The VENTANA ALK (D5F3) CDx Assay

The value of a standardized ALK IHC approach

2 1.International Agency for Research on Cancer. GLOBOCAN 2012: Estimated cancer incidence, mortality and prevalence worldwide in 2012 http://globocan.iarc.fr/Pages/fact_sheets_population.aspx Accessed March 2015

1

Lung cancer is the most common cancer worldwide

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Cancer-related mortality

Lung cancer remains a leading cause of cancer mortality, globally1

Adenocarcinomas are a distinct sub-type of non-small cell lung cancers (NSCLC)2-4

1. International Agency for Research on Cancer. GLOBOCAN 2012 2. American Cancer Society 2015 3. National Cancer Institute 2015 4. Pao W et al 2011

Lung cancer is a leading cause of death globally

Rapid disease progression of NSCLC

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Early detection and accelerated treatment is essential. With modern treatment, the average survival for Stage 3 NSCLC is 18 to 22 months versus four to six months with untreated cancer.1

Disease progression of NSCLC is rapid

Stage 1 Stage 4

Mortality

1. Progression of Non Small-Cell Lung Cancer, Oncolink, Accessed February 2016 http://www.oncolink.org/experts/article.cfm?id=1708

Treatment goal in metastatic NSCLC: prolong survival via rapid access to therapy

5 1. American Cancer Society 2015 2. National Cancer Institute 2015 3. Pao W et al 2011

LUNG CANCER

SMALL CELL LUNG CANCER (SCLC)

OTHER TYPES OF LUNG CANCER

10-15%

SQUAMOUS CELL

LARGE CELL

25-30%

10-15%

GEN

ETIC

MU

TATI

ON

S/TR

AN

SLO

CA

TIO

NS

REL

EVA

NT

TO T

REA

TMEN

T D

ECIS

ION

S KRAS

EGFR

ALK

MAPK

PI3K

ADENOCARCINOMA

40%

NON-SMALL CELL LUNG CANCER (NSCLC)

85-90%

MET

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“With the introduction of targeted therapies that can result in dramatically different outcomes based on subtype, the importance of accurate classification has been amplified.”1

Up to 30% of lung biopsies require adjunct IHC testing after morphologic evaluation.2 IHC and, more specifically, key panels of IHC antibodies, provides the necessary complement in the routine diagnosis and subtyping of lung cancer.3

1. Tacha D, Yu C, Bremer R, Qi W, Haas T. A 6-antibody panel for the classification of lung adenocarcinoma versus squamous cell carcinoma. Appl Immunohistochem Mol Morphol. 2012;20:201-207 2. Rossi, et al. Subtyping Non-Small Cell Lung Cancer. Int J Surg Pathol. 21:326.2013 3. Capelozzi, V.L. Role of immunohistochemistry in the diagnosis of lung cancer. J Bras Pneumol. 2009;35(4):375-382

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IHC is key in stratifying lung cancer

Thyroid Transcription Factor-1 (SP141) Rabbit Monoclonal Primary Antibody

Cytokeratin 5/6 (D5/16B4) Mouse Monoclonal Primary Antibody

Napsin A (MRQ-60) Mouse Monoclonal Primary Antibody

VENTANA p40 (BC28) Mouse Monoclonal Primary Antibody

Lung Carcinoid 40x Squamous Cell Carcinoma 20x

Adenocarcinoma 20x Squamous Cell Carcinoma 20x

Adenocarcinoma vs. Squamous Cell Carcinoma

NSCLC is the most common type of lung cancer, and consequently, the key focus of most diagnostic and therapeutic advances.1

TTF-1, Napsin A, p40, and CK 5/6 have been identified as an accurate and reliable combination of markers for differentiating adenocarcinoma from squamous cell carcinoma.2

1. Capelozzi, V.L. Role of immunohistochemistry in the diagnosis of lung cancer. J Bras Pneumol. 2009;35(4):375-382 2. Zhao, W., et al. ∆Np63, CK5/6, TTF-1 and napsin A, a reliable panel to subtype non-small cell lung cancer in biopsy specimens. Int J Clin Exp Pathol 2014;7(7):4247-4253

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Influential clinical guidelines recommend routine testing for ALK in all lung adenocarcinomas

Testing is required prior to initiating ALK targeted therapy for a patient1-4

•  In the event of a positive test result, the patient is eligible for approved ALK targeted therapies, such as XALKORI® (crizotinib).

