Treatments for HER2 Positive Metastatic Breast Cancer: Past, Present, and Future

Treatments for HER2 Positive Metastatic Breast Cancer: Past, Present, and Future Maria Theodoulou, MD Attending, Breast Cancer Service,MSKCC Professor of Medicine Weill Cornell Medical School

Outline 1. Biology of HER2 2. Sequencing of HER2 therapies for MBC Key clinical trials Sequential use in 1 st, 2 nd,3 rd line and beyond Current 2015 treatment algorithm 3. Future Therapies in Development

Breast Cancer Epidemiology Over 1 million estimated new cases of invasive breast cancer diagnosed annually worldwide The human epidermal growth factor receptor (HER2) is amplified and overexpressed in ~20-25% of breast cancers Distinct gene expression pattern: differs from basal- and luminal-like breast cancer subgroups Up to half of HER2-positive tumors are ERpositive Approximately 60%-75% of patients with HER2-positive tumors are node-positive Of patients with HER2-positive disease Approximately one third are between 50 and 59 years old Approximately one sixth are 60 years old Over 60% of patients with HER2-positive disease present with high-grade tumors Luminal Subtype A Luminal Subtype B ERBB2+ Basal Subtype Normal Breast like HER2 gene cluster American Cancer Society. Cancer Facts and Figures. 2011. Cobleigh et al. J Clin Oncol. 1999;17:2639. Pegram et al. Cancer Treat Res. 2000;103:57. Piccart-Gebhart et al. N Engl J Med. 2005;353:1659. Slamon et al. 29th Annual San Antonio Breast Cancer Symposium. Abstract 52 and oral presentation. Sorlie et al. Proc Natl Acad Sci U S A. 2003;100:8418. 3

The HER Family of Receptors Ligands TGF-α EGF Epiregulin Betacellulin HB-EGF Amphiregulin ORPHAN Heregulin Heregulin (neuregulin-1) Epiregulin HB-EGF Neuregulins-3, -4 HER1 HER2 HER3 HER4 PI3K Ras PTEN Raf AKT MEK MAPK Survival Cyclin D Proliferation

Normal HER2 Expression Normal (~ 20,000-50,000 receptors) HER2 receptor HER2 gene HER2 mrna Pegram et al. Cancer Treat Res. 2000;103:57.

Amplified and Overexpressed HER2 HER2-positive (Up to 2 million receptor molecules) HER2 receptor HER2 gene HER2 mrna Amplification: an abnormal increase in the HER2 gene copy number Overexpression: an abnormal increase in the number of HER2 protein receptors Pegram et al. Cancer Treat Res. 2000;103:57.

Disease-free survival probability Percentage survival 1 Disease-Free and Overall Survival in Pts With Breast Cancer Based on HER2 0.8 0.6 Not amplified (n=52) HER2 (n=ns) 0.4 0.2 Amplified (n=11) >5 copies HER2+ (n=50) 0 P=0.015 0 1 2 3 4 5 6 7 Years 0 P<0.0001 0 2 4 6 8 10 12 14 16 Years NS = not specified. Slamon et al. Science. 1987;235:177; Witton et al. J Pathol. 2003;200:290.

Trastuzumab: Mechanisms of Action HER2 1. Inhibition of receptor-receptor interactions Inhibition of phosphorylation and downstream signaling cascades Induction of apoptosis 2. Receptor-antibody complex internalization decreases protein on cell surface 3. Immune activation Complement-mediated cytotoxicity Antibody-dependent cellular cytotoxicity signaling

Survival (%) Trastuzumab Added to Chemotherapy Improves OS in MBC No. At Risk Chemotherapy plus trastuzumab 100 90 80 70 60 50 40 30 20 10 0 235 Chemotherapy alone 214 192 165 134 114 96 25.1 vs 20.3 mo p = 0.01 Chemotherapy plus trastuzumab 0 5 10 15 20 25 30 35 40 45 50 Months After Enrollment 47 11 Chemotherapy alone 234 205 160 136 116 97 76 37 13 Slamon, NEJM 2001

