1. Systemic Treatment in Head & Neck Cancer Jan B. Vermorken, MD, PhD Department of Medical Oncology Antwerp University Hospital Edegem, Belgium ESO-ESMO Masterclass in Clinical Oncology Zürich, April 4, 2011

3. Case 1: Locoregionally Advanced Head and Neck Cancer 09.07.2003 09.07.2003

5. Case 1: Locoregionally Advanced Head and Neck Cancer Treatment: 11.07.2003 PF regimen cycle I 01.08.2003 PF regimen cycle II PR (CT-scan) 26.08.2003 PF regimen cycle III 06.10.2003 RT 70 Gy in 35 sessions concomitant gemcitabine 100 mg/m²/week > 90% PR starting 01.10.03 for 7 times (CT-scan)

6. Case 1: Locoregionally Advanced Head and Neck Cancer 08.07.2003 09.01.2004

7. Case 1: Locoregionally Advanced Head and Neck Cancer

9. 1 st. TL 1 st. PLs 1 st. RT SCPL Laser CO² ASCO 1982 trial VA trial EORTC trial RTOG trial EORTC 1873 1903 1878 1970s 1994 1996 2003 2005 2007 CTscan MRI surgery radiotherapy laser Milestones in Larynx/Hypopharynx Management trial GORTEC

10. Milestones in Systemic Therapies (± RT) in Head and Neck Squamous Cell Cancer 1960s Methotrexate (ICT, CRT) 1970s Bleomycin, 5-fluorouracil, cisplatin Combination chemotherapy regimens 1980s Carboplatin Organ preservation trials start (ICT) 1990s Paclitaxel, docetaxel CCRT>RT 2000s Targeted therapies (MoAb) ICT revisited Sequential therapy (ICT  CCRT)?

14. 63 randomized trials MACH-NC = Individual patients data base 7,307 deaths (68 %) 10,741 patients Lancet 2000;355:949-55 IGR 10.00 Meta-Analysis of Chemotherapy in Head & Neck Cancer MACH-NC

15. MACH-NC: Results - Overall Survival Chemotherapy Risk P Absolute benefit timing reduction value at 5 years Adjuvant 2% NS 1% Neoadjuvant* 5% NS 2% Concomitant 19% < 0.0001 8% Total 10% < 0.0001 4% * 15 studies with PF 5% Pignon et al, 2000 (63 trials / 10.741 patients)

16. Pignon et al, Radioth Oncol 2009: 92; 4-14 (87 trials/16.485 patients) (50 concomitant trials/9615 patients)

18. CRT: Significant Increase in Acute Toxicity Acute adverse effects: Grade ≥ 3 p<0.05 ns Patients (%) p<0.01 Wendt TG, et al. J Clin Oncol 1998;16:1318–1324 0 10 20 30 40 50 60 Xerostomia Nausea/emesis Leukopenia Dermatitis Mucositis RT alone (n=140) CRT (n=130) ns, not significant CRT = CDDP + 5-FU + RT

20. Enhancement of Radiation Effects Selective Targeting of Hypoxic Cells Induction of Pro-Apoptotic Mechanisms Anti- Angiogenesis Strategies Inhibition of Cox-2 Replacement of Mutated Tumor Suppressor Genes Inhibition of EGFR Several biological mechanisms that have potential to alter sensitization strategies (Choy and MacRae, 2003)

21. EGFR-targeting Agents under Clinical Investigation in SCCHN Monoclonal antibodies Toxicity Cetuximab IMC225 chimeric human/murine IgG1 skin Matuzumab EMD72000 humanized mouse IgG1 skin Nimotuzumab h-R3 humanized mouse IgG1 systemic/hemodynamic Zalutumumab 2F8 human IgG1 skin Panitumumab ABX-EGF human IgG2 skin Tyrosine kinase inhibitors Gefitinib ZD1839 reversible EGFR skin/gastrointesinal (GI) Erlotinib OSI-774 reversible EGFR skin/GI Lapatinib GW-572016 reversible EGFR/erbB2 skin/GI/systemic Afatinib BIBW-2992 irreversible EGFR/erbB2 skin/GI/systemic Canertinib CI-0033 irreversible EGFR skin/oral/GI/systemic

