Note: Descriptions are shown in the official language in which they were submitted.
Combined Use of Pertuzumab, Trastuzu toab, and Carboplatin for Neoadjuvant
Therapy of Early-Stage HER2-Positive Breast Cancer
Field of the Invention
The present invention concerns uses for and articles of manufacture including
Pertuzumab, a
first-in-class HER2 dimerization inhibitor.
In particular, the invention concerns extending progression free survival in a
HER2-positive
breast cancer patient population; combining two HER2 antibodies to treat HER2-
positive cancer
without increasing cardiac toxicity; treating early-stage HBR2-positive breast
cancer; treating HER2-
positive cancer by co-administering a mixture of Pertuzumeb and Trasnizumab
from the same
intravenous bag; treating liteR2-positiva metastatic gastric cancer: treating
HER2-positive breast
cancer with Pertuzumab, Trastuzumab and Vinorelbine; treating HER2-positive
breast cancer with
Pertuzumab, Trastuzumab and aromatase inhibitor; and treating low HER3
ovarian, primary
peritoneal, or fallopian tube cancer.
It also concerns an article of manufacture comprising a vial with Pertuzumab
therein and a
package insert providing safety and/or efficacy data thereon; a method of
making the article of
manufacture; and a method of ensuring safe and effective use of Pertuzumab
related thereto.
In addition the invention concerns an intravenous (IV) bag containing a stable
mixture of
Pertuzumab and Trastuzu mat) suitable for administration to a cancer patient.
liackground of the Invention
Members of the HER fatuity of receptor tyrosine kinases are important
mediators of cell
growth, differentiation and survival. The receptor family includes four
distinct members including
epidermal growth factor receptor (EGFR, Erb131, or HER1), HER2 (Erb112 or
p185""), HER3
(ErbB3) and HER4 (ErbB4 or tyro2). Members of the receptor family have been
implicated in
various types of human malignancy.
A recombinant humanized version of the routine anti-HeR2 antibody 41)5
(hulviAb41)5-8,
rhuMAb HER2, Trastuzumab or HERCEPTIS1 ; U.S. Patera No. 5,821,337) is
clinically active in
patients with }R2-overexpressing metastatic breast cancers that have received
extensive prior anti-
cancer therapy (Baseiga et ca., J, aut. Ono!, 14.737-744 (1996)),
Trastuzumab received marketing approval from the Food and Drag AdminiStration
September 25, 1998 for the treatment of patients with metastatic breast cancer
whose tumors
owl:express the HER2 protein. At present, Trastuzumab is approved for use as a
single agent or in
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combination with chemotherapy or hormone therapy in the metastatic setting,
and as single agent or
in combination with chemotherapy as adjuvant treatment for patients with early-
stage HER2-positive
breast cancer. Trastuzumab-based therapy is now the recommended treatment for
patients with
HER2-positive early-stage breast cancer who do not have contraindications for
its use (Herceptin
prescribing information; NCCN Guidelines, version 2.2011). Trastuzumab plus
Docetaxel (or
paclitaxel) is a registered standard of care in the first-line metastatic
breast cancer (MBC) treatment
setting (Slamon et al. N Engl J Med. 2001;344(11):783-792.; Marty et al. .1
Clin Oncol. 2005;
23(19):4265-4274).
While the administration of Trastuzumab has led to excellent results in the
treatment of
1 10 breast cancer, recent data from a clinical trial of lapatinib
appear to suggest that even with
administration of Trastuzumab, HER2 plays an active role in tumor biology
(Geyer et al., N Engl J
Med 2006; 355:2733-2743).
Patients treated with the HER2 antibody Trastuzumab are selected for therapy
based on
HER2 expression. See, for example, W099/31140 (Paton etal.), US2003/0170234A1
(Hellmann,
S.), and US2003/0147884 (Paton etal.); as well as W001/89566, US2002/0064785,
and
US2003/0134344 (Mass eta.!.). See, also, US Patent No. 6,573,043, US Patent
No. 6,905,830, and
US2003/0152987, Cohen et al., concerning immunohistochemistry (INC) and
fluorescence in situ
hybridization (FISH) for detecting HER2 overexpression and amplification.
Thus, the optimal
management of metastatic breast cancer now takes into account not only a
patient's general
condition, medical history, and receptor status, but also the HER2 status.
Pertuzumab (also known as recombinant humanized monoclonal antibody 2C4
(rhuMAb
2C4); Genentech, Inc, South San Francisco) represents the first in a new class
of agents known as
HER dimerization inhibitors (HDI) and functions to inhibit the ability of HER2
to form active
heterodimers or homodimers with other HER receptors (such as EGER/HER1, HER2,
HER3 and
HER4). See, for example, Harari and Yarden Oncogene 19:6102-14 (2000); Yarden
and Sliwkowski.
Nat Rev Mol Cell Biol 2:127-37 (2001); Sliwkowski Nat Struct Biol 10:158-9
(2003); Cho etal.
Nature 421:756-60 (2003); and Malik eral. Pro Am Soc Cancer Res 44:176-7
(2003).
Pertuzumab blockade of the formation of HER2-HER3 heterodimers in tumor cells
has been
demonstrated to inhibit critical cell signaling, which results in reduced
tumor proliferation and
survival (Agus etal. Cancer Cell 2:127-37 (2002)).
Pertuzumab has undergone testing as a single agent in the clinic with a phase
Ia trial in
patients with advanced cancers and phase II trials in patients with ovarian
cancer and breast cancer as
well as lung and prostate cancer. In a Phase I study, patients with incurable,
locally advanced,
recurrent or metastatic solid tumors that had progressed during or after
standard therapy were treated
with Pertuzumab given intravenously every 3 weeks. Pertuzumab was generally
well tolerated.
Tumor regression was achieved in 3 of 20 patients evaluable for response. Two
patients had
confirmed partial responses. Stable disease lasting for more than 2.5 months
was observed in 6 of 21
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patients (Agus et at. Pro Ain Soc Clin Oncol 22:192 (2003)). At doses of 2.0-
15 mg/kg, the
pharmacokinetics of Pertuzumab was linear, and mean clearance ranged from 2.69
to 3.74 mL/day/kg
and the mean terminal elimination half-life ranged from 15.3 to 27.6 days.
Antibodies to Pertuzumab
were not detected (Allison et at. Pro Am Soc Clin Oncol 22:197 (2003)).
US 2006/0034842 describes methods for treating ErbB-expressing cancer with
anti-ErbB2
antibody combinations. US 2008/0102069 describes the use of Trastuzumab and
Pertuzumab in the
treatment of HER2-positive metastatic cancer, such as breast cancer. BaseIga
et al., J Clin Oncol,
2007 ASCO Annual Meeting Proceedings Part I, Col. 25, No. 18S (June 20
Supplement), 2007:1004
report the treatment of patients with pre-treated HER2-positivebreast cancer,
which has progressed
during treatment with Trastuzumab, with a combination of Trastuzumab and
Pertuzumab. Portera et
al., J Clin Oncol, 2007 ASCO Annual Meeting Proceedings Part I. Vol. 25, No.
18S (June 20
Supplement), 2007:1028 evaluated the efficacy and safety of Trastuzumab +
Pertuzumab
combination therapy in HER2-positive breast cancer patients, who had
progressive disease on
Trastuzumab-based therapy. The authors concluded that further evaluation of
the efficacy of
combination treatment was required to define the overall risk and benefit of
this treatment regimen.
Pertuzumab has been evaluated in Phase II studies in combination with
Trastuzumab in
patients with HER2-positive metastatic breast cancer who have previously
received Trastuzumab for
metastatic disease. One study, conducted by the National cancer Institute
(NCI), enrolled 11 patients
with previously treated HER2-positive metastatic breast cancer. Two out of the
11 patients exhibited
a partial response (PR) (Baselga et al., J Clin Oncol 2007 ASCO Annual Meeting
Proceedings;
25:18S (June 20 Supplement): 1004. The results of a Phase II neoadjuvant study
evaluating the
effect of a navel combination regimen of Pertuzumab and Trastuzumab plus
chemotherapy
(Docetaxel) in women with early-stage HER2-positive breast cancer, presented
at the CTRC-AACR
San Antonio Breast Cancer Symposium (SABCS), December 8-12, 2010, showed that
the two HER2
antibodies plus Docetaxel given in the neoadjuvant setting prior to surgery
significantly improved the
rate of complete tumor disappearance (pathological complete response rate,
pCR, of 45.8 percent) in
the breast by more than half compared to Trastuzumab plus Docetaxel (pCR of
29. 0 percent),
p=0.014,
Patent Publications related to HER2 antibodies include: US Patent Nos.
5,677,171;
5,720,937; 5,720,954; 5,725,856; 5,770,195; 5,772,997; 6,165,464; 6,387,371;
6,399,063; 6,015,567;
6,333,169; 4,968,603; 5,821,337; 6,054,297; 6,407,213; 6,639,055;6,719,971;
6,800,738; 5,648,237;
7,018,809; 6,267,958; 6,695,940; 6,821,515; 7,060,268; 7,682,609; 7,371,376;
6,127,526; 6,333,398;
6,797,814; 6,339,142; 6,417,335; 6,489,447; 7,074,404; 7,531,645; 7,846,441;
7,892,549; 6,573,043;
6,905,830; 7,129,840; 7,344,840; 7,468,252; 7,674,589; 6,949,245; 7,485,302;
7,498,030; 7,501,122;
7,537,931; 7,618,631; 7,862,817; 7,041,292; 6,627,196; 7,371,379; 6,632,979;
7,097,840; 7,575,748;
6,984,494; 7,279,287; 7,811,773; 7,993,834; 7,435,797; 7,850,966; 7,485,704;
7,807,799; 7,560,111;
7,879,325; 7,449,184; 7,700,299; and US 2010/0016556; US 2005/0244929; US
2001/0014326; US
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2003/0202972; US 2006/0099201; US 2010/0158899; US 2011/0236383; US
2011/0033460; US
2005/0063972; US 2006/018739; US 2009/0220492; US 2003/0147884; US
2004/0037823; US
2005/0002928; US 2007/0292419; US 2008/0187533; US 2003/0152987; US
2005/0100944; US
2006/0183150; US2008/0050748; US 2010/0120053; US 2005/0244417; US
2007/0026001; US
2008/0160026; US 2008/0241146; US 2005/0208043; US 2005/0238640; US
2006/0034842; US
2006/0073143; US 2006/0193854; US 2006/0198843; US 2011/0129464; US
2007/0184055; US
2007/0269429; US 2008/0050373; US 2006/0083739; US 2009/0087432; US
2006/0210561; US
2002/0035736; US 2002/0001587; US 2008/0226659; US 2002/0090662; US
2006/0046270; US
2008/0108096; US 007/0166753; US 2008/0112958; US 2009/0239236; US
2004/008204; US .
2009/0187007; US 2004/0106161; US 2011/0117096; US 2004/048525; US
2004/0258685; US
2009/0148401; US 2011/0117097; US 2006/0034840; US 2011/0064737; US
2005/0276812; US
2008/0171040; US 2009/0202536; US 2006/0013819; US 2006/0018899; US
2009/0285837; US
2011/0117097; US 2006/0088523; US 2010/0015157; US 2006/0121044; US
2008/0317753;
US2006/0165702; US 2009/0081223; US 2006/0188509; US 2009/0155259; US
2011/0165157; US
2006/0204505; US 2006/0212956; US 2006/0275305; US 2007/0009976; US
2007/0020261; US
2007/0037228; US 2010/0112603; US 2006/0067930; US 2007/0224203; US
2008/0038271; US
2008/0050385; 2010/0285010; US 2008/0102069; US 2010/0008975; US 2011/0027190;
US
2010/0298156; US 2009/0098135; US 2009/0148435; US 2009/0202546; US
2009/0226455; US
2009/0317387; and US 2011/0044977.
Summary of the Invention
In a first aspect, the invention concerns a method for extending progression
free survival in a
HER2-positive breast cancer patient population by 6 months or more comprising
administering
Pertuzumab, Trastuzumab and chemotherapy (e.g. taxane, such as Docetaxel) to
the patients in the
population. Optionally the method results in an objective response rate of 80%
or more in the patients
in the population. The the breast cancer is optionally metastatic or locally
recurrent, unresectable
breast cancer, or de novo Stage IV disease. In one embodiment, the patients in
the population: have
not received previous treatment or have relapsed after adjuvant therapy, have
a left ventricular
ejection fraction (LVEF) of ?.50% at baseline, and/or have an Eastern
Cooperative Oncology Group
performance status (ECOG PS) of 0 or 1. Optionally, the HER2-positive breast
cancer is defined as
immunohistochemistry (IHC) 3+ and/or fluorescence in situ hybridization (FISH)
amplification ratio
?_2Ø Optionally, the method reduces the risk of death by about 34% or more
relative to a patient
treated with Trastuzumab and the chemotherapy.
In another aspect, the invention concerns a method of combining two HER2
antibodies to
treat HER2-positive cancer without increasing cardiac toxicity in a HER2-
positive cancer patient
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population, comprising administering Pertuzumab, Trastuzumab, and chemotherapy
to the patients in
the population. Optionally, cardiac toxicity in the patient population is
monitored for incidence of
symptomatic left ventricular systolic dysfunction (LVSD) or congestive heart
failure (CHF), or for
decrease in left ventricular ejection fraction (LVEF). The HER2-positive
cancer is optionally, breast
cancer, for example metastatic or locally recurrent, unresectable breast
cancer, or de nov o Stage IV
disease.
In another aspect, the invention concerns an article of manufacture comprising
a vial with
Pertuzumab therein and a package insert, wherein the package insert provides
the safety data in Table
3 or Table 4 and/or the efficacy data in Table 2, Table 5, Figure 8, or Figure
10.
The invention additionally concerns a method for making an article of
manufacture
comprising packaging together a vial with Pertuzumab therein and a package
insert, wherein the
package insert provides the safety data in Table 3 or Table 4 and/or the
efficacy data in Table 2,
Table 5, Figure 8, or Figure 10.
In a related aspect, the invention concerns a method of ensuring safe and
effective use of
Pertuzumab comprising packaging together a vial with Pertuzumab therein and a
package insert,
wherein the package insert provides the safety data in Table 3 or Table 4
and/or the efficacy data in
Table 2, Table 5, Figure 8, or Figure 10.
Optionally, the article of manufacture comprises a single-dose vial containing
about 420mg
of Pertuzumab.
Optionally, the package insert further comprises the warning box in Example 4.
Optionally, the package insert further provides the Overall Survival (OS)
efficacy data in
Example 9 or Table 14.
In another aspect, the invention concerns a method of treating early-stage
HER2-positive
breast cancer comprising administering Pertuzumab, Trastuzumab, and
chemotherapy to a patient
with the breast cancer, wherein the chemotherapy comprises anthracycline-based
chemotherapy (for
= example, 5-FU, epirubicin, and cyclophosphamide (FEC)), or carboplatin-
based chemotherapy (for
example, Docetaxel and Carboplatin). Optionally, Pertuzumab is administered
concurrently with the
anthracycline-based chemotherapy or the carboplatin-based chemotherapy. In one
embodiment of
this method, Pertuzumab administration does not increase cardiac toxicity
relative to the treatment
without Pertuzumab. Such treatment of early-stage HER2-positive breast cancer
optionally comprises
neoadjuvant or adjuvant therapy.
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The invention further concerns a method of treating HER2-positive cancer in a
patient
comprising co-administering a mixture of Pertuzumab and Trastuzumab from the
same intravenous
bag to the patient. Such method optionally further comprises administering
chemotherapy to the
patient.
In a related aspect, the invention provides an intravenous (IV) bag containing
a stable
mixture of Pertuzumab and Trastuzumab suitable for administration to a cancer
patient. The mixture
is optionally in saline solution; e.g. comprising about 0.9% NaC1 or about
0.45% NaCl. The IV bag
is optionally a 250mL 0.9% saline polyolefin or polyvinyl chloride infusion
bag. In one embodiment,
the IV bag which contains a mixture of about 420mg or of about 840mg of
Pertuzumab and from
about 200mg to about 1000mg of Trastuzumab. In one embodiment, the mixture is
stable for up to
24 hours at 5 C or 30 C. Stability of the mixture can be evaluated by one or
more assays selected
from: color, appearance and clarity (CAC), concentration and turbidity
analysis, particulate analysis,
size exclusion chromatography (SEC), ion-exchange chromatography (IEC),
capillary zone
electrophoresis (CZE), image capillary isoelectric focusing (iCIEF), or
potency assay.
The present invention provides a new treatment regimen for gastric cancer. In
particular, the
present invention concerns the treatment of HER2-positivegastric cancer in
human subjects with a
combination of Trastuzumab, Pertuzumab and at least one chemotherapy.
In one aspect, the invention concerns a method of treating HER2-positive
gastric cancer in a
human subject, comprising administering to the subject Pertuzumab,
Trastuzumab, and a
chemotherapy.
In another aspect, the invention concerns a method of improving survival in a
human subject
with HER2-positive gastric cancer, comprising administering to the subject
Pertuzumab,
Trastuzumab, and a chemotherapy.
In yet another aspect, the invention concerns Pertuzumab for use in the
treatment of HER2-
positive gastric cancer in a human subject in combination with Trastuzumab and
a chemotherapy.
In a further aspect, the invention concerns the use of Pertuzumab in the
preparation of a
medicament for the treatment of HER2-positive gastric cancer, wherein the
treatment comprises
administration of Pertuzumab in combination with Trastuzumab and a
chemotherapy.
In a still further aspect, the invention concerns the use of Trastuzumab in
the preparation of a
medicament for the treatment of HER2-positive gastric cancer, wherein the
treatment comprises
administration of Trastuzumab in combination with Pertuzumab and a
chemotherapy.
In another aspect, the invention concerns a kit comprising a container
comprising
Pertuzumab and instructions for administration of the Pertuzumab to treat HER2-
positive gastric
cancer in a subject in combination with Trastuzumab and a chemotherapy.
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In yet another aspect, the invention concerns a kit comprising a container
comprising
Trastuzumab and instructions for administration of the Trastuzumab to treat
HER2-positivegastric
cancer in a subject in combination with Pertuzumab and a chemotherapy.
In all aspects, the gastric cancer can, for example, be non-resectable locally
advanced gastric
cancer, or metastatic gastric cancer, or advanced, post-operatively recurrent
gastric cancer, which
may not be amenable to curative therapy by known methods. In all aspects, the
gastric cancer
includes adenocarcinoma of the stomach or gastroesophageal junction. In all
aspects, in a particular
embodiment the patient did not receive prior anti-cancer treatment for
metastatic gastric cancer. In
all aspects, in a particular embodiment, the chemotherapy comprises
administration of a platin and/or
fluoropyrimidine. In certain embodiments, the platin is cisplatin. In other
embodiments, the
fluoropyrimidine comprises capecitabine and/or 5-fluorouracil (5-FU). In all
aspects, the patient's
HER2-positive status may, for example, be IFIC 3+ or IHC 2+/ISH+. In all
aspects, in particular
embodiments, the treatment improves survival, including overall survival (OS)
and/or progression
free survival (PFS) and/or response rate (RR). In all aspects, in particular
embodiments, the patient
has an ECOG PS of 0-1. In all aspects, treatment cycles are generally
separated from each other by
four weeks or less, or by three weeks or less, or by two weeks or less, or by
one week or less.
In a particular aspect, the invention concerns a method of treating HER2-
positive non-
resectable or metastatic adenocarcinoma of the stomach or gastroesophageal
junction in a human
patient who did not receive prior chemotherapy for metastatic disease, except
prior adjuvant or
neoadjuvant therapy completed more than six months before the current
treatment, comprising
administering Pertuzumab, Trastuzumab, cisplatin, and capecitabine and/or
fluorouracil (5-FU) to
the patient in an amount to improve progression free survival (PFS) and/or
overall survival (OS),
wherein the patient has an ECOG PS of 0-1. In a particular embodiment, the
patient did not receive
prior treatment with a platin.
In another aspect, the invention concerns a method of improving progression
free survival in
a patient with HER2-positive non-resectable or metastatic adenocarcinoma of
the stomach or
gastroesophageal junction comprising administering Pertuzumab to the patient
in combination with
Trastuzumab and chemotherapy.
In yet a further aspect, the invention concerns a method of treating HER2-
positive breast
cancer in a patient comprising administering Pertuzumab, Trastuzumab and
vinorelbine to the patient.
Optionally the Pertuzumab and Trastuzumab are co-administered to the patient
from a single
intravenous bag. The breast cancer is optionally metastatic or locally
advanced. In one embodiment,
the patient has not previously received systemic non-hormonal anticancer
therapy in the metastatic
setting.
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In another aspect, the invention concerns a method of treating HER2-positive
breast cancer in
a patient comprising administering Pertuzumab, Trastuzumab, and aromatase
inhibitor (e.g.
anastrazole or letrozole) to the patient. Optionally, the breast cancer is
hormone receptor-positive
advanced breast cancer, wherein the hormone receptor is estrogen receptor (ER)
and/or progesterone
receptor (PgR), for example. According to this embodiment of the invention,
patient has not
previously received systemic nonhormonal anticancer therapy in the metastatic
setting. Moreover,
the patient herein optionally receives induction chemotherapy (e.g. comprising
taxane).
In an additional embodiment, the invention concerns a method of treating a
cancer patient
comprising administering to the patient an initial dose of 840mg of Pertuzumab
followed every 3
weeks thereafter by a dose of 420mg of Pertuzumab, and further comprising re-
administering an
840mg dose of Pertuzumab to the patient if the time between two sequential
420mg doses is 6 weeks
or more. Optionally, the method further comprises administering 420mg of
Pertuzumab every 3
weeks after the re-administered 840mg dose. In one embodiment, the cancer
patient has HER2-
positive breast cancer.
In a further aspect, the invention concerns a method for treating HER2-
positive metastatic or
locally recurrent breast cancer in a patient comprising administering
Pertuzumab, Trastuzumab and
taxoid (e.g. Docetaxel, Paclitaxel, or nab-paclitaxel) to the patient, wherein
the patient has been
previously treated with a Trastuzumab and/or lapatinib as adjuvant or
neoadjuvant therapy.
In yet a further aspect, the invention concerns a method for treating low HER3
ovarian,
primary peritoneal, or fallopian tube cancer in a patient comprising
administering Pertuzumab and
chemotherapy the patient, wherein the chemotherapy comprises taxoid (e.g.
paclitaxel) or topotecan.
In an additional aspect, the invention concerns a method for treating low HER3
ovarian,
primary peritoneal, or fallopian tube cancer in a patient comprising
administering Pertuzumab and
chemotherapy to the patient, wherein the low HER3 cancer expresses HER3 mRNA
at a
concentration ratio equal or lower than about 2.81 as assessed by polymerase
chain reaction (PCR).
In one embodiment, the chemotherapy comprises gemcitabine, carboplatin,
paclitaxel, docetaxel,
topotecan, or pegylated liposomal doxorubicin (PLD). Optionally, the
chemotherapy comprises
paclitaxel or topotecan. In one embodiment, the cancer is epithelial ovarian
cancer that is platinum-
resistant or platinum-refractory.
Brief Description of the Drawings
Figure 1 provides a schematic of the HER2 protein structure, and amino acid
sequences for
Domains I-IV (SEQ ID Nos.1-4, respectively) of the extracellular domain
thereof.
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Figures 2A and 2B depict alignments of the amino acid sequences of the
variable light (VI)
(Fig. 2A) and variable heavy (Vs) (Fig. 2B) domains of murine monoclonal
antibody 2C4 (SEQ ID
Nos. 5 and 6, respectively); VL and Vs domains of variant 574/Pertuzumab (SEQ
ID Nos. 7 and 8,
respectively), and human VL and VH consensus frameworks (humid, light kappa
subgroup I; hurnIII,
heavy subgroup III) (SEQ ID Nos. 9 and 10, respectively). Asterisks identify
differences between
variable domains of Pertuzumab and murine monoclonal antibody 2C4 or between
variable domains
of Pertuzumab and the human framework. Complementarity Determining Regions
(CDRs) are in
brackets.
Figures 3A and 3B show the amino acid sequences of Pertuzumab light chain
(Fig. 3A; SEQ
ID NO. 11) and heavy chain (Fig. 3B; SEQ ID No. 12). CDRs are shown in bold.
Calculated
molecular mass of the light chain and heavy chain are 23,526.22 Da and
49,216.56 Da (cysteines in
reduced form). The carbohydrate moiety is attached to Asn 299 of the heavy
chain.
Figures 4A and 4B show the amino acid sequences of Trastuzumab light chain
(Fig. 4A; SEQ
ID NO. 13) and heavy chain (Fig. 4B; SEQ ID NO. 14), respectively. Boundaries
of the variable
light and variable heavy domains are indicated by arrows.
Figures 5A and 5B depict a variant Pertuzumab light chain sequence (Fig. 5A;
SEQ ID NO.
15) and a variant Pertuzumab heavy chain sequence (Fig. 5B; SEQ ID NO. 16),
respectively.
Figure 6 shows the study schema in Example 1. ECOG = Eastern Cooperative
Oncology
Group; PD = progressive disease. Notes: Trastuzumab, Pertuzumab, and Cisplatin
are administered
by IV infusion on Day 1 of each 3-week cycle. Capecitabine is administered
orally twice daily, from
the evening of Day 1 to the morning of Day 15 of each 3-week cycle. (a) HER2-
positive tumor
defined as either MC 3+ or IBC 2+ in combination with ISH + (i.e., IBC 3+/1SH
+ or ICH 2-F/ISH
+); (b) Trastuzumab at a loading dose of 8 mg/kg for Cycle 1 and a dose of 6
mg/kg for subsequent
cycles; (c) Pertuzumab on Day 1 of each cycle, at a loading dose of 840 mg for
Cycle 1 and a dose of
420 mg for Cycles 2-6.
Figure 7 depicts enrollment, intent-to-treat and safety populations, and
patient withdrawals in
=
the study in Example 3.
Figure 8 is a Kaplan-Meier Curve of Progression-Free Survival (PFS) as
assessed by an
Independent Review Facility (IRF) for the study in Example 3.
Figure 9 depicts PFS by Patient Subgroup for the study in Example 3.
Figure 10 depicts overall survival for the study in Example 3.
Figure 11 is an overview of the dosing schedule in HER2-positive, neoadjuvant
breast
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cancer, patients with low cardiac risk factors in Example 5. Additional
radiotherapy, hormonal
therapy and chemotherapy post surgery and during adjuvant Trastuzumab
treatment were allowed if
considered necessary by the investigator.
Figure 12 depicts mean change in LVEF (central readings) for the study in
Example 5.
Figure 13 shows pathological complete response (pCR) for the study in Example
5.
Figure 14 depicts pathological complete response by hormone receptor status in
the Example
5 study.
Figure 15 depicts Pertuzumab SEC profile of Pertuzumab/Trastuzumab mixture
(840mg) at
30 C in 0.9% saline PO IV infusion bags (1) Time= 0; (2) Time= 24 hrs.
Expanded view; full view
(inset).
Figure 16 shows Trastuzumab SEC profile of Pertuzumab/Trastuzumab mixture
(840mg) at
30 C in 0.9% saline PO IV infusion bags (1) Time= 0; (2) Time= 24 hrs.
Expanded view; full view
(inset).
Figure 17 shows Pertuzumab IEC profile of Pertuzumab/ Trastuzumab mixture at
30 C in
0.9% saline PO IV infusion bags (1) Time= 0; (2) Time= 24 hrs. Full view.
Figure 18 depicts Trastuzumab IEC profile of Pertuzumab/ Trastuzumab mixture
at 30 C in
0.9% saline PO IV infusion bags (1) Time= 0; (2) Time= 24 hrs. Expanded view;
Full view (inset).
Figure 19 depicts CE-SDS LIP non-reduced profile of Pertuzumab/ Trastuzumab
mixture at
30 C in 0.9% saline PO IV infusion bags (1) Time= 0; (2) Time= 24 hrs.
Expanded view.
Figure 20 shows CE-SDS LIP reduced profile of Pertuzumab/Trastuzumab mixture
at 30 C
in 0.9% saline PO IV infusion bags (1) Time= 0; (2) Time= 24 his. Expanded
view.
Figure 21 is CTE of Pertuzumab/Trastuzumab mixture at 30 C in 0.9% saline PO
IV
infusion bags (1) Time= 0; (2) Time= 24 hrs. Full view.
Figure 22 shows iCIEF of Pertuzumab/ Trastuzumab mixture at 30 C in 0.9%
saline PO IV
infusion bags (1) Time= 0; (2) Time= 24 hours. Full view.
Figure 23 shows potency dose response curves (vg/mL versus RFU) of Pertuzumab/
Trastuzumab mixture, Pertuzumab alone, and Trastuzumab alone in 0.9% saline PO
IV infusion bags
(1) Time = 0; (2) Time = 24 hours.
Figure 24 depicts Pertuzumab SEC profile of Pertuzumab/Trastuzumab mixture
(1560mg) in
0.9% saline IV infusion bags (1) PO 5 C TO ; (2) PO 5 C T24 his; (3) PO 30 C
TO; (4) PO 30 C
T24 hrs; (5) PVC 5 C TO; (6) PVC 5 C T24 hrs; (7) PVC 30 C TO; (8) PVC 30 C
T24 hrs.
Expanded view; full view (inset).
Figure 25 shows Trastuzumab SEC profile of Pertuzumab/Trastuzumab mixture
(1560mg) in
0.9% saline IV infusion bags (1) PO 5 C TO; (2) PO 5 C T24 hrs; (3) PO 30 C
TO; (4) PO 30 C
T24 hrs; (5) PVC 5 C TO; (6) PVC 5 C T24 hrs; (7) PVC 30 C TO; (8) PVC 30 C
T24 hrs.
Expanded view; full view (inset).
CA 02788253 2012-08-29
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Figure 26 shows Pertuzumab IEC (Pertuzumab-fast) profile of
Pertuzumab/Trastuzumab
mixture (1560mg) in 0.9% saline IV infusion bags (1) PO 5 C TO ; (2) PO 5 C
T24 hrs; (3) PO
30 C TO; (4) PO 30 C T24 hrs; (5) PVC 5 C TO; (6) PVC 5 C T24 hrs; (7) PVC 30
C TO; (8) PVC
30 C T24 hrs. Full view.
Figure 27 shows Trastuzumab TEC profile of Pertuzumab/Trastuzumab mixture
(1560mg) in
0.9% saline IV infusion bags (1) PO 5 C TO; (2) PO 5 C T24 hrs; (3) PO 30 C
TO; (4) PO 30 C
T24 hrs; (5) PVC 5 C TO; (6) PVC 5 C T24 hrs; (7) PVC 30 C TO; (8) PVC 30 C
T24 hrs. Full
view.
Figure 28 depicts study schema for Example 7.
Figure 29 shows study design for Example 8.
Figure 30 shows study design for Part 1 of Example 11.
Figure 31 shows study design for Part 2 of Example 11.
Figure 32 shows the samples taken and time points for the phase ha gastric
cancer (GC)
study in Example 1,
Figure 33 shows the demographics of the patient population in the two arms of
the GC study,
1
treated with 420 mg (Arm A) or 840 mg (Arm B) of pertuzumab.
Figure 34 shows the GC history of the patients in Arms A and B, respectively.
Figure 35 shows the GC patient disposition in Arms A and B, respectively.
Figure 36 shows the Overall Response Rate in Arms A and B, respectively, of
the GC study.
Figure 37 shows the results of pertuzumab Day 42 concentration assessment in
gastric cancer
(GC) versus metastatic breast cancer (MEC).
Detailed Description of the Preferred Embodiments
Glossary of abbreviations used herein: adverse drug reaction (ADR), adverse
event (AE),
alkaline phosphatase (ALP), absolute neutrophil count (ANC), area under the
concentration-time
curve (AUC), capillary zone electrophoresis (CZE), color, appearance and
clarity (CAC), CLinical
Evaluation Of Pertuzumab And TRAstuzumab (CLEOPATRA), confidence interval
(Cl),
chromogenic in situ hybridization (CISH), maximum concentration (C.õ),
complete response (CR),
case report form (CRF), computed tomography (CT), common terminology criteria
for adverse
events (CTCAE), Docetaxel (D), dose limiting toxicity (DLT), ethics committee
(EC), epirubicin,
cisplatin, and 5-fluorouracil (ECF), echocardiogram (ECHO), epidermal growth
factor receptor
(EGER), European Union (EU), estrogen receptor (ER), 5-fluorouracil,
methotrexate, and
doxorubicin (FAMTX), fluorescence in situ hybridization (FISH), 5-fluorouracil
(5-FU), hazard ratio
(HR), human epidermal growth factor receptor (EGER), gastric cancer (GC), good
clinical practice
(GCP), human epidermal growth factor receptor 2 (HER2), ion exchange
chromatography (IEC),
immunohistochemistry (INC), independent review facility (IRF), institutional
review board (IRB), in
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situ hybridization (ISH), intravenous (IV), image capillary isoelectric
focusing (iCIEF), left
ventricular ejection fraction (LVEF), mitomycin C, cisplatin, and 5-
fluorouracil (MCF), magnetic
resonance image (MIU), metastatic breast cancer (MBC), multiple-gated
acquisition (MUGA), not
significant (NS), overall survival (OS), pathological complete response (pCR),
polyolefin (PO),
polyvinyl chloride (PVC), progressive disease (PD), progression free survival
(PFS),
pharmacolcinetic (PK), partial response (PR), progesterone receptor (PgR),
response evaluation
criteria in solid tumors (RECIST), serious adverse event (SAE), size exclusion
chromatography
(SEC), stable disease (SD), study management team (SMT), sterile water for
injection (SWFI), time
to maximum plasma concentration (1.), upper limit of normal (ULN).
I. Definitions
The term "chemotherapy" as used herein refers to treatment comprising the
administration of
a chemotherapy, as defined hereinbelow.
"Survival" refers to the patient remaining alive, and includes overall
survival as well as
progression free survival.
"Overall survival" or "OS" refers to the patient remaining alive for a defined
period of time,
such as 1 year, 5 years, etc from the time of diagnosis or treatment. For the
purposes of the clinical
trial described in the example, overall survival (OS) is defined as the time
from the date of
randomization of patient population to the date of death from any cause.
