`Anastrozole in Postmenopausal Women With Advanced
`Breast Cancer Progressing After Prior Endocrine
`Treatment
`
`By A. Howell, J.F.R. Robertson, J. Quaresma Albano, A. Aschermannova, L. Mauriac, U.R. Kleeberg, I. Vergote,
`B. Erikstein, A. Webster, and C. Morris
`
`Purpose: To comparethe efficacy and tolerability
`of fulvestrant (formerly ICI 182,780) and anastrozole
`in postmenopausal women with advanced breast
`cancer progressing after prior endocrine treatment.
`Patients and Methods: Patients (n = 451) with ad-
`vanced breast cancer were randomizedto receive fulves-
`trant 250 mg as a once-monthly (one x 5 mL) intramus-
`cular injection or an oral dose of anastrozole 1 mgin this
`open, parallel-group, multicentertrial. The primary end
`point wastime to progression (TTP). Secondary end points
`included objective response (OR) rates, defined as com-
`plete response (CR) or partial response (PR), duration of
`response (DOR), and tolerability.
`
`Results: Patients were followed for a median period
`of 14.4 months. In terms of TIP, fulvestrant was as
`effective as anastrozole (hazard ratio, 0.98; confidence
`interval [CI], 0.80 to 1.21; P = .84). Median TTP was 5.5
`monthsfor fulvestrant and 5.1 months for anastrozole.
`
`ORrates showed a numerical advantagefor fulvestrant
`(20.7%) over anastrozole (15.7%) (odds ratio, 1.38; Cl,
`0.84 to 2.29; P = .20). Clinical benefit rates (CR + PR +
`stable disease = 24 weeks) were 44.6% for fulvestrant
`and 45.0% for anastrozole. Median DOR was 15.0
`months for fulvestrant and 14.5 months for anastro-
`zole. Both treatments were well tolerated, with 3.2%
`and 1.3% of fulvestrant- and anastrozole-treated pa-
`tients, respectively, withdrawn from treatment because
`of an adverse event.
`Conclusion: Fulvestrant was as effective as anastro-
`zole. These data confirm that fulvestrant is an addi-
`tional, effective, and well-tolerated treatment for ad-
`vanced breast cancer
`in postmenopausal women
`whosedisease progressed on prior endocrine therapy.
`J Clin Oncol 20:3396-3403. © 2002 by American
`Society of Clinical Oncology.
`
`HE TREATMENT OF breast cancer in postmeno-
`pausal women with hormone-responsive tumors is
`based on two key approaches: prevention of estrogen
`binding to the estrogen receptor (ER) using an antiestrogen,
`or lowering of estrogen levels using an aromatase inhibitor.
`The selective estrogen receptor modulator tamoxifen (Nol-
`vadex; AstraZeneca Pharmaceuticals, Macclesfield, United
`Kingdom) is the most widely used hormonal treatment for
`breast cancer and has good efficacy in hormone-sensitive
`tumors.’ Tamoxifen has also been shown to be highly
`
`
`
`From the Christie Hospital, Manchester, City Hospital, Nottingham,
`and AstraZeneca, Macclesfield, Cheshire, United Kingdom;
`Instituto
`Portugues De Oncologia De Coimbra, Coimbra, Portugal; Odborny
`Lecebny Ustav Onkologie A Pneumologie, Nova Ves Plod Plesi, Czech
`Republic; Institut Bergonie, Bordeaux, France; Haematologisch/Onkolo-
`gische Praxis, Hamburg, Germany; University Hospital Leuven, Leuven,
`Belgium; and Norwegian Radium Hospital, Odo, Norway.
`Submitted October 10, 2001; accepted April 22, 2002.
`Supported by a grant from AstraZeneca Pharmaceuticals.
`This article was published ahead of print at www.jco.org.
`Address reprint requests to A. Howell, MD, Department of Medical
`Oncology, Christie Hospital National Health Service Trust, Wilmslow
`Rd, Manchester M20 4BX, United Kingdom; email (A.H.’s assistant):
`maria.parker @christie-tr.nwest.nhs.ukto.
`© 2002 by American Society of Clinical Oncology.
`0732-183X/02/2016-3396/$20.00
`
`effective in reducing the incidence of breast cancer in
`patients at high risk of developing the disease.* Once breast
`cancer recurs or progresses after treatment with tamoxifen,
`standard follow-up treatments are the aromatase inhibitors,
`such as third-generation oral, selective aromatase mbhibitors
`mceluding anastrozole (Arimidex; AstraZeneca) or letrozole
`(Femara, Novartis Pharma AG, Basel, Switzerland).
