therapy is established as standard of care in individuals with esophageal cancer. Chemotherapy can also provide both palliation and improved survival in individuals with advanced and metastatic disease. Her2 neu and Herceptin Jun 15 7

8 The overexpression of epidermal growth factor receptor (EGFR), vascular endothelial growth factor receptor (VEGFR) and human epidermal growth factor receptor 2 (HER2) has been associated with poor prognosis in individuals with gastric and esophageal cancers. On October 20, 2010, the U. S. Food and Drug Administration granted approval for trastuzumab (Herceptin), Genentech, Inc.), in combination with cisplatin and a fluoropyrimidine (capecitabine or 5-fluorouracil), for the treatment of patients with HER2 overexpressing metastatic gastric or gastroesophageal (GE) junction adenocarcinoma, who have not received prior treatment for metastatic disease. The approval was based on a significant improvement in median overall survival (OS) of 2.5 months with trastuzumab plus chemotherapy treatment compared to chemotherapy alone demonstrated in a single, international, multicenter, openlabel, randomized clinical trial, BO18255 (ToGA trial) (Bang et al 2010). A total of 594 patients with locally advanced or metastatic HER2 overexpressing adenocarcinoma of the stomach or GE junction were randomized (1:1) to receive either trastuzumab plus chemotherapy or chemotherapy alone. Trastuzumab was administered at an initial dose of 8 mg/kg intravenously (IV) followed by 6 mg/kg every three weeks until disease progression or intolerable toxicity. The chemotherapy regimen included cisplatin 80 mg/m2 IV day 1 every three weeks for six cycles and a fluoropyrimidine (either capecitabine 1000 mg/m2 orally twice daily for fourteen days or 5-fluorouracil 800 mg/m2 /day continuous intravenous infusion (CIV) days 1-5 every three weeks for six cycles.) All tumors were confirmed to be HER2 gene amplified by FISH or protein overexpressing (IHC 3+) using validated assays performed at a central laboratory. Among the 594 patients, 82% had primary gastric cancer, 18% had primary GE junction adenocarcinoma; 97% had metastatic disease. The median age was 60 years (range 2183) and 76% were male. Asians comprised 53% of the study population, Caucasians 38%; and Hispanics 5%. Nearly all patients (95%) had tumors with HER2 gene amplification by FISH. With HER2 IHC tumor staining 47% of tumors stained 3+, 30% were 2+, and 22% were 0 or 1+. Approximately 91% of patients had an ECOG PS <1. Prior therapies included gastrectomy (23%), prior neoadjuvant and/or adjuvant therapy (7%) and prior radiotherapy (2%.) The trial was closed after the second interim analysis when 167 deaths had occurred on the trastuzumab arm and 184 deaths on the control arm. In the final OS analysis, the median OS was 13.5 months (95% CI: 11.7, 15.7) and 11.0 months (95% CI: 9.4, 12.5) in the trastuzumab and control arms, respectively. The hazard ratio (HR) was 0.73 [(95% CI: 0.60, 0.91); p-value, two sided = (nominal significance level of )] in favor of the trastuzumab arm. An updated OS analysis (227 and 221 deaths in the trastuzumab and control arms, respectively) demonstrated median OS of 13.1 (95% CI: 11.9, 15.1 mos.) and 11.7 months (95% CI: 10.3, 13.0) in the trastuzumab and control arms, respectively (HR 0.8, 95% CI 0.67, 0.97.) Exploratory OS analyses in subgroups defined by protein expression (IHC testing) suggest that trastuzumab was most effective in prolonging survival in the 294 patient subgroup with HER2 IHC 3+ tumors (HR 0.66, 95% CI 0.50, 0.87) and less effective in the 160 patient subgroup with IHC 2 + tumors (HR 0.78, 95% CI 0.55, 1.10). No trastuzumab treatment effect was apparent in the 133-patient subgroup with HER2 gene amplified, ICH 0 or 1+ tumors (HR 1.33, 95% CI 0.92, 1.92). The most common adverse reactions (< 10%) associated with trastuzumab were neutropenia, diarrhea, fatigue, anemia, stomatitis, weight loss, fever, thrombocytopenia, mucosal inflammation, nasopharyngitis, and dysgeusia. The most common grade 3 and 4 adverse reactions (>5%) related to trastuzumab were neutropenia (35%), anemia (12%), diarrhea (9%), nausea (8%), anorexia (7%), Her2 neu and Herceptin Jun 15 8

9 and vomiting (6%). About 37% of patients receiving trastuzumab plus chemotherapy had infusion-related reactions. No grade 4 infusion reactions or deaths related to infusion reactions were reported. Cardiac adverse reactions occurred at the same incidence on both study arms. The incidence of cardiac failure was < 1%. Over 90% of the deaths in both arms were due to disease progression or disease-related complications. The most common adverse reactions resulting in treatment discontinuation in the trastuzumab arm were infection, diarrhea, and febrile neutropenia. Per the FDA approval, HER2 overexpression and gene amplification should be determined using FDA-approved tests with an indication for the specific tumor type being tested. Interpretation of the test results may be affected by differences in tumor histopathology (breast, gastric, or GE junction cancer). Limitations in assay precision make it inadvisable to rely on a single method to rule out potential Herceptin benefit. Zhan et al (2011) investigated the relationship between the expression of HER2/neu and the clinical characteristics, including survival rate, of esophageal squamous