Genomics in Breast Cancer: An Overview for Nurses

1. Genomics in Breast Cancer: An Overview for Nurses Today we are going to discuss the role genomics is currently playing in breast cancer clinical practiceToday we are going to discuss the role genomics is currently playing in breast cancer clinical practice

2. Learning Objectives Provide background on breast cancer, its staging and current adjuvant treatments Distinguish between role of Genomics and Genetics in clinical practice Understand the clinical utility of new genomic tests, such as the Oncotype DX� Breast Cancer Assay Explain the Oncotype DX Recurrence Score � result and its association with risk of recurrence and prediction of chemotherapy benefit Identify the patients for whom the Oncotype DX assay has been clinically validated Describe the mechanism to obtain assistance regarding ordering and reimbursement of the Oncotype DX assay

3. Breast Cancer Figures 1 in 8 women in the United States will develop breast cancer, most occurring by age 70 Incidence: 180,000 people in the United States will be diagnosed in 2007 with invasive breast cancer including 2,000 men Over 40,000 women and men will die from the disease in 2007 Over 77% of breast cancer cases are diagnosed in people over the age of 50 Statistics from 2007Statistics from 2007

4. Breast Cancer Progress Report Breast Cancer mortality rates have decreased by 2.3% annually since 1990

5. The Stages of Breast Cancer Breast Cancer is diagnosed according to stages (stages 0 through IV) under the TNM classification. Factors used in staging of Breast Cancer: Tumor Size Size of primary tumor Nodal statusIndicates presence or absence of cancer cells in lymph nodes MetastasisIndicates if cancer cells have spread from the affected breast to other areas of the body (i.e. skin, liver, lungs, bone)

6. Early Stage Breast Cancer Stage 0Ductal carcinoma in situ (DCIS) is very early breast cancer that has not spread beyond the duct. Stage ITumor is < 2 cm and has not spread outside the breast. Stage IIANo tumor is found in the breast, but cancer is found in the axillary lymph nodes, or tumor is = 2 cm and has spread to the axillary lymph nodes, or tumor is 2-5 cm but has not spread to the axillary lymph nodes. Stage IIBTumor is 2-5 cm and has spread to the axillary lymph nodes or is > 5 cm but still confined to the breast.

7. Advanced Breast Cancer Stage IIIAThe tumor in the breast is smaller than 5 centimeters and the cancer has spread to underarm lymph nodes that are attached to each other or to other structures, OR the tumor is more than 5 centimeters across and the cancer has spread to the underarm lymph nodes. Stage IIIBTumor has spread to tissue near the breast (i.e. the skin or chest wall) and may have spread to lymph nodes within the breast area or under the arm. Stage IIICTumor has spread to the lymph nodes beneath the collarbone and near the neck, and may have spread to the lymph nodes within the breast area or under the arm and to the tissues near the breast.

8. Genetics and Genomics

9. Genetics Help us Identify Patients at High Risk of Developing Breast Cancer Genetics Genetics is the study of heredity While genetics influence genomics, genetics is responsible for only 5-10% of breast cancer Genetics is the study of genes and heredity. Genomics is the study of genes, their functions, and related techniques. The main difference between genomics and genetics is that genetics studies how inherited traits are passed from one generation to the next, as well as how traits appear by means of mutations. Genomics studies a group of genes and their inter-relationships in order to identify their combined influence on the growth and development of the organism. Genetics is the study of genes and heredity. Genomics is the study of genes, their functions, and related techniques. The main difference between genomics and genetics is that genetics studies how inherited traits are passed from one generation to the next, as well as how traits appear by means of mutations. Genomics studies a group of genes and their inter-relationships in order to identify their combined influence on the growth and development of the organism.

10. Genomics Help us Look at the Patients Individual Tumor Biology

11. Examples of Genetic and Genomic Tests Genetic Test Example of Genetic test: BRCA1 and BRCA2 look at specific gene mutations on the patient�s genetic make up that make them more susceptible to developing breast cancer in their lifetime. Example of Genomic test: Oncotype DX looks at the expression level of 21 different genes on the patient�s tumor tissue and correlates that information with the likelihood of distant recurrence in 10 years and the magnitude of chemotherapy benefit. Example of Genetic test: BRCA1 and BRCA2 look at specific gene mutations on the patient�s genetic make up that make them more susceptible to developing breast cancer in their lifetime. Example of Genomic test: Oncotype DX looks at the expression level of 21 different genes on the patient�s tumor tissue and correlates that information with the likelihood of distant recurrence in 10 years and the magnitude of chemotherapy benefit.

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13. Hormonal Therapy If 100 women with ER+, N- disease are treated with hormonal therapy how many will recur within 10 years? 85 women are disease free with hormonal therapy alone (shown in trials conducted by the NSABP as well as other cooperative groups). How can we know who are these women?85 women are disease free with hormonal therapy alone (shown in trials conducted by the NSABP as well as other cooperative groups). How can we know who are these women?

14. Chemotherapy and Hormonal Therapy If all 100 women with ER+, N- disease are treated with chemotherapy and hormonal therapy, how many will benefit from the addition of chemotherapy? By treating 100 women with chemotherapy and hormonal therapy only 4 would derive a benefit from chemotherapy treatment and 85 would have done well with hormonal therapy alone. Today, we are treating nearly all women to benefit a few. By treating 100 women with chemotherapy and hormonal therapy only 4 would derive a benefit from chemotherapy treatment and 85 would have done well with hormonal therapy alone. Today, we are treating nearly all women to benefit a few.