`A specific antiestrogen with highaffinity for the ER and
`without agonist effects may have advantages over tamox-
`ifen in the treatment of hormone-sensitive breast cancer.
`
`Fulvestrant (Faslodex, formerly known as ICI 182,780;
`AstraZeneca) 1s a novel, steroidal, ER downregulator with a
`mode of action distinct from that of tamoxifen.* Fulvestrant
`binds to the ER and a rapid loss of ER protein in the tumor
`ensues.* This downregulation of the ER levels in the tumor
`is dose dependent, as is the significant reduction in tumor
`progesterone receptor (PgR) levels.* Tamoxifen, in contrast,
`1s associated. with a rise in PgR levels, which demonstrates
`the presence of a functional estradiol pathway and confirms
`the partial agonism of tamoxifen in contrast to the “pure”
`antagonist action of fulvestrant. Preclinical studies indicated
`that fulvestrant would be effective in tamoxifen-resistant
`breast cancer.’ A phaseII trial conducted with fulvestrant in
`women with advanced breast cancer resistant to tamox-
`ifen®’ demonstrated that fulvestrant has good clinical ac-
`tivity in tamoxifen-resistant breast cancer and also sug-
`
`3396
`
`Journal of Clinical Oncology, Vol 20, No 16 (August 15), 2002: pp 3396-3403
`DOI: 10.1200/JCO.2002.10.057
`Information downloaded from jco.ascopubs.org and provided by at UNIVERSITY NOTTINGHAM on October 17, 2014 from
`Copyright © 2002 American Sodi@éy2sfeCiinigal Oncology. All rights reserved.
`
`AstraZeneca Exhibit 2028 p. |
`InnoPharma Licensing LLC v. AstraZeneca AB IPR2017-00904
`Fresenius-Kabi USA LLCv. AstraZeneca AB IPR2017-01910
`
`
`
`COMPARISON OF FULVESTRANT AND ANASTROZOLE IN ADVANCED BREAST CANCER
`
`3377
`
`gested a prolonged duration of response (DOR) when
`compared indirectly with a matched group of patients who
`received megestrol acetate after failure of tamoxifen.’
`This article reports the results of an open, randomized,
`multicenter, parallel-group, phase II clinical
`trial
`that
`comparedtheefficacy and tolerability of fulvestrant 250 mg
`administered as a once-monthly intramuscular (IM) injec-
`tion with an oral dose of anastrozole 1 mg once daily, in
`postmenopausal women with advanced breast cancer whose
`disease had progressed after prior endocrine therapy.
`
`PATIENTS AND METHODS
`
`Study Design
`
`This was an open, randomized, international, multicenter, parallel-
`group, phaseIIItrial. It was originally designed to compare two doses
`of fulvestrant (125 mg and 250 mg per month IM) with a single dose
`of anastrozole (1 mg/d orally). The study (trial 0020) was carried outin
`Europe, Australia, and South Africa and involved 83 centers. In this
`open trial, fulvestrant 250 mg was given as a one X 5-mLinjection,
`compared with the two X 2.5-mL injections that were administered in
`the North American trial 0021. Trial 0021 was a double-blind,
`double-dummytrial using the same drug doses and a similar protocol
`that ran concurrently, also appearing in the August 15, 2002, issue of
`the Journal of Clinical Oncology.* These trials were designed to be
`evaluated individually and using combined data.
`A preliminary data summary and an interim analysis were planned
`and conducted because the clinical activity of fulvestrant 125 mg had
`not been previously tested. Therefore, bothtrials included a preliminary
`data summary stage afterthe first 30 subjects in the fulvestrant 125-mg
`group (combined from bothtrials) had been treated and followed up for
`a minimum of 3 months, This interim assessment showed insufficient
`evidence ofclinical activity for the 125-mg dose of fulvestrant, with no
`objective tumor responses. The independent data monitoring commit-
`tee therefore recommended that recruitment to the fulvestrant 125-mg
`treatment arm be stopped. Patients already recruited into the 125-mg
`arm in this trial were permitted to remain on fulvestrant 125 mg or be
`withdrawn from the trial and returned to other treatments at the
`discretion of their clinician. These patients were not monitored further
`for efficacy. As a consequence of dropping this treatment arm, the
`protocol for the study was amended to be a comparison between
`fulvestrant 250 mg (IM) and anastrozole 1 mg/d orally.
