The document discusses several gene expression profiling tests for early breast cancer, including OncotypeDX, MammaPrint, and TAILORx. OncotypeDX analyzes the expression of 21 genes to calculate a recurrence score that predicts the likelihood of distant recurrence within 10 years for tamoxifen-treated patients. MammaPrint analyzes 70 genes to classify patients into low or high risk groups. The TAILORx clinical trial aims to determine which patients with early breast cancer and OncotypeDX scores of 11-25 benefit from chemotherapy using a randomized design.

1. OncotypeDX Mammaprint Dr. Jiveliouk Irina

2. Breast Cancer Early Locally advanced Metastatic

3. Early breast cancer 85 with No Distant Recurrence 15 with Distant Recurrence 100 women ; N - , ER+ After Surgery & Tamoxifen

4. Breast Cancer - Survival Pre-menopausal patients, lymph node negative time (years) survival ~30% die of breast cancer ~70% survive breast cancer

5. Prognistic and Predictive factors Lymph node involvement Age Tu size Grade Hormonal status Her 2 status

6. Early Breast cancer Surgery Chemotherapy Radiotherapy Hormonal Therapy Biologic Therapy

7. Early breast cancer 85 with No Distant Recurrence 15 with Distant Recurrence 100 women ; N - , ER+ After Surgery & Tamoxifen “ at least 85 percent of patients would be over treated with chemotherapy if it were offered to everyone . ” Paik .S. et al. N Engl J Med 2004 ;351:2817-26

8. Oncotype DX 21-gene recurrence score

9. PROLIFERATION Ki-67 STK15 Survivin Cyclin B1 MYBL2 ESTROGEN ER PR Bcl2 SCUBE2 INVASION Stromelysin 3 Cathepsin L2 HER2 GRB7 HER2 BAG1 GSTM1 REFERENCE Beta-actin GAPDH RPLPO GUS TFRC CD68 Paik et al. N Engl J Med. 2004;351:2817-2826. 16 cancer genes and 5 reference genes make up the Oncotype DX gene panel. The expression of these genes is used to calculate the recurrence score: + 0.47 x HER2 Group Score - 0.34 x ER Group Score + 1.04 x Proliferation Group Score + 0.10 x Invasion Group Score + 0.05 x CD68 - 0.08 x GSTM1 - 0.07 x BAG1 RS =

10. Results: Population distribution by Oncotype DX risk group A Multigene Assay to Predict Recurrence of Tamoxifen-Treated, Node-Negative Breast Cancer Paik .S. et al. N Engl J Med 2004 ;351:2817-26 Intermed. risk 27.0% Low risk 51.0% High risk 22.0%

11. Distant Recurrence-Free Survival (%) P < 0.00001 Paik .S. et al. N Engl J Med 2004 ;351:2817-26 93% 69% All patients Low Risk (RS < 18) Years 100 0 20 40 60 DRFS (%) 80 0 2 6 10 4 8 12 16 14 Intermediate Risk (RS 18 - 30) High Risk (RS  31)

12. Recurrence Score Low RS < 18 Rec. Rate = 6.8% C.I. = 4.0% - 9.6% Intermediate RS 18 - 31 Rec. Rate = 14.3% C.I. = 8.3% - 20.3% High RS  31 Rec. Rate = 30.5% C.I. = 23.6% - 37.4% Paik .S. et al. N Engl J Med 2004 ;351:2817-26 40 35 30 25 20 15 10 5 0 0 5 10 15 20 25 30 35 40 45 50 Recurrence Score Rate of Distant Recurrence at 10 years 95% C.I. Recurrence Rate

13. Case 1 41-year-old patient with 2.1-cm tumor Menopausal Status: Premenopausal Tumor Type: IDC ER and PR Status (IHC): Positive HER2/neu Status (IHC): Negative Histologic Grade: 1 Lymph Node Status: Negative

14. Recurrence score= 3 Patients with a Recurrence Score of 3 in clinical validation study had an Average Rate of Distance Recurrence at 10 years of 4%(95% CI: 2%–6%)

15. Case 2 Age 62 T= 1.8cm N=0 ER ++, PR - HER2 = +++ Grade 2

16. Onco type DX ™ - TAILORx - Study Design Onco type DX™ Assay No Minimal Chemotherapy Benefit Group Recurrence Score <11 (~29% of Population) Uncertain Chemotherapy Benefit Group Recurrence Score 11-25 (~44% of Population) Established Chemotherapy Benefit Group Recurrence Score >25 (~27% of Population) Stratify Tumor Size ≤2.0 cm vs. ≥ 2.1 cm Post menopausal vs. Pre-or Peri-menopausal Planned chemotherapy: Taxane-containing (i.e. paclitaxel, docetaxel) vs. Non-taxane-containing Arm A Hormonal Therapy Randomize Arm D Chemotherapy Plus Hormonal Therapy Arm B Hormonal Therapy Arm C Chemotherapy Plus Hormonal Therapy

17. Conclusions: Onco type DX TM Low RS associated with minimal chemotherapy benefit High RS associated with large chemotherapy benefit The Onco type DX Recurrence Score provides precise, quantitative information for individual patients on prognosis across and statistically independent of information on patient age, tumor size, and tumor grade.

18. Mammaprint 70-gene profile Oncotest-Teva

19. Old versus new diagnostics of cancer: from microscope to microarray High grade Low grade High risk Low risk MammaPrint

20. Prognosis Classifier for Breast Cancer based on Genomic Profiling Good signature Poor signature threshold Rows: 70 significant prognosis genes Columns: tumor samples Threshold set with 10% false negatives 91% sensitivity; 73% specificity Van ‘t Veer et al Nature 415, p530-536, 2002 Metastases: white = +

21. A Gene-Expression Signature as a Predictor of Survival in Breast Cancer Metastasis Free Survival Overall survival H.R. = 5.1 95% CI = 2.9 - 9.0 P < 0.001 H.R. = 8.6 95% CI = 4 - 19 P < 0.001 van de Vijver M.J. et al. N Eng J Med 2002 ;347(25):1999-2009. Results: all patients Good signature Poor signature Years 100 0 20 40 60 % patients metastasis free 80 0 2 4 6 8 10 12 Years 100 0 20 40 60 Overall survival (%) 80 0 2 4 6 8 10 12 85.2% 50.6% 94.5% 54.6%

22. Profiling vs. St Gallen selection (LN0, <53) improved prediction. Significantly less women classified as having a bad prognosis van de Vijver M.J. et al. N Eng J Med 2002 ;347(25):1999-2009. St Gallen St Gallen: 15% in low risk 85% in high risk Profile Profiling: 40% in good profile 60 % in poor profile

23. MINDACT Design (Microarray in Node-Negative Disease May Avoid Chemotherapy Trial) All hormone responsive patients receive endocrine therapy Clinical pathological AND 70-gene signature HIGH risk Clinical pathological AND 70-gene signature LOW risk Discordant cases Clin-Path HIGH risk 70-gene LOW risk Clin-Path LOW risk 70-gene HIGH risk Evaluate clinico-pathological risk (Adjuvant!) AND 70-gene signature risk Buyse M et al, JNCI 2006 N=3300 55% 32% n=1920 N=780 13% Use Clin-Path risk to decide on adjuvant chemotherapy or not Use 70-gene risk to decide on adjuvant chemotherapy or not No chemotherapy chemotherapy R

24. Oncotype Early breast cancer Hormonal receptor positive Her 2 Negative Mammaprint Early node negative breast cancer