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SYNOPSIS OF PROTOCOL BIG01-01/BO16348F


TITLE HERA: A randomised three-arm multi-centre comparison of 1 year and 2 years of Herceptin versus no Herceptin in women with HER2-positive primary breast cancer who have completed adjuvant chemotherapy. F. Hoffmann-La Roche Ltd. Primary breast cancer Primary Objectives To compare disease-free survival (DFS) in patients with HER2 overexpressing breast cancer who have been randomised to Herceptin for one year versus no Herceptin. To compare DFS in patients with HER2 overexpressing breast cancer who have been randomised to Herceptin for two years versus no Herceptin. To compare outcomes (DFS, OS, RFS, DDFS, TTR, TTDR, cardiac safety, overall safety) of patients treated with Herceptin for one year compared with Herceptin for two years. To compare overall survival (OS) in patients randomised to i) Herceptin for one year or no further therapy and to ii) Herceptin for two years or no further therapy. To compare relapse-free survival (RFS). To compare distant disease-free survival (DDFS). To compare time to recurrence (TTR) To compare time to distant recurrence (TTDR) To evaluate the safety and tolerability of Herceptin. To compare the incidence of cardiac dysfunction in patients treated and not treated with Herceptin. CLINICAL PHASE III

SPONSOR INDICATION OBJECTIVES

Secondary Objectives -

TRIAL DESIGN NUMBER OF SUBJECTS TARGET POPULATION

Three-arm, randomised, open-label and multicenter study in women with primary breast cancer that overexpresses HER2. 4482 patients (total enrollment) Women with primary invasive breast cancer that overexpresses HER2 (determined by IHC 3+ or FISH positive) who have completed (neo-) adjuvant systemic chemotherapy and radiotherapy, if applicable. Recruitment will last about 3 years; the final analysis will take place after the final patient has been followed for about 4 years (may need to be longer if expected number of events has not been seen by this time). Patients will be followed around 3 monthly for two years, every 6 months in years 3 to 5 and annually thereafter. Overall, patients will be followed until 10 years after last patient enrolled.

LENGTH OF STUDY

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INVESTIGATIONAL PRODUCT(S) DOSE/ROUTE/REGIMEN COMPARATOR DRUG DOSE/ROUTE/REGIMEN ASSESSMENTS OF: EFFICACY

Herceptin infusion (I.V.); Loading dose will be 8 mg/kg on day 1, followed by maintenance dose of 6 mg/kg three weeks later and thereafter every three weeks for a total of one or two years, respectively, or disease recurrence. N/A

SAFETY

DFS as determined by: - Breast cancer recurrence (assessed by CT or MRI scans, X-ray, bone scan, physical examination) - Second primary cancer (contralateral breast or non-breast malignancy) - Death from any cause as first event. OS as determined by death from any cause. Adverse events will be recorded and graded according to NCI-CTC criteria (hematological and biochemical parameters, patients symptoms and signs of toxicity) with special emphasis on cardiac safety. Cardiac events (CHF) will be graded according to NYHA. Cardiac safety of Herceptin treatment compared to no Herceptin will be assessed by an extensive cardiac monitoring and in three interim safety analyses. Patients will undergo LVEF assessments at baseline, and 3, 6, 12, 18, 24, 30, 36 and 60 months, and yearly beyond year 5 until year 10 after start of Herceptin treatment or observation. An algorithm to continue/discontinue Herceptin in an individual patient and an early cardiac safety stopping rule for the trial will be applied.

PHARMACOKINETICS/ PHARMACODYNAMICS

Pharmacokinetic substudy in 60 patients according to separate protocol Cardiac Marker substudy in about 900 patients according to separate protocol

QUALITY OF LIFE/ PHARMACOECONOMICS

N/A

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Table of Contents 1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1.1 Adjuvant Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 HER2 / c-erbB-2 and Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 Herceptin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3.1 Herceptin in the Treatment of Metastatic Breast Cancer . . . . . . . . 1.3.1.1 Monotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3.1.2 Combination of Herceptin and Chemotherapy . . . . . . . . . . . . . . . 1.3.1.3 Undesirable Effects Associated with Herceptin . . . . . . . . . . . . . . 1.3.2 Clinical Pharmacology of Herceptin . . . . . . . . . . . . . . . . . . . . . . . . 1.3.2.1 Pharmacokinetic Data from 3 Weekly Administration . . . . . . . . . . 1.3.2.2 Interactions/Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4 Adjuvant Chemotherapy in Primary Breast Cancer . . . . . . . . . . . . . . . 1.4.1 Anthracycline-based Versus CMF-based Regimens . . . . . . . . . . . . . 1.4.1.1 Anthracyclines and CMF in HER2 positive Breast Cancer . . . . . . 1.4.1.2 Taxanes in the Adjuvant Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4.2 Tamoxifen and Adjuvant Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4.2.1 Tamoxifen and HER2 Overexpression . . . . . . . . . . . . . . . . . . . . . . 1.4.3 Adjuvant Chemo-/Radiotherapy and Impairment of Left-Ventricular Ejection Fraction (LVEF) . . . . . . . . . . . . . . . . . . . . . . 1.5 Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5.1 Rationale for the Study and Study Design . . . . . . . . . . . . . . . . . . . . . 1.5.2 Rationale for Dosage Selection of Herceptin . . . . . . . . . . . . . . . . . 1.5.3 Rationale for Duration of Herceptin Therapy . . . . . . . . . . . . . . . . . 1.5.4 Rationale for Including Patients Irrespective of Nodal Status . . . . . . 1.5.5 Rationale for Several prior Adjuvant Chemotherapy Regimens, Hormonal Therapy and Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5.5.1 Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5.5.2 Hormonal Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5.5.3 Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Objectives Of The Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Primary Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 20 20 20 21 21 21 23 24 28 29 29 30 30 30 31 32 32 33 34 34 35 35 36 37 37 38 38 39 39

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2.2 Secondary Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3 Cardiac Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3.1 Cardiac Endpoints and Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Study Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Overview of Study Design and Dosing Regimen . . . . . . . . . . . . . . . . . 3.2 Number of Patients and Treatment Assignment . . . . . . . . . . . . . . . . . . 3.3 Centres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Provision of Herceptin to Patients Randomized to Receive No Herceptin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.1 Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.1.1 Eligibility Criteria for Herceptin Treatment . . . . . . . . . . . . . . . . . 3.4.1.2 Study Assessments Following Start of Herceptin Treatment . . . . 3.5 Further Changes to Study Design Following Interim Analysis . . . . . . . 3.5.1 Guidelines for Resuming Herceptin Treatment . . . . . . . . . . . . . . . . 3.5.2 Changes to the PK and Cardiac Marker Sub-studies . . . . . . . . . . . . . 4. Study Population. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Target Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Inclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 Previous and Concomitant Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Schedule Of Assessments And Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Eligibility Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.1 HER2 Screening for Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.2 Confirmation of Hormone Receptor (ER/PgR) Status . . . . . . . . . . . . 5.1.3 Prior Adjuvant Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.4 Prior Adjuvant Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.5 Concomitant Hormonal Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.5.1 Other Hormonal Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.6 Cardiac Function Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.7 Other Eligibility Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Study Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.1 Clinical Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.1.1 Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39 40 41 42 42 45 47 47 47 47 48 48 48 48 49 49 49 50 51 52 57 57 58 58 60 61 62 63 63 63 63 63

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5.2.1.2 Definitions of Outcome Measures . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2 Cardiac Safety Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2.1 Echocardiography or MUGA scans /Left Ventricular ejection Fraction (LVEF): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2.2 Independent Review of Cardiac Function . . . . . . . . . . . . . . . . . . . . 5.2.3 Laboratory Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.4 Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Relapse of Disease Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 Pharmacokinetic Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 Pharmacodynamic Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6 Quality of Life Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Investigational Product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Dose and Schedule of Herceptin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.1 Modification of the Amount of Herceptin Administered due to Changes in Patients Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Preparation and Administration of Herceptin . . . . . . . . . . . . . . . . . . . 6.3 Blinding and Randomisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4 Drug Labeling and Packaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5 Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Safety Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1 Adverse Events and Laboratory Abnormalities. . . . . . . . . . . . . . . . . . . 7.1.1 Clinical Adverse Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1.1.1 Cardiac Endpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1.2 Causality of Adverse Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1.3 Grading of Adverse Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1.4 Laboratory Test Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 Handling of Safety Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.1 Serious Adverse Events (Immediately Reportable to Roche) . . . . . . 7.2.2 Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.3 Treatment and Follow-up of Adverse Events . . . . . . . . . . . . . . . . . . . 7.2.4 Follow-up of Abnormal Laboratory Test Values . . . . . . . . . . . . . . . . 7.2.5 Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.6 Project Specific Adverse Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.7 Project Specific Instructions on Adverse Events . . . . . . . . . . . . . . . .

65 66 66 67 68 68 68 72 72 72 73 73 73 73 73 73 73 74 74 74 74 76 76 76 76 76 78 78 79 79 80 80

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7.3 Dose Modifications for Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3.1 Haematological and Non-haematologic Toxicity . . . . . . . . . . . . . . . . 7.3.2 Cardiac Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3.3 Infusion Associated Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3.4 Delay of Herceptin Administration due to Toxicity or Other Reasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4 Criteria for Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4.1 Cardiac Safety Discontinuation Criteria in an Individual Patient . . . 7.4.1.1 Congestive Heart Failure (CHF) . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4.1.2 Asymptomatic and Mildly Symptomatic Drops in LVEF . . . . . . . . 7.5 Warnings and Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5.1 Infusion Reactions, allergic-like Reactions and Hypersensitivity . . . 7.5.2 Pulmonary events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5.3 Cardiotoxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5.4 Pregnancy and Lactation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Statistical Considerations And Analytical Plan . . . . . . . . . . . . . . . . . . . . . . . 8.1 Primary and Secondary Study Variables . . . . . . . . . . . . . . . . . . . . . . . . 8.1.1 Primary Variable: Disease Free Survival . . . . . . . . . . . . . . . . . . . . . . 8.1.2 Secondary Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.2.1 Overall Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.2.2 Recurrence Free Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.2.3 Distant Disease Free Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.2.4 Time to Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.2.5 Time to Distant Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.2.6 General Safety and Tolerability . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.2.7 Cardiac Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.2.8 Other Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2 Statistical and Analytical Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.1 Statistical Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.1.1 Primary Efficacy Variable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.1.2 Secondary Efficacy Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.1.3 General Safety and Tolerability . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.1.4 Cardiac Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.1.5 Outcome for Herceptin One Year Versus Two Years . . . . . . . . .

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8.2.1.6 Analysis of Other Efficacy Variables . . . . . . . . . . . . . . . . . . . . . . . 8.2.1.7 Exploratory Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.1.8 Analysis of shed ECD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.2 Hypothesis Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.3 Types of Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.3.1 Analysis Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.3.2 Analysis of Primary Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.3.3 Cardiac Endpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2.3.4 Outcome for Herceptin One Year Versus Two Years . . . . . . . . . 8.2.3.5 Updated Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3 Sample Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3.1 Primary Efficacy Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3.2 Outcome for Herceptin One Year Versus Two Years . . . . . . . . . . . 8.4 Replacement Policy (Ensuring Adequate Numbers of Evaluable Patients) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4.1 For Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4.2 For Centres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.5 Research Proposals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.5.1 Analysis of quantitative HER2 expression in relationship to Herceptin-induced benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Data Quality Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Study Committees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1 Independent Data Monitoring Committee . . . . . . . . . . . . . . . . . . . . . . 11. References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Ethical aspects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1 Local Regulations/Declaration of Helsinki . . . . . . . . . . . . . . . . . . . . . 11.1 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 Independent Ethics Committees/Institutional Review Board . . . . . . . 12. Conditions for modifying the protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Conditions for terminating the study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. Study documentation, CRFs and record keeping . . . . . . . . . . . . . . . . . . . . .

95 95 96 96 96 96 98 98 100 100 100 100 101 102 102 102 102 102 103 103 103 104 111 111 111 112 112 113 113

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12.1 Investigator's Files / Retention of Documents . . . . . . . . . . . . . . . . . . . 14.1 Source Documents and Background Data . . . . . . . . . . . . . . . . . . . . . . 14.2 Audits and Inspections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.3 Case Report Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15. Monitoring the study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16. Confidentiality of Trial Documents and Subject Records . . . . . . . . . . . . . . 17. Publication of Data and Protection of Trade Secrets . . . . . . . . . . . . . . . . . .

113 113 114 114 114 114 115

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List of Tables Table 1 Efficacy of Herceptin according to intensity of HER2 immunostaining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 2 Efficacy Outcomes in Combined Herceptin + Chemotherapy Trial . Table 3 Overview of Cardiac Adverse Events in Pivotal Herceptin Studies . Table 4 New definition of risk categories for patients with node-negative breast cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 5 HERA study timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 6 Stratification factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 7 Schedule of Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 8 Acceptable chemotherapy regimens for participation . . . . . . . . . . . . . . Table 9 Radiotherapy guidelines for HERA trial patients . . . . . . . . . . . . . . . . . Table 10 Endocrine therapy guidelines for HERA trial patients . . . . . . . . . . . . Table 11 Actions to be taken in case of Herceptin related toxicity . . . . . . . . . Table 12 Herceptin dosing in case of delayed scheduled doses . . . . . . . . . . . Table 13 Confidence Intervals for Interim Analyses . . . . . . . . . . . . . . . . . . . . .

23 24 25 37 43 46 54 59 61 62 82 84 99

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List of Figures Figure 1 Time to Progression according to 2+, 3+ overexpression and gene amplification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2 Scheme of pre-study and study procedures . . . . . . . . . . . . . . . . . . . . . Figure 3 HER2 Screening Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 4 Algorithm for continuation and discontinuation of Herceptin based on interval LVEF assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35 44 45

87

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List of Appendices Appendix 1 TNM nomenclature for breast cancer . . . . . . . . . . . . . . . . . . . . . . . 116

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GLOSSARY OF ABBREVIATIONS
A AC ADCC ALP ALAT (SGPT) ANOVA ARDS ASAT (SGOT) AUC0- BDC BP C CALGB CAT CHF CI Clss CMF Cmax Cmin CRF CV D DCIS DDFS DFS Doxorubicin Anthracycline and cyclophosphamide containing chemotherapy Antibody-dependent cellular cytotoxicity Alkaline phosphatase Alanine aminotransferase Analysis of variance Acquired respiratory distress syndrome Aspartate aminotransferase Area under the serum concentration-time curve over the dosing interval BrEAST Data Centre Blood Pressure Cyclophosphamide Cancer and Leukemia Group-B Computerised axial tomography Congestive heart failure Confidence interval Clearance at steady state Cyclophosphamide, methotrexate, and 5-fluorouracil Maximum serum concentration Minimum serum concentration (trough) Case Report Form(s) Coefficient of Variation Docetaxel Ductal carcinoma in situ Distant disease free survival Disease free survival

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GLOSSARY OF ABBREVIATIONS
DFSS EaSt EBCTCG EC50 ECD ECG echo ECOG EF ER ESF FAS FISH FNA FSS GnRH ICF ICH IEC IHC IDMC IMN IRB ITT iv keo LCIS Disease free survival from surgery Early Stopping Early Breast Cancer Trialists Collaborative Group Plasma concentration associated with half-maximal effect Extracellular domain (of HER2 surface receptor) Electrocardiogram Echocardiogram Eastern Cooperative Oncology Group Ejection fraction Estrogen receptor Eligibility screening form Full analysis set Fluorescence in situ hybridisation Fine needle aspirate Frontier Science (Scotland) Ltd. Gonadotropin-releasing hormone Informed Consent Form International Conference on Harmonisation Independent Ethics Committee Immunohistochemistry Independent Data Monitoring Committee Internal mammary node Institutional Review Board Intent to treat Intravenous Equilibration rate constant Lobular carcinoma in situ

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GLOSSARY OF ABBREVIATIONS
LMP LVEF mmHg MRI MUGA muMAb NCI NSABP NT-proBNP OS OSS OA P PgR PK PPS QoL RFI RFS rhuMab SADR SC S.D. SDV SOP SPAM SSPM Last menstrual period Left Ventricular Ejection Fraction Millimeters of mercury Magnetic resonance imaging Multiple gated nuclear angiography Murine monoclonal antibody National Cancer Institute (US) National Surgical Adjuvant Breast and Bowel Project N-terminal pro-brain natriuretic peptide Overall survival Overall survival from surgery Ovarian ablation Paclitaxel Progesterone receptor Pharmacokinetic Per-protocol set (of analysis) Quality of life Relapse-free interval Relapse-free survival Recombinant human monoclonal antibody Serious adverse drug reaction Steering Committee Standard deviation Source data verification Standard Operating Procedure Study Procedures and Administrative Manual Study Specific Procedures Manual

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GLOSSARY OF ABBREVIATIONS
T TTP TAM t.b.d. t tmax ULN US WHO Taxanes Time to progression Tamoxifen to be determined Terminal half-life Time to achieve maximum serum concentration Upper limit of normal United States World Health Organisation

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PART I. STUDY DESIGN AND CONDUCT

1.
1.1

BACKGROUND
Introduction

Breast cancer is the most common form of malignancy occurring in women around the world. In 1999, more than 795,000 new cases (21% of all cancer sites) were diagnosed and 314,000 breast cancer deaths (14.1%) occurred. Each year, more than 180,000 women in the United States are diagnosed with breast cancer (30.4% of all cancers in American women) and 40,800 deaths (15.2% of all cancer deaths) were estimated to occur in the year 2000.[1] In Canada, an estimated 31,000 new cases of breast cancer will be diagnosed (30.7% of all cancers) with an estimated 8200 deaths from breast cancer (18.8% of all cancer cases) for the year 2000.[2] In the European Community, an estimated 135,000 new cases per year (24% of all cancers cases) and 58,000 recorded deaths per year (18% of all cancer deaths) will be reported.[3] If current breast cancer rates stay constant, a female born today has a 1 in 8 chance of developing breast cancer sometime during her life. Surgery is the main modality of local treatment for breast cancer. Surgery and/or radiotherapy can control local-regional disease in the majority of patients. However, more than 60% will ultimately die due to distant recurrence of disease. Two types of systemic adjuvant therapy have been used increasingly over the last twenty years to successfully reduce the rate of breast cancer recurrence and death. Adjuvant chemotherapy involves a combination of cytotoxic anticancer drugs; adjuvant hormone therapy deprives cancer cells of the hormone estrogen which some breast cancer cells need to grow. These therapeutic modalities are complementary and are often used in combination.

1.1.1

Adjuvant Breast Cancer

Adjuvant systemic therapy is defined as the administration of chemotherapy or hormonal therapy after primary surgery for breast cancer in order to control clinically occult micro-metastases.

1.2

HER2 / c-erbB-2 and Breast Cancer

HER2, a transmembrane Human Epidermal growth factor Receptor, has emerged as an important prognostic and potential predictive factor in breast cancer. The c-erbB2 proto-oncogene encodes a transmembrane tyrosine growth factor receptor, HER2, that is overexpressed in 15-25% of human breast cancers, and in a number of other solid tumours. In the laboratory, HER2 overexpression results in oncogenic transformation and more aggressive tumour behavior. Overexpression of HER2 in breast cancer has been correlated with high histologic grade, increased mitotic activity, p53 mutation, negative estrogen receptor (ER), absence of bcl2, and absence of lobular architecture.[4] Despite associations with other known negative prognostic factors, HER2 overexpression has been independently associated with poorer disease-free survival (DFS) and overall survival (OS) compared with tumours that do not overexpress HER2.[5,6] This adverse prognosis is particularly evident for node positive breast cancer, however evidence suggests that it may also be true for node negative disease.[7] Retrospective data suggests that breast tumours that overexpress HER2 may be particularly sensitive to certain cytotoxic drugs and less sensitive

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to others and that HER2 overexpression may be associated with relative resistance to tamoxifen. HER2 overexpression also predicts for Herceptin sensitivity.

1.3

Herceptin

Herceptin, (rhuMAb, generic name trastuzumab), is a recombinant humanised anti-p185HER-2 monoclonal antibody that binds with high affinity to the HER2 protein. It was developed as part of a strategy to antagonise the function of overexpressed HER2. Of several murine monoclonal antibodies produced against the extracellular domain of the HER2 protein, one (muMAb 4D5) was found to markedly inhibit the proliferation of HER2 overexpressing human tumour cells.[12] Efficacy was observed in non-clinical in vivo studies using the antibody alone and in combination with cytotoxic chemotherapy.[8,9] The antibody was humanised (i.e., the regions of muMAb 4D5 that determine anti-HER2 binding specificity were engineered into the framework of a generic human antibody) to limit the problem of immune stimulation seen with chronic administration of murine monoclonal antibodies. [10] The resulting antibody, rhuMAb HER2, binds specifically to the HER2 protein extracellular domain with high affinity and has been shown to inhibit the proliferation of human tumour cells that overexpress HER2 both in vitro and in vivo.[11] An important property of Herceptin is the ability to mediate profound antibody-dependent cellular cytotoxicity (ADCC) specifically against HER2 overexpressing tumour cell lines in the presence of human peripheral blood mononuclear cells. Thus, in addition to preventing tumour proliferation by blocking the cell surface HER2 molecule, Herceptin may also have direct tumour cell killing potential.[21] Xenograft models have shown synergistic interaction of Herceptin in combination with cisplatin and docetaxel at clinically relevant drug concentrations, and additive cytotoxic effects have been seen with doxorubicin and paclitaxel.[8,9] In North America and much of Europe, Herceptin is approved as monotherapy for the treatment of patients with metastatic breast cancer whose tumours overexpress the HER2 protein and who have received one or more chemotherapy regimens for metastatic disease, as well as in combination with paclitaxel in patients whose tumours overexpress the HER2 protein and who have not received prior chemotherapy for their metastatic disease.

1.3.1 1.3.1.1

Herceptin in the Treatment of Metastatic Breast Cancer Monotherapy

In an early phase II trial, Herceptin monotherapy had a response rate of 11% in 46 patients who had received prior chemotherapy ( 2 regimens for metastatic disease in 63% of the patients).[13] An additional 35% of the patients had a minor response or disease stabilisation which lasted for a median of 5.1 months. These encouraging initial results led to investigation of the efficacy of Herceptin monotherapy in the larger pivotal trial involving 222 metastatic breast cancer patients.[14] In this large monotherapy trial, recruited patients had many characteristics associated with a poor prognosis.[14] The main criterion for inclusion was the presence of metastatic breast cancer that was HER2-positive (2+ or 3+ by immunohistochemistry [IHC]) and that had relapsed following one or two prior chemotherapy regimens. The majority of patients enrolled in this study had received two prior chemotherapy regimens for metastatic disease in addition to adjuvant

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chemotherapy (68%). Prior chemotherapy regimens included anthracyclines in 94%, taxanes in 50%, and high dose chemotherapy with hematopoietic stem cell rescue in 25%. Visceral metastases, which are generally associated with fewer and more short-lived responses to chemotherapy and hormonal therapy, were present in 70% of patients. Thus, the group of patients recruited into the study had both a poor long-term prognosis and a low likelihood of response or of durable response to subsequent chemotherapy. Despite this, Herceptin monotherapy led to an objective response rate of 15% and a minor response or stable disease in a further 36% of patients, including 20 patients (9%) with disease stabilisation of at least 6 months duration. Major responses were observed in patients with soft tissue, bone, and visceral disease. Herceptin was well tolerated with no decline in health-related quality of life during treatment. The activity of first line single agent Herceptin in metastatic disease was studied in a phase II study.[15] In this study, 114 patients who had not received prior chemotherapy for metastatic disease received Herceptin monotherapy using a weekly schedule of either 4mg/kg loading dose followed by 2mg/kg weekly infusions, or an 8mg/kg load followed by 4mg/kg weekly. An overall objective response rate of 26% was observed. An additional 12% of patients achieved disease stabilisation of at least 6 months duration, giving an overall clinical benefit rate of 38%. Response rate and median time to progression were similar for both doses. Responses were seen in all sites of disease, including visceral disease. Seventy-nine percent of the responders had received prior adjuvant chemotherapy and 68% received prior anthracyclines (50% of the entire study population had adjuvant anthracyclines). Retrospective analyses have demonstrated that in the single arm first line monotherapy trial, the overall response rate was higher (18%) in the subgroup of patients whose tumours overexpressed HER2 at the 3+ level by IHC or for whom HER2 amplification was confirmed by fluorescence in situ hybridisation (FISH) (Table 1, Figure 1).[16] The same observation was made in the randomised comparison of chemotherapy versus chemotherapy plus Herceptin (Table 1).

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Table 1
Endpoints

Efficacy of Herceptin according to intensity of HER2 immunostaining


Herceptin + paclitaxel trial HER2 3+ H+P N=68 P N=77 HER2 2+ H+P N=24 P N=19 Herceptin monotherapy trials HER2 3+ H 1st line N=87 H 2nd,3rd lines N=172 18 HER2 2+ H 1st line N=27 0 H 2nd,3rd lines N=50 6

% RR 95% CI TTP in months 95% CI OS in months 95% CI

49 36-61 7.1 6-12 25 19-34

17 9-27 3 2-4 18 11-24

21 7-42 5.3 3-7 17 12-25

16 3-40 2.7 2-5 20 8-27

35

NA

3.2

NA

1.9

NA

16.4

NA

8.8

Legend: CI, confidence intervals; H, Herceptin; NA, not available; OS, overall survival; RR, response rate; P, paclitaxel; TTP, time to progression.

1.3.1.2

Combination of Herceptin and Chemotherapy

A large, randomised, controlled Phase III trial was conducted in 469 women with metastatic breast cancer whose tumours overexpressed HER2 (2+ or 3+ by IHC) and who had had no prior chemotherapy for metastatic disease.[17,18,19]] The objectives were to evaluate the efficacy and safety of weekly Herceptin in combination with first line chemotherapy regimens. Women who had received anthracyclines as adjuvant treatment were treated with paclitaxel; women with no prior anthracycline treatment received doxorubicin or epirubicin and cyclophosphamide (AC). Randomisation was to the addition or not of weekly Herceptin (4mg/kg loading dose followed by 2mg/kg weekly infusions). The combination of Herceptin and chemotherapy significantly increased response rates and prolonged the time to disease progression (TTP) compared with chemotherapy alone. Most importantly, patients treated with Herceptin and chemotherapy had a significantly longer median survival time compared with those who received chemotherapy alone (results summarised in Table 2) whether (66%) or not (33%) they subsequently received Herceptin.

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Table 2

Efficacy Outcomes in Combined Herceptin + Chemotherapy Trial


Combined Results Herceptin + All Chemotherapy (n=235)

Paclitaxel Subgroups

AC Subgroups

All Chemotherapy (n=234)

Herceptin + Paclitaxel (n=92)

Paclitaxel Alone (n=96)

Herceptin + AC A (n=143)

AC Alone (n=138)

Primary Endpoint: Time to progression B,C Median (months) 95% CI p-value (log rank) Secondary Endpoints Overall response rate B Rate (percent) 95% CI p-value (2-test) Duration of response B,C Median (months) 25%, 75% quantile Survival Time C Median (months) 95% CI p-value (log-rank)
A B C

7.2 6.9, 8.2 <0.0001

4.5 4.3, 4.9

6.7 5.2, 9.9 <0.0001

2.5 2.0, 4.3

7.6 7.2, 9.1 0.002

5.7 4.6, 7.1

45 39, 51 <0.001

29 23, 35

38 28, 48 <0.001

15 8, 22

50 42, 58 0.10

38 30, 46

8.3 5.5, 14.8

5.8 3.9, 8.5

8.3 5.1, 11.0

4.3 3.7, 7.4

8.4 5.8, 14.8

6.4 4.5, 8.5

25.1 22.2, 29.5 0.046

20.3 16.8, 24.2

22.1 16.9, 28.6 0.17

18.4 12.7, 24.4

26.8 23.3, 32.9 0.16

21.4 18.3, 26.6

AC = anthracycline (doxorubicin or epirubicin) and cyclophosphamide. Assessed by an independent Response Evaluation Committee. Kaplan Meier estimate (cut-off date: December 1999 from references 16 and 17)

1.3.1.3

Undesirable Effects Associated with Herceptin

Over 900 patients with HER2 overexpressing metastatic breast cancer have received Herceptin alone or in combination with chemotherapy in the pivotal and supporting Herceptin studies. Safety data are based on the experience with the recommended weekly dosing regimen for Herceptin in the randomised trial of chemotherapy + Herceptin (in 469 patients) and four openlabel studies of weekly Herceptin as a single agent in approximately 350 patients. To date, there is information on almost 200 patients who have been treated with Herceptin (standard weekly dosing) for over a year (1 to 2 years: 120 patients, 2 to 3 years: 63 patients, 3 to 4 years: 10 patients, longer than 4 years: 5 patients). These patients, who were treated in studies H0648g, H0649g, and H0659g, continued therapy until disease progression. No new safety

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concerns were identified in these patients who received Herceptin treatment for prolonged periods of time. Cardiac Failure/Dysfunction Signs and symptoms of cardiac dysfunction, such as dyspnea, increased cough, paroxysmal nocturnal dyspnea, peripheral oedema, S3 gallop, or reduced ejection fraction (EF), have been observed in patients treated with Herceptin. Congestive heart failure (CHF) associated with Herceptin therapy may be severe and in a few cases has been associated with disabling cardiac failure, death, and mural thrombosis leading to stroke. In order to better define this syndrome and assess the frequency of asymptomatic and symptomatic cases of cardiomyopathy, the clinical status of trial patients who developed CHF was classified using the New York Heart Association (NYHA) classification system (IIV, where IV is the most severe level of cardiac failure) (Table 3). The majority of cases of symptomatic and asymptomatic drop in left ventricular ejection fraction (LVEF) were observed in-patients treated with AC and Herceptin. In the first single agent pivotal trial [14], all patients who developed CHF had received prior anthracycline therapy.