`Aninterim analysis was conducted when 170 disease progressions or
`deaths had occurred across the remaining arms and time to progression
`(TTP) was formally analyzed. Objective response (OR) rate (defined as
`complete response [CR] + partial response [PR], using Union Inter-
`nationale Contre le Cancer criteria) and adverse event (AE) data were
`summarized. As a result of the interim analysis, the independent data
`monitoring committee recommended that both trials should continue.
`Fulvestrant 250 mg (IM) was compared with anastrozole (1 mg/d
`given orally) in terms of the primary end point of TTP. Secondary
`end points included OR, DOR,time to treatment failure (TTF), time
`to death (TTD), and tolerability. Other secondary end points were
`quality of life, symptomatic response, and pharmacokinetics. Other
`efficacy datapoints reported included clinical benefit (CR + PR +
`stable disease [SD] = 24 weeks), and duration of clinical benefit.
`All data are reported here except for pharmacokinetics, which will
`be reported elsewhere.
`
`Patient Population
`
`All patients were postmenopausal women with locally advanced or
`metastatic breast cancer whose disease had progressed during adjuvant
`endocrine therapy or first-line endocrine therapy for advanced disease.
`All women had tumors with evidence of hormonesensitivity (ie, prior
`sensitivity to hormonal therapy or known ER or PgR positivity) andlife
`expectancy of greater than 3 months, and in the opinion of the
`investigator, all were deemed appropriate candidates for subsequent
`hormonal therapy.
`For inclusion in the trial, patients had to have a World Health
`Organization performance status of = 2, histologic or cytologic
`confirmation of breast cancer, and objective evidence of recurrence or
`progression of disease that was not amenable to curative treatment,
`with the presence of at least one measurable or assessable (nonmea-
`surable) lesion. All patients had to be postmenopausal (ie, = 60 years
`old or aged = 45 years with amenorrhea for > 12 months or
`follicle-stimulating hormone levels within postmenopausal range, or
`having undergone bilateral oophorectomy).
`Exelusion criteria included the following: presence of life-threaten-
`ing metastatic visceral disease (defined as extensive hepatic involve-
`ment) or any degree of brain or leptomeningeal
`involvement or
`symptomatic pulmonary lymphangitic spread; prior treatment for breast
`cancer with fulvestrant or any aromatase inhibitor; more than one
`prior endocrine treatment for advanced breast cancer, extensive
`radiation therapy or cytotoxic treatment within the past 4 weeks;
`estrogen replacement therapy within 4 weeks of randomization;
`treatment with luteinizing hormone-releasing hormone analogs
`within 3 months of randomization; and any concurrent medical
`illness or laboratory abnormalities that would compromise safety or
`prevent interpretation of results.
`Subjects taking bisphosphonates were permitted to enterthe trial but
`their bone lesions were not considered to be assessable for response,
`although they were assessable for progression. Initiation of bisphos-
`phonate treatment during the trial was discouraged. If bisphosphonates
`were commenced in the absence of objective evidence of progression,
`bone lesions were assessed only for progression.
`All patients gave written imformed consent, and approval was
`obtained from the relevant ethical committees.
`
`Trial Treatments
`
`Fulvestrant was supplied in vials as a single-dose, castor oil-based,
`5% solution. Each vial contained 250 mg of fulvestrant at a concen-
`tration of 50 mg/mL in a volume of 5 mL. Fulvestrant 250 mg was
`administered slowly by a single one X 5-mL injection into the buttock.
`Injections were given once a month, which was defined as every 28
`days (+ 3 days). Anastrozole 1 mg was supplied as round, white,
`film-coated tablets and administered orally once daily.
`Patients continued treatment until objective disease progression or
`other events required withdrawal. At such time, trial treatment was
`stopped and standard therapy was initiated. Thereafter, patients were
`followed up until death. Patients who withdrew from trial treatment
`before disease progression were followed up until objective disease
`progression and death.
`For all patients, objective tumor assessments were undertaken every
`3 months until evidence of either objective disease progression or
`death. Patients with skin or soft tissue lesions were also assessed every
`month during the first 3 months of treatment.
`
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`Copyright © 2002 American So¢i@éy2xfsCiinigal Oncology. All rights reserved.
`
`AstraZeneca Exhibit 2028 p. 2
`
`
`
`3398
`
`Slatistical Methodology
`
`The trial was designed to detect the superiority of fulvestrant 250
`mg in terms of efficacy compared with anastrozole 1 mg. The final
`analysis was scheduled to occur when 340 events (ie, objective
`disease progression or death) had occurred across the two groups.