15. Your Patient Needs Better Tests to Assess Her Risk of Recurrence and Optimize Her Treatment Will her cancer spread? Does she need chemotherapy after surgery for her cancer type? What are the benefits and side effects of chemotherapy for her? Are there any new drugs for her cancer? Will she survive? These are all questions you receive when patients come in to your center/office after being diagnosed. As a patient, the decision to take adjuvant chemotherapy can be difficult, particularly given its side effects. Therefore we need better tests to evaluate risk of recurrence and chemotherapy benefit to customize treatment for the patient�s individual disease. The major challenge in current management of patients with N-, ER+ breast cancer, is indeed the selection of patients for adjuvant chemotherapy. These are all questions you receive when patients come in to your center/office after being diagnosed. As a patient, the decision to take adjuvant chemotherapy can be difficult, particularly given its side effects. Therefore we need better tests to evaluate risk of recurrence and chemotherapy benefit to customize treatment for the patient�s individual disease. The major challenge in current management of patients with N-, ER+ breast cancer, is indeed the selection of patients for adjuvant chemotherapy.

16. How Do We Assess Risk in Breast Cancer Patients? In the past, studies showed that age, size and tumor grade were the best available tools to predict which patients were at high risk. With the advent of computer models such as Adjuvant Online we have been able to aggregate classical pathologic criteria and help nurses and physicians better asses risk. Today, in the Genomic Era, we have better tests, such as the Oncotype DX assay, to help us identify patients whose tumor biology make them likely to recur. *A robust assay that could characterize an individual�s risk of assessment and responsiveness to treatment would enable better tailored therapeutic intervention. * Image from NCIIn the past, studies showed that age, size and tumor grade were the best available tools to predict which patients were at high risk. With the advent of computer models such as Adjuvant Online we have been able to aggregate classical pathologic criteria and help nurses and physicians better asses risk. Today, in the Genomic Era, we have better tests, such as the Oncotype DX assay, to help us identify patients whose tumor biology make them likely to recur. *A robust assay that could characterize an individual�s risk of assessment and responsiveness to treatment would enable better tailored therapeutic intervention. * Image from NCI

17. With Genomic Tools We Can Now Analyze Cancer at the Molecular Level With Genomic tools, such as the Oncotype DX assay, we can now analyze cancer at the molecular level.The behavior of cancer is dependent on many different genes, how they interact, and the conditions they create for disease to occur. Oncotype DX analyzes the expression level of a key set of genes in the patient�s tumor to quantitatively assess the likelihood of breast cancer recurrence and prediction of benefit from therapy. Gene expression looks at the mRNA abundance for a particular gene (i.e. number of copies of mRNA per nanoliter of homogenized tissue) With Genomic tools, such as the Oncotype DX assay, we can now analyze cancer at the molecular level.The behavior of cancer is dependent on many different genes, how they interact, and the conditions they create for disease to occur. Oncotype DX analyzes the expression level of a key set of genes in the patient�s tumor to quantitatively assess the likelihood of breast cancer recurrence and prediction of benefit from therapy. Gene expression looks at the mRNA abundance for a particular gene (i.e. number of copies of mRNA per nanoliter of homogenized tissue)

18. Oncotype DX�: A Genomic Assay  Oncotype DX allow us to look at your patient�s tumor and help inform decision-making about treatment that is right for her.Oncotype DX allow us to look at your patient�s tumor and help inform decision-making about treatment that is right for her.

19. Oncotype DX� 21-Gene Recurrence Score� (RS) Assay The final gene set used for the Oncotype DX assay includes the 16 cancer genes identified in the clinical trials: 5 genes are in the proliferation group, 2 in the HER2 group, 4 in the estrogen receptor group, 2 in the invasion group, and 3 are unaligned. Some of the genes are well known in the breast cancer literature; others are relatively new. The 5 reference genes are used for normalizing the expression of the cancer-related genes. The 16 genes presented in this slide were selected for the Oncotype DX� assay based on the three clinical trials, which demonstrated a consistent statistical link between these genes and distant breast cancer recurrence and the most robust predictive power across the three studies. The final gene set used for the Oncotype DX assay includes the 16 cancer genes identified in the clinical trials: 5 genes are in the proliferation group, 2 in the HER2 group, 4 in the estrogen receptor group, 2 in the invasion group, and 3 are unaligned. Some of the genes are well known in the breast cancer literature; others are relatively new. The 5 reference genes are used for normalizing the expression of the cancer-related genes. The 16 genes presented in this slide were selected for the Oncotype DX� assay based on the three clinical trials, which demonstrated a consistent statistical link between these genes and distant breast cancer recurrence and the most robust predictive power across the three studies.

20. Oncotype DX� 21-Gene Recurrence Score� (RS) Assay The Recurrence Score is calculated from the expression results for each of the 16 cancer-related genes by the equation shown in this slide The Recurrence Score (RS) ranges from 0 to 100 Although the coefficients for each gene or gene group influence the RS result, the quantitative expression for each gene can have a significant effect on the RS. For example, there is a 200-fold range of expression of ER in the quantitative RT-PCR assay. For individual tumors, the expression of any one gene can affect the Recurrence Score to a large degree. Cut-off points for Recurrence Score risk groups were defined prior to the initiation of the validation study: A low-risk group with an RS of <18 An intermediate-risk group with an RS between 18 and 30 A high-risk group with an RS of ?31 The Recurrence Score is calculated from the expression results for each of the 16 cancer-related genes by the equation shown in this slide The Recurrence Score (RS) ranges from 0 to 100 Although the coefficients for each gene or gene group influence the RS result, the quantitative expression for each gene can have a significant effect on the RS. For example, there is a 200-fold range of expression of ER in the quantitative RT-PCR assay. For individual tumors, the expression of any one gene can affect the Recurrence Score to a large degree. Cut-off points for Recurrence Score risk groups were defined prior to the initiation of the validation study: A low-risk group with an RS of <18 An intermediate-risk group with an RS between 18 and 30 A high-risk group with an RS of ?31