"Progression free survival" or "PFS" refers to the patient remaining alive,
without the cancer
progressing or getting worse. For the purpose of the clinical trial described
in the example,
progression free survival (PFS) is defined as the time from randomization of
study population to the
first documented progressive disease, or unmanageable toxicity, or death from
any cause, whichever
occurs first. Disease progression can be documented by any clinically accepted
methods, such as, for
example, radiographical progressive disease, as determined by Response
Evaluation Criteria in Solid
Tumors (RECIST) (Therasse et al., J Nail Ca last 2000; 92(3):205-216),
carcinomatous meningitis
diagnosed by cytologic evaluation of cerebral spinal fluid, and/or medical
photography to monitor
chest wall recurrences of subcutaneous lesions.
By "extending survival" is meant increasing overall or progression free
survival in a patient
treated in accordance with the present invention relative to an untreated
patient and/or relative to a
patient treated with one or more approved anti-tumor agents, but not receiving
treatment in
accordance with the present invention. In a particular example, "extending
survival" means
extending progression-free survival (PFS) and/or overall survival (OS) of
cancer patients receiving
the combination therapy of the present invention (e.g. treatment with a
combination of Pertuzumab,
Trastuzumab and a chemotherapy) relative to patients treated with Trastuzumab
and the
chemotherapy only. In another particular example, "extending survival" means
extending
progression-free survival (PFS) and/or overall survival (OS) of cancer
patients receiving the
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combination therapy of the present invention (e.g. treatment with a
combination of Pertuzumab,
Trastuzumab and a chemotherapy) relative to patients treated with Pertuzumab
and the chemotherapy
only.
An "objective response" refers to a measurable response, including complete
response (CR)
or partial response (PR).
By "complete response" or "CR" is intended the disappearance of all signs of
cancer in
response to treatment. This does not always mean the cancer has been cured.
"Partial response" or "PR" refers to a decrease in the size of one or more
tumors or lesions,
or in the extent of cancer in the body, in response to treatment.
A "HER receptor" is a receptor protein tyrosine kinase which belongs to the
HER receptor
family and includes EGER, HER2, HER3 and HER4 receptors. The HER receptor will
generally
comprise an extracellular domain, which may bind an HER ligand and/or dimerize
with another HER
receptor molecule; a lipophilic transmembrane domain; a conserved
intracellular tyrosine kinase
domain; and a carboxyl-terminal signaling domain harboring several tyrosine
residues which can be
phosphorylated. The HER receptor may be a "native sequence" HER receptor or an
"amino acid
sequence variant" thereof. Preferably the HER receptor is native sequence
human HER receptor.
The expressions "ErbB2" and "HER2" are used interchangeably herein and refer
to human
HER2 protein described, for example, in Semba et al., PNAS (USA) 82:6497-6501
(1985) and
Yamamoto et al. Nature 319:230-234 (1986) (Genebank accession number X03363).
The term
"erbB2" refers to the gene encoding human ErbB2 and "neu" refers to the gene
encoding rat p185".
Preferred HER2 is native sequence human HER2.
Herein, "HER2 extracellular domain" or "HER2 ECD" refers to a domain of HER2
that is
outside of a cell, either anchored to a cell membrane, or in circulation,
including fragments thereof.
The amino acid sequence of HER2 is shown in Figure 1. In one embodiment, the
extracellular
domain of HER2 may comprise four domains: "Domain I" (amino acid residues from
about 1-195;
SEQ ID NO:14), "Domain H" (amino acid residues from about 196-319; SEQ ID
NO:15), "Domain
III" (amino acid residues from about 320-488: SEQ ID NO:16), and "Domain IV"
(amino acid
residues from about 489-630; SEQ ID NO:17) (residue numbering without signal
peptide). See
Garrett et al. Mat. Cell., 11: 495-505 (2003), Cho et al. Nature 421: 756-760
(2003), Franklin et al.
.. Cancer Cell 5:317-328(2004), and Plowman et al. Proc. Natl. Acad. Sci.
90:1746-1750 (1993), as
well as Fig. 6 herein.
"HER3"or "ErbB3" herein refer to the receptor as disclosed, for example, in US
Pat. Nos.
5,183,884 and 5,480,968 as well as Kraus et at. PNAS (USA) 86:9193-9197
(1989).
A "low HER3" cancer is one which expresses HER3 at a level less then the
median level for
HER3 expression in the cancer type. In one embodiment, the low HER3 cancer is
epithelial ovarian,
peritoneal, or fallopian tube cancer. HER3 DNA, protein, and/or mRNA level in
the cancer can be
evaluated to determine whether the cancer is a low HER3 cancer. See, for
example, US Patent No.
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CA 02788253 2012-08-29
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7,981,418 for additional information about low HER3 cancer. Optionally, a HER3
mRNA expression
assay is performed in order to determine that the cancer is a low HER3 cancer.
In one embodiment,
HER3 inRNA level in the cancer is evaluated, e.g. using polymerasc chain
reaction (PCR), such as
quantitative reverse transcription PCR (qRT-PCR). Optionally, the cancer
expresses HER3 at a
concentration ratio equal or lower than about 2.81 as assessed qRT-PCR, e.g.
using a a COBAS
z4800 instrument.
A "HER dimer" herein is a noncovalently associated dimer comprising at least
two HER
receptors. Such complexes may form when a cell expressing two or more HER
receptors is exposed
to an HER ligand and can be isolated by immunoprecipitation and analyzed by
SDS-PAGE as
described in Sliwkowski et al., J. Bid. Chem., 269(20):14661-14665 (1994), for
example. Other
proteins, such as a cytokine receptor subunit (e.g. gp130) may be associated
with the dimer.
Preferably, the HER dimer comprises HER2.
A "HER heterodimer" herein is a noncovalently associated heterodimer
comprising at least
two different HER receptors, such as EGFR-HER2, HER2 -HER3 or HER2-HER4
heterodimers.
A "HER antibody" is an antibody that binds to a HER receptor. Optionally, the
HER
antibody further interferes with HER activation or function. Preferably, the
HER antibody binds to
the HER2 receptor. HER2 antibodies of interest herein are Pertuzumab and
Trastuzumab.
"HER activation" refers to activation, or phosphorylation, of any one or more
HER receptors.
Generally, HER activation results in signal transduction (e.g. that caused by
an intracellular kinase
domain of a HER receptor phosphorylating tyrosine residues in the HER receptor
or a substrate
polypeptide). HER activation may be mediated by HER ligand binding to a HER
dimer comprising
the HER receptor of interest. HER ligand binding to a HER dimer may activate a
kinase domain of
one or more of the HER receptors in the dimer and thereby results in
phosphorylation of tyrosine
residues in one or more of the HER receptors and/or phosphorylation of
tyrosine residues in
additional substrate polypeptides(s), such as Akt or MAPK intracellular
kinases.
"Phosphorylation" refers to the addition of one or more phosphate group(s) to
a protein, such
as a HER receptor, or substrate thereof.
An antibody which "inhibits HER dimerization" is an antibody which inhibits,
or interferes
with, formation of a HER dimer. Preferably, such an antibody binds to HER2 at
the heterodimeric
binding site thereof. The most preferred dimerization inhibiting antibody
herein is Pertuzumab or
MAb 2C4. Other examples of antibodies which inhibit HER dimerization include
antibodies which
bind to EGFR and inhibit dimerization thereof with one or more other HER
receptors (for example
EGFR monoclonal antibody 806, MAb 806, which binds to activated or
"untethered" EGFR; see
Johns et al., .1. Biol. Chem. 279(29):30375-30384 (2004)); antibodies which
bind to HER3 and inhibit
dimerization thereof with one or more other HER receptors; and antibodies
which bind to HER4 and
inhibit dimerization thereof with one or more other HER receptors.
A "HER2 dimerization inhibitor" is an agent that inhibits formation of a dimer
or
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heterodimer comprising HER2.
A "heterodimeric binding site" on HER2, refers to a region in the
extracellular domain of
HER2 that contacts, or interfaces with, a region in the extracellular domain
of EGER, HER3 or HER4
upon formation of a dimer therewith. The region is found in Domain II of HER2
(SEQ ID NO: 15).
Franklin et al. Cancer Cell 5:317-328 (2004).
A HER2 antibody that "binds to a heterodimeric binding site" of HER2, binds to
residues in
Domain II (SEQ ID NO: 2) and optionally also binds to residues in other of the
domains of the HER2
extracellular domain, such as domains I and IR, SEQ ID NOs: 1 and 3), and can
sterically hinder, at
least to some extent, formation of a HER2-EGER, HER2-HER3, or HER2-HER4
heterodimer.
Franklin et al. Cancer Cell 5:317-328 (2004) characterize the HER2-Pertuzumab
crystal structure,
deposited with the RCSB Protein Data Bank (ID Code IS78), illustrating an
exemplary antibody that
binds to the heterodimeric binding site of HER2.
An antibody that "binds to domain II" of HER2 binds to residues in domain 11
(SEQ ID NO:
2) and optionally residues in other domain(s) of HER2, such as domains I and
III (SEQ ID NOs: 1
and 3, respectively). Preferably the antibody that binds to domain II binds to
the junction between
domains I, H and III of 1-1ER2.
For the purposes herein, "Pertuzumab" and "rhuMAb 2C4", which are used
interchangeably,
refer to an antibody comprising the variable light and variable heavy amino
acid sequences in SEQ
ID NOs: 7 and 8, respectively. Where Pertuzumab is an intact antibody, it
preferably comprises an
IgG1 antibody; in one embodiment comprising the light chain amino acid
sequence in SEQ ID NO:
11 or 15, and heavy chain amino acid sequence in SEQ ID NO: 12 or 16. The
antibody is optionally
produced by recombinant Chinese Hamster Ovary (CHO) cells. The terms
"Pertuzumab" and
"rhuMAb 2C4" herein cover biosimilar versions of the drug with the United
States Adopted Name
(USAN) or International Nonproprietary Name (INN): Pertuzumab.
For the purposes herein, "Trastuzumab" and rhuMAb4D5", which are used
interchangeably,
refer to an antibody comprising the variable light and variable heavy amino
acid sequences from
within SEQ ID Nos: 13 and 14, respectively. Where Trastuzumab is an intact
antibody, it preferably
comprises an IgG1 antibody; in one embodiment comprising the light chain amino
acid sequence of
SEQ ID NO: 13 and the heavy chain amino acid sequence of SEQ ID NO: 14. The
antibody is
optionally produced by Chinese Hamster Ovary (CHO) cells. The terms
"Trastuzumab" and
"rhuMAb4D5" herein cover biosimilar versions of the drug with the United
States Adopted Name
(USAN) or International Nonproprietary Name (INN): Trastuzumab.
The term "antibody" herein is used in the broadest sense and specifically
covers monoclonal
antibodies, polyclonal antibodies, multispecific antibodies (e.g. bispecific
antibodies), and antibody
fragments, so long as they exhibit the desired biological activity.
"Humanized" forms of non-human (e.g., rodent) antibodies are chimeric
antibodies that
contain minimal sequence derived from non-human immunoglobulin. For the most
part, humanized
antibodies are human ininuutioglobulins (recipient antibody) in which residues
from a hypervariable
region of the recipient are replaced by regiduag from a hypervariable region
of a non-human species
(donor antibody) such as mouse, rat, rabbit or nonhuman primate having the
desired specificity,
affinity, and capacity. In some instances, framework region (FR) residues of
the human
irrununoglobulin arc replaced by corresponding non-human residues,
furthermore, humanized
antibodies may comprise residues that are not found in the recipient antibody
or in the donor
antibody. These modifications arc made to further refine antibody performance.
in pecral, the
humanized antibody will comprise substantially all of at least one, and
typically two, variable
domains, in which all Or substantially all of the hypervariable loops
correspond to those of a non-
.. human immunogLobulin and all or substantially all of the Rs are those of a
human inu-nunoglobulin
sequence. The humanized antibody optionally also will comprise at least a
portion of an
inimunoglohnlin constant region (Pc), typically that of a human
immitmOglobulin. For further details,
see Jones cr Nature 321:522-525 (1986); 1Ziccbmatin a al., Nature
332;323-329 (1988); and
Presta, Carr. Op. Street. Biol. 2:593-596 (1992). Humanized HER2 antibodies
specifically include
Trastuzurnab (HERCEPTENcln) as described in Table 3 of U.S. Patent 5,821,337
and as defined herein, and humanized 2C4 antibodies such .As
Pertuzamab as described and defined herein,
An "intact antibody" herein is one which comprises two antigen binding
regions, and an Fe
region. Preferably, the intact antibody has a functional Pc region.
"Antibody fragments" comprise a portion of an intaet antibody, preferably
comprising the
antigen binding region thereof. Examples of antibody fragments include Feb,
Fab', F(ab')2, and Fv
fragments; diabodies; linear antibodies; single-chain antibody molecules; and
multispecific
antibodies formed from antibody fragment(s).
"Native antibodies" are usually hcterotctramaric glyceproteins of about
150,000 daltons,
composed of two identical light (L) chains and two identical heavy (H) chains.
Each light chain it
linked to a heavy chain by one covalent disulfide bond, while the number of
disulfide linkages varies
among the heavy chains of different immunaglobulin itotypes. Each heavy and
light chain also hu
regularly spaced intrachain disulfide bridges. Each heavy chain has at one end
a variable domain
(VI) followed by a number of constant domains. Each light chain has a vatiable
domain a our end
(V() and a constant domain at its other end. The constant domain of the light
chain is aligned with
the first constant domain of the heavy chain, and the light-chain variable
domain is aligned with the
variable domain of the heavy chain Particular amino acid residues are believed
to form an interface
between the light chain and heavy chain variable domains.
The term "hypervariable region' when used herein refers to the amino acid
caskdues of an
antibody which are responsible for antigen-binding. The hypervariabie region
generally comprises
amino acid residues from a "complementaricy determining ingion" or "CDR" (e.g,
residues 24-34
(L1), 50-56 (L2) and 89-97 (L3) in the fight chain variable domain and 31-35
(HI), 50-65 (1-12) and
16
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95-102 (113) in the heavy chain variable 'domain; Kabat Cr al., Sequences of
Prottht.s of
Immunological Interest, 5th Ed, Public Health Servioa, National Institutes of
Health, Bethesda, MD.
(1991)) and/or those residues From a Thypervariable loop" (e.g. residues 26-32
(Li), 50-52 (L2) and
91-96 (L3) in the light chain variable dornain and 26-32 (11), 53-55 (I-12)
and 96-101 (H3) in the
heavy chain variable domain; Chothia and Lesk Mot, Biol. 196;901-917 (19S7)).
'Framework
Region" or "FR" residues are chose variable domain residues other than the
hypervariable region
residues as herein defined.
The term "Fc region" herein is used to define a C-terminal region of an
imitraineglobulin
heavy chain, including native sequence Fc regions and variant Fe regions.
Although the boundaries
of the Fc rcgibn of an immunoglobulin heavy chain might vary, the Minoan Ig0
heavy chain Fc
region is usually defined to stretch from an amino acid residue at position
Cys226, or from Pro230, to
the carboxyl-terminu.s thereof, The C-terminal lysine (residue 447 according
to the EU numbering
system) of the Fc region may be removed, for example, during production or
purification of the
antibody, or by recombinantly engineering the nucleic acid encoding a heavy
chain of the antibody.
Accordingly, a composition of intact antibodies may comprise antibody
populations with all 1(447
residues removed, antibody populations with no 1(447 residues removed, and
antibody populations
having a mixture of antibodies with and without the 1(447 residue.
Unless indicated otherwise, herein the numbering of the rcsiducs in an
imnamoglobulin
heavy chain is that of the U index as in Kabat et ot,, Sequences of Proteins
of linnugeotogieui
Interest, 5th Ed. Public Health Servi:e, National Institutes of Health,
Bethesda, MD (1991).
The "EU index as in Kabat" refers to the residue numbering of the
ham= IgG1 EU antibody.
A "functional Fc region" possesses an "effector function" of a native sequence
Fe region.
Exemplary "effector functions" include Clq binding; complement dependent eytio
toxicity; Fe
receptor binding: antibody-dependent cell-mediated cytutoisicity (AllltCC):
pha.goeytosis; down
regulation of cell surface receptors (e.g. B cell receptor; ncr), etc. Such
effector functions generally
requite the Fc region to he combined with a binding domain (e.g. an antibody
variable domain) and
can be assessed using various assays as herein disclosed, for e.xample.
A "native sequence Fe region" comprises an amino acid sequence identical to
the amine acid
sequence of an Fc region found in nature. Native sequence human Fc regions
include a native
sequence human 1g01 Pc region (non-A and A allotypes); native sequence human
1g32 Fc region;
nati ve sequence human IgG3 Pc region; and native sequence human %Cid Pe
region as well as
naturally occurring variants thereof,
A "variant Fe region" comprises an amino acid sequence which differs from that
of a native
sequence Fc region by virtue of at least one amino acid modification,
preferably one or more amino
acid substitution(s). Preferably, the variant Fc region has ai least one amino
acid substitution
compared to a native sequence Fa region or to the Fc region of a parent
polypaptide, e.g, from about
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one to about ten ammo acid substitutions, and preferably from about one to
about five amino acid
substitutions in a native sequence Fc region or in the Fc region of the parent
polypeptide. The variant
Fc region herein will preferably possess at least about 80% homology with a
native sequence Fc
region and/or with an Fc region of a parent polypeptide, and most preferably
at least about 90%
homology therewith, more preferably at least about 95% homology therewith.
Depending on the amino acid sequence of the constant domain of their heavy
chains, intact
antibodies can be assigned to different "classes". There are five major
classes of intact antibodies:
IgA, IgD, IgE, IgG, and IgM, and several of these may be further divided into
"subclasses" (isotypes),
e.g., IgGl, IgG2, IgG3, IgG4, IgA, and IgA2. The heavy-chain constant domains
that correspond to
the different classes of antibodies are called a, 5, E, 7, and 11,
respectively. The subunit structures and
three-dimensional configurations of different classes of immunoglobulins are
well known.
A "naked antibody" is an antibody that is not conjugated to a heterologous
molecule, such as
a cytotoxic moiety or radiolabel.
An "affinity matured" antibody is one with one or more alterations in one or
more
hypervariable regions thereof which result an improvement in the affinity of
the antibody for antigen,
=
compared to a parent antibody which does not possess those alteration(s).
Preferred affinity matured
antibodies will have nanomolar or even picomolar affinities for the target
antigen. Affinity matured
antibodies are produced by procedures known in the art. Marks et al.
Bio/Technology 10:779-783
(1992) describes affinity maturation by VH and VL domain shuffling. Random
mutagenesis of CDR
and/or framework residues is described by: Barbas et al. Proc Nat. Acad. Sci,
USA 91:3809-3813
(1994); Schier et al. Gene 169:147-155 (1995); Ye1ton et al. J. Inununol.
155:1994-2004 (1995);
Jackson et al., J. Immunol. 154(7):3310-9 (1995); and Hawkins et al, J. Mol.
Biol. 226:889-896
(1992).
A "deamidated" antibody is one in which one or more asparagine residues
thereof has been
derivitized, e.g. to an aspartic acid, a succinimide, or an iso-aspartic acid.
The terms "cancer" and "cancerous" refer to or describe the physiological
condition in
mammals that is typically characterized by unregulated cell growth.
"Gastric cancer" specifically includes metastatic or locally advanced non-
rescctable gastric
cancer, including, without limitation, histologically confirmed adenocarcinoma
of the stomach or
gastroesophageal junction with inoperable (non-resectable) locally advanced or
metastatic disease,
not amenable to curative therapy, and post-operatively recurrent advanced
gastric cancer, such as
adenocarcinoma of the stomach or gastmesophageal junction, when the intent of
the surgery was to
cure the disease.
An "advanced" cancer is one which has spread outside the site or organ of
origin, either by
local invasion or metastasis. Accordingly, the term "advanced" cancer includes
both locally
advanced and metastatic disease.
A "refractory" cancer is one which progresses even though an anti-tumor agent,
such as a
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chemotherapy, is being administered to the cancer patient. An example of a
refractory cancer is one
which is platinum refractory.
A "recurrent" cancer is one which has regrown, either at the initial site or
at a distant site,
after a response to initial therapy, such as surgery.
A "locally recurrent" cancer is cancer that returns after treatment in the
same place as a
previously treated cancer.
A "non-resectable" or "unresectable" cancer is not able to be removed
(resected) by surgery.
"Early-stage breast cancer" herein refers to breast cancer that has not spread
beyond the
breast or the axillary lymph nodes. Such cancer is generally treated with
neoadjuvant or adjuvant
therapy.
"Neoadjuvant therapy" refers to systemic therapy given prior to surgery.
"Adjuvant therapy" refers to systemic therapy given after surgery.
"Metastatic" cancer refers to cancer which has spread from one part of the
body (e.g. the
breast) to another part of the body.
Herein, a "patient" or "subject" is a human patient. The patient may be a
"cancer patient,"
i.e. one who is suffering or at risk for suffering from one or more symptoms
of cancer, in particular
gastric or breast cancer.
A "patient population" refers to a group of cancer patients. Such populations
can be used to
demonstrate statistically significant efficacy and/or safety of a drug, such
as Pertuzumab.
A "relapsed" patient is one who has signs or symptoms of cancer after
remission.
Optionally, the patient has relapsed after adjuvant or neoadjuvant therapy.
A cancer or biological sample which "displays HER expression, amplification,
or activation"
is one which, in a diagnostic test, expresses (including overexpresses) a HER
receptor, has amplified
HER gene, and/or otherwise demonstrates activation or phosphorylation of a HER
receptor.
A cancer or biological sample which "displays HER activation" is one which, in
a diagnostic
test, demonstrates activation or phosphorylation of a HER receptor. Such
activation can be
determined directly (e.g. by measuring HER phosphorylation by ELISA) or
indirectly (e.g. by gene
expression profiling or by detecting HER heterodimers, as described herein).
A cancer cell with "HER receptor overexpression or amplification" is one which
has
significantly higher levels of a HER receptor protein or gene compared to a
noncancerous cell of the
same tissue type. Such overexpression may be caused by gene amplification or
by increased
transcription or translation. HER receptor overexpression or amplification may
be determined in a
diagnostic or prognostic assay by evaluating increased levels of the HER
protein present on the
surface of a cell (e.g. via an immunohistochemistry assay; IHC).
Alternatively, or additionally, one
may measure levels of HER-encoding nucleic acid in the cell, e.g. via in situ
hybridization (ISH),
including fluorescent in situ hybridization (FISH; see W098/45479 published
October, 1998) and
chromogenic in situ hybridization (CISH; see, e.g. Tanner et al., Am. J.
Pathol. 157(5): 1467-1472
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(2000); Bella et al., J. Clin. Oncol. 26: (May 20 suppl; abstr 22147) (2008)),
southern blotting, or
polymerase chain reaction (PCR) techniques, such as quantitative real time PCR
(qRT-PCR). One
may also study HER receptor overexpression or amplification by measuring shed
antigen (e.g., HER
extracellular domain) in a biological fluid such as serum (see, e.g., U.S.
Patent No. 4,933,294 issued
June 12, 1990; W091/05264 published April 18, 1991; U.S. Patent 5,401,638
issued March 28, 1995;
and Sias et al. .1. hnniunol. Methods 132: 73-80 (1990)). Aside from the above
assays, various in vivo
assays are available to the skilled practitioner. For example, one may expose
cells within the body of
the patient to an antibody which is optionally labeled with a detectable
label, e.g. a radioactive
isotope, and binding of the antibody to cells in the patient can be evaluated,
e.g. by external scanning
for radioactivity or by analyzing a biopsy taken from a patient previously
exposed to the antibody.
A "HER2-positive" cancer comprises cancer cells which have higher than normal
levels of
HER2. Examples of HER2-positive cancer include HER2-positive breast cancer and
HER2-positive
gastric cancer. Optionally, HER2-positive cancer has an immunohistochemistry
(IHC) score of 2+ or
3+ andlor an in situ hybridization (ISH) amplification ratio >2Ø
Herein, an "anti-tumor agent" refers to a drug used to treat cancer. Non-
limiting examples of
anti-tumor agents herein include chemotherapy agents, HER dimerization
inhibitors, HER antibodies,
antibodies directed against tumor associated antigens, anti-hormonal
compounds, cytokines, EGFR-
targeted drugs, anti-angiogenic agents, tyrosine kinase inhibitors, growth
inhibitory agents and
antibodies, cytotoxic agents, antibodies that induce apoptosis, COX
inhibitors, famesyl transferase
inhibitors, antibodies that binds oncofetal protein CA 125, HER2 vaccines, Raf
or ras inhibitors,
liposomal doxorubicin, topotecan, taxene, dual tyrosine kinase inhibitors,
TLIC286, EMD-7200,
Pertuzumab, Trastuzumab, erlotinib, and bevacizumab.
The "epitope 2C4" is the region in the extracellular domain of HER2 to which
the antibody
2C4 binds. In order to screen for antibodies which bind essentially to the 2C4
epitope, a routine
cross-blocking assay such as that described in Antibodies, A Laboratory
Manual, Cold Spring Harbor
Laboratory, Ed Harlow and David Lane (1988), can be performed. Preferably the
antibody blocks
2C4's binding to HER2 by about 50% or more. Alternatively, epitope mapping can
be performed to
assess whether the antibody binds essentially to the 2C4 epitope of HER2.
Epitope 2C4 comprises
residues from Domain II (SEQ ID NO: 2) in the extracellular domain of HER2.
2C4 and Pertuzumab
binds to the extracellular domain of 1{ER2 at the junction of domains I, II
and III (SEQ ID NOs: 1, 2,
and 3, respectively). Franklin et al. Cancer Cell 5:317-328 (2004).
The "epitope 4D5" is the region in the extracellular domain of HER2 to which
the antibody
4D5 (ATCC CRL 10463) and Trastuzumab bind. This epitope is close to the
transmembrane domain
of HER2, and within Domain IV of HER2 (SEQ ID NO: 4). To screen for antibodies
which bind
essentially to the 4D5 epitope, a routine cross-blocking assay such as that
described in Antibodies, A
Laboratory Manual, Cold Spring Harbor Laboratory, Ed Harlow and David Lane
(1988), can be
performed. Alternatively, epitope mapping can be performed to assess whether
the antibody binds
CA 02788253 2012-08-29
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essentially to the 4D5 epitope of HER2 (e.g. any one or more residues in the
region from about
residue 529 to about residue 625, inclusive of the HER2 ECD, residue numbering
including signal
peptide).
"Treatment" refers to both therapeutic treatment and prophylactic or
preventative measures,
Those in need of treatment include those already with cancer as well as those
in which cancer is to be
prevented. Hence, the patient to be treated herein may have been diagnosed as
having cancer or may
be predisposed or susceptible to cancer.
The term "effective amount" refers to an amount of a drug effective to treat
cancer in the
patient. The effective amount of the drug may reduce the number of cancer
cells; reduce the tumor
size; inhibit (i.e., slow to some extent and preferably stop) cancer cell
infiltration into peripheral
organs; inhibit (i.e., slow to some extent and preferably stop) tumor
metastasis; inhibit, to some
extent, tumor growth; and/or relieve to some extent one or more of the
symptoms associated with the
cancer, To the extent the drug may prevent growth and/or kill existing cancer
cells, it may be
cytostatic and/or cytotoxic. The effective amount may extend progression free
survival (e.g. as
measured by Response Evaluation Criteria for Solid Tumors, RECIST, or CA-125
changes), result in
an objective response (including a partial response, PR, or complete response,
CR), increase overall
survival time, and/or improve one or more symptoms of cancer (e.g. as assessed
by FOSI).
The term "cytotoxic agent" as used herein refers to a substance that inhibits
or prevents the
function of cells and/or causes destruction of cells. The term is intended to
include radioactive
isotopes (e.g. At2" ,r31, 1125, Y -90,
Re', Rem, ms 153, B=1212, P32 9
and radioactive isotopes of Lu),
chemotherapeutic agents, and toxins such as small molecule toxins or
enzymatically active toxins of
bacterial, fungal, plant or animal origin, including fragments and/or variants
thereof.
A "chemotherapy" is use of a chemical compound useful in the treatment of
cancer.
Examples of chemotherapeutic agents, used in chemotherapy, include alkylating
agents such as
thiotepa and CYTOXAN cyclosphosphamide; alkyl sulfonates such as busulfan,
improsulfan and
piposulfan; aziridines such as benzodopa, carboquone, meturedopa, and uredopa;
ethylenimines and
methylamelamines including altretamine, triethylenemelamine,
trietylenephosphoramide,
triethiylenethiophosphoramide and trimethylolomelamine; TLK 286 (I'ELCYTATm);
acetogenins
(especially bullatacin and bullatacinone); delta-9-tetrahydrocannabinol
(dronabinol, MARINOLC));
beta-lapachone; lapachol; colchicines; betulinic acid; a camptothecin
(including the synthetic
analogue topotecan (HYCAMTINC)), CPT-11 (irinotecan, CAMPTOSARID),
acetylcamptothecin,
scopolectin, and 9-aininocamptothecin); bryostatin; callystatin; CC-1065
(including its adozelesin,
carzelesin and bizelesin synthetic analogues); podophyllotoxin; podophyllinic
acid; teniposide;
cryptophycins (particularly cryptophycin 1 and cryptophycin 8); dolastatin;
duocarmycin (including
the synthetic analogues, KW-2189 and CB1-TM1); eleutherobin; pancratistatin; a
sarcodictyin;
spongistatin; nitrogen mustards such as chlorambucil, chlornaphazine,
cholophosphamide,
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estramustine, ifosfamide, mechlorethamine, mechlorethamine oxide
hydrochloride, melphalan,
novembichin, phenesterine, prednimustine, trofosfamide, uracil mustard;
nitrosureas such as
carmustine, chlorozotocin, fotemustine, lomustine, nimustine, and
ranimnustine; bisphosphonates,
such as clodronate; antibiotics such as the enediyne antibiotics (e. g.,
calicheamicin, especially
calicheamicin gammall and calicheamicin omegall (see, e.g., Agnew, Chem Intl.
Ed. Engl., 33: 183-
186 (1994)) and anthracyclines such as annamycin, AD 32, alcarubicin,
daunorubicin, dexrazoxane,
DX-52-1, epirubicin, GPX-100, idarubicin, KRN5500, menogaril, dynemicin,
including dynemicin
A, an esperamicin, neocarzinostatin chromophore and related chromoprotein
enediyne antiobiotic
chromophores, aclacinomysins, actinomycin, authramycin, azaserine, bleomycins,
cactinomycin,
carabicin, carminomycin, carzinophilin, chromomycinis, dactinomycin,
detombicin, 6-diazo-5-oxo-
L-norleucine, ADRIAMYCINO doxorubicin (including morpholino-doxorubicin,
cyanomorpholino-
doxorubicin, 2-pyrrolino-doxorubicin, liposomal doxorubicin, and
deoxydoxorubicin), esorubicin,
marcellomycin, mitomycins such as mitomycin C, mycophenolic acid, nogalamycin,
olivomycins,
peplomycin, potfiromycin, puromycin, quelamycin, rodorubicin, streptonigrin,
streptozocin,
tubercidin, ubenimex, zinostatin, and zorubicin; folic acid analogues such as
denopterin, pteropterin,
and trimetrexate; purine analogs such as fludarabine, 6-mercaptopurine,
thiamiprine, and
thioguanine; pyrimidine analogs such as ancitabine, azacitidine, 6-azauridine,
carmofur, cytarabine,
dideoxyuridine, doxifluridine, enocitabine, and floxuridine; androgens such as
calusterone,
dromostanolone propionate, epitiostanol, mepitiostane, and testolactone; anti-
adrenals such as
aminoglutethimide, mitotane, and trilostane; folic acid replenisher such as
folinic acid (leucovorin);
aceglatone; anti-folate anti-neoplastie agents such as ALTMTAM, LY211 514
pemetrexed,
dihydrofolate reductase inhibitors such as methotrexate, anti-metabolites such
as 5-fluorouracil (5-
FU) and its prodrugs such as UFT, S-1 and capecitabine, and thymidylate
synthase inhibitors and
glycinamide ribonucleotide formyltransferase inhibitors such as raltitrexed
(TOMUDEXItm, TDX);
inhibitors of dihydropyrirrtidine dehydrogenase such as eniluracil;
aldophosphamide glycoside;
aminotevulinic acid; amsacrine; bestrabucil; bisantrene; edatraxate;
defofamine; demecolcine;
diaziquone; elfornithine; elliptinium acetate; an epothilone; etoglucid;
gallium nitrate; hydroxyurea;
lentinan; lonidainine; maytansinoids such as maytansine and ansamitocins;
mitoguazone;
mitoxantrone; mopidanmol; nitraerine; pentostatin; phenamet; pirarubicin;
losoxantrone; 2-
ethylhydrazide; procarbazine; PSK polysaccharide complex (JHS Natural
Products, Eugene, OR);
razoxane; rhizoxin; sizofiran; spirogermanium; tenuazonic acid; triaziquone;
2,2',2''-
trichlorotriethylamine; trichothecenes (especially T-2 toxin, verracurin A,
roridin A and anguidine);
urethan; vindesine (ELDISINE , FILDESINe); dacarbazine; mannomustine;
mitobronitol;
mitolactol; pipobroman; gacytosine; arabinoside ("Ara-C"); cyclophosphamide;
thiotepa; taxanes;
chloranbucil; gemcitabine (GEMZAR0); 6-thioguanine; mercaptopurine; platinum;
platinum analogs
or platinum-based analogs such as cisplatin, oxaliplatin and carboplatin;
vinblastine (VELBAN );
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etoposide (VP-16); ifosfamide; mitoxantrone; vincristine (ONCOVINO); vinca
alkaloid; vinorelbine
(NAVELBINE ); novantrone; edatrexate; daunomycin; aminopterin; xeloda;
ibandronate;
topoisomerase inhibitor RFS 2000; difluoromedhylornithine (DMF0); retinoids
such as retinoic acid;
pharmaceutically acceptable salts, acids or derivatives of any of the above;
as well as combinations of
two or more of the above such as CHOP, an abbreviation for a combined therapy
of
cyclophosphamide, doxorubicin, vincristine, and prednisolone, and FOLFOX, an
abbreviation for a
treatment regimen with oxaliplatin (ELOXAT1NTm) combined with 5-FU and
leucovorin.