Lapatinib Mechanism of Action Binds to intracellular ATP binding site of EGFR (ErbB-1) and HER2 (ErbB-2) preventing phosphorylation and activation HER2 HER1 Blocks downstream signaling through homodimers and heterodimers of EGFR (ErbB-1) and HER2 (ErbB-2) TK TK Dual blockade of signaling may be more effective than the single-target inhibition provided by agents such as trastuzumab Downstream signaling cascade Rusnak et al. Mol Cancer Ther 2001;1:85-94; Xia et al. Oncogene 2002;21:6255-6263; Konecny et al. Cancer Res. 2006;66:1630-1639

PHASE III: Lapatinib + Capecitabine vs Capecitabine HER2+ LABC or MBC with prior exposure to an anthracycline, a taxane and trastuzumab* N=528 R A N D O M I Z E Lapatinib 1250 mg po qd continuously + Capecitabine 2000 mg/m 2 /d po days 1-14 q 3 wk Capecitabine 2500 mg/m 2 /d po days 1-14 q 3 wk Patients on treatment until progression or unacceptable toxicity, then followed for survival *Trastuzumab must have been administered for metastatic disease Geyer et al N Engl J Med. 2006 Dec 28;355(26):2733-43 12

% of Patients Progression-Free Time to Progression (ITT) Lapatinib and Capecitabine Capecitabine 100 90 80 70 No. of patients 163 161 Median TTP (mo) 8.4 4.4 Hazard ratio (95% CI) 0.49 (0.34-0.71) P value (log-rank) <0.001 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 Weeks TTP = time to progression. Geyer CE, et al. N Engl J Med. 2006;355:2733-2743.

Capecitabine With or Without Lapatinib: Study Results Capecitabine n = 201 Lapatinib and Capecitabine n = 198 Hazard Ratio (95% CI) P Value Median time to progression (mo) 1 4.3 6.2 0.57 (0.43-0.77) 0.0001 Median progression-free survival 2 (mo) 4.4 8.4 0.47 (0.32-0.68) <0.001 Overall response rate (%) (CR + PR) 1 13.9 23.7 0.017 Overall survival 1 (%) 15.6 15.14 0.78 (0.55-1.12) 0.177 CR = complete response; PR = partial response. 1 Geyer CE, et al. Br Cancer Res Treat, 2009. 2 Geyer CE, et al. N Engl J Med. 2006;355:2733-2743.

Clinical Pathway: HER2 Positive MBC, 2007 1 st Line Taxane + Trastuzumab 2 nd Line Lapatinib + capecitabine?

Paradigm Shift: Continuing Trastuzumab After Progression HER2+ MBC with progression during or after a treatment with trastuzumab ± CT as adjuvant or first-line therapy a Primary end point: TTP R Capecitabine + Trastuzumab (n =78) 2500 mg/m2 on days 1-14, q21d + trastuzumab 6 mg/kg q3w Capecitabine (n=78) 2500 mg/m2 on days 1-14, q21d a Between 01/04 and 05/07, 156 of 482 planned patients were randomized. von Minckwitz G et al, J Clin Oncol 2009;27(12):1935-7

PFS C T OS C T C C+T P-value RR 27% 48% 0.011 CB 54% 75.3% 0.007 TTP 5.6m 8.2 m 0.034 OS 20.4m 25.5m 0.26 Continuing trastuzumab beyond progression improves efficacy of 2 nd line chemotherapy C- capecitabine T- trastuzumab von Minckwitz G et al, J Clin Oncol 2009;27(12):1935-7

