The optimal therapeutic approach to Bone Metastasis Metastatic breast cancer: current management and future perspectives The optimal therapeutic approach to Bone Metastasis Giuseppe Tonini Oncologia Medica Università Campus Biomedico - Roma g.tonini@unicampus.it

Malignant Bone Disease Is Prevalent Breast cancer commonly metastasizes to bone Up to 75% of metastatic breast patients1 Median OS ~ 2 years and may be improving 5 year prevalence ~ 4.8 million cases2 Bladder + Lung + Prostate Bone metastases cause significant morbidity Pain, fractures, loss of mobility, surgery etc Poorer quality of life and survival OS, overall survival. 1. Kinnane N. Eur J Oncol Nurs. 2007;11 Suppl 2:S28-S31. 2. Parkin DM, et al. CA Cancer J Clin. 2005;55(2):74-108. Image courtesy Dr. David Cameron.

Spinal cord compression Skeletal related events (SREs) Pathologic fracture Surgery to bone Spinal cord compression Radiotherapy to bone Hypercalcemia Page  3

Patients With Bone Metastases Are at High Risk for Developing Skeletal-Related Events SREs Placebo arm of a large randomized study Any Pathologic fracture Radiation therapy Surgical intervention Spinal cord compression Patients with SRE, % 24 months’ follow-up SRE, skeletal-related event. Data from Lipton A, et al. Cancer. 2000;88(5):1082-1090.

Pathologic Fractures Negatively Affect Survival Risk increase P value 1.29 Prostate cancer 29% .04 1.52 Breast cancer 52% < .01 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Hazard ratio Decreased mortality Increased mortality Data from Saad F, et al. Cancer. 2007;110(8):1860-1867.

Bisphosphonates: Molecular mechanism of action HMG-CoA Statins X BPs inhibit FPP synthase, thus blocking the prenylation of small signaling proteins required for cell function and survival Mevalonate Geranyl diphosphate FPP synthase X Farnesyl diphosphate (FPP) Ras S Cholesterol Geranylgeranyl diphosphate (GGPP) Rho S

The Goal of Bisphosphonate Therapy Bisphosphonates proven benefits Prevent skeletal-related events (SREs) Prevent first and subsequent SREs Delay the onset of the first SRE Palliate and control bone pain Reduce the need for analgesics and palliative radiotherapy Bisphosphonates improve patient’s quality of life

Direct antitumor effects (in vitro and animal models) Bisphosphonates Translation from preclinical studies to clinical trials Direct antitumor effects (in vitro and animal models) Synergistic effects with cytotoxic and biological drugs (in vitro and animal models) Effects on the metastatic process (animal models) Effects on angiogenesis (in vitro, animal models and in humans) Stimulation of T gamma/delta lymphocytes (in vitro, and in humans immunomodulation) Zoledronic Acid Clinical Development Program: Anti-tumour Potential Ongoing preclinical research Number of anti-tumour activities suggested To further evaluate the anti-tumour potential of zoledronic acid, pre-clinical studies are currently running/planned.1 Preliminary results of these ongoing studies demonstrate that zoledronic acid inhibits proliferation and induces apoptosis in various human myeloma and breast cancer cell lines in vitro. Zoledronic acid may also inhibit key steps in the metastatic process. Platelets, activated by tumour cells, are intimately involved in the initial thrombus formation prior to the adhesion and extravasation of tumour cells. Zoledronic acid decreases thrombin generation by human osteosarcoma cells, and reduces platelet aggregation in vitro.2 Moreover, treatment of human prostate and breast cancer cells with zoledronic acid in vitro inhibits cell invasion into extracellular matrix.3 Zoledronic acid may have an effect on nociceptors — and, therefore, may have a beneficial effect on pain. Santini D and Tonini G Ann Oncol 2007 1. Data on file. Novartis Pharma AG. 2. Marion G, Serre C-M, Trzeciak M-C, et al. Bisphosphonates inhibit the platelet-aggregating activity of tumor cells, a process involved during hematogenous dissemination of metastatic cells. Bone. 1998;23/5(suppl):S279. 3. Boissier S, Magnetto S, Delmas PD, Clezardin P. Bisphosphonates inhibit breast and prostate carcinoma cell invasion, an early event in the formation of bone metastases. Cancer Res. 2000;60:2949-2954. 8

Bisphosphonate Indications in BC Prevention of SREs HCM Multiple myeloma Breast cancer Prostate cancera Other solid tumors Clodronate (oral)  Pamidronate (IV) Zoledronic acid (IV) Ibandronate (oral and IV)  = European Registration  = Worldwide Registration BC, breast cancer; HCM, hypercalcemia of malignancy; IV, intravenous; SRE, skeletal-related event. a In the United States, prostate cancer must have progressed despite hormone therapy. Prescribing information for pamidronate and zoledronic acid is available at: www.pamidronate.com and www.zometa.com. Further information for clodronate and ibandronate is available at www.bayer.nl/ebbsc/cms/nl/healthcare/bayer_schering_pharma and www.roche.com.