Table 3

Overview of Cardiac Adverse Events in Pivotal Herceptin Studies


Combination chemotherapy and Herceptin study [17] n (%) [95%-confidence limits] AC+H AC P p-value N=143 N=135 N=95 (2) Monotherapy study [14] H alone N=213

p-value Classification of P+H (2) event according N=91 to likely aetiology 8 (8.8) 4 (4.2) 0.204 40 (28.0) 13 (9.6) <0.001 18 (8.5) Symptomatic [3.9-16.6] [1.2-10.4] [20.8-36.1] [5.2-15.9] [5.1-13.0] heart failure anthracycline like A Definitive cardiac 4 (4.4) 7 (7.4) 0.390 8 (5.6) 9 (6.7) 0.709 7 (3.3) diagnosis other [1.2-10.9] [3.0-14.6] [2.5-10.7] [3.1-12.3] [1.3-6.7] than heart failureB Event 24 (26.4) 21 (22.1) 0.497 31 (21.7) 36 (26.7) 0.331 49 (23.0) unevaluable as to [17.7-36.7] [14.2-31.8] [15.2-29.3] [19.4-35.0] [17.5-29.3] aetiology C Legend: P=paclitaxel; H=Herceptin; AC=doxorubicin or epirubicin plus cyclophosphamide Categories are mutually exclusive: patients assigned in hierarchical fashion according to ranking in Table 3.
A

B C

Preferred terms: congestive heart failure, cardiomyopathy, heart failure, left ventricular failure, lung oedema or other search terms and Case Report Form (CRF) information indicating cardiac failure (e.g. a combination of shortness of breath, dyspnea, cough increased, pulmonary congestion on X-ray, echocardiogram or MUGA findings). Cardiac event likely not related to doxorubicin toxicity (eg. pericardial tamponade, syncope, stroke, angina pectoris, myocardial ischemia, myocardial infarction, ascites). Includes preferred terms: cardiovascular disorder, shock, respiratory failure, respiratory distress, hypoxia, asthma condition most, dyspnea, cough increased, oedema, peripheral oedema, heart arrest, hypotension, palpitation, bradycardia, tachycardia, arrhythmia which are not further specified in the text of the adverse event forms in the case report forms as being definitely related to malignant disease. Any other events with insufficient information for assessment of aetiology.

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The probability of cardiac dysfunction was highest in patients who received Herceptin concurrently with anthracyclines. The data suggest that advanced age may also increase the probability of cardiac dysfunction.[18] Animal models have been used to understand the underlying mechanism for the cardiac toxicity observed in the Herceptin trials. In the HER2 knockout mouse model, deletion of HER2 resulted in abnormal development of cardiac trabeculae.[20] HER2 and HER4 receptors are expressed in neonatal and adult ventricular myocytes in a rat model. However, there are currently no human data available to explain the cardiac effects seen with Herceptin. Based on this patient and laboratory data, it is recommended that all candidates for treatment with Herceptin undergo thorough baseline cardiac assessment, including history and physical examination and one or more of the following: electrocardiogram (ECG), echocardiogram, and multiple-gated nuclear angiography (MUGA) scan. Patients treated with Herceptin should have cardiac function monitored at regular intervals, particularly patients who have received prior anthracycline based chemotherapy. Extreme caution should be exercised in treating patients with pre-existing cardiac dysfunction. The discontinuation of Herceptin therapy should be strongly considered in patients who develop clinically significant CHF, unless the benefits for an individual patient are deemed to outweigh the risk. In the clinical trials, most patients with cardiac dysfunction responded to appropriate medical therapy (often including discontinuation of Herceptin), however the safety of continuation or resumption of Herceptin in patients who develop cardiotoxicity has not been studied. Patients who develop asymptomatic cardiac dysfunction may benefit from more frequent monitoring of cardiac function (e.g., every 6 to 8 weeks), and this is recommended. If patients have a continued decrease in LVEF, but remain asymptomatic, therapy discontinuation should be considered if no clinical benefit of Herceptin therapy has been observed. Little is known about the mechanism of cardiotoxicity associated with the concomitant use of Herceptin and anthracyclines, and whether the incidence and severity are similar when these drugs are given sequentially. This is of particular importance in the adjuvant setting, since longterm breast cancer-free survival is anticipated in the majority of women. Therefore, the occurrence and nature of long- and short-term cardiac events will be closely monitored in all women participating in the HERA trial. Specific guidelines will be implemented for serial LVEF assessments and continuation or discontinuation of Herceptin based on the LVEF and other clinical cardiac parameters. Infusion-Associated Symptoms During the first infusion with Herceptin, a symptom complex most commonly consisting of chills and/or fever was observed in about 40% of patients participating in pivotal Herceptin trials. The symptoms were usually mild to moderate in severity and were effectively treated with acetaminophen, diphenhydramine, and meperidine. Herceptin discontinuation was infrequently necessary. Other signs and/or symptoms included nausea, vomiting, pain (in some cases at tumour sites), rigors, headache, dizziness, dyspnea, hypotension, rash, and asthenia have been reported infrequently. The incidence and reoccurrence of such symptoms was substantially lower with subsequent Herceptin infusions. The incidence and severity of this first infusion symptom complex was not substantially greater in patients who received doses of 4mg/kg/week versus 2mg/kg/week.[16]

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Serious adverse reactions to Herceptin infusion, including dyspnea, hypotension, wheezing bronchospasm, tachycardia, reduced oxygen saturation and respiratory distress, have been reported infrequently, the majority in patients with known pulmonary metastases. Serious reactions have been treated successfully with supportive therapy such as oxygen, beta-agonists, corticosteroids and withdrawal of Herceptin as indicated. In rare cases, these events were associated with a clinical course culminating in a fatal outcome, and patients with dyspnea at rest due to pulmonary metastases were at increased risk of such a fatal infusion reaction. Other Undesirable Effects Anemia and Leukopenia: An increased incidence of anemia and leukopenia was observed in the treatment group receiving Herceptin + chemotherapy, especially in the Herceptin + AC subgroup, compared with the subgroup receiving chemotherapy alone.[17] The majority of these cytopenic events were mild or moderate in severity, reversible, and none resulted in discontinuation of therapy with Herceptin. Hematologic toxicity is infrequent following administration of Herceptin as a single agent: the incidence of grade III leucopenia, thrombocytopenia, and anemia were all <1% and no grade IV toxicities were observed. Diarrhoea: Twenty-five percent of patients treated with Herceptin as a single agent experienced diarrhea. The incidence was slightly higher in patients receiving Herceptin in combination with chemotherapy. Most cases were of mild to moderate severity. Infection: An increased incidence of infections was observed in patients receiving Herceptin in combination with chemotherapy (compared with the chemotherapy alone arm). These consisted primarily of mild upper respiratory infections of minor clinical significance, and central venous catheter infections. Rare Adverse Events The following other adverse events occurred in at least one of the 958 patients treated with Herceptin. The extent to which any of the toxicities is related to Herceptin, concurrent drug administration, or underlying disease is difficult to judge. Body as a Whole: cellulitis, anaphylactoid reaction, ascites, hydrocephalus, radiation injury, deafness, amblyopia Cardiovascular: vascular thrombosis, pericardial effusion, cardiac arrest, hypotension, syncope, haemorrhage, shock, arrhythmia Digestive: hepatic failure, gastroenteritis, hematemesis, ileus, intestinal obstruction, colitis, oesophageal ulcer, stomatitis, pancreatitis, hepatitis Endocrine: hypothyroidism Hematological: pancytopenia, acute leukaemia, coagulation disorder, lymphangitis Metabolic: hypercalcemia, hypomagnesemia, hyponatremia, hypoglycaemia, growth retardation, weight loss Musculoskeletal: pathological fractures, bone necrosis, myopathy Nervous: convulsion, ataxia, confusion, manic reaction

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Respiratory: apnoea, pneumothorax, asthma, hypoxia, laryngitis Skin: herpes zoster, skin ulceration Urogenital: hydronephrosis, kidney failure, cervical cancer, hematuria, haemorrhagic cystitis, pyelonephritis Herceptin appears to be non-immunogenic. Only one of 903 patients evaluated in an integrated safety database developed neutralising antibodies to Herceptin. This patient had no signs or symptoms of allergy while receiving Herceptin and discontinued the study for progressive metastatic breast cancer.

1.3.2

Clinical Pharmacology of Herceptin

No studies investigating the pharmacodynamics and mechanism of action of Herceptin have been performed in humans so far. In vitro studies with SK-BR-3 cells; a HER2 overexpressing human breast cancer cell line; demonstrated that muMAb 4D5 (the murine parent of Herceptin) was cytostatic rather than cytotoxic.[21] Thus, in order to treat patients most effectively, chronic treatment was considered necessary. Prior to human use, non-clinical studies with the murine parent antibody to Herceptin (muMAb 4D5) both in vitro and in vivo revealed that maximal tumour growth inhibition was associated with antibody concentrations of between 1-23g/mL.[12] Comparable results were expected with the humanised antibody, since muMAb 4D5 and Herceptin have similar affinity for the HER2 receptor. Analyses in clinical studies showed that Herceptin has dose-dependent, non-linear pharmacokinetics, with faster clearance and shorter half-life at doses of <100 mg. The volume of distribution approximates the serum volume. Early studies of the recommended dose indicated that the half-life was approximately 6-10 days. However, more recent data suggest that the halflife is about 4 weeks (28.5 days, 95% confidence intervals, 25.5 32.8 days) using the dose recommended in the HERA protocol.[22] The non-linear kinetics are consistent with saturation of a specific receptor-mediated clearance mechanism. Overall, the PK profile probably reflects a composite of 1) interaction with tumour cell-bound HER2, 2) complexing with shed HER2 antigen (ECD), and 3) non-specific elimination similar to that observed with endogenous IgG. Serum concentrations are decreased in the presence of shed antigen and this is probably related to a faster clearance of the antibody-antigen complex than of free Herceptin.[12] Importantly, however, baseline shed antigen concentrations in the clinical studies did not show any correlation with clinical efficacy.[23,24,25] Tissue distribution has only been studied in mice, and indicated extensive Herceptin tissue distribution and specific tumour uptake. As expected for a protein, no metabolites or altered molecular forms were detected. Cross-species comparisons are difficult, however, since Herceptin does not bind to the rodent equivalent of HER2.[12] Data suggest that the distribution and elimination of Herceptin is not altered based on age or serum creatinine (up to 2.0 mg/dL).

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1.3.2.1

Pharmacokinetic Data from 3 Weekly Administration

The registered schedule for Herceptin administration is a weekly dose of 2mg/kg after a loading dose of 4mg/kg. Less frequent administration of Herceptin is clearly desirable for patients, particularly in the adjuvant setting. Less frequent dosing also appears both logical and feasible as it is known now that the half-life of Herceptin using the registered dosing schedule is approximately 4 weeks. Preliminary PK data are available from two studies evaluating the safety, tolerability and pharmacokinetics of Herceptin administered every 3 weeks to women with HER2 positive (IHC 3+ or FISH positive) metastatic breast cancer.

BO15935: Herceptin q3weekly in combination with paclitaxel [22,26] WO16229: Herceptin monotherapy q3weekly study (unpublished data)

All patients in these two studies have received Herceptin every 3 weeks by IV infusion. The initial infusion has been given over 90 minutes at a dose of 8mg/kg. All subsequent infusions were given over 90 minutes at a dose of 6mg/kg. Data from study BO15935 indicate that trough concentrations of Herceptin increased across the study period, steady state concentrations (in the range 60-70g/mL) being achieved after approximately eight to ten doses. Trough concentrations were not statistically different to those obtained with once weekly administration [Study H0649g (Genentech Inc.), [12], although trough levels were generally lower, as expected.[26] Patient exposure in this study using the q 3-weekly regimen was also similar to that seen in the pivotal studies in which Herceptin was administered weekly. The mean (CV%) exposure at steady state (AUCss) was 2341 mg.day/L for patients in BO15935 compared with 1593 mg.day/L for patients treated with weekly Herceptin. In study WO16229, preliminary pharmacokinetic data are available for 86/104 patients. Serum profiles show a large intersubject variability, mainly due to a few patients with very low levels of Herceptin associated with very high levels of shed ECD. Trough levels were similar to those seen in study BO15935 and, although generally lower than those seen with weekly dosing, as expected. Some accumulation is also evident in this study, steady state pharmacokinetics were reached at or after 10 to 12 doses.

1.3.2.2

Interactions/Special Populations

No formal clinical drug-drug interaction studies have been performed. In vitro studies suggest an additive activity of Herceptin with anthracyclines and a synergistic activity with docetaxel and cisplatin.[8,9] Pharmacokinetic data from the phase II/III studies shown that concurrent administration of AC, or of cisplatin, did not alter the half-life, clearance, or exposure of Herceptin compared to the administration of Herceptin as a single agent. PK data from the first single-agent study [14] were analyzed with respect to a number of baseline characteristics. There was no apparent relationship between PK parameters and age or renal function (baseline serum creatinine), however overweight patients tended to have higher trough concentrations. The clinical significance of this is unclear. For more detail please refer to the investigators brochure.[12]

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Preliminary data from an ongoing pharmacokinetic study (BO15935) investigating the three weekly dosing schedule in the presence and absence of paclitaxel has shown that Herceptin has no clinically important effect on the pharmacokinetics of paclitaxel.[22]

1.4

Adjuvant Chemotherapy in Primary Breast Cancer

A recent Early Breast Cancer Trialists Collaborative Group (EBCTCG) meta-analysis summarised results of randomised trials beginning before 1990 that compared different chemotherapy regimens in otherwise similar patient groups. In 47 trials comparing combination chemotherapy to no chemotherapy, a significant reduction in mortality occurred in patients receiving chemotherapy irrespective of nodal status (negative versus positive), estrogen receptor (ER) status (ER-rich versus ER-unknown, or ER-poor), and whether or not tamoxifen (TAM) was given.[27] For women <50 years of age at randomisation, OS improved from 71% to 78% in node-negative disease (absolute benefit of 7%), and from 42% to 53% in node-positive disease (absolute benefit of 11%) with 3-6 months of adjuvant polychemotherapy (CMF or anthracycline-based).[27] For women 50 to 69 years of age at randomisation, combination chemotherapy improved 10-year survival from 67% to 69% for those with node-negative disease (an absolute gain of 2%), and from 46% to 49% for those with node-positive disease (an absolute gain of 3%).[27]

1.4.1

Anthracycline-based Versus CMF-based Regimens

The largest direct comparison of anthracycline- based versus cyclophosphamide/ methotrexate/5fluorouracil (CMF) chemotherapy was carried out by the United States (US) Intergroup (trial INT0102).[28] In this trial, 2691 node negative patients were randomised to receive six cycles of either cyclophosphamide/doxorubicin/5-fluorouracil (CAF) or CMF, with a second randomisation to 5 years of TAM or no TAM. At 5 years, CAF was marginally superior to CMF for both disease-free survival (86% versus 84%, p=0.03) and overall survival (92% versus 91%, p=0.03), independent of TAM use. In node positive disease, several studies have demonstrated a superiority for anthracyclinecontaining regimens over CMF, while others have not.[29,30,31,32] Nevertheless, the Oxford Overviews of 1995 and 2000 demonstrate a significant advantage for anthracylines over CMF in terms of both DFS and OS.[27,33] The 1995 EBCTCG meta-analysis, which compared 11 anthracycline versus CMF chemotherapy trials that began in 1976 through 1989 reported 5 year recurrence-free and OS differences of 57% versus 54% (p=0.006) and 72% versus 69% (p=0.02), for anthracycline-containing polychemotherapy versus CMF, respectively.[27] The results of the 2000 overview have not yet been published but confirm a significant advantage for anthracycline polychemotherapy over CMF in the order of 3-4% absolute survival gain.[33]

1.4.1.1

Anthracyclines and CMF in HER2 positive Breast Cancer

The balance of data from all retrospective studies suggest that, compared with patients whose tumours do not overexpress HER2, those that do overexpress HER2 may derive particular benefit from anthracyclines. The benefit of CMF in this patient population is less clear. However these analyses, summarised below, are limited by their retrospective nature, incomplete data sets, and low number of HER2 positive patients on which conclusions are based. Moreover, a number of different antibodies have been used to detect HER2 overexpression by immunohistochemistry

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(IHC), and they each have different sensitivities and cut-off points, making cross-comparisons difficult. In a retrospective study of 638 patients with node-positive, hormone receptor-negative breast cancer enrolled in the National Surgical Adjuvant Breast Project (NSABP) B-11 trial, patients whose tumours overexpressed HER2 by IHC derived a preferential benefit in terms of DFS from doxorubicin compared with a similar regimen without doxorubicin (PAF [phenylalanine mustard, adriamycin, 5-FU] versus PF).[34] Another retrospective study, which examined patients enrolled in NSABP B-15 (in which node-positive women age 50-59 years old with progesterone receptors 10 fmol, and women age 49 years old, regardless of hormone receptor status, were randomised to AC alone vs AC followed by CMF versus CMF alone) found that tumour sections from 599 of 2,034 (29%) stained positive for HER2. Among these HER2 (+) women, those treated with AC had a trend toward improved DFS compared with those who received only CMF.[35] Overall, the benefit of anthracycline-containing compared with non-anthracycline containing regimens was confirmed by one trial [34] and highly suggested by two others.[35,36] Another study suggested possible improved outcome when postmenopausal HER2-positive patients were treated with the combination of anthracycline-containing chemotherapy and TAM, compared to TAM alone.[37] Two studies showed that HER2-positive but not HER2-negative tumours are particularly sensitive to anthracycline dose intensity.[38,39] The interaction between CMF and HER2 overexpression was explored retrospectively in 6,233 trial patients with less conclusive trends. Among the trials in question, one showed benefit and three showed lack of benefit from adjuvant CMF.[40,41,42,43]

1.4.1.2

Taxanes in the Adjuvant Setting

There is no evidence to support the addition of taxanes to anthracyclines in the adjuvant treatment of node negative breast cancer. The addition of paclitaxel (P) to the adjuvant treatment of node positive disease is approved in the US but not in Europe, based on the 20 and 30 month results of the Cancer and Leukemia Group-B (CALGB) 9344 trial (4AC versus 4AC followed by 4 P 175mg/m2 [AC/P]) showing a 4% improvement in DFS and 2% improvement in OS for women treated with the latter regimen.[44,45] Although these results are provocative, neither the MD Anderson trial (8FAC versus 4 P then 4FAC, n=524) nor the NSABP B28 trial (4AC versus 4AC then 4 P 225mg/m2, n=3060) show a statistical advantage for the addition of taxanes to date, although results are preliminary.[46,47] An unplanned subset analysis of the CALGB 9344 trial found a benefit of AC/P only in women with ER (-) tumours.[44] It is unclear whether the recurrence risk associated with ER (+) tumours at baseline or after treatment with AC and tamoxifen is too low to demonstrate a benefit of adding P with the CALGB sample size (about 2/3 of the patients were ER +), or whether ER (+) tumours recur later than ER (-) tumours, and thus it is too early to observe the separation in DFS and OS curves for ER (+) patients. What this kind of analysis does highlight is the need to more fully understand the target population most likely to benefit from non cross-resistant therapies. The role of adjuvant paclitaxel and docetaxel is being prospectively addressed in randomised trials comprising a total of about 24,000 women, of which the minority have been reported. Based on available data, the addition of several cycles of a taxane in high-risk disease, particularly ER (-) tumours, is reasonable, since this approach is at least equivalent to 4AC. The

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question of the benefit of taxanes in women with node positive, ER (+) tumours has not been adequately answered by the available data.[47] Weekly paclitaxel has been shown to be a safe and effective alternative to q3 weekly dosing in the treatment of advanced breast cancer [93] and in the neo-adjuvant setting [94]. Final results in 236 patients receiving neo-adjuvant treatment showed that pathological complete remission rates with weekly dosing were 28% in node-positive and 29.4% in node-negative disease, compared with 13.7% and 13.4% with the standard 3-weekly regimen in node-positive and node-negative disease, respectively.

1.4.2

Tamoxifen and Adjuvant Therapy

The EBCTCG meta-analysis of TAM versus no TAM trials supports the benefit of TAM independent of the added use of chemotherapy in both younger (<50 years) and older women with hormone receptor positive breast cancer, based on data from 37,000 women enrolled in 55 trials, with an average follow-up of ten years.[48] ER status was positive in 18,000, negative in 8,000, and unknown in about 12,000 women. The primary outcomes of interest were recurrence and death from breast cancer analysed by intention to treat analysis. The use of TAM was associated with a highly significant decrease in both recurrence and death among women with hormone receptor positive or unknown disease, and there was a significant trend of increased benefit with longer duration of therapy. There was no significant effect for women with hormone receptor negative disease, so these women were removed from analysis of estimated benefit. Overall, with five years of TAM, the relative risk reduction was 47% (2p<0.00001) for recurrence, and 26% (2p<0.00001) for death. The greatest benefit in mortality was observed in node positive disease, (n=2210, 92% ER +) with a relative risk reduction of 43% for recurrence and 28% for death with 5 years of TAM. This is equivalent to an absolute 10 year survival improvement of 10.9% (from 50.5% for no hormonal therapy, to 61.4%; 2p<0.00001). For 1 and 2 years of TAM use, the absolute 10 year survival benefits were less pronounced (4.5% and 7.2%, respectively). Although a debate exists as to whether more than 5 years of adjuvant TAM provides additional protective benefit against breast cancer recurrence or death, 5 years is considered the current standard duration of therapy pending results of large randomised comparisons of 5 versus 10 years (such as the ATLAS and ATTOM trials).

1.4.2.1

Tamoxifen and HER2 Overexpression

As with chemotherapy, data on the relationship between HER2 overexpression and efficacy of hormonal therapy are also retrospective, preliminary and inconclusive. The benefit of adjuvant TAM in HER2 positive breast cancer has been retrospectively examined among 1784 patients enrolled in 4 prospective studies, two in which tamoxifen was randomised (TAM vs observation and 2 vs 5 years TAM) and two in which tamoxifen was allocated part way through accrual of the trial.[49,50,51,52] In the TAM vs observation trial, through 15 years median follow-up, the relative risk of death for HER2 positive patients randomised to TAM compared to observation was 2.23 (95% CI 0.955.23), suggesting that those randomised to TAM had a 2-fold excess risk of death.[49] For HER2 negative patients, the hazard ratio (HR) was 0.54, suggesting that TAM is beneficial for this

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population. In the 2 vs 5 year TAM trial, longer therapy (5 years) provided more benefit than shorter therapy in women with HER2 negative tumours but not in women with HER2 positive tumours.[50] In the two studies in which TAM was allocated, one suggested similar benefit from TAM for both HER2 positive and negative patients, while the second showed inferior outcome for HER2 positive patients, particularly when treated with TAM.[51,52]

1.4.3

Adjuvant Chemo-/Radiotherapy and Ventricular Ejection Fraction (LVEF)

Impairment

of

Left-

Adjuvant chemotherapy: Anthracyclines generate superoxide radicals, which can damage myocardial cells, which lack superoxide dismutase to break them down. Cardiomyopathy with left ventricular dysfunction that can lead ultimately to CHF may develop as a result. In most adjuvant regimens the cumulative dose of anthracyclines given is below the threshold value of 450 to 550mg/m2 for doxorubicin and 900 to 1000mg/m2 for epirubicin, beyond which the risk of anthracycline-induced cardiotoxicity rises substantially. Buzdar et al. reported that after a median follow-up of 68 months the incidence of doxorubicinassociated CHF was 1% with the common FAC regimen when a cumulative dose of 300 mg/m2 was used [53]. The incidence increased to 4% when a cumulative dose of 450 mg/m2 was administered. The longest interval from the end of the doxorubicin therapy to the development of CHF was 33 months. In a group of 1492 breast cancer patients treated with the AC combination (cumulative dose doxorubicin 240 mg/m2) only 0.2 % asymptomatic and 0.1% symptomatic cardiac dysfunction and no cardiac deaths were reported after a follow-up duration of three years [53]. The rising risk of cardiac failure with increasing cumulative dose of doxorubicin was also demonstrated in a recent trial by Shapiro et al. in which breast cancer patients received either 5 or 10 cycles of AC, resulting in a cumulative dose doxorubicin of 225 and 450mg/m2 respectively. The AC10 regimen showed a 3.6 fold increased risk of cardiac events (CHF and myocardial infarctions) compared with the general population. The risk of cardiac events in AC5 patients, irrespective of the cardiac radiation therapy (RT) dose-volume, did not differ significantly from rates of cardiac events predicted for the general female population by the Framingham Heart Study.[54] Adjuvant regimens that contain epirubicin, a less cardiotoxic anthracycline analogue, result in low incidence rates of CHF. Coombes et al. reported only one case of non-fatal CHF among 380 premenopausal patients treated with the FEC regimen (cumulative dose epirubicin 300 - 400mg/m2) in a randomised trial of FEC versus CMF after a median follow-up of 4.5 years [55]. Adjuvant radiotherapy: The EBCTCG overview of radiotherapy reported an increase in cardiac mortality for patients undergoing radiotherapy after early breast cancer surgery.[56] A causal relationship between irradiation and death from myocardial infarction is also suggested when the differences in cardiac mortality after left-sided breast cancer and after right-sided breast cancer are taken into account.[57] Whether the difference is related to direct damage of the myocardium or indirectly, by damage to the left anterior coronary artery has not yet been settled.[58] Studies in which a

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higher incidence of cardiac toxicity was observed predominantly used older radiotherapy techniques without cardiac shielding. The use of radiotherapy is complimentary to local excision without mastectomy for optimal local control, and is being increasingly used after mastectomy in patients with high recurrence risk. Using modern breast irradiation techniques, with small daily fractions and computerised axial tomography (CAT) scan based field arrangements, no increased long-term risk of cardiac mortality has been found. [59] Hjris reported no difference in morbidity or mortality from ischaemic heart disease in patients treated with surgery or surgery plus radiotherapy over a median follow-up of 10 years (0.9% versus 0.8%).[60] Nowadays, most premenopausal and menopausal patients are treated with a combination of chemotherapy and radiotherapy. Evaluating the interaction between both adjuvant treatments, Hjris et al. did not find a difference in the rate of ischaemic heart disease whether radiotherapy was combined with CMF or with tamoxifen [60]. Late cardiotoxicity following radiotherapy and anthracycline based chemotherapy seems to be more pronounced, however. Valagussa et al. reported an overall incidence of 0.8% CHF among 501 breast cancer patients treated with cumulative doses of doxorubicin of 300 mg/m2 after a median follow-up duration of 7 years [61]. In a subset of 116 patients with left-sided breast cancers treated with concurrent breast radiation, the incidence of CHF increased to 2.6%, while CHF was not observed in patients with right-sided breast cancers or in patients treated with non-anthracycline chemotherapy regimens.

1.5
1.5.1

Rationale
Rationale for the Study and Study Design

Despite the significant reduction in breast cancer relapse and mortality achieved with adjuvant polychemotherapy and endocrine therapy, recurrences still occur in some breast cancer patients. Improvements in detecting the subset at risk and in further reducing the incidence of relapse are a focus of prognostic and predictive factors and of novel therapies. HER2 overexpression has been confirmed as an adverse prognostic factor and a predictive factor for response to Herceptin. It may also predict for sensitivity and relative resistance to a number of endocrine and cytotoxic drugs, although this data requires prospective confirmation. Given the adverse prognostic profile associated with HER2 overexpression and the observed efficacy of Herceptin in HER2 overexpressing metastatic breast cancer, investigation of Herceptin in the adjuvant setting is of high clinical interest. This will be a phase III multi-centre study (the HERA trial) in which HER2 positive patients are randomised to either Herceptin for one or two years or no Herceptin following completion of definitive surgery, radiotherapy, if indicated, and acceptable (neo-) adjuvant chemotherapy (all patients can receive systemic adjuvant hormonal therapy as per standard of care). The primary objective will be to compare disease-free survival (DFS) in the patients randomised to one year of Herceptin versus no Herceptin and to compare DFS in the group randomised to two years versus no Herceptin. Overall survival (OS), which is closely related to DFS in adjuvant trials, is a secondary endpoint in this trial (1 year Herceptin versus no further Herceptin and 2 years versus no further Herceptin).

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Adverse events will be monitored throughout the study. Cardiac dysfunction will be specifically monitored in all patients enrolled in the HERA trial, both during the observation/treatment period and during the protracted follow-up period. The HERA trial is confined to women whose tumours overexpress HER2 at the 3+ level (by IHC) or who have a positive FISH test for amplification of the c-erbB2 gene, the subgroup with the highest likelihood of response to Herceptin (Figure 1, Herceptin combination and monotherapy trials).[16] It provides the opportunity to explore targeting of a molecular marker with a recombinant antibody in the adjuvant setting, where tumour burden is lowest, addressing the hypothesis that minimal residual disease is an optimal target for this kind of therapy.