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1. NCCN. 2015 2. Reck M et al 2014 3.Lindeman N et al 2013 4. Tsao M et al 2013

•  National Comprehensive Cancer Network (NCCN)

•  International Association for the study of Lung Cancer (IASLC)

•  Association for Molecular Pathology (AMP)

•  European Society for Medical Oncology (ESMO)

•  College of American Pathologists (CAP)

Rapid access to testing is necessary

Patients need a fast, reliable and standardized way to assess eligibility so that the safest and most effective treatments can be promptly delivered1,2

9 1. von Laffert et al 2014 2. Mohammed et al 2011 3. Linderman et al 2013 4. Soloman B et al 2014 5. Schink et al 2014

Expert guidelines recommend results available within 10 days3-4

Only 24% of National Cancer Institute labs meet the CAP/IASLC/AMP 10 day turnaround time recommendation5

Patients with advanced NSCLC need a fast and reliable test to facilitate rapid access to XALKORI® (crizotinib)

Standardized ALK IHC is practical and sustainable

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FISH Testing IHC Testing FISH testing is costly and time consuming and requires sophisticated lab equipment and highly skilled interpretation, which can create a barrier to access3

IHC testing is practical and sustainable: it is affordable, rapid, easy to integrate and accessible to all pathologists3

Often needs to be outsourced, which adds time and expense

High IHC concordance with FISH has been demonstrated across numerous studies, varying levels of sensitivity depending on antibody used3-9

Minimum of 50 assessable tumor cells

No required minimum number of cells

1. Kwak et al 2010 2. Shaw et al 2013 3. Thunnissen et al 2012 4. Ying et al 2013 5. Ali et al 2014 6. Hutarew et al 2014 7. Le Quesne et al 2014 8. Minca et al 2013 9. Wynes et al 2014

Clinical value of the VENTANA ALK (D5F3) CDx Assay

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ALK IHC is able to detect the actual protein that is the target of therapy, compared to other tests that cannot, resulting in detection of patients that can benefit from XALKORI® (crizotinib) therapy.

1. Roche Ventana 2014 2. Thunnissen et al 2012 3. Ying et al 2013 4. Ali et al 2014 5. Hutarew et al 2014 6. Le Quesne et al 2014 7. Minca et al 2013 8. Wynes et al 2014 9. Zhou J et al 2014 10. Peled N et al 2012 11. Sun JM et al 2012

With no minimum sample size, use of the VENTANA ALK (D5F3) Assay can facilitate optimal tissue use1

The VENTANA ALK (D5F3) Assay has demonstrated comparable sensitivity and specificity relative to ALK 2-8

ALK IHC-positive, FISH-negative patients have been identified and may benefit from treatment with crizotinib9-11

1. Roche 2014

The VENTANA ALK (D5F3) CDx Assay stained with OptiView DAB Detection and Amplification is approved to identify patients eligible for treatment with XALKORI® crizotinib)1

VENTANA ALK (D5F3) CDx Assay is a complete system

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Rabbit Monoclonal Negative Control

No ALK Inhibitor

Interpretation Guide

VENTANA ALK (D5F3)

antibody dispenser

VENTANA OptiView DAB IHC Detection

and OptiView Amplification

BenchMark IHC/ISH Series

OR

ALK Inhibitor

•  There is no minimum sample size required for the VENTANA ALK (D5F3) CDx Assay, reducing need to resample

•  Successful FISH testing requires a minimum of 50 enumerable cancer cells

•  This minimum cell count, in addition to difficulties in interpreting FISH results, may lead to uninterpretable results

–  A recent study in France found that 20% of cases analyzed by FISH were uninterpretable1

No minimum sample size: VENTANA ALK (D5F3) CDx Assay reduces resampling

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VENTANA ALK (D5F3) CDx Assay on a case where FISH could not be performed due to <50 tumor cells in the sample: •  It is positive by IHC

Note small cluster of positive tumor cells

1. McLeer-Florin A et al 2012

Comparison of commercially available tests

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Type

Fully automated

Intended use from package insert

Accessibility Relative costs

Sample requirements Timing

Claims re: XALKORI® (crizotinib)

VENTANA ALK D5F3 CDx Assay

IHC

Detection of the anaplastic lymphoma kinase (ALK) protein

Highly accessible $

No required minimum number of cells

4 hours, in-house testing

Indicated as an aid in identifying patients eligible for treatment with XALKORI® (crizotinib)

ALK-FISH (Vysis, Abbott)

FISH

Detection of rearrangements involving the ALK gene in NSCLC specimens

Not routinely accessible $$$$

Minimum of 50 assessable tumor cells

12+ hours, semi-automated; typically batch or send-out testing

Qualitative test to detect rearrangements involving the ALK gene to aid in identifying those patients eligible for treatment with XALKORI® (crizotinib)