`This provided 90% powerto detect a hazard ratio (HR) = 1.43 or =
`0.70 for fulvestrant treatment compared with anastrozole treatment,
`at a significance level of 5%. To achieve the required number of
`events, it was calculated that 392 patients (196 in each treatment
`group) would be required.
`The efficacy analyses were performed according to randomized
`treatment(ie, “intention to treat”) using a nominal significance level
`of 5%. However, for the TTP and OR analyses, the significance
`level was adjusted to 4.86% because of the preliminary data
`summary of OR and the interim analysis of TTP. As a result, the
`95% confidence intervals
`(CIs) were adjusted accordingly to
`95.14%. All significance levels were two-sided.
`Although not described in the protocol, fulvestrant was retrospec-
`tively compared with anastrozole for noninferiority for OR, TTP and
`TIF. Because of the interim analysis, a one-sided Cl of 97.57% was
`used for the analyses of TTP and OR. For TTF, a one-sided CI of
`97.5% was used. These limits are identical to using the upper limit of
`the 95.14% two-sided CI from the analysis of TTP, the lower limit of
`the 95.14% two-sided Cl for the difference in response rates for OR,
`and the upper limit of the 95% two-sided CI for TTF.
`For previous United States regulatory submissions of hormonal
`treatments for advanced breast cancer, the requirements for showing
`noninferiority for TTP were based on the upper one-sided confidence
`limit for the TTP HR not being greater than 1.25 (ie, a potential
`deficiency of > 25% for the experimental treatment had to be ruled
`out).
`In the same submissions, the requirement for demonstrating
`noninferiority in terms of response rate was based on ruling out a
`deficiency in the difference in response rates of greater than 10%.
`Consequently, these criteria have been used to assess noninferiority of
`fulvestrant relative to anastrozole in thistrial.
`TIP. TTP was defined as the time from randomization until
`objective disease progression. Death was regarded as a progression
`event in those who died before disease progression. Subjects whose
`disease had not progressed at the time of analysis were right-censored
`using the last assessment date. Treatments were compared. using the
`Cox proportional hazards regression model (including the covariates
`age, performance status, measurable compared with nonmeasurable
`disease, receptor status, previous response to hormone therapy, previ-
`ous use of cytotoxic chemotherapy, and use of bisphosphonate therapy
`for bone disease). A global test was performed to determine whether
`there were significant treatment-by-baseline covariate interactions. The
`estimate of the treatment effect is expressed as an HR (fulvestrant/
`anastrozole), together with the corresponding CI and P value. TTP was
`also summarized using Kaplan-Meier curves for each treatment group,
`and the median TTP was calculated.
`TIF. TTF was defined as the number of days from randomization
`until the earliest occurrence of disease progression, death from any
`cause, or withdrawal from trial treatment for any reason. Patients who
`had not experienced treatment failure at the time of analysis were
`right-censored in the analysis at the time oftheir last assessment. Any
`patient who did not receive anytrial therapy was assigned an uncen-
`sored TTF of zero days. Statistically, TTF was analyzed in the same
`wayas TTP.
`ORrate. Responders were defined as those patients with CR or PR.
`To qualify as a responder, the patient hadto satisfy the criteria for CR
`
`HOWELL ET AL
`
`or PR on one visit with no evidence of disease recurrence or death
`
`within 4 weeks of the response assessment. Treatment differences in
`OR were assessed by comparing the proportion of responders (CR and
`PR) using a logistic regression model (with the same covariates as for
`TTP). The estimate of the treatment effect is expressed as an oddsratio
`(fulvestrant/anastrozole), together with the corresponding CI and P
`value.
`In addition, an estimate of the difference in response rates
`(fulvestrant/anastrozole) and corresponding CI was also produced.”
`DOR. The DOR wasdefined, for responding patients only, as the
`period of time from randomization to the first observation of disease
`progression. Patients who died before reaching progression were
`classed as completing their response at time of death. The DOR was
`summarized using Kaplan-Meier curves for each treatment group, and
`the median DOR was also calculated for each group.
`No statistical comparison was performed for DOR in only those
`patients responding to treatment, since this is not a randomized
`comparison. Rather, all patients were included in a statistical analysis
`of DOR,defined for responders as the time from the onset of response
`to disease progression and for nonresponders as zero. These data were
`also summarized using Kaplan-Meier curves.
`Clinical benefit. Clinical benefit was defined by the sum of CR +
`PR + SD = 24 weeks. Although a formal analysis of clinical benefit
`was not protocoled, treatment differences in the rate of clinical benefit
`were retrospectively assessed in the same way as that of OR rate. The
`duration of clinical benefit was presented as for DOR.