Bisphosphonates Approved for Breast Cancer Patients With Bone Metastases Relative Dose, Infusion Bisphosphonate potency* mg Schedule time Non-nitrogen Clodronate† 1 1,600 daily oral Single nitrogen Pamidronate§ 20 90 q3-4 wks 2 hrs Ibandronate† 857 6 q3-4 wks 1 hr 50 daily oral Two nitrogens Zoledronic acid§ 16,700 4 q3-4 wks 15 min Rationale for using bisphosphonates to treat skeletal complications of bone metastases1-10 Nitrogen-containing bisphosphonates have a variety of direct and indirect inhibitory effects on osteoclasts—they inhibit osteoclast maturation and recruitment to bone surface and inhibit osteoclast function though their effects on the mevalonate pathway (inhibition of protein prenylation). They also induce osteoclast apoptosis In vitro studies have shown that nitrogen-containing bisphosphonates inhibit the activity of farnesyl diphosphonate (FPP) synthase, an enzyme necessary for prenylation of small guanine triphosphatases (GTPases)—such as Ras, Rac, and Rho—that are involved in intracellular signaling Zoledronic acid and other bisphosphonates delay the onset and reduce the incidence of skeletal complications Similarly, through their effects on osteoblasts, tumor cells, and cytokine and growth-factor production, bisphosphonates may interrupt the vicious cycle of bone destruction and restore balance to osteoclast and osteoblast activity. This inhibition of pathologic bone resorption significantly reduces pain and the need for radiation, bone surgery, or both References 1. Berenson JR, Lipton A. Bisphosphonates in the treatment of malignant bone disease. Ann Rev Med. 1999;50:237-248. 2. Evans CE, Braidman IP. Effects of two novel bisphosphonates on bone cells in vitro. Bone Miner Res. 1994;26:95-107. 3. Green JR, Müller K, Jaeggi KA. Preclinical pharmacology of CGP 42'446, a new, potent, heterocyclic bisphosphonate compound. J Bone Miner Res. 1994;9:745-751. 4. Body JJ. Bisphosphonates in the treatment of metastatic breast cancer. J Mamm Gland Biology and Neoplasia 2001;6: 477-485. 5. Mundy GR, Yoneda T, Hiraga T. Preclinical studies with zoledronic acid and other bisphosphonates: impact on the bone microenvironment. Semin Oncol 2001;28:35-44. 6. Derenne S, Amiot M, Barille S, et al. Zoledronate is a potent inhibitor of myeloma cell growth and secretion of IL-6 and MMP-1 by the tumoral environment. J Bone Miner Res. 1999;14:2048-2056. 7. Boissier S, Ferreras M, Peyruchaud O, et al. Bisphosphonates inhibit breast and prostate carcinoma cell invasion, an early event in the formation of bone metastases. Cancer Res. 2000;60:2949-2954. 8. Aparicio A, Gardner A, Tu Y, Savage A, Berenson J, Lichtenstein A. In vitro cytoreductive effects on multiple myeloma cells induced by bisphosphonates. Leukemia. 1998;12:220-229. 9. Senaratne SG, Pirianov G, Mansi JL, Arnett TR, Colston KW. Bisphosphonates induce apoptosis in human breast cancer cell lines. Br J Cancer. 2000;82:1459-1468. 10. Adami S. Bisphosphonates in prostate carcinoma. Cancer. 1997;80:1674-1679. *Green et al. J Bone Miner Res. 1994;9:745-751. †Approved in EU §Approved in US and EU

Data From Clinical Trials

Pamidronate Reduced All Types of SREs at 2 Years in Patients With Bone Metastases From BC Pamidronate 90 mg (n = 367) Placebo (n = 384) BC, breast cancer; HCM, hypercalcemia of malignancy; SCC, spinal cord compression; SRE, skeletal-related event. Data from Lipton A, et al. Cancer. 2000;88(5):1082-1090.

Ibandronate Reduced the Skeletal Morbidity Period Rate (SMPR) in Patients With Bone Metastases From BC Skeletal Morbidity Period Rate defined as “frequency of 12-week period with SREs” during the study (2 years) P = .004 Ibandronate 6 mg (n = 154) Placebo (n = 158) BC, breast cancer; SRE, skeletal-related event. Data from Body J-J, et al. Ann Oncol. 2003;14(9):1399-1405.

Zoledronic Acid Reduced All Types of SREs at 1 Year in Patients With Bone Metastases From BC Zoledronic acid 4 mg (n = 114) Placebo (n = 113) BC, breast cancer; HCM, hypercalcemia of malignancy; SCC, spinal cord compression; SRE, skeletal-related event. Adapted from Kohno N, et al. J Clin Oncol. 2005;23(15):3314-3321.