Sources: Vysis product details http://www.abbottmolecular.com/static/cms_workspace/pdfs/US/Vysis_ALK_FISH_Probe_Kit_PI.pdf. Qiagen product details https://www.qiagen.com/gb/products/catalog/assay-technologies/complete-assay-kits/personalized-healthcare/alk-rgq-rt-pcr-kit-ruo/#productdetails

Comparison of commercially available tests

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Routine testing

Simple operation Timing Price

FISH

Other IHC

VENTANA IHC

RT-PCR

Used for screening

ALK+ tumors can be diagnosed

$

$ Fully

automated

12+ hours

4 hours

$$$$

$$$$

Treatment goal in metastatic NSCLC is to prolong survival

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LUNG CANCER

ALK TARGETED THERAPIES

ADENOCARCINOMA

NON-SMALL CELL

LUNG CANCER (NSCLC)

IHC

“Results suggest it's best to get these drugs to patients at the earliest opportunity.”1 - Benjamin Solomon, Peter MacCallum Cancer Centre, Australia

Opportunity: Prolong survival, save costs and make more immediate treatment decisions for advanced NSCLC patients by using the VENTANA ALK (D5F3) CDx Assay

1. Soloman B et al 2014

Health outcome New treatment

Cost New treatment

- Cost

Current treatment

Health outcome Current treatment

-

How to analyze cost/benefit of ALK IHC testing?

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ALK IHC shows potential economic and clinical value

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Accelerate access to care

Impact patient quality of life

Decrease diagnostic costs1

With lower costs and equivalent accuracy, the VENTANA ALK (D5F3) CDx Assay has the potential to improve efficiency and patient quality of life.

1. Roche 2014

Summary: Standardized ALK IHC approach

Clinical guidelines recommend rapid turnaround for earlier targeted therapies1

FISH is widely used but the ALK IHC is an attractive alternative2

The approved VENTANA ALK (D5F3) CDx Assay stained with OptiView DAB Detection and Amp detects the protein that is the target of therapy3

Comparable sensitivity and specificity relative to FISH7-12

No minimum sample size

Accelerates access and impacts patient quality of life13

May decrease diagnostic costs1

19 1. Linderman et al 2013 2. Thunnissen et al 2012 3 Roche et al 2014 4. Ying et al 2013 5. Ali et al 2014 6. Hutarew et al 2014 7. Le Quesne et al 2014 8. Minca et al 2013 9. Wynes et al 2014 10. Zhou J et al 2014 11. Peled N et al 2012 12. Sun JM et al 2012 13. VENTANA ALK (D5F3) Assay Budget Impact Model. Roche 2015 .

References

References

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Abbot Vysis ALK FISH Probe Kit. http://www.abbottmolecular.com/static/cms_workspace/pdfs/US/Vysis_ALK_FISH_Probe_Kit_PI.pdf

Alì, Greta, et al. "ALK Rearrangement in a Large Series of Consecutive Non-Small Cell Lung Cancers: Comparison Between a New Immunohistochemical Approach and Fluorescence In Situ Hybridization for the Screening of Patients Eligible for Crizotinib Treatment." Archives of pathology & laboratory medicine138.11 (2014): 1449-1458

American Cancer Society. Lung cancer (non-small cell). http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-what-is-non-small-cell-lung-cancer Accessed March 2015

Capelozzi, V.L. Role of immunohistochemistry in the diagnosis of lung cancer. J Bras Pneumol. 2009;35(4):375-382

Hutarew, Georg, et al. "Immunohistochemistry as a screening tool for ALK rearrangement in NSCLC: evaluation of five different ALK antibody clones and ALK FISH." Histopathology 65.3 (2014): 398-407

International Agency for Research on Cancer. GLOBOCAN 2012: Estimated cancer incidence, mortality and prevalence worldwide in 2012. http://globocan.iarc.fr/Pages/fact_sheets_population.aspx Accessed March 2015

Kwak, Eunice L., et al. "Anaplastic lymphoma kinase inhibition in non–small-cell lung cancer." New England Journal of Medicine 363.18 (2010): 1693-1703

Le Quesne, John, et al. "A Comparison of Immunohistochemical Assays and FISH in Detecting the ALK Translocation in Diagnostic Histological and Cytological Lung Tumor Material." Journal of Thoracic Oncology 9.6 (2014): 769

Lindeman, Neal I., et al. "Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology." The Journal of Molecular Diagnostics 15.4 (2013): 415-453

McLeer-Florin, Anne, et al. "Dual IHC and FISH testing for ALK gene rearrangement in lung adenocarcinomas in a routine practice: a French study. "Journal of Thoracic Oncology 7.2 (2012): 348-354