Also included in this definition are anti-hormonal agents that act to regulate
or inhibit
hormone action on tumors such as anti-estrogens and selective estrogen
receptor modulators
(SERNIs), including, for example, tamoxifen (including NOLVADEX tamoxifen),
raloxifene,
droloxifene, 4-hydroxytamoxifen, trioxifene, keoxifene, LY117018, onapristone,
and FARESTON
toremifene; aromatase inhibitors; and anti-androgens such as flutamide,
nilutamide, bicalutamide,
leuprolide, and goserelin; as well as troxacitabine (a 1,3-dioxolane
nucleoside cytosine analog);
antisense oligonucleotides, particularly those that inhibit expression of
genes in signaling pathways
implicated in abherant cell proliferation, such as, for example, PKC-alpha,
Raf, H-Ras, and epidermal
growth factor receptor (EGF-R); vaccines such as gene therapy vaccines, for
example,
ALLOVECTINO vaccine, LEUVECTIN vaccine, and VAXIDO vaccine; PROLEUKIN rIL-2;
LURTOTECAN topoisomerase 1 inhibitor; ABARELIX rmRH; and pharmaceutically
acceptable
salts, acids or derivatives of any of the above.
A "taxane" is a chemotherapy which inhibits mitosis and interferes with
microtubules.
Examples of taxanes include Paelitaxel (TAXOLO; Bristol-Myers Squibb Oncology,
Princeton,
N.J.); cremophor-free, albumin-engineered nanoparticle formulation of
paclitaxel or nab-paclitaxel
(ABRAXANETM; American Pharmaceutical Partners, Schaumberg, Illinois); and
Docetaxel
(TAXOTEREO; Rhone-Poulenc Rorer, Antony, France).
An "anthacycline" is a type of antibiotic that comes from the fungus
Streptococcus peucetius,
examples include: Daunorubicin, Doxorubicin, and Epirubicin, etc.
"Anthracycline-based chemotherapy" refers to a chemotherapy regimen that
consists of or
include one or more anthracycline. Examples include 5-FU, epirubicin, and
cyclophosphamide
(FEC); 5-FU, doxorubicin, and cyclophosphamide (FAC); doxorubicin and
cyclophosphamide (AC);
epirubicin and cyclophosphamide (EC); etc.
For the purposes herein, "carboplatin-based chemotherapy" refers to a
chemotherapy
regimen that consists of or includes one or more Carboplatins. An example is
TCH
(Docetaxel/TAXOL , Carboplatin, and Trastuzumab/HERCEPT1N0).
An "aromatase inhibitor" inhibits the enzyme aromatase, which regulates
estrogen
production in the adrenal glands. Examples of aromatase inhibitors include:
4(5)-imidazoles,
aminoglutethimide, MEGASE megestrol acetate, AROMAS1N exemestane,
formestanie,
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fadrozole, RIVISORO vorozole, FEMARA letrozole, and ARIMIDEXO anastrozole. In
one
embodiment, the aromatase inhibitor herein is letrozole or anastrozole.
An "antimetabolite chemotherapy" is use of an agent which is structurally
similar to a
metabolite, but can not be used by the body in a productive manner. Many
antimetabolite
chemotherapy interferes with the production of the nucleic acids, RNA and DNA.
Examples of
antimetabolite chemotherapeutic agents include gemcitabine (GEMZARO), 5-
fluorouracil (5-FU),
capecitabine (XELODATm), 6-mercaptopurine, methotrexate, 6-thioguanine,
pemetrexed, raltitrexed,
arabinosylcytosine ARA-C cytarabine (CYTOSAR-11,0), dacarbazine (DTIC-DOME ),
azocytosine,
deoxycytosine, pyridmidene, fludarabine (FLUDARAC), cladrabine, 2-deoxy-D-
glucose etc.
By "chemotherapy-resistant" cancer is meant that the cancer patient has
progressed while
receiving a chemotherapy regimen (i.e. the patient is "chemotherapy
refractory"), or the patient has
progressed within 12 months (for instance, within 6 months) after completing a
chemotherapy
regimen.
The term "platin" is used herein to refer to platinum based chemotherapy,
including, without
limitation, cisplatin, carboplatin, and oxaliplatin.
The term "fluoropyrimidine" is used herein to refer to an antimetabolite
chemotherapy,
including, without limitation, capecitabine, floxuridine, and fluorouracil (5-
FU).
A "fixed " or "flat" dose of a therapeutic agent herein refers to a dose that
is administered to
a human patient without regard for the weight (WT) or body surface area (BSA)
of the patient. The
fixed or flat dose is therefore not provided as a mg/kg dose or a mg/m2 dose,
but rather as an absolute
amount of the therapeutic agent
A "loading" dose herein generally comprises an initial dose of a therapeutic
agent
administered to a patient, and is followed by one or more maintenance dose(s)
thereof. Generally, a
single loading dose is administered, but multiple loading doses are
contemplated herein. Usually, the
amount of loading dose(s) administered exceeds the amount of the maintenance
dose(s) administered
and/or the loading dose(s) are administered more frequently than the
maintenance dose(s), so as to
achieve the desired steady-state concentration of the therapeutic agent
earlier than can be achieved
with the maintenance dose(s).
A "maintenance" dose herein refers to one or more doses of a therapeutic agent
administered
to the patient over a treatment period. Usually, the maintenance doses are
administered at spaced
treatment intervals, such as approximately every week, approximately every 2
weeks, approximately
every 3 weeks, or approximately every 4 weeks, preferably every 3 weeks.
"Infusion" or "infusing" refers to the introduction of a drug-containing
solution into the body
through a vein for therapeutic purposes. Generally, this is achieved via an
intravenous (IV) bag.
An "intravenous bag" or "IV bag" is a bag that can hold a solution which can
be
administered via the vein of a patient. In one embodiment, the solution is a
saline solution (e.g. about
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0.9% or about 0.45% NaC1). Optionally, the IV bag is formed from polyolefin or
polyvinal chloride.
By "co-administering" is meant intravenously administering two (or more) drugs
during the
same administration, rather than sequential infusions of the two or more
drugs. Generally, this will
involve combining the two (or more) drugs into the same IV bag prior to co-
administration thereof.
"Cardiac toxicity" refers to any toxic side effect resulting from
administration of a drug or
drug combination. Cardiac toxicity can be evaluated based on any one or more
of: incidence of
symptomatic left ventricular systolic dysfunction (LVSD) or congestive heart
failure (CHF), or
decrease in left ventricular ejection fraction (LVEF).
The phrase "without increasing cardiac toxicity" for a drug combination
including
Pertuzumab refers to an incidence of cardiac toxicity that is equal or less
than that observed in
patients treated with drugs other than Pertuzumab in the drug combination
(e.g. equal or less than that
resulting from administration of Trastuzumab and the chemotherapy, e.g.
Docetaxel).
A "vial" is a container suitable for holding a liquid or lyophilized
preparation. In one
embodiment, the vial is a single-use vial, e.g. a 20-cc single-use vial with a
stopper.
A "package insert" is a leaflet that, by order of the Food and Drug
Administration (FDA) or
other Regulatory Authority, must be placed inside the package of every
prescription drug, The leaflet
generally includes the trademark for the drug, its generic name, and its
mechanism of action; states its
indications, contraindications, warnings, precautions, adverse effects, and
dosage forms; and includes
instructions for the recommended dose, time, and route of administration.
The expression "safety data" concerns the data obtained in a controlled
clinical trial showing
the prevalence and severity of adverse events to guide the user regarding the
safety of the drug,
including guidance on how to monitor and prevent adverse reactions to the
drug. Table 3 and Table 4
herein provide safety data for Pertuzumab. The safety data comprises any one
or more (e.g. two,
three, four or more) of the most common adverse events (AFs) or adverse
reactions (ADRs) in Tables
3 and 4. For example, the safety data comprises information about neutropenia,
febrile neutropenia,
diarrhea and/or cardiac toxicity as disclosed herein.
"Efficacy data' refers to the data obtained in controlled clinical trial
showing that a drug
effectively treats a disease, such as cancer. Efficacy data for Pertuzumab is
provided in the examples
herein. As to HER2-positive metastatic or locally recurrent, unresectable
breast cancer, efficacy data
for Pertuzumab is found in Table 2, Table 5, Figure 8 and Figure 10 herein.
The safety data
comprises any one or more (e.g. two, three, four or more) of the primary
endpoint (progression free
survival, PFS, by IRF) and/or secondary enpoints (overall survival (OS);
progression free survival
(PFS) by investigator; objective response rate (ORR), including complete
response (CR), partial
response (PR), stable disease (SD), and progressive disease (PD), and/or
duration of response) in
Table 2, Table 5, Figure 8 and Figure 10. For example, the efficacy data
comprises information about
progression free survival (PFS) and/or overall survival (OS) as disclosed
herein,
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By "stable mixture" when referring to a mixture of two or more drugs, such as
Pertuzumab
and Trastuzumab" means that each of the drugs in the mixture essentially
retains its physical and
chemical stability in the mixture as evaluated by one or more analytical
assays. Exemplary analytical
assays for this purpose include: color, appearance and clarity (CAC),
concentration and turbidity
analysis, particulate analysis, size exclusion chromatography (SEC), ion-
exchange chromatography
(IEC), capillary zone electrophoresis (CZE), image capillary isoelectric
focusing (iaff), and
potency assay. In one embodiment, mixture has been shown to be stable for up
to 24 hours at 5 C or
30 C.
A drug that is administered "concurrently" witth one or more other drugs is
administered
during the same treatment cycle, on the same day of treatment as the one or
more other drugs, and,
optionally, at the same time as the one or more other drugs. For instance, for
cancer therapies given
every 3-weeks, the concurrently administered drugs are each administered on
day-1 of a 3-week
cycle.
11. Antibody and Chemotherapy Compositions
The HER2 antigen to be used for production of antibodies may be, e.g., a
soluble form of the
extracellular domain of a HER2 receptor or a portion thereof, containing the
desired epitope.
Alternatively, cells expressing HER2 at their cell surface (e.g. NTH-3T3 cells
transformed to
overexpress HER2; or a carcinoma cell line such as SK-BR-3 cells, see
Stancovslci etal. PNAS (USA)
88:8691-8695 (1991)) can be used to generate antibodies. Other forms of HER2
receptor useful for
generating antibodies will be apparent to those skilled in the art.
Various methods for making monoclonal antibodies herein are available in the
art. For
example, the monoclonal antibodies may be made using the hybridoma method
first described by
Kohler et al., Nature, 256:495 (1975), by recombinant DNA methods (U.S. Patent
No, 4,816,567).
The anti-HER2 antibodies used in accordance with the present invention,
Trastuzumab and
Pertuzurnab, are commercially available.
(i) Humanized antibodies
Methods for humanizing non-human antibodies have been described in the art.
Preferably, a
humanized antibody has one or more amino acid residues introduced into it from
a source which is
non-human. These non-human amino acid residues are often referred to as
"import" residues, which
are typically taken from an "import" variable domain. Humanization can be
essentially performed
following the method of Winter and co-workers (Jones etal., Nature, 321:522-
525 (1986);
Riechmann etal., Nature, 332:323-327 (1988); Verhoeyen etal., Science,
239:1534-1536 (1988)), by
substituting hypervariable region sequences for the corresponding sequences of
a human antibody.
Accordingly, such "humanized" antibodies are chimeric antibodies (U.S. Patent
No. 4,816,567)
wherein substantially less than an intact human variable domain has been
substituted by the
26
corresponding sequence from a non-human species. In practice, humanized
antibodies are typically
human antibodies in which some hyper variable region residues and possibly
some FR residues are
substituted by residues from analogous sites in rodent antibodies.
The choice of human variable domains, both light and heavy, to be used in
making the
humanized andbodies is very important to reduce antigenicity. According to the
so-called "best-fit"
method, the sequence of the variable domain of a rodent antibody is screened
against the entire
library of known human variable-domain sequences. The human sequence which is
closest to that of
the rodent is then accepted as the human framework region (FR) for the
humanized antibody (Sims et
al., J. Inuratnal., 012296 (1993); Chothia et al., J. Mol, Biol., 196:901
(1987)). Another method
uses a particular framework region derived from the consensus sequence of all
human antibodies of a
particular subgroup of light or heavy chains. The same framework may be used
for several different
humanized antibodies (Carter as al., Proc. Natl. Acad, Sci, USA, 89;4285
(1992); Presta at al., J.
inunknoi., 151:2623 (1993)).
It is further important that antibodies he humanized with retention of high
affinity for the
antigen and other favorable biological properties. To achieve this goal,
according to a prelerred
method, humanized antibodies are prepared by a process of analysis of the
parental sequences and
various conceptual humanized products using three-dimensional models of the
parental and
humanized sequences. Three-dimensional iminunoglobulin models are commonly
available and are
familiar to those skilled in the art. Computer programs are available which
illustrate and display
probable three-dimensional Conformational structures of selected candidate
immariciglobulin
sequences. Inspection of these displays permits analysis of the likely role of
the residues in the
functioning of the candidate immunoglebulio sequence, Le the analysis of
residues that influence
the ability of the candidate immunoglobulin to bind its antigen. In this way,
FR residues can he
selected and combined from the recipient and import sequences se that the
desired antibody
characteristic, such as increased affinity for the target antigen(s), is
achieved. In general, the
hypervariable region residues are directly and most substantially involved in
influencing antigen
binding.
US Patent No. 6,949,245 describes production of exemplary humanized HER?,
antibodies
which hind Eta2 and block ligand activation of a HER receptor.
Humanized HER2 antibodies specifically include Trastuzumab (HERCEPT1M) as
describLx1 in Table 3 of U.S. Patent 5,8,21,337 and as
defined herein; and humanized 2C4 antibodies such as Pertuzmnah as desctibed
and defined herein.
The humanized antibodies herein may, for example; comprise nonhuman
hyperVariable
region residues incorporated into a human variable heavy domain and may
further comprise a
framework region (FR) substitution at a po.Sition sclected front the group
consisting of 6911, 7113 and
731.1 utilizing the variable domain numbering system set forth in Kabat et
al., Sequences of Proteins
of Immunological Interest, 5th Ed. Public Health Service, National Institutes
of Health, Bethesda,
27
CA 2788253 2019-09-09
CA 02788253 2012-08-29
PR4753-4
MD (1991). In one embodiment, the humanized antibody comprises FR
substitutions at two or all of
positions 69H, 71H and 73H.
An exemplary humanized antibody of interest herein comprises variable heavy
domain
complementarity determining residues GFIEIDYTMX (SEQ ID NO: 17), where X is
preferably D
or S; DVNPNSGGSIYNQRFKG (SEQ ID NO:18); and/or NLGPSFYFDY (SEQ ID NO:19),
optionally comprising amino acid modifications of those CDR residues, e.g.
where the modifications
essentially maintain or improve affinity of the antibody. For example, an
antibody variant for use in
the methods of the present invention may have from about one to about seven or
about five amino
acid substitutions in the above variable heavy CDR sequences. Such antibody
variants may be
prepared by affinity maturation, e.g., as described below.
The humanized antibody may comprise variable light domain complementarity
determining
residues KASQDVSIGVA (SEQ ID NO:20); SASYXIX2X3, where X1 is preferably R or
L, X2 is
preferably Y or E, and X3 is preferably T or S (SEQ ID NO:21); and/or
QQYYIYPYT (SEQ ID
NO:22), e.g. in addition to those variable heavy domain CDR residues in the
preceding paragraph.
Such humanized antibodies optionally comprise amino acid modifications of the
above CDR
residues, e.g. where the modifications essentially maintain or improve
affinity of the antibody. For
example, the antibody variant of interest may have from about one to about
seven or about five amino
acid substitutions in the above variable light CDR sequences. Such antibody
variants may be
prepared by affinity maturation, e.g., as described below.
The present application also contemplates affinity matured antibodies which
bind HER2.
The parent antibody may be a human antibody or a humanized antibody, e.g., one
comprising the
variable light and/or variable heavy sequences of SEQ ID Nos. 7 and 8,
respectively (i.e. comprising
the VL and/or VEI of Pertuzumab). An affinity matured variant of Pertuzumab
preferably binds to
HER2 receptor with an affinity superior to that of murine 2C4 or Pertuzumab
(e.g. from about two or
about four fold, to about 100 fold or about 1000 fold improved affinity, e.g.
as assessed using a
HER2-extracellular domain (ECD) ELISA) . Exemplary variable heavy CDR residues
for
substitution include H28, H30, H34, H35, H64, H96, H99, or combinations of two
or more (e.g. two,
three, four, five, six, or seven of these residues). Examples of variable
light CDR residues for
alteration include L28, L50, L53, L56, L91, L92, L93, L94, L96, L97 or
combinations of two or more
(e.g. two to three, four, five or up to about ten of these residues).
Humanization of murine 4D5 antibody to generate humanized variants thereof,
including
Trastuzumab, is described in U.S. Pat. Nos. 5,821,337,6,054,297, 6,407,213,
6,639,055, 6,719,971,
and 6,800,738, as well as Carter et al. PNAS (USA), 89:4285-4289 (1992).
HuMAb4D5-8
(Trastuzumab) bound 1TER2 antigen 3-fold more tightly than the mouse 4D5
antibody, and had
secondary immune function (ADCC) which allowed for directed cytotoxic activity
of the humanized
antibody in the presence of human effector cells. HuMAb4D5-8 comprised
variable light (V,) CDR
residues incorporated in a VL lc subgroup I consensus framework, and variable
heavy (VH) CDR
28
CA 02788253 2012-08-29
PR4753-4
residues incorporated into a VH subgroup III consensus framework. The antibody
further comprised
framework region (FR) substitutions as positions: 71, 73, 78, and 93 of the VH
(Kabat numbering of
FR residues; and a FR substitution at position 66 of the VL (Kabat numbering
of FR residues).
Trastuzumab comprises non-A allotype human y 1 Fc region.
Various forms of the humanized antibody or affinity matured antibody are
contemplated. For
example, the humanized antibody or affinity matured antibody may be an
antibody fragment.
Alternatively, the humanized antibody or affinity matured antibody may be an
intact antibody, such
as an intact IgG1 antibody.
(ii) Pertuzionab compositions
In one embodiment of a HER2 antibody composition, the composition comprises a
mixture
of a main species Pertuzumab antibody and one or more variants thereof. The
preferred embodiment
herein of a Pertuzumab main species antibody is one comprising the variable
light and variable heavy
amino acid sequences in SEQ ID Nos. 5 and 6, and most preferably comprising a
light chain amino
acid sequence of SEQ ID No. 11, and a heavy chain amino acid sequence of SEQ
ID No. 12
(including deamidated and/or oxidized variants of those sequences). In one
embodiment, the
composition comprises a mixture of the main species Pertuzumab antibody and an
amino acid
sequence variant thereof comprising an amino-terminal leader extension.
Preferably, the amino-
terminal leader extension is on a light chain of the antibody variant (e.g. on
one or two light chains of
the antibody variant). The main species HER2 antibody or the antibody variant
may be an full length
antibody or antibody fragment (e.g. Fab of F(ab')2 fragments), but preferably
both are full length
antibodies. The antibody variant herein may comprise an amino-terminal leader
extension on any one
or more of the heavy or light chains thereof. Preferably, the amino-terminal
leader extension is on
one or two light chains of the antibody. The amino-terminal leader extension
preferably comprises or
consists of VHS-. Presence of the amino-terminal leader extension in the
composition can be
detected by various analytical techniques including, but not limited to, N-
terminal sequence analysis,
assay for charge heterogeneity (for instance, cation exchange chromatography
or capillary zone
electrophoresis), mass spectrometry, etc. The amount of the antibody variant
in the composition
generally ranges from an amount that constitutes the detection limit of any
assay (preferably N-
terminal sequence analysis) used to detect the variant to an amount less than
the amount of the main
species antibody. Generally, about 20% or less (e.g. from about 1% to about
15%, for instance from
5% to about 15%) of the antibody molecules in the composition comprise an
amino-terminal leader
extension. Such percentage amounts are preferably determined using
quantitative N-terminal
sequence analysis or cation exchange analysis (preferably using a high-
resolution, weak cation-
exchange column, such as a PROPAC WCXJ0TM cation exchange column). Aside from
the amino-
terminal leader extension variant, further amino acid sequence alterations of
the main species
antibody and/or variant are contemplated, including but not limited to an
antibody comprising a C-
29
CA 02788253 2012-08-29
PR4753-4
terminal lysine residue on one or both heavy chains thereof, a deamidated
antibody variant, etc.
Moreover, the main species antibody or variant may further comprise
glycosylation
variations, non-limiting examples of which include antibody comprising a GI or
G2 oligosaccharide
structure attached to the Fc region thereof, antibody comprising a
carbohydrate moiety attached to a
light chain thereof (e.g. one or two carbohydrate moieties, such as glucose or
galactose, attached to
one or two light chains of the antibody, for instance attached to one or more
lysine residues),
antibody comprising one or two non-glycosylated heavy chains, or antibody
comprising a sialidated
oligosaccharide attached to one or two heavy chains thereof etc.
The composition may be recovered from a genetically engineered cell line, e.g.
a Chinese
Hamster Ovary (CHO) cell line expressing the HER2 antibody, or may be prepared
by peptide
synthesis.
For more information regarding exemplary Pertuzumab compositions, see US
Patent Nos.
7,560,111 and 7,879,325 as well as US 2009/0202546A1.
(iii) Trasturtunab compositions
The Trastuzumab composition generally comprises a mixture of a main species
antibody
(comprising light and heavy chain sequences of SEQ ID NOS: 13 and 14,
respectively), and variant
forms thereof, in particular acidic variants (including deamidated variants).
Preferably, the amount of
such acidic variants in the composition is less than about 25%, or less than
about 20%, or less than
about 15%. See, U.S. Pat. No. 6,339,142. See, also, Harris et al., J.
Chromatography, B 752:233-245
(2001) concerning forms of Trastuzumab resolvable by cation-exchange
chromatography, including
Peak A (Asn30 deamidated to Asp in both light chains); Peak B (Asn55
deamidated to isoAsp in one
heavy chain); Peak 1 (Asn30 deamidated to Asp in one light chain); Peak 2
(Asn30 deamidated to
Asp in one light chain, and Asp102 isomerized to isoAsp in one heavy chain);
Peak 3 (main peak
form, or main species antibody); Peak 4 (Asp102 isomerized to isoAsp in one
heavy chain); and Peak
C (Asp102 succinimide (Asu) in one heavy chain). Such variant forms and
compositions are included
in the invention herein.
(iv) 5-FU and Cisplatin
There is no single, standard, globally accepted chemotherapeutic regimen for
advanced gastric
cancer, but 5-fluorouracil (5-FU) plus cisplatin is widely used for this
indication. In Phase II studies
in patients with no prior chemotherapy, 5-FU + cisplatin produced response
rates of approximately
40% and median overall survival of 7-10.6 months (Lacave AJ, Baron El, Anton
LM, et al. Ann
Oncol 1991;2:751-754; Rougier P, Ducreux M, Mahjoubi M, et al. Ear J Cancer
1994;30A:1263-
1269; Vanhoefer U, Wagner T, Lutz M, et al. Ear J Cancer 2001;37 Suppl 6:
abstract S27.)
(v) Capecitabine
Capecitabine has been extensively tested in patients with advanced gastric
cancer. Phase II
efficacy results for capecitabine monotherapy show response rates of 19% and
26% and an overall
survival of 8.1 and 10.0 months in studies by Koizumi et al 2003 (Koizumi W,
Kurihara M, Sasai T,
CA 02788253 2012-08-29
PR4753-4
et al. Cancer 1993;72:658-62; Sakamoto J, Chin K, Kondo K, et al. Anti-Cancer
Drugs
2006;17:2331-6. For capccitabine in combination with platinum, there are a
number of studies
showing response rates ranging from 28% to 65%, time to progression from 5.8
to 9 months, and
overall survival from 10.1 to 12 months (Kang Y, Kang WK, Shin DB, etal. J
Clin Oncology
2006;24 Suppl 18:abstract LBA4018; Park Y, Kim B, Ryoo B, et al. Proc Am Soc
Clin Oncol
2006;24 Suppl 18: abstract 4079; Kim TW, Kang YK, Ahn JH, et al. Ann Oncol
2002;13:1893-8;
Park YH, Kim BS, Ryoo BY, et al. Br J Cancer 2006;94:959-63).
III. Selecting Patients for Therapy
Detection of HER2 can be used to select patients for treatment in accordance
with the present
invention. Several FDA-approved commercial assays are available to identify
HER2-positive cancer
patients. These methods include HERCEPTEST (Dako) and PATHWAY HER2
(irnmunohistochemistry (IHC) assays) and PathVysion and HER2 FISH pharrnDxTm
(FISH assays).
Users should refer to the package inserts of specific assay kits for
information on the validation and
performance of each assay.
For example, HER2 overexpression may be analyzed by IHC, e.g. using the
HERCEPTEST
(Dako). Paraffin embedded tissue sections from a tumor biopsy may be subjected
to the IHC assay
and accorded a HER2 protein staining intensity criteria as follows:
Score 0 no staining is observed or membrane staining is observed in less than
10% of tumor
cells.
Score 1+ a faint/barely perceptible membrane staining is detected in more than
10% of the
tumor cells. The cells are only stained in part of their membrane.
Score 2+ a weak to moderate complete membrane staining is observed in more
than 10% of
the tumor cells.
Score 3+ a moderate to strong complete membrane staining is observed in more
than 10% of
the tumor cells.
Those tumors with 0 or 1+ scores for HER2 overexpression assessment may be
characterized
as HER2-negative, whereas those tumors with 2+ or 3+ scores may be
characterized as HER2-
positive.
Tumors overexpressing HER2 may be rated by immunohistochemical scores
corresponding
to the number of copies of HER2 molecules expressed per cell, and can been
determined
biochemically:
0 = 0-10,000 copies/cell,
1+ = at least about 200,000 copies/cell,
2+ = at least about 500,000 copies/cell,
3+ = at least about 2,000,000 copies/cell.
Overexpression of HER2 at the 3+ level, which leads to ligand-independent
activation of the
31
tyrosine kinas.e (Hudzialc at al., FVOC Ned, Acad. Sci, USA, 84;715927163
(1987)), occurs in
approximately 50% of beast cancers, and in these patients, relapse-free
survival and overall survival
are diminished (Stamen at al.õ5cience, 244:707-712 (1989); Slamon et al.,
Science, 235:177-182
(1987)).
The presence of HER2 protein overexpre.ss ion and gene amplification are
highly con-elated,
therefore, alternatively, or addition.aliy, the use of in sine bybridization
(ISM e.g. fluorescent in situ
hybndization (FISH), assays to detect gape amplification may also be employed
for selection of
patients appropriate for treatment in accordance with the present invention.
FISH assays such kS the
INFORM" (sold by Ventana, Arizona) or PathYysion' (Vysis, may be carried
out on
fornialin-fixed, paraffin-embedded tumor tissue to determine the extent (if
any of I-IfiR2
ampIlfjcation in the tumor.
Most cornmonly, HER2-positive status is confirmed using archival paraffin-
embedded minor
tissue, using any of the foregoing methods,
Preferably, HER2-positive patients having a 2+ or 3+ IHC score or who are ESH
or 181-1
positive are selectee far treatment in accordance with the present invention.
Scz also US Patent No. 7,981,418 for alternative assays for screening patients
for therapy
with Pertuzume b.
IV. Pharmaceutical Formulations
Therapeutic formulations of the BER2 antibodies used in accordance with the
present
invention arc prepared for storage by mixing an antibody having the desired
degree of purity with
oplional pharmaceutically acceptable carriers, excipients or stabilizers
(Reinington's Pharmaceutical
Sciences 16th edition, Osol, A. Ed, (1930)), generally in the form of
lyophilized formulations or
aqueous solutions. Antibody crystals are also contemplated (see US Pat Appin
2002/01315719)
Acceptable carriers, excipientsr or stabilizers are noutoxic to recipients-at
the dosages and
concentrations employed, and include buffers such as phosphate, eitrate, and
other organic acids;
antioxidants including ascorbic acid and tnethionine; preservatives (such as
octaclecyldimethylbenzyl ammonium chloride; hexamethonitun chloride;
benzalkonkum chloride,.
benzethornum chloride; phenol, butyl or benzyl alcohol; alic; I parabens such
as methyl or propyl
paraben; catechol; resorcinol; cyclohexanol; 5-pen tanol; and nn-cresol); low
molecular weight (less
than about 10 residues) polypeptides; proteins, such as serum albumin,
gelatin, or irnmutioglobulins;
hydrophilic polymers such as pOyvinylpyi-cpiidonc; cmica acids such as
glyciue, glutamine,
asparagine, histidine, arginine, or lysine; menosaccharides, disaccharides,
and other carbohydrates
including glucose, mannose, or dextrins; chelating agents such as EWA; sugars
such as sucrose,
mannitol, trehalose or sorbitol; salt-formirr,,,, counter-ions such as sodium;
metal complexes (e.g. Zn-
= 35 protein complexes), and/or eon-ionic surfactants such as
TWEEN`m, PLLIRONICSTh or polyethylene
glycol (PEG). Lyophilized antibody formulations are described in WO 97/0480 I.
32
CA 2788253 2019-09-09
Lyophilized antibody formulations are described in U.S. Pat. Nos. 6,267,955,
6,685,940 and
6,821,515. The preferred1-1ERCPTIN4
(Trasruininrab)
formulation is a sterile, white to pule yellow preservative-free lyophilized
powder for intravenous
(IV) administration. comprising 440 mg Prastuzurnab, 400 nig .alphaccrt-
trehalose dehydrate, 9.9 Mg
L-histidinc-I-IC1, 6.4 nig L-histidine, and 1_8 mg polyserbate 20, IJSP,
Reconsitution of 20 teL of
bacteriostaile water For injection (IIVF1), containing 1 1% benzyl alcohol as
a preservative, yields a
Maid-1;ft solution containing 21 ing/mL Trastuzumab, at pH of approxidiately
6Ø For further
details, sec the Trastuzinnab presCribing information.
The preferred Pertuzumab formulation for therapeutic use comprises 30m,g,IrtiL
Pertnzumab
.. in 20raM histidine acetate, 120mM sucrose, 0,02% polyserbate 20, at pH 6.0,
An alternate
Pert=arab formulation comprises 25. rrig/mL Pertuzumab, 10 tiuM hisddirieHCl
buffer, 240 RIM
= sucrose, 0.02% polysorbete 20, pH 6,0,
The formulation of the placebo used in the clinical trials described in the
Examples is
= equivalent to Pertuzurnab, without the active agent.
The formulation herein may also contain more than one active compound as
necessary for the
particular indication being treated, prefernbiy those with complementary
activities that do not
adversely affect each other. Various drugs which car be combined with the HER
dimerization
inhibitor are described in the Method Section below. Such molecules are
suitably present in
combination in amounts that are effective for the purpose intended.
The formulations to be used for in vivo administration must be sterile, This
is readily
accomplished by filtration through sterile filtration membranes.
V. Treatment Methods
In a first aspect of a treatment method herein, a method for extending
progression free
sUrvival (PFS) in a HER2-positive brcast cancer patient population by 6 months
or more 19 provided
which comprises administering Pertuzumab, Tra,stuzumah and chemotherapy (g,g.
mane such as
Doeetaxol) to the patients in the population. Optionally, the patient
population includes a suitable
number of patients (e.g. 290 Or more, 300 or more or 400 or more patients) so
that a statistically
.; significant extension of PFS in the population can be evaluated.
The phase III CLEOPATRA c,linical data in Example 3 below show that median PFS
assessed by investigators was 12.4 months with placebo plus Trastnzurriab plus
Uocetaxel and 15.5
months with Pertuzumab plus Trastnzumab plus Docetaxel, thus the improvement
in. median ,PFS was
6 months or moro (e.g. 6.1 months) relative to patients not receiving
Pertuzumab (i.e, patients only
receiving Trastuzurnab and Docetaxel),
In an addiiional or alternative embodiment, a method of obtaining in objective
response rate
of 50% or more in a HER2-positive breast cancer patient population is provided
which comprises
administering Perruzuriab, Trastitzumab and chemotherapy (e.g. taxane, such as
Docetaxel) to the
patients in the population.
33
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CA 02788253 2012-08-29
PR4753-4
In a related aspect, a method of combining two HER2 antibodies to treat HER2-
positive
cancer without increasing cardiac toxicity in a HER2-positive cancer patient
population is provided
which comprises administering Pertuzumab, Trastuzumab, and chemotherapy to the
patients in the
population. Optionally, the patient population includes a suitable number of
patients (e.g. 200 or
more, 300 or more or 400 or more patients) so that a statistically significant
assessment of lack of
cardiac toxicity resulting from the combination can be made. The phase III
CLEOPATRA clinical
data in Example 3 below show that combining Pertuzumab and Trastuzumab does
not exacerbate
cardiac toxicity. Cardiac toxicity can be monitored for incidence of
symptomatic left ventricular
systolic dysfunction (LVSD) or congestive heart failure (CHF), or decrease in
left ventricular ejection
fraction (LVEF), e.g. as disclosed in Example 3 below.
Optionally, the breast cancer is metastatic or locally recurrent, unresectable
breast cancer, or
de novo Stage IV disease, is defined as immunohistochemistry (NC) 3+ and/or
fluorescence in situ
hybridization (FISH) amplification ratio >2Ø
Optionally, the patients in the population have not received previous
treatment or have
relapsed after adjuvant therapy, have a left ventricular ejection fraction
(LVEF) of >50% at baseline,
and/or have an Eastern Cooperative Oncology Group performance status (ECOG PS)
of 0 or 1.
In an alternative embodiment, the invention concerns a method of treating
early-stage HER2-
positive breast cancer comprising administering Pertuzumab, Trastuzumab, and
chemotherapy to a
patient with the breast cancer, wherein the chemotherapy comprises
anthracycline-based
chemotherapy, or carboplatin-based chemotherapy. This aspect of the invention
is supported by the
clinical data in Example 5. In one embodiment, the chemotherapy comprises
anthracycline-based
chemotherapy, e.g. comprising 5-EU, epirubicin, and cyclophosphamide (FEC). In
an alternative
embodiment, the chemotherapy comprises carboplatin-based chemotherapy, e.g.
comprising taxane
(e.g. Docetaxel), Carboplatin in addition to HERCEPTIN /Trastuzumab (e.g. TCH
regimen). In one
embodiment, Pertuzumab is administered concurrently with the anthracycline-
based chemotherapy or
with the carboplatin-based chemotherapy, e.g. wherein the Pertuzumab,
Trastuzumab and
chemotherapy are administered in 3-week cycles with Pertuzumab, Trastuzumab
and the
chemotherapy being administered on day-1 of each cycle. The data in the
examples herein
demonstrates that Pertuzumab administration does not increase cardiac toxicity
relative to the
treatment without Pertuzumab (i.e relative to Trastuzumab with anthrycline-
based chemotherapy (e.g.