Phase 2 Trials of Chemotherapy Plus Trastuzumab: Response Rates Single Agent Chemo Authors RR(%) docetaxel Marty et al 61% Esteva et al 70% Vinorelbine Burstein et al 42% Jahanzeb et al 78% Capecitabine Bangemann et al 56% Liposomal doxorubicin Theodoulou et al 58% Chia et al 52% Gemcitabine O Shaughnessy et al 38% Cisplatin Pegram & Slamon 24% Combinations Paclitaxel + Carboplatin Robert et al 52% Paclitaxel + Gemcitabine Sledge et al 67% Paclitaxel + Doxorubicin Bianchi et al 88% Docetaxel + Cisplatin Pegram et al 79% Docetaxel + Carboplatin Pegram et al 58% Gemcitabine + Cisplatin Heinemann et al. 43% Gemcitabine + Carboplatin Yardley et al 66%

Preclinical Synergy Of Lapatinib + Trastuzumab In HER2+ Tumor Xenografts Greater antitumor activity with T+ L compared to either T or L alone Scaltriti et al. Oncogene 2009

Dual HER2 Blockade Improves Clinical Outcome HER2+ MBC (IHC 3+/ FISH+); Progression on anthracycline, taxane or trastuzumab; progression on most recent trastuzumab regimen R Lapatinib 1500 mg/d PO (n=148) Lapatinib 1000 mg/d PO Trastuzumab 4 2 mg/kg IV qw (n=148) Crossover allowed after 4 wk therapy n=73 End points Primary: PFS in ITT population Secondary: OS; ORR; CBR; DR; TTR; safety; QoL a 2 pts had >1 event b 3 pts recovered while remaining on treatment c Cardiac failure; cause of death: pulmonary thromboembolism Blackwell K et al JCO 2010 20

Cumulative % Alive without Progression Progression-Free Survival: Lapatinib vs Lapatinib + Trastuzumab 100 80 60 40 20 0 Subjects At Risk L 148 L+T 148 53 73 13% 21 42 28% L N = 145 L+T N = 146 Progressed or Died, n 128 127 Median PFS, wks 8.1 12.0 Hazard ratio (95% CI) 0.73 (0.57, 0.93) P value 0.008 Median OS, mo 9.5 14 Hazard ratio 0.74 (0.57, 0.97) P value 0.021 6 Mo PFS 0 10 20 30 40 50 60 Time from Randomization (wks) 13 27 5 8 0 2 Blackwell K et al, JCO 2010; Blackwell K et al., J Clin Oncol 2012

22 Clinical Implications Continued HER2 blockade beyond trastuzumab progression achieves better outcomes Capecitabine + Trastuzumab > Capecitabine Capecitabine + Lapatinib > Capecitabine Continuation of trastuzumab itself beyond progression is effective HER2 targeted therapy Dual targeting of HER2 without chemotherapy results in substantial efficacy in trastuzumab pretreated patients in the MBC setting Trastuzumab +Lapatinib > Lapatinib

Clinical Pathway: HER2 Positive MBC, 2009 1 st Line Taxane + Trastuzumab 2 nd Line and beyond Lapatinib + capecitabine Trastuzmab+ capecitabine Trastuzumab+ Lapatinib Trastuzumab + Chemo

Pertuzumab and Trastuzumab: Complementary Mechanisms of Action HER2 HER 1/3/4 Trastuzumab Pertuzumab Subdomain IV Dimerization domain Trastuzumab: Inhibits ligand-independent HER2 signaling Activates ADCC Prevents HER2 ECD shedding Pertuzumab: Inhibits ligand-dependent HER2 dimerization and signaling Activates ADCC Baselga J, et al. Presented at: 34th Annual San Antonio Breast Cancer Symposium; December 6-11, 2011; San Antonio, TX. Abstract S5-5; Baselga J, et al. J Clin Oncol. 2010;28(7):1138-1144.