`TTD.
`‘TTD was protocoled to be analyzed when at least 50% of
`the patients had died. At the time of data analysis, only 36.7%of
`patients had died and therefore no formal statistical analyses were
`made at this time.
`
`Tolerability
`
`Any detrimental change in a patient’s condition subsequent to them
`entering onto the trial and during the follow-up period after the final
`treatment (8 weeksafter last injection of fulvestrant and 30 days after
`the last day of treatment with anastrozole), which was not unequivo-
`cally due to progression of disease, was considered to be an AE. All
`safety data were listed and summarized according to the treatment
`received. No formal statistical analyses were performed on the safety
`data from this individual trial, However, a planned statistical analysis
`of predefined AEs was performed on the combined data fromthistrial
`and the North American trial: this will be reported elsewhere. The most
`common AEs (occurring at incidence of = 10%) and most common
`drug-related AEs are reported here by treatment received.
`
`Quality of Life
`
`Quality of life (QOL) was assessed using the Functional Assessment
`of Cancer Therapy (FACT)-—Breast questionnaire, which comprises the
`FACT-General QOL tool for cancer patients plus the breast cancer
`subscale. This questionnaire has been extensively validated in respect
`to its psychometric properties and sensitivity to clinical changes'®"!
`and is in use ina numberoflarge breast cancer treatmenttrials in the
`United States and Europe.
`The analysis was undertaken on data collected up to the date of
`progression, using the trial outcome index (TOI) within the FACT-
`Breast. This measure is the sumof the functional well-being, physical
`well-being and breast cancer subscale dimensions of the questionnaire.
`Patients without baseline TOI data or with data collected more than 7
`days after the start of treatment were excluded from this analysis.
`The difference in TOI over time between the fulvestrant 250-mg
`group and the anastrozole 1-mg group was compared using a general-
`
`Information downloaded from jco.ascopubs.org and provided by at UNIVERSITY NOTTINGHAM on October 17, 2014 from
`Copyright © 2002 American So¢i@éy2xfsCiinigal Oncology. All rights reserved.
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`
`COMPARISON OF FULVESTRANT AND ANASTROZOLE IN ADVANCED BREAST CANCER
`
`33979
`
`Table 1. Demographic and Pretreatment Characteristics
`Fulvestrant 250 mg (n = 222)
`Anastrozole 1 mg/d (n = 229)
`
`
`
` Characteristic No. % No. %
`
`
`
`
`
`Age, years
`Mean
`
`Range
`Weight, kg
`Mean
`
`Range
`Prior treatment
`
`Cytotoxic chemotherapy
`Endocrine therapy for advanced disease
`Adjuvant endocrine therapy
`Hormonereceptor status
`ER and/or PgR-+ve
`ER/PgR unknown
`ER/PgR-ve
`Metastatic or recurrent disease at baseline
`Breast
`Skin
`Bone.
`liver
`Lung
`Lymph nodes
`Other
`Extent of metastatic or recurrent disease at
`baseline
`
`63
`
`35-86
`
`69
`
`41-124
`
`64
`
`33-89
`
`68
`
`40-110
`
`94
`126
`121
`
`163
`51
`8
`
`21
`40
`115
`A8
`56
`78
`27
`
`42.3
`56.8
`54.5
`
`73.4
`23.0
`3.6
`
`9.5
`18.0
`51.8
`21.6
`25.2
`35.1
`T22
`
`98
`129
`I?
`
`183
`37
`9
`
`30
`35
`117
`56
`60
`83
`18
`
`A28
`56.3
`52.0
`
`AEP
`16.2
`3.9
`
`13.1
`15.3
`51.1
`24.5
`26.2
`36.2
`Te
`
`3.5
`8
`5.0
`J
`Soft tissue only
`17.5
`40
`17.1
`38
`Boneonly
`17.9
`4]
`13.5
`30
`Visceral only
`9.2
`21
`ae
`22
`Lymph node only
`04
`1
`0
`QO
`Notrecorded
`51.5
`118
`54.5
`121
`Mixed*
`62.0
`142
`59.0
`131
`Measurable lesionst
`
`Nonmeasurable lesions 38.0 91 41.0 87
`
`
`
`
`NOTE. Patients may be in more than one category.
`Abbreviations: ER, estrogen receptor; PgR, progesterone receptor.
`*Mixed is defined as breast and/or a combination of skin, bone,liver, lung, or lymph nodes.