21. The Oncotype DX� Assay is for N-, ER+ Breast Cancer Patients Oncotype DX is only validated for patients with early stage breast cancer Stage I-II, node negative, ER+ patients. As a reminder, in Stage I the cancer has spread from lobules or ducts to nearby tissue in the breast. At this stage and beyond, breast cancer is considered invasive. The tumor is 2 cm or less in diameter and has not spread to the lymph nodes. In Stage IIA, the tumor can range from 2 cm to less than 5 cm in diameter and has not spread to the lymph nodes. Oncotype DX is only validated for patients with early stage breast cancer Stage I-II, node negative, ER+ patients. As a reminder, in Stage I the cancer has spread from lobules or ducts to nearby tissue in the breast. At this stage and beyond, breast cancer is considered invasive. The tumor is 2 cm or less in diameter and has not spread to the lymph nodes. In Stage IIA, the tumor can range from 2 cm to less than 5 cm in diameter and has not spread to the lymph nodes.

22. The Oncotype DX� Assay Has Been Extensively Studied in 3,300+ Patients  Extensive evidence supporting Oncotype DX�s utility in multiple studies involving over 3,300 patients and more than 39,000 commercial assays performed in the past 3 years. We are going to look in the next couple of slides at two pivotal trials: NASBP B-14 and NASBP B-20. The references for the fully published studies are as follows from top to bottom: Cobleigh MA, Tabesh B, Bitterman P, et al. Tumor gene expression and prognosis in breast cancer patients with 10 or more positive lymph nodes. Clin Cancer Res. 2005;11(24 Pt 1):8623-8631. Paik S, Shak S, Tang G, et al. A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N Engl J Med. 2004;351(27):2817-2826. Esteva FJ, Sahin AA, Cristofanilli M, et al. Prognostic role of a multigene reverse transcriptase-PCR assay in patients with node-negative breast cancer not receiving adjuvant systemic therapy. Clin Cancer Res. 2005;11(9):3315-3319 Habel L, Shak S, Jacobs M, et al. A population-based study of tumor gene expression and risk of breast cancer death among lymph node-negative patients. Breast Cancer Res. 2006;May 31;8(3):R25 [Epub ahead of print]. Gianni L, Zambetti M, Clark K, et al. Gene expression profiles in paraffin-embedded core biopsy tissue predict response to chemotherapy in women with locally advanced breast cancer. J Clin Oncol.2005;23(29):7265-7277. Paik S, Tang G, Shak S, et al. Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol. 2006;24:3726-3734. Extensive evidence supporting Oncotype DX�s utility in multiple studies involving over 3,300 patients and more than 39,000 commercial assays performed in the past 3 years. We are going to look in the next couple of slides at two pivotal trials: NASBP B-14 and NASBP B-20. The references for the fully published studies are as follows from top to bottom: Cobleigh MA, Tabesh B, Bitterman P, et al. Tumor gene expression and prognosis in breast cancer patients with 10 or more positive lymph nodes. Clin Cancer Res. 2005;11(24 Pt 1):8623-8631. Paik S, Shak S, Tang G, et al. A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N Engl J Med. 2004;351(27):2817-2826. Esteva FJ, Sahin AA, Cristofanilli M, et al. Prognostic role of a multigene reverse transcriptase-PCR assay in patients with node-negative breast cancer not receiving adjuvant systemic therapy. Clin Cancer Res. 2005;11(9):3315-3319 Habel L, Shak S, Jacobs M, et al. A population-based study of tumor gene expression and risk of breast cancer death among lymph node-negative patients. Breast Cancer Res. 2006;May 31;8(3):R25 [Epub ahead of print]. Gianni L, Zambetti M, Clark K, et al. Gene expression profiles in paraffin-embedded core biopsy tissue predict response to chemotherapy in women with locally advanced breast cancer. J Clin Oncol.2005;23(29):7265-7277. Paik S, Tang G, Shak S, et al. Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol. 2006;24:3726-3734.

23. NASBP B-14 Validation Trial for the Oncotype DX� Assay Purpose: To evaluate the Oncotype DX 21-gene panel and its Recurrence Score� (RS) result as predictors of the likelihood of distant recurrence Population: Tumor tissue from 668 N-, ER+, tamoxifen-treated patients enrolled in the NASBP B-14 study Design: Multi-center study using a pre-defined panel of 21 genes with prospectively-defined endpoints, analysis plan and algorithm for calculation of the RS result Blinded, triplicate analysis by RT-PCR of 10 �m fixed tumor block sections The NASBP B-14 validation trial for Oncotype DX is a prospectively designed trial using archival tissue. The laboratory was blinded to the clinical outcomes. This NSABP study was performed to clinically validate the prespecified 21 gene RT-PCR assay and the Recurrence Score algorithm as a predictor of the prospectively defined primary endpoint of distant recurrence-free survival in N-, ER+ patients treated with Tamoxifen from the large multicenter NSABP B-14 study. The original B-14 trial had 2828 N-, ER+ patients who were randomized 1:1 to tamoxifen or placebo in a double-blind fashion from 1982-1988. An additional 1335 patients were registered to Tamoxifen in the 10-month period following closure of this trial in 1988, making 2617 clinically eligible tamoxifen-treated patients. Patients who were treated with tamoxifen in the randomized portion or the registered portion were eligible for the Genomic Health study.The NASBP B-14 validation trial for Oncotype DX is a prospectively designed trial using archival tissue. The laboratory was blinded to the clinical outcomes. This NSABP study was performed to clinically validate the prespecified 21 gene RT-PCR assay and the Recurrence Score algorithm as a predictor of the prospectively defined primary endpoint of distant recurrence-free survival in N-, ER+ patients treated with Tamoxifen from the large multicenter NSABP B-14 study. The original B-14 trial had 2828 N-, ER+ patients who were randomized 1:1 to tamoxifen or placebo in a double-blind fashion from 1982-1988. An additional 1335 patients were registered to Tamoxifen in the 10-month period following closure of this trial in 1988, making 2617 clinically eligible tamoxifen-treated patients. Patients who were treated with tamoxifen in the randomized portion or the registered portion were eligible for the Genomic Health study.