Figure 1

Time to Progression according to 2+, 3+ overexpression and gene amplification


Studies H0648g, H0649g, H0650g 8
7 6 5 4 3 2
Months

8 7
Months

Combination

6 5 4 3 2 1 0 P P+H

2+ 3+

1 0 648 649 650

3+ FISH+

1.5.2

Rationale for Dosage Selection of Herceptin

A three weekly administration schedule of Herceptin (6mg/kg maintenance dose every 3 weeks following a loading dose of 8mg/kg) has been selected for the HERA trial, as it is more convenient for patients, and results in similar Herceptin exposure as the weekly administration of lower doses (see section 1.4.2.1).[22] In the first line monotherapy study, an 8mg/kg loading dose followed by a weekly maintenance dose of 4mg/kg resulting in 2-fold higher exposure than will be achieved with the maintenance dose in the HERA trial, was shown to be safe and well tolerated in the metastatic setting.[15]

1.5.3

Rationale for Duration of Herceptin Therapy

The optimal duration of Herceptin therapy in the adjuvant setting has not been examined yet and the optimal duration of targeted monoclonal antibody therapy is unknown. All ongoing prospective studies are exploring the addition of one year of Herceptin to adjuvant chemotherapy. Experience with TAM has shown that five years treatment is more beneficial than two or one year.[48] In contrast, experience with chemotherapy has suggested that beyond a

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threshold cumulative dose and number of cycles, the added benefit of continuing chemotherapy is limited.[27] Clinical practice has shown that in patients given adjuvant therapy for primary breast cancer, first failures and distant metastases show a double peak pattern. The first major peak occurs at about 18-24 months after surgery and a second minor peak in the 5th to 6th year.[62,85] HER2 positive patients belong to a high-risk population which is likely to contribute greatly to the 2-year peak of relapse. The first major peak occurs at about the time when one year of adjuvant Herceptin therapy would stop, i.e. after six months of chemotherapy plus 12 months of Herceptin = 18 months. Data from in vitro and clinical models suggest that tumour growth that was controlled or reversed during treatment may be accelerated when Herceptin is discontinued.[11,14] In 1998, Pietras et al. showed that there is strong evidence for an in vivo anti-proliferative effect of rhuMAb HER2 in tumours which overexpress HER2 protein. Monoclonal antibody targeting of HER2 appears to be primarily cytostatic (rather than cytotoxic) on susceptible tumour cells, with tumour growth recurring after discontinuation of antibody administration.[21] This suggests that HER2-positive disease may need continuous down-regulation of HER2 gene expression in the clinical setting. Chronic down-regulation of HER2/neu expression also results in the activation of apoptotic cell death pathways in cells that overexpress HER2/neu.[63] It is also conceivable that multiple erbB2 downstream signals (e.g., Shc/Grb-2-Ras, PI3K-Akt, JNK, p38MAPK, PKC, etc) are involved in inducing a variety of metastasis-related properties, that can contribute to higher metastatic potential of c-erbB2-overexpressing cancer cells.[64] In summary, preclinical data suggests that one year of Herceptin treatment may be suboptimal and longer duration of treatment may be important in the HERA trial where Herceptin is given alone, after rather than concurrently with chemotherapy. This hypothesis is supported by clinical studies in patients with metastatic disease. Responses to Herceptin monotherapy were of long duration, and this appeared to be particularly in patients with less advanced disease [Table 1 and 15,16,18]. However, the burden of disease is substantially greater in the metastatic setting, and it is difficult to predict whether this would be a concern in the setting of minimal residual disease. Thus, it is desirable to determine whether extending the duration of treatment with Herceptin beyond the period of maximum risk will provide additional benefit.

1.5.4

Rationale for Including Patients Irrespective of Nodal Status

HER2 overexpression is an independent adverse prognostic factor in node positive and probably also node negative breast cancer. Therefore, patients with both node negative or node positive HER2 overexpressing early breast cancer will be eligible for participation in the HERA trial. (Neo-) adjuvant chemotherapy prior to randomisation in the HERA trial is mandatory, based on the observed improvements in ten-year OS reported in the EBCTCG meta-analysis and the increased relapse risk associated with HER2 overexpression. There is evidence to suggest that recurrence risk in node negative disease is related to an number of other tumour characteristics (Table 4).[65] The selection of therapy is most appropriately based upon knowledge of an individual's risk of tumour recurrence balanced against the short- and longterm risks of adjuvant treatment.

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Table 4
Risk Category Minimal/Low Risk2

New definition of risk categories for patients with nodenegative breast cancer
Endocrine Responsive1 ER and/or PgR positive, AND all of the following features: pT* 2 cm, AND Grade 1**, AND Age*** 35 years ER and/or PgR positive, AND at least one of the following features: pT* > 2 cm, OR Grade 2-3**, OR Age*** < 35 years Endocrine Non-Responsive1 Not Applicable

Average/High Risk

ER and PgR negative

(St. Gallen Consensus Conference 2001, [65]) Responsiveness to endocrine therapies is related to expression of ER and PgR in the tumour cells. The exact threshold of ER and/or PgR staining (with currently available immunohistochemical methods), which should be used to distinguish between endocrine responsive and endocrine non-responsive tumour is unknown. Even a low number of cells stained positive (as low as 1% of tumour cells) identify a cohort of tumours having some responsiveness to endocrine therapies. [66] Probably, as typical for biological systems, a precise threshold does not exist. However empirically chosen, about 10% positive staining of cells for either receptor might be considered as a reasonable threshold, accepted by most. Furthermore, it is clear that the lack of staining for both receptors confers endocrine non-responsiveness status. 2 Some Panel members recognise lymphatic and/or vascular invasion as a factor indicating greater risk than minimal or low. On the other hand, mucinous histological type is associated with low risk of relapse. * pT = pathological tumour size (i.e., size of the invasive component). ** Histologic and/or nuclear grade. *** Patients with breast cancer at young age have been shown to be at high risk of relapse. [67] Node-positive breast cancers are all considered at average/high risk of relapse. Offering adjuvant treatments is based upon endocrine responsiveness or non-responsiveness of the tumour and the patients menopausal status and age.
1

1.5.5 1.5.5.1

Rationale for Several prior Adjuvant Chemotherapy Regimens, Hormonal Therapy and Radiotherapy Chemotherapy

Currently, there are at least 20 adjuvant trial groups operating in Europe, with over 80 active chemotherapy trials using more than 25 schedules. In addition, numerous adjuvant chemotherapy regimens are in use for early breast cancer throughout the world in daily clinical practice. Not surprisingly, there is no agreed single standard adjuvant chemotherapy regimen in Europe. Because of this lack of consensus and the limited data available concerning the relative benefits of different regimens and TAM in the HER2 positive breast cancer population, various previously established and generally acknowledged adequate polychemotherapy regimens will be allowed.

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1.5.5.2
Tamoxifen

Hormonal Therapies

Although the use of adjuvant TAM has clearly established benefits in the general breast cancer population, the question of whether there is benefit in HER2 overexpressing breast cancers remains unresolved. Given this controversy, the use of TAM according to the registered indication in women with hormone receptor positive breast cancer [ER or progesterone receptor (PgR) positive] in the HERA trial is recommended but not mandatory. Recognising that there is little benefit associated with adjuvant TAM in women with hormone receptor negative disease (as defined by the method and definition of the local laboratory for both progesterone receptors (PgR) and ER or for ER only in centres that do not routinely measure PgR), TAM is not allowed for this subset of women participating in this study.

Aromatase Inhibitors
The aromatase inhibitors anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin) have been approved in the treatment of postmenopausal women with hormone receptor positive early invasive breast cancer. Therefore, the use of these aromatase inhibitors in the HERA trial according to the registered indication and label in your country is allowed in postmenopausal women with hormone receptor positive early invasive breast cancer.

Ovarian Ablation
Since the added benefit of ovarian ablation/suppression in premenopausal women with hormone receptor positive breast cancer who receive adjuvant chemotherapy is uncertain, ovarian ablation for such women in the HERA trial is allowed. Acceptable forms of ovarian ablation include irreversible castration through surgery or irradiation, and reversible ovarian suppression through the use of gonadotropin releasing hormone (GnRH) analogues.

1.5.5.3

Radiotherapy

Studies have reported similar rates of loco-regional recurrence in patients undergoing mastectomy without radiotherapy and patients undergoing complete tumour excision without mastectomy followed by radiotherapy to the breast.[68] Radiotherapy to the breast is mandatory in all patients whose primary tumour surgery comprises a complete local excision without mastectomy. Radiotherapy is not mandatory for patients who have undergone a mastectomy.[69] Regional radiotherapy, including the chest wall and supraclavicular regions, with or without axillary fields, is recommended in patients with four or more involved axillary nodes, including patients who have had mastectomy. This is based on results of two randomised studies that suggested survival benefit with the addition of regional irradiation to mastectomy and systemic adjuvant chemotherapy hormone therapy in women with multiple positive lymph nodes, and from the Oxford overview of radiotherapy trials.[56,70,71] Regional radiotherapy, with or without axillary fields in women with 1-3 axillary nodes, is of uncertain additional benefit and is optional. Tumour bed irradiation is mandatory for patients with pathologic dermal invasion (pT4) and 'nonresectable' deep margin invasion.

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In order to minimise cardiac irradiation, all patients who receive internal mammary node (IMN) irradiation must have the radiotherapy planned using a technique that enables minimisation of cardiac irradiation, preferably 3-D conformational CAT scan. This radiotherapy field is mandatory in patients with confirmed or suspicious IMN spread (by sentinel node technique) and optional in patients with tumours judged to be at high risk of IMN spread (such as central and medial hemisphere tumours).

2.
2.1

OBJECTIVES OF THE STUDY


Primary Objectives
To compare disease-free survival (DFS) in patients with HER2 overexpressing breast cancer who have completed acceptable adjuvant chemotherapy, and radiotherapy if applicable, and who have been randomised to Herceptin for one year versus no Herceptin. To compare disease-free survival (DFS) in patients with HER2 overexpressing breast cancer who have completed acceptable adjuvant chemotherapy, and radiotherapy if applicable, and who have been randomised to Herceptin for two years versus no Herceptin.

2.2

Secondary Objectives
To compare outcomes (DFS, OS, RFS, DDFS, TTR, TTDR, cardiac safety, overall safety) of patients treated with Herceptin for one year compared with Herceptin for two years.

To compare overall survival (OS) in patients randomised to i) Herceptin for one year or no further therapy and in patients randomised to ii) Herceptin for two years or no further therapy. To compare relapse-free survival (RFS) in patients randomised to no Herceptin versus one year of Herceptin, and in patients randomised to no Herceptin versus two years of Herceptin. To compare distant disease-free survival (DDFS) in patients randomised to no Herceptin versus one year of Herceptin, and in patients randomised to no Herceptin versus two years of Herceptin. To compare time to recurrence (TTR) in patients randomised to no Herceptin versus one year of Herceptin, and in patients randomised to no Herceptin versus two years of Herceptin. To compare time to distant recurrence (TTDR) in patients randomised to no Herceptin versus one year of Herceptin, and in patients randomised to no Herceptin versus two years of Herceptin. To evaluate the safety and tolerability of Herceptin. To compare the incidence of cardiac dysfunction in patients treated and not treated with Herceptin.

Additional exploratory analyses are described in the statistics section (Section 8).

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2.3

Cardiac Objectives

Cardiac safety will be monitored throughout the trial in all patients. The purpose of this intensive cardiac monitoring is to maximise the safety of patients participating in the trial. This is achieved by providing an algorithm for the discontinuation of Herceptin in individual patients based on interval LVEF assessments (Figure 4, Section 7.4.1.2). Also, pre-defined primary and secondary cardiac safety endpoints will permit assessment of cardiac dysfunction at three interim analyses (see Section 8). If an absolute difference of more than 4% in the incidence of primary cardiac endpoints (see definition Section 2.3.1) is observed between Herceptin and no Herceptin groups, the Independent Data Monitoring Committee (IDMC) will consider recommending stopping or modifying the trial. If a >4% absolute difference in the incidence of primary cardiac events between the treatment and observation groups is seen only in a subset of patients (e.g., those pretreated with anthracyclines) the IDMC may recommend continuation of the trial with an amendment excluding further enrollment of such patients. If the incidence of primary cardiac endpoints is similar in Herceptin and no Herceptin groups at the third interim analysis, the IDMC may recommend an amendment allowing the inclusion of patients with baseline LVEF of 50%. Rationale for the >4% stopping criterion: Four percent is the rate of NYHA class III-IV congestive heart failure that was seen in the pivotal combination trial when Herceptin was given with paclitaxel in the advanced metastatic setting (H0648g).[84] The rate of NYHA Class III-IV congestive heart failure seen with Herceptin monotherapy was 5% in this setting. Previous adjuvant breast cancer trials have reported rates of heart failure between 0.5-1.0% when adverse events were collected in the standard fashion (NSABP data). No prospective measurements of LVEF have been performed in an adjuvant breast cancer trial to date. Based on the limited data available, a consensus decision was reached among consulting cardiologists that a difference in the rate of primary cardiac events greater than 4% was unacceptable in the adjuvant setting. All patients will be monitored according to the schedule in Table 7 until it is determined by the HERA Steering Committee that it is safe to reduce the monitoring frequency, based on recommendations from the IDMC after review of cardiac data at interim analyses. It is estimated that at least 900 patients will need to be monitored intensively before reduction of cardiac monitoring intensity can be considered. Cardiac data will also be used to: Estimate the incidence of symptomatic cardiac dysfunction and asymptomatic cardiac dysfunction in the adjuvant setting in patients who received adequate systemic adjuvant therapy followed or not by Herceptin treatment for one year or two years. Identify patients at risk for cardiotoxicity with chemotherapy and/or Herceptin. Establish early detection methods (echocardiography, MUGA scan) for eventual cardiotoxicity and correlate them to outcome.

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2.3.1

Cardiac Endpoints and Definitions

There is a formal monitoring plan to assess the incidence of cardiac endpoints in patients enrolled in this trial. The following definitions of cardiac endpoints will be used: Primary cardiac endpoint: The occurrence in any patient at any time after randomisation, but prior to the start of any new anticancer therapy * of any of the following: Symptomatic congestive heart failure of NYHA class III or IV, (confirmed by a cardiologist) and a drop in LVEF of at least 10 EF points from baseline and to below 50%. Cardiac death, defined as either: Definite cardiac death: due to CHF, myocardial infarction or documented primary arrhythmia. Probable cardiac death: sudden unexpected death within 24 hours of a definite or probable cardiac event (syncope, cardiac arrest, chest pain, infarction, arrhythmia etc.) without documented aetiology.

All primary cardiac endpoints as defined above should be recorded as serious adverse events (SAEs) on the AE page in the CRF for all patients, irrespective of treatment allocation. Primary cardiac endpoints for patients in the Herceptin arms should also be reported on an SAE form. In addition, primary cardiac endpoints should also be reported on the Cardiac Event page in the CRF for all patients, irrespective of treatment allocation (see section 7.1.1.1 for details).
* The occurrence of primary cardiac endpoints after start of any new anticancer therapy will be handled as described below.

Secondary cardiac endpoint: A secondary cardiac endpoint may occur at any time after randomisation, but prior to the start of any new therapy for recurrent disease, and is defined as: A significant asymptomatic (NYHA class I) or mildly symptomatic (NYHA class II) drop in LVEF identified by MUGA scan or echocardiogram, unless the next subsequent assessment of LVEF indicates a return to levels that do not meet the definition of a significant LVEF drop. NYHA class II CHF must be confirmed by a cardiologist. A repeat assessment must be performed approximately three weeks after first documented drop (see cardiac algorithm in Figure 4). If such a repeat assessment or confirmation of NYHA class II CHF by a cardiologist is not available, the Cardiac Advisory Board shall review the case to determine acceptability as a secondary cardiac endpoint. A significant LVEF drop is defined as an absolute decrease of at least 10 EF points below baseline and to below 50%. All secondary cardiac endpoints as defined above should be reported as adverse events (AEs). However, if any of the secondary cardiac endpoints above fulfils any of the 'seriousness' criteria listed in section 7.2.1 (e.g. hospitalisation), it must also be reported as an SAE on an SAE form for patients in the Herceptin arms and on the AE page for patients in the observation arm. Please note that secondary cardiac endpoints should also be reported on the Cardiac Event page in the CRF for all patients, irrespective of treatment allocation (see section 7.1.1.1 for details).

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The reporting requirements apply to all patients, regardless of treatment assignment, according to the procedures and definitions outlined in detail in sections 7.1.1, 7.2.1, and in the Study Procedures and Administrative Manual (SPAM). All primary and secondary cardiac endpoints will be reviewed at the cardiac safety interim analyses. Autopsy reports should be obtained whenever possible in patients who have died of known or suspected cardiac events. Primary cardiac endpoints occurring after disease recurrence or second primary cancer: Attempts should be made to document primary cardiac endpoints occurring after disease progression or second primary cancer, and initiation of a new treatment, in order to get a complete picture of the potential cardiac toxicity associated with Herceptin. Events occurring after a new anti-cancer treatment has been started, however, will not contribute to the primary cardiac endpoint incidence for early trial termination. The rationale for this is that patients randomised to the observation arm may receive Herceptin at the time of relapse and that patients in all treatment groups may receive potentially cardiotoxic drugs at relapse, thus obscuring the true incidence of cardiac endpoints related to Herceptin. In addition, regular follow-up of cardiac events in patients who are followed for survival only will be difficult to guarantee and may therefore be biased. Nonetheless, primary cardiac endpoints occurring after a new anticancer treatment has been started will be collected and analysed separately. Other cardiac/cardiovascular events (e.g. acute coronary syndrome, acute myocardial infarction, or severe rhythm disturbances requiring treatment) will not be considered as primary or secondary cardiac endpoints (unless fatal; see definition of primary cardiac endpoints). These events should be reported as AEs or SAEs if applicable (see section 7.1.1.1 for details).

3.
3.1

STUDY DESIGN
Overview of Study Design and Dosing Regimen

This will be a randomised, three-arm, open-label, multi-centre study. Patients will be randomised upon completion of definitive surgery and systemic adjuvant chemotherapy to receive no Herceptin or Herceptin for one year* or two years**. If clinically indicated, all ER positive patients can receive systemic adjuvant hormonal therapy. Radiation therapy, when indicated, must have been completed prior to the start of Herceptin. Once a potential patient has been identified, her eligibility will be assessed according to inclusion/exclusion criteria (Section 4). This includes testing the patients tumour to confirm HER2 protein overexpression at the 3+ level (by IHC) and/or gene amplification (by FISH). A patient will be randomised only after confirmation of HER2 overexpression of the primary tumour, satisfaction of all other inclusion and exclusion criteria, completion of chemotherapy and, if indicated, radiotherapy, and completion of non-invasive baseline cardiac examinations. ______________________________________________________________________________
* "1 year" of Herceptin is defined as "12 calendar months of treatment from day 1 of 1st administration and 18 infusions maximum.

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**

"2 years" of Herceptin is defined as "24 calendar months of treatment from day 1 of 1st administration and 35 infusions maximum.

The study timing is displayed in Table 5; schema for study procedures and determining eligibility can be found in Figures 2 and 3, respectively. Patients randomised into the observation arm will undergo the same monitoring visit schedule after randomisation (see Table 7) as patients randomised to Herceptin (i.e., week 13, 25, and 52 during the first year on study). They will also have to undergo a follow-up visit at the same time when patients randomised to Herceptin have a formal safety follow-up visit (weeks 56 and 107, i.e., 28 days after completion of Herceptin treatment). This is necessary in order to avoid any bias in reporting of events due to differences in patients visit schedule.

Table 5
HER2 screening

HERA study timing


Randomisation Herceptin therapy (Safety) A, B follow-up C after completion of treatment period Week 56 107 Follow-up

Time Any time before randomisation but after signed screening consent form

Time Within 7 weeks from day 1 of the last chemotherapy cycle or 6 weeks from the end of radiotherapy, or definitive surgery, whichever is last

Week 1 to 52A 1 to 103B

Month 14 to 120A 27 to 120B 1 to 120C

A B C

Patients randomised to one year of Herceptin Patients randomised to two years of Herceptin Patients randomised to observation

Screening for HER2 status may be done at any time prior to randomisation, i.e. prior to or while the patient is receiving adjuvant therapy. NOTE: Confirmation of HER2 status in the HERA trial has to be done at a central laboratory prior to randomisation. For details see section 5.1.1. and Figure 3. The remainder of the screening tests must be done before randomisation within the time frames outlined in Table 7. The patient must be randomised up to a maximum of 7 weeks following day one of the last chemotherapy cycle or a maximum of 6 weeks from the end of radiotherapy or definitive surgery, whichever occurs last. For radiotherapy, this is the last day of the main irradiation course regardless of any subsequent 'boost'. Whenever possible, the first dose of Herceptin must be given within a maximum of two weeks after randomisation (unless intercurrent illness or similar unforeseen event prevents this). All patients will be followed until 10 years after last patient enrolled into the HERA trial.

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Figure 2

Scheme of pre-study and study procedures

PRIMARY MANAGEMENT [Surgery, (neo-)adjuvant chemotherapy, + adjuvant radiotherapy]

Establish eligibility PRE-HERA

HERA STRATIFICATION

RANDOMISATION

No Herceptin

Herceptin every 3 weeks x 1 year

Herceptin every 3 weeks x 2 years

Regular follow-up monitoring adverse events

Trial endpoints

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Figure 3

HER2 Screening Procedure


Local Lab Facility

IHC or FISH

2+or3+ by IHC or FISH pos.

0,1+ by IHC or Negative by Fish

Refer to central laboratory for: - FISH confirmation of local IHC 2+ results, - FISH confirmation of local FISH+ results, or - IHC confirmation of local IHC 3+ results

NOT ELIGIBLE

IHC 2+ & FISH negative

IHC 3+ or FISH positive

ELIGIBLE

Note: HER2 or FISH tests must be performed locally as an initial screen. Only in exceptional cases where local lab facilities are not available may permission be granted for centers to send tumour samples directly to the central lab.

3.2

Number of Patients and Treatment Assignment

A total of 4482 randomised patients is planned to be recruited over approximately 3 years. Randomisation is planned on a 1:1:1 basis to give 1494 patients in each of three arms: no Herceptin, one year of Herceptin and two years of Herceptin. All eligibility criteria and prerandomisation tests must be completed prior to randomisation. Patients will be stratified prior to randomisation for prognostic and other factors that may impact patients outcome (see Table 6). All patients randomised to receive Herceptin will start treatment within two weeks from randomisation. A minimisation procedure according to Pocock and Simon [89] will be used for allocation of atients to the treatment arms in order to secure a balance between the treatments for stratification factors. It is not planned to perform efficacy analyses in individual strata.

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Table 6

Stratification factors

Nodal status A: 1. Any nodal status, neo-adjuvant chemotherapy (nodal status unknown prior to chemotherapy) 2. No positive nodes, no neoadjuvant chemotherapy 3. 1-3 nodes positive, no neoadjuvant chemotherapy 4. >4 nodes positive, no neoadjuvant chemotherapy Adjuvant chemotherapy regimen: 1. no anthracyclines or taxanes 2. anthracyclines but no taxanes 3. anthracyclines + taxanes Receptor status and endocrine therapyA,B,C: 1. negative 2. positive and no endocrine therapy 3. positive and endocrine therapy Age: D 1. < 35 years 2. 35 - 49 years 3. 50 - 59 years 4. 60 years E Region

Patients with synchronous bilateral breast primaries: Stratification will be based on the highest stage tumour and will be considered hormone receptor status positive if at least one tumour has positive receptors as defined below. Hormone receptor status must be known for each patient in the study. For this study, hormone receptor status (negative or positive) will follow the definition of the local lab for both estrogen and progesterone receptors, or estrogen receptors alone for centres that do not routinely measure progesterone receptors. Actual values obtained from assays will be used to define cohorts for exploratory analyses (see Section 8.2.1.7) Endocrine therapy includes tamoxifen, anastrozole (Arimidex), letrozole (Femara), exemestane (Aromasin) and ovarian ablation. Chemotherapy induced amenorrhea is not considered endocrine therapy. based on age at time of randomisation Geographic region, as described in the SPAM

Tumour size was considered as a stratification factor but not selected because: 1) clinical tumour size is not reliable; 2) pathologic tumour size is not given in the pathology report with regularity; 3) the TNM stage is often not recorded in the patients records, making it difficult for a nonclinician who is randomising a patient to decide what information to provide. All of these factors will make stratification very difficult and because of the potential for error, will not guarantee a balance of distribution of this factor, which is the sole reason for stratifying for it. Age is used as a stratification factor instead of menopausal status because information regarding age is much more likely than menopausal status to be both available and accurate at the time of randomisation. Age is a surrogate for menopausal status, and thus should allow balanced distribution of pre and post menopausal women to all three arms. Nevertheless, recognising that

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menopausal status is biologically more important as a prognostic factor, it will be captured in the case report forms and used for the purposes of analyses of endpoints (see Section 8.2.1.7).

3.3

Centres

Approximately 600 study sites will participate in this study.

3.4
3.4.1

Provision of Herceptin to Patients Randomized to Receive No Herceptin


Rationale

Interim efficacy results of the HERA study presented on 16th May 2005 demonstrate a statistically significant increase in disease-free survival for patients who received Herceptin within approximately 2-3 months following completion of adjuvant chemotherapy or radiotherapy. Data from the joint interim analysis of two adjuvant trials with Herceptin (NSABP B-31 and NCCTG N9831) showed a survival benefit for women who received concurrent Herceptin/Taxol treatment following anthracycline based chemotherapy (AC). In early breast cancer the risk of recurrence remains high within approximately 5 years after initial diagnosis with a peak at about years 2 and 5 after diagnosis [96-99]. Based on these results, all patients originally randomized to receive no Herceptin in the HERA trial that meet specific eligibility criteria (see below) will be offered access to Herceptin under this protocol amendment (version E). All patients who were randomized to the HERA study will be informed of the interim analysis results. This process will be documented.

3.4.1.1

Eligibility Criteria for Herceptin Treatment

Patients who were randomized to receive no Herceptin and remain event free are eligible for Herceptin treatment provided they fulfill the following criteria: 1. Signed written informed consent obtained before any study specific procedures relating to protocol amendment E. 2. No clinical evidence of contralateral breast cancer and/or breast cancer recurrence (as specified by sections 5.2.1.1 and 5.3) at time of planned 1st Herceptin infusion. 3. Adequate cardiac function defined as left ventricular ejection fraction of 55% assessed by echocardiography (Simpson method) or MUGA scan and performed within 12 weeks from time of planned 1st Herceptin infusion. 4. Favourable risk-benefit assessment by the treating physician and the patient following review of relevant interim efficacy and safety data.

Patients who meet these criteria above may choose from the following three options:
1. Continue as before to receive no Herceptin treatment. 2. Receive 1 year of Herceptin treatment by direct assignment. 3. Consent to randomization to receive either 1 year or 2 years of Herceptin treatment.

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Patients choices will be registered via an Interactive Voice Response System (IVRS) and in the case of option 3, treatment will be assigned by randomization. Herceptin treatment should be started as soon as possible after direct assignment or randomization. Direct assignment and randomization of patients should be completed within 3 months of approval by the corresponding Ethics Committee/Institutional Review Board or by 31st December 2005, whichever occurs last.

3.4.1.2

Study Assessments Following Start of Herceptin Treatment

Patients receiving Herceptin under this protocol amendment (version E) will be treated and followed according to the protocol (section 5) and schedule of assessment (Table 7). Patients will start their assessment schedules at week 1 of the treatment period and carry on with all subsequent assessments (including cardiac assessments) as per Table 7 (i.e. Week 13, 25, 37 etc). Patients who are not eligible or who do not wish to receive Herceptin treatment should continue with their original assessment schedule in the observation arm. Such patients should be followed according to the protocol. It has to be emphasized that patients who remain in the observation arm continue to contribute significantly to the success of the study and provide vital data for the assessment of efficacy (overall survival) and long term safety, particularly cardiac safety, of Herceptin treatment in the adjuvant setting according to the final analysis plan.

3.5
3.5.1

Further Changes to Study Design Following Interim Analysis


Guidelines for Resuming Herceptin Treatment

Patients who were randomized to receive 1 year or 2 years of Herceptin treatment and who then voluntarily elected not to start Herceptin treatment or to discontinue Herceptin treatment voluntarily before completing their 1 year or 2 years of treatment period and now elect to initiate or resume their Herceptin treatment may do so under the same eligibility criteria as listed in section 3.4.1.1. The patient will receive Herceptin treatment from the time of re-start or initiation of therapy until the date of her original projected date for completion of Herceptin treatment. The patient will not receive Herceptin treatment to account for the period of no treatment with Herceptin. Note that all patients who have discontinued Herceptin treatment due to any other reason including Herceptin-related toxicity, adverse event (e.g. cardiac event), recurrence of disease, misrandomization etc. will not be allowed to resume Herceptin treatment under this protocol.

3.5.2

Changes to the PK and Cardiac Marker Sub-studies

No changes to the conduct of the PK sub-study are foreseen because patients randomized to the observation arm are not eligible for this sub-study. Patients enrolled in the PK sub-study continue to be followed according to the approved version of the sub-study protocol. Patients who were randomized to the observation arm of the HERA study and enrolled in the Cardiac Marker sub-study and who now start Herceptin treatment will continue to be followed

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according to the approved version of the Cardiac Marker sub-study protocol. Patients will start their assessment schedules at week 13 and carry on with all subsequent assessments as per Table 1 (i.e. Week 25, 52 etc).

4.
4.1

STUDY POPULATION
Target Population

The target population for this trial are women with non-metastatic*, operable and HER2 positive (3+ by IHC and/or FISH positive) primary breast cancer. They must have completed definitive surgery, adjuvant radiotherapy (if applicable, Section 1.5.5.3), and received prior systemic (neo-) adjuvant chemotherapy for primary breast cancer. Patients should not have received any prior anti-HER therapy, which includes agents that target other members of the HER family of receptors, e.g. Iressa. Patients may receive adjuvant hormonal therapy as per standard of care (Section 1.5.5.2).

*According to the TNM nomenclature published in the AJCC Cancer Staging Manual, 5th edition
(1997). See Appendix 1.

Radiation therapy and chemotherapy must have been completed prior to randomisation. Under no circumstances are patients who enrol in this study and who have completed treatment or observation as specified, permitted to be re-enrolled for a second time.

4.2
1. 2. 3. 4.

Inclusion Criteria
Female gender Age 18 years Eastern Cooperative Oncology Group (ECOG) performance status < 1 Non-metastatic operable primary invasive adenocarcinoma of the breast that is: histologically confirmed, adequately excisedA,F, axillary node positiveB or negativeC, and tumour size T1c according to TNM (see Appendix 1)H Known hormone receptor status (ER/PgR or ER alone) Must have received at least four cycles of an approved (neo-) adjuvant chemotherapy regimen (refer to Table 8, Section 5.1.3, for regimen guidelines) Baseline LVEF > 55% measured by echocardiography or MUGA scan after completion of all (neo-) adjuvant chemotherapy and radiotherapy. Completion of radiotherapy for any patients undergoing radiotherapy Overexpression of HER2 in the invasive component of the primary tumourG, according to one of the following definitionsD: 3+ overexpression by IHC 2+ overexpression by IHC AND fluorescence in situ hybridisation (FISH) test (PathVysion or INFORM HER-2/neu test) demonstrating c-erbB2 gene amplification (ratio of c-erbB2 gene signals to centromere 17 signals 2 or > 4 copies Her2/neu gene observed, where there is no centromere control)

Patients must meet ALL of the following criteria in order to be eligible for this study.