23. Bonner et al. N Engl J Med 2006; 354: 567-578

24. Cetuximab + RT in locally advanced SCCHN: Study design Bonner et al. N Engl J Med 2006; 354: 567-578 RT as before + ERBITUX initial 400 mg/m 2 2-h infusion then 250 mg/m 2 1-h infusion weekly for at least 7 doses RT once or twice daily or concomitant boost for 7 – 8 weeks Patients with measurable locally advanced SCCHN (stratified by KPS;node+/0;T1-3/4; RT regimen) Randomization Follow-up until disease progression or up to 5 years

26. 5-Years Survival Update and QoL Assessment 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0 10 20 30 40 50 60 70 Time (months) Probability of overall survival Bonner JA, et al. Presented at ASTRO 2008 ERBITUX + RT RT ERBITUX + RT RT 5-year survival rate 46% 36% p=0.018, HR=0.73 (0.56-0.95) 29.3 49.0 ERBITUX + RT does not adversely affect QoL, while significantly improving overall survival Curran D, et al. J Clin Oncol 2007; 25: 2191 –2197 a Post-baseline scores for the EORTC QLQ-C30 Global health status/QoL score a 100 80 60 40 20 0 RT RT + ERBITUX Baseline Week 4 Month 4 Month 8 Month 12

27. Compliance with Cetuximab or Chemotherapy when Administered with RT 1 Bonner JA, et al. N Engl J Med 2006; 354: 567 –578; 2 Huguenin P, et al. J Clin Oncol 2004; 22: 4665–4673; 3 Calais G, et al. J Natl Cancer Inst 1999; 91: 2081 – 2086; 4 Wendt TG, et al. J Clin Oncol 1998; 16: 1318 –1324 CRT arms of studies comparing CRT vs RT alone Cisplatin / 5-FU / FA 4 46% 51% 71% 90% 0 20 40 60 80 100 Carboplatin / 5-FU 3 Cisplatin 2 Cetuximab 1 Patients receiving all planned doses (%) 10 70 50 30 90 Weekly doses (median 8 doses) 2 cycles at weeks 1 and 5 3 cycles at weeks 1, 4, and 7 3 cycles at weeks 1, 3, and 6 2nd cycle 3rd cycle 3rd cycle

28. Overall Conclusion No direct comparison *level I evidence; **level II evidence; + with mono Platin therapy Chemoradiation Bioradiation ( cetuximab ) 50 trials, 9615 pts (MA)* 1 trial, 424 pts (Bonner trial)** HR of death 0.74 (0.67-0.82) + HR of death 0.74 (0.57-0.97) Main effect on local failure Modest effect on DM Only effect on local failure No effect on DM Efficacy irrespective of site and of fractionation schedule Effect may be site and RT schedule specific Significant acute toxicity which may inflict on late toxicity, in particular swallowing dysfunction Skin reaction?? Late toxicity as RT Compliance of receiving cetuximab 90% in the Bonner trial

29. Analysis of Failures in Phase III CRT or BRT Trials Trials Group Year Published Locoregional failure (%) Distant metastases (%) % of failures due to DM INT 2003 22 23 51 EORTC 2005 18 21 54 RTOG 2005 16 20 65 GORTEC Bonner 2005 2006 57 53 18 17 32 30 Modified from Posner and Vermorken, 2008