FEC) and no Pertuzumab; or relative to Trastuzumab with carboplatin-based
chemotherapy and no
Pertuzumab (i.e. TCH). The early-stage IIER2-positive breast cancer therapy
contemplated herein
includes neoadjuvant and adjuvant therapy.
34
CA 02788253 2012-08-29
PR4753-4
The invention herein also concerns a method of treating HER2-positive cancer
in a patient
comprising co-administering a mixture of Pertuzumab and Trastuzumab from the
same intravenous
bag to the patient. This embodiment is applicable to treatment of any HER2-
positive cancer,
including HER2-positive breast cancer, HER2-positive gastric cancer, HER2-
positive metastatic or
locally recurrent, unresectable breast cancer, or de 110V0 Stage IV disease,
early-stage HER2-positive
breast cancer, etc. Optionally, this method further comprises administering
chemotherapy to the
patient.
In yet another embodiment, the treatment methods of the present invention
comprise, consist
essentially of, or consist of the administration of Pertuzumab, Trastuzumab
and a chemotherapy, such
as a platin (e.g. cisplatin) and/or a fluoropurirnidine (e.g. capecitabine
and/or 5-fluorouracil (5-FU))
to treat HER2-positive gastric cancer.
In particular, the treatment methods of the present invention comprise,
consist essentially of,
or consist of the administration of Pertuzumab, Trastuzumab, and a
chemotherapy, such as a platin
and/or a fluoropurimidine, e.g. cisplatin and/or capecitabine and/or 5-
fluorouracil (5-FU), to a human
=
.=
= 15 patient with metastatic gastric cancer, non-resectable
locally advanced gastric cancer, or post-
operatively recurrent gastric cancer. In certain embodiments, the gastric
cancer is not amenable to
curative therapy.
In an alternative embodiment, a method of treating HER2-positive breast cancer
in a patient
is provided comprising administering Pertuzumab, Trastuzumab and vinorelbine
to the patient. The
breast cancer according to this embodiment is optionally metastatic or locally
advanced. Optionally,
the patient has not previously received systemic non-hormonal anticancer
therapy in the metastatic
setting.
In another aspect, the invention provides a method of treating 11ER2-positive
breast cancer in
a patient comprising administering Perruzumab, Trastuzumab, and aromatase
inhibitor (e.g.
anastrazole or letrozole) to the patient. According to this embodiment, the
breast cancer is advanced
breast cancer, including hormone receptor-positive breast cancer such as
estrogen receptor (ER)-
positive and/or progesterone receptor (PgR)-positive breast cancer.
Optionally, the patient has not
previously received systemic nonhormonal anticancer therapy in the metastatic
setting. This
treatment method optionally further comprises administering induction
chemotherapy (e.g.
comprising taxane) to the patient.
Therapy in accordance with the present invention extends progression-free
survival (PFS)
and/or overall survival (OS) of the patient treated.
The antibodies and chemotherapeutic treatments are administered to a human
patient in
accord with known methods. Specific administration schedules and formulations
are described in the
CA 02788253 2012-08-29
PR4753-4
examples herein.
According to one embodiment, Pertuzumab is administered at a dose that
produces a steady-
state Cnin of 20 p,g/mL in 90% of patients receiving Pertuzumab and
Trastuzumab.
According to one particular embodiment of the invention, a Pertuzumab of
approximately
840mg (loading dose) is administered, followed by one or more doses of
approximately 420mg
(maintenance dose(s)) of the antibody. The maintenance doses are preferably
administered about
every 3 weeks, for a total of at least two doses, until clinical progressive
disease, or unmanageable
toxicity, preferably up to about 6, or 7, or 8, or 9, or 10, or 11, or 12, or
13, or 14, or 15, or 16, or 17
or more doses. Longer treatment periods, including more treatment cycles, are
also contemplated.
1 10 According to another particular embodiment, Pertuzumab is
administered at a dose of 840
mg for all treatment cycles.
Trastuzumab typically is administered as an intravenous loading dose of about
8 mg/kg,
followed by the administration of 6 mg/kg doses in subsequent cycles.
Trastuzumab is typically
administered every 3 weeks until clinical progressive disease or unmanageable
toxicity, preferably up
to about 17 or more doses.
In a particular embodiment, Trastuzumab is administered as an intravenous (IV)
infusion on
Day 1 of each treatment cycle until investigator-assessed disease progression
or unmanageable
toxicity, at a loading dose of 8 mg/kg for Cycle 1 and a dose of 6 mg/kg for
subsequent cycles.
In another particular embodiment, Pertuzumab is administered as an IV infusion
on Day 1 of
each cycle, for a total of six cycles or until investigator assessed disease
progression or unmanageable
toxicity, whichever occurs first, either at a loading dose of 840 mg for Cycle
1 and a dose of 420 mg
for the subsequent cycles, or a loading dose of 840 mg for Cycle 1 and a dose
of 840 mg for the
subsequent cycles.
For treating gastric cancer, Cisplatin 80 mg/m2 is typically administered as
an IV infusion on
Day 1 of each cycle, for a total of at least six cycles.
For treating gastric cancer, Capecitabine 1000 mg/m2 is typically administered
orally twice
daily, from the evening of Day 1 to the morning of Day 15 of each cycle, for a
total of at least six
= cycles. Capecitabine administration may be prolonged at the discretion of
the attending clinician
after careful risk¨benefit assessment for individual patients.
Dosages and schedules for chemotherapy used to treat HER2-positive breast
cancer are
disclosed in the examples below, but other dosages and schedules are known and
contemplated
according to the invention herein.
VI. Articles of Manufacture
One embodiment of an article of manufacture herein comprises an intravenous
(IV) bag
containing a stable mixture of Pertuzumab and Trastuzumab suitable for
administration to a cancer
patient. Optionally, the mixture is in saline solution; for example comprising
about 0.9% NaC1 or
about 0.45% NaCI. An exemplary IV bag is a polyolefin or polyvinyl chloride
infusion bag, e.g. a
36
250m1., IV bag. Aceording to one embodiment of the invention, the mixture
includes about 420ing or
about giffirrig of Pertuzumab and from about 200nig to about 1000mg of
Tra,stuzurbab (e,g, from
about 400mg to about 900rng of Trastuantab).
Optionally, the mixture in the IV bag is stable for up to 24 hours at 5 C or
305C. Stability of
the mixture can bc evaluated by one or more assays selected from the group
consisting of; color,
appearance and clarity (CAC), concentration and turbidity analysis,
particulate analysis, size
exclusion chromatography (sEq, ion-exchange.chrentatography (lEC), capillary
zone
electrophoresis (CZE), image capillary isoelectric focusing (iCIEF), and
potency assay
In an alternative embodiment, the invention provides an article of manufacture
comprising a
vial with Fel-rim:mat) therein and a package insert, wherein the package
insert provides the safety
data in Table 3 or Table 4 and/or the efficacy data in Table 2, Table 5,
Figure 8, or Figure 10.
Optionally, the vial is a single-dose vial containing about 420mg of
Pertuzumab. In one embodiment,
the vial is provided inside a cardboard carton.
In a related aspect, the invention concerns a Method of snaking an article of
manufacture
' 15 comprising packaging together 4 vial with Pertummab therein and
a
package
insert,. wherein the
package insert provides the safety data in Table 3 or Table 4 and/or the
efficacy data in Table 2,
Table 5, Figure 8, or Figure 10.
In a further related aspect, the invention provides a method of ensuring safe
and effective use
of Pertuzutriab comprising packaging together a vial with Pertuzumab therein
and a package insert,
wherein the package insert, provides the safety data in Table 3 or Table 4
and/or the efficacy data in
Table 2, Table 5, Figure 8, or Figure 10.
VII. Deposit of Biological Materials
The following hybridoma cell lines have been deposited with the American Type
Culture
Collection, 10801 University Boulevard, Manassas, VA 20110-2209, LISA (ATCC):
Antibody Dcaignation ATCC No. Deposit Date
405 ATCC CRL 10463 May 24, 1990
2C4 ATCC HB-12697 April 8, 1999
Further details of the invention are illustrated by the following non-limiting
Examples.
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EXAMPLE 1
Phase Ha Study Evaluating Pertuzumab in Combination with Trastuzumab and
Chemotherapy in Patients with HER2-Positive Advanced Gastric Cancer
Despite a sharp worldwide decline in incidence and a reduction in mortality
during the
second half of the twentieth century, gastric cancer remains the world's
second leading cause of
cancer mortality, after lung cancer (Parkin, D. Oncogene 23:6329-40 (2004)).
The incidence of
gastric cancer varies widely according to geographic region (Kelley et al. J
Gan Epidemiol 56:1-9
(2003); Plummer et al. Epidemiology of gastric cancer. In: Butlet et al.,
editors. Mechanisms of
carcinogenesis: contribution of molecular epidemiology. Lyon: IARC Scientific
Publications No 157,
IARC (2004)). In Japan, Korea, China, and certain countries in Central and
South America, the
incidence is 20 to 95 cases per 100,000 men. In contrast, in the United
States, India, and Thailand,
the incidence is 4 to 8 cases per 100,000 men. The incidence in Western Europe
ranges from 37
cases per 100,000 men in parts of Italy to 12 per 100,000 men in France. The
incidence in women
follows a similar geographic pattern but is about 50% lower than that in men.
There are clear
epidemiological differences between cancer localized to the gastric cardia
(gastroesophageal
junction) and that localized to the rest of the stomach. Cancer of the cardia
accounts for 39% of
gastric cancer cases in white men in the United States but only 4% of gastric
cancers in men in Japan.
For reasons that are not clear, cancer of the gastric cardia and lower
esophagus has increased rapidly
in developed countries since the 1970s.
To date, the only potentially curative treatment for gastric cancer is
surgery. Survival rates
for gastric cancer improved significantly in Japan in recent years as a result
of earlier detection and
better surgical techniques (Inoue et al. Postgrad Med J81:419-24 (2005)).
However, in Western
Europe and North America, gastric cancer is often diagnosed at a late stage
when resection is no
longer possible. Consequently, the overall 5-year survival in these
populations does not exceed 25%
(Ajani, J. The Oncologist 10 Suppl 3:49-58 (2005); Catalano et al. Clin Rev
Oncol/Heinatol 54: 209-
41(2005)).
Regardless of their geographic region, patients with unresectable disease due
to locally
advanced growth or metastatic spread have a poor prognosis, with overall 5-
year survival within the
range of 5%-15% (Cunningham et al., Annals of Oncology 16 Suppl 1:i22-
3(2005)). For patients
with unresectable disease at diagnosis and for patients With recurrent disease
after surgery, the main
therapeutic option is chemotherapy (National Comprehensive Cancer Network.
NCCN clinical
practice guidelines in oncology. Gastric cancer. Version 1. National
Comprehensive Cancer Network,
(2006)). Chemotherapy given with palliative intent has been shown to be
superior to best supportive
care in patients with advanced gastric cancer (Wagner et al. J Clin Oncol
24:2903-9 (2006)).
Study B018255 (ToGA) was a randomized, open-label, multicenter, international,
comparative Phase III trial designed to evaluate the efficacy and safety of
Trastuzumab in
combination with chemotherapy compared with chemotherapy alone as first-line
therapy in patients
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with inoperable, locally advanced or recurrent and/or metastatic HER2-positive
adenocarcinoma of
the stomach or gastroesophageal junction. The primary objective of the study
was to compare overall
survival for patients treated with Trastuzumab combined with fluoropyrimidine
(.5-FU or
capecitabine) plus cisplatin. The results from Study B018255 demonstrated a
significant clinical
benefit when Trastuzumab was used in combination with chemotherapy in patients
with gastric
cancer. Overall survival, the primary endpoint, was significantly improved in
the Trastuzumab plus
chemotherapy arm compared with the chemotherapy alone arm (p = 0.0045, log-
rank test;
hazard ratio, 0.74). The median survival time was 13.8 months in the
Trastuzumab plus
chemotherapy arm and 11.1 months in the chemotherapy alone arm, and the risk
of death was
decreased by 26% for patients in the Trastuzumab plus chemotherapy arm. All
other secondary
endpoints demonstrated clinical significance with similar hazard and odds
ratios. (See, e.g. Bang et
al., Lancet 28; 376(9742):687-97 (2010)).
As a result of this study, Trastuzumab is now indicated, including the EU and
United States,
in combination with cisplatin plus capecitabine or 5-FU, for the treatment of
patients with HER2-
positive metastatic gastric or gastroesophageal junction adenocarcinoma who
have not received prior
treatment for metastatic disease.
At present, there is no single, standard, globally accepted chemotherapeutic
regimen for
advanced gastric cancer. Despite the success of the ToGA trial, there is a
great need for providing
new and effective treatment options for this serious condition. In particular,
there is a need for novel
therapeutic approaches that aim to avoid treatment-related morbidity and/or to
increase survival in
gastric cancer patients. Accordingly, this example is a randomized,
multicenter, open-label study
evaluating two different doses of Pertuzumab in patients with HER2-positive
adenocarcinoma of the
stomach or gastroesophageal junction. Patients are randomized in a 1:1 ratio
to two treatment arms.
Patients in Arm A receive a Pertuzumab loading dose of 840 mg for Cycle 1 and
a dose of 420 mg
for Cycles 2-6, and patients in Arm B receive Pertuzumab 840 mg for all six
cycles. Patients in both
treatment arms receive Trastuzumab, cisplatin, and capecitabine. The length of
the study is
approximately 24 months (4 months for recruitment and 20 months of follow-up
after last patient
recruited). The end of study will be when progressive disease has occurred in
all patients, or all
patients have withdrawn or discontinued from the study, whichever is earlier.
Target population
The trial involves approximately 30 patients.
Patients must meet the following criteria for study entry:
= Histologically confirmed adenocarcinoma of the stomach or
gastroesophageal junction with
inoperable locally advanced or metastatic disease, not amenable to curative
therapy.
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= Patients with advanced disease who present with a recurrence post-
operatively (when intent
of surgery was cure) are also eligible for entry.
= Measurable disease, according to the Response Evaluation Criteria in
Solid Tumors
(RECIST), v1.1, assessed using imaging techniques (computed tomography (CT) or
magnetic
resonance imaging (MRI)), or non-measurable disease that can be followed.
= HER2-positive tumor defined as either INC 3+ or IHC 2+ in combination
with ISH +, as
assessed by central laboratory on primary or metastatic tumor. ISH positivity
is defined as a ratio of
2.0 for the number of HERZ gene copies to the number of signals for CEP17.
= Availability of formalin-fixed paraffin-embedded (FFPE) tissue with at
least 5 mm of
invasive tumor for central confirmation of HER2 eligibility is mandatory.
= Eastern Cooperative Oncology Group (ECOG) Performance Status of 0 or 1.
= Baseline left ventricular ejection fraction (LVEF) 55% (measured by
echocardiogram
(ECHO) or multiple-gated acquisition (MUGA) scan).
= Life expectancy of at least 3 months.
= Male or female.
= Age 18 years.
= Signed informed consent.
= For women of childbearing potential and male participants with partners
of childbearing
potential: agreement to use a highly effective non-hormonal form of
contraception or two effective
forms of non-hormonal contraception by the patient and/or partner.
= Contraception use must continue for the duration of study treatment and
for at least 6 months
after the last dose of study medication.
Patients who meet any of the followinR criteria are excluded from study entry:
= Previous chemotherapy for advanced or metastatic disease, except that
prior adjuvant or
neoadjuvant therapy is allowed if at least 6 months has elapsed between
completion of adjuvant or
neoadjuvant therapy and enrollment in the study.
= Adjuvant or neoadjuvant therapy with a platin is not allowed.
= Lack of physical integrity of the upper gastrointestinal tract or
malabsorption syndrome (e.g.,
patients with partial or total gastrectomy can enter the study, but not those
with a jejunostomy probe).
= Active (significant or uncontrolled) gastrointestinal bleeding.
= Residual relevant toxicity resulting from previous therapy (e.g.,
neurological toxicity of
?..Grade (NCI CTCAE)), with the exception of alopecia.
= Other malignancy within the last 5 years, except for carcinoma in situ of
the cervix, or basal
cell carcinoma.
= Any of the following abnormal laboratory tests immediately prior to
randomization:
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Serum total bilirubin >1.5 times the upper limit of normal (ULN) or, for
patients with known
Gilberts syndrome, serum total bilirubin > 2 x ULN
For patients with no liver and no bone metastases:
AST or ALT >2.5xULN, and alkaline phosphatase (ALP) >2.5xULN
In patients with liver metastases and no bone metastases: AST or ALT >5xULN,
and ALP
>2.5xULN
In patients with liver metastases and bone metastases: AST or ALT >5xULN, and
ALP
>10xULN;
hi patients with bone metastases and no liver metastases: AST or ALT >2.5xULN,
and ALP
>10xULN
Albumin <25 g/L
Creatinine clearance <60 mL/min
Total white blood cell (WBC) count <2500/ L (<2.5x109/L)
Absolute neutrophil count (ANC) <1500/pL (<1.5x109/L)
Platelets <1 00,000/}tL (<100x 109/L)
= Serious cardiac illness or medical conditions including but not confined
to:
history of documented heart failure or systolic dysfunction (LVEF <50%);
high-risk uncontrolled arrhythrnias, such as atrial tachycardia with a heart
rate 1.00/min at
rest;
significant ventricular arrhythmia (ventricular tachycardia) or higher-grade
AV block
(second-degree AV block Type 2 (Mobitz II) or third-degree AV block);
angina pectoris requiring anti-anginal medication;
clinically significant valvular heart disease;
evidence of transmural infarction on ECG; poorly controlled hypertension
(e.g., systolic
.. blood pressure >180 mmHg or diastolic blood pressure >100 mmHg);
dyspnea at rest due to complications of advanced malignancy or other disease,
or requirement
for supportive oxygen therapy;
treatment with chronic or high-dose corticosteroid therapy;
inhaled steroids and short courses of oral steroids for anti-emesis or as an
appetite stimulant
are allowed;
clinically significant hearing abnormality; known dihydropyrimidine
dehydrogenase
deficiency;
history or clinical evidence of brain metastases; serious uncontrolled
systemic intereurrent
illness (e.g., infections or poorly controlled diabetes).
= Pregnant or lactating
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Women of childbearing potential must have a negative serum pregnancy test
within 7 days prior to
randomization, irrespective of the method of contraception used.
= Radiotherapy within 4 weeks prior to start of study treatment, or within
2 weeks prior to start
of study treatment if palliative radiotherapy is given to bone metastastic
site peripherally and patient
recovers from any acute toxicity.
= Major surgery within 4 weeks prior to start of study treatment, without
complete recovery.
= Known active infection with HIV, hepatitis B virus, or hepatitis C virus.
= Known hypersensitivity to any of the study drugs.
= Inability to comply with follow-up testing or procedures, as determined
by the investigator.
Investigational Medical Products: Dose, Route and Regimen
Treatment cycles are 3 weeks in length.
= Trastuzumab is administered as an intravenous (IV) infusion on Day 1 of
each cycle until
investigator-assessed disease progression or unmanageable toxicity, at a
loading dose of 8 mg/kg for
Cycle 1 and a dose of 6 mg/kg for subsequent cycles.
= Pertuzumab is administered as an IV infusion on Day 1 of each cycle, for
a total of six cycles
or until investigator assessed disease progression or unmanageable toxicity,
whichever occurs first, as
follows for each arm:
Arm A: Patients receive Pertuzumab at a loading dose of 840 mg for Cycle I and
a dose of 420 mg
for Cycles 2-6.
Arm B: Patients receive Pertuzumab at 840 mg for Cycles 1-6.
Non-Investigational Medical Products
Treatment cycles are 3 weeks in length.
= Cisplatin 80 mg/m2 is administered as an IV infusion on Day 1 of each
cycle, for a total of
six cycles.
= Capecitabine 1000 mg/m2 is administered orally twice daily, from the
evening of Day 1 to
the morning of Day 15 of each cycle, for a total of six cycles. (Capecitabine
may be prolonged at the
discretion of the investigator after careful risk¨benefit assessment for
individual patients.)
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Formulations
Formulation of Pertuzumab
Each lot of the recombinant antibodies produced for clinical purposes meets
viral safety
requirements and the United States Pharmacopeia and the European Pharmacopoeia
requirements for
sterility. Each lot meets the required specifications for identity, purity,
and potency.
Pertuzumab is provided as a single-use formulation containing 30 mg/mL
Pertuzumab
formulated in 20-mM L-histidine-acetate (pH 6.0), 120-mM sucrose, and 0.02%
polysorbate 20.
Each 20-cc vial (14.0 mL solution per vial) contains approximately 420 mg of
Pertuzumab.
Formulation of Trastuzumab
Investigational Trastuzumab is supplied as a freeze-dried preparation at a
nominal content of
150 mg per vial in most countries (vial size varies by country).
Trastuzumab is formulated in histidine, trehalose, and polysorbate 20. Once
reconstituted,
each solution contains 21 mg/mL of active drug at a pH of approximately 6Ø
Assessments
Efficacy
Investigator-assessed tumor response will be used to summarize best overall
response at the
end of Cycles 3 and 6 fur each tteatinent arm, defined as patients with a
complete or partial response
as determined by RECIST.
Safety
Safety will be assessed through summaries of adverse events, changes in
laboratory test
results, and changes in vital signs.
Pharmacokinetics/ Pharmacodynamics
Minimum (trough) serum concentration (Cmin) for Pertuzumab at Day 43 will be
assessed. In
addition, PK parameters such as CL, Vss, AUC, and half-life will be estimated.
The evaluation of
PK parameters from data collected up to Day 43 will enable modeling and
simulation for an
estimated dose that predicts a steady-state trough of tig/mL in 90% of
patients.
Statistical Analyses
Pharmacokinetic Analyses
Individual and mean serum Pertuzumab concentration¨time data will be tabulated
and plotted
by dose level. The serum pharmacoldnetics of Pertuzumab will be summarized by
estimating total
exposure (area under the curve (AUC)), maximum serum concentration (C,õõõ),
minimum serum
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CA 02788253 2012-08-29
PR4753-4
concentration (C,), time to steady-state C.x and Cmin, total serum clearance,
volume of distribution,
and elimination half-life (t1/2). Estimates for these parameters will be
tabulated and summarized by
descriptive statistics (mean, standard deviation, minimum, and maximum).
Depending on the
observed Pertuzumab serum concentration¨time data, a population PK approach
may be used to
estimate the dose that will achieve the PK target concentrations.
Observed Cmax and C, for Trastuzumab will be tabulated and summarized by
descriptive
statistics for each specified PK sampling timepoint. For all PK analyses,
actual times of sample
collection (rather than scheduled) will be used.
PK parameters (AUC, C, t1/2) of Pertuzumab will be calculated using non-
compartmental
methods, and the systemic clearance will be derived from the plasma
concentrations via standard
methods.
Analysis Populations
Intent-to-Treat Population
All randomized patients who receive at least one dose of study medication will
be included in
the intent-to-treat population (patients will be assigned to treatment groups
as randomized for
= analysis purposes).
Safety Population
All patients who received at least one dose of study medication will be
included in the safety-
evaluable population (patients will be assigned to treatment groups as
treated.)
Sample Size
The purpose of this study is to assess Cõõõ for Pertuzumab at Day 43 in
patients receiving two
different Pertuzumab dose regimens. These data will then be analyzed using a
population PK model
to identify a dose of Pertuzumab that will achieve a PK target steady-state
trough concentration of
20 p,g/mL in approximately 90% of the advanced gastric cancer patients.
Analyses using the
assumption that Pertuzumab behaves similarly to Trastuzumab in advanced
gastric cancer suggest
that with sample size of 15 patients per arm (total of 30 patients in this
study), the dose to achieve the
desired target concentration can be estimated with an acceptable degree of
precision (coefficient of
variation < 15%).
Clinical Results
The clinical results of this phase Ha gastric cancer (GC) study are shown in
Figures 32-37.
Figure 32 shows the samples taken and time points.
Figure 33 shows the demographics of the patient population in the two arms of
the GC study,
treated with 420 mg (Arm A) or 840 mg (Arm B) of pertuzumab.
Figure 34 shows the GC history of the patients in Arms A and B, respectively.
Figure 35 shows the patient disposition in Arms A and B, respectively.
Figure 36 shows the Overall Response Rate in Arms A and B, respectively.
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PR4753-4
Safety Data
Diarrhea was the most common event occurring in 90% of subjects and was
typically Grade
1 and 2 with onset in Cycle 1; no patient discontinued therapy because of
diarrhea.
Grade > 3 adverse events (AEs) (>13%) included diarrhea, stomatitis,
fatigue/asthenia,
decreased appetite, hyponatremia, anemia, and neutopenia. With the exception
of neutropenia and
hyponatremia (higher in Arm A) and decreased appetite (higher in Arm B),
incidence of these events
was similar in the standard and high-dose pertuzumab arms.
Asymptomatic change in ejection fraction (EF), neutropenic fever, rash, and
drug
hypersensitivity reaction were not associated with the higher dose of
pertuzumab.
Serious adverse events (SAEs) occurred in 60% of patients, and incidence was
not associated
with high-dose pertuzumab.
Although more patients withdrew from treatment in Arm B, it is not clear that
this was due to
a higher pertuzumab dose because events peading to treatment discontinuation
were not uniform.
Phannacokinetic (PK) Results
Figure 37 shows the results of pertuzumab Day 42 concentration assessment in
gastric cancer
(GC) (JOSHUA) versus metastatic breast cancer (MBC) (CLEO).
Summary of the results
- Pertuzumab trough concentrations are lower in GC compared to MBC.
= Between cycle concentrations (i.e. day 7, 14) are in-line with expected MBC
concentrations as clearance is linear at these higher concentrations
= Trough levels with the 840/420 mg dose are about 37% lower compared to
the
CLEOPATRA trial (Example 3), likely due to non-linear clearance at lower
concentrations (incomplete receptor saturation)
- 840/840 mg dose in GC provdes trough concentrations similar to 840/420 tog
dose in
MBC.
- Covariates have no impact on PK.
Conclusions
Based on pertuzumab PK in GC, 840/840 mg dose will be used for the treatment
of gastric
cancer. This dose is expected to maintain trough levels above the target of
>20 ug/ruL in 90% of
patients, and provides similar trough levels as those observed in MBC.
EXAMPLE 2
Phase HI Study Evaluating Pertuzumab in Combination with Trastuzumab and
Chemotherapy in Patients with HER2-Positive Advanced Gastric Cancer
This is a Phase III, randomized, open-label, multicenter clinical study
designed to assess the
efficacy of Pert uzumab in combination with Trastuzumab and chemotherapy in
patients with HER2-
positive locally advanced or metastatic gastric cancer.
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Patients in the treatment arm receive Trastuzumab, cisplatin, and capecitabine
and/or 5-
fluorouracil. In the other arm, patients are given either placebo or
Pertuzumab.
Treatment regimens:
Pertuzumab:
840 mg dose for cycles 1-6.
Trastuzumab
8 mg/kg loading dose followed by 6 mg/kg q3w
Capecitabine
1000 mg/m2 bid d1-14 q3w x 6
5-Fluorouracil
800 mg/myclay continuous iv infusion dl -5 q3w x 6
Cisplatin
800 mg/m2q3w x 6
Primary end point:
Overall survival (OS)
Secondary end points:
Progression-free survival (PFS), time to disease progression (TTP), objective
response rate
(ORR), Clinical Benefit Rate, Duration of Response, Qol, safety, pain
intensity, analgesic
consumption, weight change, pharmacokinetics.
Mail patient selection criteria
Inclusion criteria:
= Adenocarcinoma of stomach or GEJ
= Inoperable locally advanced and/or metastatic disease
= Measurable (RECIST), or non-measurable evaluable disease
= IIER2-positive tumor: IHC 2+ or 3+ and/or ISH+
= Adequate organ function and ECOG performance status <
= Written informed consent
Exclusion criteria
= Previous adjuvant chemotherapy within 6 months
= Chemotherapy for advanced disease
= Congestive heart failure or baseline LVEF <50%
= Creatinine clearance <60 mL/min
II is expected that the treatment methods described herein, comprising the
administration of
Pertuzumab, Trastuzurnab and chemotherapy(s), e.g. cisplatin and capecitabine,
will meet the
primary end point (OS). In particular, it is expected that the treatment
methods herein will be
therapeutically effective in the gastric cancer patients treated, for example,
by extending survival,
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CA 02788253 2012-08-29
PR4753-4
including overall survival (OS) and/or progression-free survival (PFS) and/or
time to disease
progression (1TP) and/or objective response rate (ORR) relative to treatment
with Trastuzumab and
chemotherapy only.
EXAMPLE 3
Results of a Phase III, Randomized, Double-Bind, Placebo-Controlled
Registration
Trial to Evaluate the Efficacy and Safety of Placebo + Trastuzumab + Docetaxel
versus
Pertuzumab + Trastuzumab + Docetaxel in Patients with Previously Untreated
11E112-Positive
Metastatic Breast Cancer (CLEOPATRA)
A protocol for evaluating Pertuzumab in HER2-positive metastatic breast cancer
is found at
http://clinicaltrials.govict2/show/NCT00567190 and in US 2009/0137387 as well
as
W02009/154651.
This example concerns the clinical data obtained in the randomized, double-
blind, placebo-
controlled Phase III trial in patients with HER2-positive MBC, who had not
received chemotherapy
or biologic therapy for their metastatic disease. Patients were randomized 1:1
to receive placebo plus
Trastuzumab plus Docetaxcl or Pertuzumab plus Trastuzumab plus Docetaxel. The
primary endpoint
was progression-free survival (PFS), based on tumor assessments. PFS was
defined as the time from
randomization to the first documented radiographic progressive disease (PD)
according to response
evaluation criteria in solid tumors (RECIST) version 1.0 (Therasse et al. J
Nail Cancer Inst 92:205-
16 (2000)) or death from any cause, if within 18 weeks of the patient's last
tumor assessment.
Secondary endpoints included overall survival (OS), PFS by investigator
assessment, objective
response rate (ORR), and safety.
Patients: Eligible patients had centrally confirmed HER2-positive (defined as
immunohistochemistry (IHC) 3+ and/or fluorescence in situ hybridization (FISH)
amplification ratio
22.0) (Carlson et al. J Natl Contpr Cane Netw 4 Suppl 3:S1-22 (2006)), locally
recurrent,
unresectable, or metastatic breast cancer, or de TIOVO Stage IV disease.
Patients were aged 218 years,
had a left ventricular ejection fraction (LVEF) of ..50% at baseline
(determined by echocardiogram
or multiple gated acquisition), and an Eastern Cooperative Oncology Group
performance status
(ECOG PS) of 0 or 1. Patients may have received one hormonal treatment for MBC
prior to
randomization, or neoadjuvant or adjuvant systemic breast cancer therapy
including Trastuzumab
and/or taxanes, provided that they experienced a disease-free interval of 212
months between
completion of neoadjuvant or adjuvant therapy and diagnosis of metastatic
disease. Exclusion criteria
included therapy for MBC (other than described above); central nervous system
metastases; history
of exposure to a cumulative dose of doxorubicin >360 mg/m2 or its equivalent;
history of LVEF
decline to <50% during or after prior Trastuzumab therapy; current
uncontrolled hypertension;
history of impaired cardiac function; impaired bone marrow, renal, or liver
function; current known
infection with HIV, HBV, or HCV; pregnancy; lactation; and refusal to use non-
hormonal
contraception.
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Procedures: Patients received a loading dose of 8 mg/kg Trastuzumab, followed
by a
maintenance dose of 6 mg/kg every 3 weeks until investigator-assessed
radiographic or clinical PD,
or unmanageable toxicity. Docetaxel was administered every 3 weeks at a
starting dose of 75 mg/m2,
escalating to 100 mg/m2 if tolerated. Per protocol, the investigator could
reduce the dose by 25% to
55 mg/m2 or 75 mg/m2 (if the patient had been dose escalated) in order to
manage tolerability. It was
recommended that patients received at least 6 cycles of Docetaxel. Pertuzumab
or placebo was given
at a fixed loading dose of 840 mg, followed by 420 mg every 3 weeks until
investigator-assessed
radiographic or clinical PD, or unmanageable toxicity. In the case of
chemotherapy discontinuation
due to cumulative toxicity, antibody therapy was continued until PD,
unacceptable toxicity, or
withdrawal of consent. All drugs were administered intravenously.
Assessments: PFS was evaluated by standard RECIST-accepted methodology every 9
weeks
by each center and by the IRF until IRF-assessed PD. Assessments of LVEF were
performed at
baseline, every 9 weeks during the treatment period, at treatment
discontinuation, every 6 months in
the first year after treatment discontinuation, then annually for up to 3
years in the follow-up period.
Laboratory parameters and ECOG status were assessed at every cycle. Adverse
events (AEs) were
monitored continuously and graded according to NCI-CTCAE version 3Ø All
cardiac events and
serious adverse events (SAEs) that were ongoing at the time of treatment
discontinuation were
followed until resolution or stabilization up to 1 year after the final dose.
Cardiac events and
treatment-related SAEs with onset post-treatment
RESULTS
Study population: A total of 808 patients were enrolled and randomized to
receive placebo
plus Trastuzumab plus Docetaxel (n = 406) or Pertuzumab plus Trastuzumab plus
Docetaxel (n =
402) (Figure 7). Baseline characteristics were similar between treatment arms
(Table 1).