24. The Recurrence Score� Result Stratifies Patients by their 10-Year Distant Recurrence-Free Survival Of the 675 available blocks in the NSABP library, 668 underwent successful evaluation with RT-PCR, representing a 99% success rate. This graph demonstrates the difference in DRFS over time for the different risk categories. The distant recurrence-free survival for the high- and low-risk groups were statistically significantly different; the 10-year distant recurrence-free survival for the low-risk category was 93% compared to 69% for the high-risk category. Of the 675 available blocks in the NSABP library, 668 underwent successful evaluation with RT-PCR, representing a 99% success rate. This graph demonstrates the difference in DRFS over time for the different risk categories. The distant recurrence-free survival for the high- and low-risk groups were statistically significantly different; the 10-year distant recurrence-free survival for the low-risk category was 93% compared to 69% for the high-risk category.

25. The Recurrence Score� Result Quantifies the Risk of Distant Recurrence (Prognosis) The graph presented in this slide indicates that the proportion of patients in the low-risk group who were recurrence-free at 10 years was significantly greater than the proportion of patients in the high risk group (P <0.00001). The risk of distant recurrence in the high-risk group is similar to that observed in node-positive patients (Bonadonna et al. Cancer 1977;39(6 Suppl):2904-15). For each risk-based cohort, the 95% confidence interval error bands have little to no overlap.The graph presented in this slide indicates that the proportion of patients in the low-risk group who were recurrence-free at 10 years was significantly greater than the proportion of patients in the high risk group (P <0.00001). The risk of distant recurrence in the high-risk group is similar to that observed in node-positive patients (Bonadonna et al. Cancer 1977;39(6 Suppl):2904-15). For each risk-based cohort, the 95% confidence interval error bands have little to no overlap.

26. The Recurrence Score� is a Continuous Predictor of the Risk of Distant Recurrence The recurrence score is a continuous predictor of tumor biology. Risks groups have been developed for statistical analysis in the clinical trials. However, each individual RS has a distinct risk of recurrence associated with it. As an example, the risk of recurrence for a patient with a RS of 20 is closer to a patient with a RS of 17 in the low risk group than to one with a RS of 29 in the intermediate risk group.The recurrence score is a continuous predictor of tumor biology. Risks groups have been developed for statistical analysis in the clinical trials. However, each individual RS has a distinct risk of recurrence associated with it. As an example, the risk of recurrence for a patient with a RS of 20 is closer to a patient with a RS of 17 in the low risk group than to one with a RS of 29 in the intermediate risk group.

27. Summary of the NASBP B-14 Trial Clinical validation study for the Oncotype DX� assay showing that the Recurrence Score� result quantifies the likelihood of distant recurrence in N- ER+, tamoxifen-treated breast cancer patients (prognosis) The Recurrence Score result identified a large subset of patients with low risk of recurrence The Recurrence Score result was a consistent predictor of distant recurrence independent of patient age, tumor size and tumor grade Using the prospectively defined 21-gene expression assay and endpoints, the RS predicted the likelihood of distant recurrence in N-, ER+ tamoxifen treated breast cancer patients. The RS provides accuracy and precision in predicting the likelihood of distant recurrence. The performance of the RS exceed standard measures such as age, tumor size and tumor grade in prognostic power and reproducibility. Overall, 50% of the patients were reclassified by the RS when compared to NCCN or St. Gallen (not shown) The RS (based upon tumor gene expression) more accurately quantifies the risk of distant recurrence than do the NCCN guidelines (based upon size, age and grade). Although all patients enrolled in B-14 were later treated with Tamoxifen, which as implications for interpretration of RS for individual patients, the tissue that was archived for analysis was taken from tumors before any systemic therapy was administered.Using the prospectively defined 21-gene expression assay and endpoints, the RS predicted the likelihood of distant recurrence in N-, ER+ tamoxifen treated breast cancer patients. The RS provides accuracy and precision in predicting the likelihood of distant recurrence. The performance of the RS exceed standard measures such as age, tumor size and tumor grade in prognostic power and reproducibility. Overall, 50% of the patients were reclassified by the RS when compared to NCCN or St. Gallen (not shown) The RS (based upon tumor gene expression) more accurately quantifies the risk of distant recurrence than do the NCCN guidelines (based upon size, age and grade). Although all patients enrolled in B-14 were later treated with Tamoxifen, which as implications for interpretration of RS for individual patients, the tissue that was archived for analysis was taken from tumors before any systemic therapy was administered.