carcinoma. The clinical data of 145 patients admitted to a single institution from 2000 to 2005, were reviewed. The HER2 protein expression and gene status in 145 esophageal carcinomas were evaluated using immunohistochemistry and fluorescence in situ hybridization. The survival rate was calculated by the Kaplan-Meier method and the log-rank test using SPSS13.0 software. Compared to normal esophageal epithelium (23/95, 24.2%), HER2 protein was overexpressed in most esophageal squamous carcinoma tissues (60/145, 41.4%), of which 45 (31.0%) were 2+ and 15 (10.4%) were 3+, HER2 overexpression associated significantly with HER2 gene amplification. The authors noted there is a correlation between the overexpression of HER2 and the differentiation of the carcinoma, the HER2 gene amplification and the differentiation of the carcinoma and the tumor stage. According to univariate analysis, there was a significant difference in survival rates when cases with and without HER-2/neu overexpression or amplification were compared. The investigators concluded HER-2/neu amplification/overexpression may be used as an independent prognostic factor in patients with esophageal squamous cancer, and patients with HER-2/neu amplification/overexpression might be potential candidates for new adjuvant therapies that involve the use of humanized monoclonal antibodies. Scientific Rationale Update June 2010 Approximately 18 to 20 percent of breast cancers have amplification and/or overexpression of the gene encoding the cell surface receptor HER2. The National Comprehensive Care Network (NCCN) recommends the determination of the HER2 tumor status for all newly diagnosed invasive breast cancers. The American Society of Clinical Oncology-College of American Pathologists also recommend HER2 status be determined for all invasive breast cancer. They note the best method to assess HER2 status, in regards both to the type of assay used and the optimal method to perform each assay, remains controversial. Status can be assessed by fluorescence in situ hybridization (FISH), including newly available types of brightfield ISH or immunohistochemistry (IHC) assay. Those who test positive are candidates for treatment with trastuzumab, which is only effective in HER2-positive cancers. The most commonly used methods for HER2 testing are fluorescence in situ hybridization (FISH) and immunohistochemistry. Several FDA-approved commercial assays are available to determine HER2 status and aid in the selection of patients for Herceptin. Approved immunohistochemistry (IHC) assays, which Her2 neu and Herceptin Jun 15 9

10 measure the level of expression of the HER2 protein, include HercepTest (DakoCytomation) and Pathway HER2 (Ventana Medical Systems Inc). Approved FISH (fluorescence in situ hybridization) assays, which detect the underlying gene alteration in the patient's tumor cells, include PathVysion (Abbott Laboratories ), HER2 FISH pharmdxn Kit (DakoCytomation, Glostrup) and INFORM HER2/neu Pro (Ventana Medical Systems Inc.) Bright-field in situ hybridization is an alternative to FISH and uses a combination of in situ methodology and a peroxidase-mediated chromogenic substrate such as diaminobenzidine [chromogenic in situ hybridization (CISH)] or multimer technology coupled with enzyme metallography [silver-enhanced in situ hybridization (SISH)] to create a marker visible under bright-field microscopy. The tissue preparation and probe hybridization procedures of FISH and CISH are similar. They differ in the method of probe detection, which in the case of CISH is based on a peroxidase reaction that can be visualized by light microscopy, obviating the need for fluorescence, and the tissue can be visualized easily along with the amplification product. Thus, the invasive tumor and corresponding histologic or nuclear grade can be correlated immediately with HER-2/neu amplification. The only CISH test FDA approved and currently available, is the SPOT-Light HER2 CISH Kit (Zymed laboratories Inc.) Silver-enhanced in situ hybridization (SISH) is a rapid fully automated assay providing permanently stained slides that are interpreted by conventional bright field microscopy which enables pathologists to evaluate slides within the context of tissue morphology. There are no FDA approved SISH test kits available at this time. In a systematic review, Cuadros and Villegas (2009) analyzed clinical and analytic validity and clinical utility for HER2 testing (IHC and FISH) for the appropriate selection of breast cancer patients who were suitable for trastuzumab therapy. A critical appraisal was performed using an ad hoc scale based on CASPe (Critical Appraisal Skills Programme Spanish) criteria of 17 studies that satisfied the inclusion criteria (i.e., breast cancer patients, IHC and FISH assays were used, specificity, reliability of IHC and FISH or concordance between both techniques were reported.) Most articles evaluated the HercepTest and PathVysion assays. FISH was considered the gold standard test. The FISH positivity rate was calculated in each IHC score category. The percentage of FISH positive results (median) was estimated as 3.5 for IHC0, 5.8 for IHC1+, 17 for IHC2+, and 83.5 for IHC3+. The reviewers concluded the findings have shown high concordance rates between IHC and FISH in tumors IHC0 and IHC1+, and discordance rates among cases with IHC2+ and IHC3+. In these cases, FISH is considered gold standard for confirming or excluding HER2 amplification. Kovacs et al (2010) evaluated the accuracy of two commercially available and commonly used HER2 antibodies (antibody A0485 and HercepTest), followed by FISH-test, in 538 consecutive breast cancers, to identify a reliable procedure for the determination of HER2-status. Immunohistochemical (IHC) analysis revealed that 282 cases (52.2%) were positive (2+/3+) for antibody A0485, while only 179 cases (33.3%) were positive (2+/3+) for HercepTest (81.2% concordance between A0485 and HercepTest). FISH-analysis of the 103 IHC discordant cases revealed 89.3% concordance with HercepTest. The results of the study, revealed a significantly higher concordance rate between HercepTest and HER2 copy number status than between antibody A0485 and HER2 copy number status. Eleven cases (11% of 103 discordant cases) with HER2-amplification were positive for antibody A0485 and false negative for HercepTest. The investigators concluded the HercepTest is a reliable and accurate IHC-assay and that in the absence of clinical outcome data for IHC-positive/FISH-negative and IHC-negative/FISH-positive patients, FISH-analysis should be performed on all IHC 2+ and 3+ cases. Her2 neu and Herceptin Jun 15 10

11 Riethdorf et al (2010) evaluated the concordance between FISH and CISH in 399 samples from adjuvant and metastatic breast cancer patients. Tumor specimens from routine diagnostic practice were analysed by IHC, FISH and CISH in four reference centers in Germany. FISH and CISH results were strongly concordant (kappa = 0.83), with 95% of cases showing agreement. Despite variable IHC scoring across testing centers, complete consensus among the three methods was observed for 246 cases, representing 91% of all IHC positive (3+) or negative (0/1+) cases. Confirmatory testing of 132 IHC equivocal (2+) cases also yielded highly concordant results between FISH and CISH. The investigators concluded this that this data validates CISH for the assessment of HER2 gene amplification in breast tumors and, confirm CISH as a valid alternative to FISH in HER2 testing. Gong et al (2009) evaluated the reliability of CISH, in 226 consecutive breast carcinomas from 2 institutions and tested CISH and FISH on the same tumor set simultaneously at different test sites. Besides manufacturers' scoring criteria, the new American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines were used to interpret HER2 status. The concordance between CISH and FISH for positive and negative results was 98.5% at site A and 98.6% at site B using the manufacturers' criteria, and 99.0% at site A and 99.1% at site B using the ASCO/CAP criteria. Reproducibility of CISH results was more than 98.0% among 3 sites using the manufacturers' criteria and 100.0% between 2 sites using the ASCO/CAP criteria. The investigators concluded the results confirm that CISH is reliable for HER2 testing per ASCO/CAP guidelines. Papouchado et al (2010) evaluated the concordance between SISH and FISH assays in determining the status of HER2 gene amplification in a cohort of 298 primary invasive breast carcinomas. They also assessed in detail the variables contributing to interobserver interpretive reproducibility of HER2 SISH among 10 pathologists. HER2 was quantified using the ratio of HER2 to CHR17 signals using the conventional historical interpretation scale and also by the American Society of Clinical Oncology/College of American Pathologists reporting scheme. For SISH status determined by consensus among 10 pathologists, overall concordance between SISH and FISH was identified in 288 of 298 cases (96.6%) using the conventional Food and Drug Administration approved criteria. Overall agreement was observed in 282 of 285 cases (98.9%) using the American Society of Clinical Oncology/College of American Pathologists result reporting scheme (with equivocal cases removed). They concluded SISH represents a novel approach for the determination of HER2 status in breast cancer. The overall concordance between SISH and FISH is excellent, and the interpretation of SISH results by pathologists is most reproducible using the HER2/CHR17 ratio. Scientific Rationale Update March 2008 The American Cancer Society estimates that 180,510 new cases of breast cancer will be diagnosed and 40,910 will die of breast cancer in the United States in Breast cancer is the most common malignancy in women in the United States and is second only to lung cancer as a cause of cancer death. The incidence of breast cancer has increased steadily in the U.S. over the past few decades, but breast cancer mortality appears to be declining, suggesting a benefit from early detection and more effective treatment. Targeted therapies such as hormonal therapy are only helpful if the tumor is hormone receptor-positive, and targeted therapies such as Herceptin (Trastuzumab) are only effective if the tumor is HER2-positive. Targeted therapy is a form of treatment that attacks specific sites and/or processes that are important to the function of cancer cells. In many cases of targeted therapy, higher levels of Her2 neu and Herceptin Jun 15 11