5. 6. 7. 8. 9.

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c-erbB2 gene amplification by FISH (PathVysion or INFORMHER-2/neu test: ratio of c-erbB2 gene signals to centromere 17 signals 2 or > 4 copies Her2/neu gene observed, where there is no centromere control) 10. Completion of all necessary baseline lab and radiologic investigations as described in Table 7. 11. Signed written informed consentE (approved by the Independent Ethics Committee [IEC] and obtained prior to any study specific screening procedures).
A

C D

Margins of the resected specimen have to be histologically free of invasive adeno-carcinoma and ductal carcinoma in situ (DCIS). Lobular carcinoma in situ (LCIS) does not count as a positive margin. Exception: Patients who have 'non-resectable' deep margin invasion are eligible provided they have had radiotherapy encompassing the region concerned. Patients with histologically documented infiltration of the skin (pT4) are eligible provided they have undergone radiotherapy encompassing the tumour bed. Node positive patients/adjuvant chemotherapy: Axillary dissection is mandatory. Sentinel node sampling is allowed provided that axillary dissection follows confirmation of a positive sentinel node(s). Node positive patients/neo-adjuvant chemotherapy: Axillary dissection is also mandatory in patients achieving "complete clinical response" after neo-adjuvant chemotherapy. Sentinel node sampling alone is NOT acceptable after neo-adjuvant chemotherapy; if used it must always be followed by a complete axillary dissection. In patients receiving neo-adjuvant chemotherapy lymph node status will be considered unknown, regardless of the results of post-chemotherapy axillary dissection. Node negative patients: Sentinel node and/or axillary dissection are acceptable. All locally positive HER2 tests must be reconfirmed by the central laboratory prior to patient entry, by submission of a tumour block or slides from the participating sites. The central lab will use the following methods for confirmation: Local 2+ by IHC or local FISH will be confirmed by FISH (PathVysion, Vysis); local IHC 3+ will be confirmed by IHC (HercepTest, DAKO). As part of screening patients need to consent to central reconfirmation of HER2 status. A written informed consent must be obtained prior to randomisation in the actual HERA study. Primary surgery aiming at resection of the tumour bed is also mandatory for patients achieving a "clinical complete response" after neo-adjuvant chemotherapy. Patients receiving neoadjuvant therapy must have HER2 confirmation on a sample of their tumour that was obtained PRIOR to starting neoadjuvant chemotherapy. Post/during chemotherapy tissue samples may not be used to establish HER2 overexpression for eligibility. Applies only for patients with negative nodes.

4.3
1. 2.

Exclusion Criteria
History of any prior (ipsi- and/or contralateral) invasive breast carcinomaA. Past or current history of malignant neoplasms, except for curatively treated: Basal and squamous cell carcinoma of the skin in situ carcinoma of the cervix Any "clinical" T4 tumour, including inflammatory breast cancer. Maximum cumulative dose of doxorubicin >360mg/m2 or maximum cumulative dose of epirubicin >720mg/m2 or any prior anthracyclines unrelated to the present breast cancer. (Neo-) or adjuvant chemotherapy using peripheral stem cell or bone marrow stem cell support. Any prior mediastinal irradiation except internal mammary node irradiation for the present breast cancerB.

Patients meeting any ONE of the following criteria are not eligible for this study.

3. 4. 5. 6.

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7.

8. 9. 10.

11. 12.

13. 14.

Patients with positive or suspicious internal mammary nodes identified by sentinel node technique which have not been irradiatedB or patients with supraclavicular lymph node involvementC. Prior use of anti-HER2 therapy for any reason or other prior biologic or immunotherapy for breast cancer. Concurrent anti-cancer treatment in another investigational trial, including hormone therapy, immunotherapy, and bisphosphonate therapyD Serious cardiac illness or medical conditionsE including but not confined to: History of documented congestive heart failure (CHF) High-risk uncontrolled arrhythmias Angina pectoris requiring antianginal medication Clinically significant valvular heart disease Evidence of transmural infarction on ECG Poorly controlled hypertensionF (e.g. systolic >180mm Hg or diastolic greater than 100mm Hg). Other concurrent serious diseases that may interfere with planned treatment including severe pulmonary conditions/illness. Any of the following abnormal laboratory tests immediately prior to randomisation: serum total bilirubin > 2.0 x upper limit of normal (ULN) alanine amino transferase (ALAT) or aspartate amino transferase (ASAT) > 2.5 x ULN alkaline phosphatase (ALP) > 2.5 x ULN serum creatinine > 2.0 x ULN; total white blood cell count (WBC) < 2,500 / mm3 absolute neutrophil count <1,500 / mm3 platelets <100,000 / mm3. Pregnant or lactating womenG. Women of childbearing potential or less than one year after menopause (unless surgically sterile) who are unable or unwilling to use adequate contraceptive measures during study treatmentH.
Previous history of ductal carcinoma in situ (DCIS) of the breast is not an exclusion criterion. For radiotherapy planning and dose details, please refer to Section 5.1.4 Clinical suspicion of supraclavicular lymph node involvement must be accompanied by a negative fine needle aspirate (FNA) or biopsy in order to be eligible. Patients may have participated in a (neo-) adjuvant chemotherapy trial prior to enrollment in the HERA trial, provided that the chemotherapy trial was approved by the HERA Executive Committee, and that patients comply with the HERA treatment and follow-up schedule (Table 7). As judged by the investigator. Patients with hypertension which is well controlled on medication are eligible. Women of child bearing potential must have a negative pregnancy test (urine or serum) within 7 days prior to randomisation and/or Herceptin treatment (see 7.2.5 and 7.5.4 for details). Examples of adequate contraceptive measures are intra-uterine device, barrier method (condoms, diaphragm), also in conjunction with spermicidal jelly, or total abstinence. Oral, injectable, or implant hormonal contraceptives are not indicated in this patient population!

A B C D

E F G

4.4

Previous and Concomitant Treatment

All concomitant and prior treatments for breast cancer must be reported in the case report forms (CRF), including:

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Date and extent of primary surgery (Neo-) adjuvant chemotherapy (anti-cancer drugs, dose per cycle [mg/m2 and total], number of cycles, dosing interval, and timing in relation to surgery). Any loco-regional radiation therapy (extent or volume and total dose). Any hormonal therapy, including TAM and/or surgical and radiation-induced ovarian ablation and drug induced ovarian suppression (type, drug name, dose and schedule, anticipated duration of therapy). Any additional medication that is necessary for the management of the patient may be used at the discretion of the investigator. Acetaminophen (paracetamol) and antihistamines (diphenhydramine) may be used to relieve Herceptin infusion-associated symptoms. Administration of any adjuvant chemotherapy will not be allowed during this study (all previous adjuvant chemo- and radiotherapy must be completed before randomisation). Patients may have started bisphosphonate therapy before entering the study. Bisphosphonate therapy can also be initiated during the HERA trial for treatment of documented osteoporosis. The use of bisphosphonates for prevention of bone metastases is not allowed before licensed for this indication and approved by the HERA Steering Committee. Concomitant use of TAM, anastrozole (Arimidex), letrozole (Femara), exemestane (Aromasin) or ovarian ablation is permitted (see further specification in section [5.1.5]).

5.

SCHEDULE OF ASSESSMENTS AND PROCEDURES

The schedule of investigations, examinations, and follow-up is outlined below in Table 7. It is planned to follow patients up to year 10 after last patient enrolled into the HERA trial. NOTE: Patients randomised into the observation arm will undergo the same monitoring visit schedule after randomisation as patients randomised to Herceptin and displayed in Table 7 (i.e., week 13, 25, and 52 during the first year on study). All patients, regardless of study arm, will have follow-up safety visits within 28 days of week 52 (until week 56) and 103 (until week 107). This is necessary in order to avoid any bias in reporting of events due to differences in patients visit schedule. The following requirements and definitions regarding specific assessments and examinations have to be considered: Medical history, physical examination, hematological and chemistry studies: These and other appropriate diagnostic testing methods may by done at more frequent intervals if clinically indicated. A minimum follow-up of every three months (physical examination only) and every six months (hematological and chemistry studies) for the first two years as well as every six months for years 3, 4, and 5, and yearly thereafter (physical examination, hematological and chemistry studies) is recommended for all patients as standard of care follow-up following primary breast cancer.

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Start of Herceptin infusion: Day 1 of week 1 is the date of first infusion for patients randomised to Herceptin. For patients randomised to the observation arm, day 1 of week 1 is the date of randomisation. HER2 determination: May be done at any time after diagnosis but before randomisation. Eligibility is determined on the basis of confirmatory immunohistochemistry (IHC) testing and/or confirmatory FISH testing, each performed by the central lab facility. A chest X-ray is required at any time there is clinical suspicion of disease recurrence. Posterior-anterior (PA) and lateral views are preferred, however a PA alone will be accepted subject to local practice. Bone X-ray(s) to rule out bone metastases is(are) mandatory in the case of a bone scan with hot spots suspicious for metastases. Vertebral column CAT scan or MRI is mandatory to rule out vertebral metastases in the case of a bone scan with hot spots suspicious for vertebral metastases. Liver imaging (ultrasound or CAT scan) to rule out metastases is mandatory in patients with liver function tests or ALP that are above the limit of normal prior to randomisation. If after randomisation, liver enzymes and ALP become abnormal, further staging work-up is indicated (chest X-ray, liver imaging, bone scan, etc) to exclude metastatic disease. Weight, performance status and vital signs (blood pressure and heart rate) should be obtained at baseline, and monitored throughout the study. In the case of weight change leading to a recalculation of the Herceptin dose this will be reported as an adverse event if the investigator has judged the weight change to be study drug related. Results of scheduled LVEF assessments must be available before/on the day of each subsequent Herceptin administration, and a decision to administer or hold that dose must be made based on the algorithm displayed in Figure 4, see Section 7.4.1.2.

Time windows allowed for actual visit schedule and infusions: Herceptin administration: 3 days of the scheduled date Specific study visit procedures: corresponding to/within 5 days prior to scheduled date of Herceptin administration Treatment period: beginning of week (number X) Safety follow up visits: 8 days Follow up visits year 2-5: 28 days Follow up visits year 6-10: 42 days

Investigators are strongly advised to adhere to the time windows in order to avoid violations of the protocol.

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Table 7
NOTE:

Schedule of Assessments
Treatment Period:
Beginning of Week number (corresponding to/within 5 days prior to Herceptin infusion number)
1 (1)A X X X 13 (5) 25 (9) 37 (13) 52 (18) 64 (22) D 79 (27) D 91 (31) D 103 (35) D

Patients randomised into the observation arm will undergo the same monitoring visit schedule after randomisation as patients randomised to Herceptin. All patients, regardless of study arm, will have follow-up safety visits within 28 days of week 52 and 103.
Prior to randomisation (Baseline) Safety follow-up (week) 8 days 56B; 107B

Mandatory items Informed Consent HER2 determination Demographics, Medical History Radiologic Exam: Chest X-ray Bone scan 5 bilateral Mammogram Liver imaging X1 (X) X2,4 (X) X3 X3

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X (X) X4 (X)

X (X) X4 (X)

Pregnancy Test Physical Exam. Card. Monitoring: ECG LVEF 6 Signs/symptoms Cardiac questionnaire

X3 X3 X3 X3 X
3

X X X X

X X X X X X

X X X X X X

X X X X X X

X X X X X X X

Hematology and Biochemistry Soluble ECD (only in subset of patients) 7 Adverse Events F SAE G Herceptin IV (q3 weekly)

X3

1 + 2 year Herceptin group (C,D)

2 year Herceptin group (D)

Follow-up Every three months ( 28 days)


Mandatory items Month 15 Month 18 Month 21
G

Follow-up Every six months ( 28 days)


Month 30 Month 36 Month 42 Month 48
B

Follow-up Every 12 months ( 42 days)B


Month 54 Month 60 Year 5+ until Year 10

Month 24

Radiologic Exam: Chest X-ray Bone scan 5 bilateral Mammogram Liver imaging X X X X (X) X4 (X) X X X (X) X4 (X) X X X (X) X4 (X) X X X (X) X4 (X) X

X4

Physical Exam. Card. Monitoring: ECG LVEF Signs/symptoms Cardiac questionnaire

X X X X X
7

X X X X X X

X X X X X

X X X X X X (X) X X (X)

X X X X X X XE X X

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Hematology and Biochemistry Soluble ECD (only in subset of patients) Adverse Events (only specific AEs as defined in the protocol) SAE (only specific SAEs as defined in protocol)
A B C D E F G H

Day 1 of week 1 corresponds to the date of first Herceptin infusion. Patients randomised into observation arm do not return until their week 13 visit All patients randomised. Timing starts from date of Herceptin treatment, or date of randomisation for observation patients. Safety follow-up visits to be performed within 4 weeks from discontinuation/completion of treatment period. Patients randomised to the 1-year Herceptin arm. Patients randomised to the 2-year Herceptin arm. Cardiac questionnaire to be filled out once at 10 years after randomization. The questionnaire is not required years 6, 7,8, or 9 post randomization. Please see section 7.1.1 and 7.2.1 for requirements and timeframes of recording of AEs in the CRF. Please see section 7.2.1 for requirements and timeframes of SAE reporting. Patients randomised to the 1-year Herceptin or observation group. Visits correspond to weeks 64, 79, 91 and 103 of the 2-year Herceptin group.

1 2 3 4 5 6 7

Within six months prior to randomisation. Within one year prior to randomisation. Within seven days prior to randomisation. Unilateral for patients with mastectomy. Plain films (CAT scan in the case of vertebral column abnormalities) are required to exclude metastatic disease if a bone scan is positive LVEF assessment results must be available prior to administration of the next scheduled Herceptin dose, and a decision to give or withhold that dose must be based on the algorithm in Section 7.4.1.2 (Figure 4). Investigated in the first 900 patients recruited only.

(X) Parenthesis indicate that the item is optional, required only if symptoms or clinical suspicion are present. Blood tests: Haematology: includes haemoglobin, total white blood cell count, absolute neutrophil count, and platelet count (see 5.2.3). Biochemistry: includes serum creatinine, blood urea nitrogen, electrolytes, AST (SGOT) or ALT (SGPT), ALP, bilirubin (see 5.2.3). Serial assessment of CA 15-3 is left to the discretion of the investigator (see 5.2.1.1). Weight: Weight should be recorded at baseline and at every scheduled visit for all patients irrespective of their treatment allocation. In addition, weight should also be recorded at any time a change in weight results in a change in Herceptin total dose. Survival follow-up: All patients irrespective of treatment allocation should be followed for survival yearly from completion/discontinuation of treatment period until 10 years after original randomisation of the last patient (see section 5.2.1.1).

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5.1

Eligibility Screening

An eligibility screening form (ESF) documenting the patients fulfilment of screening criteria must be completed for each patient once central confirmation of the HER2 status has been obtained and the patient has signed the study entry ICF. The ESF must be available for the HERA monitor for review of all potentially eligible patients for entry into the HERA trial (see SPAM). At sites where HER2 is not performed routinely then a screening consent must be obtained prior to testing. All patients need to consent to central reconfirmation of HER2 status. In addition, a written informed consent (ICF) for study entry is mandatory for eligible patients prior to randomisation into the actual HERA trial. For any tumour sample sent to the central lab for HER2 eligibility screening or confirmation, a minimum of twelve (12) UNSTAINED slides or a tumour block must be sent (6 slides for HER/2 confirmation and 6 slides for retrospective confirmation of hormone receptor status). A tumour block is clearly the preferred material.

5.1.1

HER2 Screening for Eligibility

Patient eligibility must include HER2 overexpression as defined by a score of 3+ by IHC or cerbB2 gene amplification determined by FISH alone, or in conjunction with a 2+ IHC score on the invasive component of the tumour. HER2 testing can be performed at any time after primary surgery or during adjuvant chemotherapy or radiation therapy, as long as the positive result from the central lab is known prior to randomisation. Specific administrative requirements for determination of HER2 status in patients who have received neoadjuvant chemotherapy are outlined in footnote 'G' / inclusion criteria (section 4.2). However, central confirmation of a positive HER2 status is essential prior to enrollment to the HERA study. IHC or FISH tests must be performed locally as an initial screen. Only in exceptional cases where local lab facilities are not available permission may be granted for centers to send tumour samples directly to the central lab. A list of IHC antibodies that may be used for local testing can be found in the SPAM. If local FISH test is performed, the PathVysion test (Vysis) or the INFORM HER-2/neu test (Ventana Inc.) must be used according to the test instruction leaflet. Patients with negative local FISH tests or 0 and 1+ scores by IHC are not eligible for participation in the HERA trial. Patients with local 2+ and 3+ scores by IHC are potentially eligible: tumour samples for such patients have to be sent to the central lab for verification of HER2 status by FISH (if IHC 2+ locally) or by IHC (if IHC 3+ locally). Patients with positive FISH test at the local lab are potentially eligible: tumour samples for such patients require central laboratory confirmation of the local FISH testing result prior to study entry. If FISH confirmation of a local IHC 2+ score was also performed locally and the result is positive, central confirmation of the FISH testing result, however, is still required. Note: FISH testing cannot be done on tissue samples that have been preserved using alcohol, Bouins fixative and/or acetic-formic-acids.

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5.1.2

Confirmation of Hormone Receptor (ER/PgR) Status

Hormone (ER/PgR) receptor status will be confirmed centrally on tissue specimens of patients after they have entered the HERA study. For the confirmation of the hormone receptor status (6) UNSTAINED tumour tissue slides or a tumour block must be sent to the central lab. Epitopes of the ER/PgR receptor that are recognised by immunostaining antibodies deteriorate rapidly after sectioning tissue. Therefore, for this investigation also, a tumour block is clearly preferred. NOTE: If slides sent for central confirmation of the ER/PgR status were not prepared within a maximum of four weeks before the actual analysis takes place a new set of slides has to be prepared and shipped to the central lab. Central ER/PgR confirmation will be performed by IHC. The same scoring system for both ER and PgR testing will be used to determine ER/PgR positive tumours. Carcinomas with scores 3 will be regarded as ER and/or PgR positive. [91]

5.1.3

Prior Adjuvant Chemotherapy

Table 8 below lists the chemotherapy regimens that are acceptable prior to enrolment in the HERA trial. The choice of regimen should involve consideration not only of improvements in cancer recurrence and survival, but also of potential side-effects of cytotoxic chemotherapy. Considering the eligibility criteria of the present trial, this approach should allow investigators to select the most appropriate therapy for an individual. Patients must have received a minimum of 4 cycles of chemotherapy in order to be eligible. NOTE: Investigators wishing to enrol a patient who received a regimen not listed below MUST contact the BrEAST Data Centre to determine eligibility in the individual case. The regimen that the patient in question received will be reviewed for eligibility by medical oncology advisors at Roche and at the BrEAST Data Centre. Failure to consult the BrEAST Data Centre in such circumstances constitutes a major protocol violation.

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Table 8
Regimen class
ALL REGIMENS Anthracyclines with no taxanes

Acceptable chemotherapy regimens for participation


Regimens
Patient must have received at least four cycles of an approved (neo-) adjuvant chemotherapy regimen. In all cases, the maximum cumulative allowable dose of doxorubicin (A) is 360mg/m2 and of epirubicin (E) is 720mg/m2 Regimens in this category that are allowed for the HERA trial include the association of either A or E with cyclophosphamide (C) with or without 5-fluorouracil (F), and A or E as single agents or combined with C and followed by several cycles of CMF (where M is methotrexate). Minimum allowable starting doses of A or E associated with C with or without F: AC: 60mg/m2 CAF/FAC: 50mg/m2 (q21d or q28d) EC: 90mg/m2 75mg/m2 (day 1 q21d) if given for a minimum of 6 cycles FEC/CEF: 50mg/m2 (days 1 and 8 q28d) 75mg/m2 (day 1 q21d) 60mg/m2 (day 1 q21d) if given for a minimum of 5 cycles Minimum allowable starting doses of A or E as single agents or combined with C and followed by CMF (described below): A: 75mg/m2 E: 90mg/m2 Regimens in this category that are allowed for the HERA trial include sequential or combined anthracyclines (A or E) and taxanes (paclitaxel [P] and docetaxel [D]). A or E may be combined with C with or without F. Minimum allowable starting doses of A or E (with or without C and/or F) followed by P or D (sequential regimens): A: 60mg/m2 FAC: 50mg/m2 E: 90mg/m2 60mg/m2 (day 1 q21d) if followed by D 100mg/m2 (day 1 q21d) if given for a minimum of 5 cycles FEC: 75mg/m2 P: 175mg/m2/3-hour 75 mg/m2 (q7d) D: 100mg/m2 Minimum allowable starting doses of A and E (with or without C and/or F), and P and D given concurrently (combined regimens): A: 50mg/m2 E: 75mg/m2 P: 135mg/m2/3-hour D: 60mg/m2/1-hour Regimens in this category that are allowed for the HERA trial include C combined with methotrexate (M) and F (CMF). The minimum starting dose of C is 100mg/m2/day days 1-14 if given orally and 600mg/m2 per injection if given intravenously. The recommended starting dose per injection of M is 40mg/m2 and of F is 600mg/m2. CMF given day 1 and 8 every 28 days with oral C is the preferred schedule. Other CMF schedules are acceptable but should be used preferentially in patients who cannot tolerate oral C. Any regimen that is part of a chemotherapy trial which has been approved a priori by the HERA Executive Committee A

Anthracyclines and taxanes

Non-anthracycline regimens

Other regimens
A

An updated list of these trials can be obtained from the BrEAST Data Centre. Chemotherapy trials that are initiated while recruitment to the HERA trial is ongoing can be added to this list following approval from the Executive Committee of the chemotherapy regimens and that patients can follow the HERA treatment and follow-up schedule (Table 7). Legend: A=doxorubicin; C=cyclophosphamide; D=docetaxel; E=epirubicin; F=5-fluorouracil; M=methotrexate; P=paclitaxel; T=taxane

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5.1.4

Prior Adjuvant Radiotherapy

Radiotherapy must be completed before randomisation and before delivery of the first dose of Herceptin. Table 9 summarises the guidelines for radiotherapy requirements for HERA eligibility. All patients with pathologic dermal invasion (pT4) must have had radiotherapy that at a minimum includes the involved area, regardless of the primary surgical procedure performed. Patients who have a 'non-resectable' deep margin invasion must have had radiotherapy encompassing the region concerned. A positive surgical margin refers to the presence of invasive adenocarcinoma and/or ductal carcinoma in situ (DCIS) at any cut margin of the histologic specimen. Lobular carcinoma in-situ (LCIS) does not count as a positive margin. In order to minimise cardiac irradiation, all patients who receive Internal Mammary Node (IMN) irradiation must have the radiotherapy planned using a technique that enables minimisation of cardiac irradiation, preferably three-dimensional (3-D) conformational CAT scan. This radiotherapy field is mandatory in patients with confirmed or suspicious IMN spread (by sentinel node technique) and optional in patients with tumours judged to be at high risk of IMN spread (such as central and medial hemisphere tumours). Internal mammary node irradiation is optional (to be defined a priori by each centre) for patients with tumours considered to be at high risk of IMN spread, regardless of primary surgical procedure (mastectomy or complete local excision without mastectomy). If given, this must be 3D conformation CAT scan planning techniques. Before activating the study, each centre must define a radiotherapy policy for the extent of radiotherapy volume in patients who have had a mastectomy with 0, 1-3, and >4 involved axillary nodes (see SPAM) and all patients at that centre must be treated within the framework of this policy. If the policy should change and the requirements of the study protocol are no longer satisfied then prior approval of the new policy is necessary by the HERA Steering Committee (see SPAM).

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Table 9

Radiotherapy guidelines for HERA trial patients


RADIOTHERAPY Mandatory breast fields Optional Regional (+ axillary) fields optional Regional (+ axillary) fields recommended Mandatory to involved area at least Mandatory to involved area at least

CLINICAL SCENARIO Complete excision without mastectomy Mastectomy Any surgery with 0; 1-3 nodes positive Any surgery with >4 nodes positive Any surgery with dermal invasion (pT4) Any surgery with 'non-resectable' deep margin invasion

Confirmed or suspicion of internal mammary Mandatory internal mammary node field node involvement by sentinel node procedure Mandatory planning technique, preferably 3-D conformational CAT scan, to minimise cardiac irradiation Any surgery, tumours judged to be at high risk Optional internal mammary node field. If for internal mammary node involvement. given, radiotherapy must be planned using a technique, preferably 3-D conformational CAT scan, to minimise cardiac irradiation

5.1.5

Concomitant Hormonal Therapy

Table 10 below summarises the hormone therapy guidelines for patients enrolled in the HERA trial. The individual centre definition of hormone receptor positive and negative will be used as the basis to implement these recommendations in individual patients. Since November 2002, when early results of the ATAC trial [95] were published, anastrozole (Arimidex) started to gain approval for the treatment of postmenopausal women with hormone receptor positive, early invasive breast cancer, in an increasing number of countries.

Meanwhile data from the MA.17 and BIG 1-98 trial demonstrated that letrozole is superior to tamoxifen in terms of efficacy when given as initial treatment or as extended therapy following initial tamoxifen treatment (MA.17; [100] [101]; BIG 1-98; [102]). Also exemestane following 2-3 years of tamoxifen therapy was shown to be more efficacious than the standard 5 years of tamoxifen treatment (IES trial; [103]). Both aromatase inhibitors are meanwhile licensed in numerous countries for the adjuvant treatment of hormonereceptor positive, postmenopausal women with early breast cancer. In contrast to the proven efficacy in postmenopausal patients, the utility of aromatase inhibitors in combination with LHRH analogues in premenopausal hormone receptor positive patients is still under investigation. Therefore, anastrozole, letrozole and exemestane will be allowed as an adjuvant hormonal therapy for postmenopausal women with hormone receptor positive, early invasive breast cancer, in countries where it has been registered for this indication. Their use must be consistent with the registered label. In all other countries where anastrozole, letrozole or exemestane have not been approved, switching from tamoxifen to either of these aromatase inhibitors will only be allowed in case of documented intolerance to tamoxifen therapy.

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In the future, other hormonal therapies may be allowed as adjuvant treatments within the HERA trial, if they gain regulatory approval for that indication, and receive HERA Steering Committee approval. Before activating the study, each centre must set a policy for the use of tamoxifen (TAM), ovarian ablation (OA) or both for patients enrolled in the HERA trial. Study sites must also set their local policy for the use of anastrozole, letrozole or exemestane, if their policy changes when these aromatase inhibitors become registered for use in the adjuvant setting, in their respective country. The revised centre policy form must also be submitted to the BrEAST Data Centre. During the conduct of the study, all patients enrolled must be treated within the framework of that policy (see SPAM). If the local policy should change and the requirements of the study protocol are no longer satisfied then prior approval of the new local policy is necessary by the HERA Steering Committee (see SPAM).

Table 10

Endocrine therapy guidelines for HERA trial patients


HORMONAL THERAPY None allowed Tamoxifen recommended Anastrozole, letrozole and exemestane are alternatives in hormone receptor positive, postmenopausal patients if used consistently with the country-specific label. Other hormonal therapies that become approved for use in the adjuvant setting may be used after approval by the HERA Steering Committee.
A

CLINICAL SCENARIO Hormone receptor negative Hormone receptor positive , postmenopausalB

Hormone receptor positive, premenopausalB

Tamoxifen recommended Ovarian ablation alone or combination with TAM allowed Other hormonal therapies that become approved for use in the adjuvant setting may be used after approval by the HERA Steering Committee

A B

Hormone receptor positive is defined as positive estrogen receptor and/or progesterone receptors, according to local lab definitions. For the HERA study, menopausal status will be determined at the time of randomisation. The following definitions will apply: Clearly premenopausal status: continuing menstruation throughout chemotherapy AND no prior bilateral ovariectomy AND not on estrogen replacement. Clearly postmenopausal status: prior bilateral ovariectomy OR > 12 months since last menstrual period (LMP) with no prior hysterectomy. Uncertain status (any status not included in the above categories).

An exploratory analysis of this data will be conducted as predefined in section 8.2.1.7.

5.1.5.1

Other Hormonal Therapies

No other hormonal therapy for primary breast cancer (other than that stated in section 5.1.5 above) is allowed, including pure anti-estrogens and progestational agents. The use of any other

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hormonal therapy that becomes approved for adjuvant therapy during the conduct of the HERA trial will be discussed with the HERA Steering Committee.

5.1.6

Cardiac Function Screening

All patients must have an LVEF measurement of at least 55% by (preferably) echocardiography or MUGA scan a maximum of 7 days prior to randomisation and after completion of all chemotherapy and radiotherapy, the latter if given. Investigators must be aware of local institution regulations regarding the maximum allowable frequency of repeat MUGA scans. The repeated administration of radioisotopes is limited in some nuclear medicine laboratories and some patients in this study could require monitoring on four or more occasions within one year. Patients must have a cardiac history, physical exam, and a baseline ECG prior to enrollment to exclude any cardiac condition that would render them not eligible for participation in the HERA trial, as outlined in the Eligibility Criteria, Sections 4.2 and 4.3.

5.1.7

Other Eligibility Screening

All other investigations (e.g., chest X-ray, CAT-scan, etc.) which were performed as part of standard patient care prior to primary surgery/start of adjuvant chemotherapy or within the appropriate screening window prior to randomisation, and prior to signing the definitive Informed Consent form for the study, may be used to fulfil inclusion/exclusion criteria as outlined in Table 7 (Schedule of Assessments).