Table 1: Baseline Characteristics of the Intent-to-Treat Population
Placebo + Pertuzumab +
Trastuzumab + Trastuzumab +
Docetaxel Docetaxel
(n = 406) (n = 402)
Sex, n (%)
Female 404 (99.5) 402 (100.0)
Age, years
Median 54.0 54.0
Range 27-89 22-82
Race, n (%)
Asian 133 (32.8) 128 (31.8)
Black 20(4.9) 10(2.5)
White 235 (57.9) 245 (60.9)
Other* 18(4.4) 19(4.7)
Region, n (%)
Asia 128 (31.5) 125 (31.1)
Europe 152 (37.4) 154 (38.3)
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North America 68 (16.7) 67 (16.7)
South America 58 (14.3) 56 (13.9)
ECOG status, n (%)
0 248 (61.1) 274 (68.2)
1 157 (38.7) 125 (31.1)
>2 1 (0.2) 3 (0.7)
Prior treatment status, n (%)
De novo MBe 214 (52.7) 218 (54.2)
Prior adjuvant or neoadjuvant therapy 192 (47.3) 184 (45.8)
Prior Trastuzumab treatment, n (%) 41 (10.1) 47 (11.7)
Prior anthracycline treatment, n (%) 164 (40.4) 150 (37.3)
Prior taxane treatment, n (%) 94 (23.2) 91 (22.6)
Prior hormone treatment'', n (%) 107 (26.4) 114 (28.4)
Disease type at screening, n (%)
Non-visceral 90 (22.2) 88 (21.9)
Visceral 316 (77.8) 314 (78.1)
Hormone receptor status, n (%)
ER and/or PgR positive 199 (49.0) 189 (47.0)
ER and PgR negative 196 (48.3) 212 (52.7)
Unknown 11(2.7) 1(0.2)
HER2 status IHC, n (%) 405 (100) 401 (100)
0 and 1+ 2(0.5) 4(1.0)
2+ 32(7.9) 47 (11.7)
3+ 371 (91.6) 350 (87.3)
HER2 status FISH, n (%) 387 (100) 385 (100)
Positive 383 (99.0) 384 (99.7)
Negative 4 (1.0) 1(0.3)
*Includes American Indian and Alaska Native
tNo prior chemotherapy or biological therapy
in the neoadjuvant/adjuvant or metastatic setting
Progression-free survival: Treatment with Pertuzumab plus Trastuzumab plus
Docetaxel
significantly improved PFS-IRF, stratified by prior treatment status and
region, compared with
placebo plus Trastuzumab plus Docetaxel (HR = 0.62; 95% CI 0.51 to 0.75; p
<0.0001) (Figure 8).
The median PFS-IVRF was prolonged by 6.1 months from 12.4 months with placebo
plus
Trastuzumab plus Docetaxel to 18.5 months with Pertuzumab plus Trastuzumab
plus Docetaxel. The
PFS benefit of Pertuzumab plus Trastuzumab plus Docetaxel treatment was
observed across all
predefined subgroups (Figure 9).
Assessment of PFS by investigators closely matched PFS-IRF. Median PFS
assessed by
investigators was 12.4 months with placebo plus Trastuzumab plus Docetaxel and
18.5 months with
Pertuzumab plus Trastuzumab plus Docetaxel (HR = 0.65; 95% CI 0.54 to 0.78; p
<0.0001).
Key secondary efficacy endpoints: The interim analysis of OS took place when
43% of
events (n = 165) that are planned for final OS analysis had occurred. More
deaths occurred in the
placebo plus Trastuzumab plus Docetaxel arm (n = 96; 23.6%) than in the
Pertuzumab plus
Trastuzumab plus Docetaxel arm (n = 69; 17.2%) (Figure 10). The HR (0.64; 95%
CI 0.47 to 0.88; p
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= 0.0053) for OS did not meet the O'Brien-Fleming stopping boundary of the Lan-
DeMets a-
spending function for this interim analysis of survival (HR <0.603, p
<0.0012), and therefore, was not
statistically significant. However, the data showed a strong trend suggestive
of a survival benefit in
favor of Pertuzumab plus Trastuzumab plus Docetaxel. At the time of data cut-
off, patients in both
treatments arms had been followed for OS for a median of 19.3 months (Kaplan-
Meier estimate).
The ORR was 69.3% and 80.2% in the placebo plus Trastuzumab plus Docetaxel arm
and
Pertuzumab plus Trastuzumab plus Docetaxel arm, respectively The difference in
response rates
between treatment arms was 10.8% (95% CI 4.2 to 17.5; p = 0.0011) (Table 2).
Table 2: Overall Response Rate
Placebo + Pertuzumab +
Trastuzumab + Trastuzumab +
Docetaxel Docetaxel
Patients with IRF-assessed measurable disease 336 (100) 343 (100)
at baseline, n (%)
Objective response rate 233 (69.3) 275 (80.2)
Complete response rate 14 (4.2) 19 (5.5)
Partial response rate 219 (65.2) 256 (74.6)
Stable disease 70 (20.8) 50 (14.6)
Progressive disease 28 (8.3) 13 (3.8)
Unable to assess 2 (0.6) 2 (0.6)
No response assessment 3 (0.9) 3 (0.9)
IRF, independent review facility
Treatment exposure: The median number of cycles administered per patient was
15 and 18
with median time on treatment estimated to be 11.8 and 18.1 months for placebo
plus Trastuzumab
plus Docetaxel and for Pertuzumab plus Trastuzumab plus Docetaxel,
respectively. Dose reductions
were not permitted for placebo, Pertuzumab, or Trastuzumab. Patients received
a median of eight
cycles of Docetaxel in each arm. Based on the safety population, 61(15.4%)
patients in the placebo
plus Trastuzumab plus Docetaxel arm received Docetaxel dose escalation to 100
mg/m2 at any cycle
compared with 48 (11.8%) patients in the Pertuzumab plus Trastuzumab plus
Docetaxel arm. The
median Docetaxel dose intensity was 24.8 mg/m2/week in the placebo plus
Trastuzumab plus
Docetaxel arm and 24.6 mg,/m2/week in the Pertuzumab plus Trastuzumab plus
Docetaxel arm.
Reasons for permanent discontinuation of all study treatment are presented in
Figure 7.
Tolerability and cardiac safety: The AE profile during the treatment period
was generally
balanced between treatment arms (Table 3). The incidence of the following AEs
(all grades) was
>5% higher with Pertuzumab plus Trastuzumab plus Docetaxel: diarrhea, rash,
mucosal
inflammation, febrile neutropenia, and dry skin.
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Table 3: Adverse Events (All Grades) with 2:25% Incidence in Either Arm or
2:5% Difference
Between Arms and Grade 2:3 Adverse Events with ?2% Incidence in the Safety
Population
Placebo + Pertuzimmb +
Trastuzumab + Trastuzumab +
Docetaxel Docetaxel
(n = 397) (n = 407)
Most common AEs (all grades), n (%)
Diarrhea 184 (46.3) 272 (66.8)
Alopecia 240 (60.5) 248 (60.9)
Neutropenia 197 (49.6) 215 (52.8)
Nausea 165 (41.6) 172 (42.3)
Fatigue 146 (36.8) 153 (37.6)
Rash 96 (24.2) 137 (33.7)
Decreased appetite 105 (26.4) 119 (29.2)
Mucosal inflammation 79 (19.9) 113 (27.8)
Asthenia 120 (30.2) 106 (26.0)
Edema peripheral 119 (30.0) 94 (23.1)
Constipation 99 (24.9) 61 (15.0)
Febrile neutropenia 30 (7.6) 56 (13.8)
Dry skin 17 (4.3) 43 (10.6)
Grade 2:3 AEs with an incidence rate 2:2%, n (%)
Neutropenia 182 (45.8) 199 (48.9)
Febrile neutropenia 30 (7.6) 56 (13.8)
Leukopenia 58 (14.6) 50 (12.3)
Diarrhea 20 (5.0) 32 (7.9)
Neuropathy peripheral 7 (1.8) 11(2.7)
Anemia 14(3.5) 10(2.5)
Asthenia 6(1,5) 10(2.5)
Fatigue 13 (3.3) 9 (2.2)
Granulocytopenia 9 (2.3) 6 (1.5)
Left ventricular systolic dysfunction 11(2.8) 5 (1.2)
Dyspnea 8(2.0) 4(1.0)
AE, adverse event
The incidence of the following grade 2:3 AEs was >2% higher with Pertuzumab
plus
Trastuzumab plus Docetaxel: neutropenia, febrile neutropenia, and diarrhea
(Table 3). The incidence
of grade 2:3 febrile neutropenia in patients from Asia was 12% in the placebo
plus Trastuzumab plus
Docetaxel arm and 26% in the Pertuzumab plus Trastuzumab plus Docetaxel arm;
in all other
geographical regions the incidence was <10% in both arms.
LVSD (all grades) was reported more frequently in the placebo plus Trastuzumab
plus
Docetaxel arm compared with the Pertuzumab plus Trastuzumab plus Docetaxel arm
(8.3% and
4.4%, respectively). Grade 2:3 LVSD was reported in 2.8% of patients receiving
placebo plus
Trastuzumab plus Docetaxel and in 1.2% of patients receiving Pertuzumab plus
Trastuzumab plus
Docetaxel. Among patients with a post-baseline LVEF assessment, LVEF declines
of 2:10 percentage
points from baseline to <50% at any stage during treatment were reported in
6.6% and 3.8% of
patients in the placebo plus Trastuzumab plus Docetaxel arm and Pertuzumab
plus Trastuzumab plus
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Docetaxel arm, respectively.
In the safety population, the majority of deaths in both treatment arms were
attributed to PD
(81 (20.4%) in the placebo arm, 57 (14.0%) in the Pertuzumab arm). Deaths due
to causes other than
PD were generally balanced and a similar number of patients died due to AEs
(10 (2.5%) in the
placebo arm, 8 (2.0%) in the Pertuzumab arm), with infections being the most
common cause of
death due to an AE.
DISCUSSION
These data show that the combination of the anti-HER2 monoclonal antibodies
Pertuzumab
and Trastuzumab with Docetaxel prolongs PFS in patients with HER2-positive MBC
in the first-line
setting. Treatment with Pertuzumab plus Trastuzumab plus Docetaxel exceeded
expectations by
resulting in a statistically significant reduction in PFS risk (HR = 0.62) and
an improvement in
median PFS of 6.1 months.
The combination was well tolerated and Pertuzumab did not increase rates of
symptomatic or
asymptomatic cardiac dysfunction. Before the data herein, it was expected that
treatment with two
HER2 antibodies would exacerbate cardiac toxicity. However, these data show
this was not the case
based on the tests herein for evaluating cardiac toxicity: incidence of
symptomatic left ventricular
systolic dysfunction (LVSD) including congestive heart failure (CHF), decrease
in left ventricular
ejection fraction (LVEF).
Pertuzumab-related AEs, including skin rash, mucosal inflammation, and dry
skin, were
mostly mild. There was an increased rate of grade >3 diarrhea and febrile
neutropenia with
Pertuzumab plus Trastuzumab plus Docetaxel treatment. The control arm in
CLEOPATRA had a
similar PFS to previous randomized studies that showed that the combination of
Trastuzumab and
Docetaxel in HER2-positive MBC had a median PFS of 11.7 months Marty et al. J
Clin Oncol
23:4265-74 (2005).
Without being bound by any one theory, these data indicate that targeting HER2-
positive
tumors with two anti-HER2 monoclonal antibodies with complementary mechanisms
of action
results in a more comprehensive blockade of HER2 and highlight the clinical
importance of
preventing the ligand-dependent formation HER2 dimers to optimally silence
HER2 signaling. This
study has shown that combined HER2 blockade with Trastuzumab and Pertuzumab
improves the
outcome of patients with advanced HER2-positivedisease in the first-line
setting. These data are
significant in that they support the first approved use of a HER2 dimerization
inhibitor for therapy of
HER2-positive cancer patients.
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EXAMPLE 4
Article of Manufacture Including Pertuzumab
The phase HI clinical data in Example 3 were used in the development of an
article of
manufacture comprising a vial (e.g. single-dose vial) with Pertuzumab therein
and a package insert
providing information about the safety and/or efficacy thereof, as well as a
method of making an
article of manufacture comprising packaging together Pertuzumab in a vial
(e.g. single-dose vial) and
a package insert with prescribing information regarding Pertuzumab on a
package insert as herein
below.
Pertuzumab is a sterile, clear to slightly opalescent, colorless to pale
yellow liquid for IV
infusion. Each single use vial contains 420 mg of Pertuzumab at a
concentration of 30 mg/mL in 20
niM L-histidine acetate (pH 6.0), 120 mM sucrose and 0.02% polysorbate 20.
Pertuzumab is supplied in a single-dose vial containing preservative free
liquid concentrate,
at a concentration of 30 mg/mL ready for infusion. Each vial of Pertuzumab
drug product contains a
total of 420 mg Pertuzumab. Store vials in a refrigerator at 2 C to 8 C (36 F
to 46 F) until time of
use. Keep vial in the outer carton in order to protect from light.
FULL PRESCRIBING INFORMATION
WARNING: EMBRYO-FETAL TOXICITY
Exposure to PERTUZUMAB can result in embryo-fetal death and birth defects.
Studies in animals have resulted in oligohydramnios, delayed renal
development, and death.
Advise patients of these risks and the need for effective contraception. (5.1,
8.1, 8.6)
1 INDICATIONS AND USAGE
Pertuzumab is indicated for use in combination with trastuzumab and docetaxel
for the
treatment of patients with HER2-positive metastatic breast cancer who have not
received prior anti-
HER2 therapy or chemotherapy for metastatic disease.
2 DOSAGE AND ADMINISTRATION
2.1 Recommended Doses and Schedules
The initial dose of Pertuzumab is 840 mg administered as a 60-minute
intravenous infusion,
followed every 3 weeks thereafter by a dose of 420 mg administered as an
intravenous infusion over
to 60 minutes. When administered with Pertuzumab, the recommended initial dose
of trastuzumab
25 is 8 mg/kg administered as a 90-minute intravenous infusion, followed
every 3 weeks thereafter by a
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dose of 6 mg/kg administered as an intravenous infusion over 30 to 90 minutes.
When administered
with Pertuzumab, the recommended initial dose of docetaxel is 75 mg/m2
administered as an
intravenous infusion. The dose may be escalated to 100 mg/m2 administered
every 3 weeks if the
initial dose is well tolerated.
2.2 Dose Modification
For delayed or missed doses, if the time between two sequential infusions is
less than
6 weeks, the 420 mg dose of Pertuzumab should be administered. Do not wait
until the next planned
dose. If the time between two sequential infusions is 6 weeks or more, the
initial dose of 840 mg
Pertuzumab should be re-administered as a 60-minute intravenous infusion
followed every 3 weeks
thereafter by a dose of 420 mg administered as an intravenous infusion over 30
to 60 minutes. The
infusion rate of Pertuzumab may be slowed or interrupted if the patient
develops an
infusion-associated reaction. The infusion should be discontinued immediately
if the patient
experiences a serious hypersensitivity reaction [see Warnings and Precautions
(5.2)].
Left Ventricular Ejection Fraction (LVEF):
Withhold Pertuzumab and trastuzumab dosing for at least 3 weeks for either:
= a drop in LVEF to less than 40% or
= LVEF of 40% to 45% with a 10% or greater absolute decrease below
pretreatment values
[see Warnings and Precautions (5.2)]
Pertuzumab may be resumed if the LVEF has recovered to greater than 45% or to
40% to 45% associated with less than a 10% absolute decrease below
pretreatment values.
If after a repeat assessment within approximately 3 weeks, the LVEF has not
improved, or
has declined further, discontinuation of Pertuzumab and trastuzumab should be
strongly
considered, unless the benefits for the individual patient are deemed to
outweigh the risks [see
Warnings and Precautions (5.2)]. Pertuzumab should be withheld or discontinued
if trastuzumab
treatment is withheld or discontinued. If docetaxel is discontinued, treatment
with Pertuzumab
and trastuzumab may continue. Dose reductions are not recommended for
Pertuzumab. For
docetaxel dose modifications, see docetaxel prescribing information.
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2.3 Preparation for Administration
Administer as an intravenous infusion only. Do not administer as an
intravenous push or
bolus. Do not mix Pertuzumab with other drugs,
Preparation: Prepare the solution for infusion, using aseptic technique, as
follows:
= Parenteral drug products should be inspected visually for particulates
and discoloration
prior to administration.
= Withdraw the appropriate volume of Pertuzumab solution from the vial(s).
= Dilute into a 250 mL 0.9% sodium chloride PVC or non-PVC polyolefin
infusion bag.
= Mix diluted solution by gentle inversion. Do not shake.
= Administer immediately once prepared.
= If the diluted infusion solution is not used immediately, it can be
stored at 2oC to 8oC for
up to 24 hours.
= Dilute with 0.9% Sodium Chloride injection only. Do not use dextrose (5%)
solution.
3 Dosage Forms and Strengths
Pertuzumab 420 mg/14 mL (30 mg/mL) in a single-use vial
4 Contraindications
None
5 Warnings and Precautions
5.1 Embryo-Fetal Toxicity
Pertuzumab can cause fetal harm when administered to a pregnant woman.
Treatment of
pregnant cynomolgus monkeys with pertuzumab resulted in oligohydramnios,
delayed fetal kidney
development, and embryo-fetal death. If Pertuzumab is administered during
pregnancy, or if the
patient becomes pregnant while receiving this drug, the patient should be
apprised of the potential
hazard to a fetus [see Use in Specific Populations (8.1)]. Verify pregnancy
status prior to the
initiation of Pertuzumab. Advise patients of the risks of embryo-fetal death
and birth defects and the
need for contraception during and after treatment. Advise patients to contact
their healthcare
provider immediately if they suspect they may be pregnant. If Pertuzumab is
administered during
pregnancy or if a patient becomes pregnant while receiving Pertuzumab,
immediately report exposure
to the Genentech Adverse Event Line at 1-888-835-2555. Encourage women who may
be exposed
during pregnancy to enroll in the MotHER Pregnancy Registry by contacting 1-
800-690-6720 [see
Patient Counseling Information (17)]. Monitor patients who become pregnant
during Pertuzumab
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therapy for oligohydramnios. If oligohydramnios occurs, perform fetal testing
that is appropriate for
gestational age and consistent with community standards of care. The efficacy
of intravenous
hydration in the management of oligohydramnios due to Pertuzumab exposure is
not known.
5.2 Left Ventricular Dysfunction
Decreases in LVEF have been reported with drugs that block HER2 activity,
including
Pertuzumab. In the randomized trial, Pertuzumab in combination with
trastuzumab and docetaxel
was not associated with increases in the incidence of symptomatic left
ventricular systolic
dysfunction (LVSD) or decreases in LVEF compared with placebo in combination
with trastuzumab
and docetaxel [see Clinical Studies (14.1)]. Left ventricular dysfunction
occurred in 4.4% of patients
in the Pertuzumab-treated group and 8,3% of patients in the placebo-treated
group. Symptomatic left
ventricular systolic dysfunction (congestive heart failure) occurred in 1.0%
of patients in the
Pertuzumab-treated group and 1.8% of patients in the placebo-treated group
[see Adverse Reactions
(6.1)] Patients who have received prior anthracyclines or prior radiotherapy
to the chest area may be
at higher risk of decreased LVEF. Pertuzumab has not been studied in patients
with a pretreatment
LVEF value of 50%, a prior history of CHF, decreases in LVEF to <50% during
prior trastuzumab
therapy, or conditions that could impair left ventricular function such as
uncontrolled hypertension,
recent myocardial infarction, serious cardiac arrhythmia requiring treatment
or a cumulative prior
anthracycline exposure to > 360 mg/m2 of doxorubicin or its equivalent. Assess
LVEF prior to
initiation of Pertuzumab and at regular intervals (e.g., every three months)
during treatment to ensure
that LVEF is within the institution's normal limits. If LVEF is <40%, or is
40% to 45% with a 10%
or greater absolute decrease below the pretreatment value, withhold Pertuzumab
and trastuzumab and
repeat LVEF assessment within approximately 3 weeks. Discontinue Pertuzumab
and trastuzumab if
the LVEF has not improved or has declined further, unless the benefits for the
individual patient
outweigh the risks [see Dosage and Administration (2.2)].
5.3 Infusion-Associated Reactions, Hypersensitivity Reactions/Anaphylaxis
Pertuzumab has been associated with infusion and hypersensitivity reactions
[see Adverse
Reactions (6.1)]. An infusion reaction was defined in the randomized trial as
any event described as
hypersensitivity, anaphylactic reaction, acute infusion reaction or cytokine
release syndrome
occurring during an infusion or on the same day as the infusion. The initial
dose of Pertuzumab was
given the day before trastuzumab and docetaxel to allow for the examination of
Pertuzumab-
associated reactions. On the first day, when only Pertuzumab was administered,
the overall
frequency of infusion reactions was 13.0% in the Pertuzumab-treated group and
9.8% in the placebo-
treated group. Less than 1% were grade 3 or 4. The most common infusion
reactions 1.0%) were
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pyrexia, chills, fatigue, headache, asthenia, hypersensitivity, and vomiting.
During the second cycle
when all drugs were administered on the same day, the most common infusion
reactions in the
Pertuzumab-treated group 1.0%) were fatigue, dysgeusia, hypersensitivity,
myalgia, and vomiting.
In the randomized trial, the overall frequency of hypersensitivity/anaphylaxis
reactions was 10.8% in
.. the Pertuzumab-treated group and 9.1% in the placebo-treated group. The
incidence of Grade 3 ¨ 4
hypersensitivity/anaphylaxis reactions was 2% in the Pertuzumab-treated group
and 2.5% in the
placebo-treated group according to National Cancer Institute ¨ Common
Terminology Criteria for
Adverse Events (NCI - CTCAE) (version 3). Overall, 4 patients in Pertuzumab-
treated group and
2 patients in the placebo-treated group experienced anaphylaxis. Observe
patients closely for
60 minutes after the first infusion and for 30 minutes after subsequent
infusions of Pertuzumab. If a
significant infusion-associated reaction occurs, slow or interrupt the
infusion and administer
appropriate medical therapies. Monitor patients carefully until complete
resolution of signs and
symptoms. Consider permanent discontinuation in patients with severe infusion
reactions [see
Dosage and Administration (2.2)],
5.4 HER2 Testing
Detection of HER2 protein overexpression is necessary for selection of
patients appropriate
for Pertuzumab therapy because these are the only patients studied and for
whom benefit has been
shown [see Indications and Usage ( I) and Clinical Studies (14)]. In the
randomized trial, patients
with breast cancer were required to have evidence of HER2 overexpression
defined as 3+ IHC by
Dako HERCEPTEST or FISH amplification ratio 2.0 by Dako HER2 FISH PHARMDXTm
test
kit. Only limited data were available for patients whose breast cancer was
positive by FISH, but did
not demonstrate protein overexpression by IHC. Assessment of HER2 status
should be performed by
laboratories with demonstrated proficiency in the specific technology being
utilized. Improper assay
performance, including use of sub-optimally fixed tissue, failure to utilize
specified reagents,
deviation from specific assay instructions, and failure to include appropriate
controls for assay
validation, can lead to unreliable results.
6 Adverse Reactions
The following adverse reactions are discussed in greater detail in other
sections of the label:
= Embryo-Fetal Toxicity [see Warnings and Precautions (5.1)]
= Left Ventricular Dysfunction [see Warnings and Precautions (5.2)]
= Infusion-Associated Reactions, Hypersensitivity Reactions/Anaphylaxis
[see Warnings and
Precautions (5.3)]
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6.1 Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse
reaction rates
observed in the clinical trials of a drug cannot be directly compared to rates
in the clinical trials of
another drug and may not reflect the rates observed in clinical practice. In
clinical trials, Pertuzumab
has been evaluated in more than 1400 patients with various malignancies and
treatment with
Pertuzumab was predominantly in combination with other anti-neoplastic agents.
The adverse reactions described in Table 4 were identified in 804 patients
with HER2-
1
positive metastatic breast cancer treated in the randomized trial. Patients
were randomized to receive
either Pertuzumab in combination with trastuzumab and docetaxel or placebo in
combination with
trastuzumab and docetaxel. The median duration of study treatment was 18.1
months for patients in
the Pertuzumab-treated group and 11.8 months for patients in the placebo-
treated group. No dose
adjustment was permitted for Pertuzumab or trastuzumab. The rates of adverse
events resulting in
permanent discontinuation of all study therapy were 6.1% for patients in the
Pertuzumab-treated
group and 5.3% for patients in the placebo-treated group. Adverse events led
to discontinuation of
=
docetaxel alone in 23.6% of patients in the Pertuzumab-treated group and 23.2%
of patients in the
placebo-treated group. Table 4 reports the adverse reactions that occurred in
at least 10% of patients
in the Pertuzumab-treated group. The most common adverse reactions (>30%) seen
with Pertuzumab
in combination with trastuzumab and docetaxel were diarrhea, alopecia,
neutropenia, nausea, fatigue,
rash, and peripheral neuropathy.
The most common NCI - CTCAE (version 3) Grade 3 ¨4 adverse reactions (>2%)
were
neutropenia, febrile neutropenia, leukopenia, diarrhea, peripheral neuropathy,
anemia, asthenia, and
fatigue. An increased incidence of febrile neutropenia was observed for Asian
patients in both
treatment arms compared with patients of other races and from other geographic
regions. Among
Asian patients, the incidence of febrile neutropenia was higher in the
pertuzumab-treated group
(26%) compared with the placebo-treated group (12%).
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Table 4 Summary of Adverse Reactions Occurring in 10% of
Patients on the
Pertuzumab Treatment Arm in the Randomized Trial
Body System/Adverse Pertuzumab Placebo
Reactions + trastuzumab +
trastuzumab
+ docetaxel + docetaxel
n=407 n=397
Frequency rate % Frequency rate %
All Grades All Grades
Grades 3-4 Grades 3-4
% % % %
General disorders and
administration site
conditions
Fatigue 37.6 12 36.8 3.3
Asthenia 26.0 2.5 30.2 1.5
Edema peripheral 23.1 0.5 30.0 0.8
, Mucosal inflammation 27.8 __ 1.5 19.9 1.0
, _
1 Pyrexia 18.7 1.2 17.9 0.5
, Skin and subcutaneous
tissue disorders
Alopecia 60.9 0.0 60.5 0.3
Rash 33.7 0.7 24.2 0.8
Nail disorder 22.9 1.2 22.9 0.3
Pruritus 14.0 0.0 10.1 0.0
Dry skin 10.6 0.0 4.3 0.0
Gastrointestinal
disorders
Diarrhea 66.8 7.9 46.3 5.0
Nausea 42.3 1.2 41.6 0.5
Vomiting 24.1 1.5 23.9 1.5
_Constipation 15.0 0.0 24.9 1.0
Stomatitis 18.9 0.5 15.4 0.3
_
Blood and lymphatic
i system disorders
Neutropenia 52.8 48.9 49.6 45.8
, Anemia 23.1 2.5 18.9 3.5
Leukopenia 18.2 12.3 20.4 14.6
Febrile neutropenia* 13.8 13.0 7.6 7.3
Nervous system
disorders
Neuropathy peripheral 32.4 3.2 33.8 2.0
Headache 20.9 1.2 16.9 0.5
Dysgeusia 18.4 0.0 15.6 0.0
Dizziness 12.5 0.5 12.1 0.0
Musculoskeletal and
connective tissue
disorders
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Myalgia 22.9 1.0 23.9 0.8
Arthralgia 15.5 0.2 16.1 0.8
Infections and
infestations
Upper respiratory tract 16.7 0.7 13.4 0.0
infection
Nasopharyngitis 11.8 0.0 12.8 0.3
Respiratory, thoracic
and mediastinal
disorders
Dyspnea 14.0 1.0 15.6 I 2.0
Metabolism and
nutrition disorders
Decreased appetite 29.2 1.7 26.4 1.5
Eye disorders
Lacrimation increased 14.0 0.0 13.9 0.0
Psychiatric disorders
Insomnia 13.3 0.0 13.4 I 0.0
* In this table this denotes an adverse reaction that has been reported in
association with a fatal
outcome
The following clinically relevant adverse reactions were reported in < 10% of
patients
in the Pertuzumab-treated group:
Skin and subcutaneous tissue disorders: Paronychia (7.1% in the Pertuzumab-
treated group vs.
3.5% in the placebo-treated group); Respiratory, thoracic and mediastinal
disorders: Pleural
effusion (5.2% in the Pertuzumab-treated group vs. 5.8% in the placebo-treated
group); Cardiac
disorders: Left ventricular dysfunction (4.4% in the Pertuzumab-treated group
vs. 8.3% in the
placebo-treated group) including symptomatic left ventricular systolic
dysfunction (CHF) (1.0% in
the Pertuzumab-treated group vs. 1.8% in the placebo-treated group); Immune
system disorders:
Hypersensitivity (10.1% in the Pertuzumab-treated group vs. 8.6% in placebo-
treated group).
Adverse Reactions Reported in Patients Receiving Pertuzumab and Trastuzumab
after
Discontinuation of Docetaxel
In the randomized trial, adverse reactions were reported less frequently after
discontinuation
of docetaxel treatment. All adverse reactions in the Pertuzumab and
trastuzumab treatment group
occurred in < 10% of patients with the exception of diarrhea (19.1%), upper
respiratory tract
infection (12.8%), rash (11.7%), headache (11.4%), and fatigue (11.1%).
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6.2 Immunogenicity
As with all therapeutic proteins, there is the potential for an immune
response to Pertuzumab.
Patients in the randomized trial were tested at multiple time-points for
antibodies to Pertuzumab.
Approximately 2.8% (11/386) of patients in the Pertuzumab-treated group and
6.2% (23/372) of
patients in the placebo-treated group tested positive for anti-Pertuzumab
antibodies. Of these
34 patients, none experienced anaphylactic/hypersensitivity reactions that
were clearly related to the
anti-therapeutic antibodies (ATA). The presence of pertuzumab in patient serum
at the levels
expected at the time of ATA sampling can interfere with the ability of this
assay to detect anti-
pertuzumab antibodies. In addition, the assay may be detecting antibodies to
trastuzumab. As a
result, data may not accurately reflect the true incidence of anti-pertuzumab
antibody development.
Immunogenicity data are highly dependent on the sensitivity and specificity of
the test methods used.
Additionally, the observed incidence of a positive result in a test method may
be influenced by
several factors, including sample handling, timing of sample collection, drug
interference,
concomitant medication, and the underlying disease. For these reasons,
comparison of the incidence
=
of antibodies to Pertuzumab with the incidence of antibodies to other products
may be misleading.
7 Drug Interactions
No drug-drug interactions were observed between pertuzumab and trastuzumab, or
between
pertuzumab and docetaxel.
8 Use in Specific Populations
8.1 Pregnancy
Pregnancy Category D
Risk Summary
There are no adequate and well-controlled studies of Pertuzumab in pregnant
women. Based
on findings in animal studies, Pertuzumab can cause fetal harm when
administered to a pregnant
woman. The effects of Pertuzumab are likely to be present during all
trimesters of pregnancy.
Pertuzumab administered to pregnant cynomolgus monkeys resulted in
oligohydramnios, delayed
fetal kidney development, and embryo-fetal deaths at clinically relevant
exposures of 2.5 to 20-fold
greater than the recommended human dose, based on Cn. If Pertuzumab is
administered during
pregnancy, or if a patient becomes pregnant while receiving Pertuzumab, the
patient should be
apprised of the potential hazard to the fetus. If Pertuzumab is administered
during pregnancy or if a
patient becomes pregnant while receiving Pertuzumab, immediately report
exposure to the Genentech
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Adverse Event Line at 1-888-835-2555. Encourage women who may be exposed
during pregnancy
to enroll in the MotHER Pregnancy Registry by contacting 1-800-690-6720 [see
Patient Counseling
Information (17.)].
Animal Data
Reproductive toxicology studies have been conducted in cynomolgus monkeys.
Pregnant
monkeys were treated on Gestational Day (GD)19 with loading doses of 30 to 150
mg/kg
pertuzumab, followed by bi-weekly doses of 10 to 100 mg/kg. These dose levels
resulted in
clinically relevant exposures of 2.5 to 20-fold greater than the recommended
human dose, based on
C,. Intravenous administration of pertuzumab from Gll19 through GD50 (period
of
organogenesis) was embryotoxic, with dose-dependent increases in embryo-fetal
death between
GD25 to GD70. The incidences of embryo-fetal loss were 33, 50, and 85% for
dams treated with
bi-weekly pertuzumab doses of 10, 30, and 100 mg/kg, respectively (2.5 to 20-
fold greater than the
recommended human dose, based on C.O. At Caesarean section on GD100,
oligohydramnios,
decreased relative lung and kidney weights and microscopic evidence of renal
hypoplasia consistent
with delayed renal development were identified in all pertuzumab dose groups.
Pertuzumab exposure
was reported in offspring from all treated groups, at levels of 29% to 40% of
maternal serum levels at
GD100.
8.3 Nursing Mothers
It is not known whether Pertuzumab is excreted in human milk, but human IgG is
excreted in
human milk. Because many drugs are secreted in human milk and because of the
potential for
serious adverse reactions in nursing infants from Pertuzumab, a decision
should be made whether to
discontinue nursing, or discontinue drug, taking into account the elimination
half-life of Pertuzumab
and the importance of the drug to the mother [See Warnings and Precautions
(5.1), Clinical
Pharmacology (12.3)].
=;
8.4 Pediatric Use
The safety and effectiveness of Pertuzumab have not been established in
pediatric patients.
8.5 Geriatric Use
Of 402 patients who received Pertuzumab in the randomized trial, 60 patients
(15%) were
?. 65 years of age and 5 patients (1%) were ? 75 years of age. No overall
differences in efficacy and
safety of Pertuzumab were observed between these patients and younger
patients. Based on a
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population pharmacokinetic analysis, no significant difference was observed in
the pharmacokinetics
of pertuzumab between patients < 65 years (n=306) and patients 65 years
(n=175).
8.6 Females of Reproductive Potential
Pertuzumab can cause embryo-fetal harm when administered during pregnancy.
Counsel
patients regarding pregnancy prevention and planning. Advise females of
reproductive potential to
use effective contraception while receiving Pertuzumab and for 6 months
following the last dose of
Pertuzumab. If Pertuzumab is administered during pregnancy or if a patient
becomes pregnant while
receiving Pertuzumab, immediately report exposure to the Genentech Adverse
Event Line at
1-888-835-2555. Encourage women who may be exposed during pregnancy to enroll
in the MotHER
Pregnancy Registry by contacting1-800-690-6720 [see Patient Counseling
Information (17)1.
8.7 Renal Impairment
Dose adjustments of Pertuzumab are not needed in patients with mild
(creatinine clearance
[CLcr] 60 to 90 mL/min) or moderate (CLcr 30 to 60 mL/min) renal impairment.
