EML4-ALK translocations and crizotinib

1. Please note, these are the actual video-recorded proceedings from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

3. EML4-ALK translocations and crizotinib Heather Wakelee, MD Assistant Professor of Medicine, Oncology Stanford University/Stanford Cancer Center

4. Soda et al. Nature 2007

5. ALK Pathway Translocation RAS PI3K PLC-Y STAT3/5 MEK AKT PIP2 mTOR ErK BAD IP3 S6K Cell survival Or Inversion ALK fusion protein ALK Tumor cellproliferation With permission from Bang ASCO 2010

6. FISH Assay for ALK Rearrangement* *Assay is positive if rearrangements can be detected in ≥15% of cellsFISH = fluorescence in situ hybridization Centromere Telomere 2p23 region p25.2 p25.2 ALK 29.3 p24.3 p24.3 t(2;5) ALK gene breakpoint region p24.1 p24.1 p23.2 p23.2 p22.3 p22.3 p22.1 p22.1 EML4 42.3 p16.3 p16.3 3’ 5’ p16.1 p16.1 p14 p14 p13.2 p13.2 p12 p12 ~250 kb ~300 kb q12.1 q12.1 q12.3 q12.3 Break-apart FISH assay for ALK-fusion genes q14.1 q14.1 q14.3 q14.3 q21.2 q21.2 q22.1 q22.1 q22.2 q22.2 q23.2 q23.2 q24.1 q24.1 q24.3 q24.3 q31.3 q31.3 q32.1 q32.3 q33.2 q32.1 q32.3 q33.2 Non-split signal Split signal q34 q34 q36.1 q36.3q37.2 q36.1 q36.3q37.2 ALK break-apart FISH assay[Courtesy John Iafrate, Massachusetts General Hospital] With permission from Bang ASCO 2010

7. Crizotinib: First-in-human ALK Inhibitor • Potent and selective ATP competitive oral inhibitor of ALK and MET tyrosine kinases and their oncogenic variants • Safety and activity of crizotinib examined in an expanded cohort of patients with advanced ALK-positive NSCLC1 • Crizotinib administered at the MTD of 250 mg PO twice daily 1Kwak et al. NEJM 2010;363:1693-703 Shaw ASCO 2011, Lancet Oncology 12:1004, 2011

8. Clinical and Demographic Features of ALK-Positive and ALK-Negative NSCLC Patients * At any time Shaw ASCO 2011, Lancet Oncology 12:1004, 2011

9. Tumor Responses to Crizotinib for Patients with ALK-positive NSCLC 60 40 20 0 –20 –40 –60 –80 –100 Progressive disease Stable disease Confirmed partial response Confirmed complete response Maximum change in tumor size (%) –30% * N= 76 With permission from Bang ASCO plenary 2010

10. Treatment-related Grade 3/4 Adverse Events in ALK-positive NSCLC * Based on laboratory data (n=71), ALT increase to grade 1, 52%; to grade 2, 4%; 1 patient discontinued for ALT elevation Bang ASCO 2010

11. Crizotinib Survival Analysis:Study Objectives • Examine overall survival of crizotinib-treated ALK-positive NSCLC patients • Compare the survival outcomes of crizotinib-treated vs crizotinib-naïve, ALK-positive NSCLC patients • Explore the prognostic significance of ALK rearrangement by comparing the survival outcomes of crizotinib-naïve ALK-positive and ALK-negative NSCLC patients Shaw ASCO 2011, Lancet Oncology 12:1004, 2011

12. Study Populations ALK CRIZOTINIB ALK CONTROLS WT/WT CONTROLS ALK-positive Crizotinib-treated N=82 ALK-positive Crizotinib-naïve ALK-negative EGFR-wildtype US (MGH) N=253 US/Australia N=56 US/Australia N=36 2nd/3rd line N=30 2nd line N=125 2nd line N=23 Never/light smoker AdenoCA N=28 Never/light smoker AdenoCA N=48 Never/light smoker AdenoCA N=21 Shaw ASCO 2011, Lancet Oncology 12:1004, 2011

13. Clinical and Demographic Features of Crizotinib-Treated and Control ALK-Positive NSCLC Patients * At any time Shaw ASCO 2011, Lancet Oncology 12:1004, 2011

14. Treatment Histories of Crizotinib-Treated and Control ALK-Positive NSCLC Patients * For metastatic disease Balanced for age, gender, but more with smoking history in control group Pemetrexed may lead to prolonged PFS in ALK+ pts Camidge et al. JTO 6:774, 2011 Shaw ASCO 2011, Lancet Oncology 12:1004, 2011

15. Overall Survival2nd Line Subset WT/WT Control(n=125) ALK Crizotinib(n=30) ALK Control(n=23) Median Survival, mo NR 6 11 1-yr Survival, % 70 44 47 2-yr Survival, % 55 12 32 From 2nd/3rd line crizotinib HR = 0.49, p = 0.02 Shaw ASCO 2011, Lancet Oncology 12:1004, 2011

16. Limitations of the Study • Retrospective nonrandomized study design with potential imbalances among the study populations • Potential confounding of survival outcomes by post-crizotinib therapies • Small numbers in subset analyses Shaw ASCO 2011, Lancet Oncology 12:1004, 2011

17. Resistance to Crizotinib • Resistance to crizotinib develops, usually in < 1yr • Cell line work of acquired resistance revealed1: • Amplification of EML4-ALK, secondary mutation (L1196M - gatekeeper) • Analysis of pts with secondary resistance revealed2: • Secondary resistance mutations in ALK TK domain3 • Increase in ALK CNG • Growth of other NSCLC clones (EGFR, KRAS) • HSP90 inhibitors show promise 1-Katayama Proc NAS 108:7535, 2011 2-Doebele Clin Ca Res Epub, 2012 3-Choi NEJM 363:1734, 2010

18. Research To Practice could not obtain permission to reproduce this slide at the time of publication. For further information, please see the following: Ramalingam S et al. Heat Shock Protein 90 Inhibitors in Lung Cancer: Shock and Awe? Presentation. ASCO 2011. No abstract available

19. Crizotinib Summary • Crizotinib highly effective in pts w/ ALK FISH+ NSCLC • Better diagnostics under development • Survival benefit demonstrated • Role as 1st line therapy under investigation • Currently in NCCN guidelines • Resistance in < 1 yr a major issue • Mechanisms, 2nd mutations, growth of other clones • HSP90 inhibitors, other strategies in development

20. Saturday, February 11, 2012Hollywood, Florida Co-Chairs Rogerio C Lilenbaum, MD Mark A Socinski, MD Co-Chair and Moderator Neil Love, MD Faculty Chandra P Belani, MD John Heymach, MD, PhD Pasi A Jänne, MD, PhD Thomas J Lynch Jr, MD Heather Wakelee, MD