28. NASBP B-20 Chemotherapy Benefit Trial for the Oncotype DX� Assay Purpose: To determine whether the Oncotype DX assay and its Recurrence Score� result could predict magnitude of chemotherapy benefit Population: Tumor tissue from 651 N-, ER+ patients from the NASBP B-20 study treated with either tamoxifen alone (n=227) or with tamoxifen plus CMF or MF chemotherapy (n=424) Design: Multi-center, randomized trial using a pre-defined panel of 21 genes with prospectively-defined endpoints, analysis plan and algorithm for calculation of the RS result Blinded, triplicate analysis by RT-PCR of 10 �m fixed tumor block sections The NASBP B-20 chemotherapy benefit study for Oncotype DX is a prospectively designed trial using archival tissue. The objective of this trial is listed above along with the schema of the protocol. In secondary analyses, similar results were seen when the patients treated with CMF or with MF were examined separately. The analysis by NSABP shows GHI�s B-20 study subjects were similar to all B-20 patients in the cohort and the loss of cases was principally due to blocks never being collected. Again this trial had prospectively define endpoints and the laboratory was blinded to the clinical outcomes. The NASBP B-20 chemotherapy benefit study for Oncotype DX is a prospectively designed trial using archival tissue. The objective of this trial is listed above along with the schema of the protocol. In secondary analyses, similar results were seen when the patients treated with CMF or with MF were examined separately. The analysis by NSABP shows GHI�s B-20 study subjects were similar to all B-20 patients in the cohort and the loss of cases was principally due to blocks never being collected. Again this trial had prospectively define endpoints and the laboratory was blinded to the clinical outcomes.

29. The Oncotype DX� Assay: Patients Do Not Benefit Equally from Chemotherapy These results indicate that not all women benefit equally from chemotherapy. (A)- shows all 651 patients within this trial showing the overall benefit of chemotherapy in these evaluable patients of 4.4% absolute benefit from tamoxifen + chemotherapy. Is this small overall benefit due to a little benefit in many or most of the patients, or is this small benefit due to a large benefit in a subset of the patients? (These results recapitulate the seminal findings from the original B-20 study (Fisher B, Dignam J, Wolmark N, et al. J Natl Cancer Inst. 1997;89:1673-1682) which helped open the door to widespread use of adjuvant cytotoxic therapy for this population. (D)The results in patients in the high-risk group (Recurrence Score >31) are shown here. It appears that much of the benefit associated with CMF therapy in the B-20 study was a function of the risk reduction experienced by this high-risk cohort, which represents approximately 25% of the population. The high-risk patients have a large benefit (28% absolute) from the addition of chemotherapy. (B) The results in patients in the low-risk group (Recurrence Score <18) are shown here. These patients have a very low likelihood of distant recurrence. The difference between the tamoxifen alone and tamoxifen plus chemotherapy groups is not statistically significant, so the benefit of chemotherapy appears to be minimal, if any. (C)The results in patients in the intermediate-risk group (Recurrence Score 18-30) are shown here. The patients in the intermediate-risk group, as expected, had a higher risk of distant recurrence than those in the low-risk group. The benefit of chemotherapy in the intermediate-risk patients does not appear to be large and remains unclear. We will be addressing this intermediate risk group later in our discussion (TAILORx) This type of assay helps to inform decisions about patient management. For example, patients at high risk of recurrence and/or with large chemotherapy benefit may decide, together with their physicians, to receive appropriate chemotherapy. While those at low risk and/or with little chemotherapy benefit may decide, together with their physicians, to avoid to unwanted toxicities associated with chemotherapy. These results indicate that not all women benefit equally from chemotherapy. (A)- shows all 651 patients within this trial showing the overall benefit of chemotherapy in these evaluable patients of 4.4% absolute benefit from tamoxifen + chemotherapy. Is this small overall benefit due to a little benefit in many or most of the patients, or is this small benefit due to a large benefit in a subset of the patients? (These results recapitulate the seminal findings from the original B-20 study (Fisher B, Dignam J, Wolmark N, et al. J Natl Cancer Inst. 1997;89:1673-1682) which helped open the door to widespread use of adjuvant cytotoxic therapy for this population. (D)The results in patients in the high-risk group (Recurrence Score >31) are shown here. It appears that much of the benefit associated with CMF therapy in the B-20 study was a function of the risk reduction experienced by this high-risk cohort, which represents approximately 25% of the population. The high-risk patients have a large benefit (28% absolute) from the addition of chemotherapy. (B) The results in patients in the low-risk group (Recurrence Score <18) are shown here. These patients have a very low likelihood of distant recurrence. The difference between the tamoxifen alone and tamoxifen plus chemotherapy groups is not statistically significant, so the benefit of chemotherapy appears to be minimal, if any. (C)The results in patients in the intermediate-risk group (Recurrence Score 18-30) are shown here. The patients in the intermediate-risk group, as expected, had a higher risk of distant recurrence than those in the low-risk group. The benefit of chemotherapy in the intermediate-risk patients does not appear to be large and remains unclear. We will be addressing this intermediate risk group later in our discussion (TAILORx) This type of assay helps to inform decisions about patient management. For example, patients at high risk of recurrence and/or with large chemotherapy benefit may decide, together with their physicians, to receive appropriate chemotherapy. While those at low risk and/or with little chemotherapy benefit may decide, together with their physicians, to avoid to unwanted toxicities associated with chemotherapy.

30. Patients with High RS Derive Significant Benefit from Chemotherapy (Prediction) Shown here is the absolute increase in DRFS by the addition of chemotherapy in each of the Recurrence Score risk groups. The high-risk patients gain a clear large benefit from chemotherapy, with the absolute risk of recurrence decreased by 28%. The low-risk patients have minimal, if any, benefit. The intermediate-risk patients may gain as much as a 4% absolute benefit from chemotherapy. Consideration of chemotherapy treatment in the intermediate-risk patients should take into account all factors, such as the individual Recurrence Score (an RS of 19 is different from 30), tumor size, age, grade, patient preference, etc. This intermediate group we will be discussing further when we get to the TAILORx NCI sponsored trial that is ongoing. Shown here is the absolute increase in DRFS by the addition of chemotherapy in each of the Recurrence Score risk groups. The high-risk patients gain a clear large benefit from chemotherapy, with the absolute risk of recurrence decreased by 28%. The low-risk patients have minimal, if any, benefit. The intermediate-risk patients may gain as much as a 4% absolute benefit from chemotherapy. Consideration of chemotherapy treatment in the intermediate-risk patients should take into account all factors, such as the individual Recurrence Score (an RS of 19 is different from 30), tumor size, age, grade, patient preference, etc. This intermediate group we will be discussing further when we get to the TAILORx NCI sponsored trial that is ongoing.