12 the target (for example, the HER2 receptor) in the cancer cells are associated with greater benefit for the patient when the therapy (Eg. Herceptin) is given. HER2 Approximately 20% of current HER2 testing may be inaccurate. (2007) The American Society of Clinical Oncology (ASCO) and The College of American Pathologists (CAP) have developed guideline recommendations to improve the accuracy of the human epidermal growth factor receptor 2 testing (HER2) in invasive breast cancer. These indications are listed in the policy statement. HER2 expression and/or amplification should be evaluated in every primary invasive breast cancer either at the time of diagnosis or at the time of recurrence, principally to guide selection of Herceptin in the adjuvant and/or metastatic setting. Herceptin Herceptin is a monoclonal antibody therapy that is an important treatment option for some patients with HER2-positive tumors. It may be used as adjuvant therapy with chemotherapy to reduce the risk of recurrent breast cancer, as neoadjuvant therapy combined with chemotherapy to shrink the size of the tumor before surgery, or as treatment for metastatic breast cancer. Trastuzumab can cause heart damage and should be used cautiously when combined with other heart damaging drugs, such as doxorubicin and epirubicin. The combined U.S. and European data suggest the addition of Herceptin should be the standard of care in the adjuvant and possibly the neoadjuvant treatment of HER2-positive breast cancer, as survival is improved with acceptable toxicity. Further analyses of optimal scheduling of Herceptin and cardiac monitoring schedules need to be performed. Thus, Herceptin can now be considered standard therapy for early HER2 positive breast cancer FDA Approval On January 18, 2008, Herceptin (Trastuzumab) received FDA approval as a new indication for once every three-week dosing as a single agent, for the adjuvant treatment of HER2-overexpressing node-negative (ER/PR-negative or with one high risk feature) or node-positive breast cancer, following multi-modality anthracyclinebased therapy. Herceptin should not be administered as an IV push or bolus. It should not be mixed with other drugs. Herceptin is supplied as a lyophilized, sterile powder nominally containing 440mg Trastuzumab per vial. The FDA approval was based on one-year HERA (HERceptin Adjuvant) data, which reported the following: Significant reduction of breast cancer recurrence by 46 percent (or a hazard ratio of 0.54) in women taking Herceptin for 52 weeks, with HER2-positive lymph node-positive and lymph node-negative breast cancer, compared to those patients who received standard adjuvant therapy alone; Significant improvements in disease-free survival (the length of time after treatment during which no disease is found), the primary endpoint of the study, compared to patients receiving standard adjuvant therapy alone; Safety profile; Her2 neu and Herceptin Jun 15 12

13 Congestive heart failure (weakening of the heart muscle) occurred in 2.0 percent of the women treated with Herceptin, as compared to 0.3 percent in women receiving standard adjuvant therapy alone; Grade 3-4 adverse events in the Herceptin arm occurred at a rate of less than one percent for all events. Studies and Recommendations (February 2007) There is currently an ongoing Clinical Trial to test the hypothesis that reducing the duration of adjuvant trastuzumab to 6 months from 12 months, in 4,000 women with HER-2 positive early breast cancer, produces equivalent (non-inferior) disease-free and overall survival outcomes. The starting dose of Trastuzumab is 8 mg/kg. The maintenance dose is 6 mg/kg. The anticipated end date of this trial has been updated from April 1, 2011 to March 31, Patients will receive either of the following treatments, during or after a standard regimen of chemotherapy: 1. The standard treatment i.e. a dose every 3 weeks for a year (17 doses) or 2. The research treatment i.e. 9 doses over 6 months. (2008) There are now four large randomized studies involving more than 13,000 patients demonstrating that the addition of Herceptin to standard adjuvant therapy significantly increased disease-free survival for women with early-stage HER2- positive breast cancer. More than 450,000 women have been treated with Herceptin worldwide since its first approval in Scientific Rationale Update July 2006 Several studies were published in the medical literature from 2004 to July 2006 that continue to prove the benefits of Her2/neu testing and the administration of Herceptin as first, second and third line therapy. Scientific Rationale Initial The HER-2 gene normally produces a protein called HER-2 (human epidermal growth factor receptor). This protein is responsible for growth and division of cells. In 25-30% of women with metastatic breast cancer and in varying degrees in colorectal, gastric, ovarian, pancreatic, cervical, and prostate cancers, there is a genetic alteration in the Her2/neu gene causing an increased amount of overexpression of this protein. Overexpression of her2/neu leads to unregulated cell growth and may cause transformation of cells in malignancy. The overproduction of this protein is associated with a more aggressive disease and a shortened survival as the tumor is generally resistant to chemotherapy. Her2/neu is also used a predictor of response to therapy, such as hormone therapy and chemotherapy. If the level is initially elevated then falls, it is likely that treatment is effective. If it remains elevated, the treatment is effective; and if the level falls then rises, the cancer may be recurring. The only FDA approved methods for testing Her2/neu status for selecting patients for treatment with Herceptin: immunohistochemistry (IHC) and fluorescent in situ hybridization (FISH). IHC (ImmunoHistoChemistry) The HercepTest (Dako, Inc.) is an IHC test that uses specific antibodies to measure the protein excreted by the HER2gene. A tissue sample is taken during biopsy or Her2 neu and Herceptin Jun 15 13