5.2
5.2.1 5.2.1.1

Study Assessments
Clinical Assessments Efficacy

Routine follow-up after primary breast cancer has two main goals: the first is screening for new primary or locally recurrent cancers that may be cured by early intervention. The second goal is to diagnose metastatic breast cancer. History taking and physical examination disclose 50% to 90% of recurrences, so regular office / clinic visits, usually approximately every 3 months for the first 2 years, every 3-6 months for years 3-5 and every 6-12 months beyond five years after the end of primary therapy, are advised to facilitate these activities. [72,73,74,75,76] The schedule of follow-up visits and tests for the HERA trial is the minimum required; investigators may wish to see their patients more frequently according to routine practice. Plain films (CAT scan in the case of vertebral column abnormalities) are required to exclude metastatic disease if a bone scan is positive. All patients will be followed according to the schedule outlined in Table 7, irrespective of the arm they were randomised to. They must be seen for examinations approximately at weeks 13, 25, 37, 52, 64, 79, 91, 103 (treatment period), at week 56 and 107 (safety follow-up visits after completion/discontinuation of treatment period) and every six months thereafter up to year 5 post randomisation, then yearly up to year 10 (follow-up visits).

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In addition to the visits above (see also Table 7), all patients irrespective of treatment allocation will be followed for survival once a year after completion or discontinuation of the study treatment period (one year or two years for patients in the two Herceptin arms or one year for patients in the observation arm) for any reason (e.g., disease recurrence, toxicity, experiencing a cardiac endpoint leading to discontinuation of study drug etc.) unless the patient withdraws consent to participation in the study. Survival information will be collected until 10 years after original randomisation of the last patient into the study. Safety follow-up visits: Safety follow-up visits should be performed for all patients irrespective of treatment allocation within 4 weeks following completion of the treatment periods (see above), at weeks 56 and 107. Patients who discontinue observation or Herceptin treatment within less than one year from randomisation (observation patients) or first Herceptin infusion for any reason (except withdrawal of study consent and disease recurrence) should complete the first safety follow-up visit (week 56) within 4 weeks from discontinuation (observation patients) or the last Herceptin administration. The second safety follow-up visit will be performed at week 107. All patients irrespective of treatment allocation who develop disease recurrence within one year from randomisation/first Herceptin infusion should only complete the first safety follow-up visit (week 56) and then be followed for survival yearly as described above. Patients who discontinue observation or Herceptin treatment after one year but before two years from randomisation (observation patients) or first Herceptin infusion for any reason (except withdrawal of study consent and disease recurrence) should have already completed the first safety follow-up visit at week 56. Such patients should complete the second safety follow-up visit (week 107) within 4 weeks from discontinuation (observation patients) or the last Herceptin administration. The same schedule of safety follow-up assessments applies to all patients irrespective of treatment allocation who develop disease recurrence between years 1 and 2 from randomisation/first Herceptin infusion. Such patients will then be followed for survival yearly as described above. For patients who withdraw study consent, a final treatment period/follow-up/safety followup/survival follow-up visit should be performed, if possible (see section 7.4). Disease recurrence: In case of appearance of solitary lesions suspicious for metastatic disease, or if there is diagnostic doubt about the presence of metastatic lesions, histologic or cytological proof is strongly advised. In case of a solitary bone lesion, a radiological examination should be repeated in three months and in case of progressive lytic-destructive changes on imaging, histologic or cytologic proof is not required. The presence of multiple pulmonary nodules on chest X-ray, multiple liver nodules on liver ultrasound or CAT scan, and/or multiple lytic or blastic bone lesions will be accepted without pathologic correlation. Positive bone scans must be correlated with bone X-ray or CAT scan (in the case of vertebral hot spots suspicious for metastases, a CAT scan is mandatory). In case of negative X-ray or CAT scan (no tumour evidence), the bone scan should be repeated regularly, until evidence of progression.

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The following conditions do not constitute objective proof of recurrence in themselves, but should prompt a work-up to rule out an objective local, regional, and distant recurrence, as defined below (Section 5.2.1.2): a rise in CA 15-3 and/or CEA a significant decline in ECOG performance status that is not reasonably explained by concomitant illness.

As described above, patients with disease recurrence should not be followed according to the schedule outlined in Table 7. They should be followed for survival once a year following disease recurrence. In addition, patients irrespective of treatment allocation who develop disease recurrence within 2 years from randomisation/first Herceptin infusion should also complete one or both safety follow-up visits as described above.

5.2.1.2

Definitions of Outcome Measures

The primary endpoint in the present trial is Disease-Free Survival (DFS). DFS is defined as the time from randomisation until the first event. An event is defined as any loco-regional or distant recurrence of breast cancer, the development of secondary primary cancer other than basal or squamous carcinoma of the skin and carcinoma in situ of the cervix, or death from any cause without documentation of one of these events. LCIS is not considered an event. Diagnosis of a second primary cancer must be confirmed histologically whenever possible. The diagnosis of a first breast cancer recurrence can be made only when both clinical and laboratory findings meet the criteria for loco-regional or distant recurrence defined below. Secondary endpoints include Overall Survival (OS), Recurrence Free Survival (RFS), Distant Disease-Free Survival (DDFS), Time to Recurrence (TTR) and Time to Distant Recurrence (TTDR). Overall Survival is defined from time of randomisation to death due to any cause. Recurrence Free Survival (RFS) is defined as the time from randomisation to the first local, regional and/or distant tumour recurrence. Second primary cancers, contralateral breast cancer, and deaths without evidence of disease are treated as censoring events. (RFS is included in this protocol because it may be a more biologically relevant endpoint than DFS for assessing the efficacy of Herceptin). Distant Disease-free survival (DDFS) is defined as the time between randomisation and the date of the first distant tumour recurrence, second primary cancer, or contralateral breast cancer, whichever occurs first. Local and regional recurrences are ignored for calculating DDFS. Deaths without evidence of disease are treated as censoring events. Time to Recurrence (TTR) is defined as the time between randomisation and the date of the first local, regional, or distant tumour recurrence. Contralateral breast cancer and second non breast

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malignancy are ignored for calculating TTR. Deaths prior to breast cancer recurrence are treated as censoring events. Time to distant recurrence (TTDR) is defined as the time between randomisation and the date of the first distant tumour recurrence. Local and regional recurrences and contralateral breast cancer and second non breast malignancy are ignored for calculating TTDR. Deaths prior to distant breast cancer recurrence are treated as censoring events. Detailed guidance on procedures how to determine relapse of disease is provided in Section [5.3] Histological or cytological proof of a recurrence is always preferred. Local or regional recurrences can be either operable or inoperable, and this information should be recorded on the CRF.

5.2.2

Cardiac Safety Assessment

A higher frequency of cardiac dysfunction was seen in patients who received Herceptin in combination with anthracyclines in the chemotherapy plus Herceptin study in the metastatic setting. The occurrence of symptomatic and/or asymptomatic cardiac dysfunction among patients participating in the HERA study, especially if pre-treated with anthracycline-containing chemotherapy, cannot be excluded. Patients with underlying risk factors including advanced age, hypertension, pre-existing heart disease (which did not require exclusion of the patient at the time of screening), internal mammary node radiation, and high cumulative anthracyclines doses, may be more susceptible to cardiac events. Hence, cardiac safety will be monitored in all patients throughout the trial. In order to minimise cardiac risk, mediastinal internal mammary node irradiation must be planned using three-dimensional conformational CAT scanning or a similar technique to minimise cardiac irradiation. ECG: Standard 12 lead electrocardiogram will be performed at screening and as displayed in Table 7.

5.2.2.1

Echocardiography or MUGA scans /Left Ventricular ejection Fraction (LVEF):

Prior to randomisation, patients must have an acceptable LVEF (55%) as assessed by echocardiogram and/or MUGA scan, and the follow-up LVEF assessments must be performed by the same method. Subsequent scheduled echocardiograms or MUGA scans must be performed before the next scheduled dose of Herceptin as outlined in the schedule of assessments (Table 7). In addition, any patient who develops clinical signs or symptoms suspicious of cardiac failure should undergo an LVEF assessment. Full details of the monitoring schedule, cardiac endpoints, and rationale can be found in Section 2.3 and Table 7. Patients who experience symptomatic cardiac events or confirmed and persistent drops in LVEF, whether or not symptomatic, must discontinue Herceptin treatment as outlined

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in Section 7.3.2 and 7.4.1. and Figure 4. The frequency of cardiac monitoring is increased for such patients (see Section 7.4.1) Echocardiography: Echocardiography will be performed by or under the supervision of an experienced cardiologist, preferably at the same high-volume echo-laboratory for the duration of the study. It is strongly recommended that all echocardiograms for an individual patient be performed by the same laboratory and operator. When using echocardiography, an adequate acoustic window is a pre-requisite for the use of this LVEF assessment technique in a given patient. The guidelines of the American Society of Echocardiography will be used.[86,87] For details of echocardiography methods refer to the SPAM. Among the first 900 patients enrolled, those with echocardiogram monitoring of LVEF function must have all echocardiograms recorded on videotape. All videotapes recorded in these 900 patients at baseline and during the first 6 months on study [i.e., in week 13 and week 25 (as depicted in Table 7)] and any unscheduled LVEF assessments performed up to week 25 (to confirm observed LVEF drops, or in patients with signs and symptoms of cardiac dysfunction), must be forwarded to the Core Lab (Cardio Analytics Ltd.) for independent review within 4 weeks of the examination. Tapes will be used for review of echocardiography procedures and assessments by the Core Lab as a quality control measure. After week 25, should a video recording of the echocardiogram be requested for central review, the investigator will be informed accordingly, prior to the assessment. Details for shipment the videotapes are provided in the SPAM. Tracking of timely video tape shipment will be done by the on-site monitors and the Core Lab as outlined in the SPAM as well. MUGA scans: If the LVEF is monitored with MUGA scans, investigators are strongly urged to schedule the MUGA scans at the same radiology facility where the patients baseline MUGA scan was done, whenever possible. Among the first 900 patients enrolled, for those with MUGA scan monitoring, all radiology reports [i.e., at baseline, week 13 and week 25 (as depicted in Table 7)], including any unscheduled LVEF assessments (to confirm observed LVEF drops, or signs and symptoms of cardiac dysfunction), must be forwarded for review within 4 weeks of the examination as described in the SPAM. Thereafter, a review of MUGA scan reports will be continued on a random basis, and these reports must be provided upon request.

5.2.2.2

Independent Review of Cardiac Function

A close monitoring of cardiac function in the first 900 patients enrolled into this trial is planned. The involvement of a Core Lab for the maintenance of high quality standards was proven to be useful in other clinical trials. [90] In order to accomplish a high quality of echocardiographic monitoring of cardiac function across all study sites an independent review of echocardiography video tapes will be performed by a Core Lab. The Core Lab comprises cardiologists and technicians of a Contract Research Organisation (CRO, Cardio Analytics) and will be blinded to treatment assignment. The primary responsibility of the Core Lab is to review the quality of echocardiography videotapes obtained at baseline, after 3 months and 6 months after start of Herceptin treatment or observation.

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The Core Lab will review echocardiograms on an ongoing basis for quality assurance and protocol adherence. Cardiac endpoints will be reviewed and adjudicated by the Core Lab before results/data are forwarded to the IDMC by the BrEAST Data Centre. Measures will be taken to improve testing/assessment procedures and ensure protocol compliance with the cardiac monitoring procedures. As a general rule, results of the review of cardiac monitoring video tapes will override echocardiography measurements done at the study site because reviewers are blinded to the actual treatment a patient has received. While enrollment and individual patient management will be based entirely on echocardiographic examinations done by or under the supervision of cardiologists locally, cardiac reviewers at the Core Lab will consult cardiologists at local study sites in case of discrepancies and try to clarify inconsistencies as well as take measures to improve quality of subsequent assessments. After the first 900 patients, random checks will be performed and centres must provide echocardiogram videos and MUGA scan reports upon request (MUGA scan reports not to be shipped to the Core Lab, but must be forwarded for review within 4 weeks of the examination as described in the SPAM).

5.2.3

Laboratory Assessments

Blood samples will be taken for haematological and serum biochemical monitoring. These analyses will be performed by the local lab. Table 7 outlines the schedule of laboratory assessments required throughout the study. Haematology: Haemoglobin, Platelet count, WBC count, neutrophil count Biochemistry: Sodium, Potassium, Blood Urea Nitrogen, Creatinine, Alkaline Phosphatase, AST (SGOT) or ALT (SGPT), total Bilirubin. Serum shed antigen. In addition, blood samples will be obtained at regular intervals for subsequent determination of serum shed HER2 antigen (ECD; for details see 5.5).

5.2.4

Safety

Patients will be assessed by prior medical history, prior treatments for cancer (i.e., adjuvant chemotherapy and radiotherapy, prior start of hormonal therapy, if applicable), vital signs (including blood pressure, pulse rate, temperature, and weight), ECOG performance status, physical examination, and concomitant medications. The physical examination must include a careful examination of the cardiovascular system. Prior to each Herceptin administration and at each follow-up visit during the treatment and observation period, patients should be assessed for safety and adverse events. The investigator should ask the patient about adverse events experienced in the interval between doses. For details about adverse event reporting, please refer to sections 7.1.1 and 7.1.2 of the protocol and to the SPAM.

5.3

Relapse of Disease Procedures

The diagnosis of a first breast cancer relapse or second primary cancer can be made only when clinical, radiological and laboratory findings meet specific acceptable criteria as defined below.

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Suspicious findings do usually not constitute criteria for breast cancer recurrence, nor are they an indication to alter protocol therapy. Under certain circumstances, however, suspicious findings that remain suspicious may be clinically so relevant that they lead to the indication for a change in the therapy. In cases of diagnostic doubt (e.g. ill-defined, palpable mass in an irradiated breast), histological or cytological confirmation of recurrence should be obtained whenever possible. Some patients may develop a suspicious recurrence that leads to death quite quickly without having the possibility to confirm relapse of disease. Efforts should be made to obtain an autopsy report in such patients. The earliest date of diagnosis of recurrent disease should be used and recorded. This could be based on clinical, radiological, histological or cytological evidence. The relapse of disease has to be backdated to the date of the first diagnosis of lesion (i.e., an objective finding), not to the date of occurrence of the first symptom. For example, a patient presenting with abdominal pain is found to have a possible lesion on liver CT scan of uncertain significance. If a subsequent CT scan confirms disease progression, the date of the first diagnostic CT scan should be taken as the date of recurrence (not the date of presentation with abdominal pain). Thus, the actual date of relapse of disease is the time of first appearance of a suspicious lesion (in a radiological procedure in this case), later proven to be a definitive recurrence or metastasis. Recurrent disease includes: local, regional, distant recurrence, contralateral breast, and second (non-breast) malignancy. NOTE: Types of recurrent disease are listed below, along with acceptable methods of confirmation of recurrence. a) Local recurrence In the ipsilateral breast after lumpectomy: Defined as evidence of tumour (except LCIS) in the ipsilateral breast after lumpectomy. Patients who develop clinical evidence of tumour recurrence in the remainder of the ipsilateral breast should have a biopsy of the suspicious lesion to confirm the diagnosis. Acceptable: positive histology or cytology Local recurrence (other than ipsilateral breast after lumpectomy):

Defined as evidence of tumour in any soft tissue or skin of the ipsilateral chest wall after mastectomy. This includes the area bounded by the midline of the sternum, extending superiorly to the clavicle, and inferiorly to the costal margin. Soft tissue recurrences in this area extending into the bony chest wall or across the midline will be considered as evidence of local recurrence. Acceptable: positive histology or cytology: Treatment after local recurrence for patients who received breast-conserving surgery:

Under rare circumstances the investigator may decide to re-initiate treatment with Herceptin in individual patients after operable local relapse in the ipsilateral conserved breast. Details of such treatment (e.g. Herceptin, surgery) must be recorded on the post-study treatment page in the CRF.

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Initiation, re-initiation or discontinuation of treatment with Herceptin, will be at the discretion of the investigator. Note: Herceptin for such therapy will not be provided as part of the HERA protocol but may be given to the patient outside of this clinical study. Patients who develop a local other than an operable relapse in the ipsilateral conserved breast should be treated according to the decision of the investigator and the patient. b) Regional recurrence Defined as the development of tumour in the ipsilateral internal mammary and/or ipsilateral axillary lymph nodes, as well as extranodal soft tissue of the ipsilateral axilla. Regional recurrence does not include supraclavicular lymph nodes or tumour in the opposite breast. Acceptable: Positive histology or cytology, or Chest-x-ray, CT-scan or MRI (especially in case of internal mammary lymph nodes if no biopsy was performed) c) Distant recurrence Defined as evidence of tumour in all areas, with the exception of those described in Sections a) and b) above The following criteria apply: Skin, subcutaneous tissue, and lymph nodes (other than local or regional) NOTE: ipsilateral supraclavicular lymph nodes count as distant metastases! Acceptable: positive cytology, aspirate or biopsy, or radiological (by CT scan or MRI or ultrasound) evidence of metastatic disease. Bone

Acceptable: X-ray, CT scan, or MRI evidence of lytic or blastic lesions consistent with bone metastasis, or Bone scan (requires additional radiological investigation, alone not acceptable in case of diagnostic doubt), or Biopsy proof of bone metastases or cytology Bone marrow positive cytology or histology or MRI scan

Acceptable:

Lung

Acceptable:

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Radiologic evidence of multiple pulmonary nodules consistent with pulmonary metastases Positive cytology or histology (practically rarely performed with the exception of solitary nodules

NOTE: For solitary lung lesions, cytological or histological confirmation should be obtained in case of diagnostic doubt. Proof of neoplastic pleural effusions should be established by cytology or pleural biopsy. Liver Abdominal CT scan, liver scan, ultrasound, or MRI consistent with liver metastases, or Liver biopsy or fine needle aspiration.

Acceptable:

NOTE: If radiological findings are not definitive (especially with solitary liver nodules) a liver biopsy is recommended.; however, if a biopsy is not performed, serial scans should be obtained if possible to document stability or progression. Central nervous system Positive MRI or CT scan, usually in a patient with neurologic symptoms, or Biopsy or cytology (e.g., for a diagnosis of meningeal involvement). However, meningeal involvement may also be diagnosed by CT scan or MRI and depending from the general status of the patient additional investigations (including cytology of the cerebrospinal fluid).

Acceptable:

d) Contralateral invasive breast cancer Acceptable:

positive cytology or histology

e) Second primary malignancy (breast or other cancer) Any positive diagnosis of a second primary cancer other than basal or squamous cell carcinoma of the skin, or carcinoma in situ of the cervix will be considered an event in the analysis of DFS. Lobular carcinoma in situ of the breast (LCIS) is not considered an event. The diagnosis of a second primary cancer must be confirmed histologically. NOTE: Patients diagnosed with a second primary malignancy but with no evidence of breast cancer recurrence will remain on study wherever possible if considered by the investigator to be in the patients best interest. They. should continue according to the protocol and schedule of assessment, f) Death without recurrence Any death related to causes other than breast cancer or second (non-breast) primary is considered an event. g) Other noteworthy events The following events should be recorded on the follow-up CRF. These events are NOT considered recurrent disease, but must be recorded.

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Ipsilateral and contralateral Lobular carcinoma in situ (LCIS) Carcinoma in situ of the cervix

Basal or squamous cell carcinoma of the skin Please note: Following recurrence, all patients should be followed for survival as described in section 5.2.1.1. In addition, safety follow-up visit(s) should be performed. Please refer to section 5.2.1.1 for further details.

5.4

Pharmacokinetic Assessments

PK assessments of Herceptin serum levels will be made on a small subset of patients only. Testing and evaluating PK samples is described in a separate protocol and a corresponding separate consent procedure, since this investigation will be conducted in about 2% of the planned total study population.

5.5

Pharmacodynamic Assessments

Shed Extracellular Domain (ECD):


Published data suggest that serum ECD (in the metastatic setting) is not a predictor for response to either hormonal therapy or chemotherapy including anthracyclines, but it is a prognostic factor in breast carcinoma. If elevated at baseline, serum ECD may be a useful tool in monitoring early and overall response to therapy with Herceptin. Likewise, rising ECD levels may be an early indicator for disease recurrence or progression. This biologic investigation will be completed to address each of the following aims: To determine whether serum levels of shed ECD measured at different time points constitute a prognostic and/or predictive factor for disease free survival and/or survival, and To determine whether serum levels of shed ECD are increased at the time of relapse relative to their pre-treatment levels.

Serum for the measurement of shed ECD will be collected at the times specified in the schedule of assessments in approximately the first 900 patients recruited into the HERA trial, for the first five years of follow-up until disease relapse, withdrawn consent or death whichever comes first, and at time of relapse. Samples will be assayed at a central laboratory at the end of the study (see SPAM).

Cardiac Marker Sub-Protocol:


The potential predictive value of N-Terminal Pro-Brain Natriuretic Peptide (NT-proBNP) and/or other cardiac markers for the early detection of asymptomatic cardiac dysfunction, onset of congestive heart failure and the potential value for general cardiac monitoring will be explored in a subset of patients based on a separate sub-study protocol and a corresponding separate consent procedure.

5.6

Quality of Life Assessments

There are no planned QoL assessments.

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6.
6.1

INVESTIGATIONAL PRODUCT
Dose and Schedule of Herceptin

Patients are randomised following the completion of adjuvant systemic chemotherapy and radiotherapy to either Herceptin for 1 year, for 2 years, or to no Herceptin. Concomitant hormone therapy is allowed as per standard of care (Section 5.1.5 and Table 10). Herceptin will be administered in an outpatient setting at the schedule prescribed in the protocol. The starting dose of Herceptin will be 8mg/kg. The second and all subsequent maintenance doses will be 6mg/kg. Herceptin will be administered over a 90-minute-period for all doses. It should not be administered as an i.v. push or bolus. Patients should be observed for at least six hours after the start of the first dose of Herceptin (i.e., 4 hours from the end of the infusion). If no adverse events occur with the first infusion, the observation period for the second infusion may be shortened to 2 hours after the start of the infusion (i.e., hour from the end of the infusion). On very rare occasions, patients have experienced the onset of infusion symptoms or pulmonary symptoms more than six hours after the start of the Herceptin infusion. Patients should be warned of the possibility of such a late onset and should be instructed to contact their physician if these symptoms occur.

6.1.1

Modification of the Amount of Herceptin Administered due to Changes in Patients Weight

The amount of Herceptin administered is calculated according to the patients actual body weight, with no upper or lower limit. The amount to be administered must be re-calculated if a patients body weight has changed by > 10% (increased or decreased) from the last calculation. Weight should be recorded at baseline and at every scheduled visit for all patients irrespective of their treatment allocation. In addition, weight should also be recorded at any time a change in weight results in a change in Herceptin total dose.

6.2

Preparation and Administration of Herceptin

Details on formulation, drug preparation, dosage and administration are described in the SPAM.

6.3

Blinding and Randomisation

This is an open-label, randomised, three arm study. Thus, neither patients nor treating physicians will be blinded to the therapy assigned and given. Details of the randomisation procedure, stratification and the minimisation procedure applied are outlined in Sections 3.2, Table 6, and the SPAM.

6.4

Drug Labeling and Packaging

Details of packaging and labeling are described in the SPAM.

6.5

Compliance

Accountability and patient compliance will be assessed by maintaining adequate drug dispensing and return records (see SPAM).

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7.
7.1
7.1.1

SAFETY ISSUES
Adverse Events and Laboratory Abnormalities
Clinical Adverse Events

An Adverse Event (AE) is any untoward medical occurrence in a patient or clinical investigation subject to whom a pharmaceutical product has been administered, and which does not necessarily have to have a causal relationship with this treatment. An Adverse Event can therefore be any unfavourable and unintended sign (including an abnormal laboratory finding, for example), symptom, or disease temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product. Pre-existing conditions, which worsen during the study, are to be reported as Adverse Events.

All AEs should be reported in all patients for the first 2 years + 28 days post enrolment irrespective of the treatment allocation. The time span of 2 years was chosen to avoid imbalances in reporting adverse events among the three study arms and to cover all 3 arms equally. The 2 year + 28 days reporting rule does not apply to patients who discontinue the prescribed study treatment (Herceptin for 1 year or 2 years or observation for 1 year) prematurely, for example due to relapse of disease or withdrawal. For such patients, all AEs must be reported until 28 days after the last administration of Herceptin (for patients originally randomised into the Herceptin arms) or the date of relapse/withdrawal (for patients randomised to the observation arm). For observation patients who received Herceptin as per protocol amendment E the reporting period for all adverse events begins with the start of treatment and ends 28 days after the last administration of study drug. Cardiac or cardiovascular events, second primary malignancies, pregnancies and events considered related to study drug should be reported as AE throughout the course of the study up to study year 10. With respect to the assessment of relatedness investigators should bear in mind that washout of Herceptin is only complete 24 weeks after stopping Herceptin treatment due to the half life of Herceptin of 28.5 days. Deaths not due to progression of disease should be reported until 10 years of the last patient enrolled into the study. (For reporting of pregnancies and deaths, please see section 7.2.2 and 7.2.5. For reporting of Serious Adverse Events (SAEs), please see section 7.2.1.) Information on second primary malignancies, pregnancies and deaths not due to progression of disease, which were not recorded due to reporting specifications of previous protocol versions will be retrospectively collected.
All clinical adverse events encountered during the clinical study will be reported on the AE page in the CRF. The intensity of adverse events will be graded according to section 7.1.3 (i.e., NCICTC criteria, NYHA classification) and reported in detail as indicated in the CRF. A detailed description of the severity scales can be found in the SPAM.

7.1.1.1

Cardiac Endpoints

Based on the definitions of primary and secondary cardiac endpoints in section 2.3.1 the following reporting and grading requirements will apply to cardiac endpoints:

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Primary cardiac endpoints have to be recorded as SAEs on the AE pages and graded according to the New York Heart Association (NYHA) Classification System (see SPAM for further details). Symptomatic cardiac failure of NYHA class III or IV should be reported as a syndrome with the NYHA class. In addition, an SAE form for patients in the Herceptin arms and the AE page for patients in the observation arm should be submitted to Roche. The Cardiac Event page in the CRF must also be completed for every patient experiencing a primary cardiac endpoint. Please note, that information about primary cardiac endpoints occurring after start of a new anticancer therapy should be collected, wherever possible (see section 2.3.1). Secondary cardiac endpoints: Confirmed 'significant' and asymptomatic drops in LVEF (NYHA class I) have to be reported on the AE pages in the CRF and should be graded for intensity according to the New York Heart Association (NYHA) Classification System (see SPAM). In addition, the 'Cardiac Event' page in the CRF has to be completed. Confirmed 'significant' drops in LVEF that are mildly symptomatic (NYHA class II) have to be reported and graded according to the New York Heart Association (NYHA) Classification System (see SPAM for further details) on the AE and the 'Cardiac Event' pages in the CRF.

A significant LVEF drop is defined as an absolute decrease of at least 10 EF points below the baseline measurement and to below 50%.
Any secondary cardiac endpoint determined by the CAB must be retrospectively recorded on an AE page in the CRF. In addition the 'Cardiac Event' page in the CRF has to be completed. If a secondary cardiac endpoint fulfils any of the criteria for seriousness listed in section 7.2.1 (e.g. hospitalisation), it must also be reported as an SAE on an SAE form for patients in the Herceptin arms and on the AE page for patients in the observation arm. Symptomatic declines in LVEF that do not meet the criteria for a secondary cardiac endpoint (e.g. a decline of <10 EF points from baseline and to <50%, or a decline of 10 EF points and to 50% or above) are not expected to be common. These events should be reported as AEs or SAEs, if applicable, as described above. Asymptomatic declines in LVEF that do not meet the criteria for significant, do not qualify as a secondary cardiac endpoint and will not be reported as AEs or on the Cardiac Event page in the CRF. Other cardiac/cardiovascular events (e.g. acute coronary syndrome, acute myocardial infarction, or severe rhythm disturbances requiring treatment) will not qualify as primary or secondary cardiac endpoints, and have to be reported as AEs or SAEs as specified in sections 7.1.1 and 7.2.1 of the protocol and in the SPAM.

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7.1.2

Causality of Adverse Events

The relationship of an adverse event to the treatment should be assessed by the investigator as either YES or NO. If there is a reasonable suspected causal relationship to the study medication, i.e. there are facts (evidence) or arguments to suggest a causal relationship (remote, possibly, probably related), causality should be assessed as YES.

7.1.3

Grading of Adverse Events

The COMMON TOXICITY CRITERIA (NCI-CTC) Version 2.0 will be used for grading of adverse events except for symptomatic cardiac failure (NYHA class II/III/IV), in which case the New York Heart Association (NYHA) Classification System should be used. Asymptomatic LVEF drops identified as secondary cardiac endpoints will also be graded according to NYHA classification criteria. NCI-CTC grades 1, 2, 3, and 4 refer to NYHA classes I, II, III, and IV, respectively. A description of these criteria can be found in the SPAM. For adverse events for which the CTC does not provide a grading scale, the severity will be graded according to the following four-point scale (mild, moderate, severe, life threatening) and reported in detail as indicated in the CRF: Mild Moderate Severe discomfort noticed but no disruption of normal daily activity. discomfort sufficient to reduce or affect daily activity. inability to work or perform normal daily activity

Life-Threatening represents an immediate threat to life.

7.1.4

Laboratory Test Abnormalities

Laboratory test results will be recorded on the laboratory results pages of the Case Report Form, or appear on electronically produced laboratory reports submitted directly from the central laboratory, if applicable. Laboratory test value abnormalities as such should not be reported as adverse events on the AE CRF page unless they result in a clinically relevant condition or are NCI-CTC grade 3 and more.

7.2
7.2.1

Handling of Safety Parameters


Serious Adverse Events (Immediately Reportable to Roche)

All SAEs have to be reported to Roche based on the requirements summarized by the Roche Standard Operating Procedures for Serious Adverse Events. A Serious adverse event (SAE) or Serious Adverse Drug Reaction (SADR) is any untoward medical occurrence that at any dose

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Results in death; is life-threatening (i.e. the patient was at immediate risk of death at the time the reaction was observed); requires new hospitalisation or prolongation of hospitalisation; results in persistent or significant disability/incapacity; is a congenital anomaly/birth defect; is medically important (i.e. important adverse reactions that are not immediately life threatening or do not result in death or hospitalisation but may jeopardise the patient or may require intervention to prevent one of the other outcomes listed above), including symptomatic congestive heart failure.