CLEOPATRA study design n=406 Trastuzumab + Placebo PD Patients with HER2-positive MBC centrally confirmed (N=808) 1:1 Docetaxel 6 cycles recommended Trastuzumab + Pertuzumab PD n=402 Docetaxel 6 cycles recommended Randomization was stratified by geographic region and prior treatment status (neo/adjuvant chemotherapy received or not) HER2, human epidermal growth factor receptor 2; MBC, metastatic breast cancer; PD, progressive disease Baselga et al, NEJM 2012

OS (%) Final OS Analysis Median follow-up 50 months (range 0 70 months) n at risk Ptz + T + D Pla + T + D 100 90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 402 406 HR 0.68 95% CI = 0.56, 0.84 p = 0.0002 371 350 318 289 Time (months) 268 230 40.8 months 226 179 Δ 15.7 months 104 91 Ptz + T + D Pla + T + D 56.5 months 28 23 1 0 ITT population. Stratified by geographic region and neo/adjuvant chemotherapy. CI, confidence interval; Pla, placebo; Ptz, pertuzumab. Swain et al 2014 27

Conclusion CLEOPATRA demonstrated a statistically significant improvement in PFS and OS. Acceptable safety signals Docetaxel + Tratuzumab + Pertuzumab is now a standard of care for patients with HER2+ MBC in the first-line setting

Phase II Study: Paclitaxel + Trastuzumab + Pertuzumab for HER2+ MBC N = 69 HER2 + 0-1 prior Rx 1 endpoint=6 mo PFS q week q 3 weeks. Paclitaxel at 80 mg/m 2 q 3 weeks. every 4 cycles.. cardiac biomarkers every 2 cycles. Pertuzumab at 840mg load 420 mg q 3 w Trastuzumab at 8 mg/kg load 6 mg/kg q 3 w ECHO w/ strain imaging N Iyengar, Rebecca Rohrer, Melanie Chen, Erinn Bacchus, Angemael Syldor, Nicola Hamilton, Dang et al, JCO 2015

Paclitaxel+ Tratuzumab+ Pertuzumab: Response

Primary Endpoint: 6-month PFS Very well tolerated No febrile neutropenia

NCCN /ASCO GUIDELINES: HER2+ MBC Preferred 1 st -line Rx: Docetaxel + HP (CLEOPATRA study) Paclitaxel + HP (MSKCC study) Giordano et al, JCO 2014; NCCN v.3, 2013

Clinical Pathway: HER2 Positive MBC, 2012 1 st Line Taxane + Trastuzumab + Pertuzumab 2 nd Line and beyond Lapatinib + capecitabine Trastuzmab+ capecitabine Trastuzumab+ Lapatinib Trastuzumab + Chemo

Ado Trastuzumab Emtansine (T-DM1) Antibody-conjugate Binds to HER2 with affinity similar to trastuzumab Provides intracellular delivery of mertansine Derivative of maytansine, a natural-product microtubule polymerization inhibitor 20-100 more potent than vincristine Phase 1 Trial: 34% RR Ben Nulsen, Nicola Hamilton, Modi et al

EMILIA Study Design HER2+ (central) LABC or MBC (N=980) T-DM1 3.6 mg/kg q3w IV PD Prior taxane and trastuzumab Progression on metastatic tx or within 6 mos of adjuvant tx 1:1 Capecitabine 1000 mg/m 2 orally bid, days 1 14, q3w + Lapatinib 1250 mg/day orally qd PD Stratification factors: World region, number of prior chemo regimens for MBC or unresectable LABC, presence of visceral disease Primary end points: PFS by independent review, OS, and safety Key secondary end points: PFS by investigator, ORR, duration of response, time to symptom progression Blackwell et al, Plenary Verma S et al, NEJM 2012

Proportion progression-free Progression-Free Survival by Independent Review 1.0 0.8 0.6 Median (mos) No. events Cap + Lap 6.4 304 T-DM1 9.6 265 Stratified HR=0.650 (95% CI, 0.55, 0.77) P<0.001 0.4 0.2 0.0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 Time (mos) No. at risk by independent review: Cap + Lap 496 404 310 176 129 73 53 35 25 14 9 8 5 1 0 0 T-DM1 495 419 341 236 183 130 101 72 54 44 30 18 9 3 1 0 Unstratified HR=0.66 (P<0.0001). Verma S et al, NEJM 2012

Overall Survival Verma S et al, NEJM 2012

EMILIA: Conclusion T-DM1 demonstrated improved efficacy over cape + lapatinib: PFS(HR=0.65; P<0.001) OS (HR=0.68; P<0.001) Safety and secondary end points favored T-DM1 T-DM1 is an effective option for HER2-positive metastatic breast cancer