14 surgery and a slide is prepared from the tumor block. It is then stained and the result of the test is reported as 0, 1+, 2+, or 3+. If a tumor is scored at a level 2+ or 3+, it is considered positive. Tumors with IHC 2+ scores are considered borderline though a few patients with level 2 over expression will benefit from Herceptin. Tumors with a 3+ score from an IHC test are distinctly positive, and many patients at this level would benefit from Herceptin therapy. FISH (Fluorescent in situ hybridization) Assay FISH evaluates the genetic level for gene amplification using a DNA probe that binds to the actual HER-2 gene. The gene can be directly visualized and the number of Her-2 neu genes per tumor cell can be quantified. The FISH test, which can be done on new or old tumor tissue samples, is considered the most accurate test for HER2/neu gene malfunction. It is the preferred method for testing older tissue either positive or negative. There are two tests that have been marketed: PathVysion from Vysis and Inform, developed by Oncor and marketed by Ventana. Oncor Inform is indicated for use as an adjunct to existing clinical and pathologic information currently used as prognostic indicators in the risk stratification of breast cancer in patients who have had a primary, invasive, localized breast cancer and who are lymph node negative. PathVysion HER 2 DNA Probe Kit (FISH) is intended for use as an adjunct to existing clinical and pathological information currently used as prognostic factors in stage II, node positive breast cancer patients. It is also indicated for use as an aid to predict disease free and over-all survival in patients with stage II, node positive breast cancer treated with adjuvant cyclophosphamide, doxorubicin and 5-fluorouracid (CAF) chemotherapy. Normally, there should be two chromosome, 17 signals and two HER-2 gene signals. This indicates a ratio of 1:1, meaning there is one HER-2 signal for each chromosome 17 signal, which is a normal result. However, when the ration is greater than 2:1, this means there are more than one HER-2 signal for each chromosome 17. This means that the HER-2 gene is amplified, which is abnormal. Recent data from large retrospective studies in breast cancer patients have revealed that survival results for women with Her-2/neu overexpression in the absence of Her-2/nue gene amplification is statistically indistinguishable from patients who are negative with both techniques. A positive FISH results by itself, with or without IHC corroboration, is a significantly better discriminator of adverse prognosis. Herceptin Herceptin (chemical name trastuzumab) is the only immune treatment currently available for breast cancer. It has been approved by the U.S. Food and Drug Administration (FDA) for women with metastatic HER2 positive breast cancer, and it is available in clinical trials for women with early-stage HER positive breast cancer involving lymph nodes. Herceptin is only effective against breast cancers that over express the Her-2 neu protein. About one out of every four breast cancers is HER2 positive. Though the appropriate duration of therapy is uncertain, most studies involve patients who are treated with Herceptin intravenously on a weekly basis for 9 weeks. The FDA approved Herceptin for treating metastatic HER2 positive breast cancer based on three major studies. One of these studies tested the effectiveness of Herceptin for women with HER2 positive tumors whose breast cancer recurred after standard chemotherapy. Herceptin shrank the tumors in 14% of these women. One Her2 neu and Herceptin Jun 15 14

15 average, the positive response to Herceptin lasted 9 months, and lengthened the women s survival by an average of about 13 months. This is a significant result, especially since metastatic breast cancer that is HER2 positive tends to be aggressive. Herceptin with chemotherapy In the other studies, improved results occurred when women with metastatic disease were treated with Herceptin and Taxol (paclitaxel) or Adriamycin (chemical name: doxorubicin) plus Cytoxan (chemical name: cyclophosphamide). These drug combinations shrank the tumors of nearly half the women (45%) treated. In contrast, less than one-third (29%) of those women who received chemotherapy alone had a similar response. When Herceptin was added to the chemotherapy, it boosted survival by an average of five months compared to chemotherapy alone. A small number of the women taking the combination of Herceptin and Adriamycin had significant heart problems, including congestive heart failure. Adriamycin is considered responsible for the majority of this effect. Herceptin on its own rarely causes heart damage. But the two drugs given together resulted in more heart damaged than expected. For this reason, the combination of Herceptin and Adriamycin is no longer recommended. Navelbine (Vinorelbine) chemotherapy combined with