Independent Meta-analysis of Phase III Trials of Bisphosphonates for Prevention of SREs in mBC Risk reduction P value 0.59 IV ZOL 4 mg 41% .001 (Kohno 2005) 0.77 IV PAM 90 mg 23% < .001 (Aredia study 18 and 19) 0.82 IV Ibandronate 6 mg 18% .04 (Body 2003) 0.86 Oral Ibandronate 50 mg 14% .08 (Body 2004) Oral clodronate 1,600 mg (Kristensen 1999) 31% (Paterson 1993) 17% (Tubiana-Hulin 2001) 8% 0.69 0.83 .03 (pooled) 0.92 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Cochrane database comparing placebo-controlled trials in breast cancer setting. IV, intravenous; mBC, metastatic breast cancer; PAM, pamidronate; SRE, skeletal-related event; ZOL, zoledronic acid. Adapted from Pavlakis N, et al. Cochrane Database Syst Rev. 2005:CDC003474.

In favor of zoledronic acid In favor of pamidronate Breast Cancer—Benefits of ZOL Are Beyond Those of PAM and Continue After the Onset of SREs ZOL reduced the risk of experiencing any SRE on study or after the first SRE by ~30% vs PAMa in a large, double-blind, phase III trial Risk reduction P value All SREs (n = 766) .015 0.711 29% 0.690 Excluding first SRE 31% .045 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Relative risk In favor of zoledronic acid In favor of pamidronate a As determined by Andersen-Gill multiple event analysis. PAM, pamidronate (90 mg q 3-4 wk); SRE, skeletal-related event; ZOL, zoledronic acid (4 mg q 3-4 wk). Adapted from Zheng M, et al. Poster presented at: 9th International Conference on Primary Therapy of Early Breast Cancer; January 26-29, 2005; St. Gallen, Switzerland. Poster 104.

Bisphosphonates Palliate Bone Pain in mBC Zoledronic acid 4 mg q 4 wk Placebo 1.8 Ibandronate 6 mg q 4 wk Placebo *P < .05 1.7 Increased pain 1.6 1.5 1.4 BPI mean change from baseline Median bone pain score 1.3 * 1.2 Decreased pain * * * 1.1 * * * * * * * * * 1.0 0.9 12 24 36 43 60 72 84 96 Time on study, weeks1 Time, weeks2 Similar results observed in trials of IV pamidronate (90 mg q 3 - 4 wk)3 Patients continued to receive chemotherapy or standard treatment for breast cancer. mBC, metastatic breast cancer. 1. Adapted from Kohno N, et al. J Clin Oncol. 2005;23(15):3314-3321; 2.Adapted from Body J-J, et al. Ann Oncol. 2003;14(9):1399-1405; 3. Lipton A, et al. Cancer. 2000;88(5):1082-1090.

Zoledronic Acid reduces %SRE both before and after occurrence of pain 19% relative reduction 39% relative reduction Patients with an SRE, % Patients with no pain at baseline Patients with pain at baseline Eastham J, et al. Presented at: American Society of Clinical Oncology Annual Meeting, 2005. Abstract 4561.

ZOL Significantly Improves Most Quality-of-Life Measures in Patients With Bone Metastases From BC * Graph depicts overall mean change from baseline quality-of-life scores reported at final visit after 9 infusions. ZOL, zoledronic acid; BC, breast cancer; EORTC QLQ, European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire. *P < 0.05 compared with baseline values. Adapted from Wardley A, et al. Br J Cancer. 2005;92(10):1869-1876.

NTX and outcome in breast cancer

Biochemical Markers of Bone Resorption Enzymes/intermediates specific to bone turnover Pyridinoline (PYD) Deoxypyridinoline (DPD) Tartrate-resistant acid phosphatase type 5b (TRAcP-5b) Collagen peptides released during bone resorption C-telopeptide of type I collagen (CTX) N-telopeptide of type I collagen (NTX) Osteoclast regulators Bone sialoprotein (BSP) RANKL Osteoprotegerin (OPG) RANKL/OPG ratio Lipton A, et al. Clin Lymphoma Myeloma. 2007;7(5):346-353. 23

NTX Levels Are Often Elevated in Patients With Bone Lesions Patients with each cancer type were categorised as low NTX, moderate NTX, or high NTX 100 NTX (nmol/mmol CR) 75 High ( 100) Moderate (50-99) Proportion of patients, % 50 Low (< 50) 25 Prostate cancer Breast cancer Multiple myeloma NSCLC Other solid tumours Adapted from Coleman R, et al. J Clin Oncol. 2005;23(22):4925-4935. 24

New evidences: Denosumab in patients with advanced breast cancer

Pre-fusion Osteoclast Multinucleated Osteoclast RANK Ligand Is an Essential Mediator of Osteoclast Formation, Function, and Survival CFU-M Pre-fusion Osteoclast RANKL RANK M-CSF Multinucleated Osteoclast Hormones Growth factors Cytokines Activated Osteoclast Osteoblasts Bone Formation CFU-M = colony forming unit macrophage M-CSF = macrophage colony stimulating factor Bone Resorption Adapted from Boyle WJ, et al. Nature. 2003;423:337-342. 29