31. Randomized Trials of ICT in LA-HNC Revisited Trial Arms Outcome CA 139-322 (2005) PF vs PPF CCR (TTP , OS*) Resectable/nonresectable CRT (CDP) Improved with PPF EORTC 24971/TAX 323 PF vs TPF PFS (RR, OS)° Nonresectable (2007) RT Improved with TPF TAX 324 (2007) PF vs TPF OS (PFS , RR)° Resectable/nonresectable CRT (Cb) Improved with TPF GORTEC 2000-01 PF vs TPF LP (OS, DFS) + Resectable (2006) T(P)L vs RT Improved with TPF *significant only in unresectable disease (JCO); °NEJM; + ASCO 2006

32. SCCHN: Docetaxel in Locally-Advanced Disease Overall Survival TAX 324 30% reduction in risk of death TAX 323 27% reduction in risk of death TPF PF 50 Survival Time (months) Survival Probability (%) Survival Time (months) 0 6 12 18 24 30 36 42 48 54 60 66 72 0 10 20 30 40 60 70 80 90 100 TPF PF Survival Time (months) Survival Time (months) 0 6 12 18 24 30 36 42 48 54 60 66 72 Posner et al, 2007 Resectable/unresectable disease Vermorken et al, 2007 Unresectable disease

33. EORTC 24971/TAX 323 Toxicity NCIC-CTC Grade 3-4 PF (n=179) TPF (n=173) Toxicity % % Anemia/ thrombocytopenia 13/ 18 9/ 3 Neutropenia 53 77 Nausea/vomiting 7/4 <1/<1 Diarrhea 3 3 Stomatitis 11 5 Infection 6 7 Febrile neutropenia 3 5 Hearing loss 3 0 Toxic deaths 5.5 2.3 Primary prophylactic antibiotics were given per protocol for TPF Vermorken et al, N Engl J Med 2007; 357: 1695-1704

34. EORTC 24971/TAX 323 Quality of Life Analysis: QLQ-C30 Global Health Bernier et al. ASCO 2006; Abstract 5522 PF TPF (N=142) (N=143) Cycle 2 Least Square Mean QLQ-C30 Score [99% CI] 100 90 80 70 60 50 40 30 20 10 0 Cycle 4 6 mos. Post RT 9 mos. Post RT Least Square Mean TPF vs PF: p=0.01 CI=Confidence Interval; RT=Radiotherapy

37. Randomized Trials of Sequential Therapy versus Concurrent Chemoradiation Only Group Regimen TPF (or PF) x 3  CRT (cisplatin) TTCC (Sp) CRT (cisplatin) TPF x 3  CRT (carboplatin) Boston (US) CRT (cisplatin) TPF x 2  THFX Chicago (US) THFX XRT (cetuximab) TPF x 3 XRT (PF) GCTCC (It) XRT (cetuximab) XRT (PF)

41. Prognostic Significance of HPV Overall Survival Ang K et al. N Engl J Med 2010;361:24-35

42. The 3-year rates of overall survival were 93.0% (95% CI, 88.3 to 97.7) in the low-risk group, 70.8% (95% CI, 60.7 to 80.8) in the intermediate-risk group, and 46.2% (95% CI, 34.7 to 57.7) in the high-risk group. Ang K et al. N Engl J Med 2010;361:24-35

45. Development of Chemotherapy in R/M SCCHN 1977: cisplatin shows efficacy in 1 st -line SCCHN CABO, cisplatin, methotrexate, bleomycin, vincristine *significant Clavel et al. Ann Oncol 1994; Forastiere et al. JCO 1992; Gibson et al. JCO 2005; Grose et al. Cancer Treat Rep 1985; Vermorken et al. NEJM 2008; Wittes et al. Cancer Treat Rep 1977 N Regimen ORR (%) Median OS (months) Significant OS benefit Grose et al 1985 100 Methotrexate Cisplatin 16 8 5.0 4.5 No Forastiere et al 1992 277 Cisplatin + 5-FU Carboplatin + 5-FU Methotrexate 32* 21 10 6.6 5.0 5.6 No Clavel et al 1994 382 CABO Cisplatin + 5-FU Cisplatin 34* 31* 15 7.3 7.3 7.3 No Gibson et al 2005 218 Cisplatin + 5-FU Cisplatin + paclitaxel 27 26 8.7 8.1 No Vermorken et al 2008 442 Platinum + 5-FU Platinum + 5-FU + Cetuximab 20 36* 7.4 10.1* Yes