Herceptin has also been studied recently in clinical trials. Currently, Navelbine is approved by the FDA only for the treatment of non-small cell lung cancer. In one study, women with metastatic HER2 positive breast cancer received both Herceptin and Navelbine weekly. The drug combination shrank the tumors in 75% of the women. The most common side effect, which occurred in about one quarter of the women, was a temporary decrease in white blood cells, though no serious side effect occurred. Clinical trials are underway to determine if survival is improved with this drug combination. Clinical trials are also being performed on Herceptin combined with Taxol and Gemzar. For now, Gemzar is FDA-approved only for treating pancreatic and lung cancer. Review History June 2004 Medical Advisory Council July 2006 Update. Removed requirement that Herceptin is indicated only for Stage IV metastatic breast cancer March 2007 Coding Updates March 2008 Update. Codes Reviewed. Revisions- added 2008 FDA indication for Herceptin dosage. Added 2007 American Society of Clinical Oncology / College of American Pathologists guideline recommendations for HER2 testing in invasive breast cancer June 2008 Changed policy name to Her2/neu. Removed criteria for Herceptin from the policy statement. Removed section on current protocol of Herceptin administration from scientific rationale update March 2008 June 2010 Update no revision Her2 neu and Herceptin Jun 15 15

16 June 2011 June 2012 June 2013 June 2014 June 2015 Based on recommendations from the NCCN and the US FDA, updated policy to include testing of tumor HER2-neu overexpression using immunohistochemistry (IHC) or fluorescence in situ hybridization (FISH) as medically necessary in individuals with inoperable locally advanced, recurrent, or metastatic adenocarcinoma of the stomach, esophagus or esophagogastric (GE) junction when traustuzumab therapy is being considered Update. No Revisions. Update. Added definition of equivocal HER2 results. Added NCCN 2013 breast cancer recommendation that 2+ expression of HER2- neu by IHC should be additionally examined by FISH or other in situ hybridization methods. Codes updated. Update. Added updated information from the College of American Pathology (CAP) to #3 in the Policy Statement. Codes updated. Update. Added additional information to policy statement from NCCN regarding equivocal HER2 results and added information regarding 2+ and 3+ HER2 neu status. Codes updated. This policy is based on the following evidence-based guidelines: 1. Wolff AC, Hammond ME, Schwartz JN, et al. American Society of Clinical Oncology, College of American Pathologists. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol 2007 Jan 1;25(1): Updated November Available at: 2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Esphoageal and Esophagogastric Junction Cancers. Version Update Version Updated Version National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Gastric Cancer. Version Update Version Updated Version National Comprehensive Cancer Network. NCCN Clinical Practice of Oncology. Breast Cancer. Version Update Version Update Version Updated Version References Update June Burstein H. Adjuvant medical therapy for HER2-positive breast cancer. UpToDate. February 9, Cochrane DR, Bernales S, Jacobsen BM, et al. Role of the androgen receptor in breast cancer and preclinical analysis of enzalutamide. Breast Cancer Res 2014; 16:R7. 3. Di Leo A, Jerusalem G, Petruzelka L, et al. Final overall survival: fulvestrant 500 mg vs 250 mg in the randomized CONFIRM trial. J Natl Cancer Inst 2014; 106:djt Ellis M, Naughton MJ. Ma C. Treatment approach to metastatic hormone receptor-positive breast cancer: Endocrine therapy. UpToDate. March 3, Finn RS, Crown JP, Lang I, et al. The cyclin-dependent kinase 4/6 inhibitor palbociclib in combination with letrozole versus letrozole alone as first-line treatment of oestrogen receptor-positive, HER2-negative, advanced breast cancer (PALOMA-1/TRIO-18): a randomised phase 2 study. Lancet Oncol 2015; 16: Perez EA, Romond EH, Suman VJ, et al. Trastuzumab plus adjuvant chemotherapy for human epidermal growth factor receptor 2-positive breast Her2 neu and Herceptin Jun 15 16

17 cancer: planned joint analysis of overall survival from NSABP B-31 and NCCTG tran9831. J Clin Oncol 2014; 32: Piccart M, Hortobagyi GN, Campone M, et al. Everolimus plus exemestane for hormone-receptor-positive, human epidermal growth factor receptor-2-negative advanced breast cancer: overall survival results from BOLERO-2. Ann Oncol 2014; 25: Piccart-Gebhart MJ, Holmes AP, Baselga J, et al. First results from the phase III ALTTO trial (BIG 2-06; NCCTG [Alliance] N063D) comparing one year of anti- HER2 therapy with lapatinib alone (L), trastuzumab alone (T), their sequence (T L), or their combination (T+L) in the adjuvant treatment of HER2-positive early breast cancer (EBC). J Clin Oncol 32:5s, Available at: 9. Robertson JF, Llombart-Cussac A, Feltl D, et al. Fulvestrant 500 mg versus anastrozole as first-line treatment for advanced breast cancer: Overall survival from the phase II first study San Antonio Breast Cancer Symposium; References Update June ASCO-CAP HER2 Test Guideline Recommendations. Summary of Guideline 2007 and 2013 Recommendations. 