`tMeasurable lesions werelesions that were clinically measurable in two perpendicular axes with at least one dimension being = 2.5 cm or measurable using
`imaging in two perpendicular axes with at least one dimension being = 1.0 cm.
`
`ized linear mixed model (ie, a random coefficients model) with the
`same covariates as for TTP. A graph of the mean TOI (+ standard
`deviation) over time was also produced.
`
`RESULTS
`
`Patients
`
`A total of 451 patients were randomized to fulvestrant 250
`mg (n = 222) or to anastrozole | mg once daily (n = 229) and
`were followed for a median period of 14.4 months. The
`majority of patients (97% 1n the fulvestrant group and 98% in
`the anastrozole group) had previously been treated with tamox-
`ifen as either adjuvant therapy or for advanced disease. The
`other patients were previously treated with droloxifene, gos-
`erelin, idoxifene, megestrol acetate, or toremifene. A total of
`
`95 patients in the fulvestrant group and 100 patients in the
`anastrozole group had only recetved endocrine therapy as
`adjuvant treatment. Of these, the majority (80.0%) stopped
`treatment less than 365 days before randomization.
`The characteristics of the patients in the two treatment
`groups are given in Table 1. Patients in the fulvestrant and the
`anastrozole groups were well matched in terms of age, weight,
`breast cancer history, and ER/PgR status. Only 11.8% of
`patients m the fulvestrant group and 7.5% of patients in the
`anastrozole group had bisphosphonate therapy.
`
`Efficacy
`
`TTP. At the time of analysis, 183 (82.4%) of 222 of
`those patients randomized to fulvestrant had progressed, as
`
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`
`
`
`
`
`Proportionwithoutprogression Fulvestrant 250 mg
`
`
`
`
`Median TTP: Fulvestrant
`Anastrozole
`
`5.5 months
`5,1 months
`
`o a
`
`
`
`Proportionnotfailing
`
`ee Anastrozole 1 mg
`
`Time to progression (months)
`
`HOWELL ET AL
`
`
`
`4.6 months
`Median TTF: Fulvestrant
`Anastrozole 4.1 months
`
`
`
` Fulvestrant 250 mg
`aermare Anastrozole 1 mg
`
`Time to treatmentfailure (months)
`
`Fig 1. Kaplan-Meier estimates for time to progression.
`
`Fig 2. Kaplan-Meierestimates for time to treatmentfailure.
`
`had 191 (83.4%) of 229 of those randomizedto anastrozole.
`The statistical analysis showed that there was no evidence
`of a statistically significant difference in TTP between
`fulvestrant and anastrozole (HR, 0.98; 95.14% CI, 0.80 to
`1.21, P = .84). The 95.14% CI indicates that the risk of
`progression for patients randomized to fulvestrant 250 mg
`could be between 20% lower and 21% higher than it is for
`patients randomized to anastrozole. These data fulfill the
`criteria for noninferiority of fulvestrant relative to anastro-
`zole. The Kaplan-Meier curves for TTP with fulvestrant and
`anastrozole are shown in Fig 1. The median TTP was 5.5
`months for fulvestrant and 5.1 months for anastrozole.
`TIF. Atthe trial cutoff date, 188 patients (84.7%) in the
`fulvestrant group and 196 patients (85.6%) in the anastro-
`zole group had experienced treatmentfailure. Thestatistical
`analysis showed that fulvestrant was not significantly dif-
`ferent from anastrozole in terms of TTF (HR, 0.97; 95% CI,
`0.80 to 1.19; P = .81)
`(@ig 2), and the criteria for
`noninferiority of fulvestrant were fulfilled. The median TTF
`was 4.6 months for fulvestrant and 4.1 months for anastro-
`
`zole. Of those patients whose treatment failed, 94.7% of the
`fulvestrant group and 95.4% of the anastrozole group
`experienced treatment failure because of disease progres-
`sion. Other teasons for treatment failure included AEs
`
`(fulvestrant v anastrozole, 1.6% v 1.5%), protocol noncom-
`pliance (1.1% v 2.0%), and withdrawal of informed consent
`(1.1% v 0.5%).
`ORrate. At the time ofdata cutoff, 20.7% of patients in
`the fulvestrant group and 15.7% ofthose in the anastrozole
`group had evidence of OR (ie, had a best OR of CR or PR)
`(Table 2). The statistical analysis for OR showed no
`statistically sigrificant difference between fulvestrant and
`anastrozole (difference in response rates, 4.8%; 95.14% CI,
`—2.19%, to 14.23%), and the criteria for noninferiority of
`fulvestrant were fulfilled. There was a nonsignificant nu-
`merical advantage for fulvestrant over anastrozole, with the
`
`odds of attaining OR being 38% higher in the fulvestrant
`group (odds ratio, 1.38; 95.14% CL, 0.84 to 2.29; P = .20).