Minca, Eugen C., et al. "ALK Status Testing in Non–Small Cell Lung Carcinoma: Correlation Between Ultrasensitive IHC and FISH." The Journal of Molecular Diagnostics 15.3 (2013): 341-346

References

Mohammed, Nasiruddin, et al. "Rapid Disease Progression With Delay in Treatment of Non–Small-Cell Lung Cancer." International Journal of Radiation Oncology* Biology* Physics 79.2 (2011): 466-472

National Cancer Institute. Non-Small cell lung cancer (PDQ) http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/healthprofessional Accessed March 2015

NCCN. Non-small cell lung cancer Guidelines version 4.2015

Oncolink. Progression of Non Small-Cell Lung Cancer, Oncolink, Accessed February 2016 http://www.oncolink.org/experts/article.cfm?id=1708

Pao, William, and Nicolas Girard. "New driver mutations in non-small-cell lung cancer." The Lancet oncology 12.2 (2011): 175-180

Peled, Nir, et al. "Next-Generation Sequencing Identifies and Immunohistochemistry Confirms a Novel Crizotinib-Sensitive ALK Rearrangement in a Patient with Metastatic Non–Small-Cell Lung Cancer."Journal of Thoracic Oncology 7.9 (2012): e14-e16

Qiagen ALK RT-PCR. https://www.qiagen.com/gb/products/catalog/assay-technologies/complete-assay-kits/personalized-healthcare/alk-rgq-rt-pcr-kit-ruo/#productdetails

Reck M, Reinmuth N, De Ruysscher D et al. Metastatic non-small-cell lung cancer (NSCLC): ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology 25 (Suppl 3) (2014) iii27-iii39

Roche Ventana. (2014). anti-ALK (D5F3) Rabbit Monoclonal Primary Antibody, 1–4 Rossi, et al. Subtyping Non-Small Cell Lung Cancer. Int J Surg Pathol. 21:326.2013

Schink et al. Biomarker testing methods in breast, gastric, and lung cancers: A benchmarking survey of NCI cancer centers. Journal of Clinical Oncology 31.15 (2013) e22093

Shaw, Alice T., et al. "Crizotinib versus chemotherapy in advanced ALK-positive lung cancer." New England Journal of Medicine 368.25 (2013): 2385-2394

Solomon, Benjamin J., et al. "First-line crizotinib versus chemotherapy in ALK-positive lung cancer." New England Journal of Medicine 371.23 (2014): 2167-2177

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References Sun, Jong-Mu, et al. "A Dramatic Response to Crizotinib in a Non–Small-Cell Lung Cancer Patient with IHC-Positive and FISH-Negative ALK." Journal of Thoracic Oncology 7.12 (2012): e36-e38

Tacha D, Yu C, Bremer R, Qi W, Haas T. A 6-antibody panel for the classification of lung adenocarcinoma versus squamous cell carcinoma. Appl Immunohistochem Mol Morphol. 2012;20:201-207

Thunnissen, Erik, et al. "EML4-ALK testing in non-small cell carcinomas of the lung: a review with recommendations." Virchows Archiv 461.3 (2012): 245-257

Tsao, M. S., F. R. Hirsch, and Y. Yatabe. "IASLC atlas of ALK testing in lung cancer." Aurora, CO, International Society for the Study of Lung Cancer (2013)

VENTANA ALK (D5F3) Assay Budget Impact Model. Roche 2015

von Laffert, Maximilian, et al. "Multicenter ALK Testing in Non–Small-Cell Lung Cancer: Results of a Round Robin Test." Journal of Thoracic Oncology 9.10 (2014): 1464-1469

Wynes, Murry W., Lynette M. Sholl, and Manfred Dietel. "An international interpretation study using the ALK IHC antibody D5F3 and a sensitive detection kit demonstrates high concordance between ALK IHC and ALK FISH and between evaluators." Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 9.5 (2014): 631

XALKORI Prescribing Information (USA)

XALKORI Summary of Product Characteristics (UK)

Ying, J., et al. "Diagnostic value of a novel fully automated immunochemistry assay for detection of ALK rearrangement in primary lung adenocarcinoma. "Annals of oncology (2013): mdt295

Zhao, W., et al. ∆Np63, CK5/6, TTF-1 and napsin A, a reliable panel to subtype non-small cell lung cancer in biopsy specimens. Int J Clin Exp Pathol 2014;7(7):4247-4253

Zhou, Jianya, et al. "Cell block from malignant pleural effusion might be a valid alternative sample for ALK detection in patients with advanced non small cell lung cancer." Histopathology (2014)

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