No dose
adjustment can be recommended for patients with severe renal impairment (CLcr
less than
30 mLlmin) because of the limited pharmacokinetic data available [see Clinical
Pharmacology
(12.3)1.
8.8 Hepatic Impairment
No clinical studies have been conducted to evaluate the effect of hepatic
impairment on the
pharmacokinetics of pertuzumab.
10 O'VERDOSAGE
No drug overdoses have been reported with Pertuzumab to date.
11 Description
Pertuzumab is a recombinant humanized monoclonal antibody that targets the
extracellular
dimerization domain (Subdomain II) of the human epidermal growth factor
receptor 2 protein
(HERZ). Pertuzumab is produced by recombinant DNA technology in a mammalian
cell (Chinese
Hamster Ovary) culture containing the antibiotic, gentamicin. Gentamicin is
not detectable in the
final product. Pertuzumab has an approximate molecular weight of 148 kDa.
Pertuzumab is a sterile,
clear to slightly opalescent, colorless to pale brown liquid for intravenous
infusion. Each single use
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vial contains 420 mg of pertuzumab at a concentration of 30 mg/mL in 20 mM L-
histidine acetate
(pH 6.0), 120 mM sucrose and 0.02% polysorbate 20.
12 Clinical Pharmacology
12.1 Mechanism of Action
Pertuzumab targets the extracellular dimerization domain (Subdomain II) of the
human
epidermal growth factor receptor 2 protein (HER2) and, thereby, blocks ligand-
dependent
hcterodimerization of HER2 with other HER family members, including EGFR, HER3
and HER4.
As a result, pertuzumab inhibits ligand-initiated intracellular signaling
through two major signal
pathways, mitogen-activated protein (MAP) kinase and phosphoinositide 3-kinase
(PI3K). Inhibition
of these signaling pathways can result in cell growth arrest and apoptosis,
respectively. In addition,
pertuzumab mediates antibody-dependent cell-mediated cytotoxicity (ADCC).
While pertuzumab
alone inhibited the proliferation of human tumor cells, the combination of
pertuzumab and
trastuzumab significantly augmented anti-tumor activity in HER2-overexpressing
xenograft models.
12.2 Pharmaenkineties
Pertuzumab demonstrated linear pharmacokinetics at a dose range of 2 ¨ 25
mg/kg. Based
on a population PK analysis that included 481 patients, the median clearance
(CL) of pertuzumab was
0.24 L/day and the median half-life was 18 days. With an initial dose of 840
mg followed by a
maintenance dose of 420 mg every three weeks thereafter, the steady-state
concentration of
pertuzumab was reached after the first maintenance dose. The population PK
analysis suggested no
PK differences based on age, gender, and ethnicity (Japanese vs. non-
Japanese). Baseline serum
albumin level and lean body weight as covariates only exerted a minor
influence on PK parameters.
Therefore, no dose adjustments based on body weight or baseline albumin level
are needed. No drug-
drug interactions were observed between pertuzumab and trastuzumab, or between
pertuzumab and
docetaxel in a sub-study of 37 patients in the randomized trial. No dedicated
renal impairment trial
for Pertuzumab has been conducted. Based on the results of the population
pharmacolcinetic analysis,
pertuzumab exposure in patients with mild (CLcr 60 to 90 mL/min, n=200) and
moderate renal
impairment (CLcr 30 to 60 mL/min, n=71) were similar to those in patients with
normal renal
function (CLcr greater than 90 mL/inin, n=200), No relationship between CLcr
and pertuzumab
exposure was observed over the range of observed CLcr (27 to 244 mL/min).
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12.3 Cardiac Electrophysiology
The effect of pertuzumab with an initial dose of 840 mg followed by a
maintenance dose of
420 mg every three weeks on QTc interval was evaluated in a subgroup of 20
patients with HER2-
positive breast cancer in the randomized trial. No large changes in the mean
QT interval (i.e., greater
than 20 ms) from placebo based on Fridericia correction method were detected
in the trial. A small
increase in the mean QTc interval (i.e., less than 10 ms) cannot be excluded
because of the limitations
of the trial design.
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
Long-term studies in animals have not been performed to evaluate the
carcinogenic potential
of pertuzumab. Studies have not been performed to evaluate the mutagenic
potential of pertuzumab.
No specific fertility studies in animals have been performed to evaluate the
effect of pertuzumab. No
adverse effects on male and female reproductive organs were observed in repeat-
dose toxicity studies
of up to six months duration in cynomolgus monkeys.
14 Clinical Studies
14.1 Metastatic Breast Cancer
The randomized trial was a multicenter, double-blind, placebo-controlled trial
of 808 patients
with HER2-positive metastatic breast cancer. Breast tumor specimens were
required to show HER2
overexpression defined as 3+ IHC or FISH amplification ratio 2.0 determined at
a central
laboratory. Patients were randomized 1:1 to receive placebo plus trastuzumab
and docetaxel or
Pertuzumab plus trastuzumab and docetaxel. Randomization was stratified by
prior treatment (prior
or no prior adjuvant/neoadjuvant anti-HER2 therapy or chemotherapy) and
geographic region
(Europe, North America, South America, and Asia). Patients with prior adjuvant
or neoadjuvant
therapy were required to have a disease-free interval of greater than 12
months before trial
enrollment. Pertuzumab was given intravenously at an initial dose of 840 mg,
followed by 420 mg
every 3 weeks thereafter. Trastuzumab was given intravenously at an initial
dose of 8 mg/kg,
followed by 6 mg/kg every 3 weeks thereafter. Patients were treated with
Pertuzumab and
trastuzumab until progression of disease, withdrawal of consent, or
unacceptable toxicity. Docetaxel
was given as an initial dose of 75 mg/m2 by intravenous infusion every 3 weeks
for at least 6 cycles.
The docetaxel dose could be escalated to 100 mg/m2 at the investigator's
discretion if the initial dose
was well tolerated.
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At the time of the primary analysis, the mean number of cycles of study
treatment
administered was 16.2 in the placebo-treated group and 19.9 in the Pertuzumab-
treated group.
The primary endpoint of the randomized trial was progression-free survival
(PFS) as assessed
by an independent review facility (IRF). PFS was defined as the time from the
date of randomization
to the date of disease progression or death (from any cause) if the death
occurred within 18 weeks of
the last tumor assessment. Additional endpoints included overall survival
(OS), PFS (investigator-
assessed), objective response rate (ORR) and duration of response.
Patient demographic and baseline characteristics were balanced between the
treatment arms.
The median age was 54 (range 22 to 89 years), 59% were White, 32% were Asian,
and 4% were
Black. All were women with the exception of 2 patients. Seventeen percent of
patients were
enrolled in North America, 14% in South America, 38% in Europe, and 31% in
Asia. Tumor
prognostic characteristics, including hormone receptor status (positive 48%,
negative 50%), presence
1; of visceral disease (78%) and non-visceral disease only (22%) were
similar in the study arms.
Approximately half of the patients received prior adjuvant or neoadjuvant anti-
HER2 therapy or
chemotherapy (placebo 47%, Pertuzumab 46%). Among patients with hormone
receptor positive
tumors, 45% received prior adjuvant hormonal therapy and 11% received hormonal
therapy for
metastatic disease. Eleven percent of patients received prior adjuvant or
neoadjuvant trastuzumab.
The randomized trial demonstrated a statistically significant improvement in
IRF-assessed
PFS in the Pertuzumab-treated group compared with the placebo-treated group
[hazard ratio (HR) =
0.62(95% CI: 0.51,0.75), p <0.0001] and an increase in median PFS of 6.1
months (median PFS of
18.5 months in the Pertuzumab-treated group vs. 12.4 months in the placebo-
treated group) (see
Figure 8). The results for investigator-assessed PFS were comparable to those
observed for 1RF-
assessed PFS. Consistent results were observed across several patient
subgroups including age (< 65
or ?: 65 years), race, geographic region, prior adjuvant/neoadjuvant anti-HER2
therapy or
chemotherapy (yes or no), and prior adjuvant/neoadjuvant trastuzumab (yes or
no). In the subgroup
of patients with hormone receptor-negative disease (n=408), the hazard ratio
was 0.55 (95% CI: 0.42,
0.72). In the subgroup of patients with hormone receptor-positive disease
(n=388), the hazard ratio
was 0.72 (95% Cl: 0.55, 0.95). In the subgroup of patients with disease
limited to non-visceral
metastasis (n=178), the hazard ratio was 0,96(95% CI: 0.61, 1.52).
At the time of the PFS analysis, 165 patients had died. More deaths occurred
in the placebo-
treated group (23.6%) compared with the Pertuzumab-treated group (17.2%). At
the interim OS
analysis, the results were not mature and did not meet the pre-specified
stopping boundary for
statistical significance. See Table 5 and Figure 10.
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Table 5 Summary of Efficacy from the Randomized Trial
Pertuzumab Placebo
+ trastuzumab + trastuzumab
+ docetaxel + docetaxel HR
Parameter n=402 n=406 (95% CI) p-value
Progression-Free Survival
(independent review)
0.62
(0.51, 0.75 <0.0001
)
No. of patients with an event 191 (47.5%) 242 (59.6%)
Median months 18.5 12.4
Overall Survival
(interim analysis) 0.64
0.0053*
(0.47, 0.88)
No. of patients with an event 69 (17.2%) 96 (23.6%)
Objective Response Rate
(ORR)
No. of patients analyzed 343 336
Objective response (CR + PR) 275 (80.2%) 233 (69.3%)
Complete response (CR) 19 (5.5%) 14 (4.2%)
Partial Response (PR) 256 (74.6%) 219 (65.2%)
Median Duration of Response
(months) 20.2 12.5
* The HR and p-value for the interim analysis of Overall Survival did not meet
the pre-defined
stopping boundary (HR 0.603, p 0.0012).
16 How Supplied/Storage and Handling
16.1 How Supplied
Pertuzumab is supplied as a 420 mg/14 niL (30 mg/mL) single-use vial
containing
preservative-free solution. NDC 50242-145-01. Store vials in a refrigerator at
2 C to 8 C
(36 F to 46 F) until time of use. Keep vial in the outer carton in order to
protect from light.
DO NOT FREEZE. DO NOT SHAKE.
17 Patient Counseling Information
Advise pregnant women and females of reproductive potential that Pertuzumab
exposure can
result in fetal harm, including embryo-fetal death or birth defects [see
Warnings and Precautions
(5.1) and Use in Specific Populations (8.1)1
Advise females of reproductive potential to use effective contraception while
receiving
Pertuzumab and for 6 months following the last dose of Pertuzumab [see
Warnings and Precautions
(5.1) and Use in Special Populations (8.6)]
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Advise nursing mothers treated with Pertuzumab to discontinue nursing or
discontinue
Pertuzumab, taking into account the importance of the drug to the mother [see
Use in Specific
Populations (8.3)].
Encourage women who are exposed to Pertuzumab during pregnancy to enroll in
the
MotHER Pregnancy Registry by contacting 1-800-690-6720 [see Warnings and
Precautions (5.1)
and Use in Specific Populations (8.1)1
Thus, the comprehensive phase III safety and efficacy data for Pertuzumab as
in Example 3
provide for the article of manufacture in this example. This article of
manufacture can be used in a
method of ensuring safe and effective use of Pertuzumab to treat patients.
EXAMPLE 5
Early-Stage Breast Cancer Therapy with Pertuzumab
Anthracyclines (generally used in combination with 5-FU and cyclophosphamide)
have a
central role in the management of breast cancer. Romond et al. NEJM 353(16):
1673-1684 (2005),
and Poole at al. NEJM 355 (18): 1851-1852(2006),
Taxanes are also integral in standard regimens for the treatment of breast
cancer, used in
combination with anthracyclines in a regimen known as TAC (Martin et at. NEJM
352 (22): 2302-
2313 (2005)) or in sequence with anthracyclines in a regimen known as AC->T
(Romond et al.,
supra; Joensuu et al. NEJM 354 (8): 809-820 (2006)).
Carboplatin is both an active and well tolerated chemotherapy agent and there
are studies in
breast cancer which show clear efficacy in combination with a taxane and
Trastuzumab in a regimen
known as TCH (Slamon et al. BCIRG 006. SABS (2007); Robert et al. J. Clin.
Oncol. 24: 2786-2792
(2006)). However, in metastatic breast cancer, there are negative data (Forbes
et al. BCIRG 007 Proc.
Am. Soc. Clin. Oncol. Abstract No. LBA516 (2006)).
A previous neoadjuvant study with Pertuzumab (NeoSphere) evaluated it in
combination
with Docetaxel and Trastuzumab (Gianni at al. Cancer Research 70 (24) (Suppl.
2) (December
2010)), but not in combination with anthracycline-based or carboplatin-based
chemotherapy.
The following chemotherapy regimens were evaluated in this example:
FEC Breast cancer therapy consisting of 5- fluorouracil, epirubicin and
cyclophosphamide.
FEC ->T Sequential chemotherapy, consisting of courses of FEC
chemotherapy followed by courses of Docetaxel.
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TCH Chemotherapy regimen for HER2-positive breast
cancer
combination comprising taxane (Docetaxel), Carboplatin, and .
Trastuzumab (HERCEPTINO)
The treatment arms in this study were:
Arm A
Courses of 5-Fluorouracil, Epirubicin and Cyclophosphamide (FEC) followed by
courses of
Docetaxel (T) (FEC ->T) with Trastuzumab and Pertuzumab given from the start
of the
chemotherapy regimen (i.e. concurrently with the anthracycline)
5-Fluorouracil (500 mg/m2), epimbicin (100 mg/m2) followed by cyclophosphamide
(600
mg/m2) for three cycles, followed by Docetaxel for three cycles with
Trastuzumab (8 mg/kg on day 1
of the first treatment with epirubicin and 6 mg/kg every 3 weeks thereafter)
and Pertuzumab (840 mg
on day 1 of the treatment with FEC with 420 mg every 3 weeks thereafter). The
starting dose for
Docetaxel is 75 mg/m2for Cycle 4 (first Docetaxel cycle) then 100 mg/m2 for
Cycles 5-6, if no dose
limiting toxicity occurs. All drugs will be administered by the IV route.
OR
Arm B
FEC ->T with Trastuzumab and Pertuzumab given from the start of the taxane
treatment (i.e.
following the anthracycline)
5-Fluorouracil (500 mg/m2), epirubicin (100 mg/m2) followed by
cyclophosphamide (600
mg/m2) for three cycles, followed by Docetaxel for three cycles with
Trastuzumab (8 mg/kg on day 1
of the first treatment with Docetaxel and 6 mg/kg every 3 weeks thereafter)
and Pertuzumab (840 mg
on day 1 on the first day of Docetaxel with 420 mg every 3 weeks thereafter).
The starting dose for
Docetaxel is 75 mg/m2for Cycle 4 (first Docetaxel cycle) then 100 mg/m2 for
Cycles 5-6, if no dose
1
limiting toxicity occurs. All drugs will be administered by the IV route.
OR
Arm C
Taxane (Docetaxel), Carboplatin and Trastuzumab (TCH) with Pertuzumab, with
both
antibodies being given from the start of the chemotherapy.
Carboplatin (AUC6 using Calvert's Formula) followed by Docetaxel on day 1 with
Trastuzumab (8 mg/kg on day 1 of the first treatment with Carboplatin and
Docetaxel and 6 mg/kg
every 3 weeks thereafter) and Pertuzumab (840 mg on day 1 with 420 mg every 3
weeks thereafter)
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for six cycles. The dose for Docetaxel is 75 mg/m2 for all cycles. All drugs
will be administered by
the IV route.
All patients will receive Trastuzumab every three weeks for a total of one
year from the start
of treatment (from Cycle 1-17 for patients in Arms A and C and Cycle 4-20 for
patients in Arm B)
whether they receive additional chemotherapy or not.
Primary Objective
The primary objective was evaluated when all patients had received six cycles
of
neoadjuvant treatment, had their surgery and all necessary samples taken or
were withdrawn from the
study whichever is earlier.
Secondary Objectives
To make a preliminary assessment of the activity associated with each regimen
as indicated
by the complete pathological response rate.
i To evaluate the safety profiles of each treatment regimen,
including pre-operative
(neoadjuvant) and post-operative (adjuvant) treatment.
To investigate the overall survival, the time to clinical response, time-to-
response, disease
free survival and progression free survival for each treatment arm.
To investigate the biomarkers that may be associated with primary and
secondary efficacy
endpoints in accordance with each treatment arm.
To investigate the rate of breast conservative surgery for all patients with
T2-3 tumors for
whom mastectomy was planned at diagnosis.
An overall assessment of the risk and benefit of each regimen will be made.
Overview of Study Design
= This was a Phase II open-label, randomized, multi-center trial to
evaluate the tolerability and
activity associated with Trastuzurnab and Pertuzumab when used in addition to
anthracycline-based
or carboplatin-based chemotherapy regimens as neoadjuvant therapy in patients
with HER2-positive
breast cancer which was early stage and >2cm in diameter or locally advanced
or inflammatory (see
Figure 11).
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Six cycles of active chemotherapy were administered. However, if it was
considered that
patients required further therapy post surgery, it was suggested that those
patients who had received
FEC->T were given CMF (cyclophosphamide, methotrexate and 5-fluorouracfl) and
that those
patients who had received TCH, but who are deemed to require further
chemotherapy received FEC
(5-fluorouracil, epirubicin and cyclophosphamide).
After the completion of surgery (and after the completion of post-operative
chemotherapy if
required), patients received radiotherapy as per local clinical standard and
those patients whose
tumors were estrogen-receptor positive received hormone manipulation as per
local clinical standard.
In summary, all patients received at least 6 cycles of active chemotherapy and
the two
antibodies, Pertuzumab and Trastuzumab plus surgery and radiotherapy (as per
local standard) plus
any hormone manipulation indicated (as per local standard) and continued to
receive Trastuzumab to
one year in total.
Patients whose neoadjuvant study treatment was discontinued prior to surgery
were managed
as per local practice. Approximately 28 days after the last dose of study
medication, patients will be
asked to perform a final safety assessment (called Final Visit).
Study Population
Overview
Female patients, aged 18 years or more, with early stage HER2-positive breast
cancer whose
primary tumors are > 2 cm with no metastases.
Inclusion Criteria
1. Female patients with locally advanced, inflammatory or early stage,
unilateral and histologically
confirmed invasive breast cancer. The initial breast cancer assessment should
be performed by a
physician with experience in surgery for breast cancer. Patients with
inflammatory breast cancer
must be able to have a core needle biopsy.
2. Primary tumor > 2cm in diameter.
3. HER2-positive breast cancer confirmed by a central laboratory. Tumors must
be HER2 3+ by
IHC or FISH/CISH + (FISH/CISH positivity mandatory for HER2 2+ tumors).
4. Availability of FITE tissue (Buffered Formalin method of fixation will
be accepted) for central
confirmation of HER2 eligibility (FITE tumor tissue will subsequently be used
for assessing
status of biomarkers).
5. Female patients, age? 18 years.
6. Baseline LVEF 55% (measured by echocardiography or MUGA).
7. Performance status ECOG Lc. 1.
8. At least 4 weeks since major unrelated surgery, with full recovery.
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Concomitant Medication and Treatment
Allowed Therapies
Concomitant treatments are any prescription medications, over-the-counter
preparations,
herbal remedies or radiotherapy used by a patient in the interval beginning 7
days prior to the patient
.. being recruited into the study and continuing through the study.
The following treatments are permitted during the study:
I. Acceptable methods of contraception must be used when the female patient
or male partner is not
surgical sterilized or does not meet the study definition of post-menopausal (
12 months of
amenorrhea).
2. H1 and H2 antagonist (e.g. diphenhydramine, cimetidine)
3. Analgesics (e.g. paracetamol/acetaminophen, meperidine, opioids)
4. Short term use of corticosteroids to treat or prevent allergic or
infusion reactions
5. Antiemetics (approved prophylactic serotonin-antagonists, benzodiazepines,
ondansetron etc)
6. Medication to treat diarrhea (e.g. loperamide)
7. Colony stimulating factors (e.g. G-CSF)
8. Estrogen receptor antagonist (e.g. tamoxifen) or aromatase inhibitors (e.g.
anastrazole,
exemestane) after completion of post-operative chemotherapy as per local
practice.
Excluded Therapies
The following therapies are excluded during the treatment period of the study:
9. Anti-cancer therapies other than those administered in this study,
including cytotoxic
chemotherapy, radiotherapy, (except for adjuvant radiotherapy for breast
cancer after completion
of chemotherapy or additional adjuvant chemotherapy immediately post-surgery,
if deemed
necessary) immunotherapy, and biological anti-cancer therapy.
10. Any targeted therapy.
11. Treatment with steroids except for thyroid hormone replacement therapy and
short term
corticosteroid, in order to treat or prevent allergic or infusion reactions.
12. High doses of systemic corticosteroids. High dose is considered as > 20 mg
of dexamethasone a
day (or equivalent) for > 7 consecutive days.
13. Any investigational agent, except for those used for this study.
14. Initiation of herbal remedies, Herbal remedies initiated prior to study
entry and continuing during
the study are permitted and must be reported on the appropriate eCRF.
15. Any oral, injected or implanted hormonal methods of contraception,
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RESULTS
The baseline characteristics of the patients with HER2-positive early-stage
breast cancer are provided
below.
Table 6: Baseline Characteristics in the Safety Population
FEC+H+P x3 FEC x3 -> T+H+P x3 TCH+P x6
-> T+H+P x3
n=72 11=75 n=76
Median age, years (range) 49.0 (27-77) 49.0 (24-75)
50.0 (30-81)
ECOG PS 0, n (%) 65 (91.5) 66 (88.0) 67 (88.2)
1, n(%) 6(8.5) 9(12.0) 9(11.8)
ER and/or PR-positive, n (%) 39 (53.4) 35 (46.7) 40 (51.9)
ER and PR-negative, n (%) 34 (46.6) 40 (53.3) 37 (48.1)
Disease type, n (%)
Operable 53 (72.6) 54 (72.0) 49 (63.6)
Locally advanced 15 (20.5) 17 (22.7) 24 (31.2)
Inflammatory 5 (6.8) 4 (5.3) 4 (5.2)
HER2 IHC 0 and 1+, n (%) 1(1.4)
2+, n (%) 5(6.8) 1(1.3) 2(2.6)
3+, n (%) 67 (91.8) 74 (98.7) 75 (97.4)
HER2 FISH-positive, n (%) 69 (94.5) 69 (92.0) 73 (94.8)
FISH-negative, n (%) 1(1.3) 2 (2.6)
Unknown, n (%) 4 (5.5) 5 (6.7) 2 (2.6)
CBE, clinical breast examination; ECOG PS, Eastern Cooperative Oncology Group
performance
status; ER, estrogen receptor; FEC, 5-fluorouracil, epirubicin,
cyclophosphamide; FISH, fluorescence
in situ hybridisation; H, Trastuzumab; NC, immunohistochemistry; P,
Pertuzumab; PR, progesterone
receptor; T, Docetaxel; TCH, Docetaxel/Carboplatin/Trastuzumab
Safety data are shown in Figure 12 and Tables 7 and 8 below.
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Table 7: Cardiac Events Overall
FEC+H+P x3 FEC x3 --> T+H+P x3 TCH+P x6
¨> T+H+P x3
n = 72 n = 75 n = 76
Symptomatic LVSD (grade .3),
2 (2.7) 1(1.3)
n (%)
LVSD (all grades), n (%) 5 (6.9) 3 (4.0) 5 (6.6)
LVEF decline >10% points from
(6.9) 5 (6.7) 5 (6.6)
baseline to <50%, n (%)
FEC, 5-fluorouracil, epirubicin, cyclophosphamide; H, Trastuzumab; LVEF, left
ventricular ejection
fraction; LVSD, left ventricular systolic dysfunction; P, Pertuzumab; T,
Docetaxel; TCH,
Docetaxel/Carboplatin/Trastuzumab
5
Table 8: Ten Most Common Adverse Events During Neoadjuvant Treatment Grade > 3
FEC+14+P x3 FEC x3 ---> T+H+P x3 TCH+P
x6
-4 T+H+P x3
Adverse event, n n = 72 n = 75 n = 76
(%)
Neutropenia 34(472) 32 (42.7) 35 (46.1)
Febrile
13(18.1) 7(9.3) 13 (17.1)
neutropenia
Leukopenia 14 (19.4) 9(12.0) 9(11.8)
Diarrhea 3(4.2) 4(5.3) 9(11.8)
Anemia 1(1.4) 2(2.7) 13 (17.1)
Thrombocytopenia 9(11.8)
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Vomiting 2 (2.7) 4 (5.3)
Fatigue 3 (3.9)
Alanine
aminotransferase 3 (3.9)
inc.
Drug
2(2.8) 2 (2.6)
hypersensitivity
FEC, 5-fluorouracil, epirubicin, cyclophosphamide; H, Trastuzumab; P,
Pertuzumab; T, Docetaxel;
TCH, Docetaxel/Carboplatin/Trastuzumab
Efficacy data are provided in Figures 13 and 14 as well as Tables 9 and 10
below.
Table 9: Clinical Response Rate During Neoadjuvant Treatment
1
FEC+H+P x3 FEC x3 T+H+P x3 TCH+P x6
--> T+H+P x3
n = 73 n = 75 n = 77
Objective response rate, n
(%) 67 (91.8) 71 (94.7) 69 (89.6)
Complete response rate 37 (50.7) 21 (28.0) 31 (40.3)
Partial response rate 30 (41.1) 50(667) 38 (49.4)
Stable disease, n (%) 3(4.1) 1(1.3) 5(6.5)
.;
Progressive disease, n (%) 1(1.3)
No assessment, n (%) 3 (4.1) 2 (2.7) 3 (3.9)
FEC, 5-fluorouraciI, epirubicin, cyclophosphamide; H, Trastuzumab; P,
Pertuzumab; T, Docetaxel;
TCH, Docetaxel/Carboplatin/Trastuzumab
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Table 10: Breast Conserving Surgery in Patients for Whom Mastectomy was
Planned
FEC+H-4-P x3 FEC x3 ¨> T-i-11+P x3 TCH+P x6
¨ T+H+P x3
n = 46 n = 36 n37
Achieved, n (%) 10 (21.7) 6 (16.7) 10 (27.0)
(95% CI) (10.9-36.4) (6.4-32.8) (13.8-44.1)
Not achieved, n (%) 36 (78.3) 30 (83.3) 27 (73.0)
CI, confidence interval; FEC, 5-fluorouracil, epirubicin, cyclophosphamide; H,
Trastuzumab; P,
Pertuzumab; T, Docetaxel; TCH, Docetaxel/Carboplatin/Trastuzumab
CONCLUSIONS
= Results from this study indicate a low incidence of symptomatic and
asymptomatic LVSD
across all arms
¨ Concurrent
administration of Pertuzumab plus Trastuzumab with epirubicin resulted
in similar cardiac tolerability compared with sequential administration or the
anthracycline-free regimen
= Neutropenia, febrile neutropenia, leukopenia and diarrhea were most
frequently reported
adverse events (grade >3) across all arms
= Regardless of chemotherapy chosen, the combination of Pertuzumab with
Trastuzumab in the
neoadjuvant setting resulted in high pathological complete response (pCR)
rates (57 to 66%)
= TRYPHAENA supports the use of Pertuzumab and Trastuzumab plus anthracyline-
based or
carboplatin-based chemotherapy in the neoadjuvant and adjuvant settings of
early-stage
breast cancer.
EXAMPLE 6
Co-Administration of Pertuzumab and Trastuzumab
In the phase III clinical trials above Pertuzumab was administered by
intravenous (1V)
infusion in saline IV bags to patients with 1-IER2-positive metastatic breast
cancer followed by
Trastuzumab and the chemotherapeutic agent Docetaxel also using saline IV
infusions. The IV
infusion process for Pertuzumab and Trastuzumab takes approximately 60 to 90
minutes each with a
to 60 minute patient observation period after each drug. Due to this treatment
regimen per patient,
25 a visit can take up to 7.5 hours total. As medical payments for both
drugs and drug administration
services have been under scrutiny in the recent past, there has been emphasis
on business practices to
shorten time and to increase medical resource utilization in clinical and
hospital settings. Increased
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efficiency of patient care, compliance and treatment is expected by shortening
the time patients spend
in the clinic for each cycle of treatment.
As part of the phase III Pertuzumab clinical trials, Pertuzumab and
Trastuzumab are
administered through intravenous (IV) infusion to patients sequentially, i.e.
one drug after the other.
While Pertuzumab is given as a flat dose (420mg for maintenance, 840mg for
loading), Trastuzumab
is weight based (6mg/kg for maintenance doses). To increase convenience and
minimize the in-clinic
time for the patients, the feasibility of co-administering Pertuzumab with
Trastuzumab in a single
250mL 0.9% saline polyolefin (PO) or polyvinyl chloride (PVC) IV infusion bag
was assessed. The
individual monoclonal antibodies have been demonstrated to be stable in
infusion bags (PO and/or
PVC) over 24 hours at 5 C and 30 C. In this study, the compatibility and
stability of Pertuzumab
(420mg and 840mg) mixed with either 420mg Trastuzumab (6mg/kg dose for a 70kg
patient) or
720mg (6mg/kg for a 120kg patient) in IV bags for up to 24 hours at 5 C or 30
C was evaluated. The
controls (i.e. Pertuzumab alone in an IV bag, Trastuzumab alone in an IV bag)
and the monoclonal
antibody (mAb) mixture samples were assessed using the existing Pertuzumab and
Trastuzumab
analytical methods, which include color, appearance and clarity (CAC),
concentration and turbidity
by UV-spec scan, particulate analysis by HIAC-Royco, size exclusion
chromatography (SEC), and
ion-exchange chromatography (1EC). Additionally, capillary zone
electrophoresis (CZE), image
capillary isoelectric focusing (iCIEF), and potency (the Pertuzumab anti-
proliferation assay only) was
utilized to measure the admixtures containing 1:1 of Pertuzumab:Trastuzumab
and their respective
controls (420mg Pertuzumab only and 420mg Trastuzumab only) only as a
representative case.
Results showed no observable differences by the above assays in the
Pertuzumab/
Trastuzumab mixtures between the time zero (TO) control and the sample stored
up to 24 hours at
either 5 C or 30 C, The physicochemical assays as listed above were able to
detect both molecules as
well as the minor variants in the drug mixture, though some overlaps of
monoclonal antibody species
were seen in the chromatograms. Furthermore, the drug mixture tested by the
Pertuzumab specific
inhibition of cell proliferation assay showed comparable potency before and
after storage. The results
from this study showed the Pertuzumab and Trastuzumab admixtures are
physically and chemically
stable in an IV infusion bag for up to 24 hours at 5 C or 30 C and can be used
for clinical
administration if necessary.
Dose I: 840mg Pertuzumab/Trastuzumab mixture (420mg Pertuzumab and 420mg
Trastuzumab)
Sample Preparation: All procedures were performed aseptically under a laminar
flow hood.
PO IV infusion bag samples with three types of drug combinations were prepared
for this study: 1)
420mg Pertuzumab/ 420mg Trastuzumab mixture, 2) 420mg Pertuzumab alone, and 3)
420mg
Trastuzumab alone. The Pertuzumab and Trastuzumab alone samples served as
controls.
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Trastuzumab was reconstituted with 20mL of bacteriostatic water for injection
(BWFI) and
left on lab bench for approximately 15 minutes prior to use. To prepare the
Pertuzumab/ Trastuzumab
sample dose, 14mL of Pertuzumab (420mg) was diluted directly into the IV
infusion bag that
contained a nominal 250mL ( 25mL overage) 0.9% saline solution, without
removing an equal
amount of saline, followed by 20rriL of the reconstituted Trastuzumab (420mg)
using an 18 gauge
needle at room temperature. The total concentration of the two proteins
combined in the 250mL IV
bag was expected to be approximately 3mg/mL. Similarly, the Pertuzumab (420mg)
alone IV bag
was prepared with 14mL of the 30mg,/mL drug product directly diluted into an
IV infusion bag. The
final expected concentration was approximately lmg/mL. The Trastuzumab (420mg)
alone IV
infusion bag was also prepared in the same manner except 20mL of the 21 mg/mL
drug product was
added into the bag. The final expected concentration was approximately lmg/mL.
The PO IV bags were manually mixed thoroughly by a gentle back and forth
rocking motion
several times to ensure homogeneity. After mixing, 10mL of sample was removed
with a syringe
from each bag and stored in sterile 15cc falcon tubes to be used as the
diluted sample control at time
zero (TO). The IV bags were then stored covered in foil at 30 C for 24 hours
(T24). Immediately after
storage, the remainder of the sample was removed with a syringe from each bag
and placed into
sterile 250 mL PETG containers. The TO and T24 samples were held for up to 24
hours at 5 C or
immediately analyzed by CAC, UV-spec scan (concentration and turbidity), SEC,
lEC, CZE, iCIEF,
HIAC-Royco, as well as potency. The product quality of the samples was tested
by the Pertuzumab
and Trastuzumab product specific SEC and TEC methods, while only the
Pertuzumab specific
.=
potency method was performed. The other assays utilized were non-product
specific methods. All
assays were qualified for the intended testing in their respective molecules
and used without further
method optimization.
Dose IL 1560mg Pertuzumabarastuzumab mixture (840mg Pertuzumab and 720mg
Trastuzumab)
Sample preparation: The upper range of the mAb co-administration dose was
examined
(1560mg total mixture: 840mg Pertuzumab and 720mg Trastuzumab) in PO and PVC
IV infusion
bag samples. In the event that an increase in protein aggregation is observed,
the propensity of the
formation of high molecular weight species (HMWS) would more likely occur at
the upper dose of
1560mg total mAb rather than the mixture containing 840mg. To mitigate the
risk during in-use
conditions at the high dose range, both PO and PVC IV infusion bags were
studied to ensure no
interactions were seen.