31. Summary of the NASBP B-20 Trial The Recurrence Score� (RS) result not only quantifies the risk of recurrence in women with N-, ER+ breast cancer, but also predicts the magnitude of chemotherapy benefit (predictive) Patients with a low RS have minimal, if any benefit, from chemotherapy while patients with a high RS have a significant benefit from chemotherapy Benefits of adjuvant treatment differ by Recurrence Score risk category: Benefits of tamoxifen are greater in patients with low risk or intermediate risk tumors (Paik et al. JCO, 2005 ASCO Annual Meeting Proceedings. Vol 23, No. 16S, 2005: 510) Benefits of chemotherapy are greater in patients with high risk tumors Benefits of adjuvant treatment differ by Recurrence Score risk category: Benefits of tamoxifen are greater in patients with low risk or intermediate risk tumors (Paik et al. JCO, 2005 ASCO Annual Meeting Proceedings. Vol 23, No. 16S, 2005: 510) Benefits of chemotherapy are greater in patients with high risk tumors

32. The Oncotype DX� Assay in Clinical Practice Let�s transition over and talk about how health care professionals like yourself get access to Oncotype DX and the process surrounding ordering within your institution. Let�s transition over and talk about how health care professionals like yourself get access to Oncotype DX and the process surrounding ordering within your institution.

33. The Oncotype DX� Assay Recommended in ASCO Clinical Practice Guidelines The Oncotype DX assay is recommended on the ASCO Clinical Practice Guidelines for use in newly diagnosed patients with N-, ER+ breast cancer to: Predict risk of recurrence Identify patients who are predicted to obtain the most therapeutic benefit from tamoxifen and may not require chemotherapy Identify patients with high RS scores who appear to derive greater benefit from chemotherapy (specifically CMF) than from tamoxifen Conclusions may not be generalizable to hormonal therapies other than tamoxifen, or to other chemotherapy regimens The Oncotype DX assay is the only multi-parameter gene expression assay found to show clinical utility in breast cancer

34. The Oncotype DX� Assay Recommended for Consideration in NCCN Clinical Practice Guidelines

35. The Oncotype DX� Assay in Clinical Practice The Oncotype DX assay has been available since January 2004. Genomic Health has a Clinical Laboratory Improvement Act/Amendment (CLIA)- certified reference lab. The assay requires sending a tumor block or 6 fixed, paraffin-embedded sections of 10 �m each to Genomic Health. The turnaround time for the assay is 10 to 14 days calendar days from the time that Genomic Health receives the patient�s tumor specimen.The Oncotype DX assay has been available since January 2004. Genomic Health has a Clinical Laboratory Improvement Act/Amendment (CLIA)- certified reference lab. The assay requires sending a tumor block or 6 fixed, paraffin-embedded sections of 10 �m each to Genomic Health. The turnaround time for the assay is 10 to 14 days calendar days from the time that Genomic Health receives the patient�s tumor specimen.

36. Reimbursement Support for Your Practice for the Oncotype DX� Assay Genomic Health helps your patient and practice by taking assignment of benefits and managing the billing and claims process The Genomic Access Program (GAP) performs comprehensive benefits investigations and informs patients of their coverage and potential financial responsibility within 2 business days Well trained client service and reimbursement staff are available and willing to work one-on-one with offices/accounts/ and patients as needed. There is a full brochure available to the patients outlining all of these services. (Refer to patient education brochure located on slide 40)Well trained client service and reimbursement staff are available and willing to work one-on-one with offices/accounts/ and patients as needed. There is a full brochure available to the patients outlining all of these services. (Refer to patient education brochure located on slide 40)

37. The Oncotype DX� Assay Is Widely Covered in the United States Oncotype DX is covered by several insurance plans representing 165+ million lives in the US� Plans include: Medicare�, Aetna, United Healthcare, Kaiser Permanente, Cigna, WellPoint, Highmark BC, Harvard Pilgrim, BC/BS of Michigan, BC/BS FEP, CareFirst BC/BS, BC/BS of Minnesota, BC/BS of Alabama, BC/BS of New Jersey and others GAP also provides a generous financial assistance to qualifying patients Covered lives: number of lives with coverage either by policies or contracts. GAP- Genomic Access Program- patient education brochure completely outlines the services these professionals provide (these include): Services provided: Benefit Investigations Prior Authorizations when needed Processing of Claims Appeals � up to 3 levels to include independent medical review if available Communication with physician�s office and patient throughout the reimbursement process (GAP Brochure provided to patients) Uninsured Patient Assistance Program Financial Assistance for insured patients who meet eligibility requirements Covered lives: number of lives with coverage either by policies or contracts. GAP- Genomic Access Program- patient education brochure completely outlines the services these professionals provide (these include): Services provided: Benefit Investigations Prior Authorizations when needed Processing of Claims Appeals � up to 3 levels to include independent medical review if available Communication with physician�s office and patient throughout the reimbursement process (GAP Brochure provided to patients) Uninsured Patient Assistance Program Financial Assistance for insured patients who meet eligibility requirements

38. Procedure for Ordering the Oncotype DX� Assay Procedure as of September 2007Procedure as of September 2007

39. Oncotype DX� Patient Report The patient report includes: Recurrence Score� (RS) Average 10-year distant recurrence rate for that RS Graph of 10-year recurrence risk as a function of RS in tamoxifen-treated patients The report is sent to: Treating physician Submitting pathologist A detailed report is generated, showing the assay result as a Recurrence Score (RS). The report also provides an interpretation of the RS as the average 10-year distant recurrence rate for that RS in the clinical trial population (including 95% confidence interval) and the position of that RS on a graph of RS as a continuous variable. The report is sent by fax, overnight mail, or secure online transfer to the treating physicians and submitting pathologist and any additional physicians named on the requisition form. The Oncotype DX� report is not directly distributed to patients.A detailed report is generated, showing the assay result as a Recurrence Score (RS). The report also provides an interpretation of the RS as the average 10-year distant recurrence rate for that RS in the clinical trial population (including 95% confidence interval) and the position of that RS on a graph of RS as a continuous variable. The report is sent by fax, overnight mail, or secure online transfer to the treating physicians and submitting pathologist and any additional physicians named on the requisition form. The Oncotype DX� report is not directly distributed to patients.