Bone Resorption Inhibited Osteoprotegerin (OPG) Prevents RANK Ligand Binding to RANK and Inhibits Osteoclast Formation, Function, and Survival CFU-M Osteoclast Precursor RANKL RANK OPG Hormones Growth factors Cytokines Osteoclast Formation, Function, and Survival Inhibited Osteoblasts Bone Resorption Inhibited Bone Formation CFU-M = colony forming unit macrophage M-CSF = macrophage colony stimulating factor For Internal Use Only. Amgen Confidential. Adapted from Boyle WJ, et al. Nature. 2003;423:337-342. 30

RANK Ligand Drives an Increase in Osteoclast Activity Alterations of the RANK Ligand / OPG ratio are critical in the pathogenesis of bone diseases that result from increased bone resorption1-3 OPG RANK Ligand The relative balance between RANK Ligand and OPG is regulated by cytokines and hormones and determines osteoclast activity. Alterations of the RANK Ligand/OPG ratio are critical in the pathogenesis of bone diseases that result in increased bone resorption. Unopposed RANK Ligand (i.e., an elevated RANK Ligand/OPG ratio) within the skeleton promotes bone loss, while restoring a balanced RANK Ligand/OPG ratio or inhibiting RANK Ligand decreases osteoclast activation and bone resorption. In many diseases involving increased bone resorption, RANK Ligand expression is upregulated by osteoclastogenic factors (growth factors, hormones, cytokines) while OPG expression is simultaneously downregulated.1-3 Hofbauer LC, et al. Clinical implications of the osteoprotegerin/RANKL/RANK system for bone and vascular diseases. JAMA. 2004;292:490-5. Lacey DL, et al. Osteoprotegerin Ligand is a Cytokine that Regulates Osteoclast Differentiation and Activation. Cell. 1998;93:165–76 Boyle WJ, et al. Osteoclast Differentiation and Activation. Nature. 2003;423:337-42. Promotes OC activation Prevents OC activation Osteoclast Activity 1Hofbauer LC, et al. JAMA. 2004;292:490-5. 2Lacey DL, et al. Cell. 1998;93:165-76. 3Boyle WJ, et al. Nature. 2003;423:337-42.

Pharmacologic Properties of Denosumab Model of Denosumab Fully human monoclonal antibody IgG2 isotype High affinity for human RANK Ligand High specificity for RANK Ligand No detectable binding to TNFα, TNFβ, TRAIL, or CD40L No neutralizing antibodies detected in clinical trials to date Denosumab, an investigational fully human monoclonal antibody (IgG2), binds with high affinity and specificity to human RANK (receptor activator of nuclear factor kappa B) ligand, an essential mediator of osteoclast activity.1-3 No neutralizing antibodies have been detected in clinical trials to date.1,3 Binding of denosumab to RANK Ligand was investigated in an in-vitro study using flow cytometry and ELISA. Binding affinity was measured using BIAcore and a kinetic exclusion assay. Denosumab bound both soluble and membrane-bound forms of human RANK Ligand. This binding was inhibited by excess human RANK Ligand, but not by TNF-, TNF-, TRAIL or CD40 Ligand. The dissociation constants of denosumab were calculated to be 9.5 x 10-11M and 3 x 10-12M using the BIAcore and kinetic exclusion assay, respectively.2 No neutralizing antibodies have been detected in clinical trials to date: In a phase 1, double-blind study, 49 healthy postmenopausal women were randomized to receive a single dose of denosumab 0.01, 0.03, 0.1, 0.3, 1.0, or 3.0 mg/kg or placebo. No anti-denosumab antibodies were detected in subjects enrolled in this study.1 In a phase 2 study, 412 postmenopausal women with low bone mineral density (BMD) were randomized to receive denosumab SC either every three months (6, 14, or 30 mg) or every six months (14, 60, 100, or 210 mg), open-label alendronate (70mg orally once weekly), or placebo. Denosumab-binding antibodies were observed in two subjects—one at 1 month and the other at 12 months. These antibodies were not neutralizing and were not detected in subsequent samples in either subject.3 The effects of denosumab on bone resorption appear reversible.3 Note: The graphic in the slide is a ribbon depiction of denosumab. Bekker PJ, et al. J Bone Miner Res. 2004;19:1059-1066. Elliott R, et al. Osteoporos Int. 2007;18:S54. Abstract P149. McClung MR, et al. New Engl J Med. 2006;354:821-831. Bekker PJ, et al. J Bone Miner Res. 2004;19:1059-1066. Data on file, Amgen. Elliott R, et al. Osteoporos Int. 2007;18:S54. Abstract P149. McClung MR, et al. New Engl J Med. 2006;354:821-31. TNF = tumor necrosis factor; TRAIL = TNFα-related apoptosis-inducing Ligand

Bone Resorption Inhibited Denosumab Binds RANK Ligand and Inhibits Osteoclast-Mediated Bone Destruction CFU-M Pre-Fusion Osteoclast RANKL RANK Denosumab Hormones Growth factors Cytokines Osteoclast Formation, Function, and Survival Inhibited Denosumab is the first fully human monoclonal antibody in clinical development that specifically targets RANK Ligand, an essential mediator of osteoclast formation, function, and survival.1,2 Lewiecki EM, et al. Exper Opin Biol Ther. 2006;6:1041-1050. McClung ER, et al. New Engl J Med. 2006;354:821-831. Osteoblasts Bone Formation Bone Resorption Inhibited Provided as an educational resource. Do not copy or distribute.