The term life-threatening refers to an event in which the patient was at an immediate risk of death at the time of the event; it does not refer to an event which could hypothetically have caused death had it become more severe. Medical and scientific judgement should be exercised in deciding whether expedited reporting to the sponsor is appropriate in other situations, such as important medical events that may not be immediately life-threatening or result in death or hospitalisation but may jeopardise the patient or may require intervention to prevent one of the outcomes listed in the definitions above. These situations should also usually be considered serious. Examples of such events are intensive treatment in an emergency room or at home for allergic bronchospasm; blood dyscrasias or convulsions that do not result in hospitalisation; or development of drug dependency or drug abuse. The term severe is a measure of intensity, thus a severe adverse event is not necessarily serious. For example, nausea of several hours duration may be rated as severe, but may not be clinically serious. For serious adverse events, the following details must be assessed and recorded on the adverse event pages of the Case Report Form: intensity; relationship to test substance, action taken, and outcome of the event. The following timeframes for SAE reporting are applicable: when the patient signed the Informed Consent until first study drug administration (for patients originally randomised to Herceptin) or date of randomisation (for observation patients), only SAEs that are caused by trial related procedures must be reported. Between first study drug administration (for patients originally randomised to Herceptin) or date of randomisation (for observation patients) until 2 years + 28 days all SAEs irrespective of type and causal relationship have to be reported. The 2 year + 28 days reporting rule does not apply to patients who discontinue the prescribed study treatment (Herceptin for 1 year or 2 years or observation for 1year) prematurely, for example due to relapse of disease or withdrawal. For such patients, all SAEs must be reported until 28 days after the last administration of Herceptin (for patients originally randomised into the Herceptin arms) or the date of relapse/withdrawal (for patients randomised to the observation arm).

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For observation patients who received Herceptin as per protocol amendment E the reporting period for SAEs, irrespective of type, begins with the start of treatment and ends 28 days after the last administration of study drug. All cardiac or cardiovascular events and events considered related to study drug, that are serious should be reported as SAE up to study year 10. With respect to the assessment of relatedness investigators should bear in mind that washout of Herceptin is only complete 24 weeks after stopping Herceptin treatment due to the half life of Herceptin of 28.5 days. All second primary malignancies and pregnancies need to be reported as SAEs up to study year 10. Deaths not due to progression of disease should be reported as SAE up to 10 years of last patient enrolled. (For reporting of deaths please also see section 7.2.2).
As stated in section 2.3.1 primary cardiac endpoints (symptomatic CHF and cardiac death) will be reported as serious adverse events (SAEs). The investigator must notify their Ethics Review Committee/Institutional Review Board of such events occurring in the Herceptin treated patients in writing as soon as is practical and in accordance with international and local laws and regulations. Details of the SAE reporting process and the SAE flow are described in the SPAM.

7.2.2

Death

Apart from death due to progression of disease, any death occurring during the study, whether considered treatment-related or not, should be reported as adverse event in the CRF and reported as SAE. Also, any death occuring in survival follow-up, which is not due to progression of disease should be recorded in the CRF and reported as SAE. Any death not due to progression of disease which was not yet recorded in the CRF due to reporting specifications of previous protocol versions will be retrospectively collected.
However, it should be noted that death is considered an outcome, not an event. Therefore, a death related to study drug should have the contributing event reported as an SAE. Deaths related to progression of the underlying disease during the course of the study will not be reported as an SAE, but should be reported on the appropriate CRF page (unless the patient has withdrawn consent).

7.2.3

Treatment and Follow-up of Adverse Events

Adverse events, especially those considered related to study drug, should be followed up until they have returned to baseline status or stabilised. If a clear explanation for the event is established it should be recorded in the CRF. It is a special follow-up requirement of this study to report cardiac or cardiovascular events occurring after completion of the treatment or observation phase (2 years) and beyond the common 28 days safety follow-up. All cardiac and cardiovascular events should be reported until 10 years after randomisation.

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Cardiologists who conduct the ejection fraction measurements and investigators who perform all other regular cardiac assessments will be provided with specific CRF pages where the results of all cardiac examinations will be recorded. The investigator needs also to determine if the criteria of a primary cardiac endpoint (see 2.3.1; symptomatic CHF or cardiac death) are fulfilled. If a patient has been treated with any kind of potentially cardiotoxic chemo- or other therapy due to disease recurrence, this information will also be entered onto a specific CRF page and be collected until year 10 after randomisation if possible.

7.2.4

Follow-up of Abnormal Laboratory Test Values

In the event of unexplained abnormal laboratory test values, the tests should be repeated immediately and followed up until they have returned to the normal range and/or an adequate explanation for the abnormality is found. If a clear explanation or cause is established, this should be recorded in the CRF.

7.2.5

Pregnancy

All patients should be recommended to avoid pregnancy for 2.5 years after completion of all adjuvant radio- and/or chemotherapy and randomisation into the HERA trial. This will also include patients randomised into the observation arm of HERA. Women who may get pregnant must have a negative pregnancy test (blood or urine -HCG) test within 7 days prior to randomisation. The pregnancy test must be repeated in patients randomised into one of the Herceptin treatment arms if: a negative pregnancy test was obtained prior to randomisation but the time window between this first test and the start of Herceptin treatment is > 7days, and/or a patient has missed any periods or if the menstrual cycle becomes very irregular whilst on Herceptin during the trial.

Examples of adequate contraceptive measures are intra-uterine device, barrier method (condoms, diaphragm), also in conjunction with spermicidal jelly, or total abstinence. Oral, injectable, or implant hormonal contraceptives are not indicated in this patient population! If a patient gets pregnant while in this study, she must inform the investigator immediately. Because of the possible risks to the unborn child, the study drug will be stopped permanently in patients receiving Herceptin treatment [7.2.1]. If a suspected pregnancy is confirmed as a non-pregnancy, the patient may resume therapy with Herceptin. Pregnancies must be reported as SAE in all patients until study year 10. The investigator should counsel the patient about the unknown risks to the fetus associated with the use of Herceptin during embryogenesis and fetal development [7.5.4]. Monitoring of the patient should continue until conclusion of the pregnancy and the patient should maintain the same follow-up schedule prescribed in the HERA trial.

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7.2.6

Project Specific Adverse Events

Recurrence of Disease Recurrence of neoplasia should not be reported as an adverse event or serious adverse event. Findings that are clearly consistent with the expected progression of the underlying cancer should not be reported as an adverse event. However, if there is any uncertainty about a finding being due solely to progression of neoplasia, the finding should be reported as an adverse event or serious adverse event as appropriate. Cardiac Dysfunction LVEF data is collected in the CRFs. Asymptomatic declines in LVEF of less than 10 EF points and asymptomatic declines that remain above 50%, should not be reported as Adverse Events. Symptomatic cardiac failure should be reported as a syndrome and not the individual signs and symptoms and should be graded according to the New York Heart Association (NYHA) Classification System (see SPAM). Infusion Reactions Symptoms and adverse events associated with the Herceptin infusion must be reported as individual symptoms rather than as the single term "infusion reaction". An adverse event may be considered associated with the infusion of Herceptin if it starts during the infusion or within 24 hours of the start of the infusion. The following convention for collection of these data will apply: 1. The specific symptoms will be captured as appropriate on the CRF adverse event pages. 2. Severity for each adverse event will be recorded as above. 3. Generally, infusion related symptoms should be considered to be those described in the investigators brochure (IB) and beginning within the first 24 hours following Herceptin infusion such as fever, chills, hypotension, etc.

7.2.7

Project Specific Instructions on Adverse Events

Leukaemia/Myelodysplastic Syndrome There is no evidence that the use of Herceptin is associated with an increased risk of patients developing secondary haematological malignancies. However details of such cases should be reported to F. Hoffmann-La Roche as an adverse event during the study or as a spontaneous report if it is diagnosed after the patient has left the study. Clinical details and histology reports, including any cytogenetic testing, should be included with the report. Immune complex disease / Anti-Herceptin antibodies In the clinical development program only 1 in 903 patients who were tested developed antiHerceptin antibodies. However, to continue to improve the assessment of the risk of antiHerceptin antibodies F. Hoffmann-La Roche will continue to test selected patients for antibodies. If a patient develops signs or symptoms consistent with immune complex disease (glomerulonephritis, haemolytic anaemia, polyarteritis etc.) an adverse event (for patients within a clinical trial) or a spontaneous report must be made to Roche (and patient should stop Herceptin). Roche will then contact the patients clinician and request a blood sample for

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autoantibody testing. The result of this test will be made known to the patients clinician; if unrelated to Herceptin antibody formation, the patient may resume Herceptin treatment if judged by the investigator that the patients benefit outweighs a potential risk and is in the patients best interests.

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7.3
7.3.1

Dose Modifications for Toxicity


Haematological and Non-haematologic Toxicity

All actions to be taken in case of toxicities attributable to Herceptin are shown in Table 11 below.

Table 11

Actions to be taken in case of Herceptin related toxicity


Action Continue Herceptin therapy Hold Herceptin therapy until recovery to grade <2

Toxicity related to Herceptin 1. Non-haematological, grade 1 or 2 (NCICTC; excluding cardiac*) 2. Non-haematological, grade 3 or 4 (NCICTC; excluding cardiac*), and toxicity resolved within a maximum of 5 weeks calculated from last planned administration 3. Non-haematological, grade 3 or 4 (NCICTC; excluding cardiac*), and toxicity NOT resolved to grade <2 or disappeared within a maximum of 5 weeks calculated from last planned administration 4. Non-haematological, grade 3 or 4 (NCICTC; excluding cardiac*), upon rechallenge with Herceptin 5. Cardiac (asymptomatic drop in LVEF or symptomatic congestive heart failure)

Action (discontinue or resume Herceptin therapy) in individual cases to be decided by HERA Executive Committee

Discontinue Herceptin therapy permanently

Herceptin therapy to be held, continued or resumed according to the algorithm depicted in Figure 4 on page 71 Herceptin therapy to be discontinued permanently in case of symptomatic CHF

6. Cardiac (NCI-CTC; other cardiac toxicities not covered by treatment algorithm in Figure 4) 7. Haematological
* Severity corresponding to NYHA criteria

Actions must follow rules 1. to 4. for nonhaematological toxicities Herceptin dose should not be held

7.3.2

Cardiac Function

All patients must have a baseline LVEF greater or equal to 55% prior to randomisation. LVEF will be monitored according to the schedule of assessments (Table 7). If an investigator is concerned that an adverse event may be related to cardiac dysfunction, an additional LVEF measurement should be performed. A significant LVEF drop is defined as an absolute decrease of at least 10 points below the baseline measurement and to below 50%. Patients with a significant drop in LVEF (defined in Section 2.3) may continue or must discontinue Herceptin as outlined in the algorithm in Section 7.4.1.2 (Figure 4).

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Herceptin has to be discontinued in patients who develop NYHA class III/IV cardiac dysfunction. In such patients Herceptin will not resume, even after resolution of symptoms or normalisation of LVEF. However, patients will remain in the study and complete all assessments as planned. Recommendations regarding administration of cardiac medication: Cardiac medication will be initiated at discretion of the investigator/cardiologist. While cardiac medication is usually not recommended in case of an asymptomatic drop in LVEF NOT fulfilling NYHA class III/IV criteria such treatment may be initiated at the discretion of the investigator if there is an asymptomatic drop and the LVEF is < 40%.

7.3.3

Infusion Associated Symptoms

Patients with pulmonary disease or pre-existing respiratory compromise may be at increased risk from serious infusion symptoms. Patients with metastatic disease are not eligible for HERA, however careful consideration must be made before enrolling patients with chronic lung disease into this clinical trial. Patients that experience a life threatening infusion reaction on the first dose (e.g. tachypnea, bronchospasm, hypotension, hypoxia) should be withdrawn from study medications. Patients that experience severe or moderate infusion symptoms may be managed by: Slowing or stopping the Herceptin infusion Supportive care with oxygen, beta agonists, antihistamines, corticosteroids for example.

Patients that experience mild or moderate infusion symptoms may be treated with antipyretics and antihistamines. Patients that experience mild, moderate or severe infusion reactions on the first dose may be retreated with Herceptin. Premedication with corticosteroids, antihistamines, and antipyretics may be used before subsequent Herceptin infusions.

7.3.4

Delay of Herceptin Administration due to Toxicity or Other Reasons

All actions taken in case of a delay of Herceptin dosing due to non-haematological toxicity or other reasons are summarised in Table 12. Note, that all cases of asymptomatic drop in LVEF or symptomatic cardiac heart failure have to be treated according to the algorithm depicted in Figure 4.

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Table 12

Herceptin dosing in case of delayed scheduled doses

Delay of Herceptin Action Administration Dose delayed by up to and including 7 days (28 days from last actual dose) It is recommended to give a dose of 6 mg/kg as soon as possible (don't wait until the next planned cycle) and carry on the maintenance doses (6 mg/kg q3w) according to the original schedule.

Dose delayed more than It is recommended to re-start the treatment as if she were a new 7 days (>28 days from patient. The treatment should be re-started as soon as possible (do last actual dose) not wait until the next planned cycle) with a loading dose of 8 mg/kg followed by the usual maintenance dose of 6 mg/kg q3w afterwards. Every effort should be made in order to avoid a situation that a patient misses more than one scheduled dose of Herceptin. The recommendations above are applicable regardless of the interval since the commencement of therapy (first, second cycle, etc.) and regardless of the reason for the delay (i.e., they also apply to patients with treatment delays due to LVEF drops, as recommended in the cardiac monitoring algorithm, displayed in Figure 4).

7.4

Criteria for Withdrawal

Patients have the right to withdraw from the study at any time for any reason without prejudice to their subsequent care. The investigator also has the right to withdraw patients from the study if it is in the best interest of the patient. An excessive rate of withdrawals can render the study non interpretable; therefore, unnecessary withdrawal of subjects should be avoided. If patients wish to stop treatment with Herceptin prematurely but do not have relapse of disease, they should still attend all remaining study visits, if possible, as planned according to their treatment allocation and assessments described in Table 7 and in section [5.2]. Patients who discontinue the treatment period (one year or two years for patients in the Herceptin arms and one year for patients in the observation arm) prematurely for any reason should complete the safety follow-up visit(s) as described in section [5.2]. Should a patient decide to withdraw consent to further participation in the trial, all efforts will be made to complete and report data up to the date of withdrawal. A final treatment period/followup/safety follow-up/survival follow-up visit should be performed if possible. Instructions for documenting reasons for patient withdrawal can be found in the SPAM. Should a patient develop recurrence of disease during treatment and withdraw consent to participation in the study then recurrence of disease will be recorded as the reason for withdrawal from the study in the CRF. Patients who meet cardiac toxicity criteria for discontinuation of Herceptin as outlined in section [7.3] should still be followed according to their treatment allocation and assessments described in Table 7 and in section [5.2], unless they withdraw their consent to further participation in the study.

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7.4.1 7.4.1.1

Cardiac Safety Discontinuation Criteria in an Individual Patient Congestive Heart Failure (CHF)

CHF of NYHA class III or IV is a primary cardiac endpoint. Herceptin will be discontinued in any patient who develops clinical signs and symptoms suggesting CHF, with the diagnosis confirmed by a drop in LVEF by MUGA or echocardiogram and corresponding clinical findings. Although the same test (echocardiogram or MUGA scan) that was used at baseline and throughout the trial for an individual is preferred, either test will be acceptable, given the acute nature of the clinical situation. The patient will be followed according to the assessments described in Table 7 and in section [5.2]. The CHF should be treated and followed according to standard medical practice. For all patients experiencing a primary cardiac endpoint, the frequency of cardiac monitoring (LVEF assessment) will be increased and must be performed at all patient visits shown in Table 7 up to year 2 and then every 3 months for a total of 2 years following the initial diagnosis of CHF. Thereafter, LVEF assessments should be performed annually at all remaining patient visits up to year 10. In addition, any change in the symptoms of the patients CHF including the NYHA class should be provided on a follow-up SAE page for patients in the Herceptin arms, and on the AE page as updated, additional information for patients in the observation arm up to year 10.

7.4.1.2

Asymptomatic and Mildly Symptomatic Drops in LVEF

Confirmed significant asymptomatic (NYHA class I) and mildly symptomatic (NYHA class II) drops in LVEF are secondary cardiac endpoints. At the present time, there are inadequate data available to assess the prognostic significance of asymptomatic drops of LVEF. However, to ensure the safety of patients in the trial, Herceptin must be discontinued in all patients for whom a drop of LVEF to below 45% is documented and confirmed with a subsequent repeat assessment approximately 3 weeks after the first assessment, using the same assessment method (see algorithm in Figure 4). These patients will be followed according to the assessments described in Table 7 and in section [5.2]. The frequency of cardiac monitoring (LVEF assessment) will be increased and will be performed at all patient visits shown in Table 7 up to year 2 and then every 3 months for a total of 2 years following the initial diagnosis of CHF (NYHA class I or II). Thereafter, LVEF assessments should be performed annually at all remaining patient visits up to year 10. In addition, any change in the symptoms of the patients CHF including the NYHA class should be provided on the AE page as updated, additional information up to year 10. For patients whose LVEF drops to values between 45 and 49%, the decision to stop or continue Herceptin is based on the algorithm below. If Herceptin is held for 2 consecutive cycles, it must be discontinued. Thereafter, patients will be followed according to the assessments described in Table 7 and in section [5.2]. The cardiac monitoring schedule (LVEF assessment) will be increased and performed at all patient visits shown in Table 7 up to year 2 and then every 3 months for a total of 2 years from discontinuation of Herceptin. Thereafter, LVEF assessments should be performed annually at all remaining patient visits up to year 10. In addition, any change in the symptoms of the patients CHF including the NYHA class should be provided on the AE page as updated, additional information up to year 10. The same requirements apply to patients experiencing a secondary cardiac endpoint in the observation arm.

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For patients who experience a primary or secondary cardiac endpoint, the choice of the method of further LVEF determination for the intensive cardiac monitoring phase (e.g., three monthly echocardiographic monitoring instead of MUGA scanning) is left to the discretion of the investigator.

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Figure 4

Algorithm for continuation and discontinuation of Herceptin based on interval LVEF assessments

LVEF < 50

LVEF >/= 50

LVEF </= 44

LVEF 45-49

CONTINUE HERCEPTIN

HOLD Herceptin Repeat LVEF in 3 weeks

>/=10 EF points from baseline HOLD Herceptin Repeat LVEF in 3 weeks

<10 EF points from baseline

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LVEF </= 44 OR LVEF 45-49 and >/= 10 points from baseline

LVEF 45-49 and <10 points from baseline OR LVEF >49

LVEF </=44 OR LVEF 45-49 and >/= 10 points from baseline

LVEF 45-49 and <10 points from baseline OR LVEF >49

CONTINUE HERCEPTIN

STOP HERCEPTIN

RESUME HERCEPTIN

STOP HERCEPTIN

RESUME HERCEPTIN

Note: LVEF assessment results must be available before/on the day of the next scheduled Herceptin administrations, and a decision to give or hold that dose must be made based on this algorithm.

7.5

Warnings and Precautions

Serious adverse reactions including infusion reactions, hypersensitivity, allergic-like reactions and pulmonary events have been observed in patients receiving Herceptin therapy. These severe reactions were usually associated with the first infusion of Herceptin and generally occurred during or immediately following the infusion. For some patients, symptoms progressively worsened and led to further pulmonary complications. Initial improvement followed by clinical deterioration and delayed reactions with rapid clinical deterioration have also been reported. Fatalities have occurred within hours and up to one week following infusion. On very rare occasions, patients have experienced the onset of infusion symptoms or pulmonary symptoms more than six hours after the start of the Herceptin infusion. Patients should be warned of the possibility of such a late onset and should be instructed to contact their physician if these symptoms occur. Patients who have dyspnea at rest due to co-morbidities may be at increased risk of a fatal infusion reaction. Because the half-life of Herceptin is approximately 28.5 days (95% confidence intervals, 25.5 32.8 days), Herceptin may persist in the circulation for up to 20 weeks (range 18-24 weeks) after stopping Herceptin treatment. Patients who receive anthracyclines after stopping Herceptin may possibly be at increased risk of cardiotoxicity. If possible, physicians should avoid anthracycline-based therapy for up to 24 weeks after stopping Herceptin. If anthracyclines are used then the patient should have careful cardiac monitoring.

7.5.1

Infusion Reactions, allergic-like Reactions and Hypersensitivity

Serious adverse reactions to Herceptin infusion that have been reported infrequently include dyspnea, hypotension, wheezing, bronchospasm, asthma tachycardia, reduced oxygen saturation, anaphylaxis, respiratory distress, urticaria and angioedema. The majority of these events occur during or within 2.5 hours of the start of the first infusion. Should an infusion reaction occur the Herceptin infusion should be discontinued and the patient monitored until resolution of any observed symptoms. The majority of patients experienced resolution of symptoms and subsequently received further infusions of Herceptin. Serious reactions have been treated successfully with supportive therapy such as oxygen, beta-agonists, and corticosteroids. In rare cases, these reactions are associated with a clinical course culminating in a fatal outcome. Patients with dyspnea at rest due to co-morbidities may be at increased risk of a fatal infusion reaction. Therefore, these patients should not be treated with Herceptin.

7.5.2

Pulmonary events

Severe pulmonary events have been reported rarely with the use of Herceptin in patients with advanced breast cancer in the post-marketing setting. These rare events have occasionally been fatal. Rare cases of pulmonary infiltrates, acute respiratory distress syndrome, pneumonia, pneumonitis, pleural effusion, respiratory distress, acute pulmonary oedema and respiratory insufficiency have been reported. These events may occur as part of an infusion-related reaction or with a delayed onset. Patients who are experiencing dyspnea at rest due to complications of advanced malignancy and co-morbidities may be at increased risk of pulmonary events. Therefore, these patients should not be treated with Herceptin.

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7.5.3

Cardiotoxicity

Heart failure (NYHA class II-IV) has been observed in patients receiving Herceptin therapy alone or in combination with paclitaxel, particularly following anthracycline (doxorubicin or epirubicin)containing chemotherapy. This may be moderate to severe and has been associated with death. Patients with significant cardiac disease are excluded from the HERA trial (see inclusion and exclusion criteria, Section 4.2 and 4.3). All candidates for treatment with Herceptin, but especially those with prior anthracycline and cyclophosphamide (AC) exposure, must undergo baseline cardiac assessment including history and physical examination, ECG, echocardiogram, and/or MUGA scan. A careful risk-benefit assessment should be made before deciding to treat with Herceptin. Cardiac function must be monitored during treatment (see Schedule of Assessments, Table 7). Monitoring may help to identify patients who develop cardiac dysfunction. Patients who develop asymptomatic cardiac dysfunction must have more frequent monitoring (e.g. every 6-8 weeks) and may have to discontinue Herceptin (see algorithm Figure 4). Caution should be exercised in treating patients with a history of hypertension or documented coronary artery disease, if not excluded from the HERA trial for other reasons. If symptomatic cardiac failure develops during Herceptin therapy, it should be treated with the standard medications for this purpose. The safety of continuation or resumption of Herceptin in patients who experience cardiotoxicity has not been prospectively studied. However, most patients who developed heart failure in the pivotal trials improved with standard medical treatment. This included diuretics, cardiac glycosides, and/or angiotensin-converting enzyme inhibitors. The majority of patients with cardiac symptoms and evidence of a clinical benefit of Herceptin treatment in the pivotal trials continued on weekly therapy with Herceptin without additional clinical cardiac events.

7.5.4
Pregnancy:

Pregnancy and Lactation

Reproduction studies have been conducted in cynomolgus monkeys at doses up to 25 times that of the weekly human maintenance dose of 2 mg/kg Herceptinand have revealed no evidence of impaired fertility or harm to the foetus. Placental transfer of trastuzumab during the early (Days 20 - 50 of gestation) and late (Days 120 - 150 of gestation) foetal development period was observed. It is not known whether Herceptin can cause foetal harm when administered to a pregnant woman or whether it can affect reproductive capacity. As animal reproduction studies are not always predictive of human response, Herceptin should be avoided during pregnancy. Lactation: A study conducted in lactating cynomolgus monkeys at doses 25 times that of the weekly human maintenance dose of 2 mg/kg Herceptin demonstrated that trastuzumab is secreted in the milk. The presence of trastuzumab in the serum of infant cynomolgus monkeys was not associated with any adverse effects on their growth or development from birth to 1 month of age. It is not known whether trastuzumab is secreted in human milk. IgG1 is secreted into human milk, and the potential for harm to the infant is unknown.

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8.

STATISTICAL CONSIDERATIONS AND ANALYTICAL PLAN

Protocol version E specified that an interim efficacy analysis should be conducted once half of the required events (half of the 951 disease-free survival events) across all three study arms had been observed in the clinical database (see section 8.2.3.2). This interim efficacy analysis was reviewed by the IDMC on 25th April 2005 and demonstrated overwhelming efficacy of Herceptin compared with no Herceptin ([104]). Subsequently the IDMC recommended the disclosure of data from the one year Herceptin and the observation study arm. Data of the 2 years Herceptin study arm were not disclosed in order to maintain the blind for the comparison of 1 year versus 2 years of Herceptin treatment. Similarly, the three other large adjuvant trials (NSABP-B31, NCCTG N9831 and BCIRG006) with 12 months of Herceptin had demonstrated the efficacy of this treatment in their interim analyses ([105] [106]). At the same time, published data from a small group of patients in a Finnish trial who received nine weeks of Herceptin concomitantly with the non-anthracycline part of their chemotherapy showed a statistically significant risk reduction at three years of follow-up whilst no cardiac toxicity was observed ([107]). In light of balancing benefit and related toxicity, the question of appropriate duration of Herceptin therapy has therefore become of key interest. Consequently the statistical analysis plan was revised and will be driven by the comparison of one year versus two years of Herceptin in order to account for this change in focus of the trial.

8.1 8.1.1

Primary and Secondary Study Variables Primary Variable: Disease Free Survival

The primary efficacy variable is Disease Free Survival (DFS). DFS is defined as the time between randomisation and the date of first event (events are defined in Section 5.2.1.2). For patients who have not had an event at the time of data analysis, so called censored observations are taken into account for the analysis. The censored observation is the date of last follow-up. In a further supplemental analysis, patients who were randomized to the observation arm and who received Herceptin before first event will be censored at the time of first Herceptin infusion.

8.1.2 8.1.2.1

Secondary Variables Overall Survival

Overall Survival (OS) is defined as the time between randomisation and the date of death due to any cause. For patients still alive at time of analysis the censoring time is the date of last followup. In a further supplemental analysis, patients who were randomised to the observation arm and who received Herceptin will be censored at the time of first Herceptin infusion.

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8.1.2.2

Recurrence Free Survival

Recurrence Free Survival (RFS) is defined as the time between randomisation and the date of the first local, regional, or distant tumour recurrence (as defined in Section 5.2.1.2). For patients with second primary cancers, contralateral breast cancer or death without evidence of disease relapse, the date of these events is the censoring time. For patients still alive and disease free at time of analysis the censoring time is the date of last follow-up. In a further supplemental analysis, patients who were randomised to the observation arm and who received Herceptin before first local, regional, or distant recurrence will be censored at the time of first Herceptin infusion.

8.1.2.3

Distant Disease Free Survival

Distant Disease Free Survival (DDFS) is defined as the time between randomisation and the date of the first distant tumour recurrence, second primary cancer, or contralateral breast cancer, whichever occurs first (as defined in Section 5.2.1.2). Local and regional recurrences are ignored for calculating DDFS. For patients still alive and free of distant disease at time of analysis the censoring time is the date of last follow-up. In a further supplemental analysis, patients who were randomised to the observation arm and who received Herceptin before first distant recurrence will be censored at the time of first Herceptin infusion.

8.1.2.4

Time to Recurrence

Time to Recurrence (TTR) is defined as the time between randomisation and the date of the first local, regional, or distant tumour recurrence. Contralateral breast cancer and second non breast malignancy are ignored for calculating TTR. Deaths prior to breast cancer recurrence are treated as censoring events. In a further supplemental analysis, patients who were randomised to the observation arm and who received Herceptin before first local, regional, or distant recurrence will be censored at the time of first Herceptin infusion.

8.1.2.5

Time to Distant Recurrence

Time to distant recurrence (TTDR) is defined as the time between randomisation and the date of the first distant tumour recurrence. Local and regional recurrences and contralateral breast cancer and second non breast malignancy are ignored for calculating TTDR. Deaths prior to distant breast cancer recurrence are treated as censoring events. In a further supplemental analysis, patients who were randomised to the observation arm and who received Herceptin before first distant recurrence will be censored at the time of first Herceptin infusion.

8.1.2.6

General Safety and Tolerability

The safety and tolerance of Herceptin will be assessed as a secondary objective. This will consist mainly of adverse events, including cardiac events (cardiac endpoints and other cardiac events that are not cardiac endpoints, as defined in section 2.3.1).

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8.1.2.7

Cardiac Dysfunction

Cardiac dysfunction is assessed by primary and secondary cardiac endpoints. The following definitions of cardiac endpoints will be used, for events occurring at any time after randomisation, but prior to the start of any new therapy for recurrent disease: Primary cardiac endpoint The primary cardiac endpoint is symptomatic cardiac dysfunction, defined as the occurrence of symptomatic congestive heart failure or definite or probable cardiac death (as defined in Section 2.3.1). Secondary cardiac endpoint The secondary cardiac endpoint is a significant LVEF drop, as defined in Section 2.3.1. In particular, a significant drop in LVEF is defined as an absolute decrease of at least 10 points below the baseline measurement and to below 50%.