Three types of drug combinations (mixture, 840mg Pertuzumab alone, and 720mg
Trastuzumab alone) were prepared and handled similar to the dose I study. The
Pertuzumab/
Trastuzumab mixture contained 28mL of Pertuzumab (840mg) diluted directly into
either PO or PVC
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IV infusion bags followed by 34mL of the reconstituted Trastuzumab (720mg)
using an 18 gauge
needle at room temperature. The total concentration of the two mAbs combined
in a single 250mL IV
bag was expected to be approximately 5mg/mL. For the controls, Pertuzumab and
Trastuzumab
alone IV infusion bag samples were prepared and handled similar to the dose I
study, except 28mL of
30mg/mL Pertuzumab and 34mL of 21mg/mL Trastuzumab was directly diluted into
each PO or
PVC IV infusion bag. The final expected concentration was approximately 3mg/mL
for the
Pertuzumab (840mg) and Trastuzumab (720mg) alone samples. The bags were stored
uncovered at
either 5 C or 30 C for up to 24 hours. The TO and T24 samples were analyzed
immediately or held
for up to 24 to 48 hours at 5 C by CAC, UV-spec scan (concentration and
turbidity), SEC, TEC, and
HIAC-Royco.
Details of the types of doses, IV infusion bags, dose & preparation, storage
temperatures, and
assays are summarized in Table 11
Table 11: IV Bag Type, Dose, Preparation & Study Conditions
IV bag type Total dose, Dilution Storage Assays
(approx 250inL, concentration (into approx temperature
0.9 %Iskta) 250nd, IV bag) (up to 24hrs)
Dose (n=1)
840mg, Add 14mL P (-30mg/mL)
= approx 3mg/mL + 20mL T (-
21mg/mL) CAC, UV spec scan
(concentration,
420ingb, Add 14mL P (-30mg/mL) turbidity), SEC,
EEC,
PO 30 C
approx 2mg/mL CZE, icIEF, HIAC-
Royco, potency
420mgb, Add 20mL T (-21 mg/mL)
approx lmg/mL
Dose H (n=1)
PO and PVC" 1560mg, Add 28inL P (-30mg/mL)
approx 5mg/mL + 34rnL T (-21mg/mL)
5 C CAC, UV spec
scan
840mg", Add 28rnL P (-30mg/mL) (concentration
&
approx 3mg/mL 30 C turbidity),
SEC, IEC,
PO and PVC HIAC-Royco
720mg", Add 34mL T (-21mg/mL)
approx 3mg/mL
a n=2
b control
P= Pertuzumab; Tm Trastuzumab
Assays
All samples were held at 5 C or immediately analyzed. Typically, samples were
analyzed within 24
to 48 hours of preparation and storage. The following assays were conducted to
ascertain product
quality and short term stability of Pertuzumab/ Trastuzumab mixture,
Pertuzumab alone, and
Trastuzumab alone samples diluted into saline IV infusion bags. Since several
assays, i.e. SEC, TEC,
CZE, iCIEF, and potency, were not optimized for quantitative assessment of the
mAb mixtures, only
chromatographic or electropherographic overlays of these samples and their
individual controls
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before and after storage at 5 C or 30 C are shown here. For consistency, no
values, e.g. percent peak
area, were calculated for all three sample types from the liquid
chromatography and electrophorectic
assays that were performed.
Color, Appearance, and Clarity (CAC)
The color, appearance, and clarity of the samples were determined by visual
inspection under a
white fluorescence light with black and white background at room temperature.
A 3cc glass vial was
filled with 1 mL of each sample for CAC testing. A negative control (purified
water) with the
corresponding sample volume was used for comparison.
UV- Vis Spectrophotometer Scan for Concentration Measurements
The concentration was determined by measurement of the UV-absorbance on an
11P8453
spectrophotometer via volumetric sample preparation. The instrument was
blanked with 0.9% saline.
Absorbance at Anu,(278nm or 279nm) and 320nm in a quartz cuvette with 1-cm
path length were
measured for each sample. The absorbance at 320nm is used to correct for
background light scattering
in solution. The concentration determination was calculated by using the
absorptivity of 1.50 (mg/mL)"
lcm-1 for both Pertuzumab and Trastuzumab molecules.
Am ¨A3, 1
Pr otein Concentration(mg/mL) = x Dilution Factor x _____
1.50 cuvette
pathlength
Size Exclusion Chromatography (SEC: Pertuzumab specific and Trastuzumab
specific)
Each sample was injected into a TOSOHAAS column G3000 SWXL, 7.8 X 300rnm at
ambient temperature on an AGILENT 1100 HPLC. The eluted peaks were monitored
at 280nm.
Chromatographic integrations were analyzed by the CHROMELEON software. The
autosampler
temperature was held at 2-8 C throughout the run and mobile phases used were
0.2M potassium
phosphate, 0.25mM potassium chloride, pH 6.2 and 100mM potassium phosphate, pH
6.8 for
Pertuzumab-assay and Trastuzumab-assay, respectively. The recommended
injection load as
specified by the test procedure was 200 lig with an injection volume of 20
ttL. The diluted 420mg
sample was injected at a load less than the recommended amount due to the low
concentration of the
protein after dilution in the IV bags. The maximum injection volume of the
HPLC sample loop was
100 pt, which limits the volume that is able to be injected at one time. As a
result, the injection
volumes were modified to 100 p,L at 160 jag protein for the Pertuzumab alone
and Trastuzumab alone
samples (420 mg dose group) and 73 pt, at 200 fig protein for the
Pertuzumab/Trastuzumab mixture
(840 mg dose group). Modification in the injection volumes have been utilized
in previous IV bag
studies and are necessary when handling low concentration samples.
Ion-exchange Chromatography (IEC)
The analysis of carboxypeptidase B (CpB)- digested Pertuzumab and Trastuzumab
for
charge heterogeneity was employed by IEC for each sample. For the Pertuzumab
specific TEC,
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samples were either tested with regular IEC ("Pertuzumab-regular IEC") or a
modified "fast" version
of lEC ("Pertuzumab-IEC-fast") for high throughput, method for the purpose of
these experiments.
The IEC assays utilized the a DIONEXO WCX weak cation exchange column
equilibrated with
solvent A (20mM MES, 1mM Na2EDTA pH 6.00) and solvent B (250mM sodium chloride
in solvent
A) monitored at 280nm for Pertuzumab-regular IEC and Pertuzumab-IEC-fast,
whereas solvent A
(10mM sodium phosphate, pH 7.5) and solvent B (100mM sodium chloride in
Solvent A) monitored
at 214nm was used for Trastuzumab on an AGFLENT 1100 HPLC. The peaks were
eluted at a flow
rate of 0.8 mL/min with an increasing gradient of 18%-100% solvent B over 35
minutes and 90
minutes for Pertuzumab-regular-IEC and Pertuzumab-IEC- fast, respectively, and
15%400% solvent
B over 55 minutes for Trastuzumab-IEC. Column temperatures were maintained at
either 34 C or
42 C and ambient for Pertuzumab-regular-IEC or Pertuzumab-fast-IEC and
Trastuzumab-IEC,
respectively, while the auto sampler temperature was held at 2-8 C throughout
the run.
HIAC.ROYCOTM light obscuration for sub-visible particles
Particulate counts in the diluted drug product were carried out using the
HIACROYCOTM
Liquid Particulate Counting System model 9703. Average cumulative numbers of
particles at 101.t.m
and 2511m per milliliter were tabulated in each sample using PHARMSPEC v2.0Tm.
The test
procedure was modified for a small- volume method, utilizing either four lmL
readings or four
0.4mL readings per a test session while discarding the first reading of each
sample. The HIAC-
ROYCOTM samples were degassed under vacuum for approximately 10-15 minutes
each. The size
below 101.tm was not collected for this sample set.
=
UV- Vis Spectrophotometer Scan for Turbidity Measurements
The optical density of the samples from the IV bag (1mg/mL or 3mg/mL) was
measured in a
quartz cuvette with a 1-cm path length on a HP8453 spectrophotometer. The
sample readings were
blanked against purified water. The absorbance measurements were recorded at
340nm, 345nm,
350nm, 355nm, and 360nm and the turbidity was expressed as an average of these
wavelengths.
Capillary Zone Electrophoresis, CZE
CZE was performed using a PROTEOMELAB PA800Tm capillary electrophoresis system
(Beckman Coulter) with neutral-coated capillary (50 m x 50 cm). The buffer
consisted of 40 rnM E-
, amino caproic acid/acetic acid, pH 4.5, 0.2% hydroxypropyl methyl
cellulose (HPMC). Samples
were diluted to 0.5 mg/mL in water and injected into the capillary at 1 psi
for 10 seconds. Separation
was performed using a voltage of 30 kV for 15 minutes, and the species were
detected by UV at 214
nm.
CE-SDS-LIF, reduced and non-reduced
Each sample was derivatized with 5 carboxytetramethylrhodamine succinimidyl
ester, a
fluorescent dye. After removing the free dye through gel filtration (using NAP-
5 columns), non-
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reduced samples were prepared by adding 40 m_M iodoacetamide and heated at 70
C for 5 minutes.
For the analysis of the reduced samples, the derivatized samples were mixed
with SDS to a final
concentration of 1% (v/v) and 10 mL of a solution containing 1 M DTT, and
heated at 70 C for 20
minutes. The prepared samples were analyzed on a Beckman Coulter ProteomeLab
PA800 system
using a 50 mm I.D. 31.2 cm fused silica capillary maintained at 20 C
throughout the analysis.
Samples were introduced into the capillary by electrokinetic injection at 10
kV for 40 seconds. The
separation was conducted at a constant voltage of 15 kV in the reversed
polarity (negative to positive)
mode using CE-SDS running buffer as the sieving medium. An argon ion laser
operating at 488 nm
was used for fluorescence excitation with the resulting emission signal
monitored at 560 nm.
iCIEF
The distribution of charge variants of the Pertuzumab/Trastuzumab mixture,
Pertuzumab alone,
and Trastuzumab alone was assessed by iCIEF using an iCE280TM analyzer
(Convergent Bioscience)
with a fluorocarbon coated capillary cartridge (100 um x 5 cm). The ampholyte
solution consisted of
a mixture of 0.35% methyl cellulose (MC), 0.47% Pharmalyte 3-10 carrier
ampholytes, 2.66%
Pharmalyte 8-10.5 carrier ampholytes, and 0.20% pI markers 7.05 and 9.77 in
purified water. The
anolyte was 80 m1\4 phosphoric acid, and the catholyte was 100 mM sodium
hydroxide, both in
0.10% methylcellulose. Samples were diluted in purified water and CpB was
added to each diluted
sample at an enzyme to substrate ratio of 1:100 followed by incubation at 37 C
for 20 minutes. The
CpB treated samples were mixed with the ampholyte solution and then focused by
introducing a
potential of 1500 V for one minute, followed by a potential of 3000 V for 10
minutes. An image of
the focused Pertuzumab charge variants was obtained by passing 280 nm
ultraviolet light through the
capillary and into the lens of a charge coupled device digital camera. This
image was then analyzed
to determine the distribution of the various charge variants.
Anti-Proliferation Potency Assay
This test procedure is based on the ability of Pertuzumab to inhibit the
proliferation of MDA
MB 175 VII human breast carcinoma cells. Briefly, cells were seeded in 96-well
tissue culture
microtiter plates and incubated overnight at 37 C under 5% CO2 to allow cell
attachment. The
following day, the culture medium was removed and serial dilutions of each
standard, controls, and
sample(s) were added to the plates. The plates were then incubated for fours
days at 37 C under 5%
CO2 and the relative number of viable cells was quantified indirectly using a
redox dye,
ALAMARBLUE according to the manufacturer's protocol. Each sample was assayed
in triplicate
and the changes in color as measured by fluorescence were directly
proportional to the number living
cells in the culture. The absorbance of each well was then measured on a
fluorescence 96-well plate
reader. The results, expressed in relative fluorescence units (RFU), were
plotted against the antibody
concentration. No quantitative measurements were made, or possible, since
there was no
Pertuzumab/Trastuzurnab mixture reference available. Therefore, the results
are comparisons of the
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dose response curves only.
RESULTS AND DISCUSSION
Dose I: 840mg total Pertuzumab/ Trastuzumab mixture (420mg Pertuzumab and
420mg
Trastuzumab)
The product quality of the total 840mg Pertuzumab/Trastuzumab mixture (420mg
Pertuzumab and 420mg Trastuzumab), Pertuzumab alone (420mg), and Trastuzumab
alone (420mg)
in IV infusion bags (n=1) before and after storage at 30 C for up to 24 hours
was assessed by CAC,
concentration measurements by UV-spec scan, turbidity, and H1AC Royco (Table
12). The
Pertuzumab and Trastuzumab alone IV infusion bags are considered controls that
were also prepared
to assess the ability of the assay to pick up the appropriate product
attributes.
Table 12: Dose I 840mg: Stability data for Pertuzumab/Trastuzumab mixture,
Pertuzumab,
or Trastuzumab in 0.9% saline PO IV infusion bags (n=1)
iv bag
Sample type Amount Timepoint Temp CAC
Cone. Turbidity Light Obscuration
total particles total particles
mg Maris) C liquid mg/mL AU >
lOurn/mL > 25um/mL
pertuzumab/
trastuzumab PO 840 0 30 CL, CO 2.7 0.016 1
0
mixture 840 24 30 CL, CO 2.7 0.016 6
0
=
pertuzumab PO 420 0 30 CL, CO 1.4 0.012 3
0
420 24 30 CL, CO 1.4 0.011 4 0
trastuzumab PO 420 0 30 CL, CO 1.5 0.012 1
0
420 24 30 CL, CO 1.5 0.011 6 .. 0
saline only 2 1
'Color, Appearance and Clarity: CL =clear ; SOPL= slightly opalescent, CO=
colorless.
RT= room temperature
Color, appearance, and clarity: CL= clear; SOPL= slightly opalescent, CO=
colorless
After storage, the Pertuzumab/Trastuzumab mixture, Pertuzumab alone, and
Trastuzumab
=,
alone samples appeared as a clear and colorless liquid with no visible
particles as observed by CAC.
The concentration and turbidity measurements showed no measureable changes in
any of the three
sample types after 24 hours at 30 C. Particulate analysis by HIAC Royco
detected no more than 6
particles greater than or equal to 10um size and no particles greater than 25
p.m size for
Pertuzumab/Trastuzumab mixture, Pertuzumab alone, or Trastuzumab alone samples
post storage.
These results are comparable to the 0.9% saline only solution. The lack of
visible precipitation or
particulates indicates that the admixture and the controls are sufficiently
stable upon dilution in the
0.9% saline IV infusion bags. The Pertuzumab/Trastuzumab mixture diluted in
saline were run on
SEC, both Pertuzumab and Trastuzumab specific methods, and showed comparable
peak profiles
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between TO and T24 (Figures 15 and 16). No increases were observed in the high
molecular weight
species (HMWS) and low molecular weight species (LMWS). Similarly, no changes
were observed
in the main peak in any sample. The main peak and the peak area of the RMWS
and LMWS overlay
and cannot be distinguished in the Pertuzumab/ Trastuzumab mixture due the
size similarity between
Pertuzumab and Trastuzumab (molecular weight approximately 150kD).
Furthermore, comparison of
TO and T24 for both the Pertuzumab and Trastuzumab alone sample showed no
observable changes
in peak area or profile as detected by the two SEC methods listed above.
Two product specific methods for Pertuzumab or Trastuzumab IEC was utilized to
analyze the
Pertuzumab/Trastuzumab mixture (Figures 17 and 18). In the cation-exchange
chromatography
assays, each molecule typically contain three distinct areas that are eluted
based on relative charge,
with the early eluting acidic variants, followed by the main peak, and lastly
the late eluting basic
variants. In the Pertuzumab and Trastuzumab alone chromatograms, the profile
exhibiting the acidic
variants, main peak, and the basic variants was observed and deemed comparable
between the
starting material and post storage at 30 C. These results are also consistent
with prior studies
conducted in saline IV infusion bags for the either Pertuzumab or Trastuzumab
alone. For the
Pertuzumab/ Trastuzumab mixture chromatogram, the Pertuzumab peaks elute first
followed by the
Trastuzumab peaks. Due to the nature of cation-exchange separation and the net
charge difference
between Pertuzumab (-pI 8.7) and Trastuzumab (-pI 8.9), two main peaks, or
major charged species,
are observed in the Pertuzumab/Trastuzumab mixture. In contrast, the SEC assay
separates based on
the hydrodynamic size of the molecule and show only one main peak due to the
size similarity
between Pertuzumab and Trastuzumab. The charged regions of each molecule
appear to overlap with
each other in the Pertuzumab/Trastuzumab mixture. Specifically, the Pertuzumab
basic variants
expected to elute at approximately 32 minutes and at 35 minutes appear to
overlap with the main
peak of Trastuzumab (Figures 17 & 18). Furthermore, the acidic variants of
Trastuzumab expected to
elute before the Trastuzumab main peak co-elute with the Pertuzumab basic
variants and main peak.
Despite the overlapping peak regions, the Pertuzumab/Trastuzumab mixture
exhibited comparable
chromatographic peak profiles before and after storage in IV saline bags for
24 hours at 30 C.
The Pertuzumab/Trastuzumab mixture, Pertuzumab alone, and Trastuzumab alone
samples
were also assayed on CE-SDS LIP under non-reduced conditions after storage for
24 hours at 30 C.
The Pertuzumab/Trastuzumab mixture showed consistent peak profiles with no
observable changes
after storage compared to the starting material (Figures 19 & 20). A very
slight baseline level
variation attributed to noise is also observed and does not impact peak area.
Similar to SEC, the non-
reduced Pertuzumab/Trastuzumab mixture showed only one superimposed monomer
constituting
both the Pertuzumab and Trastuzumab main species. The Pertuzumab and
Trastuzumab alone
samples showed no changes at TO compared to T24. However, individual molecular
attributes, e.g.
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fragment peak level and species, between Pertuzumab/Trastuzumab mixture,
Pertuzumab alone, and
Trastuzumab alone was observed as expected.
Two major peaks known as the light chain (LC) and heavy chain (HC) are
detected at 17 and
21.5 minutes, respectively, when Pertuzumab/ Trastuzumab mixture, Pertuzumab
alone, and
Trastuzumab alone was run on CE-SDS LIP reduced with DT[ (Figure 20). No
increase in
fragmentation or concomitant decrease in the LC and HC was seen post storage
at 30 C for the
Pertuzumab/ Trastuzumab mixture. Furthermore, no detectable peak profile
differences were noticed
in the Pertuzumab and Trastuzumab alone samples post storage.
The charge separation assays CL.b and iCIEF show comparable peak profiles for
the Pertuzumab/
Trastuzumab mixture after storage at 30 C (Figures 21 & 22). The Pertuzumab
and Trastuzumab
alone when compared to their respective TO also showed consistent peak
profiles with no changes
after storage. Furthermore, the presence of various minor species was also
observed, although no new
peaks were detected upon dilution in the IV bag saline solution. As seen in
the charge based IEC
assay, two main peaks flanked by smaller overlapping peaks can be detected and
was attributed to the
difference in the molecular pt.
The potency results based on comparison of the dose response curve showed no
impact on the
potency of the Pertuzumab/Trastuzumab mixture stored at 30 C for 24 hours
compared to its
corresponding TO dose response curve (Figure 23). The Trastuzumab alone showed
little activity in
the Pertuzumab potency assay. The Pertuzumab/Trastuzumab mixture dose response
curve compared
to the dose response curve of Pertuzumab or Trastuzumab alone showed that
lower doses of the
Pertuzumab/Trastuzumab mixture were needed to inhibit the growth of cells as
compared to
Pertuzumab alone, suggesting there may be an additive or synergistic effect on
the inhibition of cell
proliferation for the mixture.
Dose II: 1560mg total Pertuzumab/Trastuzumab mixture (Ming Pertuzumab and
720mg
Trastuzumab)
In addition to the dose I study at 840mg total mAb, a higher dose of 1560mg
mixture (840mg
Pertuzumab and 720mg Trastuzumab), and their individual drug product controls
(840mg
Pertuzumab alone and 720mg Trastuzumab alone) was selected to investigate the
impact of diluting
these three mAb types in PO or PVC IV infusion bags at 5 C or 30 C for up to
24 hours. The product
quality of these IV infusion bags before and after storage was assessed by
CAC, UV-spec scan
(concentration and turbidity), and HIAC- ROYCOTm are summarized in Table 13
and SEC and EEC
are shown in Figures 24-27.
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Table 13: Dose II 1560mg: Stability data for Pertuzumabffrastuzumab mixture,
Pertuzumab, or Trastuzumab in 0.9% saline PO IV infusion bags (n=1 for
control; n=2 for
mixture)
IV bag
Sample type Amount Temp Timepoint CAC'
Conc. Turbidity Light Obscuration
total total
particles
particles
mg C Hour(s) liquid
mg/mL AU > lOuriihnL > 25um/mL
pertuzumab/
trastuzumab PO 1560 5 0 CL, CO 4.9 0.013
20 1
mixture 24 CL, CO 4.7 0.016 15
1
1560 30 0 CL, CO 5.0 0.014 8 0
24 CL, CO 4.9 0.018 18
0
pertuzumab PO 840 5 0 CL, CO 2.9 0.007 1
0
24 CL, CO 2.9 0.005 6 0
840 30 0 CL, CO 2.8 0.006 6
0
24 CL, CO 2.8 0.004 9 0
trastuzumab PO 720 5 0 CL, CO 2.6 0.004 4
0
24 CL, CO 2.6 0.005 13
0
720 30 0 CL, CO 2.5 0.007
19 0
24 CL, CO 2.5 0.004 14
0
pertuzumab/
trastuzumab PVC 1560 5 0 CL, CO 4.9 0.016
18 0
mixture 24 CL, CO 4.7 0.015 18
0
1560 30 0 CL, CO 4.8 0.016 24 0
24 CL, CO 4.8 0.012 17
0
pertuzumab PVC 840 5 0 CL, CO 2.9 0.006
13 0
24 CL, CO 2.7 0.004 10
0
840 30 0 CL, CO 2.8 0.006 6
0
24 CL, CO 2.8 0.006 11
0
=
trastuzumab PVC 720 5 0 CL, CO 2.5 0.007 7
0
24 CL, CO 2.5 0.004 9 0
720 30 0 CL, CO 2.5 0.003
18 0
24 CL, CO 2.5 0.005 19
0
a Color, Appearance and Clarity: CL =clear ; SOPL= slightly opalescent, CO=
colorless.
Two PO or PVC IV infusion bags each were prepared for the
Pertuzumab/Trastuzumab mixture
condition while only one IV infusion bag was prepared for the Pertuzumab and
Trastuzumab alone
samples.
Particulates from these bags were determined by visual observation, turbidity,
and HIAC-Royco
measurements. All samples appeared clear and colorless after storage at 5 C or
30 C for up to 24
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hours. No visible particulate matter was observed and there was no significant
change in the turbidity
post storage. For the Pertuzumab/ Trastuzumab mixture, Pertuzumab alone, and
Trastuzumab alone,
the HIAC-Royco showed comparable particle values before and after storage,
with zero to 10
particles increase per milliliter at >10 grn and zero particle increase per
milliliter at >25 gm for both
PO and PVC IV infusion bags stored at either 5 C or 30 C. Similarly, the
Pertuzumab and
Trastuzumab alone samples also exhibited no significant particle differences
before and after storage
in PO or PVC IV infusion bags. For all three sample types, the UV-spec scan
showed no changes
beyond normal assay variability in protein concentration, indicating the
absence of protein adsorption
or precipitation in the IV infusion bags between TO and T24 hours at 5 C or 30
C storage.
The Pertuzumab/ Trastuzumab mixture, Pertuzumab alone, and Trastuzumab alone
samples were
analyzed using Pertuzumab or Trastuzumab specific SEC and IEC methods to
assess their physical
and chemical stability, respectively, as previously described. For the
Pertuzumab/ Trastuzumab
mixture, no changes in SEC were observed in the chromatographic profiles
between the TO and the
T24 hour samples at 5 C or 30 C in either PO or PVC IV infusion bags (Figures
24 and 25), similar
to the 840mg mixture dose I results. In addition, no increase or decrease in
the high molecular weight
species (HMWS), main peak, and low molecular weight species (LMWS) was
observed, which
indicates a stable dosing solution at the upper ranges of protein content in
0.9% saline. Likewise,
Pertuzumab alone and Trastuzumab alone samples also showed no changes after
storage in the IV
infusion bags.
fEC analysis, using both the Pertuzumab or Trastuzumab specific methods, of
the Pertuzumab/
Trastuzumab mixture was used to assess chemical stability and showed
comparable charge variant
peak profiles with no observed changes relative to the initial time point
after exposure to 5 C or 30 C
in the PO or PVC IV infusion bags (Figures 26 and 27). Although a significant
overlap of the charge
variant species of the two mAbs were observed, these peaks species were not
impacted from the
increase in the triAb content of the IV infusion bag. Pertuzumab alone or
Trastuzumab alone samples
in PO or PVC IV infusion bags showed no changes before and after exposure to 5
C or 30 C. These
results are consistent with the 840mg dose I study.
CONCLUSION
All physicochemical assays indicate no significant changes in the mixtures (up
to 840mg
Pertuzumab and 720mg Trastuzumab for a 1560mg total dose) or in the individual
Pertuzumab (up to
840mg) and Trastuzumab (up to 720mg) IV infusion bags (PO or PVC) for TO to
T24 hours at 5 C or
30 C. Furthermore, the potency of the mixture (up to 840mg) and the individual
mAbs before and
after storage were comparable. No differences were observed in the IV bags
that contained the
admixture of Pertuzumab and Trastuzumab when compared to the individual mAb
components in IV
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bags over the course of this study. The current study also demonstrates that
many of the assays used
to measure the individual mAbs were sufficient to qualitatively characterize
the admixture,
EXAMPLE 7
Co-Administration of Pertuzumab and Trastuzumab, and
Combination Therapy with Vinorelbine
This is a randomized, two-arm, open-label, multicenter Phase H trial to
evaluate Pertuzumab in
patients with HER2-positive advanced breast cancer (metastatic or locally
advanced) who have not
previously received systemic non-hormonal anticancer therapy in the metastatic
setting. The study
design is shown in Figure 28.
Patients are randomly assigned in a 2:1 ratio to one of two treatment arms:
= Pertuzumab given in combination with Trastuzumab and vinorelbine (Arm A)
= Trastuzumab and vinorelbine (control arm Arm B)
Arm A will consist of two cohorts as follows:
Cohort 1: (first 95 patients): Pertuzumab and Trastuzumab administered
sequentially in
=
separate infusion bags, followed by vinorelbine. Patients will receive
Pertuzumab followed by
Trastuzumab sequentially in separate infusion bags, followed by vinorelbine.
Pertuzumab (IV infusion)
Administered on Day 1 of the first treatment cycle as a loading dose of 840
mg, followed by
420 mg on Day 1 of each subsequent 3 weekly cycle.
Initial infusions of Pertuzumab will be administered over 90 ( 10) minutes
and patients
observed for at least 30 minutes from the end of infusion for infusion-related
symptoms such as
fever, chills etc. Interruption or slowing of the infusion may reduce such
symptoms. If the infusion is
well tolerated, subsequent infusions may be administered over 30 ( 10)
minutes with patients
observed for a further 30 minutes.
Trastuzumab (IV infusion)
Day 1 of the first treatment cycle as a loading dose of 8 mg/kg, followed by 6
mg/kg on Day
1 of each subsequent 3 weekly cycle; to be administered in line with product
labeling.
Vinorelbine (IV infusion after Trastuzumabl
Day 1 and Day 8 of the first treatment cycle at a dose of 25 mg/m2 followed by
30-35 mg,/m2
on Day 1 and Day 8 of each subsequent 3 weekly cycle; to be administered in
line with product
labeling.
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Cohort 2: The second 95 patients will receive Pertuzumab and Trastuzumab
administered
together in a single infusion bag from Cycle 2 onwards, followed by
vinorelbine.
Cycle I dosing
For the first cycle of treatment, Pertuzumab and Trastuzumab will be
administered in separate
infusion bags as described for Cohort 1.
Vinorelbine will be administered after Pertuzumab and Trastuzumab as described
for Cohort 1.
Subsequent cycle dosing
If administration of all three drugs was well tolerated in Cycle 1, then on
Day 1 of each subsequent 3
weekly treatment cycle, Pertuzumab 420 mg and Trastuzumab 6 mg/kg will be
given together in a
single infusion bag.
The first combined infusion of Pertuzumab and Trastuzumab should be
administered over 90
( 10) minutes with cardiac monitoring and close observation for infusion-
associated reactions during
the procedure, followed by a 60 minute observation period. If this first
combined infusion is well
tolerated, subsequent combined infusions can be administered over 60 ( 10)
minutes followed by a
30 minute observation period with cardiac monitoring.
Vinorelbine will he administered after Pertuzumab and Trastuzumab as described
for Cohort 1.
Control arm - Arm B
A total of 95 patients will be randomized to arm B.
Trastuzumab (IV infusion)
Day 1 of the first treatment cycle as a loading dose of 8 mg/kg, followed by 6
mg/kg on Day 1 of
each subsequent 3 weekly cycle; to be administered in line with product
labeling.
Vinorelbine (IV infusion after Trastuzumab)
Day 1 and Day 8 of the first treatment cycle at a dose of 25 mg/m2 followed by
30-35 mg/m2 on Day
1 and Day 8 of each subsequent 3 weekly cycle; to be administered in line with
product labeling.
Efficacy Outcomes:
Primary
= To compare objective overall response rates (ORR) assessed by a blinded
independent review
committee (IRC) of Pertuzumab given in combination with Trastuzumab and
vinorelbine versus
Trastuzumab and vinorelbine
Secondary
= Within the Pertuzumab treatment group to compare the efficacy and safety
of Pertuzumab and
Trastuzumab administered together in a single infusion bag versus conventional
sequential
administration in separate infusion bags
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= To compare Pertuzumab given in combination with Trastuzumab and
vinorelbine versus
Trastuzumab and vinorelbine with respect to:
o ORR assessed by the Investigator
o Time to response assessed by IRC and Investigator
o Duration of response assessed by 1RC and Investigator
o Progression free survival (PFS)
o Time to progression ( FfP)
o Overall survival (OS)
o Safety and tolerability
Quality of life (EQ-5D and FACT-B questionnaires)
Inclusion Criteria
Patients must meet the following criteria to be eligible for this study
according to the timing of the
Schedule of Assessments:
1. Female or male patients aged 18 years or older
=
2. Histologically or cytologically confirmed and documented adenocarcinoma of
the breast with
metastatic or locally advanced disease not amenable to curative resection
3. HER2-positive (defined as either immunohistochemistry (IHC) 3+ or in
situ hybridization
(ISH) positive) as assessed by local laboratory on primary or metastatic tumor
(ISH positivity
is defined as a ratio of 2.0 or greater for the number of HER2 gene copies to
the number of
signals for CEP17, or for single probe tests, a HER2 gene count greater than
4).
4. At least one measurable lesion and/or non-measurable disease evaluable
according to
Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1
5. ECOG performance status 0 or 1
6. Left ventricular ejection fraction (LVEF) of at least 50%
7. Negative pregnancy test in women of childbearing potential (premenopausal
or less than 12
months of amenorrhea post-menopause, and who have not undergone surgical
sterilization)
8. For women of childbearing potential who are sexually active,
agreement to use a highly-
effective, non-hormonal form of contraception or two effective forms of non-
hormonal
contraception during and for at least 6 months post study treatment
9. Fertile males willing and able to use effective non-hormonal means of
contraception (barrier
method of contraception in conjunction with spermicidal jelly, or surgical
sterilization)
during and for at least 6 months post-study treatment
10. Life expectancy of at least 12 weeks
Exclusion Criteria
Patients who meet any of the following exclusion criteria will not be eligible
for this study:
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I. Previous systemic non-hormonal anticancer therapy in the
metastatic or locally advanced breast
cancer setting
2. Previous approved or investigative anti-HER2 agents in any breast cancer
treatment setting,
except Trastuzumab in the adjuvant or neoadjuvant setting
3. Disease progression while receiving Trastuzumab in the adjuvant or
neoadjuvant setting
4. Disease-free interval from completion of adjuvant or neo-adjuvant
systemic non-hormonal
treatment to recurrent disease of less than 6 months
5. History of persistent grade 2 or higher (NCI-CTC, Version 4.0)
hematological toxicity resulting
from previous adjuvant or neoadjuvant therapy
6. Radiographic evidence of central nervous system (CNS) metastases as
assessed by CT or IVIRI
7. Current peripheral neuropathy of grade 3 or greater (NCI-CTC, Version
4.0)
8. History of other malignancy within the last 5 years, except for
carcinoma in situ of the cervix or
basal cell carcinoma
9. Serious uncontrolled concomitant disease that would contraindicate the
use of any of the
investigational drugs used in this study or that would put the patient at high
risk for treatment
related complications
10. Inadequate organ function, evidenced by the following laboratory results:
= Absolute neutrophil count <1,500 cells/mm3
= Platelet count <100,000 cells/mm3
= Hemoglobin <9 g/dL
= Total bilirubin greater than upper limit of normal (ULN) (unless the
patient has
documented Gilbert's syndrome)
= AST (SGOT) or ALT (SGPT) >2.5 x ULN
= AST (SGOT) or ALT (SGPT) >1.5 x ULN with concurrent serum alkaline
phosphatase
>2.5 x ULN; Serum alkaline phosphatase may be >2.5 x ULN only if bone
metastases
are present and AST (SGOT) and ALT (SGPT) <1.5 x ULN
1 = Serum creatinine >2.0 mg/dL or 177 pmol/L
= International normalized ratio (INR) and activated partial thromboplastin
time or partial
thromboplastin time (aPTT or PTT) >1.5 x ULN (unless on therapeutic
coagulation)
11. Uncontrolled hypertension (systolic >150 mm Hg and/or diastolic >100 mm
Hg) or clinically
significant (i.e. active) cardiovascular disease: cerebrovascular accident
(CVA)/stroke or
myocardial infarction within 6 months prior to first study medication,
unstable angina, congestive
heart failure (CHF) of New York Heart Association (NYHA) grade II or higher,
or serious
cardiac arrhythmia requiring medication
12. Current known infection with HIV, HBV, or HCV
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13. Dyspnea at rest due to complications of advanced malignancy, or other
disease requiring
continuous oxygen therapy
14. Major surgical procedure or significant traumatic injury within 28 days
prior to randomization or
anticipation of need for major surgery during the course of study treatment
.. 15. Receipt of intravenous (IV) antibiotics for infection within 14 days
prior to randomization
16. Current chronic daily treatment with corticosteroids (dose equivalent to
or greater than
mg/day methylprednisolone), excluding inhaled steroids
17. Known hypersensitivity to any of the study medications or to excipients of
recombinant human
or humanized antibodies
10 18. History of receiving any investigational treatment within 28 days
prior to randomization
19. Concurrent participation in any clinical trial
It is anticipated that the treatment herein will demonstrate the safety and
efficacy of co-
administration of pertuzmab and Trastuzumab from the same intravenous (IV) bag
to patients with
HER2-positive cancer (exemplified by HER2-positive breast cancer), as well as
the safety and
efficacy of Pertuzumab in combination in vinorelbine according to any one or
more of the primary or
secondary efficacy outcomes above.