Clinical Pathway: HER2 Positive MBC, 2013 1 st Line Taxane + Trastuzumab+ Pertuzumab 2 nd Line Ado Trastuzumab Emtansine (T-DM1) 3 rd Line and beyond Lapatinib + capecitabine Trastuzmab+ capecitabine Trastuzumab+ Lapatinib Trastuzumab + Chemo

Phase III T-DM1 1 st line Trial: MARIANNE Taxane + Trastuzumab N=1092 HER2+ MBC First-line TDM1 TDM1+ Pertuzumab 1 Endpoint: PFS 2 Endpoints: OS, TTF, DOR, ORR, CBR T= paclitaxel 80 m/m weekly or docetaxel at 75-100 m/m q 3 w H=trastuzumab 2 mg/kg q w or 6 mg/kg q 3 w P=pertuzumab at 840 mg load 420mg q 3 w TDM= trastuzumab/dm1 at 3.6 mg/kg q 3 w

Clinical Pathway: HER2 Positive MBC, 2015 HER2+ MBC ER- *ER+ Taxane/trastuzumab/pertuzumab Ado Trastuzumab Emtansine (T-DM1) Letrozole +/- lapatinib AI or tamoxifen +/- trastuzumab ER- guidelines Lapatinib/capecitabine Trastuzumab/capecitabine Trastuzumab/lapatinib Trastuzumab/chemotherapy T-DM1 if not received earlier Pertuzumab if not received earlier *No OS advantage with hormone therapy plus anti-her2 therapy Giordano et al. JCO 2014 (ASCO GUIDELINES)

Timeline of HER2 Therapy for HER2+ MBC 1980 s 1998 2006 Discovery of erbb2 as an oncogenic driver of breast cancer Trastuzumab 1 st line Rx of HER2+ MBC with paclitaxel; monotherapy Trastuzumab approved for adjuvant Rx Of NP+ BC 2007 2008 2012 2013 2013 Lapatinib approved for 2 nd line Rx of MBC with capecitabine Pertuzumab approval for 1 st line Rx of MBC with paclitaxel and trastuzumab Trastuzumab approved for adjuvant Rx of high risk NN- BC Ado Trastuzumab Emtansine (T-DM1) approval for 2 nd line Rx of MBC Pertuzumab Approval for neoadjuvant BC

FUTURE 43

HER2 Therapies in Metastatic BC LJM716 R05479599 MM-302 BYL719 afatinib GDC-0032 MMK206 Gajria et al. Exp Rev Anticancer Ther 2011

BOLERO-3: Study Design N = 572* Locally advanced or metastatic HER2 + breast cancer Prior taxane required TRAS resistance Adjuvant: progression on or within 12 months of TRAS Metastatic: progression within 4 weeks of TRAS Measurable disease only Randomize 1:1 Stratification by prior lapatinib use (yes/no) Everolimus (5 mg PO daily) + Vinorelbine (25 mg/m 2 weekly) + TRAS (2 mg/kg week ) (n = 284) Placebo (PO daily) + Vinorelbine (25 mg/m 2 weekly) + TRAS (2 mg/kg weekly*) (n = 285) Therapy until PD or intolerable toxicity Endpoints: Primary: PFS Secondary: OS, ORR, time to deterioration of ECOG PS, safety, DoR, CBR, and QoL * Actual enrollment was 569. Following a 4-mg/kg loading dose on day 1, cycle 1 (1 cycle = every 21 days). Abbreviations: CBR, clinical benefit rate; DoR, Duration of response; ECOG, Eastern Cooperative Oncology Group; HER2, human epidermal growth factor receptor 2; ORR, overall response rate; OS overall survival; PD, progressive disease; PFS, progressive-free survival; PO, oral; PS, performance status; QoL, quality of life. http://www.clinicaltrials.gov/ct2/show/nct01007942?term=bolero3&rank=1 45 O Regan et al, ASCO 2013