8.1.2.8

Other Variables

Disease Free Survival from definitive surgery (DFSS) and Overall Survival from definitive surgery (OSS) are defined in the same way as for DFS and OS, respectively, but calculated from the date of surgery rather than the date of randomisation. These exploratory analyses will only be conducted for patients who did not have neo-adjuvant therapy. It is recognised that these variables may be biased measures of the true outcome from the date of surgery because patients who are not randomised due to events that occur between surgery and the potential date of randomisation (e.g., disease recurrence or ineligible post-chemotherapy cardiac function test) can not be included in the analysis. Sites of failure will be classified as defined in Section 5.2.1.

8.2 8.2.1 8.2.1.1

Statistical and Analytical Methods Statistical Model Primary Efficacy Variable

The primary objective is to compare DFS for patients randomised to receive no Herceptin versus those randomised to one year of Herceptin, and to compare DFS for patients randomised to receive no Herceptin versus those randomised to receive two years of Herceptin. Each of these pair wise comparisons will be made using an unstratified log rank test with a modified Bonferroni alpha level adjustment according to the method of Holm [79], so that the overall trial-wide alpha level is 0.05 (see section 8.2.2). Kaplan-Meier curves will be calculated and displayed. Five year DFS rates and 95% confidence limits of these will be given for each treatment group. Risk ratios and 95% confidence limits of them will be given for each pair wise comparison. The primary analysis will be based on the full analysis set (FAS), using an intent-to-treat principle. Section 8.2.3.1 gives the definition of the analysis population.

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Expanded analysis for DFS Cox proportional hazards regression models will be tried in an exploratory manner, to determine if adjustment for covariates will modify the conclusions from the primary analysis. Variables to be considered are the stratification factors as well as other disease or patient related prognostic or predictive factors (e.g. Menopausal status, race, loco-regional radiotherapy, type of surgery).

8.2.1.2

Secondary Efficacy Variables

Overall Survival (OS), Recurrence Free Survival (RFS), Distant Disease Free Survival (DDFS), Time to Recurrence (TTR) and Time to Distant Recurrence (TTDR) will be analyzed using unstratified log rank tests with each of the pair wise comparisons made using Bonferroni-Holm alpha level adjustments [79] (see section 8.2.2). Kaplan-Meier curves will be calculated and displayed. Five year rates and 95% confidence limits of them will be given for each treatment group. Risk ratios and 95% confidence limits of them will be given for each pair wise comparison. The analyses will be performed for the full analysis set (FAS). Expanded analyses will be performed as for DFS.

8.2.1.3

General Safety and Tolerability

All safety parameters will be analyzed and presented in terms of listings and summary tables based on the safety population. Adverse events will be assessed according to the NCI-CTC version 2.0 grading system. The most extreme intensity per patient will be used for reporting. Frequencies will be given for adverse events, detailed by body system and treatment group. Summaries will be given for all events as well as breakdowns by intensity and by relation to treatment. Because the trial cannot be blinded and follow-up visit schedules are likely to be more frequent for patients assigned to Herceptin, comparative assessment of safety and tolerance between Herceptin and no further treatment may be difficult to ascertain.

8.2.1.4

Cardiac Dysfunction

The analysis of cardiac dysfunction will be based on the safety population (see section 8.2.3.1). Primary cardiac endpoint The primary cardiac endpoint will be summarised for the Herceptin versus no Herceptin groups by presenting the incidence of symptomatic congestive heart failure or cardiac death, along with the 95% two-sided confidence limits according to Pearson-Clopper [78]. The difference in incidences will be presented and the Hauck-Anderson [92] approach will be used to calculate the 95% confidence limits for the difference. Secondary cardiac endpoint The secondary cardiac endpoint will be summarised for the Herceptin versus no Herceptin groups by presenting the incidence of secondary cardiac endpoints (confirmed significant drops in LVEF or secondary endpoints determined by the Cardiac Advisory Board), along with the 95% two-sided confidence limits according to Pearson-Clopper. The difference in

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incidences will be presented and the Hauck-Anderson approach will be used to calculate the 95% confidence limits for the difference.
Other cardiac analyses

Primary cardiac endpoints occurring after the start of new therapy for recurrence of disease or second primary cancer will be listed separately.
Other cardiac events not qualifying as primary or secondary cardiac endpoints, such as acute coronary syndrome, will be summarised as part of the adverse event reporting. In addition, LVEF will be summarised by presenting frequencies over time for the safety population (see section 8.2.3.1) of the following categories: Increase or no change from baseline Decrease of < 10 points from baseline Decrease of 10 points from baseline LVEF < 50% LVEF < 50% and decrease of 10 points from baseline.

It is understood that some of these categories are overlapping.

8.2.1.5

Outcome for Herceptin One Year Versus Two Years

Efficacy analyses that compare the two Herceptin groups will be a so-called landmark analysis performed on the full analysis set for the comparison of one year versus two years of Herceptin treatment (FAS1vs2, see section 8.2.3.1). The primary parameter will be DFS. The comparison will be done using the unstratified log rank test on a 5% alpha level. Secondary parameters will be OS, RFS, DDFS, TTR and TTDR that will be analysed using the same methods. For each parameter, Kaplan-Meier curves will be calculated and displayed. In addition, 5 year rates and 95% confidence limits of them will be provided for each treatment group. Risk ratios and 95% confidence limits of them will be provided for the comparison between the groups.
These analyses will assess whether it was worthwhile to continue treatment beyond one year for patients who have remained disease free during one year of treatment. With 729 DFS events observed across the two Herceptin study arms (FAS1vs2) beyond one year, there is an 80% power to obtain a two-sided p-value 0.05 if the true risk ratio is 0.80 (accounting for two efficacy interim analyses). Additional analyses will be performed to investigate whether a trend exists for increasing effectiveness with increasing duration of Herceptin. A Cox model analysis with a covariate coded as 0 for no Herceptin, 1 for one year of Herceptin, and 2 for two years of Herceptin will indicate whether such a trend exists.

HERA results comparing 1 year of Herceptin treatment versus observation showed a difference in the time course of disease-free survival treatment effects according to steroid hormone receptor status of the primary tumor. On the basis of these findings, it is prospectively planned to evaluate one year versus two years of Herceptin treatment

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separately for the receptor-negative (ER and PgR both negative) and the receptor-positive (either ER or PgR positive) cohorts.

8.2.1.6

Analysis of Other Efficacy Variables

DFSS and OSS will be analyzed for the FAS only. Interpretation will be cautious due to potential bias. Kaplan-Meier curves will be calculated and displayed. Five year rates and 95% confidence limits of them will be given for each treatment group. Risk ratios and 95% confidence limits of them will be given for each pair wise comparison. Sites of failure will be analyzed for the FAS only. Frequency tables by treatment group will be provided. In addition, the time to first central nervous system (CNS) recurrence will be evaluated. A competing risk (cumulative incidence) plot will be displayed.

8.2.1.7

Exploratory Analyses

Exploratory analyses will be performed to ascertain whether the magnitude of the effectiveness of Herceptin might differ according to patient sub-populations. These exploratory analyses will be the focus for the follow-up evaluations detailed in section 8.2.3.5. Variables to be considered for defining subgroups of interest include the stratification factors as well as other disease or patient related prognostic or predictive factors. Based on information available in 2001 special attention will be given to the following factors: i) Values obtained from assays for ER and PgR of the primary tumour (based on information collected on the type of assay used, the actual quantitative value obtained from the assay and the lab determination of negative and positive, tumours expressing no steroid hormone receptors will be distinguished from those with low values (i.e., some expression but classified as negative) and those with positive values,

ii) Use of tamoxifen with or without ovarian ablation, and use of an aromatase inhibitor, iii) Menopausal status determined at the time of randomisation (because menopausal status for premenopausal women is likely to change due to adjuvant chemotherapy) according to modified recommendations of the NCI Cooperative Group Committee on Common Data Elements: Clearly premenopausal status: continuing menstruation throughout chemotherapy AND no prior bilateral ovariectomy AND not on estrogen replacement Clearly postmenopausal status: prior bilateral ovariectomy OR >12 months since last menstrual period (LMP) with no prior hysterectomy Uncertain status: any status not included in the above categories iv) Age category at time of randomisation (< 35, 35-49, 50-59, 60). Additional factors may also be considered based on results from other trials that will be reported during the next years. Treatment effects, Kaplan-Meier estimates at 5 years and risk ratios with confidence intervals will be estimated separately for the defined subgroups.

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8.2.1.8

Analysis of shed ECD

The time course of shed ECD levels in serum (absolute values and changes from baseline at each time point) will be summarised by treatment group. The summaries will be made for all patients as well as being split for patients who relapse and patients who dont relapse. For patients who relapse, the change from baseline in ECD level at time of relapse will be summarised to see if levels are increased at time of relapse. The relationship of shed ECD with DFS and survival will be analysed by inclusion of ECD levels (at baseline, as well as selected time points) in exploratory Cox proportional hazards models (for the subset of patients in whom shed ECD was measured).

8.2.2

Hypothesis Testing

Let hO, hH1 and hH2 be the hazard rates in the observation, 1-year Herceptin and 2-year Herceptin arms, respectively. The null and alternative hypotheses can be formulated as: For the observation vs 1 year Herceptin comparison: H01 : hO = hH1 H11 : hO hH1 there is no treatment difference in hazard rates. there is a treatment difference in hazard rates.

For the observation vs 2 year Herceptin comparison: H02 : hO = hH2 H12 : hO hH2 there is no treatment difference in hazard rates. there is a treatment difference in hazard rates.

The null hypotheses will be tested with unstratified log rank tests (two-sided) following a stepdown adjustment procedure of the Bonferroni method as proposed by Holm [79]. In this procedure the testing is conducted in a decreasing order of significance. The smallest of the pvalues will be tested at a level /2. If the corresponding hypothesis is rejected then the second pvalue will be tested at a level , otherwise both null hypotheses are accepted. The overall significance level for this test procedure is .

8.2.3 8.2.3.1

Types of Analyses Analysis Sets

Full analysis set for the comparisons to observation (FAS) The full analysis set consists of all randomised patients as they were originally randomised, irrespective of Herceptin treatment received and eligibility. The primary analysis will be based on the full analysis set (ITT principle). Full analysis set for the comparison of 1 year versus 2 years of Herceptin (FAS1vs2): The full analysis set for the 1 year Herceptin vs 2 years Herceptin comparison consists of patients originally randomised to Herceptin who were event-free (no recurrence or death) for at least 1 year after randomisation, irrespective of Herceptin treatment received and eligibility.

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Safety population The safety population consists of all patients who are randomised. The safety profile of each of the following groups will be based on data prior to recurrence.

Observation group:

Patients originally randomised to observation or Herceptin who did not receive any Herceptin prior to recurrence Information from patients originally randomised to observation who receive Herceptin prior to recurrence until the date of the first administration of Herceptin prior to recurrence. This includes assessments (LVEF assessments, ECG, cardiac questionnaire, vital signs, radiological examination, laboratory assessments) performed on the date of the first administration of Herceptin. This does not include adverse events, cardiac events or Herceptin administration on the date of the first Herceptin administration. Information from patients originally randomised to Herceptin who initially refused Herceptin until the date of the first administration of Herceptin prior to recurrence following the release of the trial results. This includes assessments (LVEF assessments, ECG, cardiac questionnaire, vital signs, radiological examination, laboratory assessments) performed on the date of the first administration of Herceptin. This does not include adverse events, cardiac events or Herceptin administration on the date of the first Herceptin administration.

1 year Herceptin group:

Patients who were randomised to 1 year of Herceptin treatment and who received Herceptin prior to recurrence. This does not include patients who initially refused treatment with Herceptin and started treatment with Herceptin following the release of the trial results.

2 year Herceptin group:

Patients who were randomised to 2 years of Herceptin treatment and who received Herceptin prior to recurrence. This does not include patients who initially refused treatment with Herceptin and started treatment with Herceptin following the release of the trial results.

Remain in Observation group:

Information from patients originally randomised to observation only who register to remain on observation on or after the date of registration to remain in the observation arm. This includes adverse events, cardiac events and assessments (LVEF assessments, ECG, cardiac questionnaire, vital signs, radiological examinations, laboratory assessments) performed on the date of the registration to remain in the observation arm.

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New Herceptin group:

Information from patients originally randomised to observation who receive Herceptin prior to recurrence on or after the date of first Herceptin administration. This includes adverse events, cardiac events and Herceptin administration on the date of first Herceptin administration. This does not include assessments (LVEF assessments, ECG, cardiac questionnaire, vital signs, radiological examinations, laboratory assessments) performed on the date of first Herceptin administration.

All baseline information and all efficacy information (with the exception of the comparison of 1 year versus 2 years Herceptin) will be analysed on the FAS population. The comparison of the 1 year versus 2 years Herceptin will be analysed on the FAS1vs2 population. All safety information will be analysed on the basis of the safety population.

8.2.3.2

Analysis of Primary Efficacy

One interim analysis is planned, to compare DFS for patients randomised to one year of Herceptin versus no Herceptin and two years of Herceptin versus no Herceptin. This interim analysis will be performed after half of the calculated 951 events (see section 8.3.1) have been observed, that is after 475 events. The interim analysis will be performed by an independent statistician from Frontier Science. The results of the interim analysis will be presented to the IDMC. The purpose of the interim analysis is to evaluate whether there is an overwhelming difference in the efficacy observed in either of the Herceptin groups compared to the no Herceptin group in terms of DFS. In case either of the tests are significant, the IDMC may recommend early termination of the trial. If neither of the tests are significant the study will continue as planned and the sample size (number of patients to be enrolled in order to see the required number of events) may be re-estimated based on the event rate in the no Herceptin group. The interim analysis will follow a sequential plan according to OBrien-Fleming as implemented by Lan and DeMets [77]. As determined by the EaSt-2000 (Early Stopping) statistical software package [80] the significance levels for the most significant pair wise comparison will be 0.0010 for the interim analysis and 0.0247 for the final analysis. This assures an overall significance level of 0.025 for the more significant pair wise comparison. If significance is reached, the significance levels for the second pair wise comparison will be 0.0020 for the interim analysis and 0.0494 for the final analysis. The overall study-wide significance level for this procedure is 0.05.

8.2.3.3

Cardiac Endpoints

The interim analyses of cardiac endpoints will be performed by an independent statistician from Frontier Science. The results of the interim analyses will be presented to the IDMC. Three pre-defined interim analyses of cardiac endpoints are planned: after the first 300, 600, and 900 patients have been enrolled and treated (or followed, in the case of patients randomised to no Herceptin) for 6 months. If an absolute difference of more than 4% in the incidence of primary cardiac endpoints (symptomatic cardiac dysfunction) is observed between the Herceptin groups and the no Herceptin group, the IDMC will consider recommending stopping or modifying the

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trial. If the true difference in the incidence of primary cardiac endpoints is 2% (e.g., 1% versus 3%) then there is approximately a 10% chance of observing an absolute difference of more than 4% for at least one of the three interim analyses. If an increased incidence of symptomatic cardiac dysfunction is seen in the subgroup of patients pre-treated with anthracyclines, but not in the subgroup of patients who received no anthracyclines, the IDMC may recommend continuation of the trial with an amendment excluding further enrollment of patients pre-treated with anthracycline-based chemotherapy. The IDMC will work according to guidelines predefined in the IDMC Procedures Manual. The decision of the IDMC will be made based on looking at the difference in rates of symptomatic cardiac dysfunction between the Herceptin versus no Herceptin groups, and the 95% two-sided confidence limits for the difference, as well as the rates in each group. If the assumed rate of symptomatic cardiac toxicity is 1% in non Herceptin treated patients, then a 4% observed increase in this rate among the Herceptin treated patients would give the following confidence limits for each of the interim analyses (confidence coefficient is not adjusted for multiple interim analyses).

Table 13

Confidence Intervals for Interim Analyses


2-sided 95% confidence limits based on Hauck-Anderson method -0.1% - 8.1% 1.2% - 6.8% 1.8% - 6.2%

Number of patients Observation Herceptin 100 200 300 200 400 600

For example, at the third interim analysis if the observed difference in rates is 4% then we are 95% confident that the true difference in rates is between 1.8% and 6.2%. In addition to the main analyses based on the incidence of primary cardiac endpoints, exploratory analyses that account for possible differences in length of follow-up or completion of cardiac evaluations over time between treatment groups will also be performed. For example, cumulative incidence estimates of cardiac dysfunction will be calculated over time and compared between treatment groups. As there is insufficient data at this time to be able to assess the prognostic significance of asymptomatic drops in LVEF, the incidence of secondary cardiac endpoints (significant LVEF drops) will also be assessed in the interim analyses. If the difference in the treatment arms is considered acceptable the IDMC will make a recommendation to continue the trial as planned. In addition, all reported serious adverse events including other cardiac events that are not cardiac endpoints (e.g., occurring after disease recurrence) will be assessed by the IDMC.

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8.2.3.4

Outcome for Herceptin One Year Versus Two Years

The comparison of 1 year versus 2 years of Herceptin treatment will be performed on the FAS1vs2 analysis set (see section 8.2.3.1). This population will allow a so-called landmark analysis to be performed. As per recommendation of the HERA IDMC, a first interim analysis of the 1 year versus 2 years Herceptin study arm will be conducted in fall 2006. The recommendation of a timedriven analysis is based on the reasoning that at the end of 2006 a substantial number of patients from the observation arm, having elected to receive Herceptin, will have completed 1 year of treatment and any evidence of benefit of a longer treatment duration with Herceptin would directly impact on these patients. A second interim analysis will be performed when 500 DFS events in the FAS1vs2 analysis set have been observed in the database. The interim analysis will be conducted on a clean data base as defined by data management procedures. The interim analysis will follow a sequential plan according to OBrien-Fleming as implemented by Lan and DeMets. Significance levels will be determined by EaSt 4 statistical software package. The final efficacy analysis of the study will be performed after 729 DFS events in the FAS1vs2 analysis set have been observed in the database. If the IDMC recommends releasing the results of any interim analysis and the HERA Executive Committee and Steering Committee adopt the recommendation, this will be considered the final analysis.

8.2.3.5

Updated Analyses

In order to capture additional data from patients followed for the full duration of the protocol further updated analyses will be performed every two years until 10 years after the original randomization of the last patient .

8.3
8.3.1

Sample Size
Primary Efficacy Analysis

The following assumptions have been used to determine the sample size for this three-arm study: The five-year DFS percentage in the control group is assumed to be 65%. It is difficult to obtain an accurate estimate for this as few data are available on the outcome of patients with HER2 overexpression at the 3+ level who received currently available chemotherapy regimens. Retrospective data from randomised trials suggest that the DFS rate is lower in women with HER2 overexpressing breast cancer. In the NSABP B-15 trial, patients were treated with either CMF, AC, or AC followed by CMF. Among 1,368 patients retrospectively assayed for HER2 status, and treated in one of the anthracycline containing arms, 5-year DFS rates were 61% and 35% for HER2 overexpressing cancers with 1-3 or >3 involved nodes. Our assumption of a 65% control group rate for the current trial is based on the anticipated mixture of cases with either high risk node negative or node positive HER2 overexpressing breast cancer, as well as the fact that adjuvant trial results improve over time. [33]

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Two pair wise tests will be performed, using an alpha level adjustment according to Holm. [79] The sample size is calculated based on the most significant of the two comparisons at an alpha level of /2 = 0.025 (see section 8.2.3.3 for significance levels for the interim and final analysis stopping boundaries). It is assumed the following holds true for each pair wise test: The 5-year DFS rate on the observation arm is 65%. A 23% reduction in the risk of an event for DFS is considered a clinically meaningful benefit. This corresponds to a risk ratio of 0.77 and a 5-year DFS rate for the Herceptin arm of 71.8%. Recruitment was 1 case in 2001, 173 from January to June 2002, 519 from July 2002 to December 2002, 1021 from January 2003 to June 2003, and assumed to be 170 per month after June 2003. Total enrolment of 4482 patients should be completed in approximately 3 years. The accrual rate in EaSt was adjusted (annualized) to account for the slow start. Calculations used an annualized recruitment rate of 1992 patients per year over 2.25 years. The follow-up period after accrual terminates will be 2 years for the primary core analysis. A 5% dropout rate for the Herceptin arm(s) is projected and dropouts are assumed to have the same efficacy distribution as the observation arm.

With the above assumptions a log rank test on DFS requires 1494 patients per treatment arm to achieve 80% power to detect a hazard ratio of 0.77 at a two-sided significance level =0.025 assuming that 634 events are seen for the most significant of the two pair wise comparisons and one interim analysis and one final analysis are planned. This leads to a target sample size of 4482 patients and a target number of 951 events study-wide. The number of events, and required sample size to achieve that number of events was calculated using the failure time data module in EaSt-2000 [80].

8.3.2

Outcome for Herceptin One Year Versus Two Years

The following assumptions are made for the comparison of 1 year Herceptin vs 2 years Herceptin:

The 5-year DFS rate for the 1 year Herceptin arm is 70% A 20% reduction in the risk of a DFS event at least one year after randomisation is considered clinically meaningful benefit. This corresponds to a risk ratio of 0.80 and a 5 year DFS rate for the 2 years Herceptin arm of 74.9% The accrual rate in EaSt was adjusted (annualised) to account for the slow start. Calculations used an annualised recruitment rate of 1992 patients per year over 2.25 years (664 patients per year over 2.25 years per treatment arm). Allowing for 7% patients originally randomised to Herceptin failing to reach 1 year after randomisation disease-free, the annualised recruitment rate used for the calculations for 1 year Herceptin vs 2 years Herceptin was 1235 patients per year.

With the above assumptions and 729 DFS events observed across the Herceptin arms beyond 1 year, there is an 80% power to obtain a two-sided p-value < 0.05 if the true risk

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ratio is 0.80 (accounting for 2 efficacy interim analyses). (For details of interim efficacy analyses, please see section 8.2.3.4.) The stopping boundaries for the 1 year Herceptin vs 2 years Herceptin comparison will be adjusted when the exact number of DFS events occurring at least 1 year after randomisation in the database for the analysis is known. If 340 DFS events occurring at least 1 year after randomisation are observed in the database as of 31st October 2006, the significance level for the interim analysis is 0.0027. With 500 DFS events occurring at least 1 year after randomisation, the significance level for the interim analysis is 0.0137. With 729 DFS event occurring at least 1 year after randomisation, the significance level for the interim analysis is 0.0455. The interim analyses will follow a sequential plan according to OBrien-Fleming as implemented by Lan and DeMets. Significance levels will be determined by EaSt 4 statistical software package.

8.4
8.4.1

Replacement Policy (Ensuring Adequate Numbers of Evaluable Patients)


For Patients

No patient prematurely discontinued from the study for any reason will be replaced.

8.4.2

For Centres

A centre may be replaced or closed for the following administrative reasons: Excessively slow recruitment. Poor protocol adherence

8.5

Research Proposals

Additional research projects may be conducted on the basis of HERA clinical data. Any research proposal must be approved by the HERA Steering Committee and must follow the procedures described in the HERA research proposal guidelines. Results of a research proposal will be published by the responsible author.

8.5.1 Analysis of quantitative HER2 expression in relationship to Herceptininduced benefit


The analysis will be conducted as a nested case-control study linking quantitative HER2 staining of slides from the primary tumour to DFS benefit brought about by Herceptin. The research proposal will be submitted as subpart of HERA protocol amendment F to the local Ethic Committee/Institutional Review Board.

8.5.2 CNS substudy


The objectives of the study are to investigate incidence and type of CNS relapse in relation to clinical and conventional tumour factors, and to systemic treatment at the time of CNS relapse. Furthermore, clinical severity, treatment and prognosis of such CNS relapse shall be investigated. In order to conduct this analysis a few additional data from the patients medical charts may be collected (type of CNS relapse, symptom state, treatments received).

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9.

DATA QUALITY ASSURANCE

The overall procedures for quality assurance of clinical study data are described in the SPAM, and in Roche and BrEAST Standard Operating Procedures (SOPs). Accurate and reliable data collection will be assured by verification and cross-check of the CRFs against the investigators records by the study monitor (source document verification), and the maintenance of a drug-dispensing log by the investigator. A set of project specific data entry conventions will be created if appropriate. Data collected will be entered into the study database from the working copy of the original CRF. A comprehensive validation check program will verify the data and discrepancy reports will be generated accordingly for resolution by the investigator. As patients complete the study (or prematurely withdraw) and their signed CRFs become available, a second data entry will be performed from the original, signed CRF. A comparison check will be run to identify and resolve any discrepancies between the first and second data entry. Once the database is locked, a quality assurance (QA) check is performed on 1000 randomly chosen data points that are compared with the original CRFs. This sample size is sufficient to ensure that, with 99% confidence, the true error rate is less than 1% if fewer than 3/1000 discrepancies between the database and the CRF are detected. Throughout the study the HERA Study Management Team will review data according to the Data Review Plan. SDV of key efficacy and safety parameters will be performed throughout the study as defined in the Study Specific Procedures Manual (SSPM).

10.
10.1

STUDY COMMITTEES
Independent Data Monitoring Committee

An Independent Data Monitoring Committee (IDMC) which is regularly used by the International Breast Cancer Study Group (IBCSG) will be used to ensure patients safety and the feasibility and progress of this protocol (Details are being displayed in the SPAM).

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11.
1. 2. 3. 4.

REFERENCES
CA A Cancer Journal for Clinicians, Cancer Statistics 2000, American Cancer Society, Inc., Atlanta, USA, Lippincott-Raven Publishers, Vol 50,No 1, 2000. National Cancer Institute of Canada: Canadian Cancer Statistics 2000, Toronto, Canada, 2000. Jensen OM, Esteve J, Moeller H, et al. Cancer in the European Community and its member states. Eur J Cancer 26:1167-1256, 1993. Menard S, Caslini P, Tomasic G, et al. Pathobiologic identification of two distinct breast carcinoma subsets with diverging clinical behaviors. Breast Cancer Res Treat 55:169-177, 1999 Slamon DJ, Clark GM, Wong SG, et al. Human breast cancer: correlation of relapse and survival with amplification of the Her-2/neu oncogene. Science 235:177-182, 1987 Paterson MC, Dietrich KD, Danyluk J, et al. Correlation between c-erbB-2 amplification and risk of recurrent disease in node-negative breast cancer. Cancer Res 51:556-567, 1991 Hamilton A and Piccart M. The contribution of molecular markers to the prediction of response in the treatment of breast cancer: A review of the literature on HER-2, p53 and BCL-2. Ann Oncol 11:647-663, 2000 Pegram M, Hsu S, Lewis G, et al. Inhibitory effects of combinations of HER-2/neu antibody and chemotherapeutic agents used for treatment of human breast cancers. Oncogene 18:2241-2251, 1999 Baselga J, Norton L, Albanell J, et al. Recombinant humanized anti-HER2 antibody (Herceptin) enhances the antitumour activity of paclitaxel and doxorubicin against HER2/neu overexpressing human breast cancer xenografts. Cancer Res 58:2825-2831, 1998 Carter P, Presta L, Gorman CM, Ridgway JB, Henner D, Wong WL, et al. Humanization of an anti-p185HER2 antibody for human cancer treatment. Proc Natl Acad Sci USA 89:42584289, 1992. Sliwkowski MX, Lofgren JA, Lewis GD, et al. Nonclinical studies addressing the mechanism of action of trastuzumab (Herceptin). Semin Oncol 26 (4 suppl 12):60-70, 1999 Herceptin Investigators Brochure, Version 4 May 2002. Baselga J, Tripathy D, Mendelsohn J, et al. Phase II study of weekly intravenous recombinant humanized anti-p185HER2 monoclonal antibody in patients with HER2/neuoverexpressing metastatic breast cancer. J Clin Oncol 14:737-744, 1996 Cobleigh MA, Vogel CL, Tripathy D, et al. Efficacy and safety of herceptin (humanized anti-her2 antibody) as a single agent in 222 women with her2 overexpression who relapsed following chemotherapy for metastatic breast cancer. Proc Am Soc Clin Oncol 17:97a, (abstract 376), 1998 Vogel C, Cobleigh M, Tripathy D, et al. First-line, non-hormonal, treatment of women with HER2 overexpressing metastatic breast cancer with Herceptin (Trastuzumab, humanized anti-HER2 antibody). Proc Am Soc Clin Oncol 19:71a (abstr 275), 2000 Vogel C, Cobleigh M, Tripathy D et al. First-line single-agent Herceptin (H) therapy for women with HER2-overexpressing metastatic breast cancer (MBC). Eur J Cancer 36 Suppl 5:S53 (abstract 40), 2000 Slamon D, Leyland-Jones B, Shak S, et al. Addition of Herceptin (Humanized anti-her2 antibody) to first line chemotherapy for her2 overexpressing metastatic breast cancer

5. 6. 7.

8.

9.

10.

11. 12. 13.

14.

15.

16.

17.

Roche Protocol BO16348F (Ro 45-2317) - Page 104

18.

19.

20. 21.

22.

23.

24.

25.

26.

27. 28.

29.

30.