With Daily Supplements of Calcium and Vitamin D Randomized Phase II trial of denosumab in patients with bone metastases from prostate cancer, breast cancer and other neoplasms after intravenous bisphosphonates Patients with bone metastases and elevated uNTx levels despite ongoing IV bisphosphonate therapy Screening/ Randomization n = 38 Denosumab 180 mg SC Q4W 25 Weeks of Treatment With Daily Supplements of Calcium and Vitamin D n = 36 Denosumab 180 mg SC Q12W n = 37 IV BP Q4W Extension/ Follow-up Study Design (20040114) Fizazi K et al., J Clin Oncol, 10:15-64, 2009

The decrease of uNTx was higher in the denosumab group IV BP Q4W (n= 35) Total SC Denosumab (n = 69) SC Denosumab 180 mg Q12W (n = 33) SC Denosumab 180 mg Q4W (n = 36) Visit Week 2 5 9 13 17 21 25 -100 -80 -60 -40 -20 20 40 60 80 100 Median Percent Change From Baseline in uNTx Corrected by Creatinine Fizazi K et al., J Clin Oncol, 10:15-64, 2009

The incidence of SRE was higher in the bisphosphonate group IV BP Q4W 30 Pooled SC Denosumab Group Proportion of Patients With a First On-Study SRE SC Denosumab 180 mg Q4W 25 SC Denosumab 180 mg Q12W 20 15 10 5 20 40 60 80 100 120 140 160 180 Study Day Fizazi K et al., J Clin Oncol, 10:15-64, 2009

Delay/Prevention of SRE (Skeletal Related Events): Denosumab VS Zoledronic Acid Phase 3 Clinical Trials in Patients With Advanced Cancer ECCO Meeting 2009 Delay/Prevention of SRE (Skeletal Related Events): 20050136: A Randomized, Double-blind, Multicenter, Phase 3 Study of Denosumab Compared With Zoledronic Acid (Zometa®) in the Treatment of Bone Metastases in Advanced Breast Cancer (n=1960) The slide above outlines two out of three of the Denosumab Phase 3 clinical trials in patients with advanced cancer across tumor types. The third study will be described by Dr. Smith in the following presentation. clinicaltrials.gov 37

N = 1020 Zoledronic acid 4 mg IV* and SC placebo every 4 weeks Study Design (20050136) Key Inclusion Adults with advanced breast cancer and confirmed bone metastases Key Exclusion Current or prior intravenous bisphosphonate administration N = 1020 Zoledronic acid 4 mg IV* and SC placebo every 4 weeks N = 1026 Denosumab 120 mg SC and Placebo IV* every 4 weeks Supplemental Calcium and Vitamin D This slide is animated due the complexity A total of 2046 eligible adult subjects who were naïve to intravenous bisphosphonates were randomized in a double-blind, double-dummy design to receive subcutaneous denosumab 120 mg or intravenous zoledronic acid (ZA) 4 mg adjusted for creatinine clearance every 4 weeks The key inclusion criterion was that there was evidence of bone metastasis based on x-ray, CT, or MRI The key exclusion criterion was no prior IV bisphosphonate. Prior oral bisphosphonate use for osteoporosis was allowed Zoledronic acid was administered per Zometa® prescribing information. IV product dose that was either zoledronic acid or placebo was calculated according to baseline creatinine clearance. Subsequent doses were withheld if there was elevation of the serum creatinine and the IV product was only reinstituted once the serum creatinine had returned to within 10% of baseline levels. This dose and schedule is per the Zometa® label. Subjects with creatinine clearance < 30 mL/min were excluded per the Zometa® label There was no modification of the subcutaneous product, which included denosumab or placebo either at baseline or on study Subjects were stratified by previous SRE, prior oral bisphosphonate, current chemotherapy, and geographic region (Japan vs others) All subjects were strongly recommended to take daily supplemental calcium (500 mg) and vitamin D (400 IU) No crossover was allowed during the treatment phase The median time on study was 17 months for both treatment arms The median time on treatment was 16.5 months for both treatment arms The study duration was 34 months The primary endpoint was time to first on-study SRE, defined as pathologic fracture, radiation therapy or surgery to bone, or spinal cord compression. Secondary endpoints included a superiority test for time to first and time to first-and-subsequent on-study SRE. Subject Disposition 46% of subjects in the denosumab arm and 45% of subjects in the zoledronic arm remained on study through the primary data analysis cut-off date The main reasons for study discontinuation were deaths, disease progression, and consent withdrawn Reference Stopeck A et al. European Journal of Cancer Supplements, Vol. 7, No 3, September 2009, Page 2. Abstract 2LBA and Oral Presentation. 1° Endpoint 2° Endpoints Time to first on-study SRE (non-inferiority) Time to first on-study SRE (superiority) Time to first and subsequent on-study SRE (superiority) *IV product dose adjusted for baseline creatinine clearance and subsequent dose intervals determined by serum creatinine (per Zometa® label) Stopeck A, et al. Eur J Can Suppl. 2009;7:2. Abstract 2LBA and Oral Presentation. 38