2. O'Sullivan CC, Swain SM. Pertuzumab: Evolving therapeutic strategies in the management of HER2-overexpressing breast cancer. Expert Opin Biol Ther. 2013;13(5): Schneeweiss A, Chia S, Hickish T, et al. Pertuzumab plus trastuzumab in combination with standard neoadjuvant anthracycline-containing and anthracycline-free chemotherapy regimens in patients with HER2-positive early breast cancer: A randomized phase II cardiac safety study (TRYPHAENA). Ann Oncol. 2013;24(9): Semiglazov VF, Bozhok AA, Semiglazova, et al. HER2-positive breast cancer: Standard and double targeted therapy. Vopr Onkol. 2013;59(3): References Update June Goldhirsch A, Picart-Gebhart M, Proctor M, et al. HERA TRIAL: 2 years versus 1 year of trastuzumab after adjuvant chemotherapy in women with HER2- positive early breast cancer at 8 years of median follow up. Cancer Research: December 15, 2012; Volume 72, Issue 24, Supplement 3. doi: / SABCS12-S Hechtman JF, Polydorides AD. HER2/neu gene amplification and protein overexpression in gastric and gastroesophageal junction adenocarcinoma: a review of histopathology, diagnostic testing, and clinical implications. Arch Pathol Lab Med Jun;136(6): doi: /arpa RS. 3. Lindstrom LS, Karlsson E, Wilking LM, et al. Clinically used breast cancer markers such as estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 are unstable throughout tumor progression. J Clin Oncol Jul 20; 30(21): doi: /JCO Epub 2012 Jun Summary of ASCO/CAP HER2 Guideline Recommendations. Optimal tissue handling requirements. Revised per the 2011 ASCO/CAP Clinical Notice on HER2 and ER/PgR. Available at: of_recommendations.pdf 5. Verma S, Miles D, Gianni L, et al. Trastuzumab emtansine for HER2-positive advanced breast cancer. N Engl J Med Nov 8; 367 (19): doi: /NEJMoa Epub 2012 Oct 1.. References Update June 2012 Her2 neu and Herceptin Jun 15 17

18 1. Desmedt C, Di Leo A, de Azambuja E, et al. Multifactorial approach to predicting resistance to anthracyclines. J Clin Oncol 2011; 29: Di Leo A, Desmedt C, Bartlett JM, et al. HER2 and TOP2A as predictive markers for anthracycline-containing chemotherapy regimens as adjuvant treatment of breast cancer: a meta-analysis of individual patient data. Lancet Oncol 2011; 12: Fabi A, Di Benedetto A, Metro G, et al. HER2 protein and gene variation between primary and metastatic breast cancer: significance and impact on patient care. Clin Cancer Res 2011; 17: Glynn RW, Mahon S, Curran C, et al. TOP2A amplification in the absence of that of HER-2/neu: toward individualization of chemotherapeutic practice in breast cancer. Oncologist 2011; 16: Hammond ME, Hayes DF, Wolff AC. Clinical Notice for American Society of Clinical Oncology-College of American Pathologists guideline recommendations on ER/PgR and HER2 testing in breast cancer. J Clin Oncol 2011; 29:e Hayes DF. Steady progress against HER2-positive breast cancer. N Engl J Med 2011; 365: Leyland-Jones B, Smith BR. Serum HER2 testing in patients with HER2-positive breast cancer: the death knell tolls. Lancet Oncol 2011; 12: Slamon D, Eiermann W, Robert N, et al. Adjuvant trastuzumab in HER2- positive breast cancer. N Engl J Med 2011; 365: Yamauchi H, Hayes DF. HER2 and predicting response to therapy in breast cancer. UpToDate. January Updated October 29, References Update June Albarello L, Pecciarini L, Doglioni C. HER2 testing in gastric cancer. Adv Anat Pathol 2011; 18: Bang YJ, Van Cutsem E, Feyereislova A, et al. Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial. Lancet 2010; 376: Bouché O, Penault-Llorca F. HER2 and gastric cancer: a novel therapeutic target for trastuzumab. Bull Cancer Dec;97(12): Croxtall JD, McKeage K. Trastuzumab: in HER2-positive metastatic gastric cancer. Drugs Dec 3;70(17): De Vita F, Giuliani F, Silvestris N, et al. Human epidermal growth factor receptor 2 (HER2) in gastric cancer: a new therapeutic target. Cancer Treat Rev Nov;36 Suppl 3:S Jørgensen JT. Targeted HER2 treatment in advanced gastric cancer. Oncology. 2010;78(1): Lordick F. Trastuzumab: a new treatment option for HER2-positive metastatic gastric and gastroesophageal junction cancer. Future Oncol Feb;7(2): Lorenzen S, Lordick F. How will human epidermal growth factor receptor 2- neu data impact clinical management of gastric cancer? Curr Opin Oncol Apr Rüschoff J, Nagelmeier I, Baretton G, et al. Her2 testing in gastric cancer. What is different in comparison to breast cancer?. Pathologe May;31(3): Safran H, Dipetrillo T, Akerman P, et al. Phase I/II study of trastuzumab, paclitaxel, cisplatin and radiation for locally advanced, HER2 overexpressing, esophageal adenocarcinoma. Int J Radiat Oncol Biol Phys Feb 1;67(2): Sato-Kuwabara Y, Neves JI, Fregnani JH, et al. Evaluation of gene amplification and protein expression of HER-2/neu in esophageal squamous Her2 neu and Herceptin Jun 15 18