46. Vermorken et al. N Engl J Med 2008: 359: 1116-27

47. EXTREME: Responses to Treatment and Survival Variable PF+cetuximab n=222 PF n=220 HR or OR (95% CI) P value Survival – mo overall progression-free 10.1 (8.6 -11.2) 5.6 (5.0 - 6.0) 7.4 (6.4-8.3) 3.3 (2.9-4.3) HR 0.80 (0.60-0.99) HR 0.54 (0.43-0.67) 0.04 <0.001 Best response - % overall disease control 36 (29-42) 81 (75-86) 20 (15-25) 60 (53-67) OR 2.33 (1.50-3.60) OR 2.88 (1.87-4.44) <0.001 <0.001 Time to TRT failure-mo 4.8 (4.0-5.6) 3.0 (2.8-3.4) HR 0.59 (0.48-0.73) <0.001 Duration of response 5.6 (4.7-6.0) 4.7 (3.6-5.9) HR 0.76 (0.50-1.17) 0.21 PF=cisplatin or carboplatin + 5-FU; HR=hazard ratio; OR: odds ratio Vermorken et al. N Engl J Med 2008: 359: 1116-27

48. EXTREME: Symptom Control Mean change from boaseline t worst post-baseline score Pain Swallowing problems Sense problems Speech problems Social eating problems Problems with social contact p=0.0027 p=0.0162 p=0.5702 p=0.0787 p=0.0694 p=0.7732 p=0.2237 -9.99 +3.51 -9.17 +5.21 -2.60 +4.42 -7.81 +1.33 -9.98 +0.24 -2.64 - 0.43 -2.55 +4.37 Problems with reduced sexuality Worsening symptoms Improving symptoms Cetuximab + chemotherapy Chemotherapy alone Mesia et al, Ann Oncol 2010 (doi 10,1093/annonc/mdq077)

49. EXTREME: Most relevant grade 3/4 adverse events Modified from Vermorken et al, N Engl J Med 2008: 359: 1116-27

50. EXTREME: Quality of life a a <50% of patients completed a baseline questionnaire; = 95% CIs for difference in treatment groups 100 80 60 40 20 0 -20 Global health status/QoL Erbitux + CTX CTX Erbitux + CTX CTX Baseline (n=109) (n=94) Cycle 3 (n=80) (n=63) 6 months (n=45) (n=20) Mesia et al, Ann Oncol 2010 (doi 10,1093/annonc/mdq077 )

52. Adding Cetuximab to Chemotherapy Shows Consistent Efficacy in 1st-line R/M SCCHN Vermorken JB, et al. N Engl J Med 2008;359:1116–1127; Burtness B, et al. J Clin Oncol 2005;23:8646–8654; Bourhis J, et al. J Clin Oncol 2006;24:2866–2872; Hitt R, et al. ASCO 2007 (Abstract No. 6012; updated information presented); Buentzel J, et al. ASCO 2007 (Abstract 6077) a p<0.001; b p=0.04; c p=0.03; d Median OS not reached after a median follow-up of 5.6 months; e TTP Author Phase Regimen ORR (% ) Median PFS (months ) Median OS (months) Burtness et al. III CDDP + cetuximab CDDP + placebo 26 c 10 4.2 2.7 9.2 8.0 Bourhis et al. I/II PF + cetux i ma b 36 5.1 e 9.8 Vermorken et al. III PF + cetuximab PF 36 a 20 5.6 a 3.3 10.1 b 7.4 Hitt et al. II Pacli + cetuxima b 60 5.0 NR d Buentzel et al. II Pacli/Carbo + cetuximab 56 5.0 e 8.0