EXAMPLE 8
Pertuzumab Combined with Aromatase Inhibitors
This example is a randomized, two-arm, open-label, multicenter phase H study
demonstrating
the efficacy and safety of Pertuzumab given in combination with Trastuzumab
plus an aromatase
inhibitor in first line patients with HER2-positive and hormone receptor-
positive advanced
(metastatic or locally advanced) breast cancer.
Primary Objectives
To compare progression-free survival (PFS) of Pertuzumab given in combination
with
Trastuzumab plus an aromatase inhibitor (AI) versus Trastuzumab plus an AT.
Secondary Objectives
To compare Pertuzumab given in combination with Trastuzumab plus an AT versus
Trastuzumab plus an Al with respect to:
- Overall survival (OS)
- Overall response rate (ORR)
- Clinical benefit rate (CBR)
- Duration of response
- Time to response
- Safety and tolerability
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- Quality of life (EQ-5D questionnaires)
Trial Design
Patients will be randomly assigned in a 1:1 ratio to one of two treatment
arms:
- Pertuzumab in combination with Trastuzumab plus an Al (Arm A).
- Trastuzumab plus an Al (control arm Arm B).
At the investigator's discretion, patients may also receive induction
chemotherapy (a taxane,
either Docetaxel or paclitaxel), in combination with the assigned monoclonal
antibody treatment arm
up to the first 18 weeks of the treatment period. In patients receiving
induction chemotherapy,
treatment with the AT will start after the chemotherapy induction phase.
Stratification factors for analysis will be:
- Chosen to receive induction chemotherapy (Yes/No).
- Time since adjuvant hormone therapy (<12 months, >12 months, or no
prior hormone
therapy).
Patients with HER2-positive and hormone receptor-positive (estrogen receptor
(ER)-positive
and/or progesterone receptor (PgR)-positive) advanced breast cancer
(metastatic or locally advanced)
who have not previously received systemic nonhormonal anticancer therapy in
the metastatic setting.
Inclusion Criteria
1, Age greater than or equal to 18 years.
2. Postmenopausal status >1 year (fulfilling one or more of National
Comprehensive Cancer Network
(NCCN) guideline criteria, Version 2.2011).
3. Histologically or cytologically confirmed and documented adenocarcinoma of
the breast with
metastatic or locally advanced disease not amenable to curative resection.
4. HER2-positive (defined as either 1HC 3+ or ISH positive) as assessed by
local laboratory on
primary or metastatic tumor (ISH positivity is defined as a ratio of 2.0 or
greater for the number of
HER2 gene copies to the number of signals for CEP17, or for single probe
tests, a HER2 gene count
greater than 4).
5. Hormone receptor-positive defined as ER-positive and/or PgR-positive
assessed locally as defined
by institutional criteria.
6. At least one measurable lesion and/or non-measurable disease evaluable
according to Response
Evaluation Criteria In Solid Tumors (RECIST) version 1.1.
7. ECOG performance status 0 or 1.
8. Left ventricular ejection fraction (LVEF) of at least 50%.
9. Life expectancy of at least 12 weeks.
Exclusion Criteria
1. Previous systemic non-hormonal anticancer therapy in the metastatic or
locally advanced breast
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cancer setting.
2. Disease-free interval from completion of adjuvant or neo-adjuvant systemic
non-hormonal
treatment to recurrence of within 6 months.
3. Previous approved or investigative anti-HER2 agents in any breast cancer
treatment setting, except
Trastuzumab and/or lapatinib in the neoadjuvant or adjuvant setting.
4. Disease progression while receiving Trastuzumab and/or lapatinib in the
adjuvant setting.
5. History of persistent grade 2 or higher (NCI-CTC, Version 4.0)
hematological toxicity resulting
from previous adjuvant or neo-adjuvant therapy.
6. Radiographic evidence of central nervous system (CNS) metastases as
assessed by CT or MRI.
7. Current peripheral neuropathy of grade 3 or higher (NCI-CTC, Version 4.0).
8. History of other malignancy within the last 5 years, except for carcinoma
in situ of the cervix or
basal cell carcinoma.
9. Serious uncontrolled concomitant disease that would contraindicate the use
of any of the
investigational drugs used in this study or that would put the patient at high
risk for treatment related
complications.
10. Inadequate organ function, evidenced by the following laboratory results:
- Absolute neutrophil count <1,500 ce115/mm3.
- Platelet count <100,000 cells/mm.3.
- Hemoglobin <9 g/dL.
- Total bilirubin greater than the upper limit of normal (ULN) (unless the
patient has documented
Gilbert's syndrome).
- AST (SGOT) or ALT (SGPT) >2,5 x ULN.
- AST (SGOT) or ALT (SGPT) >1,5 x ULN with concurrent serum alkaline
phosphatase >2.5 x
ULN Serum alkaline phosphatase may be >2.5 x ULN only if bone metastases are
present and AST
(SGOT) and ALT (SGPT) <1.5 x ULN.
- Serum creatinine >2.0 mg/dL or 177 mon.
- International normalized ratio (INR) and activated partial thromboplastin
time (aPTT) or partial
thromboplastin time (PTT) >1.5 x ULN (unless on therapeutic coagulation).
11. Uncontrolled hypertension (systolic >150 mm Hg and/or diastolic >100 mm
Hg) or clinically
significant (i.e. active) cardiovascular disease: cerebrovascular accident
(CVA)/stroke or myocardial
infarction within 6 months prior to first study medication, unstable angina,
congestive heart failure
(CHF) of New York Heart Association (NYHA) grade II or higher, or serious
cardiac arrhythmia
requiring medication.
12. Current known infection with HIV, HBV, or HCV.
13. Dyspnea at rest due to complications of advanced malignancy, or other
disease requiring
continuous oxygen therapy.
14. Major surgical procedure or significant traumatic injury within 28 days
prior to randomization or
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anticipation of needed for major surgery during the course of study treatment.
15. Lack of physical integrity of the upper gastrointestinal tract, clinically
significant malabsorption
syndrome, or inability to take oral medication.
16. Receipt of intravenous antibiotics for infection within 14 days prior to
randomization.
17. Current chronic daily treatment with corticosteroids (dose of 10 mg/day
methylprednisolone
equivalent), excluding inhaled steroids.
18. Known hypersensitivity to any of the study medications or to excipients of
recombinant human or
humanized antibodies.
19. History of receiving any investigational treatment within 28 days prior to
randomization.
20. Concurrent participation in any clinical trial.
Arm A
Pertuzumab (IV infusion)
Administered on Day 1 of the first treatment cycle as a loading dose of 840
mg, followed by 420 mg
on Day 1 of each subsequent 3 weekly cycle.
Initial infusions of Pertuzumab will be administered over 90 ( 10) minutes and
patients
observed for at least 30 minutes from the end of infusion for infusion-related
symptoms such as
fever, chills etc. Interruption or slowing of the infusion may reduce such
symptoms. If the infusion is
well tolerated, subsequent infusions may be administered over 30 ( 10)
minutes with patients
observed for a further 30 minutes.
Trastuzumab (IV infusion administered after Pertuzumab) Day 1 of the first
treatment cycle
as a loading dose of 8 mg/kg, followed by 6 mg/kg on Day 1 of each subsequent
3 weekly cycle; to
be administered in line with product labeling.
AT (oral)
Administered in line with product labeling (anastrozole: 1 mg once daily;
letrozole: 2.5 mg
once daily).
Induction chemotherapy
Patients receiving induction chemotherapy up to the first 18 weeks of the
treatment period
will receive a taxane (Docetaxel every 3 weeks or paclitaxel weekly),
administered in line with the
1 30 respective product labeling. Chemotherapy will be administered
after the monoclonal antibody
(Pertuzumab and/or Trastuzumab) infusions.
In patients receiving induction chemotherapy treatment with the Al will start
after the
chemotherapy induction phase.
Control arm - Arm B
Trastuzumab (IV infusion)
Day 1 of the first treatment cycle as a loading dose of 8 mg/kg, followed by 6
mg/kg on Day
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1 of each subsequent 3 weekly cycle; to be administered in line with product
labeling.
Al (oral)
Administered in line with product labeling (anastrozole: 1 mg once daily;
letrozole; 2.5 mg
once daily).
Induction chemotherapy
Same as for investigational arm.
Primary Efficacy Outcome
PFS (defined as the time from randomization until the first radiographically
documented
progression of disease or death from any cause, whichever occurs first).
Secondary Efficacy Outcome
- OS
- ORR
- CBR
- Duration of response
- Time to response
Safety
- Incidence and severity of adverse events (AEs) and serious
adverse events (SAEs)
- Incidence of Cl-IF
=
- LVEF over the course of the study
- Laboratory test abnormalities
It is anticipated that the the combination of Pertuzumab, Trastuzumab and Al
will be safe and
effective in the patient population and that the addition of Pertuzumab to
Trastuzumab and an Al will
extend progression-free survival (PFS) compared to Trastuzumab plus an Al
without Pertuzumab.
EXAMPLE 9
Pertuzumab for Improving Overall Survival (OS) in Cancer Patients
Background: In the CLEOPATRA study in Example 3 above, 808 pts with HER2-
positive
first-line (IL) metastatic breast cancer (MBC) were randomized to treatment
with
Placebo+Trastuzumab+ Docetaxel (Pla+T+ D) or Pertuzumab+Trastuzumab+Docetaxel
(P+T+D).
The primary endpoint of independently reviewed progression-free survival was
significantly
improved with P+T+D vs Pla+T+D (hazard ratio (HR)=0.62; P<0.0001; medians,
18.5 vs 12.4 mths)
(Example 3 above). This example includes a second interim overall survival
(OS) analysis after
longer follow-up.
Methods: This interim overall survival (OS) analysis was performed applying
the Lan-
DeMets a-spending function with the O'Brien-Fleming (OBF) stopping boundary to
maintain the
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overall Type I error at 5%. Based on the number of OS events observed, the OBF
boundary for
statistical significance at this analysis was P<0.0138. The log-rank test,
stratified by prior treatment
status and geographic region, was used to compare OS between arms in the
intention-to-treat
population. The Kaplan-Meier approach was used to estimate the median OS in
both arms; a
stratified Cox proportional hazard model was used to estimate HR and 95% CIs.
Subgroup analyses
of OS were performed for the stratification factors and other key baseline
characteristics.
Results: At the time of this analysis, median follow-up was 30 mths and 267
deaths (69% of
planned events for the final analysis) had occurred. The results showed a
statistically significant
improvement in OS in favor of P+T+D (HR=0.66; 95% confidence interval (CI),
0.52-0.84;
P=0.0008). This HR represents a 34% reduction in the risk of death. The
analysis achieved statistical
significance and is therefore considered the confirmatory OS analysis. The
median OS was 37.6 mths
in the Pia arm and has not yet been reached in the P arm. The treatment effect
was generally
consistent in predefined subgroups based on baseline variables and
stratification factors, including:
prior (neo)adjuvant therapy (HR-=0,66; 95% CI, 0.46-094); no prior
(neo)adjuvant therapy
(HR=0.66; 95% Cl, 0.47-0.93); prior (neo)adjuvant T (HR=0.68; 95% CI, 0.30-
1.55); hormone
receptor-negative disease (HR=0.57; 95% CI, 0.41-0.79); and hormone receptor-
positive disease
(HR=0.73; 95% CI, 0.50-1.06). Kaplan-Meier estimates of OS rates show survival
benefit with
P+T+D at 1, 2, and 3 yrs.
Table 14: Overall Survival Benefit with Pertuzumab
Pla+T+D P+T+D A
Survival rates, %
1 yr 89.0 94.4 5.4
2 yrs 69.4 80.7 11.3
3 yrs 50.4 65.8 15.4
The majority of pts received anti-cancer therapy after discontinuation of
study treatment
(64% Pla arm, 56% P arm). Subsequent therapy with HER2-directed agents (T,
lapatinib, T
emtansine) was balanced between arms. Causes of death remained unchanged from
the first interim
OS analysis, with the most common cause being progressive disease. Adverse
events leading to death
were rare and balanced between arms.
Conclusions: Treatment of pts with HER2-positive IL MBC with P+T+D compared
with
Pla+T+D was associated with an improvement in OS, which was both statistically
significant and
clinically meaningful. These results show that combined HER2 blockade and
chemotherapy using the
P+T+D regimen can be considered a standard of care for pts with HER2-positive
MBC in the 1L
setting.
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These data regarding OS can be included on the package insert with prescribing
information
regarding Pertuzumab in an article of manufacture as in Example 4 above, for
example.
EXAMPLE 10
Pertuzumab and Trastuzumab with a Taxane as First-Line Therapy for Patients
with HER2-
Positive Advanced Breast Cancer (PERUSE)
Background: Pertuzumab (P), a humanized monoclonal antibody, inhibits
signaling
downstream of HER2 by binding to the dimerization domain of the receptor and
preventing
heterodimerization with other HER family members. The epitope recognized by P
is distinct from
that bound by trastuzumab (H) and so their complementary mechanisms of action
result in a more
comprehensive HER2 blockade. Data from the phase III trial CLEOPATRA showed
significantly
improved PFS in patients (pts) receiving P + H + docetaxel compared with H +
docetaxel + placebo
as first-line treatment for HER2-positive metastatic breast cancer (BC),
Trial design: This is a phase 1Mb, multicenter, open-label, single-arm study
in pts with
HER2-positive metastatic or locally recurrent BC who have not been treated
with systemic
nonhormonal anticancer therapy for metastatic cancer. Pts will receive, P: 840
mg initial dose, 420
mg q3w IV; H: 8 mg/kg initial dose, 6 mg/kg q3w IV; taxane: docetaxel,
paclitaxel, or nab-paclitaxel
according to local guidelines. Treatment will be administered until disease
progression or
unacceptable toxicity. A planned protocol amendment will allow hormone
receptor-positive pts to
receive endocrine therapy alongside P+H after completion of taxane therapy, in
line with clinical
practice.
Eligibility criteria: At baseline, pts must have an LVEF of >50%, an ECOG PS
of 0, 1, or 2,
a disease-free interval of >6 months, and must not have received prior anti-
HER2 agents for the
treatment of metastatic BC. Prior H and/or lapatinib in the (neo)adjuvant
setting is permitted,
providing there was no disease progression during treatment. Pts must not have
experienced other
malignancies within the last 5 yrs other than carcinoma in situ of the cervix
or basal cell carcinoma.
There must be no clinical or radiographic evidence of CNS metastases or
clinically significant
cardiovascular disease.
Specific aims: As H was not widely available in the (neo)adjuvant setting
prior to
CLEOPATRA recruitment, a relatively low proportion of pts in CLEOPATRA had
previously
received H. PERUSE will assess the safety and tolerability of P+H + choice of
taxane as first-line
therapy for pts with HER2-positive metastatic or locally advanced BC in a pt
population likely to
have experienced wider exposure to prior H therapy,
Statistical methods: The primary endpoints of the PERUSE study are safety and
tolerability.
Secondary endpoints include PFS, OS, ORR, CBR, duration of response, time to
response and QoL.
The final analysis will be performed when 1500 pts have been followed up for
at least 12 months
after the last pt receives last study treatment unless they have been lost to
follow-up, withdrawn
consent, or died, or if the study is prematurely terminated by the sponsor.
Safety analyses are planned
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after enrollment of ¨350, 700, and 1000 pts. Additionally, a data and safety
monitoring board will
review safety data after ¨50 pts have been enrolled and then every 6 months.
It is anticipated that the pertuzumab and trastuzumab with a taxane will be
effective as first-
line therapy for patients with HER2-positive advanced breast cancer according
to the protocol in this
example.
EXAMPLE 11
Pertuzumab in Combination with Chemotherapy in Low HER3 Ovarian Cancer
Epithelial ovarian cancer, along with primary peritoneal, and fallopian tube
carcinoma, is the
fifth leading cause of cancer-related deaths in women in Europe (Bray et at.
Int. J. Cancer 113:977-
90 (2005)). Ovarian cancer is often not diagnosed until it has progressed to
an advanced stage, at
which point the standard treatment is surgical resection followed by
chemotherapy. Although the
addition of taxanes to platinum-based chemotherapy has resulted in
approximately 80% of patients
achieving complete response (CR), the disease recurs in most patients, and
more than 50% of patients
diagnosed with epithelial ovarian cancer eventually die from their disease (Du
Bois et at. Cancer
115:1234-1244 (2009)). Following failure of platinum-based chemotherapy, there
are few therapeutic
options. Patients with platinum-sensitive disease (disease recurrence occurs
more than 6 months after
last cycle of platinum-based chemotherapy) are often retreated with platinum-
based therapy and have
a progression-free survival (PFS) of approximately 9-10; however, for patients
with primary
platinum-resistant disease, the prognosis is considerably worse. For these
patients, re-treatment with
platinum-based therapy or surgery is not reasonable, instead, patients with
platinum-resistant are
often treated with single-agent chemotherapy such as topotecan, pegylated
liposomal doxorubicin
(PLD), paclitaxel and gemcitabine.
Objective response rates for patients with platinum-resistant disease ranges
between 10-20%
while median progression free survival (PFS) ranges between 3.5-4 months.
Platinum-resistant
disease is not curable; the goals of treatment for these patients include
palliation of symptoms,
prolonged survival and improvements in quality of life (QoL). Overall, results
from major clinical
trials conducted over the last 20 years show that the median PFS for patients
with advanced disease
ranges between 16-23 months while median overall survival (OS) ranges between
31-65 months.
The majority of ovarian cancer cell lines and many ovarian cancer biopsy
samples express all
members of the HER family of receptors (Campiglio et at. J. Cell Biochem
73:522-32 (1999)). EGFR
and HER2 have been studied the most extensively, and multiple agents targeting
the receptor or
associated intracellular tyrosine kinases have been tested.
In a recent study, quantitative HER2 protein analyses demonstrated that
malignant ovarian
tumors have significantly higher levels of HER2 compared with benign ovarian
tumors and normal
ovaries. Furthermore, a correlation between HER2 and HER3 protein levels has
been seen
(Steffensen et al. Int J Oncol. 33:195-204 (2008)). Studies in cell culture
systems have shown that
heregulin-activated HER3¨HER2 heterodimers elicit the strongest proliferative
and transformation
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responses of any possible receptor combination (Pinkas-Kramarski et at. EMBO
J. 15:2452-67
(1996); Riese et al. Mol Cell Biol 15:5770-6 (1995). Erratum in: Mol Cell Biol
16:735 (1996)). The
potency of these biologic responses is likely the result of the dual and
efficient activation of the MAP
kinase and PI3 kinase pathways. Furthermore, HER3 is the most potent activator
of the PI3
kinase/AKT pathway (Olayioye et al. EMBO J 19:3159-67 (2000)). Studies in HER2-
amplified
breast cancer cell lines show that HER3 but not EGFR was critical for HER2
signaling, and that
HER3 inhibited growth in three-dimensional culture and induced rapid tumor
regression of in vivo
xenografts (Lee-Hoeflich et al. Cancer Res 68:5878-87 (2008)).
Additionally, HER3 expression has been implicated as a possible risk factor in
ovarian
cancer (Tanner et al. J Clin Oncol 24:4317-23 (2006)).
In a Phase II multicenter trial (TOC2689g) in patients with advanced ovarian
cancer that recurred after treatment with or were refractory to platinum-based
chemotherapy, patients
who were enrolled in Cohort 1 (n=61) received a loading dose of 840 mg
pertuzumab, followed by
420 mg pertuzumab on Day I of each 3-week cycle, and patients in Cohort 2
(n=62) received 1050
mg pertuzumab on Day 1 of each 3-week cycle. Similar outcomes were observed in
both cohorts in
terms of overall response rate and median PFS. Eight patients (4 in each
cohort) had evidence of
stable disease (SD) lasting at least 6 months. Median PFS and OS were 6.6
weeks and 52.7 weeks,
respectively, for the overall population.
The results of this study led to two randomized Phase II trials in platinum-
sensitive and
platinum-resistant populations. In Study TOC3258g, the efficacy and safety of
gemcitabine +
pertuzumab versus gemcitabine + placebo were evaluated in patients with
advanced ovarian, primary
peritoneal, or fallopian tube cancer that was resistant to platinum-based
chemotherapy (Amler et at. J
Clin Oncol 26:5552 (2008)). The study allowed patients to cross over to
receive pertuzumab at the
time of disease progression. There was a median PFS of 2.6 months in the
gemcitabine + placebo arm
and 2.9 months in the gemcitabine + pertuzumab arm. Median OS was similar
between the treatment
arms. Of the most common adverse events (AEs), those increased (by at least 6
patients) in the
pertuzumab-treated cohort included fatigue, nausea, diarrhea, back pain,
dyspepsia, stomatitis,
headache, epistaxis, rhinorrhea, rash, and Grade 3-4 neutropenia.
In Study B017931, 149 patients with ovarian cancer who experienced a
recurrence 6 months
after a platinum-based therapy were randomized to receive a combination of
paclitaxel and
carboplatin or gemcitabine with or without pertuzumab. After 6 treatment
cycles, chemotherapy was
discontinued, and patients in the chemotherapy + pertuzumab arm continued to
receive pertuzumab
alone for up to 11 additional cycles (total of 17 cycles of pertuzumab). There
were no significant
differences in the PFS or OS for the overall group. Median PFS was 34.1 weeks
for the
chemotherapy + pertuzumab group versus 31.3 for the chemotherapy alone group;
however, an
exploratory subset analyses of HER3 mRNA expression with a treatment-free
interval of 6-12
months indicated a trend toward clinical benefit in patients who express high
levels of HER3 mRNA
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(Kaye et al. J Clin Oncol 26:5520 (2008)).
Archival tissue samples from patients enrolled in both randomized Phase II
studies were
examined by quantitative reverse transcriptase polymerase chain reaction (qRT-
PCR) for mRNA
expression levels of the HER receptors EGFR, HER2, HER3, and two HER ligands:
amphiregulin
and betacellulin.
Only tumor HER3 mRNA expression was associated with a significant difference
in PFS.
For patients who achieved a clinical response, PRs were observed in 9 patients
on the gemcitabine +
pertuzumab arm and 3 on the gemcitabine + placebo arm. Six of the gemcitabine
+ pertuzumab
patients with PRs had tumor HER3 mRNA levels lower than the median level. In
contrast, no patients
in the gemcitabine + placebo arm whose tumor HER3 mRNA levels were lower than
the median
level of the study population experienced a PR. An additional 6 patients
achieved PRs, and all of
these patients had tumor HER3 mRNA levels at or above the median level of the
study population.
Of these patients, 3 received gemcitabine + pertuzumab and 3 received
gemcitabine + placebo,
suggesting no effect of pertuzumab in this population.
Patients with low HER3 mRNA expression (lower than the median level of the
study
population) demonstrated a PFS hazard ratio (HR) of 0.32 in contrast to1.68
for patients with HER3
mRNA expression greater than or equal to the median level; i.e. the effect of
adding pertuzumab
trended in the opposite direction. No significant benefit was detected in OS
for patients with low
HER3 mRNA expression; however, a trend toward greater OS was observed in
patients receiving
pertuzumab. The OS for patients expressing high HER3 mRNA expression
demonstrated an HR of
1.59.
To assess the prognostic value, HER3 mRNA expression was correlated with PFS
and OS for
patients in the gemcitabine + placebo arm. Median PFS was 1.4 months for
patients with low HER3
mRNA expression (n = 35), comparedwith 5.5 months for patients with high HER3
mRNA
expression (n = 24). Similarly, median OS for patients with low HER3 mRNA
expression was 8,4
months, compared with 18.2 months for patients with high HER3 mRNA expression.
In Study B017931, in patients with low HER3 triRNA expression (lower than the
median
level of this study population), no treatment effect was seen. However, in an
exploratory analysis of
patients with a treatment-free interval of 6-12 months, there was a trend
toward benefit for the
combination of chemotherapy with pertuzumab in terms of PFS.
Overview of this Study
This is a multicenter trial with two parts; a non-randomized safety run-in
Part 1 and a
randomized, double-blind Part 2.
Part 1 will be performed to assess safety and tolerability of pertuzumab in a
new
combination with two chemotherapeutic agents (topotecan or paclitaxel). Part 2
of the trial is a
randomized, double-blind, placebo controlled, two-arm, multicenter,
prospective trial of pertuzumab
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in combination with chemotherapy (topotecan, paclitaxel, or gemcitabine).
Patients will receive trial
medication until disease progression as per the Response Evaluation Criteria
in Solid Tumors
(RECIST) version 1.1, disease progression according to the Gynecologic Cancer
Intergroup (GCIG)
criteria of CA-125 assessable disease, unacceptable toxicity, withdrawal of
consent, or death. PFS
will be assessed in Part 1 of the trial, but due to small number of patients
and PFS events per cohort,
results will be descriptive only. The trial design for Part 1 of the study is
provided in Figure 30.
In Part 2 of the trial, patients will be randomized in a 1:1 ratio to receive
either:
- Arm A: Pertuzumab in combination with chemotherapy (topotecan, paclitaxel,
or gemcitabine), or
- Arm B: Pertuzumab-placebo plus chemotherapy (topotecan, paclitaxel, or
gemcitabine).
The allocation of study medication will be double-blind with respect to
whether the patient
receives pertuzumab or pertuzumab-placebo. The chemotherapy agent allocated
will be at the
discretion of the investigator.
Stratification factors for Part 2 of the trial will be:
- Selected chemotherapy cohort (topotecan vs. paclitaxel vs.
gemcitabine).
- Previous anti-angiogenic therapy (yes vs. no). If a patient has previously
participated in a
blinded trial with an anti-angiogenic agent, the patient will be enrolled in
the same stratum
with patients known to have previously received an anti-angiogenic agent.
- Treatment-free interval (1141) since platinum therapy (strictly less
than 3 months vs. 3 to 6
months inclusive, prior to first study treatment).
The trial design for Part 2 of the study is provided in Figure 31.
Primary Objectives of the Study:
Part 1: The primary objective for Part 1 of this study is to determine the
safety and
tolerability of pertuzumab in combination with either topotecan or paclitaxel.
Part 2: The primary objective for Part 2 of this study is to determine if
pertuzumab plus
chemotherapy is superior to placebo plus chemotherapy as measured by PFS.
Secondary Objectives of the Study:
Part 1: The secondary objective for Part 1 of this study is to evaluate
descriptively the PFS
of pertuzumab in combination with either topotecan or paclitaxel.
Part 2: The secondary objectives for Part 2 of this study are to determine if
pertuzumab plus chemotherapy is superior to placebo plus chemotherapy with
respect to:
- OS.
- Objective response rate. =
- Biological progression-free interval (PFlmo)-
- Safety and tolerability.
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- QoL.
Efficacy Outcome Measures
The following efficacy outcome measures will be measured in Part 1 of the
trial:
-PFS, which is defined as the time from randomization into Part 1 of the
trial, until disease
progression per RECIST version 1.1 or according to GCIG criteria in CA-125
assessable disease or
death from any cause, whichever occurs first.
The efficacy outcome measures for Part 2 of the trial are as follows:
lb - PFS, which is defined as the time from randomization into Part 2 of
the trial, until disease
progression per RECIST version 1.1 or according to GCIG criteria in CA-125
assessable disease or
death from any cause, whichever occurs first.
- OS, defined as the time from randomization into Part 2 of the trial until
death from any
cause.
- Objective response rate (ORR), which will be based on RECIST version 1.1 and
assessed
by the best (confirmed) overall response (BOR); defined as the best response
recorded from the start
of the treatment in Part 2 of the trial until disease progression/recurrence
(taking as reference for PD,
the smallest measurements recorded since the treatment started in Part 2 of
the trial). Patients need to
have two consecutive assessments of partial response (PR) or complete response
(CR) to be a
.. responder. PR or CR has to be confirmed by 2 consecutive tumor evaluations
spaced at least 4 weeks
apart. Only patients with measurable disease at baseline will be included in
the analysis of objective
response.
- Patients who have a response as per RECIST version 1.1 and using the 50%
response
criteria for CA-125 are defined as responders, whereas patients who only have
response as defined
per RECIST are defined as RECIST responders. Patients who do not have a
response as per RECIST,
but have a response defined using the 50% response criteria for CA-125 are
defined as CA-125
responders.
- PFIEno, defined on the basis of a progressive serial elevation of serum CA-
125 (assessed
according to the CGIG criteria) as the time from the date of randomization
into Part 2 of the trial to
first documented increase in CA-125 levels to: two times the upper limit of
normal (for patients with
normal pretreatment CA-125 or elevated pretreatment CA-125 and initial
normalization on-
treatment), or two times the nadir value (for patients with elevated baseline
CA-125 that did not
normalize on-treatment).
.. Safety Outcome Measures
In Part 1 of the study safety and tolerability will be assessed after all
patients have received 3
cycles of treatment.
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In addition, safety outcome measures for this study will be assessed in both
Parts 1 and 2 of
the study, and are as follows:
- Incidence, nature, and severity of all AEs, serious adverse events (SAEs),
AEs with NCI-
CTCAE version 4.0 Grades >3, and AEs that caused premature withdrawal from
study medication.
- Premature withdrawal from the study and study treatment.
- Cardiac disorders / Incidence of congestive heart failure
- Laboratory test abnormalities.
- Left ventricular ejection fraction
Inclusion Criteria
1. Female patients aged 18 years or older.
2. Low HER3 mRNA expression levels (concentration ratio equal or lower than
2.81, as
assessed by qRT-PCR on a COBAS z480 instrument).
3. Histologically or cytologically confirmed and documented epithelial ovarian
cancer that is
platinum-resistant or refractory (defined as progression within 6 months from
completion of a
minimum of 4 platinum therapy cycles or progression during platinum therapy).
==
4. At least one measurable lesion and/or non-measurable disease according to
RECIST
version 1.1, or cancer antigen-125 (CA-125) assessable disease according to
Gynecologic Center
Intergroup (GCIG) criteria. The following histological types are eligible:
- Adenocarcinoma not otherwise specified,
- Clear cell adenocarcinoma.
- Endoinctrioid adenocarcinoma.
- Malignant Brenner's tumor.
- Mixed epithelial carcinoma including malignant mixed
Milaerial.' tumors.
- Mucinous adenocarcinoma.
- Serous adenocarcinoma.
- Transitional cell carcinoma.
- Undifferentiated carcinoma,
5. Eastern Cooperative Oncology Group (ECOG) performance status 0 to 2.
6. LVEF greater than or equal to 55%.
Pertuzumab Dosage and Administration
Pertuzumab and pertuzumab-placebo will be administered as an intravenous
infusion on Day
1 of the first treatment cycle as a loading dose of 840, followed by 420 mg on
Day 1 of each
subsequent 3-weekly cycle. The initial infusion of pertuzumab/pertuzumab-
placebo will be
administered over 60 minutes followed by a 60-minute observational period in a
seated position if the
infusion is well tolerated, subsequent infusions may be given over 30 minutes,
followed by a 30-
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minute observational period, after which the chemotherapy agent will be
administered. Pre-
medication should be implemented according to local practices and the chosen
chemotherapy.
Topotecan Dosage and Administration
Topotecan should be administered 1.25 mg/m2 as a 30-minute intravenous
infusion daily on
Days 1-5 every 3 weeks, as per the directions in the summary of product
characteristics.
Paclitaxel Dosage and Administration
Paclitaxel should be administered 80 mg/m2 as a 1-hour i.v. infusion on Days
1, 8, 15 and
22. Pharmacists should follow the summary of product characteristics for
information regarding the
preparation and administration of the 80 mg/m2 dose.
Gemcitabine Dosage and Administration
Gemcitabine (Part 2 of the study only) should be administered 1000 mg/m2 as a
30-minute
intravenous infusion on Days 1 and 8 every 3 weeks as per the directions
described in the summary
of product characteristics.
HER3 mRNA Expression
Patients will be asked to specifically consent to the collection and testing
of primary tumor
tissue samples to assess HER3 mRNA level, including mRNA and protein levels of
other HER
family receptors e.g. HER2, before they provide consent to participate in the
trial. Only patients who
have tumors expressing low levels of HER3 mRNA will be eligible to participate
in the trial.
During the initial screening for HER3 mRNA levels, other receptors of the
HER family (e.g. EGER, HER2, or HER4) will be assessed at the mRNA level
and/or protein level in
.. parallel to the HER3 assessment, in order to obtain a more complete picture
of the status of HER
family receptors by mRNA level.
The cut-off defined for study eligibility is defined as a concentration ratio
of <2.81 as
assessed by qRT-PCR on a COBAS z4800 instrument using the "COBAS HER2 & HER3
(qRT-
PCR) mRNA expression assay" provided by Roche Molecular Diagnostics. The
rationale for cut off
definition is based on a cut off modeling in previous studies as well as on a
transformation function
that had to be introduced since the assay was switched to a new instrument;
the COBAS z480 . It is
anticipated that 40-50% of screened patients will have HER3 mRNA levels below
the cutoff of 2.81
and that 30% of patients expressing low levels of HER3 mRNA will be ineligible
for enrollment
owing to other inclusion/exclusion criteria.
Submission of a formalin-fixed, paraffin-embedded tumor specimen of the
primary tumor
from the original surgery will be required for all patients prior to
screening; cytology specimens are
not acceptable replacements. Patients will be assessed for HER3 mRNA
expression level, as well as
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mRNA expression and protein expression levels of other HER family receptors by
the use of a qRT-
PCR assay and MC. Such assessment of HER receptor raRNA/protein expression
will occur after
obtaining the patient's informed consent at any time after the primary surgery
and prior to screening.
It is anticipated that pertuzumab in combination with topotecan or paclitaxel
will be safe and
effective in patients with epithelial ovarian, primary peritoneal, or
fallopian tube cancer.
In addition, it is anticipated that pertuzumab plus chemotherapy (topotecan,
paclitaxel, or
gemcitabine) will be superior to placebo plus chemotherapy in patients with
epithelial ovarian,
primary peritoneal, or fallopian tube cancer where efficacy is measured by
PFS.
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