Time to First On-Study SRE 1.00 HR 0.82 (95% CI: 0.71, 0.95) P < 0.0001 (Non-inferiority) P = 0.01 (Superiority)* * Adjusted for multiplicity 0.75 Proportion of Subjects Without SRE 0.50 KM Estimate of Median Months 0.25 The primary endpoint is represented on a Kaplan Meier curve Denosumab was superior to zoledronic acid and reduced the risk of a first on-study SRE by 18% with a confidence interval from 0.71 to 0.95. The P value was less than 0.0001 for noninferiority and equal to 0.01 for superiority The median time to first on-study SRE was not reached for denosumab and was 26.5 months for zoledronic acid The 2 most common components of SREs were fractures and radiation to bone Approximately 30-37% of subjects experienced an on-study SRE Reference Stopeck A et al. European Journal of Cancer Supplements, Vol. 7, No 3, September 2009, Page 2. Abstract 2LBA and Oral Presentation. Denosumab Not reached Zoledronic acid 26.5 3 6 9 12 15 18 21 24 27 30 Months Subjects at risk Zoledronic Acid 1020 829 676 584 498 427 296 191 94 29 Denosumab 1026 839 697 602 514 437 306 189 99 26 Stopeck A, et al. Eur J Can Suppl. 2009;7:2. Abstract 2LBA and Oral Presentation. 39

Time to First and Subsequent On-Study SRE* (Multiple Event Analysis) * Events that occurred at least 21 days apart 1.5 Total # of Events Denosumab 474 Zoledronic acid 608 1.0 Cumulative Mean Number of SRE For the secondary endpoint of time to first and subsequent SRE, otherwise known as the multiple event analysis, denosumab was also superior to zoledronic acid and reduced the risk of multiple events by 23% (rate ratio: 0.77; 95% CI: 0.66–0.89; P=0.001) Reference Stopeck A et al. European Journal of Cancer Supplements, Vol. 7, No 3, September 2009, Page 2. Abstract 2LBA and Oral Presentation. 0.5 Rate Ratio 0.77 (95% CI: 0.66, 0.89) P = 0.001† 3 6 9 12 15 18 21 24 27 30 Months † Adjusted for multiplicity Stopeck A, et al. Eur J Can Suppl. 2009;7:2. Abstract 2LBA and Oral Presentation. 40

Adverse Events of Interest Event, n (%) Zoledronic Acid (N = 1013) Denosumab (N = 1020) Infectious AEs 494 (48.8) 473 (46.4) Infectious serious AEs 83 (8.2) 71 (7.0) Acute phase reactions (first 3 days) 277 (27.3) 106 (10.4) Potential renal toxicity AEs* 86 (8.5) 50 (4.9) Renal failure 25 (2.5) 2 (0.2) Acute renal failure 7 (0.7) 1 (< 0.1) Cumulative rate of ONJ† 14 (1.4) 20 (2.0) Year 1 5 (0.5) 8 (0.8) Year 2 12 (1.2) 19 (1.9) New primary malignancy Additional safety results of note include infectious AEs and infectious serious AEs, both of which were approximately balanced on the 2 arms A prespecified analysis of adverse event terms that could represent a flu-like illness or acute phase reactions reported in the first 3 days after treatment occurred was performed. These adverse events occurred much less frequently with denosumab than with zoledronic acid In another prespecified analysis, adverse event terms that could represent renal toxicity also occurred less frequently with denosumab despite appropriate renal dosing with zoledronic acid per the prescribing information Osteonecrosis of the jaw occurred infrequently and was not significantly different between treatment arms (prespecified P value of 0.39) Reference Stopeck A et al. European Journal of Cancer Supplements, Vol. 7, No 3, September 2009, Page 2. Abstract 2LBA and Oral Presentation. *Includes blood creatinine increased, hypercreatininemia, oliguria, renal impairment, proteinuria, renal failure, urine output decreased, creatinine renal clearance decreased, renal failure acute, renal function test abnormal, anuria, blood urea increased, renal failure chronic No neutralizing anti-denosumab antibodies were detected † P = 0.39 Stopeck A, et al. Eur J Can Suppl. 2009;7:2. Abstract 2LBA and Oral Presentation. 41

Bone metastases: radiotherapy and orthopedic surgery

Linee Guida AIOM 2008 La radioterapia e controllo del dolore (1) Non vi è differenza statisticamente significativa nel controllo del dolore tra ipofrazionamenti di durata più protratta e quelli più brevi. Livello di evidenza: I; Grado di raccomandazione: A Il trattamento antalgico effettuato in fase iniziale della comparsa del dolore consente di ottenere una maggiore percentuale di risposta completa. Livello di evidenza: II; Grado di raccomandazione: B Non vi è differenza statisticamente significativa nel controllo del dolore e del rischio di frattura tra trattamenti multifrazionati (1-2 settimane) e quelli in singola frazione (8 Gy).