`Clinical benefit rates (CR + PR + SD = 24 weeks) of
`44.6% and 45.0% were observed for fulvestrant and
`
`anastrozole, respectively (Table 2), with the analysis
`showing nostatistically significant difference (difference
`in clinical benefit rates, —0.95%; 95% CI, —10.12% to
`8.64%, P = .85).
`Further follow-up was performed to obtain more com-
`plete
`information for DOR (median follow-up, 22.6
`months). The median DOR, as measured from randomiza-
`tion to progression,
`in those patients who responded to
`treatment was 15.0 monthsfor fulvestrant (n = 48) and 14.5
`months for anastrozole (n = 39), Kaplan-Meier curves for
`
`Table 2. Best Objective Responses for Fulvestrant, 250 mg IM or
`Anastrozole 1 mg Orally od
`Fulvestrant
`Anastrozole
`(n = 222)
`(n = 229)
`No.
`%
`No.
`%e
`
`CR
`10
`AS
`4
`1.7
`PR
`36
`16.2
`32
`14.0
`
`Total (OR)
`SD > 24 weeks
`SD < 24 weeks
`
`46
`53
`3
`
`20.7*
`23.9
`1.4
`
`36
`67
`3
`
`15.7
`29.3
`1.3
`
`2.6
`6
`A5
`10
`Not progressedt
`51.1
`117
`49.5
`110
`Progressed
`84.3
`193
`79.3
`176
`Total
`45.0
`103
`AA.6F
`99
`Clinical benefit (CR + PR +
`SD = 24 weeks)
`Abbreviations: CR, complete response; PR, partial response; SD, stable
`disease.
`
`“Difference in response rates, 4.8%; 95.14% Cl, —2.19% to 14.23%.
`tPatients with a best response of “not progressed” were not assessable for
`response except for progression (eg, patients with bone-only disease taking
`bisphosphonates).
`Differencein clinical benefit rates, —0.95%; 95% Cl, —10.12% to 8.64%;
`P= 85.
`
`Information downloaded from jco.ascopubs.org and provided by at UNIVERSITY NOTTINGHAM on October 17, 2014 from
`Copyright © 2002 American So¢i@éy2xfactinigal Oncology. All rights reserved.
`
`AstraZeneca Exhibit 2028 p. 5
`
`
`
`COMPARISON OF FULVESTRANT AND ANASTROZOLE IN ADVANCED BREAST CANCER
`
`3401
`
`
`
`Proportionresponding
`
`
`
`Median DOR:Fulvestrant 15.0 months
`Anastrozole 14.5 months
`
`1.0
`0.9
`0.8
`0.7
`0.6
`0.5
`0.4
`0.3
`
`Naw ewe 1
`0.2
`
`ra —— Fulvestrant 250 mg
`—+' Anastrozole 1 mg
` 0 2 4 6 8B 10 12 1416 18 20 22 24 26 28 30 32 34 36 38 40
`
`
`
`
`
`Duration of response (months)
`
`1.0
`0.9
`0.8
`0.7
`0.6
`0.5
`0.4
`0.3
`0.2
`0.1
`
`
`
`
`
`Proportionwithclinicalbenefit
`
`Median DOCB:Fulvestrant 11.7 months
`Anastrozole 11.4 months
`
`
`
`
`— Fulvestrant250mgoe=
`
`— -» Anastrozole 1 mg
`2
`4
`6
`8
`10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
`
`
`0
`
`Duration ofclinical benefit (months)
`
`Fig 3. Kaplan-Meier estimates for duration of response (responding
`patients only}.
`
`Fig 5. Kaplan-Meier estimates for duration of clinical benefit (DOCB).
`
`DORwith fulvestrant and anastrozole are shown 1n Fig 3. In
`addition, DOR using all patients—where DOR wasdefined
`as from the onset of response to disease progression for
`responders and as zero for nonresponders—was signifi-
`cantly greater for fulvestrant compared with anastrozole
`(ratio of average response durations, 1.27; 95% CL, 1.05 to
`1.55; P = .01; Fig 4). The median duration of clinical
`benefit was 11.7 months in the fulvestrant group (n = 100)
`and 11.4 months in the anastrozole group (n = 104; Fig 5).