Probability, % BOLERO-3: Primary Endpoint Progression-Free Survival by Local Assessment 100 80 60 Hazard ratio = 0.78; 95% CI [0.65, 0.95] Log-rank P value =.0067 Median PFS Everolimus: 7.00 months; 95% CI [6.74, 8.18] Placebo: 5.78 months; 95% CI [5.49, 6.90] 40 20 Censoring times Everolimus (n/n = 196/284) Placebo (n/n = 219/285) 0 Number of Patients Still at Risk Everolimus 284 259 233 200 161 126 98 78 54 40 35 26 18 14 14 9 5 4 Placebo 285 253 202 177 138 109 85 64 49 38 26 23 19 16 12 10 7 4 Abbreviations: CI, confidence interval. 0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 Time, weeks Interim OS data not mature 90 96 102 O Regan et al, ASCO 2013 46

BOLERO-3: Most Common Adverse Events (Nonhematologic) Everolimus Arm (N = 280) Placebo Arm (N = 282) Adverse Event, % All Grades Grade 3 Grade 4 All Grades Grade 3 Grade 4 Stomatitis 63 13 0 28 1 0 Fatigue 43 12 <1 42 4 0 Pyrexia 39 3 0 23 1 0 Diarrhea 38 4 0 31 1 0 Nausea 35 3 0 37 1 0 Decreased appetite 33 1 0 17 1 0 Constipation 30 <1 0 31 <1 0 Rash 25 0 0 18 1 0 Hyperglycemia* 9 4 2 5 2 1 Noninfectious pneumonitis* 6 <1 <1 3 1 <1 Hyperlipidemia* 2 0 0 1 0 0 * Included as adverse events of interest despite lower frequency. 47 O Regan et al, ASCO 2013

BOLERO-3: Summary Addition of everolimus to trastuzumab + vinorelbine significantly prolongs PFS by 1.2 mo (p = 0.0067) Adverse events consistent with previous experience with everolimus Interim OS data are not yet mature PROOF OF CONCEPT THAT BLOCKING THE PATHWAY - NOT THE RECEPTOR - IS AN EFFECTIVE ANTI-CANCER STRATEGY FOR HER2+ BC 48

Mechanisms of activation of the PI3K-AKT-mTOR pathway RTK signaling & activating mutations Neuregulin HER2 amplification ~15-20% BrCa HER2 HER3 PI3K PI3KCA mutation ~ 25-30% AKT1 mutation ~1-5% BrCa AKT PTEN Loss of PTEN ~15-20% BrCa Cell size translation Courtesy of S. Chandarlapaty mtor Proliferation Survival Invasion -p85-pi3k mutation -Loss of INPP4B -PDK1 amplification -Overexpression of HER3/IGF1R/EGFR - Phlpp loss

Phase 1 Trial: LJM716+BYL719+Trastuzumab Payal Shah, Stephen Zamora, Valentina Sterlin, Joe Gonzalez et al 2014

HER2 Therapies in Metastatic BC LJM716 R05479599 MM-302 BYL719 afatinib GDC-0032 MMK206 Gajria et al. Exp Rev Anticancer Ther 2011

17AAG Inhibition of HER2+ SKBr-3 Cells HER2 is one of the most sensitive clients Control 17-AAG x 24 h P. Munster, personal communication

Phase 2 Trial of 17-AAG plus Trastuzumab: Best Response (n=25) 60 40 % change from baseline 20 0-20 -40-60 -80-100 Response Code Progressive Disease Stable Disease Partial Response Modi et al, Clin Cancer Res, 2011