Linee Guida AIOM 2008 La re-irradiazione (2) La reirradiazione delle metastasi ossee è possibile e consente di ottenere una palliazione efficace, specie per pazienti in buone condizioni generali (ECOG 0-1) che hanno avuto una buona risposta al primo ciclo di radioterapia. Seduta unica di 4 Gy. Livello di evidenza: III; Grado di raccomandazione: B La percentuale di ritrattamento è risultata significativamente più alta dopo trattamento in seduta unica

Linee Guida AIOM 2008 La chirurgia ortopedica delle metastasi ossee - Indicazioni - Metastasi solitarie da tumore primitivo a buona prognosi (mammella, prostata, rene, tiroide diff.). Il trattamento chirurgico in questi casi deve comprendere l’asportazione della lesione metastatica con margini i più ampi possibile, e la ricostruzione stabile del segmento operato. Livello di evidenza: IV; Forza raccomandazione: B

Linee Guida AIOM 2008 La compressione spinale: Radioterapia Non esiste una dimostrazione certa della superiorità della chirurgia rispetto alla radioterapia e viceversa Per i pazienti con compressione midollare metastatica e prognosi favorevole è indicato un trattamento radiante con un ipofrazionamento prolungato del tipo 3-30 Gy . Livello di evidenza III, Forza di raccomandazione C Per i pazienti con compressione midollare metastatica e prognosi sfavorevole è indicato un trattamento radiante ipofrazionato (8 Gy per 2 fino a 16 Gy in una settimana) o in dose unica (8 Gy). Livello di evidenza I, Forza di raccomandazione A E’ possibile la reirradiazione in pazienti adeguatamente selezionati (non deficit neurologici, prognosi favorevole) Livello di evidenza VI, Forza di raccomandazione C

Linee Guida AIOM 2008 La compressione spinale: Chirurgia ortopedica La chirurgia va riservata a casi molto selezionati Chirurgia seguita da radioterapia: Instabilità della colonna. Presenza di frammenti ossei causa di compressione midollare o radicolare. In caso di dubbi diagnostici Paziente in buone condizioni generali con compressione in sede singola e aggredibile chirurgicamente e lunga aspettativa di vita. Chirurgia esclusiva: Peggioramento dello status neurologico durante o dopo la radioterapia Compressione midollare recidiva in una sede precedentemente irradiata e/o dove una reirradiazione sia controindicata.

Linee Guida AIOM 2008 La terapia radiometabolica La radioterapia metabolica con somministrazione di Sr-89 è efficace nel controllo del dolore nei pazienti con multiple metastasi ossee come la radioterapia a fasci esterni (massima indicazione nel carcinoma prostatico ormono-refrattario plurimetastatizzato). Livello di evidenza: I; Grado di raccomandazione: A L’aggiunta della terapia radiometabolica alla radioterapia a fasci esterni non aumenta la probabilità di controllo del dolore. Livello di evidenza: I; Grado di raccomandazione: B

Linee Guida AIOM 2008 La vertebroplastica La vertebroplastica e la cifoplastica sono da considerare: in pazienti con dolore intrattabile e non responsivo da lesione spinale metastatica in pazienti con fratture patologiche il cui stato clinico non permette di eseguire interventi chirurgici tradizionali. Queste tecniche meno invasive consistono nell’iniezione di cemento acrilico nel corpo vertebrale e, nel caso della cifoplastica, di aiutare a ripristinare il profilo sagittale del rachide dorsale e lombare Livello di evidenza: IV; Forza raccomandazione: B

Conclusions: 2009 AIOM Guidelines for breast cancer bone metastases

Linee guida AIOM 2009 Neoplasia mammaria metastatica i BP sono in grado di ridurre il rischio di SRE e di ritardarne significativamente il tempo di comparsa. EVIDENZA: I. GRADO DI RACCOMANDAZIONE: A I BP hanno una documentato effetto sul dolore e migliorano la qualità della vita. E’ consigliabile sulla base delle evidenze utilizzare un aminobisfosfonato per via endovenosa. EVIDENZA: I. GRADO DI RACCOMANDAZIONE: A Lo zoledronato sembra essere più efficace del pamidronato. Mancano dati di riferimento diretto con l’ ibandronato. EVIDENZA: II. GRADO DI RACCOMANDAZIONE: A