`TTD. As specified in the protocol, TTD (overall sur-
`vival) will be analyzed when more than 50% ofthe patients
`have died. At the time of this data analysis, 82 patients
`(36.9%) 1n the fulvestrant group and 83 patients (36.2%) in
`the anastrozole group had died, therefore, no formal statis-
`tical analyses have been conducted. The formal analysis of
`TTD will be presented in a future publication.
`
`Tolerability
`
`Both fulvestrant and anastrozole were well tolerated, with
`only seven fulvestrant patients (3.2%) and three anastrozole
`patients (1.3%) withdrawn because of AEs. A wide range of
`AEs was reported by patients in both treatment groups,
`mostly of mild to moderate intensity. The incidence of side
`
`effects considered important with endocrine therapy (ful-
`vestrant Vv anastrozole), such as weight gain (0.5% v 1.7%),
`thromboembolic events (3.7% v 1.7%), and vaginitis (1.8%
`v 1.3%), was low in both treatment groups. The incidence of
`joint disorders including arthralgia was lower inthe fulves-
`trant-treated group than in the anastrozole-treated group
`(1.4% v 8.3%). The most frequently reported AEs and the
`most common drug-related AEs are shownin Tables 3 and
`4, respectively.
`The 219 patients treated with fulvestrant received a
`total of 1,898 injections. Sixteen patients (7.3%) in the
`fulvestrant treatment group reported myection site AEs
`(comprising injection site pain,
`inflammation, hemor-
`rhage, hypersensitivity, and reaction). Only 20 injections
`out of the total of 1,898 (1.1%) resulted in an injection
`site event. All of these events were of mild mtensity and
`nonserious, and only one patient with an injection site
`event withdrewfrom thetrial.
`
`QOL
`
`A graph of the mean TOI (+ standard deviation) over
`time is shown in Fig 6. Analysis of QOL data up to disease
`progression showed that the QOL was maintained over time
`
`Ratio of average response durations 1.27
`(95% Cl, 1.05 to 1.55; P= ,01)
`
`0.35
`
`03
`0.25
`
`0.24"
`0.15
`0.1
`
`
`
`Proportionresponding
`
`+ Anastrozole 1 mg 0
`
`— -
`2
`
`0
`
`4
`
`6
`
`8
`
`10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
`
`Duration of response (months)
`
`Fig 4. Kaplan-Meier estimates for duration of response(all patients).
`
`Table 3. Most Common Adverse Events Occurring in = 10% of Patients
`Fulvestrant (n = 219)
`Anastrozole (n = 230)
`
` No. % No. %
`
`
`
`18.3
`42
`21:9
`48
`Nausea
`13.0
`30
`16.0
`38
`Vasodilatation
`18.7
`A3
`15.1
`aa
`Asthenia
`78
`18
`12.8
`28
`Vomiting
`11.3
`26
`12.8
`28
`Bone pain
`5x
`13
`119
`26
`Pharyngitis
`7A
`17
`10.5
`23
`Constipation
`10.9
`25
`10.0
`22
`Headache
`
`
`
`
`21 96 28Pain 12,2
`
`Information downloaded from jco.ascopubs.org and provided by at UNIVERSITY NOTTINGHAM on October 17, 2014 from
`Copyright © 2002 American So¢i@éy2xfactinigal Oncology. All rights reserved.
`
`AstraZeneca Exhibit 2028 p. 6
`
`
`
`3402
`
`HOWELL ET AL
`
`
`
`
`
`
`
`——Fulvestrant
`— ®-> Anastrozole
`
`
`
`Meantreatmentoutcomeindex(TOI)
`
`Table 4. Most Common Drug-Related Adverse Events (excluding injection
`
`site events) Occurring in = 2% of Patients
`Fulvestrant (h = 219)
`Anastrozole (nh = 230)
` No. % No. %
`
`
`
`
`Vasodilatation
`Nausea
`
`26
`1g
`
`TL
`8.7
`
`22
`20
`
`12.6
`87
`
`3.5
`8
`27
`6
`Sweating
`3.0
`7
`27
`6
`Headache
`48
`ul
`2.3
`5
`Asthenia
`
`Anorexia 3.9 2 0.9 9
`
`
`
`
`and that the treatments were not statistically significantly
`different (P = .3846).
`
`DISCUSSION
`
`This multinational, randomized, open-label, phase III
`study in postmenopausal women with advanced breast
`cancer progressing after prior endocrine therapy was
`designed to comp