(Her2+/MBC) markedly increases anticancer activity: a randomised, multinational controlled phase III trial. Proc Am Soc Clin Oncol 17:98a, (abstr 377), 1998 Norton L, Slamon D, Leyland-Jones B, et al. Overall survival advantage to simultaneous chemotherapy plus the humanized anti-HER2 monoclonal antibody Herceptin in HER2overexpressing metastatic breast cancer. Proc Am Soc Clin Oncol 127a, (abstract 483), 1999 Slamon DJ, Leyland-Jones B, Shal S, Fuchs H, Paton V, Bajamonde A, Fleming T, Eiermann W, Wolter J, Pegram M, Baselga J, Norton L. Use of chemotherapy plus monoclonal antibody against HER2 for metastatisc breast cancer that overexpresses HER2. N Eng J Med 344:783-792, 2001 Chien KR. Myocyte survival pathways and cardiomyopathy: implications for trastuzumab cardiotoxicity. Semin Oncol Dec 27(6 Suppl 11):9-14 (discussion 92-100), 2000 Pietras RJ, Pegram MD, Finn RS, Maneval DA, Slamon DJ. Remission of human breast cancer xenografts on therapy with humanized monoclonal antibody to HER-2 receptor and DNA-reactive drugs. Oncogene 17:2235-2249, 1998 Leyland-Jones B, Hemmings F, Arnold A, Veram S, Ayoub JP. Pharmacokinetics of Herceptin Administered with Paclitaxel every three weeks. Breast Cancer Res and Treat 64:124 (abstract 534), 2000 Muller V, Witzel I, Ramirez J, et al. Relevance of HER-2/neu concentration in serum of patients with metastatic breast cancer for prognosis and prediction of therapy response. Eur J Cancer 36 Suppl 5, S104 (abstract 312), 2000 Mehta RR, McDermott JH, Hieken TJ, et al. Plasma c-erbB-2 levels in breast cancer patients: prognostic significance in predicting response to chemotherapy. J Clin Oncol 16:2409-2416, 1998 Lufmer D, Schnabel S, Flath B, et al. Course of the serum level of the shed ERBB-2 oncoprotein in metastatic breast cancer: A diagnostic tool to optimise Herceptin treatment? Proc Am Soc Clin Oncol 18:109a (abstract 411), 1999 Leyland-Jones B, Arnold A, Gelmon K, Verma S, Rakhit A, and Howell J. A pharmacokinetic (PK) study of Herceptin administered with paclitaxel i.v. every 3 week. Eur J Cancer 36 Suppl 5:S53 (abstract 41), 2000 EBCTCG. Polychemotherapy for early breast cancer: an overview of the randomised trials. Lancet 352:930-942, 1998 Hutchins L, Green S, Ravdin P, et al. CMF versus CAF with and without tamoxifen in highrisk node-negative breast cancer patients and a natural history follow-up study in low-risk node-negative patients: first results of Intergroup trial INT 0102. Proc Am Soc Clin Oncol 17:1a (abstract 2), 1998 Fisher B, Brown AM, Dimitrov NV, et al. Two months of doxorubicin-cyclophosphamide with and without interval reinduction therapy compared with six months of cyclophosphamide, methotrexate, and fluorouracil in positive-node breast cancer patients with tamoxifen-nonresponsive tumours: Results from the National Surgical Adjuvant breast and Bowel Project B-15. J Clin Oncol 8:1483-1496, 1990 Levine MN, Bramwell VH, Pritchard KI, et al. Randomised trial of intensive cyclophosphamide, epirubicin, and fluorouracil chemotherapy compared with cyclophosphamide, methotrexate, and fluorouracil in premenopausal women with nodepositive breast cancer. J Clin Oncol 16:2651-2658, 1998

Roche Protocol BO16348F (Ro 45-2317) - Page 105

31. Di Leo A, Larsimont D, Beauduin A, et al. CMF or anthracycline-based chemotherapy for node-positive breast cancer patients: 4 year results of a Belgian randomised clinical trial with predictive markers analysis. Proc Am Soc Clin Oncol 18;69a (abstract 258), 1999 32. Mouridsen HT, Andersen J, Anderson M, et al. Adjuvant anthracycline in breast cancer. Improved outcome in premenopausal patients following substitution of methotrexate in the CMF combination with epirubicin. Proc Am Soc Clin Oncol 18:68a (abstract 254), 1999 33. Early Breast Cancer Trialists Collaborative Group. 2000 analysis Overview results. Fifth Meeting of the Early Breast Cancer Trialists Collaborative Group. Oxford, UK, 21-23 September, 2000 34. Paik S, Bryant J, Park C, et al. ErbB-2 and response to doxorubicin in patients with axillary lymph node-positive hormone receptor-negative breast cancer. J Natl Cancer Inst 90:13611370, 1998 35. Paik S, Bryant J, Tan-Chiu E, et al. HER2 and choice of adjuvant chemotherapy for invasive breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-15. J Natl Cancer Inst 92:1991-1998, 2000 36. Di Leo A, Larsimont D, Beauduin A, et al. CMF or anthracycline-based chemotherapy for node-positive breast cancer patients: 4 year results of a Belgian randomised clinical trial with predictive markers analysis. Proc Am Soc Clin Oncol 18:69a (abstract 258), 1999 37. Ravdin PM, Green S, Albain KS, et al. Initial report of the SWOG biological correlative study of c-erbB-2 expression as a predictor of outcome in a trial comparing adjuvant CAF T with tamoxifen alone. Proc Am Soc Clin Oncol 17:97a (abstract 374), 1998 38. Thor AD, Berry DA, Budman DR, et al. ErbB-2, p53, and efficacy of adjuvant therapy in lymph node-positive breast cancer. J Natl Cancer Inst 90:1346-1360, 1998 39. Clahsen PC, Van de Velde CJH, Duval C, et al. P53 protein accumulation and response to adjuvant chemotherapy in premenopausal women with node-negative early breast cancer. J Clin Oncol 16:470-479, 1998 40. Menard S, Valagussa P, Pilotti S, et al. Benefit of CMF treatment in lymph node-positive breast cancer overexpressing HER2. Proc Am Soc Clin Oncol 18, 69a (abstract 257), 1999 41. Miles DW, Harris WH, Gillett CE, Smith P, and Barnes DM. Effect of c-erbB(2) and estrogen receptor status on survival in women with primary breast cancer treated with adjuvant cyclophosphamide/methotrexate/fluorouracil. Int J Cancer 84:354-359, 1999 42. Allred DC, Clark GM, Tandon AK, et al. HER-2/neu in node-negative breast cancer: prognostic significance of overexpression influenced by the presence of in situ carcinoma. J Clin Oncol 10:599-605, 1992 43. Gusterson BA, Gelber RD, Goldhirsch A, et al. Prognostic importance of c-erbB-2 expression in breast cancer. J Clin Oncol 10:1049-1056, 1992 44. Henderson IC, Berry D, Demetri G, et al. Improved disease-free and overall survival from the addition of sequential paclitaxel but not from the escalation of doxorubicin dose level in the adjuvant chemotherapy of patients with node-positive primary breast cancer. Proc Am Soc Clin Oncol 17:101a (abstract 390A), 1998 45. Taxol (paclitaxel) scientific package insert; summary of product characteristics (SPC). 46. Thomas E, Buzdar A, Theriault R, Singletary S, Booser D, Valero V, et al. Role of paclitaxel in adjuvant therapy of operable breast cancer : preliminary results of a prospective randomised clinical trial. Proc Am Soc Clin Oncol 19: 74a (abstract 285), 2000

Roche Protocol BO16348F (Ro 45-2317) - Page 106

47. Mamounas EP. Evaluating the use of paclitaxel following doxorubicin/cyclo-phosphamide in patients with breast cancer and positive axillary node. Proceed NIH Consensus Development Conference on Adjuvant Therapy for Breast Cancer, November 1-3, 2000 48. Early Breast Cancer Trialists Collaborative Group. Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet 351:1451-1467, 1998 49. Bianco AR, De Laurentiis M, Carlomagno C, et al. HER2 overexpression predicts adjuvant tamoxifen (TAM) failure for early breast cancer (EBC): complete data at 20 Yr of the Naples GUN randomised trial. Proc Am Soc Clin Oncol 19:75a (abstract 289), 2000 50. Stl O, Ferno M, Borg A, et al. ERBB2 expression and the benefit from 5 versus 2 years of adjuvant Tamoxifen for postmenopausal stage II breast cancer patients. Breast Cancer Res Treat 46:32 (abstract 112), 1997 51. Berry D, Muss H, Thor A, et al. HER-2/neu and p53 expression versus tamoxifen resistance in estrogen receptor-positive, node-positive breast cancer. J Clin Oncol 18:3471-3479, 2000 52. Brg A, Baldetorp B, Ferno M, et al. ERBB2 amplification is associated with tamoxifen resistance in steroid-receptor positive breast cancer. Cancer Letters 81:137-144, 1994 53. Buzdar AU, Marcus C, Smith TL, Blumenschein GR. Early and delayed clinical cardiotoxicity of doxorubicin. Cancer 55: 2761-2765, 1985 54. Shapiro CL, Hardenbergh PH, Gelman R et al. Cardiac effects of adjuvant doxorubicin and radiation therapy in breast cancer patients. J Clin Oncol 16: 3493-3501, 1998 55. Coombes RC, Bliss JM, Wils J et al. Adjuvant cyclophosphamide, methotrexate, and fluorouracil versus fluorouracil, epirubicin, and cyclophosphamide chemotherapy in premenopausal women with axillary node-positive operable breast cancer: results of a randomised trial. The International Collaborative Cancer Group. J Clin Oncol 14: 35-45, 1996 56. Early Breast Cancer Trialists Collaborative Group. Radiotherapy for early breast cancer. Cochrane Database Syst Rev:2:CD003647. 57. Paszat LF, Mackillop WJ, Groome PA et al. Mortality from myocardial infarction after adjuvant radiotherapy for breast cancer in the surveillance, epidemiology, and end-results cancer registries. J Clin Oncol 16: 2625-2631, 1998 58. Fuller SA, Haybittle JL, Smith RE, Dobbs HJ. Cardiac doses in post-operative breast irradiation. Radiother Oncol 25: 19-24, 1992. 59. Rutqvist LE, Liedberg A, Hammar N, Dalberg K. Myocardial infarction among women with early-stage breast cancer treated with conservative surgery and breast irradiation. Int J Radiat Oncol Biol Phys 40: 359-363, 1998 60. Hjris I, Overgaard M, Christensen JJ, Overgaard J. Morbidity and mortality of ischaemic heart disease in high-risk breast- cancer patients after adjuvant postmastectomy systemic treatment with or without radiotherapy: analysis of DBCG 82b and 82c randomised trials. Radiotherapy Committee of the Danish Breast Cancer Cooperative Group. Lancet 354: 1425-1430, 1999 61. Valagussa P, Zambetti M, Biasi S et al. Cardiac effects following adjuvant chemotherapy and breast irradiation in operable breast cancer. Ann Oncol 5: 209-216, 1994 62. Menard, S, Calini P, Tomasic G, et. Al. Pathologic identification of two distinct breast carcinoma subsets with diverging clinical behaviors. Breast Cancer Res Treat 55: 169-177, 1999

Roche Protocol BO16348F (Ro 45-2317) - Page 107

63. Roh H, Pippin J & Drebin JA. Down-Regulation of HER2/neu Expression Induces Apoptosis in Human Cancer Cells That Overexpress HER2/neu. Canc Res 60:560-565, 2000 64. Yu D & Hung M-C. Overexpression of ErbB2 in cancer and ErbB2-targeting strategies. Oncogene 19:6115-6121, 2000 65. Goldhirsch A, Glick JH, Gelber RD, Coates AS, and Senn HJ: Meeting highlights: International consensus panel on the treatment of primary breast cancer. J Clin Oncol 19:3817-27, 2001 66. Harvey JM, Clark GM, Osborne CK, et al: Estrogen receptor status by immunohistochemistry is superior to the ligand-binding assay for predicting response to adjuvant endocrine therapy in breast cancer. J Clin Oncol 17: 1474-81, 1999 67. Goldhirsch A, Gelber RD, Yothers F et al: Adjuvant treatment of very young women with breast cancer: Need for tailored treatments. J Nat Cancer Inst (in press), 2001 68. Engelsman E, Klijn JCM, Rubens RD, et al. Classical CMF versus a 3-weekly intravenous CMF schedule in postmenopausal patients with advanced breast cancer. Eur J Cancer 27:966-970, 1991 69. Recht A, Edge SB, Solin LJ, Robinson DS, et al. Postmastectomy radiotherapy: guidelines of the American Society of Clinical Oncology. J Clin Oncol 19: 1539-1569, 2001 70. Ragaz J, Jackson SM, Le N, et al: Adjuvant radiotherapy and chemotherapy in node positive premenopausal women with breast cancer. N Engl J Med 337:956-962, 1997 71. Bonadonna G, Brusamolino E, Valagussa P, et al. Combination chemotherapy as an adjuvant treatment in operable breast cancer. N Engl J Med 294:405-410, 1976 72. Carlson RW, Goldstein LJ, Gradishar WJ, Lichter AS, McCormick B, Moe RE, Theriault RL: NCCN Breast Cancer Practice Guidelines. The National Comprehensive Cancer Network. Oncology (Huntingt). 10:47-75, 1996. 73. Gilles CR, Hole DJ: Survival outcome of care by specialist surgeons in breast cancer: A study of 3786 patients in the West of Scotland. Br Med J 312:145-148, 1996 74. Hannisdal E, Gundersen N, Kvaloy S, et al. Follow-up of breast cancer patients stage I II. A baseline strategy. Eur J Cancer 29A:992-997, 1993. 75. Rosselli Del Turco M, Palli D, Cariddi A, et al. The efficacy of intensive follow-up testing in breast cancer cases. Ann Oncol 6(suppl.2):S37-S39, 1995 76. Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer 1;63(1):181-7, 1989 77. Lan, K.K.G, DeMets D.L. Discrete sequential boundaries for clinical trials Biometrika 70.3, 659-663, 1983 78. Clopper CJ and Pearson ES. The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrika 26 , 404-413, p 410, 1934 79. Holm S. A simple sequential rejective multiple test procedure. Scand J of Statistics 6:65-70, 1979 80. EaSt 2000 (Early Stopping) statistical software package. Cytel Corporation, Cambridge, MA, USA, 2000 81. Perez EA: HER-2 as a Prognostic, Predictive, and Therapeutic Target in Breast Cancer. Cancer Control 6: 233-240, 1999 82. Christian MC, McCabe MS, Korn EL, Abrams JS, Kaplan RS, Friedman MA. The National Cancer Institute audit of the National Surgical Adjuvant Breast and Bowel Project Protocol B-06. N Engl J Med 333(22):1469-74, 1995

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83. Overgaard H, Hansen PS, Overgaard J, et al: Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 337:949-955, 1997 84. Cobleigh MA, Vogel CL, Tripathy D, Robert NJ, Scholl S, Fehrenbacher L, Wolter JM, Paton V, Shak S, Lieberman G, Slamon DJ. Multinational study of the efficacy and safety of humanized anti-HER2 monoclonal antibody in woman who have HER2. N Engl J Med 344:783-792, 2001 85. Demicheli R, Bonadonna G, Rosalba M, Brambilla C, Ferrari L, Moliterni A, Zambetti M, Valagussa P. Comparative analysis of breast cancer recurrence risk for patients receiving or not receiving adjuvant cyclophosphamide, methotrexate, fluorouracil (CMF). Data supporting the occurrence of 'cures'. Breast Can Res Treat 53: 209-215, 1999 86. Sahn D, DeMaria A, Kisslo J et al. The committee of M-Mode standardisation of the American Society of Echocardiography: Recommendations regarding quantification in MMode echocardiography. Results of a survey of echocardiographic measurements. Circulation 58: 1072-83, 1978 87. Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 2:358-367, 1989 88. Fisher B, Brown AM, Dimitrov NV et al. Two months of doxorubicin-cyclophosphamide with and without interval reinduction therapy compared with 6 months of cyclophosphamide, methotrexate, and fluorouracil in positive-node breast cancer patients with tamoxifen-nonresponsive tumors: results from the National Surgical Adjuvant Breast and Bowel Project B-15. J Clin Oncol 8: 1483-1496, 1990 89. Pocock SJ, Simon R: Sequential treatment assignment with balancing for prognostic factors in the controlled clinical trial. Biometrics 31:103-115, 1975 90. Holmvang L, Hasbak P, Clemmensen P, Wagner G, Grande P: Differences between local investigator and core laboratory interpretation of the admission electrocardiogram in patients with unstable angina pectoris or non-Q-wave myocardial infarction (a Thrombin Inhibition in Myocardial Ischemia [TRIM] substudy). Am J Cardiol 82:54-60, 1998 91. Harvey JM, Clark GM, Osborne CK, Allred DC: Estrogen receptor status by immunohistochemistry is superior to the ligand-binding assay for predicting response to adjuvant endocrine therapy in breast cancer. J Clin Oncol 17:1474-81, 1999 92. Hauck WW and Anderson S: A comparison of large sample confidence interval methods for the difference of two binomial probabilities. The American Statistician 4:40, 1986 93. Lueck HJ and Roch H: Weekly paclitaxel: an effective and well-tolerated treatment in patients with advanced breast cancer. Crit Rev Oncol/Hematol 44:S15-S30, 2002. 94. Green MC, Buzdar AU, Smith T, et al.: Weekly paclitaxel followed by FAC as primary systemic chemotherapy of operable breast cancer improves pathologic complete remission rates when compared to every 3-week paclitaxel therapy followed by FAC - final results of a prospective phase III randomized trial. Proc Am Soc Clin Oncol 21:135, 2002 95. The ATAC (Arimidex, Tamoxifen Alone or in Combination) Trialists' Group: Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early breast cancer: first results of the ATAC randomised trial. Lancet 2002; 359: 21312139

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96. Jatoi I, Tsimelzon A, Weiss H, Clark GM, Hilsenbeck SG. Hazard rates of recurrence following diagnosis of primary breast cancer. Breast Cancer Res Treat, 89:173-178, 2005 97. Baum M, Badwe RA: Does surgery influence the natural history of breast cancer? In: Johnson H, Jr (ed) Breast Cancer: Controversies in Management. Futura Publishing Company, Inc., Armonk, NY, 1994, pp 6169 98. Demicheli R, Abbattista A, Miceli R, Valagussa P, Bonadonna G: Time distribution of the recurrence risk for breast cancer patients undergoing mastectomy: further support about the concept of tumor dormancy. Breast Cancer Res Treat 41: 177185, 1996 99. Karrison TG, Ferguson DJ, Meier P: Dormancy of mammary carcinoma after mastectomy. J Natl Cancer Inst 91: 8085, 1999 100. Goss PE, Ingle JN, Martino S et al. Randomised trial of letrozole following tamoxifen as extended adjuvant therapy in receptor-positive breast cancer: updated findings from NCIC CTG MA.17. J Natl Cancer Inst 97:1262-1271 (2005) 101. Ingle JN, Tu D, Pater JL et al. Duration of letrozole treatment and outcomes in the placebo-controlled NCIC CTG MA.17 extended adjuvant therapy trial. Breast Cancer Res Treatment (2006) 102. The Breast International Group (BIG) 1-98 Collaborative Group, A comparison of letrozole and tamoxifen in postmenopausal women with early breast cancer. New England Journal of Medicine 353:2747-2757 (2005) 103. Coombes RC, Hall E, Gibson LJ et al. A randomized trial of exemestane after two to three years of tamoxifen therapy in postmenopausal women with primary breast cancer. New England Journal of Medicine 350:1081-1092 (2004) 104. Piccart-Gebhart MJ, Procter M, Leyland-Jones B et al. Trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer. New England Journal of Medicine 353:1659-1672 (2005) 105. Romond EH, Perez EA, Bryant J et al. Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer. New England Journal of Medicine 353:16731684 (2005) 106. Slamon D, Eiermann W, Pienkowski T et al. Phase III trial comparing AC-T with ACTH and with TCH in the adjuvant treatment of HER2 positive early breast cancer patients: first interim efficacy analysis. SABC 2005 107. Joensuu H, Kellokumpu-Lehtinen PL, Bono P et al. Adjuvant docetaxel or vinorelbine with or without trastuzumab for breast cancer. New England Journal of Medicine 354:809-820 (2006)

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PART II: ETHICS AND GENERAL STUDY ADMINISTRATION 12.


12.1

ETHICAL ASPECTS
Local Regulations/Declaration of Helsinki

The investigator will ensure that this study is conducted in full conformance with the principles of the Declaration of Helsinki (as amended in Tokyo, Venice, Hong Kong, South Africa, Edinburgh) or with the laws and regulations of the country in which the research is conducted, whichever affords the greater protection to the individual. The study must fully adhere to the principles outlined in Guideline for Good Clinical Practice ICH Tripartite Guideline (January 1997) or with local law if it affords greater protection to the subject. For studies conducted in the USA or under US IND, the investigator will additionally ensure that the basic principles of Good Clinical Practice as outlined in the current version of 21 CFR, subchapter D, part 312, Responsibilities of Sponsors and Investigators, part 50, Protection of Human Subjects, and part 56, Institutional Review Boards, are adhered to. In other countries where Guideline for Good Clinical Practice exist Roche and the investigators will strictly ensure adherence to the stated provisions.

11.1

Informed Consent

It is the responsibility of the investigator, or a person designated by the investigator (if acceptable by local regulations), to obtain written informed consent from each subject participating in this study, after adequate explanation of the aims, methods, objectives, anticipated benefits, and potential hazards of the study. It must also be explained to the subjects that they are completely free to refuse to enter the study or to withdraw from it at any time for any reason. Appropriate forms for obtaining written informed consent will be provided by the investigator or by the BrEAST Data Centre. For subjects not qualified or incapable of giving legal consent, written consent must be obtained from the legally acceptable representative. In the case where both the subject and his/her legally acceptable representative are unable to read, an impartial witness should be present during the entire informed consent discussion. After the subject and representative have orally consented to participation in the trial, the witness signature on the form will attest that the information in the consent form was accurately explained and understood. The investigator or designee must also explain that the subjects are completely free to refuse to enter the study or to withdraw from it at any time, for any reason. The Case Report Forms for this study contain a section for documenting informed subject consent, and this must be completed appropriately. If new safety information results in significant changes in the risk/benefit assessment, the consent form should be reviewed and updated if necessary. All subjects (including those already being treated) should be informed of the new information, given a copy of the revised form and give their consent to continue in the study. In a life-threatening situation where a patient is unconscious or otherwise unable to communicate, the emergency is such that there is not enough time to obtain consent from the patient's legally acceptable representative, and there is no other or better treatment available, it is permissible to

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treat the patient under protocol with consent of both the investigator and another physician not involved in the study, with appropriate documentation submitted to the Institutional Review Board (IRB) within 5 days. If this collaboration is not immediately possible, there must be a written evaluation by a physician independent of the study and the appropriate documentation be submitted to the IRB within five days of treating the patient. In addition, the patient or his/her legally acceptable representative should be informed about the trial as soon as possible and consent to continue, giving written consent as described above.In a life-threatening situation where a patient is unconscious or otherwise unable to communicate, the emergency is such that there is not enough time to obtain consent from the patient's legally acceptable representative, and there is no other or better treatment available, it is permissible to treat the patient under protocol with consent of the investigator, with appropriate documentation that the Independent Ethics committee (IEC) had approved the procedures used to enroll patients in such situations. In addition, the patient or his/her legally acceptable representative should be informed about the trial as soon as possible and consent to continue, giving written consent as described above.

11.2

Independent Ethics Committees/Institutional Review Board

This protocol and any accompanying material provided to the subject (such as subject information sheets or descriptions of the study used to obtain informed consent) as well as any advertising or compensation given to the patient, will be submitted by the investigator to an Independent Ethics Committee. Approval from the committee must be obtained before starting the study, and should be documented in a letter to the investigator specifying the date on which the committee met and granted the approval. Any modifications made to the protocol after receipt of the Independent Ethics Committee approval must also be submitted by the investigator to the Committee in accordance with local procedures and regulatory requirements. When no local review board exists, the investigator is expected to submit the protocol to a regional committee. If no regional committee exists, Roche will assist the investigator in submitting the protocol to the European Ethics Review Committee. It is the understanding of the sponsor that this protocol (and any modifications) as well as appropriate consent procedures, will be reviewed and approved by an Institutional Review Board. This board must operate in accordance with the current Federal Regulations. A letter or certificate of approval will be sent by the investigator to the sponsor prior to initiation of the study, and also whenever subsequent modifications to the protocol are made.

12.

CONDITIONS FOR MODIFYING THE PROTOCOL

Protocol modifications to this ongoing study must be made only after consultation of the Steering Committee (containing both, the investigator and sponsor membership) and the BrEAST Data Centre. Protocol modifications must be prepared jointly by Roche and a representative of the BrEAST Data Centre and initially reviewed and approved by the Steering Committee. All protocol modifications must be submitted to the appropriate Independent Ethics Committee or Institutional Review Board for information and approval in accordance with local requirements, and to Regulatory Agencies if required. Approval must be awaited before any changes can be implemented, except for changes necessary to eliminate an immediate hazard to trial subjects, or

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when the change(s) involves only logistical or administrative aspects of the trial (e.g. change in monitor(s), change of telephone number(s).

13.

CONDITIONS FOR TERMINATING THE STUDY

Both, the sponsor and the investigator reserve the right to terminate the study at any time. The Steering Committee can recommend termination of the study to the sponsor and all involved investigators. In terminating the study, BrEAST Data Centre, the sponsor and the investigator will assure that adequate consideration is given to the protection of the patients interests.

14.
12.1

STUDY DOCUMENTATION, CRFS AND RECORD KEEPING


Investigator's Files / Retention of Documents

The Investigator must maintain adequate and accurate records to enable the conduct of the study to be fully documented and the study data to be subsequently verified. These documents should be classified into two different separate categories (1) Investigator's Study File, and (2) subject clinical source documents. The Investigator's Study File will contain the protocol/amendments, Case Report and Query Forms, Independent Ethics Committee/Institutional Review Board and governmental approval with correspondence, sample informed consent, drug records, staff curriculum vitae and authorisation forms and other appropriate documents/correspondence etc. Subject clinical source documents (usually defined by the project in advance to record key efficacy/safety parameters independent of the CRFs) would include patient hospital/clinic records, physician's and nurse's notes, appointment book, original laboratory reports, ECG, EEG, X-ray, pathology and special assessment reports, signed informed consent forms, consultant letters, and subject screening and enrollment logs. The Investigator must keep these two categories of documents on file for at least 15 years after completion or discontinuation of the study. After that period of time the documents may be destroyed, subject to local regulations. Should the Investigator wish to assign the study records to another party or move them to another location, Roche must be notified in advance. If the Investigator can not guarantee this archiving requirement at the investigational site for any or all of the documents, special arrangements must be made between the Investigator and Roche to store these in a sealed container(s) outside of the site so that they can be returned sealed to the Investigator in case of a regulatory audit. Where source documents are required for the continued care of the patient, appropriate copies should be made for storing outside of the site.

14.1

Source Documents and Background Data

The investigator shall supply the sponsor and the BrEAST Data Centre with any required background data from the study documentation or clinic records on request. This is particularly important when Case Report Forms are illegible or when errors in data transcription are suspected. In case of special problems and/or governmental queries or requests for audit inspections, it is also necessary to have access to the complete study records, provided that patient confidentiality is protected.

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14.2

Audits and Inspections

The investigator should understand that source documents for this trial should be made available to appropriately qualified personnel from the Sponsors Research Quality Assurance Unit, the BrEAST Data Centre, or its designees, or to health authority inspectors after appropriate notification. The verification of the Case Report Form data must be by direct inspection of source documents.

14.3

Case Report Forms

For each patient enrolled, a Case Report Form must be completed and signed by the principal investigator or authorised delegate from the study staff. This also applies to records for those patients who fail to complete the study (even during a screening period if a Case Report Form was initiated). If a patient withdraws from the study, the reason must be noted on the Case Report Form. If a patient is withdrawn from the study because of a treatment-limiting adverse event, thorough efforts should be made to clearly document the outcome. All forms should be typed or filled out using indelible ink, and must be legible. Errors should be crossed out but not obliterated, the correction inserted, and the change initialed and dated by the investigator or his/her authorised delegate. The investigator should ensure the accuracy, completeness, legibility, and timeliness of the data reported to the sponsor in the CRFs and in all required reports.

15.

MONITORING THE STUDY

It is understood that the responsible monitor (or designee) will contact and visit the investigator regularly and will be allowed, on request, to inspect the various records of the trial (Case Report Forms and other pertinent data) provided that patient confidentiality is maintained in accord with local requirements. It will be the monitor's responsibility to inspect the Case Report Forms at regular intervals throughout the study, to verify the adherence to the protocol and the completeness, consistency and accuracy of the data being entered on them. The monitor should have access to laboratory test reports and other patient records needed to verify the entries on the Case Report Form. The investigator (or his/her deputy) agrees to cooperate with the monitor to ensure that any problems detected in the course of these monitoring visits are resolved.

16.

CONFIDENTIALITY OF TRIAL DOCUMENTS AND SUBJECT RECORDS

The investigator must assure that subjects anonymity will be maintained and that their identities are protected from unauthorised parties. On CRFs or other documents submitted to the sponsor, subjects should not be identified by their names, but by an identification code. The investigator should keep a subject enrollment log showing codes, names and addresses. The investigator should maintain documents not for submission to the BrEAST Data Centre or the sponsor, e.g., subjects written consent forms, in strict confidence.

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17.

PUBLICATION OF DATA AND PROTECTION OF TRADE SECRETS

The results of this study will be published or presented at scientific meetings with the approval of the Steering Committee and in accordance with the main contract for the trial. In accord with standard editorial and ethical practice, the Steering Committee will generally support publication of multicentre trials only in their entirety and not as individual centre data. A coordinating investigator will be designated by mutual agreement to coordinate and prepare the final publication. There will be one main publication. All proposals/manuscripts of subsequent publications have to be submitted to the Steering Committee, reviewed and approved by this body. Since the sponsor is represented on the Steering Committee this allows the sponsor to protect proprietary information and to provide comments based on information from other studies that may not yet be available to the investigators.

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Appendix 1

TNM nomenclature for breast cancer


Tumour (T)

T0 Tis T1

No evidence of primary tumour Carcinoma in situ 2cm T1mic T1a T1b T1c 0.1 cm 0.5 cm > 0.5 cm-1 cm > 1 cm-2 cm

T2 T3 T4

>2 cm-5 cm >5 cm Any size, with direct extension to chest wall or skin (excluding pectoral muscle) T4a T4b T4c T4d Extension to chest wall Edema or ulceration of skin or presence of satellite nodules Both T4a and T4b Inflammatory carcinoma

N0 N1 N2 N3 M0 M1

Nodes (N) No regional lymph node metastasis


Metastasis to movable ipsilateral axillary lymph node or nodes Metastasis to ipsilateral axillary lymph node or nodes fixed to one another or to other structures Metastasis to ipsilateral internal mammary lymph node or nodes

Metastasis (M)
No distant metastases Distant metastasis, including metastasis to ipsilateral supraclavicular lymph node or nodes

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.

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