Linee Guida AIOM 2009 La supplementazione A tutti i pazienti che effettuano bisfosfonati per via endovenosa o orale è raccomandata una supplementazione di calcio e vitamina D. Grado raccomandazione A E’ molto probabile che le dosi raccomandate: 500 mg di calcio e 400 UI non siano adeguate e debbano essere raddoppiate. Grado raccomandazione B Utile monitoraggio di calcemia (ionizzata o corretta per albumina) durante il trattamento con bisfosfonati al fine di correggere valori ipocalcemici severi con dosi adeguate di vitamina D Grado raccomandazione C

Linee guida AIOM 2009 Durata, quando iniziare, quando terminare La durata consigliata, in assenza di sufficienti dati, è di almeno 2 anni. Inoltre il proseguimento della terapia con acido zoledronico dopo la comparsa di un evento scheletrico ha portato ad una riduzione, statisticamente significativa, nella comparsa di successivi eventi Evidenza: V; Grado di raccomandazione: B Visto il beneficio dei bisfosfonati sulla prevenzione anche del primo SRE e sul dolore, viene consigliato di iniziare tale trattamento al momento dell’evidenza radiologica di metastasi ossee anche in assenza di sintomi. Evidenza: VI; Grado di raccomandazione: B

Linee Guida AIOM 2009 NTX come parametro di efficacia dei bifosfonati Valori basali di NTX e variazioni di NTX dopo acido zoledronico correlano con l’efficacia del farmaco. La discesa dell’NTX durante il trattamento con acido zoledronico correla con i parametri di efficacia A tutt’oggi tuttavia l’NTX non possiede tutti i requisiti per poter essere utilizzato routinariamente nella pratica clinica. Livello evidenza: III; grado raccomandazione: C

Linee Guida AIOM 2009 Impatto dei bifosfonati sul dolore e QOL I BP si sono dimostrati in grado di offrire significativi e duraturi miglioramenti del dolore osseo Livello di Evidenza I; forza di raccomandazione A i BP non sostituiscono la terapia anti-dolorifica convenzionale ma contribuiscono con effetto additivo co-analgesico. Solo un numero limitato di studi dimostra significativi miglioramenti della qualità della vita Livello di evidenza II; Forza di raccomandazione A

Linee Guida AIOM 2009 I bifosfonati nel paziente anziano e/o con comorbidità I BP sono raccomandati anche nei pazienti anziani con metastasi ossee per prevenire gli eventi scheletrici. Carcinoma mammario: acido zoledronico, ibandronato, pamidronato, clodronato. Altre neoplasie: acido zoledronico Livello di evidenza VI; Forza di raccomandazione B L’acido zoledronico, l’ibandronato ed il pamidronato possono contribuire efficacemente a ridurre il dolore osseo in questa tipologia di pazienti In questi pazienti è necessario uno stretto monitoraggio della funzionalità renale, nonché il controllo e l’ottimizzazione dello stato di idratazione

Linee Guida AIOM 2009 Multidisciplinarietà e Centri di Osteoncologia Negli ultimi anni è nato in Italia un nuovo modello organizzativo per l’approccio multidisciplinare al paziente con metastasi ossee, che prevede il coinvolgimento di diverse figure professionali: l’oncologo, il palliativista , il radioterapista, l’ortopedico, il medico nucleare, il radiologo diagnosta e interventista, il fisiatra, il patologo clinico , l’anatomo-patologo, il biologo, l’infermiere professionale e il data manager. Dal 2003 sono iniziate esperienze multidisciplinari a Torino, Forlì, Reggio Calabria, Modena, Genova, Roma (Università Campus Bio-Medico) e Grottaferrata. I primi risultati sul loro effetto positivo comincia a essere segnalato da parte dei pazienti (livello di soddisfazione alto, molto utile questo approccio e no disagio dalla presenza di diverse figure) Livello di evidenza : V; Grado di raccomandazione B

Future directions New directions in metastatic bone disease include personalised BP therapy, such as using bone markers to guide frequency of BP administration and bone targeting agents such as denosumab Early data suggest that zoledronic acid might have a role in the prevention of metastatic disease, though whether this is a direct effect on cancer cells, or indirect via the bone marrow micro- environment, or both, is as yet undiscovered.

Future directions Over 20,000 patients with breast, prostate or lung cancer are currently participating in adjuvant Bisphosphonates randomised trials. The results of these trials should be available in the next few years, and this will establish whether BPs given early in the course of cancer will be able to prevent the formation of metastases, bone or otherwise.

Università Campus Bio-Medico, Roma Oncologia Medica Università Campus Bio-Medico, Roma Giuseppe Tonini Daniele Santini Bruno Vincenzi Annalisa La Cesa Claudia Grilli Sara Galluzzo Simona Gasparro Vladimir Virzì Gaia Schiavon Valentina Leoni Marianna Silletta Francesco Pantano Maria Elisabetta Fratto Alice Calvieri Olga Venditti Chiara Spoto Salvatore Intagliata Calogero Gucciardino Francesco Guida Iacopo Fioroni Alice Zoccoli Marzia Mazzaroni Rita Proietti Cristina Lucarelli Viviana Mordanini