40. How Can Nurses be Involved with the Oncotype DX� Assay? Identify appropriate patients Stage I/II, lymph node negative, ER positive, who need to make decisions regarding adjuvant chemotherapy Not for DCIS patients Not for lymph node positive patients Educate patients on the Oncotype DX assay Help inform and assist with enrollment of eligible patients on the TAILORx trial TAILORx trial to be discussed laterTAILORx trial to be discussed later

41. Oncotype DX� Resources for Nurses Patient Education Brochure English and Spanish My Breast Cancer Coach Interactive online program developed with the Breast Cancer Network of Strength. This program enables newly diagnosed women to personalize their online search for breast cancer information by answering a series of eight questions about their diagnosis, based on the information contained in their pathology reports www.MyTreatmentDecision.com Patient website providing an overview of invasive breast cancer and the tools used to determine recurrence risk and help make treatment decisions

42. Genomic Health�s Commitment to Nursing Offer educational programs and activities on Genomics at both local and national levels Provide accurate medical and clinical information in a timely manner, including one on one assistance from our medical team Provide valuable assay results that are reliable, sensitive and reproducible Deliver actionable insights that can improve decision making for breast cancer patients Address reimbursement concerns Provide patient education and support Partner with advocacy groups to support breast cancer efforts

43. Patient Cases

49. Integration of New Tests in Clinical Decision-Making: TAILORx

50. The premise of the trial is that the Oncotype DX� assay is able to identify women who will benefit from chemotherapy and women who will have little or no benefit from chemotherapy. Therefore, the implications of this premise for the study are that many women are currently being overtreated and could benefit from hormonal therapy alone, and other patients are getting inadequate treatment and could benefit from chemotherapy. Through this trial many of these patients will now be appropriately treated based upon their risk of recurrence and likelihood of chemotherapy benefit. However, there are some woman for whom uncertainty still exists about the likelihood of benefit from chemotherapy, and these women will be randomized to determine if there is a group that largely receives chemotherapy plus hormone therapy now but may do no worse with hormonal therapy alone. The premise of the trial is that the Oncotype DX� assay is able to identify women who will benefit from chemotherapy and women who will have little or no benefit from chemotherapy. Therefore, the implications of this premise for the study are that many women are currently being overtreated and could benefit from hormonal therapy alone, and other patients are getting inadequate treatment and could benefit from chemotherapy. Through this trial many of these patients will now be appropriately treated based upon their risk of recurrence and likelihood of chemotherapy benefit. However, there are some woman for whom uncertainty still exists about the likelihood of benefit from chemotherapy, and these women will be randomized to determine if there is a group that largely receives chemotherapy plus hormone therapy now but may do no worse with hormonal therapy alone.

51. TAILORx Schema This is the schema of the TAILORx trial. The eligible patients for this trial are N�, ER+ and are candidates for chemotherapy (ie, patients who do not have comorbid conditions that would preclude them from receiving chemotherapy and who are willing to take it if recommended). Also, HER2+ patients are not eligible for this trial. The fact that the Breast Cancer Intergroup is stratifying patients for the TAILORx trial by the Oncotype DX� assay demonstrates that this assay is widely accepted and validated in the study population. Treatment will be based on the results of the assay. Patients will be stratified as follows: Patients with a Recurrence Score below 11 will receive hormonal therapy alone. Patients with a Recurrence Score between 11 and 25 will be randomized to either hormonal therapy alone or hormonal therapy + chemotherapy. This is the primary study group. This corresponds approximately to a risk of recurrence at 10 years of 10%-20%. Patients with a Recurrence Score greater than 25 will receive chemotherapy + hormonal therapy. Since this trial has a dealer�s choice�type design, individual investigators can select the type of hormonal therapy and chemotherapy from a list included in the protocol. The groups in this trial do not correspond to the low-, intermediate-, and high-risk cutoffs found on the Oncotype DX� report. However, the cutoffs for the TAILORx trial were picked for different reasons from those involved with the selection of cutoffs for the validation trial and the Oncotype DX� report. The cutoffs in the study were selected to correspond with specific risk levels. For instance, the TAILORx investigators concluded that it was not ethical to deprive a women of chemotherapy if she had a risk level above 20%.This is the schema of the TAILORx trial. The eligible patients for this trial are N�, ER+ and are candidates for chemotherapy (ie, patients who do not have comorbid conditions that would preclude them from receiving chemotherapy and who are willing to take it if recommended). Also, HER2+ patients are not eligible for this trial. The fact that the Breast Cancer Intergroup is stratifying patients for the TAILORx trial by the Oncotype DX� assay demonstrates that this assay is widely accepted and validated in the study population. Treatment will be based on the results of the assay. Patients will be stratified as follows: Patients with a Recurrence Score below 11 will receive hormonal therapy alone. Patients with a Recurrence Score between 11 and 25 will be randomized to either hormonal therapy alone or hormonal therapy + chemotherapy. This is the primary study group. This corresponds approximately to a risk of recurrence at 10 years of 10%-20%. Patients with a Recurrence Score greater than 25 will receive chemotherapy + hormonal therapy. Since this trial has a dealer�s choice�type design, individual investigators can select the type of hormonal therapy and chemotherapy from a list included in the protocol. The groups in this trial do not correspond to the low-, intermediate-, and high-risk cutoffs found on the Oncotype DX� report. However, the cutoffs for the TAILORx trial were picked for different reasons from those involved with the selection of cutoffs for the validation trial and the Oncotype DX� report. The cutoffs in the study were selected to correspond with specific risk levels. For instance, the TAILORx investigators concluded that it was not ethical to deprive a women of chemotherapy if she had a risk level above 20%.