19 cell carcinoma using Fluorescence in situ Hybridization (FISH) and immunohistochemistry. BMC Cancer Jan 7;9: Thompson SK, Sullivan TR, Davies R, Ruszkiewicz AR. HER-2/neu Gene Amplification in Esophageal Adenocarcinoma and Its Influence on Survival. Ann Surg Oncol Jan U.S. FDA. Trastuzumab. 14. Zhan N, Dong WG, Tang YF, et al. Analysis of HER2 gene amplification and protein expression in esophageal squamous cell carcinoma. Med Oncol Feb 13. References Update June Cuadros M, Villegas R. Systematic review of HER2 breast cancer testing. Appl Immunohistochem Mol Morphol Jan;17(1): Francis GD, Jones MA, Beadle GF, Stein SR. Bright-field in situ hybridization for HER2 gene amplification in breast cancer using tissue microarrays: correlation between chromogenic (CISH) and automated silver-enhanced (SISH) methods with patient outcome. Diagn Mol Pathol Jun;18(2): Gong Y, Sweet W, Duh YJ, et al. Chromogenic in situ hybridization is a reliable method for detecting HER2 gene status in breast cancer: a multicenter study using conventional scoring criteria and the new ASCO/CAP recommendations. Am J Clin Pathol Apr;131(4): Kovács A, Stenman G. HER2-testing in 538 consecutive breast cancer cases using FISH and immunohistochemistry. Pathol Res Pract Jan 15;206(1): Papouchado BG, Myles J, Lloyd RV, et al. Silver In Situ Hybridization (SISH) For Determination of HER2 Gene Status in Breast Carcinoma: Comparison With FISH and Assessment of Interobserver Reproducibility. Am J Surg Pathol Apr Pothos A, Plastira K, Plastiras A, et al. Comparison of chromogenic in situ hybridisation with fluorescence in situ hybridisation and immunohistochemistry for the assessment of her-2/neu oncogene in archival material of breast carcinoma. Acta Histochem Cytochem Jun 27;41(3): Penault-Llorca F, Bilous M, Dowsett M, Hanna W, et al. Emerging technologies for assessing HER2 amplification. Am J Clin Pathol Oct;132(4): Riethdorf S, Hoegel B, John B, et al. Prospective multi-centre study to validate chromogenic in situ hybridisation for the assessment of HER2 gene amplification in specimens from adjuvant and metastatic breast cancer patients. J Cancer Res Clin Oncol Apr U.S.Food and Drug Administration. SPOT-Light HER2 CISH Kit. References Updated March HERceptin Adjuvant (HERA) FDA Approval. January Marsh S, Phillips MS. Integrating pharmacogenomics into oncology clinical practice. Expert Review of Clinical Pharmacology. January 2008, Vol. 1, No. 1, Pages (doi: / ) 3. Gerber D. Targeted Therapies: A New Generation of Cancer Treatments. American Family Physician. February 1, Volume 77, Number Wolff AC, Elizabeth M, Hammond H, et al. American Society of Clinical Oncology/College of American Pathologists Guideline Recommendations for 5. Human Epidermal Growth Factor Receptor 2 Testing (HER2) in Breast Cancer. Arch Pathol Lab Med. Vol 131, January Harris L, Fritsche H, Mennel R, et al. American Society of Clinical Oncology 2007 Update of Recommendations for the Use of Tumor Markers in Breast Cancer. Journal of Clinical Oncology. Volume 25, Number 33, November 20, Her2 neu and Herceptin Jun 15 19

20 7. Barclay L, Nghiem HT. Guidelines Updated for Use of Tumor Markers in Breast Cancer. 11/21/ Clinical Trial for Duration of Herceptin with Chemotherapy 6 vs 12 months. Available at: 9. Protocol of treatment with trastuzumab (Herceptin) in adjuvant conditions. Institut National du Cancer. References Updated July Practice Guidelines in Oncology National Comprehensive Cancer Network v Bozzetti C, et al. Evaluation of HER-2/neu amplification and other biological markers as predictors of response to neoadjuvant anthracycline-based chemotherapy in primary breast cancer: the role of anthracycline dose intensity. Am J Clini Oncol Apr;29(2): Al-Ahwal MS. HER-2 positivity and correlations with other histopathologic features in breast cancer patients hospital based study. J Pak Med Assoc Feb; 56(2): Martinez SR, et al. The utility of estrogen receptor, progesterone receptor, and Her-2/neu status to predict survival in patients undergoing hepatic resection for breast cancer metastases. Am J Surg Feb; 191(2): Emens LA. Trastuzumab: targeted therapy for the management of HER-2/nueoverexpressing metastatic breast cancer. Am J Ther May-Jun; 12(3): Tripathy D. Targeted therapies in breast cancer. Breast J Mar-Apr;11 Suppl 1:S30-5. References Initial 1. American Society of Clinical Oncology. Tumor Markers in Breast and Colorectal Cancer Bartlett, J., et al. The Clinical Evaluation of HER-2 Status: Which Test to Use. Journal of Pathology. April 2003; 199(4): Bartlett, J.M., et al. Evaluating HER2 Amplification and Overexpression in Breast Cancer. Journal of Pathology. November 2001; 1954(4): Baselga, J. Herceptin Alone or in Combination with Chemotherapy in the Treatment of HER2-Positive Metastatic Breast Cancer; Pivotal Trials. Oncology. 2001; 61 (supplement2): Cell Markers and Ctyogenetics Committee College of American Pathologists. Clinical Laboratory Assays for HER-2/neu Amplification and Overexpression: Quality Assurance, Standardization, and Proficiency Testing. Archives of Pathology and Laboratory Medicine. July 2002; 126(7): Baselga J. Norton L, Albanell J, et al. Recombinant humanized anti-her2 antibody (Herceptin) enhances the antitumor activity of paclitaxel and doxorubicin against HER2/new overexpressing human breast cancer xenografts. Cancer Res. 1998;58(13): Cobleigh MA, Vogel CL, Tripathy D, et al. Multinational study of the efficacy and safety of humanized anti-her2 monoclonal antibody in women who have HER2-overexpressing metastatic breast cancer that has progressed after chemotherapy for metastatic disease. J Clin Oncol. 1999;17(9): McNeil C. Herceptin raises its sights beyond advanced breast cancer. J Natl Cancer Inst. 1998;90(12): Bast RC, Ravdin P, Hayes DF, et al. ASCO special article update of recommendations for the use of tumor markers in breast and colorectal cancer: Clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001;19(6): Her2 neu and Herceptin Jun 15 20