53. Completed Randomized Trials in First-Line Recurrent/Metastatic SCCHN Study/Reference N Regimen RR (%) PFS (mo) OS (mo) ECOG 5397/ Burtness et al 2005 117 Cisplatin + cetuximab Cisplatin + placebo 26 a 10 4.2 2.7 9.2 8.0 EXTREME/ Vermorken et al 2008 442 PF 1 + cetuximab PF 1 36 a 20 5.6 b 3.3 10.1 c 7.4 SPECTRUM/ Vermorken et al 2010 657 PF 2 + panitumumab PF 2 36 a 25 5.8 b 4.6 11.1 9.0 PF 1 = cisplatin or carboplatin plus 5-FU; PF 2 = cisplatin plus 5-FU a, b, c : significant differences

54. EGFR Inhibitor Response Rates in SCCHN Prior CT= for recurrent/metastatic disease Drug Phase/ prior CT Reference Response Rate Cetuximab II Pt- refract Vermorken, JCO, 2007 13% Erlotinib II 0-1 lines Soulieres, JCO, 2004 4% Gefitinib II 0-1 lines Cohen, JCO, 2003 11% II 0-5 lines Cohen, CCR, 2005 2% II 0-1 lines Kirby, BJC, 2006 9% III Pt + (A) Stewart, JCO, 2009 8% Lapatinib II unclear Abidoye, ASCO 2006 0% Cetuximab II prior Pt Seiwert, ASCO 2010 13% BIBW 2992 II prior Pt Seiwert, ASCO 2010 22%

55. Completed Randomized Trials in 2nd-Line Recurrent/Metastatic SCCHN Study/Reference N Regimen RR (%) PFS OS (mo) IMEX Stewart et al, 2009 486 Gefitinib (250 mg) Gefitinib (500 mg) Methotrexate 2.7 7.6 3.9 ND ND ND 5.6 6.0 6.7 ECOG 1302 Argiris et al, 2009 270 D + Gefitinib D + placebo 12 6 3.3 2.2 6.8 6.2 Zalute Machiels et al, 2010 286 Z + BSC (-MTX) BSC (optional MTX) 6 1 2.3* 1.9* 6.7° 5.2° BSC = best supportive care; Z = zalutumumab; MTX = methotrexate; ND = no data *HR (95% CI): 0.62 (0.47-0.83), p=0,0010; °HR (95% CI): 0.77 (0.57-1.05), p=0.0648

56. Cetuximab and Beyond Where do we go from here?

59. Novel Agents Not Targeting EGFR in Recurrent or Metastatic SCCHN Target Single agent Combination Bevacizumab Angiogenesis No data Promising/ongoing Sorafenib Angiogenesis Low/mod activity Ongoing Sunitinib Angiogenesis Low activity - Dasatinib Src, others Low activity Planned Bortezomib Proteasome Low activity Low activity Vorinostat HDAC Low activity - Figitumumab IGF-1R Low activity - Cixutumumab IGF-1R Ongoing Ongoing Everolimus mTOR Ongoing Ongoing

60. Treatment Combined anti-EGFR Treatment with Gefitinib and Cetuximab P. Matar et al Clin Cancer Res 2004; 10: 6487-6501 Courtesy of Dr. Baselga, 2006

63. Targets for Next-generation Therapy Tumor cell Nucleus 3 3. Signal transduction pathways Ras, raf, MAPK, MEK, ERK, AKT protein kinase C, PI3K 1 1. Growth factors and growth-factor receptors HER family, c-kit/SCFR 2 2. Extracellular matrix/ angiogenic pathways VEGFR, integrins, MMPs 4 4. Cell-survival pathways Cyclin-dependent kinases, mTOR, cGMP, COX-2, p53, Bcl-2 5. Protein production Proteasome 5