HSP90 Inhibitor Compounds in Clinical Development HSP90 INHIBITOR COMPANY PHASE TUMOR TYPE Geldanamycin Derivatives Tanespimycin (17-AAG) Kosan Biosciences/ Britstol Myers Squibb II III Breast, renal, thyroid, ovarian, lymphoma, leukemia Multiple Myeloma Retaspimycin (IPI-504) Infinity Pharmaceuticals II III NSCLC, liposarcoma, Breast (HER2+) GIST (closed) Alvespimycin (17-DMAG) Synthetic Inhibitors Kosan Biosciences/ Bristol Myers Squibb CNF2024 (BIIB021) Biogen Idec I II I Solid tumors, refractory leukemias Breast (HER2+), solid tumors GIST NVP-AUY922 Novartis II Breast, solid tumors, multiple myeloma SNX-5422 Esanex Inc I Solid tumors, hematological malignancies, HER2+ cancers STA-9090 (Ganetespib) Synta Pharmaceuticals I/II/III Solid tumors, hematological malignancies, HER2+ breast cancer PU-H71 MSKCC/ NCI I Solid tumors, triple negative breast cancer AT 13387 NCI I/II Solid tumors, prostate DS 2248 Daiichi Sankyo Inc I Solid tumors XL 888 Exelixis Inc I Solid tumors Debio 0932 DebioPharm SA I Solid tumors

Phase 1 Trial of HSP90 Inhibition in HER2+ MBC TAXOL TRASTUZUMAB GANETESPIB DEFINE MTD EVALUATE SAFETY AMEND TO FIRST LINE SETTING IN COMBINATION WITH PERTUZUMAB Komal Jhaveri, Tara O Neill, Deirdre Neville, et al

Summary HER2 Targeted Therapy has transformed the lives of many patients Use new agents for HER2+ MBC in sequence Trastuzumab Pertuzumab - T-DM1 Lapatinib Biomarkers under development Advancing promising agents into the early stage setting

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Clinical Characteristics of Patients by Characteristic Age, years CLS-B Status All Patients (n=237) Patients without CLS-B (n=115) Patients with CLS-B (n=122) Median (range) 48 (22 90) 47 (25 90) 49 (22 80) 0.38 Race, n (%) BMI Asian 14 (6.0%) 7 (6.1%) 7 (5.8%) Black 17 (7.3%) 6 (5.3%) 11 (9.2%) White 203 (86.8%) 101 (88.6%) 102 (85.0%) 0.55 Median (range) 25.3 (17.3 50.0) 23.1 (17.3 35.7) 28.3 (18.4 50.0) <0.001 Menopausal status, n (%) Pre 144 (60.8%) 80 (69.6%) 64 (52.5%) Post 93 (39.2%) 35 (30.4%) 58 (47.5%) 0.008 Hypertension, n (%) No 201 (84.8%) 102 (88.7%) 99 (81.2%) Yes 36 (15.2%) 13 (11.3%) 23 (18.9%) 0.15 Diabetes, n (%) No 227 (95.8%) 112 (97.4%) 115 (94.3%) Yes 10 (4.2%) 3 (2.6%) 7 (5.7%) 0.34 Iyengar et al. Cancer Prev Res 2015. P

Clinical Characteristics of Patients by Characteristic Severity of Breast WATi Breast WAT Inflammation None (n=115) Mild (n=59) Severe (n=59) P Age, years Median (range) 47 (25 90) 46 (22 72) 50 (27 80) 0.15 Race, n (%) BMI Asian 7 (6.1%) 3 (5.3%) 4 (6.8%) Black 6 (5.3%) 1 (1.8%) 9 (15.3%) White 101 (88.6%) 53 (93.0%) 46 (78.0%) 0.07 Median (range) 23.1 (17.3 35.7) 26.0 (20.4 40.2) 29.8 (18.4 50.0) <0.001 Menopausal Status, n (%) Pre 80 (69.6%) 39 (66.1%) 22 (37.3%) Post 35 (30.4%) 20 (33.9%) 37 (62.7%) <0.001 Hypertension, n (%) No 102 (88.7%) 52 (88.1%) 44 (74.6%) Yes 13 (11.3%) 7 (11.9%) 15 (25.4%) <0.05 Diabetes, n (%) No 112 (97.4%) 58 (98.3%) 53 (89.8%) Yes 3 (2.6%) 1 (1.7%) 6 (10.2%) 0.05 Iyengar et al. Cancer Prev Res 2015.