52. This study has a non-inferiority design. The working premise is that patients in the mid-range Recurrence Score risk group will do �no worse� with hormonal therapy alone than they would with hormonal therapy plus from chemotherapy. Note: The study does not directly assess the validity of the Oncotype DX� assay. In fact, this trial design is predicated on the assumption that the assay is fully validated. For a patient with a RS <11, chemotherapy will not be given. For a patient with a RS >25, chemotherapy will be given. In other words, the risk generated from the RS is felt to be validated and is actionable, based on the references below. Paik S, Shak S, Tang G, et al. A multi-gene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N Engl J Med. 2004;351(27):2817-2826. Paik S, Tang G, Shak S, et al. Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol. 2006 Aug 10;24(23) [Epub ahead of print May 23, 2006]. Habel L, Shak S, Jacobs M, et al. A population-based study of tumor gene expression and risk of breast cancer death among lymph node-negative patients. Breast Cancer Res. 2006;May 31;8(3):R25 [Epub ahead of print]. Simon R. Roadmap for developing and validating therapeutically relevant genomic classifiers. J Clin Oncol. 2005;23(29):7332-7341. This study has a non-inferiority design. The working premise is that patients in the mid-range Recurrence Score risk group will do �no worse� with hormonal therapy alone than they would with hormonal therapy plus from chemotherapy. Note: The study does not directly assess the validity of the Oncotype DX� assay. In fact, this trial design is predicated on the assumption that the assay is fully validated. For a patient with a RS <11, chemotherapy will not be given. For a patient with a RS >25, chemotherapy will be given. In other words, the risk generated from the RS is felt to be validated and is actionable, based on the references below. Paik S, Shak S, Tang G, et al. A multi-gene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N Engl J Med. 2004;351(27):2817-2826. Paik S, Tang G, Shak S, et al. Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol. 2006 Aug 10;24(23) [Epub ahead of print May 23, 2006]. Habel L, Shak S, Jacobs M, et al. A population-based study of tumor gene expression and risk of breast cancer death among lymph node-negative patients. Breast Cancer Res. 2006;May 31;8(3):R25 [Epub ahead of print]. Simon R. Roadmap for developing and validating therapeutically relevant genomic classifiers. J Clin Oncol. 2005;23(29):7332-7341.

53. Financial Considerations Costs associated with treating the patient and any supportive care will be billed by local practices in the normal manner. Genomic Health will submit claims to relevant health plans for the cost of the Oncotype DX� assay � just as they do for patients outside this study. In those cases where specific claims for this test are denied, Genomic Health will facilitate appeals. If, after pursuing appeals, any patient is left with an outstanding balance for the test, and for those patients who are uninsured or who have copayments or deductibles, Genomic Health will waive all rights to seek payment from the patient. This policy ensures that out-of-pocket costs for patients enrolled in this study will be $0, eliminating the sample bias that might occur if insurance coverage or financial status affected enrollment decisions.Financial Considerations Costs associated with treating the patient and any supportive care will be billed by local practices in the normal manner. Genomic Health will submit claims to relevant health plans for the cost of the Oncotype DX� assay � just as they do for patients outside this study. In those cases where specific claims for this test are denied, Genomic Health will facilitate appeals. If, after pursuing appeals, any patient is left with an outstanding balance for the test, and for those patients who are uninsured or who have copayments or deductibles, Genomic Health will waive all rights to seek payment from the patient. This policy ensures that out-of-pocket costs for patients enrolled in this study will be $0, eliminating the sample bias that might occur if insurance coverage or financial status affected enrollment decisions.

54. TAILORx Information Resources Protocol and General Information Clinical Trials Support Unit 1-888-823-5923 CTSUcontact@westat.com www.ctsu.org Eligibility Questions Eastern Cooperative Oncology Group ecog.tailorx@jimmy.harvard.edu www.ecog.org TAILORx Patient Education Materials Eastern Cooperative Oncology Group http://www.ecog.org/general/tailorx.html Oncotype DX� Information Genomic Health Customer Service 1-866-ONCOTYPE (1-866-662-6897) www.oncotypedx.com

55. Conclusions

56. Recurrence Score� in N-, ER+ patients Oncotype DX� is a Standardized and Quantitative Assay The Recurrence Score has been correlated with Distant recurrence rate at 10 years assuming 5 years of tamoxifen treatment (the higher the score, the higher the distant recurrence rate) Chemotherapy benefit (the higher the score, the greater the impact of chemotherapy on 10 year distant recurrence-free survival)The Recurrence Score has been correlated with Distant recurrence rate at 10 years assuming 5 years of tamoxifen treatment (the higher the score, the higher the distant recurrence rate) Chemotherapy benefit (the higher the score, the greater the impact of chemotherapy on 10 year distant recurrence-free survival)

57. Oncotype DX� Summary The Oncotype DX Recurrence Score� assay predicts likelihood of recurrence (prognostic) and magnitude of adjuvant treatment benefit for chemotherapy (predictive) The Oncotype DX Recurrence Score assay shows consistent results across multiple independent studies