% CLS-B+ Cases % Cases with severe inflammation % CLS-B+ Cases % CLS-B+ Cases WATi is more common and more severe in obese CB and postmenopausal DC women % cases with CLS-B 100 80 60 40 20 P<0.001 P<0.001 39/73 40/116 43/48 % cases with CLS-B 100 80 60 40 20 P=0.008 P=0.008 58/93 64/144 D E % cases with CLS-B 0 100 80 60 40 20 0 < Lean 25 25-29.9 Ow 30 Ob P<0.001 P<0.001 27/83 < Lean 25 Pre Pre 13/33 < Lean 25 Post BMI 37/61 Ow 25 Ob Pre BMI Menopausal Status 45/60 Ow 25 Ob Post E F % cases with severe inflammation 0 100 80 60 40 20 0 P=0.003 P=0.003 6/27 Lean < 25 Pre 7/13 Premenopause Postmenopause 16/37 30/45 Lean < 25 OwOb 25 Post Pre BMI Menopausal Status OwOb 25 Post Iyengar et al. Cancer Prev Res 2015.

Mean adipocyte size (µ) Mean adipocyte size (µ) Mean adipocyte size (µ) Mean adipocyte size (µ) Mean adipocyte size (µ) Mean adipocyte size (µ) Mean adipocyte size (µ) Mean adipocyte size (µ) Mean adipocyte size (µ) Mean adipocyte size (µ) Mean adipo A C Average adipocyte size ( ) Average adipocyte size ( ) Adipocyte size correlates with BMI and 60 WATi, and is larger in postmenopausal and obese women BMI 120 100 80 60 rho=0.63, P<0.001 ρ=0.63, P<0.001 120 P<0.001 100 80 60 40 20 0 A Average adipocyte size ( ) 120 100 80 60 rho=0.63, P<0.001 ρ=0.63, P<0.001 20 25 30 35 40 45 50 20 25 30 35 40 45 50 CLS-B CLS-B + BMI BMI C Average adipocyte size ( ) 0 None Mild Severe 0 None Mild Severe Inflammation Inflammation E 120 P<0.001 100 80 60 40 20 Iyengar et al. Cancer Prev Res 2015. B Average adipocyte size ( ) D Average adipocyte size ( ) 120 P<0.001 100 80 60 40 20 0 120 P=0.002 P=0.002 100 80 60 40 20 B Average adipocyte size ( ) D Average adipocyte size ( ) 120 P<0.001 100 80 60 40 20 0 CLS-B - CLS-B + 120 P=0.002 P=0.002 100 80 60 40 20 0 0 Premenopause Pre menopause Post Post- Menopausal Status Premenopause Pre menopause Post Post- Menopausal Status C Average adipocyte size ( ) Average ad 80 CLS-B CLS-B + - E Average adipocyte size ( ) 120 P<0.001 100 80 60 40 20 0 120 P<0.001 100 80 60 40 20 20 25 30 35 40 45 50 None Mild Severe Inflammation < 25 Lean Pre Pre < 25 25 Lean OwOb Post Pre Post Pre BMI Menopausal Status 25 OwOb Post Post

Inflammation Occurs Consistently between Adipose Depots Sites CLS Absent at Both Sites CLS Present at Both Sites Discordant CLS Status P Left versus Right breast Breast versus Abdomen Patients, n (%) 17 (27.0%) 32 (50.8%) 14 (22.2%) CLS/cm 2 Median (range) 0.6 (0.2 51.9) 0.2 (0.1 0.5) <0.001 Patients, n (%) 3 (23.1%) 7 (53.8%) 3 (23.1%) CLS/cm 2 Median (range) 1.5 (0.4 26.7) 0.3 (0.2 1.1) 0.12 Iyengar et al. Cancer Prev Res 2015.

Conclusions WATi occurs in most obese/overweight individuals Postmenopausal state is independently associated with presence & severity of WATi WATi occurs across adipose depots

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